Video Abstract

Video Abstract

OBJECTIVES:

Our first aim was to examine baseline differences in body dissatisfaction, depression, and anxiety symptoms by gender, age, and Tanner (ie, pubertal) stage. Our second aim was to test for changes in youth symptoms over the first year of receiving gender-affirming hormone therapy. Our third aim was to examine potential differences in change over time by demographic and treatment characteristics. Youth experiences of suicidal ideation, suicide attempt, and nonsuicidal self-injury (NSSI) are also reported.

METHODS:

Participants (n = 148; ages 9–18 years; mean age 14.9 years) were receiving gender-affirming hormone therapy at a multidisciplinary program in Dallas, Texas (n = 25 puberty suppression only; n = 123 feminizing or masculinizing hormone therapy). Participants completed surveys assessing body dissatisfaction (Body Image Scale), depression (Quick Inventory of Depressive Symptoms), and anxiety (Screen for Child Anxiety Related Emotional Disorders) at initial presentation to the clinic and at follow-up. Clinicians completed the Quick Inventory of Depressive Symptoms and collected information on youth experiences of suicidal ideation, suicide attempt, and NSSI.

RESULTS:

Affirmed males reported greater depression and anxiety at baseline, but these differences were small (P < .01). Youth reported large improvements in body dissatisfaction (P < .001), small to moderate improvements in self-report of depressive symptoms (P < .001), and small improvements in total anxiety symptoms (P < .01). No demographic or treatment-related characteristics were associated with change over time. Lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively.

CONCLUSIONS:

Results provide further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction. Modest initial improvements in mental health were also evident.

What’s Known on This Subject:

Guidelines exist for providing gender-affirming hormone therapy (ie, puberty suppression and masculinizing or feminizing hormone therapy) to transgender youth; however, little research has been conducted on the impact of treatment on body dissatisfaction and mental health and factors that may influence this impact.

What This Study Adds:

One year of receiving gender-affirming hormone therapy resulted in large reductions in youth body dissatisfaction and modest improvements in mental health. No demographic or treatment-related factors were associated with change over time.

Two influential longitudinal studies from the Netherlands have helped establish guidelines for providing gender-affirming hormone therapy (ie, puberty suppression and masculinizing or feminizing hormone therapy) to transgender youth with gender dysphoria.1,2  De Vries et al3  conducted a prospective study with 70 youth who received puberty suppression (ie, medication to stop the progression of puberty). After 2 years, internalizing, externalizing, and depressive symptoms improved along with global functioning, but there was no improvement in body dissatisfaction or anxiety symptoms. A subset of the same cohort (n = 55) was reassessed after masculinizing or feminizing hormone therapy and gender-affirming surgery (vaginoplasty or mastectomy and hysterectomy), at which point there was a sustained improvement in global functioning and most measures of mental health. Gender dysphoria and body dissatisfaction also improved, and self-reported quality of life was similar to the Dutch population.4  However, patients were not evaluated after masculinizing or feminizing hormone therapy alone.

In the only other longitudinal study of youth, participants seen in a gender clinic in the United Kingdom (n = 35) demonstrated improvement in clinician assessment of psychosocial functioning after 12 months of receiving puberty suppression.5  Only 1 cross-sectional study has included a subset of transgender youth (n = 82 of 202). In comparison with those who had not started treatment, individuals who received both puberty suppression and/or masculinizing or feminizing hormone therapy as well as surgery had more favorable body image but not those who received puberty suppression and/or masculinizing or feminizing hormone therapy only.6  Within this study, youth and adults as well as those receiving puberty suppression and/or masculinizing or feminizing hormone therapy were combined.

The benefits of gender-affirming treatment are better described in adults. A recent review of 5 longitudinal and 2 cross-sectional studies found that receipt of masculinizing or feminizing hormone therapy alone was associated with improved depression in 5 of 7 studies, improved anxiety in 2 of 2 studies, and better quality of life in 3 of 3 studies.7  Two studies also found lower rates of body uneasiness in adults who received masculinizing or feminizing hormone therapy alone (ie, dissatisfaction with body parts and negative body-related experiences, such as avoidance and self-monitoring).8,9 

Understanding the impact of gender-affirming hormone therapy on the mental health of transgender youth is critical given the health disparities documented in this population. Within samples of transgender youth presenting for gender-affirming hormone therapy, estimates of clinically significant depressive symptoms or diagnoses have averaged in the range of 30% to 60%,1013  and estimates of clinically significant anxiety symptoms or diagnoses have averaged in the range of 20% to 30%.11,1416  Lifetime history of suicidal ideation (average range 30%–50%),10,11,16  suicide attempt (average range 15%–30%),10,11,13  and nonsuicidal self-injury (NSSI) (average range 20%–40%)12,13,16  also appear common.

There is also some evidence that rates of mental health concerns may vary by gender, but no clear pattern has emerged.11,14,15,17  Two studies have found higher levels of body dissatisfaction among affirmed females (ie, individuals assigned male at birth who identify as female) in comparison with affirmed males (ie, individuals assigned female at birth who identify as male).6,18  Changes associated with puberty, as reflected in age and/or Tanner stage (ie, stage of puberty), may exacerbate body dissatisfaction and mental health concerns. Fewer studies have examined differences by age; however, one study found greater symptoms of depression but not anxiety among older adolescents,16  and one study found higher levels of body dissatisfaction.4  None have specifically examined the impact of Tanner stage.

Our first aim in this study was to explore how transgender youth baseline body dissatisfaction, depression, and anxiety symptoms vary on the basis of their gender, age at initial assessment, and Tanner stage at first medical visit. Consistent with our earlier article examining differences in mental health functioning using the Child Behavior Checklist and Youth Self-Report,14  we hypothesized that affirmed males will report greater symptoms of depression and anxiety. We also hypothesized that older age and greater Tanner stage will be associated with higher ratings of body dissatisfaction and more symptoms of depression and anxiety.

Our second aim was to examine how transgender youth body dissatisfaction, depression, and anxiety symptoms change over the first year of receiving gender-affirming hormone therapy. We anticipated improvements in each of these domains but did not have any a priori hypotheses regarding which domains would demonstrate the greatest improvements.

Our third aim was to explore how any changes over time vary by affirmed gender, Tanner stage, age, type of treatment, months on masculinizing or feminizing hormone therapy, mental health treatment received, and whether chest (ie, “top”) surgery was also obtained (among those assigned female at birth). We hypothesized that older age, greater Tanner stage, receipt of puberty suppression only, fewer months on masculinizing or feminizing hormone therapy, and lack of chest surgery will be associated with fewer changes over time. Lastly, for descriptive purposes, we report information on lifetime and follow-up rates of suicidal ideation, suicide attempts, NSSI, and mental health treatment.

Participants are youth who received gender-affirming hormone therapy with a multidisciplinary program in Dallas, Texas. Before initiating care, participants and their families participated in an initial assessment with the program’s psychologist, psychiatrist, and/or clinical therapist after parents completed a phone intake survey and provided a referral letter from a licensed therapist or counselor documenting the presence of gender dysphoria (this letter is no longer required). Approximately 34% of families did not follow-up after the phone intake. Initial assessments occurred between August 2014 and March 2018, with most occurring in 2017 (41%) or 2016 (37%). At home before this visit, participants completed self-report measures of depression, anxiety, and body dissatisfaction. During the visit, clinicians also completed a report of depressive symptoms and collected information regarding lifetime and recent suicidal ideation, suicide attempts, and NSSI as well as current participation in therapy and support groups and use of psychiatric medication(s).

After the assessment, participants were discussed by the multidisciplinary team of providers from psychology, social work, pediatric endocrinology, pediatric and adolescent gynecology, and adolescent medicine. The Endocrine Society Clinical Practice Guidelines2  guided the initiation of hormone therapy. Chest surgery was not performed within the program, but participants were provided with referrals when requested.

Approximately 1 year after this initial assessment (range: 11–18 months), all patients were asked to participate in a yearly reassessment visit. Participants were readministered self-report measures, and clinicians again completed a report of depressive symptoms and documented information about suicidal ideation, suicide attempts, NSSI, and mental health treatment.

Survey and clinician data were entered into a research database for analysis along with demographic and treatment-related information (ie, Tanner stage at first medical visit, treatment start and end dates, and chest surgery date extracted from physicians’ notes). All participants provided consent, or assent with parent consent, to allow this information to be used for research. The study was approved by the institutional review board at the University of Texas Southwestern Medical Center.

Participants were asked to self-report their gender identity (all ages) and sexual orientation (age 12 and older). These responses were recorded verbatim by the clinician and entered into the research database. Gender identities were coded into the following categories: (1) male, boy, or man; (2) male spectrum (eg, “trans masculine” or “masculine nonbinary”); (3) female, girl, or woman; (4) female spectrum (eg, “mostly female, slightly nonbinary”); and (5) nonbinary (eg, “agender” or “part girl, part boy”).

To assess body dissatisfaction, participants aged 12 years and older rated their degree of dissatisfaction with 29 areas of the body using the Body Image Scale (BIS).19  Participants of all ages completed the Screen for Child Anxiety Related Emotional Disorders (SCARED), which produces a total score as well as subscale scores for panic-related, social, separation-related, generalized, and school avoidance–related anxiety symptoms,20  as well as the Quick Inventory of Depressive Symptoms (QIDS)21  to measure symptoms of depression that reflect the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for major depressive disorder.22  The QIDS produces a total score that can also be grouped into clinical categories: not elevated (0–5), mild (6–10), moderate (11–15), and severe (16–27). Clinicians also completed the clinician version of the QIDS. When the percentage of missing values for each total score and subscale score was ≤15%, missing values were imputed by using the mean of nonmissing values.

To examine baseline differences in depression (QIDS self and clinician), anxiety (SCARED), and body dissatisfaction (BIS), bivariate correlation coefficients were first examined by using Pearson’s r for age, Spearman’s ρ for Tanner stage, and point biserial for gender. Variables with significant correlations were then simultaneously entered into a linear regression for each outcome, and Cohen’s f2 was calculated as a measure of effect size (0.1 = small, 0.25 = moderate, and 0.4 = large).23 

To examine change over time, QIDS (self and clinician), SCARED, and BIS scores were first tested for normality by using the Kolmogorov-Smirnov test. Changes in normally distributed variables were examined by using paired t tests, and the Wilcoxon rank test was used when the Kolmogorov-Smirnov value was significant. Cohen’s d was used as a measure of effect size (0.2 = small, 0.5 = moderate, and 0.8 = large).23  Changes in clinical groupings on the QIDS were also examined by using the Wilcoxon rank test. For both baseline and longitudinal analyses, we planned to first examine the SCARED total score then test for differences in subscale scores only if this change was significant.

To test for associations between change scores and demographic and treatment characteristics, change scores were calculated by subtracting baseline scores from follow-up scores for variables that exhibited a significant change over time. Bivariate correlation coefficients were then examined by using Pearson’s r for age and months on feminizing or masculinizing hormone therapy, Spearman’s ρ for Tanner stage and therapy frequency, and point biserial for gender, treatment type, psychiatric medication use, support group participation, and chest surgery receipt (for those assigned female at birth). We planned to include any variables with significant correlations in a linear regression. P < .01 was significant for all statistical tests to help account for the overall number of tests. Confidence intervals (CIs) are reported at the 95% level.

Figure 1 presents a flow diagram of participants who were due for follow-up (≥18 months since initial assessment), participants with follow-up data, and the reasons why follow-up data were not available or excluded. The mean number of months between initial assessment and reassessments was 14.9 (SD 2.1). Table 1 presents demographic information on participants. At the initial assessment, patients ranged in age from 9 to 18 years (mean 15.4; SD 2.0). All but 1 participant met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria for gender dysphoria. This participant subsequently met criteria at a follow-up visit and was started on treatment. Participants who started puberty suppression only did so at a mean age of 13.7 years (range 9.8–14.9; SD 1.5), and participants started feminizing or masculinizing hormone therapy at a mean age of 16.2 years (range 13.2–18.6; SD 1.2). For participants who were on masculinizing or feminizing hormone therapy, the mean length of time receiving treatment before follow-up was 10.9 months (range 1–18; SD 3.3). During the follow-up period, 2 participants stopped puberty suppression without starting masculinizing or feminizing hormone therapy, and no participants stopped masculinizing or feminizing hormone therapy. Fifteen affirmed males obtained chest surgery at an average age of 17.1 years (range 15.2–18.7; SD 1.2) and at an average of 9.2 months from baseline (range 3.0–16.0; SD 3.3).

FIGURE 1

Flow diagram.

FIGURE 1

Flow diagram.

TABLE 1

Participant Demographics

n (%)
Gender identity  
 Male, boy, or guy 81 (55) 
 Male spectrum 9 (6) 
 Female, girl, or woman 52 (35) 
 Female spectrum 2 (1) 
 Something elsea 3 (2) 
Assigned sex  
 Male 55 (37) 
 Female 94 (63) 
Sexual orientationb  
 Pansexual 25 (20) 
 Straight 24 (19) 
 Bisexual 15 (12) 
 Gay 12 (10) 
 Unsure 12 (10) 
 No label 11 (9) 
 Asexual 10 (8) 
 Something else 10 (8) 
 Lesbian 6 (5) 
Race  
 White 137 (95) 
 African American 3 (2) 
 Multiracial 3 (2) 
 American Indian 1 (1) 
Ethnicity  
 Hispanic 24 (17) 
 Non-Hispanic 120 (83) 
Tanner stage  
 I 3 (2) 
 II 6 (4) 
 III 5 (4) 
 IV 32 (23) 
 V 94 (67) 
Treatment typec  
 Puberty suppression only 25 (17) 
 Masculinizing or femininizing therapy only 93 (63) 
 Both treatments 30 (20) 
n (%)
Gender identity  
 Male, boy, or guy 81 (55) 
 Male spectrum 9 (6) 
 Female, girl, or woman 52 (35) 
 Female spectrum 2 (1) 
 Something elsea 3 (2) 
Assigned sex  
 Male 55 (37) 
 Female 94 (63) 
Sexual orientationb  
 Pansexual 25 (20) 
 Straight 24 (19) 
 Bisexual 15 (12) 
 Gay 12 (10) 
 Unsure 12 (10) 
 No label 11 (9) 
 Asexual 10 (8) 
 Something else 10 (8) 
 Lesbian 6 (5) 
Race  
 White 137 (95) 
 African American 3 (2) 
 Multiracial 3 (2) 
 American Indian 1 (1) 
Ethnicity  
 Hispanic 24 (17) 
 Non-Hispanic 120 (83) 
Tanner stage  
 I 3 (2) 
 II 6 (4) 
 III 5 (4) 
 IV 32 (23) 
 V 94 (67) 
Treatment typec  
 Puberty suppression only 25 (17) 
 Masculinizing or femininizing therapy only 93 (63) 
 Both treatments 30 (20) 
a

Excluded from gender analyses.

b

Age 12 and older.

c

Masculinizing or feminizing therapy only and both treatments were collapsed for analysis by treatment type.

Table 2 presents means, SDs, and ranges for QIDS, SCARED, and BIS scores at initial assessment and follow-up for the full sample as well as by gender and treatment type. At baseline, affirmed males had greater clinician-reported depressive symptoms (CI −3.76 to −0.81), self-reported depressive symptoms (CI −4.46 to −0.79), total anxiety symptoms (CI −14.94 to −3.99), panic symptoms (CI −5.88 to −1.78), and school avoidance symptoms (CI −1.81, to −0.36) in comparison with affirmed females. However, Cohen’s f2 effect sizes were all in the small range (0.07, 0.06, 0.09, 0.10, and 0.07, respectively). No differences were found by age or Tanner stage.

TABLE 2

Body Dissatisfaction, Depression, and Anxiety Symptoms at Baseline and Follow-up

nRangeaBaseline, Mean (SD)Follow-up, Mean (SD)
Body dissatisfaction (BIS)  0–116   
 Full sampleb 96  69.9 (15.6) 51.7 (18.4) 
 Affirmed males 66  71.1 (13.4) 52.9 (16.8) 
 Affirmed females 30  67.5 (19.5) 49.0 (21.6) 
 Puberty suppression 10  64.1 (18.2) 53.8 (20.1) 
 Feminine or masculine hormone therapy 86  70.7 (15.2) 51.4 (18.3) 
Depressive symptoms (QIDS), self reportc  0–27   
 Full sampleb 118  9.4 (5.2) 7.3 (4.6) 
 Affirmed males 76  10.4 (5.0) 7.5 (4.5) 
 Affirmed females 40  7.5 (4.9) 6.6 (4.4) 
 Puberty suppression 13  8.2 (6.1) 7.0 (5.6) 
 Feminine or masculine hormone therapy 105  9.6 (5.0) 7.4 (4.5) 
Depressive symptoms (QIDS), clinician reportc  0–27   
 Full sample 125  5.8 (4.2) 5.9 (3.9) 
 Affirmed males 78  6.7 (4.4) 6.2 (4.1) 
 Affirmed females 45  4.2 (3.2) 5.4 (3.4) 
 Puberty suppression 19  5.3 (4.9) 5.5 (4.8) 
 Feminine or masculine hormone therapy 106  5.9 (4.1) 6.0 (3.8) 
Anxiety symptoms (SCARED), total scorec  0–82   
 Full sampled 102  32.4 (16.3) 28.6 (16.1) 
 Affirmed males 65  35.4 (16.5) 29.8 (15.5) 
 Affirmed females 33  26.4 (14.2) 24.3 (15.4) 
 Puberty suppression 22  31.8 (16.6) 29.3 (17.1) 
 Feminine or masculine hormone therapy 80  32.6 (16.3) 28.4 (15.9) 
Panic symptoms (SCARED)c  0–26   
 Full sample 104  8.2 (6.3) 7.1 (6.3) 
 Affirmed males 66  9.3 (6.5) 7.9 (6.5) 
 Affirmed females 34  5.7 (4.9) 5.1 (4.9) 
 Puberty suppression 22  8.7 (6.5) 7.2 (5.7) 
 Feminine or masculine hormone therapy 82  8.1 (6.3) 7.1 (6.5) 
Generalized anxiety symptoms (SCARED)  0–18   
 Full sample 104  9.7 (5.1) 8.7 (5.1) 
 Affirmed males 66  10.4 (5.0) 9.0 (5.1) 
 Affirmed females 34  8.6 (5.1) 8.0 (5.1) 
 Puberty suppression 22  8.5 (5.2) 8.2 (5.4) 
 Feminine or masculine hormone therapy 82  10.0 (5.1) 8.8 (5.0) 
Social anxiety symptoms (SCARED)  0–14   
 Full sample 104  8.0 (4.1) 7.6 (4.3) 
 Affirmed males 66  8.5 (4.0) 7.8 (4.1) 
 Affirmed females 34  7.1 (3.9) 6.8 (4.4) 
 Puberty suppression 22  6.3 (3.6) 7.3 (4.7) 
 Feminine or masculine hormone therapy 82  8.5 (4.1) 7.7 (4.2) 
Separation anxiety symptoms (SCARED)e  0–16   
 Full sample 103  4.0 (3.4) 3.3 (2.7) 
 Affirmed males 65  4.2 (3.4) 3.4 (2.6) 
 Affirmed females 34  3.4 (3.3) 2.7 (2.3) 
 Puberty suppression 22  5.8 (4.0) 4.2 (3.1) 
 Feminine or masculine hormone therapy 81  3.5 (3.0) 3.1 (2.5) 
School avoidance symptoms (SCARED)c  0–8   
 Full sample 102  2.6 (2.2) 2.0 (2.1) 
 Affirmed males 65  2.9 (2.3) 2.0 (2.3) 
 Affirmed females 33  1.8 (1.7) 1.9 (2.1) 
 Puberty suppression 22  2.6 (2.7) 2.4 (2.4) 
 Feminine or masculine hormone therapy 80  2.6 (2.1) 2.0 (2.0) 
nRangeaBaseline, Mean (SD)Follow-up, Mean (SD)
Body dissatisfaction (BIS)  0–116   
 Full sampleb 96  69.9 (15.6) 51.7 (18.4) 
 Affirmed males 66  71.1 (13.4) 52.9 (16.8) 
 Affirmed females 30  67.5 (19.5) 49.0 (21.6) 
 Puberty suppression 10  64.1 (18.2) 53.8 (20.1) 
 Feminine or masculine hormone therapy 86  70.7 (15.2) 51.4 (18.3) 
Depressive symptoms (QIDS), self reportc  0–27   
 Full sampleb 118  9.4 (5.2) 7.3 (4.6) 
 Affirmed males 76  10.4 (5.0) 7.5 (4.5) 
 Affirmed females 40  7.5 (4.9) 6.6 (4.4) 
 Puberty suppression 13  8.2 (6.1) 7.0 (5.6) 
 Feminine or masculine hormone therapy 105  9.6 (5.0) 7.4 (4.5) 
Depressive symptoms (QIDS), clinician reportc  0–27   
 Full sample 125  5.8 (4.2) 5.9 (3.9) 
 Affirmed males 78  6.7 (4.4) 6.2 (4.1) 
 Affirmed females 45  4.2 (3.2) 5.4 (3.4) 
 Puberty suppression 19  5.3 (4.9) 5.5 (4.8) 
 Feminine or masculine hormone therapy 106  5.9 (4.1) 6.0 (3.8) 
Anxiety symptoms (SCARED), total scorec  0–82   
 Full sampled 102  32.4 (16.3) 28.6 (16.1) 
 Affirmed males 65  35.4 (16.5) 29.8 (15.5) 
 Affirmed females 33  26.4 (14.2) 24.3 (15.4) 
 Puberty suppression 22  31.8 (16.6) 29.3 (17.1) 
 Feminine or masculine hormone therapy 80  32.6 (16.3) 28.4 (15.9) 
Panic symptoms (SCARED)c  0–26   
 Full sample 104  8.2 (6.3) 7.1 (6.3) 
 Affirmed males 66  9.3 (6.5) 7.9 (6.5) 
 Affirmed females 34  5.7 (4.9) 5.1 (4.9) 
 Puberty suppression 22  8.7 (6.5) 7.2 (5.7) 
 Feminine or masculine hormone therapy 82  8.1 (6.3) 7.1 (6.5) 
Generalized anxiety symptoms (SCARED)  0–18   
 Full sample 104  9.7 (5.1) 8.7 (5.1) 
 Affirmed males 66  10.4 (5.0) 9.0 (5.1) 
 Affirmed females 34  8.6 (5.1) 8.0 (5.1) 
 Puberty suppression 22  8.5 (5.2) 8.2 (5.4) 
 Feminine or masculine hormone therapy 82  10.0 (5.1) 8.8 (5.0) 
Social anxiety symptoms (SCARED)  0–14   
 Full sample 104  8.0 (4.1) 7.6 (4.3) 
 Affirmed males 66  8.5 (4.0) 7.8 (4.1) 
 Affirmed females 34  7.1 (3.9) 6.8 (4.4) 
 Puberty suppression 22  6.3 (3.6) 7.3 (4.7) 
 Feminine or masculine hormone therapy 82  8.5 (4.1) 7.7 (4.2) 
Separation anxiety symptoms (SCARED)e  0–16   
 Full sample 103  4.0 (3.4) 3.3 (2.7) 
 Affirmed males 65  4.2 (3.4) 3.4 (2.6) 
 Affirmed females 34  3.4 (3.3) 2.7 (2.3) 
 Puberty suppression 22  5.8 (4.0) 4.2 (3.1) 
 Feminine or masculine hormone therapy 81  3.5 (3.0) 3.1 (2.5) 
School avoidance symptoms (SCARED)c  0–8   
 Full sample 102  2.6 (2.2) 2.0 (2.1) 
 Affirmed males 65  2.9 (2.3) 2.0 (2.3) 
 Affirmed females 33  1.8 (1.7) 1.9 (2.1) 
 Puberty suppression 22  2.6 (2.7) 2.4 (2.4) 
 Feminine or masculine hormone therapy 80  2.6 (2.1) 2.0 (2.0) 
a

Absolute range.

b

Significant change from initial assessment to follow-up (P < .001).

c

Significant difference in baseline scores by gender (P < .01).

d

Significant change from initial assessment to follow-up (P < .01).

e

Significant difference in baseline scores by age (P < .01).

Within the full sample, a significant decrease in body dissatisfaction (CI 14.74 to 21.90), self-reported depressive symptoms (CI 1.24 to 2.97), and total anxiety symptoms (CI 1.05 to 6.70) was observed during the follow-up period. Decreases in generalized, separation, and school-related anxiety symptoms were significant at the P < .05 level but not the P < .01 level. No change in clinician report of depressive symptoms was found. Cohen’s d effect sizes were large for change in BIS scores (1.04), small to moderate for change in QIDS self-report scores (0.44), and small for change in SCARED total scores (0.27). Table 3 reports the percentage of the sample that fell into each clinical category on the QIDS at initial assessment and follow-up. A significant change was also found in self-reported depressive symptom categories (P < .001) but not clinician-reported categories. No correlations were found between change scores and demographic and treatment-related characteristics. Although change scores were generally higher for participants who received chest surgery, no correlations were significant.

TABLE 3

Depressive Symptoms (QIDS) Scoring Ranges

RangeSelf-ReportaClinician Report
Baseline, N (%)Follow-up, N (%)Baseline, N (%)Follow-up, N (%)
Not elevated 0–5 33 (25) 51 (40) 73 (53) 67 (49) 
Mild 6–10 46 (35) 48 (37) 44 (32) 49 (36) 
Moderate 11–15 29 (22) 22 (17) 15 (11) 16 (12) 
Severe 16–27 24 (18) 8 (6) 5 (4) 4 (3) 
RangeSelf-ReportaClinician Report
Baseline, N (%)Follow-up, N (%)Baseline, N (%)Follow-up, N (%)
Not elevated 0–5 33 (25) 51 (40) 73 (53) 67 (49) 
Mild 6–10 46 (35) 48 (37) 44 (32) 49 (36) 
Moderate 11–15 29 (22) 22 (17) 15 (11) 16 (12) 
Severe 16–27 24 (18) 8 (6) 5 (4) 4 (3) 
a

Significant change from initial assessment to follow-up (P < .001).

Table 4 presents descriptive data on mental health treatment, and Table 5 presents data on suicidal ideation, suicide attempt, and NSSI. During the follow-up period, the distribution of therapy frequency was as follows: none (16%), less than every 3 months (15%), every 2 to 3 months (12%), monthly (22%), every other week (21%), and weekly (14%). Of those who experienced suicidal ideation during the follow-up period, 94% had a lifetime history. These figures were 67% for suicide attempt and 87% for NSSI.

TABLE 4

Mental Health Treatment

At Initial Assessment, n (%)Follow-up Period, n (%)
Psychiatric medication 67 (47) 80 (61) 
Therapist or counselor 144 (97) 114 (84) 
Support groupa 60 (43) 45 (35) 
At Initial Assessment, n (%)Follow-up Period, n (%)
Psychiatric medication 67 (47) 80 (61) 
Therapist or counselor 144 (97) 114 (84) 
Support groupa 60 (43) 45 (35) 
a

Participation by parents and/or youth (eg, transgender family support organization; lesbian, gay, bisexual, and transgender youth center; or school-based Gay-Straight Alliance).

TABLE 5

Suicidal Ideation, Suicide Attempt, and NSSI

Lifetime, n (%)1–3 mo Before Initial Assessment,an (%)Follow-up Period, n (%)
Passive ideation 105 (81) 33 (25) 51 (38) 
Suicide attempt 20 (15) 3 (2) 6 (5) 
NSSI 68 (52) 13 (10) 23 (17) 
Lifetime, n (%)1–3 mo Before Initial Assessment,an (%)Follow-up Period, n (%)
Passive ideation 105 (81) 33 (25) 51 (38) 
Suicide attempt 20 (15) 3 (2) 6 (5) 
NSSI 68 (52) 13 (10) 23 (17) 
a

One month for passive ideation and 3 months for NSSI and suicide attempt(s).

Youth reported large improvements in body dissatisfaction during the 1-year follow-up period. The amount of improvement was not related to treatment type. These findings are consistent with a handful of studies that have documented improvements in body dissatisfaction within samples of adults receiving feminizing or masculinizing hormone therapy8,9  but contrast with the 2 existing studies of youth. Within the longitudinal cohort from Amsterdam, puberty suppression alone was not associated with improvements in body dissatisfaction,3  and within a cross-sectional study with a mixed sample of youth and adults, puberty suppression and/or feminizing or masculinizing hormone therapy was not associated with more favorable body image.6  In contrast to the Amsterdam sample, youth in the current study were younger when starting puberty suppression (age: mean 12.5 and range 9.8–14.9 versus mean 13.7 and range 11.1–17.0).

Age, puberty stage, length of time receiving feminizing or masculinizing hormone therapy, and receipt of chest surgery were also not associated with amount of improvement. However, the sample size of participants receiving puberty suppression only and chest surgery were small, and variations in months on feminizing or masculinizing hormone therapy may not have been meaningful enough in the relatively short follow-up period. Most participants (90%) were also in advanced stages of puberty (Tanner stage IV or V) when presenting for care. Limitations associated with collecting data within a busy clinical setting with multiple providers also resulted in missing data. Nonetheless, results suggest that youth receiving gender-affirming hormone therapy experience meaningful short-term improvements in body dissatisfaction, and no participants discontinued feminizing or masculinizing hormone therapy. These results provide additional support for the incorporation of these treatments into the standards of care for transgender youth experiencing gender dysphoria.1,2 

Youth also reported modest improvements in mental health functioning during the follow-up period. These results are consistent with the existing longitudinal studies of youth.35  Several factors may help explain why improvements were not greater than what was observed. Although physical changes associated with feminizing or masculinizing hormone therapy often start within the first 3 months, changes continue over the course of several years. Furthermore, environmental stressors associated with one’s transgender status may not improve after hormone therapy and could potentially worsen should they increase the youth’s visibility as a transgender person. Research has consistently documented higher rates of bullying among transgender youth in comparison with nontransgender youth.24,25  Within the current study, rates of school avoidance–related anxiety did not improve over the follow-up period.

The larger political context is also important to consider. Within Texas, where the current study was conducted, a well-publicized “bathroom bill” was introduced during the study period that prohibited transgender people from using a restroom that was different from the sex on their birth certificate, although the bill ultimately failed to pass.26  As a whole, the mental health functioning of youth from the present clinic as well as youth from a handful of other US- and European-based clinics appears poorer than the mental health functioning of youth from the Amsterdam clinic.11,14,17  Previous studies have attributed this difference to Amsterdam’s social and political climate, which is known to be more supportive of the lesbian, gay, bisexual, and transgender population.17 

Consistent with our study examining baseline differences in mental health functioning as measured by the Child Behavior Checklist and Youth Self-Report,14  affirmed males reported greater symptoms of depression and several forms of anxiety in comparison with affirmed females. However, the effect size of these differences was smaller within the current study in comparison with the former. Differences in measurement approach may help explain the mixed findings regarding gender differences in mental health functioning across youth clinics.11,15,17  Although some research suggests that nonclinic samples of affirmed male youth report more experiences of bullying,24  affirmed females are thought to experience greater stigma regarding expression of femininity. Consistent with the current sample, the sex ratio of youth presenting to clinics also appears to be shifting from more affirmed females to more affirmed males presenting for care.27  Although causes of this shift are largely unknown, they may be associated with other shifts in clinical presentations (eg, mental health and psychosocial functioning).

The current study is the largest longitudinal study of youth receiving gender-affirming hormone therapy to date and documents important improvements in body dissatisfaction over the first year of treatment. Continued longitudinal study of this population will increase the field’s understanding of the benefits of gender-affirming hormone therapy and assist providers in better anticipating needs. Follow-up periods of several years or more will help document the full impact of the physical changes with feminizing or masculinizing hormone therapy, and larger sample sizes will improve the ability to examine the specific impacts of treatment type and chest surgery. Greater consideration of intersectionality and sociocultural context will further strengthen these efforts.

Rong Huang, MS, provided consultation on the data analysis.

Dr Kuper oversaw data collection, conducted data analysis, and drafted the manuscript; Drs Stewart, Lau, and Lopez conceptualized and designed the study and provided feedback on manuscript drafts; Dr Preston assisted with drafting the manuscript; and all authors contributed to the development of study aims, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.

FUNDING: Research reported in this publication was supported by Children’s Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of Children’s Health. The Research Electronic Data Capture database was funded by the Clinical and Translational Science Awards program National Insitutes of Health grant UL1-RR024982 awarded to the UT Southwestern Center For Translational Medicine.

     
  • BIS

    Body Image Scale

  •  
  • CI

    confidence interval

  •  
  • NSSI

    nonsuicidal self-injury

  •  
  • QIDS

    Quick Inventory of Depressive Symptoms

  •  
  • SCARED

    Screen for Child Anxiety Related Emotional Disorders

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Lopez has participated as a member of an advisory board for Endo International; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.