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

• 回顧納入 22 篇論文中的 20 項研究。只有一項是隨機試驗；多數隨著時間追蹤患者群體，四項是單一時間點的快照。
• 多數研究少於 60 人，全來自專科性別門診。20 項中有八項來自義大利，只有 3 項看了青少年。
• 荷爾蒙與較好的生活品質（7 項研究）、較少的憂鬱（12 項研究）和較少的焦慮（8 項研究）有關，但有數項研究發現沒有變化。
• 回顧者將生活品質、憂鬱和焦慮的證據評為低品質，並且對自殺無法得出結論。
• 唯一的自殺研究來自阿姆斯特丹門診，發現跨性別女性的自殺死亡率是一般人口的 5.7 倍。回顧者判定它有嚴重的偏誤風險。
• 在荷蘭的青少年組中，使用青春期阻斷劑（暫停青春期的藥物）期間憂鬱有所改善，但在之後使用跨性別荷爾蒙後，與起始時相比的整體改善就不再明確。
• WPATH 為其治療指引委託並部分出資這項回顧。
• 2024 年公開的法庭文件顯示，WPATH 曾尋求核准霍普金斯團隊論文的權利，而這是 WPATH 實施該規定後唯一發表的論文。

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.