Only 2% of Children Who Begin Gender-Affirming Hormone Treatment Stop

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A new, large study found that 98% of those who began gender-affirming hormones as adolescents were continuing treatment five years later. Getty Images
  • A study published in The Lancet Child & Adolescent Health indicates that it’s extremely rare for people who begin gender-affirming hormone treatment as adolescents to discontinue treatment.
  • Healthcare providers believe the study dispels the myth that de-transitioning is rampant.
  • Providers hope the study offers more reasons to validate youth who seek gender-affirming treatment. They shared other ways communities can show support for a population at a higher risk for poor mental health outcomes.

People who start gender-affirming hormone treatment during adolescence rarely discontinue, according to a new study published in The Lancet Child & Adolescent Health.

The study, the largest to date, indicated that 98% or 704 out of 720 participants who began gender-affirming hormone treatment during adolescence were still receiving it at a follow-up appointment.

Though the study was performed by researchers in the Netherlands, it comes at a critical time in the debate over gender-affirming hormone care in the United States.

The first trial in the U.S. over a statewide ban on gender-affirming care began last week.

The case, Brandt v. Rutledge, is in response to Arkansas’ first-of-its-kind ban on gender-affirming care in 2021.

Three states (Alabama, Texas, and Arizona) followed, with more than a dozen more considering similar legislation.

The American Academy of Pediatrics (AAP) submitted briefs to fight the Arkansas ban and has said it’s reaching out to lawmakers to “express concerns about the harmful legislation.”

“It’s very controversial, especially in the U.S., since it is believed by some that children and adolescents don’t have the capacity to truly understand what gender they should be and any discomfort they feel with their bodies is potentially temporary,” says Dr. Zishan Khan, a child, adolescent and adult psychiatrist with Mindpath Health. “However, this study suggests that this is not actually true for the vast majority of individuals that take the more extreme measures of stopping puberty and starting gender-affirming hormone therapy.”

Another study, published in Pediatrics in July, also highlighted the rarity of changing gender identity.

It indicated that 94% of the 317 participating patients maintained their gender identity at a five-year follow-up.

According to data compiled by Reuters and Komodo Health, Inc., the percentage of children ages 6 to 17 diagnosed with gender dysphoria nearly tripled to 42,000 from 2017 to 2021.

Experts say that, for them, access to gender-affirming hormone treatment can be lifesaving, and they hope this study helps confirm the need for it.

How the study highlights the need for gender-affirming care

Researchers evaluated medical records from a gender identity clinic in Amsterdam. The 720 participants were using a puberty-suppressing treatment for at least three months before using gender-affirming hormones. They began this puberty-suppressing treatment before turning 18.

Of the participants, 31% (220) were assigned male at birth. These individuals had a median age of 14 when initiating puberty-suppressing treatment and a median age of 20 after the follow-up. The other 69% (500) participants were assigned female at birth and had a median age of 16 when beginning puberty-suppressing treatment. Their median age was 19 years old post-follow-up.

Researchers wrote that the time between initiating treatment and the follow-up varied by the patient and emphasized caution when interpreting data from the shortest intervals. Still, Khan believes the results are significant.

“What this study shows is that the vast majority of adolescents that make the difficult decision to transition from the gender assigned to them at birth are truly invested and in it for the long haul,” he says. “This isn’t just a silly phase they are going through and a period of time that will pass due to them not being comfortable with the natural changes every human experiences when going through puberty.”

But what about the 2% that chose to cease gender-affirming hormone therapy before the follow-up?

The researchers write that they aren’t sure why the patients discontinued hormone treatment and noted that it isn’t clear if they regretted the decision to transition. They emphasized that there could be many explanations, such as:

  • lack of awareness about the need to keep receiving hormone treatment after a gonadectomy, which is the surgical removal of the testes or ovaries
  • non-binary-identifying individuals who wanted to use the hormone treatment for a short duration

“Non-binary has more recently come into use and light,” explains Dr. Jennifer Osipoff, FAAP, a pediatric endocrinologist at Stony Brook Children’s Hospital. “Somebody who is a trans male who stops taking testosterone may not stop taking it because they do not want to be a male. They may have reached the masculinization that they were hoping to get, such as facial hair. It doesn’t mean they were unhappy with their decision.”

Osipoff agrees that further research into why a small percentage of people stop is important.

Research published in 2021 suggested that reasons for de-transitioning were largely external and included financial, family, and societal stigma.

“Some may stop due to the transphobic climate that is in our society today,” Lee Phillips, EdD, LCSW, CST, a psychotherapist.

What is gender-affirming care?

Gender-affirming hormone treatment is under a larger umbrella regarding gender-affirming care.

Osipoff says gender-affirming care varies by person and can also include the use of their correct pronouns and names by providers and surgery.

The use of hormone treatment in teenagers has been at the center of controversy in the legal and medical communities. Puberty blockers can delay gender expression characteristics that a youth patient may not want, such as:

  • breast development
  • widening hips
  • facial hair
  • deepening voice

Dr. Michelle Forcier, a FOLX Health clinician, stresses that puberty blockers are reversible. Though it’s rare for adolescents to change their minds, they can.

“A child can take these medications and stop them without lifelong and future implications,” she says. “They give youth and parents time to catch up and learn more about their gender identity, to understand gender care options, and to make careful decisions about their current and future gender identity.”

Research indicates that an adolescent receiving gender-affirming hormone treatment has better mental health outcomes, including one study published in 2022.

Meanwhile, a 2020 study by Pediatrics indicated that adolescents who received gender-affirming medical care later in puberty were more likely to have poorer mental health, including depression, and commit self-harm than their peers who started early.

“So many youth feel relieved when they know they do not have to go or keep going through the wrong puberty,” Forcier says. “They no longer have to watch and live in a body that is going through irreversible changes that mark them as physically and socially in the wrong gendered body. With that relief, we can see a reduction in mental health concerns such as anxiety, depression, suicidality, difficulty concentrating, and difficulties at home and school.”

Forcier and Osipoff say there is some concern about decreasing bone mineral density temporarily.

A 2020 study suggested that early-pubertal transgender youth had lower bone mineral density, but the authors said that low calcium intake and physical activity could play a role.

How to support adolescents through gender-affirming care

The statistics on mental health and gender-incongruent teens are grim.

A 2018 review pointed to research that indicated that almost one-third of transgender teens had attempted suicide.

Anxiety and depression are also more common in trans youth than in cisgender youth. Non-healthcare providers can’t administer gender-affirming hormone treatment, but experts share that they can help in other ways, including:

  • using the correct pronouns and names
  • ensuring adolescents with gender dysphoria have access to mental health care
  • supporting families of youth with gender dysphoria
  • increasing representation of gender-incongruent individuals
  • being anti-transphobic

A small 2018 study of 129 transgender youth indicated that using the chosen name of a transgender person reduced mental health risks.

Forcier suggests normalizing asking everyone about pronouns so that the burden doesn’t fall on trans and non-binary people.

“When you introduce yourself in a conversation, offer and include your asserted name and pronouns as part of those conversations. Ask others what names and pronouns they use,” Forcier says.

Using pronouns on nametags, office doors, and social media accounts is also helpful, Forcier adds.

Though gender-affirming hormone treatment can lead to better mental health outcomes, Osipoff stresses trans and non-binary youth are at a higher risk for suicide, depression, and anxiety.

Reaching out to a mental health provider specializing in transgender care can help them navigate their treatment during their gender journeys.

Treatment and support can also help parents and family members.

“It is important to find support in the community,” Phillips says. “This helps the parent or parents or caretakers feel less alone.”

Phillips suggests genderspectrum.org, which hosts free online groups for pre-teens, teens, parents, and caregivers.

Forcier advises people to include imagery and stories about diverse identities in stories, newsletters, and pamphlets. School officials and other adults can partner with or support LGBTQ pride events and organizations like Gay Straight Alliances (GSA) so transgender and non-binary youth feel less isolated.

Finally, Forcier says it’s imperative to root out internal and external biases.

“Calling out, correcting, or stopping others who use biased language or are discriminating against a TGD person is also important to create safe spaces for our youth in our communities,” Forcier says.

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