Accessing hormone therapy to affirm gender identity as a transgender teen could mean better mental health in the long run than for those who wait until adulthood or never receive treatment, according to a new Stanford University study.
The research comes as an international group of transgender health experts released a draft of the World Professional Association for Transgender Health's eighth version of the Standards of Care.
It is the first time in nearly a decade the 350-page tome that medical and insurance professionals rely on for guidance is being updated, including the sections focused on transgender health care, reported the New York Times.
The Times reported the new guidelines dropped requiring psychological assessment for adults before accessing hormone therapy. However, the guidelines are more conservative for teens. The draft guidelines recommend that teens undergo mental health assessments and have questioned their gender identity for "several years" before being allowed hormone therapy or surgery.
The draft has landed psychologists in two different camps: pro-pre-assessment care and pro-gender-affirming care as more transgender teens assert their gender identity.
Pro-assessment clinicians are cautious about the risks, such as long-term effects of puberty blockers and other drugs, potential detransitioning, and other issues. Pro-gender-affirming care clinicians believe a psychological analysis is an "unnecessary barrier" for transgender teens who are at risk of mental health issues, including suicide.
Commentary on the draft guidelines closed January 16. A final draft of the new Standards of Care is anticipated sometime in the spring.
A new study, "Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults," from the Stanford School of Medicine backs pro-gender-affirming care clinicians and a growing canon of research on gender-affirming care. The study, published January 12 in the online journal PLOS ONE suggests transgender youth who receive treatment in line with their gender identity early have better mental health outcomes and lower substance abuse in the long run than transgender individuals who wait until adulthood.
PLOS ONE is a peer-reviewed open access scientific journal published by the Public Library of Science.
Researchers led by Stanford's Dr. Jack Turban analyzed data from the 2015 Transgender Survey (USTS). Turban's team zeroed in on 21,598 transgender respondents out of the total 27,715 participants in the survey. The survey is believed to be the largest to date of transgender adults in the U.S., including participants from all 50 states, Washington, D.C., and the country's five territories.
The researchers compared controlled data from the survey based on 13 factors independent of receiving or not receiving hormone treatment to a control group of participants that underwent hormone treatment. The researchers discovered participants in the control group had lower odds of experiencing severe mental health issues, suicidal thoughts, and substance abuse. Participants who accessed hormone therapy in their teens (early or later) and adulthood reduced the odds of severe psychological distress by 222%, 153%, and 81%, respectively. Earlier access to hormone therapy reduced thoughts of suicide by 135% in people who began hormones in their early teens, 62% in those who began in their late teens, and 21% in those who began as adults, according to the study.
Turban, who is gay, recognized there is no one way to be transgender and that not everyone wants to, or can, receive hormone treatment to affirm their gender.
"There's no one correct way to be transgender," said Turban, who is the chief fellow in child and adolescent psychiatry at Stanford University School of Medicine, in a January 12 Stanford Medicine news release. "Some transgender people do not want to take hormones and feel comfortable with their bodies the way they are."
However, results of the research showed people denied access to gender-affirming hormone treatment can cause significant distress, Turban said.
Additionally, the study found that binge drinking and a lifetime of illicit drug use were lower for those who began using hormones in their early or late teens than those who began hormones in adulthood.
The opposite was true for those who started hormone treatment in adulthood and those who never accessed the treatment. They were more likely to engage in binge drinking and drug use, according to the study.
"This was a measure of mental health improving over time," said Turban. "People were more likely to meet those criteria if they accessed and took hormones than if they hadn't."
The finding implies that access to hormones improved mental health rather than the other way around, Turban said. He noted other research showing positive results in mental health outcomes connected to gender-affirming hormone treatment, but this study is the first to zero in on the impact of at what age treatment begins — during adolescence or adulthood, he said.
"The study reaffirmed what most physicians in this space note clinically, that gender-affirming medical care for transgender adolescents appears to result in improved mental health," Turban wrote in an email interview with the Bay Area Reporter.
Turban's team of researchers from Harvard University, the Fenway Institute, and Brigham and Women's Hospital affirmed the benefits of transgender youth accessing hormone therapy as opposed to waiting until adulthood.
Transgender people who have access to hormone therapy during adolescence were significantly less likely to experience major mental health disorders, had fewer thoughts of suicide and had fewer issues with substance abuse than those who waited until later in life, according to the findings.
Turban attributed this finding to early treatment potentially boosting self-confidence as opposed to transgender people who wait to access treatment as adults.
"It appears that starting gender-affirming hormones during adolescence shielded young people from this risk," he wrote. "It may be that this earlier self-actualization puts people at lower risk of using substances to alleviate difficult emotions in the future."
However, Turban stressed the need for "careful screening for substance use disorders and culturally tailored interventions to prevent the development of these conditions."
Supporting trans youth
Christopher Holleran, MFT, who is a therapist at SF Therapy Collective, the for-profit side of Queer LifeSpace, one of San Francisco's LGBTQ mental health providers, wasn't surprised by the study's findings, he told the B.A.R.
"If you work with trans youth in a clinical setting or trans individuals or gender-nonconforming or -expansive individual's you kind of recognize the benefits of hormone replacement therapy for some people, and how that can greatly impact mental health," said Holleran, a gay man, who also serves as clinical director and training director at Queer LifeSpace.
Holleran said that he has worked with youth his entire career — from being a teacher to a developmental researcher before becoming a therapist.
Bisexual trans femme PFLAG board member Lilith Rose wishes they had access to hormone therapy and other gender-affirming resources as young as 5 or 6 years old. The 25-year-old didn't transition until they were an adult.
"We need medical care for our trans kids as early as possible," Rose told the B.A.R. excited that science is corroborating what they see in PFLAG's support groups in San Francisco, "Is a really great feeling."
Longtime transgender activist Cecilia Chung, who's a member of the San Francisco Health Commission, told ABC7 News that there are some narratives today that are "very hostile and damaging" especially toward younger transgender people.
Holleran agreed, calling shame "one of the most intolerable feelings to carry."
"Unfortunately, it's a hallmark of the queer experience, particularly these days," Holleran said. "Because the trans community is being vilified so openly and so aggressively right now."
Kelly K., a San Francisco parent of a transgender child who didn't want to use her full last name and declined to provide her transgender daughter's name to protect their privacy, worries about the anti-transgender laws being proposed across the country. She doesn't feel safe as a parent of a transgender child even living in San Francisco. She's fully aware that there is a possibility these state laws could form a basis for federal law if conservative politicians have their way.
"It feels threatening," K. said. Her heart goes out to parents of transgender youth in states passing laws blocking their children from access to gender-affirming care.
Chung, who is the senior director of strategic initiatives and evaluation at the Transgender Law Center, hopes the research will serve as a tool to strengthen the organization's work fighting and winning policy battles.
It is one of Turban's hopes, too, that the paper's findings will be a useful tool for lawmakers and policymakers.
Holleran was skeptical about the study potentially influencing politicians.
According to the Human Rights Campaign, 2021 was a record-breaking year of anti-LGBTQ, especially anti-transgender, laws introduced across the United States and the deadliest year ever for transgender people with 51 killings.
HRC tracked more than 268 anti-LGBTQ+ bills and 147 specifically anti-trans bills introduced in legislatures across the country in 2021, according to the organization's January 13 news release. Ten states enacted a record 26 anti-LGBTQ bills last year.
"We are hopeful that policymakers will turn to data when making decisions regarding legislation that would impact transgender youth," wrote Stanford's Turban. "Based on the data we have so far, it appears that outlawing gender-affirming hormones for transgender youth would lead to bad mental health outcomes."
Puberty is a sensitive time for any teen, but many transgender teens have "negative reactions to living in bodies that develop during puberty in ways that don't match who they know themselves to be," he stated.
Turban said it can be "very damaging" explaining "individuals who feel uncomfortable developing breasts may react by binding their chests so tightly they develop skin infections or rib fractures."
Gender-affirming hormone therapy can help bring a transgender teen's body in line in a way that matches with their gender identity.
Mental health providers and doctors aren't surprised by these issues, but legislators might be, he said.
"Unfortunately, a lot of legislators have never met any transgender youth," said Turban, who believes the study is "particularly relevant now because many state legislatures are introducing bills that would outlaw this kind of care for 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," he said expressing hope in the face of the recent wave of anti-LGBTQ, especially anti-transgender, laws.
Turban hopes the study's findings will help guide legislators and policymakers to create better laws to protect and help transgender and gender non-conforming people, especially youths.
Rose agreed, telling the B.A.R. they hope lawmakers will look at the science and vote for "what is the best for our communities" rather than "reacting with fear of something that they don't understand.
"Everyone's situation is different. Their own journey with gender, with everything, but specifically with gender is always going to be different," they said, pointing out that "placing laws preventing people from pursuing what they know is best from them is never going to work for everybody."
"People have their own path to understanding their identity, and if someone's blocked from their path" it doesn't stop them from "trying to figure out how to pursue their true self," Rose said. It also prevents LGBTQ community organizations from giving proper support and resources to the community.
Chung is hopeful, despite the anti-transgender backlash and sluggish movement of pro-transgender legislation and policies.
Holleran isn't as hopeful, noting that conservatives are authoring anti-transgender laws across the country for political gain.
"It's really more about pushing a political agenda," he said. He is more optimistic about the study's findings changing the hearts and minds of parents.
"I think it could be incredibly impactful and effective with parents who might have children who are questioning their gender and really just how important it is to take those conversations very seriously," he said.
K. took her daughter's cry for help seriously. The family knew something was wrong, but they couldn't figure it out.
"We knew that there was some way that we weren't serving her as parents. We just couldn't figure out what it was," said the 48-year-old bisexual mother of three who serves on the board of PFLAG San Francisco told the B.A.R.
Then one night she found a suicide note from her daughter on her pillow. Her daughter was in the first grade at the time. K. jumped into action. She worked with a school social worker for two years before they were referred to a gender clinic in San Francisco. It was a shock, but the family adjusted, educated themselves, and embraced their transgender daughter who was heading into the fifth grade at the time. They created a ceremony for her coming out. They helped her choose her name, hosted a coming out party, and were by her side at the clinic.
"Once we started getting her access to care, it was like a totally different person," she said. "It has been kind of the key that has opened the door and awareness to possibilities.
"She is a very happy person right now and it's as a direct result of that," K. said.
The Stanford Medical study "affirms what my experience has been," she added.
Chung is amazed families are increasingly accepting their transgender children.
"It's not something that we could even imagine 40 years ago when I first transitioned," she told ABC7.
Turban agreed, calling family acceptance and support "one of the greatest predictors of good mental health outcomes for transgender people," he told ABC7 News.
"Just having parents who say 'We love you no matter what. We accept your gender identity. We validate who you are as a person.' That does so much to make someone's mental health better," he said.
The B.A.R. attempted to get transgender youth and young adults' perspectives about the study's findings, but other organizations contacted declined to make anyone available, citing the Health Insurance Portability and Accountability Act.
The American Academy of Child & Adolescent Psychiatry (supported by industry sponsors Arbor and Pfizer), the Harvey L. and Maud C. Sorensen Foundation, the National Institute of Mental Health, and the Health Resources and Services Administration funded the research.
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