O4313: Psychosocial Outcomes Associated with Gender-Affirming Care in Pediatric Patients-A Systematic Review

Background: There is disagreement in the medical community about the best course of treatment for pediatric gender dysphoria. To provide support for recommendations, we examined the body of evidence evaluating the effects of hormone therapy (ie, puberty suppressing agents and cross-sex hormones) in transgender, nonbinary, and other gender-diverse (TGNB) adolescents.

Methods: Eligible studies were experimental, observational, or descriptive studies published after 2010 that included TGNB adolescents receiving puberty suppressors or cross-sex hormones as either study eligibility criteria, exposures, or outcomes. Reproducible/structured searches were conducted in Ovid Medline and Embase. We also contacted experts and checked trial registries and reference lists in relevant publications. Selected studies compared TGNB patients before-and-after treatment or compared treated-versus-untreated TGNB patients. Abstract and full-text eligibility screening was performed in duplicate, while data extraction and risk-of-bias (RoB) assessment was conducted by a single author, with accuracy assessed by a second.

Results: In total, out of 1425 unique citations retrieved, 224 met eligibility criteria. Of those, N=16 studies examined psychosocial outcomes, with 8 examining emotional and behavioral problems, 7 examining psychological functioning, and 6 examining quality-of-life. N=14 studies reported before-and-after comparisons (Table 1) and N=5 studies reported treated-versus-untreated comparisons (Table 2).

In before-and-after comparisons, results were generally favorable, with many significantly improved findings across psychosocial outcomes (15 metrics across 10 studies). Only one study showed a significantly worsened outcome: functioning age-appropriately in peer relationships. In treated-versus-untreated comparisons, 3 studies showed significantly improved scores across 8 psychosocial metrics. Overall, hormone therapy improved emotional and behavioral problems, psychological functioning, and patient quality of life. All 4 studies examining psychological functioning with the Children’s Global Assessment Scale (CGAS) showed significant improvements with hormone therapy. Results for most other metrics varied from nonsignificant changes to significant improvements, with the exception of the peer-relationship functioning outcome that significantly worsened.

All included studies had at least a moderate RoB. Study limitations included lower quality study designs such as descriptive and observational; there is a lack of more robust evidence (eg, randomized controlled trials). Additionally, sample sizes in studies following youth over multiple years tend to be small, and outcome measures were often subjective, based on self-report. Additional key limitations include inconsistent treatments and timing between study cohorts, and possible confounding due to varying levels of familial and social support, psychological counseling, timing of treatment, and access to therapy and gender affirming surgery.

Conclusion: While systematic reviews with higher quality of evidence are still desired, our review suggests that hormone therapy for the treatment of gender dysphoria significantly improves psychosocial functioning in TGNB adolescents based on the currently available observational evidence.