Psychosocial Functioning in Transgender Youth after 2 Years of Hormones

Abstract

Background: Limited prospective outcome data exist regarding transgender and nonbinary youth receiving gender-affirming hormones (GAH; testosterone or estradiol).

Methods: We characterized the longitudinal course of psychosocial functioning during the 2 years after GAH initiation in a prospective cohort of transgender and nonbinary youth in the United States. Participants were enrolled in a four-site prospective, observational study of physical and psychosocial outcomes. Participants completed the Transgender Congruence Scale, the Beck Depression Inventory-II, the Revised Children's Manifest Anxiety Scale (Second Edition), and the Positive Affect and Life Satisfaction measures from the NIH (National Institutes of Health) Toolbox Emotion Battery at baseline and at 6, 12, 18, and 24 months after GAH initiation. We used latent growth curve modeling to examine individual trajectories of appearance congruence, depression, anxiety, positive affect, and life satisfaction over a period of 2 years. We also examined how initial levels of and rates of change in appearance congruence correlated with those of each psychosocial outcome.

Results: A total of 315 transgender and nonbinary participants 12 to 20 years of age (mean [±SD], 16±1.9) were enrolled in the study. A total of 190 participants (60.3%) were transmasculine (i.e., persons designated female at birth who identify along the masculine spectrum), 185 (58.7%) were non-Latinx or non-Latine White, and 25 (7.9%) had received previous pubertal suppression treatment. During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms. The most common adverse event was suicidal ideation (in 11 participants [3.5%]); death by suicide occurred in 2 participants.

Conclusions: In this 2-year study involving transgender and nonbinary youth, GAH improved appearance congruence and psychosocial functioning. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development.).

Figure 1.. Appearance Congruence and Depression, Anxiety, Positive Affect, and Life Satisfaction.

Parallel-process latent growth curve models are depicted. A linear latent growth curve model was fitted for each outcome, with model-based estimates of baseline scores (intercept) and rates of linear change over time (slope). Parallel-process models can provide tests of how aspects of trajectories relate to each other. Each panel provides estimates for correlations between baseline scores of appearance congruence and each outcome (intercept correlations, arcs displayed on the left side of each panel), correlations between rate of change of appearance congruence and rate of change of each outcome (slope correlations, arcs displayed on the right side of each panel), and effects of baseline scores on slopes (straight lines in the middle of each panel). Solid black lines and arcs indicate significant effects (confidence intervals for variable estimates do not contain 0); nonsignificant effects are shown with dashed gray lines. All models were controlled for age, designated sex at birth, racial and ethnic identity, and early gender-affirming care (not shown for ease of interpretation).

Figure 2.. Psychosocial Outcomes during 2 Years of GAH.

Shown are changes in participant-reported measures over a period of 2 years of treatment with gender-affirming hormones (GAH). Scores on the Appearance Congruence subscale of the Transgender Congruence Scale (Panel A) range from 1 to 5, with higher scores indicating greater appearance congruence. T scores for the Positive Affect measure from the NIH (National Institutes of Health) Toolbox Emotion Battery (Panel B) range from 0 to 100, with higher scores indicating greater positive affect. T scores for the Life Satisfaction measure from the NIH Toolbox Emotion Battery (Panel C) range from 0 to 100, with higher scores indicating greater life satisfaction. Scores on the Beck Depression Inventory–II (Panel D) range from 0 to 63, with higher scores indicating greater depression. T scores on the Revised Children’s Manifest Anxiety Scale (Second Edition) (Panel D), range from 0 to 100, with higher scores indicating greater anxiety. Individual scores are depicted with orange triangles for youth initiating GAH in early puberty (“Yes”) and with blue circles for youth who did not initiate GAH in early puberty (“No”). Lines indicate mean scores for each group, with gray shaded bands for 95% confidence intervals.