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

• Обзор включил 20 исследований в 22 статьях. Лишь одно было рандомизированным испытанием; большинство наблюдали группы пациентов во времени, а четыре были разовыми срезами.
• В большинстве исследований было менее 60 человек, все из специализированных гендерных клиник. Восемь из 20 были из Италии, и лишь 3 рассматривали подростков.
• Гормоны были связаны с лучшим качеством жизни (7 исследований), меньшей депрессией (12 исследований) и меньшей тревогой (8 исследований), но в нескольких исследованиях изменений не было.
• Рецензенты оценили доказательства по качеству жизни, депрессии и тревоге как низкого качества и не смогли сделать вывода о самоубийстве.
• Единственное исследование самоубийств, из амстердамской клиники, показало, что транс-женщины умирали от самоубийства в 5,7 раза чаще, чем в общей популяции. Рецензенты оценили его как имеющее серьёзный риск предвзятости.
• В нидерландской группе подростков депрессия улучшилась на блокаторах пубертата (препаратах, приостанавливающих половое созревание), но после последующих кросс-половых гормонов общее улучшение по сравнению с началом уже не было явным.
• WPATH заказала и частично оплатила обзор, чтобы использовать его в своих руководствах по лечению.
• Судебные документы, опубликованные в 2024 году, говорят, что WPATH добивалась права одобрять статьи команды Хопкинса и что это была единственная статья, опубликованная после введения WPATH этого правила.

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.