Transgender mental health: What age is best to begin hormone treatment?

Data suggests that transgender people who begin hormone treatment in adolescence, have better mental health than those waiting until adulthood

According to research led by the Stanford University School of Medicine, gender-affirming hormone treatment – with oestrogen or testosterone – can enable a transgender teenager to go through puberty in a way that matches their gender identity.

The study drew on data from the largest-ever survey of U.S. transgender adults, a group of more than 27,000 people who responded in 2015.

It revealed that transgender people who began hormone treatment in adolescence had fewer thoughts of suicide, were less likely to experience major mental health disorders and had fewer problems with substance abuse than those who started hormones in adulthood.

Additionally, results from the survey identified better mental health among those who received hormones at any age, than those who desired but never received the treatment.

Bringing physical characteristics in line with gender identity

The researchers evaluated data from the survey in 2015, which had responses from 27,715 transgender people nationwide. Participants were at least 18 when they were surveyed were to complete all-encompassing questionnaires about their lives.

Considering how some transgender people do not want hormone treatment, the study primarily focused on the 21,598 participants who had reported that they wanted to receive hormones.

Results were examined based on when participants began hormone therapy: 119 began at age 14 or 15 (early adolescence), 362 began at age 16 or 17 (late adolescence), 12,257 began after their 18th birthday (adulthood), and 8,860 participants, who served as the control group, wanted but never received hormone therapy.

Answering questions about their mental health: such as their history of suicidal thoughts and suicide attempts, and their history of binge drinking and illicit drug use, the participants completed a questionnaire to assess whether they had experienced severe psychological distress – whether in the past month they had met the criteria for a diagnosable mental illness.

The analysis was controlled for numerous factors which could influence participants’ mental health independently of whether they received hormone treatment, these factors included:

• age at the time of the survey
• gender identity
• sex assigned at birth
• sexual orientation
• race or ethnicity
• level of family support for gender identity
• relationship status
• level of education
• employment status
• household income
• use of pubertal suppression treatment
• any attempts to force them to be cisgender
• experience of any verbal, physical or sexual harassment based on their gender identity in grades K-12

Participants who began hormones in adolescence had lower odds of binge drinking and lifetime illicit drug use

Compared with members of the control group, participants who underwent hormone treatment had lower odds of experiencing severe psychological distress during the previous month and lower odds of suicidal ideation in the previous year. Odds of severe psychological distress were reduced by 222%, 153% and 81% for those who began hormones in early adolescence, late adolescence and adulthood.

Additionally, the odds of previous-year suicidal ideation were 135% lower in people who began hormones in early adolescence, 62% lower in those who began in late adolescence and 21% lower in those who began as adults, when compared with the control group.

However, the study identified that those who started hormone treatment in adulthood were more likely to engage in binge drinking and use of illicit substances than those who never had hormone treatment. As well as this, in some cases, taking hormones increased confidence and social engagement may be linked to substance use.

The researchers also assessed whether participants in each group had ever been suicidal but had not had suicidal feelings in the previous year, to gain a sense of whether participants’ mental health before treatment influenced their ability to gain access to treatment.

“Gender-affirming care is beneficial from a mental health perspective”

Jack Turban, MD, a postdoctoral scholar in paediatric and adolescent psychiatry at Stanford Medicine, said: “This study is particularly relevant now because many state legislatures are introducing bills that would outlaw this kind of care for transgender youth. We are adding to the evidence base that shows why gender-affirming care is beneficial from a mental health perspective.

“Some individuals may become more confident and socially engaged when they begin taking hormones. This finding speaks to the importance of creating culturally tailored substance-use counselling programs for transgender individuals. This was a measure of mental health improving over time. People were more likely to meet those criteria if they accessed and took hormones than if they hadn’t.”

The conclusions of the study imply that access to hormones generally improved mental health, rather than the other way around.

“Being denied access to treatment can cause significant distress”

Turban continued: “There’s no one correct way to be transgender. Some transgender people do not want to take hormones and feel comfortable with their bodies the way they are. Young people seeking care at gender clinics are routinely offered counselling as part of their treatment to help them figure out what types of care best fit their circumstances.

“For those who desire gender-affirming hormones, being denied access to the treatment can cause significant distress. For some transgender youth, their negative reactions to living in bodies that develop during puberty in ways that don’t match who they know themselves to be can be very damaging.”

An instance of trans youth potentially damaging their bodies during puberty can be seen with instances of individuals who feel uncomfortable developing breasts, who may react by binding their chests so tightly they develop skin infections or rib fractures.

Turban added: “These results won’t be surprising to providers, but unfortunately a lot of legislators have never met any transgender youth. It’s important for legislators to see the numbers that back up the experiences of transgender youth, their families and the people who work in this field.”

The research team hope that legislators across the US will use these results to adapt their policy decisions. Although several bills to ban gender-affirming medical care for transgender youth have been introduced in state legislatures in recent years, nearly all have failed to become law. All major medical organizations support provision of gender-affirming medical care, including hormone therapy for patients who desire it and who meet criteria set out transgender and health organisations.