29% van de jongeren in genderklinieken verandert van gedachten over medische transitie

Verschuivingen in gendergerelateerde medische verzoeken van transgender en genderdiverse adolescenten

Cohort- & registerstudies Detransitie & spijt

Authors: Ariel Cohen, Veronica Gomez-Lobo, Laura Willing, David Call, Lauren F. Damle, Lawrence J. D'Angelo, Amber Song, John F. Strang
Journal: Journal of Adolescent Health
Year: 2023
Source: https://www.sciencedirect.com/science/article/abs/pii/S1054139X22007194

Summary

Clinicians at a Washington, DC children's gender clinic reviewed the records of 68 teenagers who had asked for cross-sex hormones or surgery. They also interviewed each young person's mental health clinician about how those requests changed. About three in ten (29%) changed their minds at some point. Most changes came before any treatment, and the most common pattern was stepping back from a request and later asking again. Five stopped asking altogether. Three changed after starting hormones: two stopped after reaching their goals and one stopped with regret. Nonbinary youth were more likely to change. The authors conclude that changing one's mind is a normal part of teenage gender exploration and that ongoing mental health support is valuable. The study is small, from one clinic, relied on clinicians' memories rather than the teens, and left out many followed under two years.

Key findings

Van 68 tieners die om cross-sex hormonen en/of operaties hadden gevraagd, veranderden 20 (29%) hun verzoek tijdens de follow-up.
Non-binaire jongeren vormden een groter deel van wie veranderde (9 van de 20, tegenover 6 van de 48 die niet veranderden). Leeftijd, autisme en geboortegeslacht maakten geen duidelijk verschil.
17 van de 20 veranderingen (85%) vonden plaats voordat een behandeling begon. Het meest voorkomende patroon (9 jongeren, 45%) was behandeling vragen, het verzoek intrekken en later opnieuw vragen.
Vijf jongeren (een kwart van wie veranderde) trokken hun verzoek in en vernieuwden het niet tijdens de follow-up, en nog een jongere overwoog alleen in de toekomst behandeling.
Drie veranderden na het starten van hormonen: twee stopten na het bereiken van hun doelen, en één stopte en meldde spijt, terwijl die ook een ernstige psychische aandoening had.
Negen van de 20 die veranderden (45%) beschreven ook een verandering in genderidentiteit, meestal van trans man of trans vrouw naar non-binair. Bij één jongere liep de identiteit via identificatie met het geboortegeslacht voordat die uitkwam bij trans man.
De redenen vielen in twee groepen: nog zoeken naar hun gender (meer levenservaring willen, identiteit verkennen) en druk van anderen (gebrek aan steun, zorgen over coming-out, ervaren groepsdruk).

Abstract

Purpose: Gender-affirming hormones and/or surgeries seeking to change the body can have potentially lasting effects. Changes in requests for these therapies among gender-diverse youth are not well-understood. The study aim is to characterize factors associated with shifts in gender-related medical requests.

Methods: This mixed-methods study used retrospective chart review and qualitative interviews with clinicians. Of 130 youth receiving clinical gender care at Children's National Hospital, 68 met inclusion criteria. Qualitative interview analysis was performed to identify patterns and themes around shifts in gender-related medical requests over time. Statistical analysis employed chi-square and t-tests to compare characteristics in the shift versus no-shift groups and kappa statistics to calculate qualitative coding agreement.

Results: Of the 68 youth followed over time (mean age 15.11 years, 47% autistic, 22% nonbinary), 20 (29%) reported a shift in request. No significant differences were found by age, autism status, or designated sex at birth. More youth with shifts were nonbinary (p = .012). Six shift profiles were identified from qualitative interviews with excellent reliability (κ = 0.865). Four of the profiles reflect shifts in request prior to starting treatment (85% sample); two involved shifts after commencing treatment (15%). The most common profile reflected a medical request that was made, withdrawn, and re-requested (45%).

Discussion: Shifts in gender-affirming medical requests by gender-diverse youth may not be uncommon during the adolescent's gender discernment process, and may more likely occur among nonbinary youth. Many individuals who experience shifts away from medical treatment may later resume the request.

Conclusion

Shifts in requests for gender-affirming hormone therapy and/or surgery by gender diverse youth may not be uncommon during their gender discernment process. These shifts may be more likely to occur among nonbinary youth. Initial evidence suggests that these shifts may not be more common among autistic youth. Many youth who experience shifts away from medical treatment may later resume the request. Given these findings, to meet the gender-affirming goals and needs of youth, clinicians providing gender-affirming hormones and/or surgery must continue to clarify goals of treatment, intended outcomes, or stop-points (e.g., once a specific amount of secondary sex development occurs) over time. The clinic for this study employed most elements of the Dutch gender care approach. It is important to note that not all gender clinics employ this approach (e.g. some gender services programs advocate for informed consent for gender-affirming medical treatment without mental health evaluations). By requiring a relationship with mental health services to obtain gender-affirming hormones and/or surgery, the Dutch model may be challenging to provide, given limited availability of mental health providers with gender expertise. Our study shows that there is likely a benefit and a potential role for mental health services to support youth even when shifting away from a request for medical gender-affirming interventions, as a shift in request is not necessarily a final ending point in the gender discernment process.

Methodological limitations

Second-hand information: Reasons and patterns came from interviews with each young person's mental health clinician and from records, not from the young people. The authors call this the main limitation, and it means memories and interpretations could be wrong.
Clinicians judging their own patients: The three clinicians interviewed (also co-authors) were the young people's own clinic staff, and they themselves picked out who had changed. Coding was done in the same hospital, so nobody independent checked why requests changed.
Very small numbers: Only 20 young people changed, spread across six patterns and eight reasons. The authors say this was too few to compare patterns statistically, so links such as regret with mental illness rest on one or two cases.
Who was included skews the figure: Young people with no change were included only if followed for at least two years. The 62 left out were older at first visit and moved to adult care sooner, so the 29% depends heavily on who was included and is not a general rate.
Short window: Young people were only followed while in the children's program, and older teens moved to adult care quickly, so later changes, stopping or detransition were missed.
One unusual clinic: A single specialist centre, mostly white patients, with a dedicated autism and gender service (47% autistic). The authors say this limits how far the results apply elsewhere.
Broad meaning of 'change': Stopping hormones after reaching one's goals was counted as a change alongside withdrawing a request and regret, so the headline 29% mixes very different experiences.
Some categories less reliable: Coders agreed very well on the overall patterns, but only fairly on the reason 'exploring gender identity', which the authors say should be treated with caution.
Missing timing: The data did not record the time between first visit and assessment, so how quickly requests changed after contact with the clinic is unknown.
Depends on the type of care: The clinic followed most of the Dutch approach, with required mental health involvement. Results may differ at clinics that give hormones on request with less exploration, as the authors note.
Funding and disclosures: Funded by the US National Institutes of Health's internal research program. The conflicts-of-interest section in the public version of the paper is blank, so disclosures could not be checked.

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Summary

Key findings

Abstract

Conclusion