The effect of cross-sex hormonal treatment on gender dysphoria individuals' mental health: a systematic review
Authors Costa R, Colizzi M
Received 2 June 2016
Accepted for publication 24 June 2016
Published 4 August 2016 Volume 2016:12 Pages 1953—1966
Checked for plagiarism Yes
Review by Single-blind
Peer reviewers approved by Dr Amy Norman
Peer reviewer comments 2
Editor who approved publication: Dr Roger Pinder
Rosalia Costa,1 Marco Colizzi2
1Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, Tavistock Centre, 2Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
Abstract: Cross-sex hormonal treatment represents a main aspect of gender dysphoria health care pathway. However, it is still debated whether this intervention translates into a better mental well-being for the individual and which mechanisms may underlie this association. Although sex reassignment surgery has been the subject of extensive investigation, few studies have specifically focused on hormonal treatment in recent years. Here, we systematically review all studies examining the effect of cross-sex hormonal treatment on mental health and well-being in gender dysphoria. Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Instead, compared to female-to-male individuals, hormone-treated male-to-female individuals seem to benefit more in terms of a reduction in their body uneasiness and personality-related psychopathology and an amelioration of their emotional functioning. Less consistent findings support an association between hormonal treatment and other mental health-related dimensions. In particular, depression, global psychopathology, and psychosocial functioning difficulties appear to reduce only in some studies, while others do not suggest any improvement in these domains. Results from longitudinal studies support more consistently the association between hormonal treatment and improved mental health. On the contrary, a number of cross-sectional studies do not support this evidence. This review provides possible biological explanation vs psychological explanation (direct effect vs indirect effect) for the hormonal treatment-induced better mental well-being. In conclusion, this review indicates that gender dysphoria-related mental distress may benefit from hormonal treatment intervention, suggesting a transient reaction to the nonsatisfaction connected to the incongruent body image rather than a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.
Keywords: estrogen, testosterone, transsexualism, psychiatry, psychosocial wellbeing
A strong and persistent cross-gender identification as well as a persistent discomfort with one’s natal sex or a sense of inappropriateness in the gender role of that sex has been considered as a core aspect of nonconforming gender identity since the first inclusion of the condition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association.1 Until the last DSM revision,2 the condition has been known as “transsexualism/gender identity disorder”.1,3,4 In 2013, the American Psychiatric Association has significantly revised the condition definition in an attempt to balance between the competing issues of depathologizing nonconforming gender identity vs access to care.2,5 As a consequence, the condition has been renamed “gender dysphoria” in order to imply a diagnostic entity in its own right, not necessarily associated with severe comorbid psychiatric findings, and better characterize the gender incongruence-related experience and discomfort.2 However, psychiatric comorbidity among individuals with gender dysphoria is still a matter of discussion. Some studies have reported a high prevalence of major psychiatric disorders in gender dysphoria.6–8 Instead, other research suggests a low level of psychopathology.9–11 A recent review has concluded that gender dysphoria individuals appear to have a higher risk of psychiatric comorbidity.12 However, as reported by the authors, many studies were methodologically weak, and sex reassignment procedures appeared to be beneficial in reducing mental distress.12 Therefore, the lack of consistency between studies about gender dysphoria individuals’ psychiatric comorbidity could be partially explained by their design, which usually did not explore the role of the lack of treatment in gender dysphoria individuals’ mental distress.
For most gender dysphoria individuals, the subjective experience of persistent cross-gender identification and discomfort with their natal sex may be a stressful situation and cause clinical distress or impairment in important areas of functioning.9,13,14 Suffering from severe gender incongruence usually leads individuals to pursue hormone treatment and sex reassignment surgery. The purpose of these sex reassignment procedures is to alleviate the individual’s distress by reducing the discrepancy between the individuals’ biological sex and their experience.15 Over the last few decades, research has prevalently focused on the effect of sex reassignment surgery on gender dysphoria individuals’ mental health. In particular, previous research has suggested that sex reassignment surgery improves gender dysphoria individuals’ well-being, increasing their personal and general satisfaction,16–18 self-confidence with body image,19–22 and quality of life.23–26 In contrast, the role of the cross-sex hormonal treatment in the well-being of gender dysphoria individuals has been the subject of relatively little investigation. A 2010 meta-analysis has identified 28 observational studies of the effect of sex reassignment on gender dysphoria individuals’ well-being.27 However, only five studies specifically examined the impact of hormonal treatment and two of them focused on gender-related cognitive aspects, which could be influenced by cross-sex hormones and per se do not inform on hormone-treated individuals’ mental health or well-being.28,29 The remaining three studies addressed the effect of hormonal treatment on gender dysphoria individuals’ psychological profile,30 emotional repercussions,31 and transformation satisfaction.32 However, due to its design, the latter one32 could not infer an association between hormonal treatment and better transformation satisfaction.
Studying the effect of cross-sex hormonal treatment on mental health in gender dysphoria may help to disentangle the burden of psychiatric comorbidity among individuals suffering from this condition. In recent years, a larger body of evidence has accumulated from studies on the specific effect of hormonal treatment on different mental health-related outcome measures. The purpose of this review is to bring together and discuss all available data generated by cross-sectional and longitudinal studies that have investigated the effect of hormone therapy on mental health by carrying out a systematic literature search for all such data.
Materials and methods
Inclusion criteria for studies were as follows: 1) studies in gender dysphoria, 2) studies investigating the mid/long-term effects of cross-sex hormonal treatment, and 3) studies measuring mental health-related parameters, including a) depression, b) anxiety, c) personality, d) quality of life, e) dissociative symptoms, f) psychopathology, g) psychosocial/emotional functioning, h) distress, and i) self-esteem. Exclusion criteria were as follows: 1) studies in which cross-sex hormonal treatment was not the intervention of interest (ie, studies including cross-sex hormonal treatment only as a confounder/covariate of no interest) and 2) studies in which the mental health-related outcomes were not directly reported upon.
A final search was undertaken on May 16, 2016. The search terms used were as follows: (gender dysphoria or gender identity disorder or transsexualism) and (hormon* or cross-sex hormonal treatment or hormone therapy) and (psych* or psychiatry or psychopathology or mental health or anxiety or depression). This search was undertaken in Medline, EMBASE, and PsycINFO using the OvidSP platform. All studies published in any language and indexed in the above databases were included. Reference lists from all identified relevant studies, reviews, and conference abstracts were screened for any additional relevant studies.
Demographic and methodological variables and outcome data for studies identified were extracted into a spreadsheet. Primary outcomes of interest were mental health-related parameters. These were compared within hormone-treated cohorts and/or between hormone-treated and nonhormone-treated control groups.
Risk of bias
Risk of bias and quality assessment of the methodologically heterogeneous group of studies (Table 1) reviewed here required a suitably inclusive and flexible approach. For this purpose, an adapted set of criteria, suggested by the Agency for Healthcare Research and Quality guidance,33 amended as appropriate for observational studies in humans were used (Table 2). Risk of systematic bias across studies was further identified by assessing all articles for possible confounding factors, such as study population definition, mental health comorbidity, attrition, comparability of subjects, cross-sex hormonal treatment duration, type, and dosage (Table 3).
Table 1 Studies included in the review
In total, 680 records were identified. All abstracts of the records were screened against the inclusion and exclusion criteria. A final list of 17 studies was identified for systematic analysis in this review. Cumulatively, the included studies investigated different aspects of mental health (Table 1) in response to cross-sex hormonal treatment, using both independent-groups (cross-sectional studies) and repeated measures (longitudinal studies) designs. These include 1) depression, mood states, and self-esteem; 2) anxiety and tension; 3) global and personality-related psychopathology; 4) mental health-related quality of life; 5) dissociative symptoms; 6) psychosocial, interpersonal, and emotional functioning; and 7) social distress, perceived stress, and body uneasiness. Key findings are reported in Table 2, and a brief synopsis of them is reported later.
Effect of cross-sex hormonal treatment on depression, mood states, and self-esteem
Depression and its features have been the most extensively investigated mental health-related parameters in gender dysphoria individuals receiving hormonal treatment. The first study to investigate this issue was carried out in 1983.34 This cross-sectional study assessed male-to-female (MtF) individuals’ psychological adjustment depending on their hormonal treatment status. The research did not find any significant difference in terms of depressive symptoms between MtFs with and without hormonal treatment.34 In a second study, Slabbekoorn et al31 asked female-to-male (FtM) individuals to keep a mood diary during their testosterone administration. Results indicated no mood changes when assessing depressed mood and other mood-related parameters from baseline to after the fourth testosterone injection.31 Miles et al29 used a unique design to disentangle the hormonal treatment contribution to mood in gender dysphoria. Using both independent groups (longitudinal study) and repeated measure (cross-sectional study) designs, this study consistently indicated that hormone-treated MtFs are more composed and confident. Authors also tested for the effect of hormonal treatment withdrawal and duration on mood. Intriguingly, they reported no significant association.29 In recent years, four more studies have investigated the association between hormonal treatment and depression, using commonly used questionnaires/scales.35–38 Apart from a study,38 which reported no significant differences in terms of depression (it only investigated MtFs), the remaining studies reported lower depressive symptoms in gender dysphoria individuals receiving hormonal treatment.35–37 Two of these studies also assessed self-esteem, reporting higher levels of self-esteem due to the hormonal treatment intervention.36,38
Effect of cross-sex hormonal treatment on anxiety and tension
Different from depression, anxiety has been investigated only recently, with three studies addressing this aspect over the last 5 years.35,37,38 All these three investigations (two cross-sectional studies and one longitudinal one) have consistently reported a reduction in symptoms of anxiety among individuals receiving hormone therapy. A previous research had studied tension as a measure of psychological adjustment, reporting no significant differences between MtFs with and without hormonal treatment.34
Effect of cross-sex hormonal treatment on global and personality-related psychopathology
This review has identified three recent studies about the effect of cross-sex hormonal treatment on a global measure of psychopathology.37,39,40 Intriguingly, all these studies used the same questionnaire. However, while two studies described a significant decrease in global psychopathology occurring after the initiation of hormone therapy,37,40 a third one did not find any difference between hormone-treated and nonhormone-treated individuals.39 Interestingly, according to the authors, their negative finding may be attributable to the restricted range and low levels of psychopathology observed in their sample.
Three other studies investigated personality-related psychopathology as a function of cross-sex hormonal treatment, using a similar methodology.30,41,42 Using a common measure of personality, this body of research has suggested a reduction in personality-related psychopathology among gender dysphoria individuals receiving hormone therapy. However, as one study focused only on MtF individuals30 and a second study reported hormonal treatment to be beneficial only in MtF and not in FtM individuals,41 there is still little evidence to suggest a positive effect of cross-sex hormonal treatment on FtM individuals’ personality-related psychopathology.42 Leavitt et al30 also indicated that the hormone-treated MtF individuals’ overall personality-related psychopathology tends to approximate the norms for male populations and negatively correlates with the hormone therapy duration.
Effect of cross-sex hormonal treatment on mental health-related quality of life
The first study to investigate the quality of life among gender dysphoria individuals receiving hormonal treatment was performed in 2006 on a large sample of FtM individuals.24 With ~250 FtMs receiving cross-sex hormonal treatment, this study sample represents the largest one identified in this systematic review. The research reported higher emotional, social, and mental quality of life in hormone-treated FtM adults, with hormonal treatment duration associated with higher emotional quality of life.24 Three more recent studies confirmed a better psychosocial and mental quality of life in both MtFs and FtMs receiving hormone therapy.36,43,44 One study also compared hormone-treated individuals with a control group, reporting a higher mental health-related quality of life in gender dysphoria individuals.43
Effect of cross-sex hormonal treatment on dissociative symptoms
To date, only one study has investigated the prevalence of dissociative symptoms among gender dysphoria individuals receiving cross-sex hormonal treatment.45 Results of this longitudinal study suggest that suffering from dissociative symptoms may be a common clinical feature in the context of untreated gender dysphoria. Interestingly, this research indicated a significant reduction in gender dysphoria individuals’ dissociative symptoms after the beginning of cross-sex hormonal treatment. It is worth reporting that the high prevalence of dissociative symptoms among untreated gender dysphoria individuals was greatly due to the gender-related sense of strangeness. This issue could explain why the dissociative experience was less intense when gender dysphoria individuals received hormone therapy. The unease with the biological sex and the aversion to the corresponding sex-specific body forms belong by definition to the gender dysphoria diagnosis.2 Therefore, authors argued whether dissociation represents a genuine feature of gender dysphoria rather than a clinically relevant pathological manifestation, highlighting the need for additional/exclusion criteria for a differential diagnosis.45
Effect of cross-sex hormonal treatment on psychosocial, interpersonal, and emotional functioning
Psychosocial functioning has been the domain receiving most attention after depression in hormone-treated individuals. Different aspects have been investigated, such as emotional31 and social components.34,38 Also two studies have investigated a global measure of psychosocial functioning.36,37 Impact of hormone therapy on emotional functioning appeared to be different in MtF and FtM individuals, with more generally positive effects in MtF and some undesirable effects in FtM individuals.31 While Blanchard et al34 did not find any effect of hormone therapy on social adjustment, a more recent study has identified less problems with socialization and interpersonal functioning in gender dysphoria individuals receiving hormone therapy.38 Finally, mixed results have emerged from studies investigating global psychosocial functioning, with a study reporting less functional impairment after the beginning of hormone therapy37 and another one finding no significant differences as a result of hormonal treatment.36
Effect of cross-sex hormonal treatment on social distress, perceived stress, and body uneasiness
This review identified three studies specifically analyzing distress intensity among gender dysphoria individuals and how it could be influenced by the hormonal treatment intervention.14,35,39 These studies used the following three different measures of distress: 1) social distress, ie, avoidance and subjective distress about social interactions; 2) perceived stress, ie, perception of social life experiences as stressful and unpredictable/uncontrollable; and 3) body uneasiness, ie, gender-related distress and discomfort. Using a cross-sectional design, Gómez-Gil et al35 reported that gender dysphoria individuals who have not received hormonal treatment show higher levels of social distress than those receiving cross-sex hormones. Consistent with these findings,35 in a second study, hormone-treated gender dysphoria individuals showed lower perceived stress, which overlapped with that found in the normative sample.14 The last study addressed the impact of hormonal treatment on body-related distress, suggesting a gender-specific effect. In fact, MtF individuals’ body uneasiness was lower in the context of cross-sex hormonal treatment, and the reduction correlated negatively with the cumulative dose of estradiol.39 Instead, FtM subjects did not appear to benefit from the hormone therapy in terms of body uneasiness. Authors themselves commented on it as an unexpected finding, which could be due to the individual’s still unsatisfactory comfort with the body at a private/personal level rather than involving a social dimension.39
Risk of systematic bias across studies
While generally well designed, results mentioned earlier need to be considered in light of certain limitations. Apart from one study,39 all the others came from only one clinic and some of them had a relatively small sample size. Most importantly, as no study used a blinded randomized controlled trial design, results could have also different explanations because of the study design(s). Moreover, type and dosage of cross-sex hormonal treatment were often not reported, and when reported, there was poor consistency across studies. The same weakness applied to hormone therapy duration. While differences between analyzed groups were generally taken into account, more than half the studies did not mention/control for psychiatric comorbidity, which could have represented a critical bias in this kind of investigation. Finally, while studies were generally strict on the defined study population (formal diagnosis according to DSM criteria used at the time of the study), recruitment/follow-up attrition represented an issue for some of the studies identified in this review.
This is the first systematic review of all studies examining the effect of cross-sex hormonal treatment on mental health and psychosocial well-being in gender dysphoria. A previous review has mainly focused on the psychosocial outcome of gender dysphoria individuals receiving sex reassignment surgery.27 After the publication of that review, the literature has seen an increasing number of studies specifically interested in whether sex hormones induce any improvement in terms of mental health and psychosocial well-being. Overall, this review demonstrates that cross-sex hormonal treatment has definite effects on mental health, generally ameliorating gender dysphoria individuals’ well-being at different levels. Taking into account the risks of bias reported earlier, cross-sex hormonal treatment does not seem to affect any of the parameters investigated, except emotional functioning, with a reported higher prevalence of aggressive emotions and lower affect intensity in FtMs receiving hormonal treatment.31
More specifically, when treated with hormone therapy, gender dysphoria individuals reported less anxiety,35,37,38 dissociation,45 perceived stress,14 social distress,35 and higher mental health-related quality of life24,36,43,44 and self-esteem.36,38 Also, compared to FtM individuals, MtF individuals seemed to benefit more in terms of body uneasiness,39 emotional functioning,31 and personality-related psychopathology.30,41,42 More mixed results emerged from studies investigating other mental health-related dimensions. In particular, recent studies suggested reduced depressive symptoms in hormone-treated gender dysphoria individuals,35–37 despite previous evidence of no association between cross-sex hormonal treatment and depression among MtF34 and FtM individuals.31 Similarly, global psychopathology appeared to be reduced in two studies,8,37 while a third one did not detect any change.39 Finally, while two studies indicated less functional impairment37 and reduced problems with socialization and interpersonal functioning in gender dysphoria individuals receiving hormone therapy,38 two other studies did not find any effect of hormone therapy on social adjustment34 and psychosocial functioning.36 Negative findings generally came from studies involving a cross-sectional design. On the contrary, the few longitudinal studies identified in this review were consistent in indicating an association between hormonal treatment and better mental health.14,29,31,37,40,45 Conducting observations of the same subjects over a period of time, longitudinal studies can establish sequences of events and better detect changes in the characteristics of the target population, also due to their higher statistical power.
Some of the studies included in this review offered a comparison of hormone-treated gender dysphoria individuals to normal range values of normative data for a general population. Interestingly, all these studies indicated that after the beginning of the cross-sex hormonal treatment, gender dysphoria individuals express distress levels similar to the general population in several mental health-related dimensions, including perceived stress,14 dissociative symptoms,45 personality-related psychopathology,30 mental health-related quality of life,43 and global psychopathology.40 These results are in-line with the majority of the previous studies, indicating that hormone therapy decreases the psychiatric comorbidities often associated with a lack of hormonal treatment.27
The finding of a reduced mental distress in the context of hormone-treated gender dysphoria may have several explanations. The question arising is whether cross-sex hormones exert a direct effect on distress levels, implying a biological explanation for their reduction, or rather indirectly elicit a better mental health, implying a psychological mechanism possibly related to the physical changes. Biologically, sex hormones may exert different effects on mental distress. Specifically, estrogens may increase mental distress, making individuals more prone to anxiety and depression.46 Instead, androgens can reduce mental distress, promoting feelings of euphoria and energy47 and also eliciting stress and hostility.48 As a consequence, mental distress should increase in MtF individuals as a consequence of the biological effect of estrogens. Conversely, due to the biological effects of androgens, hormone therapy should induce both positive and negative effects on FtM individuals’ mental distress, depending on the mental health parameters evaluated. The only finding in support of a biological mechanism for the observed changes in mental distress is the increase in the prevalence of aggressive emotions among hormone-treated FtM individuals.31 Nevertheless, studies included in this review found that hormonal treatment has a positive effect on both MtF and FtM individuals’ mental health. In addition, this amelioration is more pronounced in MtF individuals, who should be more negatively affected by the cross-sex hormonal treatment intervention according to the biological explanation. In light of all this evidence, this review does not support the hypothesis of a direct effect of hormone therapy on mental well-being in gender dysphoria. Instead, the distress reduction might be an indirect effect of hormone therapy, as already hypothesized by Kuiper and Cohen-Kettenis.32 Mental distress may be considered a reaction to the nonsatisfaction arising by the incongruence between the individual’s experienced gender and biological sex. Cross-sex hormonal treatment is supposed to mitigate such incongruence, inducing desired physical changes that could eventually be responsible for the individual’s better mental state and psychological well-being. In other words, thanks to the body changes obtained, gender dysphoria individuals may experience a reduction in their mental distress. In addition, other psychological explanations support the hypothesis of an indirect effect of hormonal treatment on mental well-being. Due to incongruence between their physical appearance and internal experience, nonhormone-treated gender dysphoria individuals may face major difficulties in managing their gender identity at a social level. Hormonal treatment may reinforce the gender affirmation with a better social recognition. This would explain why in some studies hormonal treatment seems to have a beneficial effect on the social dimension rather than on the private dimension of mental well-being.39 Finally, as delaying hormonal treatment has been reported to often disappoint gender dysphoria individuals, also increasing their distress,37,45 we cannot exclude that accessing care and receiving eligibility for hormone therapy may help in reducing distress, representing an acceptance of the individual’s needs and requirements. In order to promote the highest standards of health for individuals seeking gender transitioning, the importance of facilitating access to care and reducing barriers across countries and cultures cannot be overemphasized. Several factors have been identified, which can affect gender dysphoria individuals’ access to care and eventually lead to a nonsatisfactory outcome, such as stigma, violence, fear of being seen as different, lack of/inadequate access to specialized health care professionals and/or services, and poor access to health care pathway-related information.49
This review suggests that gender dysphoria-related mental distress may benefit from hormonal treatment intervention. Even recognizing the suffering of nonhormone-treated gender dysphoria individuals, which represents a possible risk factor for more severe or full-syndromal psychiatric disorders,12 mental distress in gender dysphoria may be considered as a transient reaction to the nonsatisfaction connected to the incongruent body image and not necessarily a stable psychiatric comorbidity. In this perspective, timely hormonal treatment intervention represents a crucial issue in gender dysphoria individuals’ mental health-related outcome.
The authors would like to thank all patients and colleagues met during the years of clinical research activity. A special thank goes to the Gender Unit at the University of Bari, Bari, Italy, and the Gender Identity Development Service at the Tavistock and Portman NHS Foundation Trust, London, UK. There was no funding source for this study.
The authors report no conflicts of interest in this work.
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