87 % des ados néerlandais sous bloqueurs sont passés aux hormones croisées ; 3,5 % ont arrêté, dysphorie atténuée

Trajectoires d'adolescents traités par analogues de l'hormone de libération des gonadotrophines pour dysphorie de genre

Études de cohorte & registres Détransition & regret Bloqueurs de puberté

Authors: Tessa Brik, Lieke J.J.J. Vrouenraets, Martine C. de Vries, Sabine E. Hannema
Journal: Archives of Sexual Behavior
Year: 2020
Source: https://doi.org/10.1007/s10508-020-01660-8

Summary

Puberty blockers are often described as a "pause button" that gives teenagers time to think about their gender. This study from one Dutch clinic checked what actually happened to the 143 teens who started blockers there between 2010 and 2018. Almost all (87%) went on to cross-sex hormones, usually within a year. Only nine stopped blockers, and five of those (3.5%) no longer wanted gender treatment. The authors say the high rate of moving on may be because the clinic only chose teens very likely to continue. They openly say their study cannot tell whether blockers themselves make teens more likely to stay on the medical path. Many trans boys started blockers at about 16, when puberty was mostly over. Tracking stopped once hormones began, so the study tells us nothing about long-term health or later detransition.

Key findings

Sur 214 adolescents de la clinique de Leyde assez âgés et assez avancés dans la puberté, 143 (67 %) ont été jugés aptes aux bloqueurs de puberté, et tous ont commencé entre novembre 2010 et janvier 2018.
125 (87 %) sont passés aux hormones du sexe opposé après une durée typique de 10 mois sous bloqueurs ; 5 étaient encore trop jeunes pour les hormones et 6 avaient changé de clinique.
Neuf adolescents (6 %) ont arrêté les bloqueurs. Quatre d'entre eux voulaient encore un traitement lié au genre et ont arrêté à cause d'effets secondaires, de troubles de l'humeur ou de raisons pratiques ; un a repris et trois ont ensuite commencé des hormones ou des médicaments pour arrêter les règles.
Cinq adolescents (3,5 %) ne voulaient plus de traitement lié au genre. Leurs raisons comprenaient le sentiment d'être non binaire, être tombé amoureux, et des problèmes personnels ou familiaux qui empêchaient d'explorer leurs sentiments.
Vingt adolescents sont restés sous bloqueurs plus longtemps que ce que prévoyait le plan de la clinique, le plus souvent à cause d'une vie familiale ou sociale instable, d'autres affections comme l'autisme ou la dépression, ou de raisons pratiques.
L'âge typique de début était de 15 ans pour les filles trans et de 16 ans pour les garçons trans ; beaucoup ont donc commencé tard dans la puberté ou après, quand les bloqueurs ont peu d'effet physique.
Les auteurs reconnaissent que leur étude ne peut pas montrer si les bloqueurs eux-mêmes rendent plus probable la persistance de la détresse de genre.

Abstract

Gonadotropin-releasing hormone analogues (GnRHa) are recommended as initial treatment for adolescents diagnosed with gender dysphoria, providing time to follow gender identity development and consider further treatment wishes without distress caused by unwanted pubertal changes. This has been described as an extended diagnostic phase. However, there are also concerns about the physical, neurocognitive, and psychosocial effects of this treatment. In this retrospective study, we document trajectories after the initiation of GnRHa and explore reasons for extended use and discontinuation of GnRHa. Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys; median age, 15.0 years [range, 11.1-18.6] and 16.1 years [range, 10.1-17.9]). After a median duration of 0.8 years (0.3-3.8) on GnRHa, 125 (87%) started gender-affirming hormones (GAH). Nine (6%) discontinued GnRHa, five of whom no longer wished gender-affirming treatment. Thirteen had used GnRHa for longer than required by protocol for reasons other than logistics and regularly met with a mental health professional during this time, supporting the use of GnRHa treatment as an extended diagnostic phase. In conclusion, the vast majority who started GnRHa proceeded to GAH, possibly due to eligibility criteria that select those highly likely to pursue further gender-affirming treatment. Due to the observational character of the study, it is not possible to say if GnRHa treatment itself influenced the outcome. Few individuals discontinued GnRHa, and only 3.5% no longer wished gender-affirming treatment.

Conclusion

A small number of adolescents discontinued GnRHa because they no longer wished gender-affirming treatment, showing that gender identity can still fluctuate on GnRHa in some adolescents; whether gender dysphoria would have subsided in more of them without GnRHa is uncertain. Some used GnRHa for a prolonged period while regularly meeting a mental health professional, consistent with GnRHa as an extended diagnostic phase. The great majority continued to gender-affirming hormones, possibly because eligibility criteria select those highly likely to pursue further treatment, and this should be taken into account when counselling adolescents and parents.

Methodological limitations

No comparison group: The study did not include teens who went without blockers. So it cannot tell whether the 87% who moved on had settled identities, were carefully chosen, or were pushed further along the path by the blockers themselves. The authors say this openly.
Based on old medical files: What happened to each teen, and why some stopped, came from routine clinic notes. If notes were incomplete or unclear, the reasons recorded may be wrong or missing.
Short follow-up: Teens were only tracked until they started hormones or until July 2019. The authors note gender distress might return in those who stopped, and nobody checked whether those who continued later detransitioned.
Some results unknown: Six teens moved to other clinics and five were not yet old enough for hormones when data were collected, so we do not know what happened to them.
Only pre-screened teens: A third of teens old enough were not given blockers, including those without a confirmed diagnosis and those with other problems. The results only apply to a carefully chosen group.
Small, single clinic: 143 patients from one Dutch clinic, with only 9 who stopped, gives rough numbers that may not hold for other clinics or countries.
Treatment came late: Many trans boys started blockers at about 16, when puberty is mostly finished. So the idea of a "pause to explore" barely applied, and some patients told the team blockers added nothing at that stage.
No health results measured: The study only reports which path teens took. It did not measure mental health, bone strength, thinking skills or sexual development, so it says nothing about benefit or harm.
Rules changed during the study: The clinic lowered the age for starting hormones in 2016 and 2017. This changed how long teens stayed on blockers and makes the time on blockers harder to interpret.
Authors have ties to the treatment: Two authors (M.C. de Vries and S.E. Hannema) were paid for talks by Ferring, a drug company, and all the authors work at the clinic that gives the treatment.

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Summary

Key findings

Abstract

Conclusion