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29% of Gender Clinic Youth Change Their Minds About Medical Transition

Shifts in gender-related medical requests among gender diverse youth

transition outcomespuberty suppressiongender dysphoriaqualitative researchautismgender-affirming caremixed-methods
Authors
Ariel Cohen, Veronica Gomez-Lobo, Laura Willing, David Call, Lauren F. Damle, Lawrence J. D'Angelo, Amber Song, John F. Strang,
Year
2023

Methodological Limitations

  • The qualitative data on youth-reported shift reasons and shift profile trajectories were obtained from interviews with clinicians and medical records, not directly from the youth themselves, introducing potential information bias and recall bias despite efforts to mitigate it: 'An overarching limitation in the current study design is that the information of youth-reported shift reasons and trajectories of the shift profiles were identified from interviews with each young person's mental health clinician and from their medical record, but not the youth themselves.'
  • The study was limited to a single referral center with predominantly Caucasian demographics, severely limiting generalizability: 'Our study was limited in that it only included a single referral center and the demographics that it serves, which were predominantly Caucasian. This does not represent the racial and ethnic makeup of the gender diverse population at large, limiting the generalizability of these findings.'
  • The sample size of 20 youth experiencing shifts, while described as the largest to date, is still very small and limits generalizability, with subgroup sizes too small for statistical analysis: 'Our sample of 20 youth experiencing a shift, which is the largest described to date, is still relatively small and thus limits generalizability of the findings... these sizes precluded statistical analysis, particularly among the different shift profile groups.'
  • The identified shift reasons are unlikely to be comprehensive due to small sample size, demographic homogeneity, and lack of direct youth input: 'The youth-reported reasons for experiencing a shift are unlikely to be fully comprehensive across all gender diverse youth, given the small sample size, our sample's demographic, and even smaller subgroup sizes.'
  • The study design may have introduced selection bias by excluding youth who arrived in late adolescence and transitioned to adult care before meeting the 2-year monitoring requirement: 'Important for contextualization of this this study, the excluded cohort was older than the analyzed sample at first visit; when patients arrive in late adolescence, they transition to adult care more quickly and were therefore less likely to meet the inclusion requirement for the two-year study monitoring period.'
  • The simplified shift profiles may not fully capture how youth's goals and needs are met by treatment, particularly for those who stopped treatment because goals were satisfied: 'simplifying our shift profiles to whether a young person re-requests a treatment or stopped a treatment may not capture a complete picture of how their goals and needs are met by gender-affirming hormones and/or surgery.'
  • The dataset did not include the time interval between intake and patient evaluation, potentially missing important temporal information: 'Finally, our data set did not include the time interval between intake and patient evaluation.'
  • The study's enrichment for autistic youth due to a specialized clinic may not reflect the broader gender-diverse youth population, though this was partially addressed by comparative analytics.
  • The inter-rater reliability for 'Exploring gender identity' was only fair (κ = 0.34), requiring cautious interpretation, yet this reason was still used in the analysis: 'Exploring gender identity had fair inter-rater reliability and therefore this classification should be interpreted with caution.'
  • The study conflates pubertal suppression with other medical requests in its exclusion criteria despite acknowledging their different purposes, potentially excluding relevant youth who only had shifts in suppression requests.
  • The clinicians conducting the interviews (DC, JFS, LW) were also the treating clinicians for the youth, creating potential dual-role conflicts and bias in reporting—clinicians may have been motivated to present outcomes favorably or may have had incomplete recall despite EHR review.
  • The coding team included clinicians from the same institution (including a pediatric gynecologist experienced in gender care and the first author AC who conducted interviews), raising concerns about institutional confirmation bias and lack of independent outside perspective in qualitative analysis.
  • The study's framing of Profile 5 (treatment completed, gender needs met) as a 'shift' is questionable—this appears to be a successful treatment outcome rather than a genuine shift or fluctuation in request, potentially inflating the reported shift rate.
  • The significant psychiatric comorbidity in Profile 4 and Profile 6 youth (delusions/thought instability) raises ethical concerns about whether these individuals had adequate capacity for informed consent to treatment, yet this is not critically examined.
  • The study's conclusion that 'shifts may not be uncommon' is based on 29% of a pre-selected sample who already met criteria for requesting hormones/surgery and being monitored for 2+ years, which may overestimate shift prevalence in the broader gender-diverse youth population.

Key Findings

  • Nearly one-third (29%) of gender-diverse youth in the study shifted their requests for gender-affirming hormones or surgery over time, suggesting such changes are not uncommon during adolescent gender exploration.
  • Nonbinary youth were significantly more likely to experience shifts in medical requests compared to binary transgender youth, though no differences were found by age, autism status, or sex assigned at birth.
  • The most common pattern (45% of those with shifts) involved youth making a request, withdrawing it, and later re-requesting treatment—indicating that stepping back from medical requests is often temporary rather than final.
  • Most shifts (85%) occurred before any treatment began, and only one participant in the entire study expressed regret after starting treatment, consistent with prior research that regret is rare.
  • Key reasons for shifts fell into two main themes: ongoing gender discovery (wanting more time, exploring identity) and interpersonal influences (lack of support, coming-out worries, peer pressure), with mental health clinicians playing a valuable role in supporting youth through this non-linear process.

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 = 0.012). 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%). Conclusions: 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. Keywords: transgender, gender diverse, gender affirming hormones, gender affirming surgery, gender dysphoria, gender incongruence, adolescence

Summary

This mixed-methods study of 68 gender-diverse youth found that 29% experienced shifts in their requests for gender-affirming hormones or surgery during their gender discernment process, with nonbinary youth more likely to experience such shifts. The researchers identified six distinct shift profiles and eight underlying reasons for these changes, finding that most shifts occurred before treatment began and that many youth who withdrew requests later re-requested treatment. The findings suggest that shifts in medical requests are not uncommon during adolescence and highlight the importance of ongoing mental health support throughout the gender exploration process.

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.