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Introduction to Hormone Therapy

For some trans, Two-Spirit, and nonbinary (TTNB) young people, hormone therapy is an important part of their gender-affirming care plan. Hormone therapy refers to the prescription of medications, such as testosterone and estrogen, to help a person align their body with their gender, as a treatment for gender incongruence.1–3 Hormone therapy produces changes in the body associated with secondary sex characteristics, such as facial hair or breast growth.1–3 Hormone therapy may be taken in various forms, including by injection, topical gel, patch, and oral medications. Doses and length of treatment are based on a person’s gender health goals, their response to treatment, and their healthcare provider’s recommendations. Gender health means living in the gender that feels most real or comfortable, and freely expressing that gender.4

Research about Hormone Therapy for TTNB Youth

The following section summarizes research findings showing that gender-affirming hormone therapy can improve TTNB youth wellbeing, is effective, and can be prescribed safely to TTNB youth.

Gender-affirming hormone therapy improves TTNB youth well-being  

TTNB youth who access hormone therapy have improved mental health. Gender-affirming hormone therapy can provide relief from gender-related distress as a person’s body becomes more aligned with their gender. TTNB youth taking hormone therapy report lower anxiety, depression, and suicidality.5–7

TTNB youth also have improved overall well-being and life satisfaction. Not only can mental health concerns improve with hormone therapy, but overall well-being can also improve. In a longitudinal study, TTNB youth who had accessed puberty blockers, hormone therapy, and gender-affirming surgery reported quality of life, life satisfaction, and happiness similar to peers of the same age in the general population.6 Recent research confirms improved life satisfaction among TTNB youth who receive hormone therapy.5

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Hormone therapy is effective

Hormone therapy is effective in helping people meet their gender health goals. Some TTNB youth who experience gender-related distress access hormone therapy to make changes to their bodies. Hormone therapy is reliably used to address gender health/embodiment goals such as changing body fat distribution, body hair, and muscle mass.1–3

Testosterone is effective in producing changes that support some TTNB youth to live more fully in their gender. Testosterone therapies can increase muscle mass in the body, increase facial and body hair growth, stop menstrual periods, and lower the voice.2,3 These and other effects of testosterone develop slowly and vary according to the dose taken, length of time taking the medication, and the genetics and metabolics of the person taking the medication.

Estrogen, sometimes prescribed in combination with other medications (testosterone blockers/anti-androgens), also supports some TTNB youth in reaching gender goals. Estrogen therapies can slow facial and body hair growth, shift body fat, make skin softer, and cause breasts to grow.1–3 These and other effects of estrogen develop slowly and vary according to the dose taken, length of time a person takes the medication, and the genetics and metabolics of the person taking the medication.

Hormone therapy is prescribed safely for TTNB youth

Research shows the risks of hormone therapy are low. For TTNB youth who opt to receive gender-affirming hormone therapy as part of their care, the benefits generally outweigh the risks.8–10 Research with TTNB youth taking hormone therapy shows that liver function, kidney function, cholesterol and blood pressure typically do not change. If there are changes, these usually stay in normal ranges for the person’s experienced gender.1,11–17 Similar to sex hormones produced by the body, hormone therapy supports the development of strong bones during puberty.11

As with all medications, there may be side effects. Medications, including gender-affirming hormone therapy, are prescribed when their expected benefits outweigh potential side effects.2,9,18 Care planning for hormone therapy should include discussion of possible side effects and ways to manage them. 2,9,18 Options for managing side effects may include changing the way the medication is delivered or how often it is taken.9

Youth can talk with a healthcare provider about whether hormone therapy is right for them. Topics to discuss include benefits, risks, and preventative care. For TTNB youth who proceed with  gender-affirming hormone therapy, the benefits generally outweigh the risks. However, youth and healthcare providers should discuss personal health history, family history, individual risks, and any recommended preventative care.9,18 For example, youth considering taking hormone therapy should discuss potential effects of hormone therapy on fertility with their healthcare provider.9

Gender-Affirming Hormone Therapy

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References

  1. Hannema SE, Schagen SEE, Cohen-Kettenis PT, Delemarre-van de Waal HA. Efficacy and Safety of Pubertal Induction Using 17beta-Estradiol in Transgirls. The Journal of clinical endocrinology and metabolism. 2017;102(7):2356-2363. doi:10.1210/jc.2017-00373
  2. Mahfouda S, Moore JK, Siafarikas A, et al. Gender-affirming hormones and surgery in transgender children and adolescents. The lancet Diabetes & endocrinology. 2019;7(6):484-498. doi:10.1016/S2213-8587(18)30305-X
  3. Vance SR Jr, Ehrensaft D, Rosenthal SM. Psychological and Medical Care of Gender Nonconforming Youth. Pediatrics. 2014;134(6):1184-1192. doi:10.1542/peds.2014-0772
  4. Hidalgo MA, Ehrensaft D, Tishelman AC, et al. The gender affirmative model: What we know and what we aim to learn. Human Development. 2013;56(5):285-290. doi:10.1159/000355235
  5. Chen D, Berona J, Chan YM, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. The New England journal of medicine. 2023;388(3):240-250. doi:10.1056/NEJMoa2206297
  6. de Vries ALC, McGuire JK, Steensma TD, Wagenaar ECF, Doreleijers TAH, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958
  7. Grannis C, Leibowitz SF, Gahn S, et al. Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology. 2021;132(7612148, qgc):105358. doi:10.1016/j.psyneuen.2021.105358
  8. Mullins ES, Geer R, Metcalf M, et al. Thrombosis Risk in Transgender Adolescents Receiving Gender-Affirming Hormone Therapy. Pediatrics. 2021;147(4). doi:10.1542/peds.2020-023549
  9. Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022;23(sup1):S1-S259. doi:10.1080/26895269.2022.2100644
  10. Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society. 2021;5(4):bvab011. doi:10.1210/jendso/bvab011
  11. Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. The Journal of clinical endocrinology and metabolism. 2020;105(12). doi:10.1210/clinem/dgaa604
  12. Jarin J, Pine-Twaddell E, Trotman G, et al. Cross-Sex Hormones and Metabolic Parameters in Adolescents With Gender Dysphoria. Pediatrics. 2017;139(5):e20163173. doi:10.1542/peds.2016-3173
  13. Perl L, Segev-Becker A, Israeli G, Elkon-Tamir E, Oren A. Blood Pressure Dynamics After Pubertal Suppression with Gonadotropin-Releasing Hormone Analogs Followed by Testosterone Treatment in Transgender Male Adolescents: A Pilot Study. LGBT health. 2020;7(6):340-344. doi:10.1089/lgbt.2020.0026
  14. Perl L, Elkon-Tamir E, Segev-Becker A, Israeli G, Brener A, Oren A. Blood pressure dynamics after pubertal suppression with gonadotropin-releasing hormone analogs followed by estradiol treatment in transgender female adolescents: a pilot study. Journal of pediatric endocrinology & metabolism : JPEM. 2021;34(6):741-745. doi:10.1515/jpem-2021-0172
  15. Stoffers IE, De Vries MC, Hannema SE. Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine. 2019;16(9):1459-1468. doi:10.1016/j.jsxm.2019.06.014
  16. Millington K, Chan YM. Lipoprotein subtypes after testosterone therapy in transmasculine adolescents. Journal of clinical lipidology. 2021;15(6):840-844. doi:10.1016/j.jacl.2021.09.051
  17. Tack LJW, Heyse R, Craen M, et al. Consecutive Cyproterone Acetate and Estradiol Treatment in Late-Pubertal Transgender Female Adolescents. The journal of sexual medicine. 2017;14(5):747-757. doi:10.1016/j.jsxm.2017.03.251
  18. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658

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