30% Discontinuation Rate: Over 1 in 4 Trans-Identified Youth Stop Hormones Within 4 Years

Continuation of Gender Affirming Hormones Among Transgender Adolescents and Adults

Cohort & registry studies Detransition & regret Cross-sex hormones

Authors: Christina M. Roberts, David A. Klein, Terry A. Adirim, Natasha A. Schvey, Elizabeth Hisle-Gorman
Journal: The Journal of Clinical Endocrinology & Metabolism
Year: 2022
Source: academic.oup.com/jcem/article/107/9/e3937/6572526

Summary

This study used US military health insurance pharmacy records to see how many people who started cross-sex hormones kept refilling them. Of 952 patients, mostly young children of service members, an estimated 70% were still refilling at four years, so roughly three in ten stopped. Females taking testosterone were about 2.4 times as likely to stop as males taking oestrogen. People who started as adults stopped more often than those who started as minors (about 36% vs 26%). The authors say this should reassure people worried about whether minors can agree to hormones. That conclusion goes beyond the data. The study counted prescription refills, not regret, wellbeing or detransition. It could not see why anyone stopped or whether they got hormones elsewhere. And most patients were followed for a short time, so the four-year figures rest on relatively few people.

Key findings

After 4 years, an estimated 70% were still filling hormone prescriptions through military insurance, so roughly 3 in 10 had stopped.
81% of males taking oestrogen kept going, compared with 64% of females taking testosterone. Females on testosterone were about 2.4 times as likely to stop.
74% of those who started as minors kept going, compared with 64% of those who started as adults. Adult starters were about 1.7 times as likely to stop, and about 1 in 4 minors stopped within 4 years.
Stopping was defined as no new prescription for more than 90 days after the last supply ran out, while the person was still using other military health care (on average for 324 more days).
Family income (judged by the service member's rank), family role and the 2016 change to official insurance cover made no measurable difference to whether people kept going.
The study recorded no reasons for stopping and had no information on regret, detransition, mental health or satisfaction, so staying on hormones cannot be read as proof of benefit.
Numbers rose steeply over the decade: 58% of patients had their first gender-related appointment in the last 22 months of the study.

Abstract

Introduction: Concerns about future regret and treatment discontinuation have led to restricted access to gender-affirming medical treatment for transgender and gender-diverse (TGD) minors in some jurisdictions. However, these concerns are merely speculative because few studies have examined gender-affirming hormone continuation rates among TGD individuals. Methods: We performed a secondary analysis of 2009 to 2018 medical and pharmacy records from the US Military Healthcare System. We identified TGD patients who were children and spouses of active-duty, retired, or deceased military members using International Classification of Diseases-9/10 codes. We assessed initiation and continuation of gender-affirming hormones using pharmacy records. Kaplan-Meier and Cox proportional hazard analyses estimated continuation rates. Results: The study sample included 627 transmasculine and 325 transfeminine individuals with an average age of 19.2 ± 5.3 years. The 4-year gender-affirming hormone continuation rate was 70.2% (95% CI, 63.9-76.5). Transfeminine individuals had a higher continuation rate than transmasculine individuals 81.0% (72.0%-90.0%) vs 64.4% (56.0%-72.8%). People who started hormones as minors had higher continuation rate than people who started as adults 74.4% (66.0%-82.8%) vs 64.4% (56.0%-72.8%). Continuation was not associated with household income or family member type. In Cox regression, both transmasculine gender identity (hazard ratio, 2.40; 95% CI, 1.50-3.86) and starting hormones as an adult (hazard ratio, 1.69; 95% CI, 1.14-2.52) were independently associated with increased discontinuation rates. Discussion: Our results suggest that >70% of TGD individuals who start gender-affirming hormones will continue use beyond 4 years, with higher continuation rates in transfeminine individuals. Patients who start hormones, with their parents' assistance, before age 18 years have higher continuation rates than adults.

Conclusion

In our study, transmasculine individuals were more likely to discontinue use of gender-affirming hormones during the first 4 years of use than transfeminine individuals. We also found that individuals who start gender-affirming hormones before reaching the age of legal majority are less likely to subsequently discontinue use when compared with individuals who start hormones after becoming a legal adult. If replicated in future studies, the improved continuation rate among patients who are not legal adults at the time of treatment should provide some reassurance to those concerned about the ability of minors to provide informed assent to use of gender-affirming hormones. A higher continuation rate among minors could also be used to inform the actions of legislators and judges who wish to prohibit gender-affirming treatment for minors to protect them from the consequences of health care decisions they make with the assistance of their parents and health care providers.

Methodological limitations

Refills are not results: The only thing measured was whether people kept filling prescriptions. There was no measure of gender distress, mental health, quality of life, regret or detransition. Yet the authors use the findings to argue that minors can give meaningful agreement to treatment and to advise lawmakers.
Reasons for stopping unknown: The authors admit they cannot know why people stopped refilling. Stopping could mean detransition, side effects, cost, moving away, or feeling they had reached their goals. Irwig's commentary in the same journal (2022) named this as a key weakness.
Hormones from other sources missed: Prescriptions paid out of pocket, through other insurance, or from non-medical sources were not seen, which could make stopping look more common than it was. On the other hand, people who stopped and left military care were dropped rather than counted as stopping, which could make it look less common.
Short, uneven follow-up: 58% of patients first came in during the last 22 months of data, so many were tracked only briefly. The 4-year figures therefore rest on far fewer people who were actually followed that long, and that number is not given in the summary of the paper.
Arbitrary cut-off for stopping: A 90-day gap after the last supply ran out counted as stopping. Irwig noted this is short. The authors did not test other cut-offs or track people who restarted.
Birth sex guessed from records: Birth sex was taken from the sex recorded at the first visit in the data. The authors admit this may be wrong or reflect an earlier change of gender marker.
Few other factors considered: The analysis allowed only for gender identity and age at starting. Mental health conditions, autism, family support, type of prescriber and year of treatment were not examined. So the difference between minors and adults cannot be put down to age or parental support.
Untested explanation for the age gap: The authors credit parental support for minors staying on hormones longer, but had no data on parents. Minors may also have been followed for less time or been more closely watched while living at home.
Unusual group: 90% were children of service members, 71% from enlisted (non-officer) families, and active-duty personnel were left out. Results may not apply to civilian clinics or other countries.
Practice has changed: The data cover 2009 to 2018, before the large rise in teenage girls seeking care and before recent evidence reviews. This limits how well it applies to young people seeking care today.
Written with a policy position: The introduction calls concerns about regret 'merely speculative' before showing any results, and the conclusion speaks to lawmakers and judges, suggesting the paper was framed to support a position. The lead author later published a call to protect military youths' access to gender-affirming care (Roberts, American Journal of Public Health 2023).
Authors work for the system studied: Most co-authors work for the Uniformed Services University or the US Department of Defense, whose health system and insurance policy the study looks at. The authors declare no conflicts of interest.

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Summary

Key findings

Abstract

Conclusion