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Study Illustrates Value of Access to Gender-Affirming Hormones

A study published in PLOS One found that access to gender-affirming hormones during adolescence is associated with better mental health outcomes among transgender adults. It is the first large-scale controlled study of gender-affirming hormone initiation during adolescence, the first study to compare access to gender-affirming hormones during adolescence vs. adulthood, and adds important new knowledge to the evolving field of transgender health care.

“These results argue against waiting until adulthood to offer gender-affirming hormones to transgender adolescents and suggest that doing so may put patients at greater mental health risk,” says senior study author Dr. Alex S. Keuroghlian, who directs the National LGBTQIA+ Health Education Center at The Fenway Institute and the Massachusetts General Hospital Psychiatry Gender Identity Program. “They also add to the growing evidence base suggesting that legislation restricting transgender adolescents’ access to gender-affirming medical care would result in adverse mental health outcomes.”

The study, titled “Access To Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults,” compared past-month severe psychological distress and past-year suicidal ideation of 12,738 transgender adults who had accessed gender-affirming hormones during early adolescence, late adolescence, or adulthood with those of 8,860 transgender adults who desired gender-affirming hormones but had never accessed them. Among participants who accessed gender-affirming hormones during early adolescence (age 14 to 15), it found that the odds of severe psychological distress were decreased 222% and the odds of past-year suicidal ideation were decreased 135%.

Among those who accessed gender-affirming hormones during late adolescence (age 16 to 17), odds of severe psychological distress and past-year suicide ideation were decreased by 153 percent and 62%, respectively. Compared with adults who desired but never accessed gender-affirming hormones, odds of decreased severe psychological distress and past-year suicide ideation among those who first accessed gender-affirming hormones during adulthood were 81% and 21%, respectively.

Other important findings from the study include the following:

• A large proportion of transgender people desire but never access gender-affirming hormones. In this study, 41% of those who desired gender-affirming hormones were unable to access them.

• Although odds of past-year suicidal ideation were significantly lower among those who accessed gender-affirming hormones during adolescence or adulthood, rates of past-year suicidal ideation were still high—as compared with the general population—even among study participants who reported having access to gender-affirming hormones. This finding suggests that other psychosocial stressors experienced by transgender people, such as employment discrimination, lack of access to public facilities, and acts of bias-motivated harassment and violence, contribute to chronic minority stress, which negatively affects health outcomes.

• Those who first accessed gender-affirming hormones during adulthood were more likely to report past-month binge drinking and lifetime illicit drug use than those who reported desiring but never accessing gender-affirming hormones. This finding is partly explained by the fact that transgender people often become more socially engaged following the increased confidence that comes along with gender affirmation. But these results, along with the higher prevalence of substance use disorders among transgender people, support the need for routine screening for substance use and the development of culturally responsive substance use disorder prevention and treatment interventions.

“This study highlights that the U.S. has failed to make gender-affirming medical care accessible,” says lead study author Dr. Jack Turban, chief fellow in child & adolescent psychiatry at the Stanford University School of Medicine. “We urgently need to work on training more clinicians and combatting insurance discrimination.”

Turban also cautions that “lack of access to gender-affirming medical care could drive the use of nonprescribed gender-affirming hormones through the purchase of hormones online or on the black market without medical monitoring, which may lead to adverse physical health outcomes.”

“Access To Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults” is based on data from the 2015 U.S. Transgender Survey conducted by the National Center for Transgender Equality which surveyed over 27,000 transgender people in all 50 states, Washington D.C., Puerto Rico, U.S. territories abroad, and U.S. military bases on a multitude of questions about their lives.

The paper is the latest in a series of secondary analyses of the groundbreaking 2015 survey evaluating factors that affect the mental health outcomes of transgender and gender diverse people. Prior papers include “Factors Leading to ‘Detransition’ Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis,” published in 2021 in LGBT Health, “Association Between Gender-Affirming Surgeries and Mental Health Outcomes,” published in 2021 in JAMA Surgery, “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation,” published in 2020 in Pediatrics, and “Association Between Recalled Exposure to Gender Identity Conversion Efforts and Suicide Attempts,” published in 2020 in JAMA Psychiatry.

“Access to Gender-Affirming Hormones During Adolescence and Mental Health Outcomes Among Transgender Adults” was authored by researchers affiliated with the Division of Child & Adolescent Psychiatry, Stanford University School of Medicine, the Department of Psychiatry, Massachusetts General Hospital, The Fenway Institute at Fenway Health, the Department of Psychiatry, Harvard Medical School, the Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, the Department of Medicine, Harvard Medical School, and the Department of Epidemiology, Harvard T.H. Chan School of Public Health.

Source: Fenway Health