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
- Authors
- Christina M. Roberts, David A. Klein, Terry A. Adirim, Natasha A. Schvey, Elizabeth Hisle-Gorman
- Year
- 2022
- Journal
- The Journal of Clinical Endocrinology & Metabolism
Methodological Limitations
- The study cannot distinguish between true discontinuation and patients obtaining hormones through alternative means (out-of-pocket, non-medical channels, or different insurance), likely underestimating continuation rates. The authors acknowledge: 'If patients elected to pay out of pocket for hormones, accessed hormones through nonmedical channels, or used a different insurance plan to pay for treatment before and/or after obtaining gender-affirming hormones using TRICARE insurance, we did not capture this information.'
- The study relies on administrative billing data with no patient-level clinical information, making it impossible to determine reasons for discontinuation. The authors state: 'We cannot know why patients in our study stopped obtaining refills of gender-affirming hormones using their TRICARE insurance.'
- The use of sex recorded at first encounter as a proxy for sex assigned at birth may be inaccurate. The authors note: 'It is possible that this information is wrong or reflects a change in gender marker that occurred before the beginning of our study interval.'
- The study population is highly specific (dependents of military service members with TRICARE insurance) and may not be generalizable to the broader transgender population. The sample was 90% dependent children, 70% from enlisted families, and excluded active-duty servicemembers entirely.
- The 90-day gap definition for discontinuation is arbitrary and may misclassify patients who temporarily paused hormones or had supply gaps for other reasons.
- The analysis of insurance coverage effects was limited to only 22 months of post-policy change data, which the authors acknowledge as a constraint: 'We limited our analysis of the influence of official insurance coverage to the first 22 months after starting gender-affirming hormones because we only had 22 months of data after the change occurred.'
- The study cannot assess regret directly, yet the Discussion and Conclusion make policy implications about informed consent for minors. The authors admit: 'The lack of patient level detail in our study makes it impossible to predict individual patient outcomes with our findings.'
- The higher continuation rate in minors may reflect parental gatekeeping rather than more informed decision-making. The authors hypothesize parental support explains the difference but cannot test this mechanism with available data.
- The finding that transfeminine individuals have higher continuation rates than transmasculine individuals is novel and unexplained, yet the authors speculate about osteoporosis screening needs without evidence linking discontinuation to oophorectomy in their data.
- The study period (2009-2018) captures a time of rapidly changing social and clinical contexts for transgender care, which may affect the relevance of continuation patterns to current practice.
- Potential conflict of interest: Multiple authors are affiliated with the US Department of Defense and Uniformed Services University, and the study evaluates a DOD healthcare policy change. While the authors state 'no competing interests,' the institutional affiliations suggest potential implicit pressure to support policy positions favorable to the military healthcare system.
Key Findings
- 70% continuation rate at 4 years — roughly 3 in 10 people stopped filling hormone prescriptions within the study period.
- Transfeminine patients continued at higher rates (81%) than transmasculine patients (64%) — females seeking masculinization were 2.4 times more likely to discontinue.
- Minors had higher continuation (74%) than adults (64%) — those who started before 18 were less likely to stop.
- Socioeconomic factors showed no effect — family income, parental military rank, and whether care was officially covered didn't influence continuation rates.
- The study only tracked prescription refills, not reasons or outcomes — continuation does not indicate satisfaction, and the authors could not determine why people stopped.
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.
Summary
This study analyzed U.S. Military Healthcare System records from 2009-2018 to examine gender-affirming hormone continuation rates among 952 transgender and gender-diverse adolescents and adults. The researchers found that over 70% of patients continued hormone therapy for at least four years, with higher continuation rates among transfeminine individuals (81%) compared to transmasculine individuals (64%), and among those who started treatment as minors (74%) versus adults (64%). These findings suggest that concerns about regret and discontinuation among transgender youth may be overstated, and that minors with parental support can provide meaningful informed assent for gender-affirming hormone treatment.
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.