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Transgender Hormone Therapy

Written by Dr. Sarah Anderson, Dr. Ramon Martinez III
Published on May 3, 2023
Research Highlights

The health consequences of long-term hormone replacement therapy are not well studied.

Puberty blockers are fully reversible drugs that delay the onset of puberty.

The impact of policies that prohibit gender-affirming healthcare has not been studied.

A transgender person's biological sex does not match their sense of being a man, woman, or non-binary. Gender dysphoria is when this difference causes persistent distress (Ahmad 2013).

  • The American Academy of Pediatrics and American Medical Association consider best practices for transgender healthcare to include puberty blockers, hormone replacement therapy (HRT), and surgery (Coleman 2022; Rafferty 2018; Deutsch 2016).

Transgender people use HRT for masculinization or feminization.

HRT for transgender patients aims to match testosterone or estrogen levels with their gender identity. HRT is started after puberty and taken throughout life (Coleman 2022).

Testosterone HRT is a “masculinizing hormone therapy," leading to:

  • More acne and facial/body hair.
  • Increased muscle mass and strength.
  • Different scalp hair growth (e.g., baldness), fat distribution, and voice pitch.
  • Reproductive changes (e.g., loss of period, clitoral enlargement, vaginal atrophy; Coleman 2022; Hembree 2017).

Estrogen HRT is a "feminizing therapy" causing:

  • Different fat distribution and skin softening.
  • Breast growth and more scalp hair.
  • Less body hair, muscle mass and strength.
  • Lower sex drive, spontaneous erections, sperm production, and testicular volume (Coleman 2022; Hembree 2017).

There is not scientific consensus about the health risks of HRT due to small sample sizes, study inconsistencies, and short follow-up times.

  • Adverse events (e.g., heart attack, stroke, blood clots) are not reported enough to assess the risk of HRT (Maraka 2017).
  • HRT reduces fertility in some, but not all, transgender patients (Klein 2018).
  • Potential risks of masculinizing HRT include undesirable cholesterol changes and high red blood cell count (Maraka 2017).
  • Health risks of feminization HRT may include higher triglyceride levels and, depending on the type of estrogen prescribed, the risk of blood clots (Maraka 2017; Kesteren 2003).

Stopping HRT reverses most physical changes.

  • Growth of breasts is the only permanent change in feminizing HRT.
  • Masculinization HRT changes clitoral growth, facial hair growth, voice changes, and male-pattern baldness permanently (UCSF 2020).

Among cisgender patients, stopping hormone therapy causes endocrine withdrawal symptoms (e.g., hot flashes, fatigue, anxiety, headaches, muscle and joint pain; Hochberg 2003).

Neither the physical nor psychological impact of involuntarily stopping HRT among transgender patients has been studied.

 

Puberty blockers are reversible.

Puberty blockers stop hormones that initiate puberty and are approved for children who start puberty under the ages of 8 (female) and 9 (male). Medication is typically used for 1 to 5 years (Watson 2015).

No matter how long puberty blockers are used, puberty resumes once stopped (Coleman 2022). The health impact of delaying typically timed puberty or the impact of denying transgender youth this care has not been studied.

In a study of 70 transgender youth, puberty blockers decreased depression, behavioral and emotional problems, and improved general functioning (de Vries 2011).

A small study found no negative health effects of puberty blockers on kidney or liver function in transgender youth.

  • Participants had slower height growth, lower lean body mass, and more body fat after treatment. It is unclear if these changes were a health concern (Schagen 2016).

 

Some states restrict youth access to hormone therapies.

In the last two years, 16 states prohibited some or all medical care for transgender youth (Figure 1). How these policies impact families, youth mental health, healthcare professional liabilities, and healthcare costs is unclear.

Figure 1. State laws regarding transgender youth medical care. Dark orange states prohibit medication and surgical care, light orange prohibit surgical care, red triangles add felony provisions for medical professionals, and yellow triangles restrict care via executive action. Blue states have passed legal protections, access, and coverage for youth transgender care. Stars (*) indicate proposed policy.

Medical Professionals. Current legislation:

  • allows medical professionals providing gender-affirming care to be charged with a misdemeanor or felony (AL, FL, ID, IN, ND)
  • prohibits physicians from referring patients to other medical professionals for gender-affirming care (AZ, IN, IA, KY, WV)
  • disciplines physicians via state boards and licensure loss (FL, GA, IN, KY, TN, WV)
  • subjects medical professionals to civil lawsuits (FL, GA, IN, IA, KY, TN, WV; UCLA 2023).

Families. Some legislation classifies guardians who seek gender-affirming care for their children as child abusers or classifies care as mutilation (UCLA 2023).

Financial Impacts. Some states restrict Medicaid from covering gender-affirming care or allow private insurance to opt out of coverage, requiring self-financing (UCLA 2023).

Transgender suicide incidence is 32% higher in states without transgender protections (Perez-Brumer, 2015). To learn more, read our Science Note Transgender Therapy & Mental Health.

 

MOST Policy Initiative is a 501(c)3 nonprofit organization that provides nonpartisan research information to members of the Missouri General Assembly upon request. This Science Note is intended for informational purposes and does not indicate support or opposition to a particular bill or policy approach. Please contact ramon@mostpolicyinitiative.org with any questions.

 

References

Ahmad S., Barrett J., Beaini A., Bouman W., Davies A., Greener H., Lenihan P., Lorimer S., Murjan S., Richards C., Seal L. , Stradins L. (2013) Gender dysphoria services: a guide for general practitioners and other healthcare staff, Sexual and Relationship Therapy, 28:3, 172-185, DOI: 10.1080/14681994.2013.808884 

Coleman, A. E. Radix, W. P. Bouman, G. R. Brown, A. L. C. de Vries, M. B. Deutsch, R. Ettner, L. Fraser, M. Goodman, J. Green, A. B. Hancock, T. W. Johnson, D. H. Karasic, G. A. Knudson, S. F. Leibowitz, H. F. L. Meyer-Bahlburg, S. J. Monstrey, J. Motmans, L. Nahata, T. O. Nieder, S. L. Reisner, C. Richards, L. S. Schechter, V. Tangpricha, A. C. Tishelman, M. A. A. Van Trotsenburg, S. Winter, K. Ducheny, N. J. Adams, T. M. Adrián, L. R. Allen, D. Azul, H. Bagga, K. Başar, D. S. Bathory, J. J. Belinky, D. R. Berg, J. U. Berli, R. O. Bluebond-Langner, M.- B. Bouman, M. L. Bowers, P. J. Brassard, J. Byrne, L. Capitán, C. J. Cargill, J. M. Carswell, S. C. Chang, G. Chelvakumar, T. Corneil, K. B. Dalke, G. De Cuypere, E. de Vries, M. Den Heijer, A. H. Devor, C. Dhejne, A. D’Marco, E. K. Edmiston, L. Edwards-Leeper, R. Ehrbar, D. Ehrensaft, J. Eisfeld, E. Elaut, L. Erickson-Schroth, J. L. Feldman, A. D. Fisher, M. M. Garcia, L. Gijs, S. E. Green, B. P. Hall, T. L. D. Hardy, M. S. Irwig, L. A. Jacobs, A. C. Janssen, K. Johnson, D. T. Klink, B. P. C. Kreukels, L. E. Kuper, E. J. Kvach, M. A. Malouf, R. Massey, T. Mazur, C. McLachlan, S. D. Morrison, S. W. Mosser, P. M. Neira, U. Nygren, J. M. Oates, J. Obedin-Maliver, G. Pagkalos, J. Patton, N. Phanuphak, K. Rachlin, T. Reed, G. N. Rider, J. Ristori, S. Robbins-Cherry, S. A. Roberts, K. A. Rodriguez-Wallberg, S. M. Rosenthal, K. Sabir, J. D. Safer, A. I. Scheim, L. J. Seal, T. J. Sehoole, K. Spencer, C. St. Amand, T. D. Steensma, J. F. Strang, G. B. Taylor, K. Tilleman, G. G. T’Sjoen, L. N. Vala, N. M. Van Mello, J. F. Veale, J. A. Vencill, B. Vincent, L. M. Wesp, M. A. West & J. Arcelus (2022) Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, International Journal of Transgender Health, 23:sup1, S1-S259, DOI: 10.1080/26895269.2022.2100644

de Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. The journal of sexual medicine, 8(8), 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943.x 

Deutsch, M. B., Radix, A., & Reisner, S. (2016). What's in a Guideline? Developing Collaborative and Sound Research Designs that Substantiate Best Practice Recommendations for Transgender Health Care. AMA journal of ethics, 18(11), 1098–1106. https://doi.org/10.1001/journalofethics.2016.18.11.stas1-1611 

Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T'Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of clinical endocrinology and metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658 

Hochberg Z., Pacak K., Chrousos G., Endocrine Withdrawal Syndromes, Endocrine Reviews, Volume 24, Issue 4, 1 August 2003, Pages 523–538, https://doi.org/10.1210/er.2001-0014 

Maraka S., Ospina N., Rodriguez-Gutierrez R., Davidge-Pitts C., Nippoldt T.,  Prokop L., Murad M., Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3914–3923, https://doi.org/10.1210/jc.2017-01643 

Rafferty, J., COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, & SECTION ON LESBIAN, GAY, BISEXUAL, AND TRANSGENDER HEALTH AND WELLNESS (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4), e20182162.  https://doi.org/10.1542/peds.2018-2162 

Redfield, E., Conron, K., Tentido, W., & Browning, E. (2023, March). Prohibiting Gender-Affirming Medical Care for Youth. Retrieved from UCLA School of Law Williams Institute: https://williamsinstitute.law.ucla.edu/publications/bans-trans-youth-health-care/ 

Schagen, S. E., Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Hannema, S. E. (2016). Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents. The journal of sexual medicine, 13(7), 1125–1132. https://doi.org/10.1016/j.jsxm.2016.05.004 

University of California Transgender Care. (2020, July). Hormone Therapy. Retrieved from University of California Transgender Care: https://transcare.ucsf.edu/welcome-0 

van Kesteren, P. J., Asscheman, H., Megens, J. A., & Gooren, L. J. (1997). Mortality and morbidity in transsexual subjects treated with cross-sex hormones. Clinical endocrinology, 47(3), 337–342. https://doi.org/10.1046/j.1365-2265.1997.2601068.x 

Watson, S. E., Greene, A., Lewis, K., & Eugster, E. A. (2015). BIRD'S-EYE VIEW OF GnRH ANALOG USE IN A PEDIATRIC ENDOCRINOLOGY REFERRAL CENTER. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 21(6), 586–589. https://doi.org/10.4158/EP14412.OR

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