Hormone Replacement Therapy as a Form of Gender-Affirming Mental Health Care

Access to healthcare is a fundamental right, and it should be no different for transgender individuals. Hormone replacement therapy (HRT) has been established as a form of life-saving, gender-affirming care for transgender individuals. Studies have shown that the mental health of those who are on HRT is significantly better, and the risk of suicidality is reduced for them than that of those who are not (Koch et al., 2019). This is due to the fact that HRT alleviates gender dysphoria—distress one may feel when their assigned gender at birth does not match their gender identity—and reduces low self-esteem and rates of depression. For many transgender individuals around the world, access to gender-affirming care is acknowledged as one of the most important aspects of their lives. Gender-affirming care gives transgender individuals a reason to love and accept who they are. However, many people may never receive the same level of care, especially in the United States, where transphobia in healthcare runs rampant. Transphobia within the healthcare system is a direct consequence of transphobia in society, which contributes to decreased mental health states and higher rates of depression. 

The Minority Stress Model (MSM) is a theory that depicts how gender and sexual minorities may be prone to higher levels of mental distress and fear due to the discrimination they face in society. The MSM, which proposes the understanding in which discrimination and stressors contribute to negative mental health aspects within minority groups, is crucial in understanding how these factors contribute towards the lives of transgender individuals. Transgender and gender non-conforming individuals are more prone to experiencing negative mental health due to transphobia and a lack of social support (Amand et al., 2011). 

HRT being inaccessible within the healthcare system in the United States leaves transgender individuals at a loss. Among the populations of those unable to access HRT, the negative impact on their mental health can lead to isolation, suicidal ideation, substance abuse, and depression (Olson-Kennedy, 2016). Transgender individuals are prone to negative mental health issues, and transgender suicide rates are far higher than those of their cisgender counterparts (Mann et al., 2024). Due to this, proper medical care is hard for many transgender people to obtain, and the lack of proper knowledge among healthcare providers negatively impacts the treatment transgender individuals receive. Studies have shown that 42% of PCPs reported “not receiving any education about transgender healthcare during medical school, residency, or fellowship training, and 60% received additional education about transgender healthcare after completing formal training” (Yip et. al., 2024). 

There are many factors that affect who is able to access HRT, such as age, location, and socioeconomic standing. Age and location often go hand in hand in regards to transgender patients in states with anti-trans laws, specifically trans youth. In many states, it is illegal for healthcare providers to award transgender youth with gender-affirming care. In terms of socioeconomic status, many low-income transgender individuals lack the funds and resources to receive the care they need. HRT is rarely covered by insurance in the United States, and it is costly for those who do not have insurance. For example, the price of HRT for low-income transgender individuals is $720 for transgender men and $2370 for transgender women. The cost for higher-income transgender individuals—who receive insurance coverage—is $230 for trans men and $500 for trans women (Koch et al., 2019).

  Low-income transgender individuals may lack the funds to afford HRT without insurance coverage, and due to this, their mental health may decline severely. Private insurance companies are more likely to cover the costs of HRT as opposed to government programs. Medicaid, a government program that provides health insurance to lower-income individuals, does not cover HRT as opposed to private health insurances, and as many as 17 states do not have explicit policies surrounding HRT coverage (Mann et al., 2024). For lower-income individuals, their reported bad mental health days were 9 out of 30 days, and there was a significantly greater incidence of mental distress within this population (Mann et al., 2024). The decline of transgender mental health is largely attributed to the state of the healthcare system in the United States and the resources awarded to these individuals, or lack thereof.

The mental health of higher-income transgender individuals is directly correlated to the fact that they have the resources to see the proper doctors and healthcare providers needed to achieve the proper care. A diagnosis of gender dysphoria from a psychiatrist or therapist is needed to obtain gender-affirming care in the US, which creates a barrier between those who have access to these resources and those who do not (Koch et al., 2019). Oftentimes transgender individuals may be denied access simply because their provider does not believe HRT is medically necessary (Olson-Kennedy, 2016). Additionally, many healthcare providers with transgender patients often lack the proper knowledge needed to treat these patients (Olson-Kennedy, 2016), which has resulted in a large percentage of transgender individuals educating their doctors on their own treatment. More than one-third of these patients have reported feeling discomfort when disclosing their gender identity to primary care providers in fear of being denied treatment and facing hostility (Amand et al., 2011). 

The importance of proper mental health care is imperative in treating transgender patients, although mental health services as a whole are largely inaccessible and lack the proper research in regards to understanding the nature of the transgender experience (Olson-Kennedy, 2016). Therapists and other mental health care providers must be able to understand the socioeconomic and political context behind the importance of HRT as a form of life-saving care. The ability to provide their patients with the treatment they need can save the lives of these individuals. Understanding the complex nature of gender dysphoria and how to treat transgender patients in order to improve their mental health can make a vast difference.

The effects of HRT have been proven to be an important aspect of mental health care for transgender patients and have positively impacted the lives of many. In order to improve the lives of transgender individuals, reducing costs and making HRT more accessible by educating healthcare providers on the positive aspects of HRT will only serve to promote positive mental health and save the lives of many more.

References

Amand, C. S., Fitzgerald, K. M., Pardo, S. T., & Babcock, J. (2011). The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals. Journal of Gay & Lesbian Mental Health, 15(3), 281–299. https://doi.org/10.1080/19359705.2011.581195

Koch, J. M., McLachlan, C., Victor, C. J., Westcott, J., & Yager, C. (2019). The cost of being transgender: where socio-economic status, global health care systems, and gender identity intersect. Psychology & Sexuality, 11(1–2), 103–119. https://doi.org/10.1080/19419899.2019.1660705

Mann, S. (2024). Access to gender-affirming care and transgender mental health: evidence from medicaid coverage. American Journal of Health Economics, 10(2), 162–181. https://doi.org/10.1086/728080 

Olson-Kennedy, J. (2016). Mental Health Disparities Among Transgender Youth: Rethinking the Role of Professionals. JAMA Pediatrics, 170(5), 423–424. https://doi.org/10.1001/jamapediatrics.2016.0155 

Yip, A. T., Charat, S., Silva, J., & Blumenthal, J. (2024). Primary care provider beliefs and knowledge of prescribing gender-affirming hormone therapy to transgender and gender diverse patients. BMC Primary Care, 25(1). https://doi.org/10.1186/s12875-024-02599-8