Feminine figures: body image and physical characteristics in trans women after puberty suppression and subsequent estradiol therapy.

Background: Several studies have demonstrated an improvement in body image following gender-affirming hormone treatment (GAHT). In transgender girls, puberty suppression (PS) can be initiated before GAHT to prevent masculinization.

Aim: The aim of this study is to assess body image, self-esteem and its determinants in trans women who received PS prior to GAHT.

Methods: Forty-two trans women from a specialized gender clinic who initiated treatment <18 years were included in this cross-sectional study of whom 23 initiated PS in early puberty (Tanner stage G2-3), and 19 in late puberty (Tanner stage G4-5).

Outcomes: Body Image Scale (BIS) scores, ranging from 1 (very satisfied) to 5 (very dissatisfied), Rosenberg self-esteem scores and anthropometric measurements were collected.

Results: Participants were aged 20.1 ± 2.0 years and used GAHT for 4.2 ± 1.6 years. Mean total BIS score was 2.4 ± 0.6, indicating satisfaction. Height, BMI, foot length, and waist circumference correlated with corresponding BIS items, with smaller measurements being associated with higher satisfaction. Although total BIS scores were comparable between the early and late pubertal group (β0.3, 95% CI -0.05;0.7), most BIS items (24/27) scored lower in the early PS group, particularly voice (β-1.4, 95% CI -1.9;-0.8), Adam's apple (β-0.6 95% CI -1.2;0.001) and weight (β-1.1 95% CI -1.9;-0.4). Self-esteem correlated negatively with BIS scores (β-4.5, 95% CI -6.6;-2.5).

Clinical implications: This study reports the potential benefits of PS, especially when initiated early in puberty, on body satisfaction, particularly with voice, and self-esteem in trans women. Clinicians should consider these outcomes when counseling on gender-affirming care and its timing, while also addressing many other factors potentially affecting body image and self-esteem, such as mental wellbeing, social support, quality of life, and other physical parameters like obesity.

Strengths and limitations: Strengths include systematic data collection and the integration of objective and subjective variables. Limitations include a small sample size and potential selection bias due to exclusion criteria and non-participation, possibly affecting generalizability.

Conclusion: Trans women using PS prior to GAHT are overall satisfied with their bodies and have average self-esteem. More feminine anthropometric measurements correspond to higher body satisfaction. Moreover, early start with PS is associated with higher satisfaction with voice, a characteristic strongly influenced by pubertal testosterone exposure.