After requiring increased support before starting gender-affirming hormone therapy, most people see their needs decrease over time.
A world-first Australian study has found certain trans individuals require lower levels of mental health support and medication after initiating gender-affirming hormone therapy.
Research has shown that trans and gender diverse individuals who pursue gender-affirming hormone therapy have improved psychological and mental health outcomes such as quality of life, depression and anxiety.
However, there is limited international literature investigating the longer-term effects of GAHT on mental healthcare utilisation.
Now, a new Australian study – believed to be the largest population-based study of GAHT recipients in the world, and the first to find a population-level associations on how mental healthcare utilisation changes pre- and post-GAHT initiation – has found that although mental healthcare use displays a slight increase around the time people first start taking GAHT, there are substantial reductions in the following years.
“These results have important implications for social and health policy,” the researchers wrote in eClinicalMedicine.
“In the context of recent attempts to restrict access to gender-affirming care, both internationally and within Australia, this study adds to a growing body of evidence highlighting the positive mental health impacts of GAHT.”
Data were sourced from the Person-Level Integrated Data Asset, a platform that links individual Census data with various administrative datasets, including healthcare records (Medicare).
Trans people were identified through a combination of gender and medication prescription data: people accessing testosterone-based GAHT were included if they had ever used testosterone and were currently (or previously) listed as female, while people accessing oestradiol-based GAHT were included if they had used oestradiol and were currently or previously male.
People taking both oestradiol and testosterone were excluded from the current study, as were people receiving GAHT prior to the start of the study period and those who started GAHT before turning 15 years.
All Medicare-subsidised out-of-hospital mental health services (i.e., mental health services provided by GPs, psychiatrists, psychologists or other allied health professionals) and mental health-related prescriptions (antidepressants and anxiolytics) were included as outcomes.
Researchers identified 32,241 individuals who commended GAHT between 2013 and 2024. A larger proportion of these individuals started using e-GAHT (20,358; 63.1% of the total sample) compared to t-GAHT (11,883; 36.1%).
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Individuals who received t-GAHT were younger at the time of first use than people receiving e-GAHT (mean age 25 years versus 34 years), although a greater proportion of individuals treated with e-GAHT had started receiving treatment at an earlier point in the study. One in five people treated with e-GAHT initiated treatment between 2013 and 2016, compared to 6.7% of people receiving t-GAHT.
People receiving t-GAHT had greater mental health service usage and a larger number of mental health-related prescriptions prior to starting GAHT (3.1 and 2.6 per year, respectively) compared to the e-GAHT group (1.6 per year for both outcomes).
After controlling for confounding factors such as sex assigned at birth, age of GAHT initiation and certain health predispositions, t-GAHT recipients had higher mental healthcare usage (an estimated 0.52 more services per person) and a greater number of mental health-related prescriptions (estimated 0.15 more per person) in the 12 months prior to starting GAHT compared to people who had not initiated GAHT, although the latter comparison was not statistically significant.
However, there was a significant reduction in mental healthcare usage after five years of GAHT, where t-GAHT recipients used fewer mental health services (estimated 2.59 fewer per person) and were issued fewer prescriptions (1.02 fewer per person). This corresponds to a 73% and 34% reduction, respectively, compared to baseline levels.
Similar trends were seen in the subgroup of people who received e-GAHT. There was an increase in mental health service usage in year leading up to GAHT initiation (2.10 more per person) but a smaller post-initiation reduction (0.29 fewer). Mental health-related prescriptions increased for up to two years post-initiation (1.22 more per person) but dropped with time (0.53 more per person at five years post-initiation).
Unsurprisingly, people with greater levels of pre-treatment mental health care engagement had larger reductions in both mental health services usage and prescriptions in the five years after starting GAHT. The reductions seen in the e-GAHT and t-GAHT groups were similar.
Researchers noted that the increased need for mental health support during the immediate pre-treatment period was in line with treatment guidelines that recommend providing additional support to patients at this time.
“The observed reduction in mental health service use following GAHT initiation significantly adds to the evidence suggesting that GAHT improves mental health and wellbeing among trans people accessing this care,” they wrote, before offering a potential explanation for the differences seen in people receiving e-GAHT and t-GAHT,” they wrote.
“One may expect that medically transitioning could lead to different experiences for t-GAHT compared to e-GAHT recipients.
“Several studies have found that oestradiol is associated with smaller changes in gender dysphoria and mental health outcomes, particularly in the short-term.
“Transitioning has also been linked to greater societal stigma and discrimination for transfeminine individuals relative to transmasculine individuals, including more substantial earnings penalties.
“Our results do however suggest that unmet need for mental health treatment plays an important role for mental healthcare demand around GAHT initiation. For instance, we observe that increased utilisation of mental health prescriptions among GAHT recipients was driven by those with lower initial levels of mental healthcare engagement.”
The authors highlighted several important limitations to the research. First, they noted that using mental health services and receiving/filling prescriptions does not fully capture the need for mental health support.
“Individuals may require care but be unable or unwilling to access it, and reductions in mental healthcare use could, in some cases, reflect disengagement rather than improvements in mental health. However, given GAHT is linked to substantial improvements in self-reported mental health, this interpretation may be less likely” they wrote.
Furthermore, the use of administrative and healthcare data in the current study meant the population of transgender people included in their analyses did not include individuals who wanted to use – but could not access – GAHT.
“It is also likely that there is selection among trans people that received GAHT, including differences in earlier vs later access,” the authors wrote.
“For example, those under 18 years of age who do not have family support will not be able to receive GAHT. The scarce supply of gender affirming clinics and clinicians providing GAHT in Australia is also likely to impact access, particularly for people living in rural and remote areas.”
Finally, the authors acknowledged that because GAHT is only one part of the gender-affirming care journey, they were unable to separate the effects of starting GAHT on mental health from other types of care involved in the journey, such as puberty blockers or surgery.
“Similarly, many factors contributing to psychological vulnerability may not be directly influenced by GAHT. Future work should consider other important outcomes such as daily functioning, social and economic participation, and broader resource utilisation patterns, including hospitalisations,” they noted.
Despite these important limitations, the researchers were confident in the potential implications of their findings.
“Enhancing public access to gender-affirming care for trans Australians should be considered to improve mental health and reduce associated healthcare costs. Restrictions on GAHT access may have long term deleterious mental health effects for trans people,” they concluded.
