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

• レビューには、22本の論文にまたがる20件の研究が含まれていました。無作為化試験は1件だけで、大半は患者のグループを時間の経過とともに追跡したもので、4件は1回限りのスナップショットでした。
• 大半の研究は60人未満で、すべて専門のジェンダークリニックからでした。20件のうち8件はイタリアのもので、10代を調べたのは3件だけでした。
• ホルモンは、より良い生活の質（7件の研究）、うつ病の減少（12件）、不安の減少（8件）と関連していましたが、いくつかの研究では変化は見られませんでした。
• レビュー担当者は、生活の質、うつ病、不安のエビデンスを低品質と評価し、自殺については結論を出せませんでした。
• 自殺に関する唯一の研究は、アムステルダムのクリニックのもので、トランス女性の自殺による死亡率が一般の人々の5.7倍であることが分かりました。レビュー担当者はこれを、深刻なバイアスのリスクがあると判断しました。
• オランダの10代のグループでは、うつ病は思春期ブロッカー（思春期を一時停止させる薬）の間に改善しましたが、その後の異性ホルモンの後は、開始時点からの全体的な改善は明確ではなくなりました。
• WPATHは、治療ガイドラインに情報を提供するために、このレビューを依頼し、一部費用を出しました。
• 2024年に公開された裁判資料は、WPATHがホプキンスのチームの論文を承認する権利を求めたこと、そしてWPATHがその規則を導入した後に公表された論文はこれだけだったことを示唆しています。

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.