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

• 该综述纳入了22篇论文中的20项研究。只有一项是随机试验；大多数随时间追踪患者群体，四项是一次性的横断面调查。
• 大多数研究的人数少于60人，全部来自专科性别诊所。20项研究中有8项来自意大利，只有3项研究了青少年。
• 激素与更好的生活质量（7项研究）、更少的抑郁（12项研究）和更少的焦虑（8项研究）有关，但有几项研究没有发现变化。
• 评审者将关于生活质量、抑郁和焦虑的证据评为低质量，并且对自杀无法得出结论。
• 唯一的自杀研究来自阿姆斯特丹诊所，发现跨性别女性死于自杀的比率是普通人群的5.7倍。评审者判断它存在严重的偏倚风险。
• 在荷兰青少年组中，使用青春期阻断剂（暂停青春期的药物）期间抑郁有所改善，但在之后使用跨性别激素后，从开始时算起的总体改善就不再明确了。
• WPATH委托并部分资助了这项综述，以便为其治疗指南提供依据。
• 2024年公布的法庭文件表明，WPATH曾寻求批准霍普金斯团队论文的权利，而这是WPATH引入该规则之后发表的唯一一篇论文。

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.