A Scale to Center and Measure Trans Women/Transfeminine Persons' Satisfaction with Feminizing Hormone Therapy: Results of the Feminizing Hormone Satisfaction Scale (FEM-SQ)

Background and Purpose: Feminizing hormone therapy (FHT) is essential for the well-being of trans women and gender diverse transfeminine persons who seek it. FHT accessibility can directly influence mental health and quality of life. Despite its significance, there are notable gaps in research regarding trans women/transfeminine persons’ perceived satisfaction with FHT, stemming from a lack of tools to adequately assess such satisfaction. Thus, our team sought to address this gap by utilizing community-based participatory research methods to develop and test the FEM-SQ to assess trans women/transfeminine persons’ satisfaction with FHT. Such a scale may be useful both for research and fostering patient-provider collaborative FHT decision-making.

Methods: Our interdisciplinary team developed the FEM-SQ and piloted it with trans women/transfeminine persons and FHT prescribers. The scale was designed to measure the importance of social, emotional, and physical changes anticipated with FHT, as well as participants’ satisfaction with each change and overall satisfaction. We then employed a convergent parallel mixed methods study design, administering a cross-sectional online survey with 227 trans women/transfeminine persons aged 18+ taking FHT for 3+ months living in Canada. The survey included the FEM-SQ (Version 3, Importance sub-scale=17 items; Satisfaction sub-scale=18 items), as well as open-ended questions eliciting further in-depth responses regarding satisfaction with each change. We analyzed quantitative data utilizing descriptive statistics (means, SDs, proportions); Cronbach’s alpha was computed to measure sub-scale internal reliability. Qualitative data were analyzed using a thematic approach.

Results: Participants (mean age 32, SD: 11) mostly identified as trans women (78.0%) and white (72.7%). The FEM-SQ's Importance and Satisfaction sub-scales demonstrated good internal reliability (Cronbach’s alpha of 0.7985 and 0.8709, respectively). Importance sub-scale scores were high, averaging 74.09 (SD = 7.81) out of 85. The Satisfaction sub-scale further demonstrated a positive trend, with an overall mean satisfaction score of 65.38 (SD = 9.96) out of 90, reflecting generally positive satisfaction levels with FHT. Participants were most satisfied with softening of the skin (mean: 4.47, SD: 0.71); comfort with friends (mean: 4.33, SD: 0.83); and self-love (mean: 4.20, SD: 0.96) (max score of 5). Participants were least satisfied with FHT’s impact on thinned/slowed growth of facial hair (mean: 2.96, SD: 1.27); changes to sex drive (mean: 3.61, SD: 1.17); and breast growth (mean: 3.62, SD: 1.07) (max score of 5). Qualitative feedback underscored the complexity of medical transition, the critical importance of FHT in participants’ lives, and the significant role of social support and healthcare teams in supporting trans women/transfeminine persons taking FHT.

Conclusions and Implications: The FEM-SQ effectively captured a broad range of trans women/transfeminine persons’ experiences with FHT, indicating that despite some areas of lower satisfaction, overall FHT is profoundly positive for most. Through these findings, we advocate for an ecological and person-centered approach to FHT, encouraging dialogue between clinicians and patients to accommodate each individual's unique needs, aspirations, and experiences. This approach may foster a deeper understanding of trans and gender diverse peoples’ needs and better-tailored healthcare interventions, highlighting the essential nature of FHT to many trans and gender diverse people.