Summary

WPATH, the main international trans health body, part-funded Johns Hopkins to review the evidence for its 2022 treatment guidelines. The reviewers found 20 studies, mostly small European clinic studies. These reported better quality of life and less depression and anxiety after starting hormones, and none reported harm to mental health. But the reviewers rated every conclusion as low-quality evidence, because of biased study designs, small numbers and the effects of surgery being mixed in. Only one study looked at suicide, so no conclusion was possible. The authors still called hormones 'essential' care, a stronger claim than their own ratings support. Court documents released in 2024 showed WPATH tried to control what the Hopkins team could publish. This was the only review published after WPATH brought in an approval rule. It shows weak evidence, not proven benefits.

Key findings

• Die Übersicht schloss 20 Studien in 22 Arbeiten ein. Nur eine war eine randomisierte Studie; die meisten verfolgten Patientengruppen über die Zeit, und vier waren einmalige Momentaufnahmen.
• Die meisten Studien hatten weniger als 60 Personen, alle aus spezialisierten Gender-Kliniken. Acht der 20 stammten aus Italien, und nur 3 betrachteten Jugendliche.
• Hormone hingen mit besserer Lebensqualität (7 Studien), weniger Depression (12 Studien) und weniger Angst (8 Studien) zusammen, aber mehrere Studien fanden keine Veränderung.
• Die Gutachter stuften die Evidenz zu Lebensqualität, Depression und Angst als niedrige Qualität ein und konnten zu Suizid keine Schlussfolgerung ziehen.
• Die einzige Suizidstudie, aus der Amsterdamer Klinik, fand, dass trans Frauen mit der 5,7-fachen Rate der Allgemeinbevölkerung durch Suizid starben. Die Gutachter beurteilten sie als mit ernstem Verzerrungsrisiko behaftet.
• In der niederländischen Jugendgruppe besserte sich die Depression unter Pubertätsblockern (Medikamente, die die Pubertät anhalten), aber nach späteren gegengeschlechtlichen Hormonen war die Gesamtverbesserung gegenüber dem Beginn nicht mehr klar.
• WPATH gab die Übersicht in Auftrag und bezahlte sie teilweise, um ihre Behandlungsleitlinien zu untermauern.
• 2024 veröffentlichte Gerichtsdokumente deuten darauf hin, dass WPATH das Recht anstrebte, die Arbeiten des Hopkins-Teams zu genehmigen, und dass dies die einzige Arbeit war, die nach Einführung dieser Regel durch WPATH veröffentlicht wurde.

Abstract

We sought to systematically review the effect of gender-affirming hormone therapy on psychological outcomes among transgender people. We searched PubMed, Embase, and PsycINFO through June 10, 2020 for studies evaluating quality of life (QOL), depression, anxiety, and death by suicide in the context of gender-affirming hormone therapy among transgender people of any age. We excluded case studies and studies reporting on less than 3 months of follow-up. We included 20 studies reported in 22 publications. Fifteen were trials or prospective cohorts, one was a retrospective cohort, and 4 were cross-sectional. Seven assessed QOL, 12 assessed depression, 8 assessed anxiety, and 1 assessed death by suicide. Three studies included trans-feminine people only; 7 included trans-masculine people only, and 10 included both. Three studies focused on adolescents. Hormone therapy was associated with increased QOL, decreased depression, and decreased anxiety. Associations were similar across gender identity and age. Certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions. We could not draw any conclusions about death by suicide. Future studies should investigate the psychological benefits of hormone therapy among larger and more diverse groups of transgender people using study designs that more effectively isolate the effects of hormone treatment.

Conclusion

Hormone therapy was associated with increased QOL, decreased depression, and decreased anxiety, with similar associations across gender identity and age. Certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions; the strength of evidence for each outcome was graded low. No conclusions could be drawn about death by suicide. Despite these limitations, the authors stated that hormone therapy is likely associated with improvements in QOL, depression and anxiety, that no study showed harm to mental health, and that these benefits make hormone therapy 'an essential component of care'. They called for larger, more diverse studies using designs that better isolate the effects of hormones.