30%停药率：超过1/4的跨性别青年在4年内停止激素治疗

跨性别青少年和成人中性别肯定激素的持续使用

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

4年后，估计有70%的人仍在通过军队保险配取激素处方，也就是说约十分之三已经停药。
服用雌激素的男性中81%继续用药，而服用睾酮的女性为64%。服用睾酮的女性停药的可能性约为2.4倍。
未成年时开始的人中74%继续用药，成年后开始的人为64%。成年后开始的人停药的可能性约为1.7倍，而未成年人中约四分之一在4年内停药。
停药的定义是：在上一次药物用完后超过90天没有新的处方，且此人仍在使用其他军队医疗服务（平均又持续了324天）。
家庭收入（根据军人的军衔判断）、家庭角色以及2016年官方保险覆盖范围的变化，对人们是否继续用药没有可测量的影响。
该研究没有记录停药的原因，也没有关于后悔、去过渡、心理健康或满意度的信息，因此继续使用激素不能被视为获益的证明。
十年间人数急剧上升：58%的患者在研究的最后22个月内才首次进行与性别相关的就诊。

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