Transgender individuals are individuals whose gender identity or gender expression does not conform to that typically associated with the sex to which they were at birth, in the absence of an underlying mental disorder or chromosomal abnormality that could be the cause of this experience. The concept of gender dysphoria featured in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Diseases, Tenth Revision (ICD-10)1,2 refers to the distress caused by this incongruence between gender identity and the sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics),3,4 and not all transgender individuals experience it. During the development of the International Classification of Diseases, Eleventh Revision (ICD-11), the World Health Organization (WHO) redefined gender identity-related health, replacing categories like “transsexualism” and introducing the concept of “gender incongruence”. This category is included in the so-called Z codes, which are codes used to define a variety of psychosocial factors or life events and do not fit into a diagnostic category.5

In transgender adolescents, puberty suppression at an early age (Tanner stages 2 and 3) seeks to alleviate the suffering caused by the development of secondary sex characteristics, to widen the temporal window for decision-making, as at this stage the treatment is still reversible, and to facilitate social transition to the new gender role.6,7 Thus, a study conducted in the Netherlands by Cohen-Kettenis et al in transgender youth that had undergone puberty suppression analysed behavioural problems, depression, anxiety and overall functioning and found considerable improvement in every scale following treatment.8,9

In a study published in Pediatrics, Spack et al. reported similar outcomes applying the ‘Dutch model’ to those found by De Vries and Cohen-Kettenis in 2014.10

Outside the works we have just mentioned, the literature on the psychosocial impact of hormone therapy in transgender youth is scarce. More specifically, no such study has been conducted in Spain, and none of those conducted elsewhere included a control group. For this reason, the objectives of our study were to assess the psychosocial status of patients seeking care in the paediatric endocrinology clinic for gender incongruence and the impact on psychosocial status of cross-sex hormone therapy (CSHT) at 1 year of treatment.

We analysed data for 53 participants aged 14–18 years, of who 23 were trans gender (16 [69%] trans male and 7 [31%] trans female) and 30 were healthy cisgender controls (12 [40%] female and 18 [60%] male). All were Caucasian of Spanish descent except for 2 trans participants, 1 Asian participant of Chinese descent and 1 black participant from Colombia. We did not find significant differences in the socioeconomic status between the trans participants and the cis controls (P=.2). Approximately 40% to 50% of participants in each group were of middle socioeconomic status and had parents with a university education (Table 1).

We found that 30.4% of the trans participants (n=7) and 30% of the cis controls (n=9) had previously used mental health services, while only 1 trans participant (4.3%) had ever received psychiatric medication (Table 1).

The trans participants had a supportive social environment, as 100% had disclosed their transgender identity to their parents and 82% (19 out of 22) had disclosed it in their respective schools. In addition, 95% (22 out of 23) reported being addressed by their chosen names at home and 82% in their school.

In many cases, both families and the health professionals that habitually work with trans adolescents need to make decisions without the support of clear scientific evidence. But, as any professional that works with trans youth and their families knows, in a population that faces this level of discrimination16–18 and in which self-harm, suicidal ideation, anxiety and other problems are so prevalent, the risk associated with not performing any kind of intervention is very high.19–21

Medical treatment of transgender adolescents has been a controversial issue since it was first reported in the Netherlands in 1998.22 Since 2013, our paediatric endocrinology clinic offers multidisciplinary treatment to patients with adolescent-onset gender dysphoria, with collaboration of social workers, psychologists, psychiatrists, gynaecologists, dermatologists, paediatricians and endocrinologists. At present, our clinic manages 50 patients receiving hormone therapy for this indication, mostly following the latest recommendations of the World Professional Association for Transgender Health,3 with a model similar to the one recommended by Hembree4 and the Cohen-Kettenis group.8 That is, patients that have reached a stage of pubertal development of at least Tanner 2 or 3, without psychiatric comorbidity that could play a role in gender dysphoria, with adequate social, family and psychological support and that have demonstrated an understanding of the risks and benefits of hormone therapy.

At present, the scientific community does not consider transgender identities pathological. Removing transgender identities from the classification of psychiatric disorders and placing related problems in the Z codes is a solution that allows their depathologisation, including them in the classification criteria related to factors that have an impact on health status.5 Until recently, the few manuals available to guide the management of trans patients mainly focused on the incongruence between the sex assigned at birth and the gender identity of the individual, and particularly on the distress caused by this discrepancy.2 This distress may or may not be directly associated with the possibility of freely expressing gender identity, being able to transition if so desired, the support received by the family and the general social environment and the degree of transphobia experienced. In our study, all trans participants experienced gender dysphoria at T0, which had resolved in all at 1 year of CSHT, which demonstrates that this dysphoria is not a necessary condition in transgender individuals and is not always present in transgender youth.

In our sample, the families of transgender participants provided a highly supportive environment, as demonstrated by the family APGAR scores. This could explain the highly favourable outcomes observed at 1 year of treatment with CSHT. The support of families and physicians is essential to the adequate and healthy neuropsychological development of transgender adolescents.6,7,23 Initiation of CSHT and the associated physical changes at younger ages than currently recommended in management protocols (16 years) may have psychological benefits, given the particular importance of fitting in the peer group during adolescence. In fact, we found excellent results in the SDQ, with a significant improvement between T0 and T1 in the trans group in emotional symptoms, conduct problems, hyperactivity and prosocial behaviour, which were comparable to those of the control group at T1 (Tables 2 and 3).

We know that a high proportion of transgender youth experience anxiety and depression, and there is evidence in the literature on the mental health of trans children and youth whose desired identities are affirmed and supported by their families. In this sense, the family plays an essential role in improving the lives of these minors, acting as a protective factor against depression, which is why it is important to implement strategies that promote the support of families due to their impact on mental health.24–31

We found substantial improvement in the mean scores and percentiles in the STAI state anxiety and trait anxiety scales in the trans group after 1 year of CSHT. We also found differences at T0 compared to the control group that had improved at T1, as the differences had decreased, although not disappeared (Tables 4 and 5). We also found substantial improvement in the BDI-II scores. Before initiation of hormone therapy, all trans participants had scores corresponding to some level of depression. After 1 year of CSHT, 70% had scores in the normal range. These findings suggest that initiation of CSHT at earlier ages than recommended at present, with adequate family support in general or specifically expressed in the decision of allowing an early social transition, may be associated with better mental health outcomes in transgender children.

Our findings are consistent with those of the longitudinal study published in Pediatrics by Annelou de Vries in 2014.8 The levels of anxiety, emotional distress and behavioural disturbances and depressive symptoms and the experience of gender dysphoria in transgender participants were similar or better compared to those of their cisgender peers matched for age at 1 year of CSHT. Based on this body of evidence, it is essential for paediatric providers to have updated knowledge and an unbiased attitude on this reality, the concerns regarding the future impact of these interventions and the lack of evidence on their long-term adverse effects.32 We ought to mention the recent position statement of the Asociación Española de Pediatría (Spanish Association of Paediatrics) on the approach to gender diverse and transgender identities in children and adolescents.33 This document does not simply adopt the depathologising perspective that is increasingly espoused by health professionals, but pushes beyond, calling for a necessary shift in social perception, as it considers that diversity in gender identity and expression enriches humankind.

Keeping in mind that age should not be the main criterion for initiation of hormone therapy in transgender minors, we, as other authors before us, hope for the development of more flexible management protocols.34

The authors have no conflicts of interest to declare.