The study, published in the online journal PLOS ONE, suggests transgender youth who receive hormone replacement treatment early on have better mental health outcomes and lower substance abuse in the long run than transgender individuals who wait until adulthood. “Hormone replacement therapy” is a blanket term that covers several different hormone-related treatments, including the use of estrogen to treat female menopause. The type of hormone replacement therapy covered in this study is a treatment that alters a person’s levels of hormones like testosterone and estrogen to better reflect their gender identity.
Timing Matters
Using data from a 2015 survey of over 27,000 US transgender adults, the study was controlled for factors such as participant age at the time of the survey, gender identity, sex assigned at birth, race, and whether the individuals involved went on hormone blockers prior to hormone replacement therapy. Since some trans people don’t want hormone replacement therapy, the researchers focused on the group who did want HRT within the larger survey pool. Results showed that trans people who 1) wanted HRT and 2) got access to it before they turned 18, were less prone to severe psychological distress and suicidal ideation than those who got hormone replacement therapy later or not at all. And the difference between the groups was striking. As stated in the Stanford Medicine press release: “Odds of severe psychological distress were reduced by 222%, 153% and 81% for those who began hormones in early adolescence, late adolescence, and adulthood, respectively. Odds of previous-year suicidal ideation were 135% lower in people who began hormones in early adolescence, 62% lower in those who began in late adolescence, and 21% lower in those who began as adults, compared with the control group.” “In addition, participants who began hormones in early or late adolescence had lower odds of past-month binge drinking and lifetime illicit drug use than those who began hormones in adulthood,” the study stated. Given that transgender people are at much higher risk than the general population of severe mental illness, these findings provide an opportunity to improve the mental health of some trans teens on both a short- and long-term basis.
Barriers to Transition Care
Several major medical associations, including the American Academy of Pediatrics and Endocrine Society, support providing transition-related medical care for minors. Clinicians, though, remain divided over exactly how young kids can receive HRT. The World Professional Organization for Transgender Health (WPATH) an international organization dedicated to transgender care, recently released a new draft version of their formal set of guidelines for transgender adolescent care. While these guidelines advise some caution – therapy for minors prior to receiving hormones, for example, is emphasized—they do state that the provision of transition-related medical care to minors is encouraged. Trans young people who are pre-pubescent can be prescribed puberty blockers in order to “buy time” prior to hormone replacement therapy, allowing them to experience the puberty that aligns with their gender alongside other teens. This can be a more accessible option while teens work towards starting on HRT. HRT does come with some medical risks—a loss of bone density, and a loss of fertility among them—but for many trans teens, it’s life-changing. However, most US state laws make receiving HRT under 18 quite difficult. As 18 is under the age of full consent for most medical procedures, parents must first consent for their child to pursue hormonal treatment. In most states, young people must then go through counseling with a qualified therapist for several months, and then consult with an endocrinologist before beginning hormone replacement therapy. The barriers to receiving transition-related healthcare exist primarily because being transgender is pathologized, and misinformation around care for transgender teens abounds. Several states have introduced bills that would make it a crime for providers to help teens access transition-related care. That would mean that the mental health benefits of HRT would no longer be accessible for transgender teens in those states. Dr. A. Bedient, DO, practices general medicine in South Dakota, a state where multiple anti-trans bills were introduced this year. They serve trans young people in their practice and note that before allowing a minor to start HRT, they make sure that young person begins therapy—and, ideally, their whole family goes to therapy, too. “When it comes to kids, I really do want them to see someone mental-health-wise before we start," Bedient said. “That’s not to gatekeep, that’s just because it’s a big change in their life.” Bedient also makes sure to talk through the risks and complexities of both masculinizing and feminizing hormone therapy with patients—transfeminine teens, for example, have to deal with the responsibility of a slightly more complicated medication regimen, while transmasculine teens need to continue to avoid issues like an unexpected pregnancy while on hormones. “HRT is a big step, and it is a big life change, and it’s not going to magically make everything better for you, which I think some people think it is—you still have to put in the work yourself.” On the whole, though, Bedient says that what they’ve seen in serving as a physician to transgender teens aligns with the PLOS ONE study. “I think HRT makes people a lot more comfortable, and that reflects in the way they interact with the world and other people," they said. As some kids begin their medical transition, they are able to flourish in ways that were never possible for them before. “I wish people could see it…because sometimes, it’s a whole different kid,” Bedient said. “And you could have easily seen this kid walking down the road of depression and suicide…and now they have things to live for.”
Teens Describe the Benefits
Joey Borrelli was one of those teens. Borrelli, who is now 21, went through an arduous process to begin HRT when he was 17. This included months and months of therapy with one of the few trans-affirming therapists he could find in his hometown of St. Louis, Missouri, then multiple consultations with an endocrinologist with a months-long waiting list. However, Borrelli said, once he got the treatment, it allowed him to reach levels of mental and physical wellness that would otherwise have been impossible. “Now, I’m a lot more present in my body, and I’m happy with my body image,” Borrelli said. “I feel like I woke up one day and, I saw me. I’m finally me.” Borrelli says that waiting any longer than he did to begin taking testosterone would have made him a less happy person. “I think that I would be a very different person and…just have suffered a lot more, and been a lot more unhappy if I had to wait until being 18 to have access to what I recognized I needed… to be whole, to achieve the same normal as my peers.” Christine Hyman is the mother of another trans child who was able to access HRT early: her son, Corey, began his testosterone treatment on his 14th birthday. The change in his mental health, Hyman said, is “night and day.” Prior to going on T, Corey attempted suicide, self-isolated from his peers, and had to be withdrawn from school, Hyman said. Now, two years on testosterone, he’s a “comfortable, happy kid,” who advocates for other trans teens regularly in his state legislature. He and his mother — who is a board member of the trans family advocacy group Transparent — work together to explain why access to hormone replacement therapy has been so life-changing for Corey. “He speaks for himself, but also for the kids who can’t,” Hyman said. The WPATH guidelines on transition-related healthcare for minors should be finalized in late spring 2022.
