87% holenderskich nastolatków na blokerach przeszło na hormony płci przeciwnej; 3,5% przerwało, bo dysforia ustąpiła

Trajektorie nastolatków leczonych analogami hormonu uwalniającego gonadotropiny z powodu dysforii płciowej

Badania kohortowe i rejestrowe Detransycja i żal Blokery pokwitania

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

Spośród 214 nastolatków w poradni w Lejdzie, którzy byli wystarczająco starzy i wystarczająco zaawansowani w dojrzewaniu, 143 (67%) uznano za odpowiednich do blokerów dojrzewania i wszyscy zaczęli je między listopadem 2010 a styczniem 2018 roku.
125 (87%) przeszło na hormony płci przeciwnej po typowo 10 miesiącach na blokerach; 5 było jeszcze zbyt młodych na hormony, a 6 przeniosło się do innych poradni.
Dziewięciu nastolatków (6%) przerwało blokery. Czworo z nich nadal chciało leczenia związanego z płcią i przerwało z powodu skutków ubocznych, problemów z nastrojem lub względów praktycznych; jedna osoba zaczęła ponownie, a troje później rozpoczęło hormony lub leki wstrzymujące miesiączki.
Pięcioro nastolatków (3,5%) nie chciało już leczenia związanego z płcią. Ich powody obejmowały poczucie niebinarności, zakochanie się oraz problemy osobiste lub rodzinne, które przeszkadzały w badaniu własnych uczuć.
Dwadzieścioro nastolatków pozostało na blokerach dłużej, niż wymagał plan poradni, najczęściej z powodu niestabilnego życia rodzinnego lub społecznego, innych schorzeń, takich jak autyzm lub depresja, lub względów praktycznych.
Typowy wiek rozpoczęcia wynosił 15 lat u dziewcząt transpłciowych i 16 lat u chłopców transpłciowych, więc wielu zaczynało późno w dojrzewaniu lub po nim, gdy blokery niewiele zmieniają fizycznie.
Autorzy przyznają, że ich badanie nie może pokazać, czy same blokery zwiększają prawdopodobieństwo utrzymywania się cierpienia związanego z płcią.

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