Highs, Lows, and Hormones: A Qualitative Metasynthesis of Transgender Individuals’ Experiences Undergoing Gender-Affirming Hormone Therapy

Figures & data

Table 1. Quality assessment tool for appropriate community engagement of trans and gender diverse communities in research.

	Score
Item	Evident	Unclear	No
Methodology and Research Design
1. Relevance of research and methodological approach has been carefully considered, with potential community benefit to trans communities clearly articulated.	1	0	0
2. The study allows for the inclusive measurement of an individual’s self-identified gender identity.	1	0	0
3. There is clearly communicated, meaningful community engagement in every step across the research process from study conception, design, interpretation, data analysis, and knowledge translation.	1	0	0
Analysis, Interpretation, and Presentation of Results
4. There is a clear statement made by the research team about their positionality in retrospect to the current participants.	1	0	0
5. The presentation of results does not dismiss or devalue the historical, and continuing, validity of trans identities, for example indigenous “third genders.”	1	0	0
6. Research is presented using culturally and gender sensitive, non-judgmental terminology that avoids stigmatization, discrimination and inherently pathological descriptive terms, research questions, and presentation of results.	1	0	0
7. Confidentiality procedures are clearly described including the use of pseudonym and protection of identities within participant’s communities.	1	0	0
8. Clear reference is made to the intersectional nature of a trans identity, including consideration of how multiple domains may influence study outcomes.	1	0	0
Total:

This tool is not designed for excluding or ranking studies, Rather the aim of this tool is to offer poignant reflection on the overall appropriateness of studies involving trans and gender diverse participants. Higher cumulative best practice scores indicate greater level of meaningful community engagement.

Figure 1. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram.

Table 2. Demographic details of included studies.

Author (Year)	Country	Sample	Aim of study	Analysis Method	NICE	Community Engagement
Abreu et al. (2020)	USA	Focus Groups (N = 15) 15 Transgender women, Mage = 42.8 (22–61) Hispanic = 3, Latina = 4, White Latina/Hispanic = 3, Indigenous Native Latina = 1, Mulata Latina = 1, Mestiza = 1, White = 1, No answer = 1	Explore Latina transwomen experiences with healthcare systems.	Thematic Analysis	++	6
Aguayo-Romero et al. (2015)	Colombia	Life History Interviews (n= 14): Mage = 30.4 (22–46) Focus group (n=11): Mage = 27.9 (21–41) All participants identified broadly as transgender. Ethnic/racial identity not described.	How personal and social factors influence gender affirmation through GAHT and body modification.	Use of iterative coding with deliberation across a team of 5	++	6
Alanko et al. (2019)	Finland	Semi-structured interviews (N=19) 10 males, nine females. N = 19 Mage = 35.20 (21–62) All white	Investigate the experiences of coping and resilience in Finnish transgender adults.	Grounded Theory	++	4
Araya et al. (2021)	USA	Semi-structured interviews (N = 30) 18 transmasculine, 12 transfeminine, Mage = 17.5 (15–20) White = 26, American Indian or Asian American = 4, Hispanic = 5	To understand Transgender adolescents’ experiences with romantic relationships.	Thematic Analysis	++	6
Brown et al. (2012)	USA	Semi-structured interviews (N =9) 9 Male-to-Female Transsexuals, Mage = 33.8 (27–66)	To understand the career experiences of transsexual women.	Consensual qualitative research	++	6
Budge et al. 2012	USA	Semi-structured interviews (N = 18) 13 Male-to-Female, 2 Female-to-Male, 2 gender queer, 1 biologically male cross-dresser, Mage = 45.17 (20–67) White = 14, White and Native American = 4	To explore the emotional experiences of Transgender individuals during GAHT.	Grounded Theory	++	7
Carlile et al. (2021)	UK	Dyadic semi-structured interviews with parents and Transgender or non-binary young people (N = 27) 6 trans male, 1, trans female, 2 as male, one as girl, 2 as trans male AND non-binary, 2 as non-binary, Mage = 15 (5–20) White British/English = 11, non-disclosed ethnic minority = 1, Scottish and Welsh = 1	To understand the experiences of Trans and non-binary children, youth decision-making to seek affirming care.	Iterative thematic analysis	++	6
Cheng (2020)	China	Semi-structured interviews (N = 1), 1 participant identified as male-to-female, Age information not provided, Chinese.	To understand the transitioning experience through a case study of one Chinese trans-woman.	Interpretative phenomenological analysis	++	5
Dadasovich et al. (2017)	USA	Focus groups (N =14), all Transgender men, Mage = NA (20–44) White = 77.1%, Black = 6.6%, Latino = 3.3%, Asian = 4.9%, Other race/ethnicity = 8.2%.	To explore testosterone, use among transman and how it relates to increased behavioral risk for HIV.	Independent coding of qualitative data in team of 2	+	5
Doorduin et al. 2014	The Nether-lands	Semi-structured interviews (N = 12) 4 Transman/boy, 3 Transsexual, 2 Transgender (broadly), 2 Gender dysphoric, 1 Transwoman, Mage = 43.33 (19–60) White Dutch = 11, White Dutch and Jewish = 1.	To understand the connection between sexual development and gender development.	Grounded Theory	+	4
Giovanardi et al. (2019)	Italy	Semi-structured interviews (N = 10), all Trans women, Mage = 37.40 (23–62) Race/ethnicity not described.	To understand the perspectives of older Trans people on hormone suppression.	Consensual Qualitative Research Method	++	4
Klein et al. (2018)	USA	Semi-structured interviews and blogs (N = 1), identified as female-to male, aged 20 at study start. Race/ethnicity not described.	To understand the experiences of a Transgender college student as they commence GAHT.	Narrative approach	++	5
Lindley et al. 2020	USA	Semi-structured interviews (N = 14), 8 Female-to-Male/Trans Man, 3 male/masculine, 2 Male-to-Female, 1 gender-nonconforming, Median age = 25 (18–35). White non-Hispanic = 6, Hispanic/Mexican = 3, African American = 1, American Indian = 1, No answer = 3.	To understand ecologically different levels of influence have impact on participant’s sexuality.	Deductive content analysis	++	6
Loza et al. 2017	USA	Semi-structured interviews (N = 13), all transgender women, all aged 18+ (no other age information available). Mexican/Latina = 7, no other race/ethnicity information provided.	To understand health risks and barriers to care for Transgender women living on a USA—Mexico border city.	Ethnographic and phenomenological techniques.	++	6
Mohamed et al. 2018	UK	Open-ended questionnaire (N = 67), all Transgender women, Mage = 48.67 (20–79) White = 96%, Mixed ethnicity = 4.	To understand Transgender women’s experiences and attitudes toward hormone therapy, particularly as they age.	Inductive thematic analysis	++	6
Padilla et al. (2018)	Puerto Rico	Ethnographic observations and semi-structured interviews (N = 39), all Transwomen, Mage = 29 (range not provided) Race/ethnicity not described.	To understand hormone and silicone injection in Puerto Rican Transwomen.	Elaborate process of coding as a team.	++	6
Petry (2015)	Brazil	Narrative Interviews using a pre-structured script (N = 7), all Transwomen, age information not provided. Race/ethnicity not described.	To understand Transwomen’s experience of GAHT and sex-reassignment surgery.	Organization of reportedly important information.	+	4
Regmi et al. (2019)	Nepal	Focus Groups (n=62), all transwomen, Mage = 23.06 (range not provided). Semi-structured Interviews (n=9), all transwomen, age information not provided. Bahmin/Chhetri = 26, Newar = 8, Janajati = 25, Dalit = 3	To understand the usage and side effects of hormones in transgender women in Nepal.	Thematic Analysis	++	6
Restar et al. (2019)	The Philip-pines	Semi-structured interviews (N = 9). All Transwomen, Mage = 25.6 (18–29) Race/ethnicity not described.	Understanding how decisions around GAHT can be influenced and connect with antiretroviral therapy for HIV.	Thematic Analysis	++	5
Riggs et al. (2020)	Australia	Dyadic semi-structured interviews with parents and Transgender or non-binary young people (N = 10), 5 males, 4 females, 1 non-binary, Mage = 14.3 (range not provided) Race/ethnicity not described.	To explore how young Transgender people and their parents perceive the medical care they have experienced.	Thematic Analysis	++	3
Romito et al. (2021)	USA	Semi-structured interviews (N = 9), 7 females at birth, 2 as male at birth, Mage = 17 (16–20) White = 7, Ethnic minority = 2.	To explore how gender identity and gender-transitioning influence body image and disordered eating.	Identifying themes in case studies.	++	6
Rosenberg et al. (2019)	Australia	Semi-structured interviews (N = 12), all transwomen, Mage = N/A (23–54) Race/ethnicity not described.	To understand how Transgender women navigate changes in sexuality following GAHT.	Thematic Analysis	++	6
Pullen Sansfaçon et al. 2019	Canada	Semi-structured interviews (N = 35), 14 Transfeminine, 22 Transmasculine*, Mage = N/A, 4 aged 9–11, 14 aged 13–15, 17 aged 16–17. White/Anglo-Saxon/Caucasian/Irish/Canadian/Québécois = 24, Non-white or Indigenous = 4, No answer = 7.	To understand Transgender youth’s experiences, including their goals, perspectives toward care, and feelings about medical interventions.	Grounded Theory and Thematic Analysis	++	7
Y. Singh et al. (2014)	India	Focus Groups (n=7), 57% hijra, 43% transgender, Mage = 27.4 (17–46) Semi-structured interviews (N = 30), ~60% transgender, 23% hijra, woman (n=4), Mage = 27.1 (19–54) Race/ethnicity not described.	To understand male-to-female individual’s access to and use of gender transition services in 7 Indian cities.	Grounded Theory and Thematic Analysis	++	6
Van Schuylenbergh et al. (2019)	Belgium	Semi-structured interviews (N = 9). All women, Mage = 46.22 (40–54) Country of origin: Spain = 1, Belgium = 1, Ecuador = 7.	To explore uncontrolled GAHT, silicone usage and condom usage in Transgender sex workers.	Grounded theory.	++	6
R. Wassersug et al. (2007)	Canada	Semi-structured interviews (N = 12), all women, Mage = 46 (30–63). White Canadian born = 11, Latina born in Central America = 1	To explore Transgender women’s experiences undergoing GAHT.	Independent coding of qualitative data in team of 6.	++	5
Winter and Doussantousse (2009)	Laos	Structured Interview (N = 112), 50% kathoey (transgender women), 37.5% third gender/women of the second kind, 12.5% women/“real woman,” Mage = 21.84 (14–36) Race/ethnicity not described.	To explore South-East Asian Transgender people’s perspectives on GAHT, including their experiences on GAHT and how it is accessed.	Qualitative information was quantified into portions of samples who endorsed similar responses.	+	6
R. J. Wassersug and Gray (2011)**	Canada	Semi-structured interviews (N = 12), all transwomen, Mage = 46 (30–63) White Canadian born = 11, Latina born in Central America = 1	To compare the transitioning experiences of Transgender woman compared to cisgendered men undergoing prostate cancer therapy.	Interpretative phenomenology techniques.	++	1

Ps = Participants; GAHT = Gender Affirming Hormone Therapy. All gender identities are self-identified by participants. The terminology used in this table is from the original published articles include in this review and may not reflect contemporary language and may be considered offensive to some. * = numbers exceed total number of participants, however, are reported directly from the paper. ** Participants are the same as in R. Wassersug et al. (2007). NICE = National Institute for Healthcare and Excellence Checklist for Qualitative Research; Community engagement assessed with the purpose built Quality Assessment Tool For Appropriate Community Engagement of Trans and Gender Diverse Communities in Research, scores out of a possible 8.

Table

Section and Topic	Item #	Checklist item	Location where item is reported
TITLE
Title	1	Identify the report as a systematic review.	Page 2
ABSTRACT
Abstract	2	See the PRISMA 2020 for Abstracts checklist.	Page 1
INTRODUCTION
Rationale	3	Describe the rationale for the review in the context of existing knowledge.	Page 3–4
Objectives	4	Provide an explicit statement of the objective(s) or question(s) the review addresses.	Page 3–4
METHODS
Eligibility criteria	5	Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses.	Page 4–5
Information sources	6	Specify all databases, registers, websites, organizations, reference lists and other sources searched or consulted to identify studies. Specify the date when each source was last searched or consulted.	Page 4
Search strategy	7	Present the full search strategies for all databases, registers and websites, including any filters and limits used.	Appendix A
Selection process	8	Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.	Page 4
Data collection process	9	Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.	Pages 5–6
Data items	10a	List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.	Page 6
	10b	List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.	Page 6
Study risk of bias assessment	11	Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.	Page 5
Effect measures	12	Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results.	N/A (qualitative research)
Synthesis methods	13a	Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).	Page 6
	13b	Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.	Page 6
	13c	Describe any methods used to tabulate or visually display results of individual studies and syntheses.	Page 6
	13d	Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.	Page 6
	13e	Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression).	Page 6
	13f	Describe any sensitivity analyses conducted to assess robustness of the synthesized results.	N/A (no meta-analysis conducted
Reporting bias assessment	14	Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases).	Page 5
Certainty assessment	15	Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome.	N/A
RESULTS
Study selection	16a	Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.	Figure 1
	16b	Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded.	Figure 1
Study characteristics	17	Cite each included study and present its characteristics.	Table 2
Risk of bias in studies	18	Present assessments of risk of bias for each included study.	Table 2
Results of individual studies	19	For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimate and its precision (e.g. confidence/credible interval), ideally using structured tables or plots.	N/A (no meta-analysis conducted
Results of syntheses	20a	For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies.	Page 7
	20b	Present results of all statistical syntheses conducted. If meta-analysis was done, present for each the summary estimate and its precision (e.g. confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.	N/A (no meta-analysis conducted
	20c	Present results of all investigations of possible causes of heterogeneity among study results.	N/A (no meta-analysis conducted
	20d	Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results.	N/A (no meta-analysis conducted
Reporting biases	21	Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed.	N/A (no meta-analysis conducted
Certainty of evidence	22	Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed.	N/A (no meta-analysis conducted
DISCUSSION
Discussion	23a	Provide a general interpretation of the results in the context of other evidence.	Pages 12–15
	23b	Discuss any limitations of the evidence included in the review.	Pages 14–15
	23c	Discuss any limitations of the review processes used.	Pages 14–15.
	23d	Discuss implications of the results for practice, policy, and future research.	Pages 12–15
OTHER INFORMATION
Registration and protocol	24a	Provide registration information for the review, including register name and registration number, or state that the review was not registered.	Page 4
	24b	Indicate where the review protocol can be accessed, or state that a protocol was not prepared.	Page 4
	24c	Describe and explain any amendments to information provided at registration or in the protocol.	Page 4
Support	25	Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review.	Title Page
Competing interests	26	Declare any competing interests of review authors.	Page 15
Availability of data, code and other materials	27	Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.	Page 15

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Data availability statement

Data extracted from included studies is described in Table 2 and is otherwise available in their published forms. All other resources are not publicly available.