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18 Detransitioned After Testosterone: Norwegian Study Shows 22% Leave Treatment Without Medical Intervention

Treatment trajectories among children and adolescents referred to the Norwegian National Center for Gender Incongruence

cohort studytransition outcomesdetransitionpuberty suppression
Authors
Cecilie Bjertness Nyquist, Leila Torgersen, Linda W. David, Trond Haaken Diseth, Kjersti Gulbrandsen, Anne Waehre
Year
2025
Journal
Acta Paediatrica

Methodological Limitations

  • Retrospective chart review design with potential for missing information: 'Data were retrieved from a quality registry based on a retrospective chart review; therefore, some information could be missing' (Section 4.1).
  • Incomplete capture of treatment outside the study institution: 'Information on treatment by health care providers outside OUS was only possible to register in GIRCA if clinicians at OUS were informed and had documented the treatment in medical charts' (Section 2.4.1), and 'it does not include persons who obtain treatment from other healthcare professionals or self-medicate' (Section 4.1).
  • Potential underestimation of detransition: 'persons discontinuing medical treatment might be lost to follow-up' and 'our detransition numbers being an underestimate' (Section 4). The study also notes 'There could be missing data in GIRCA regarding trajectories if this occurred after a discharge from the NCGI or if clinicians at OUS were not informed' (Section 2.4).
  • Changing clinical criteria over time confounding temporal comparisons: 'Given the evolving scientific discussions over the two decades, criteria for gender-affirming treatment may have varied over time' (Section 4.1).
  • Short follow-up time for recent referrals limiting interpretability: 'due to shorter follow-up time among those referred in recent years, one cannot interpret these numbers' (Section 3.4), and 'The lower percentage of GAHT reported in the most recent years is more difficult to interpret owing to the different time spans from referral to treatment initiation' (Section 4).
  • Inability to distinguish childhood vs. adolescent onset of gender incongruence: 'our study could not differentiate between those with a childhood onset of GI/GD and those with adolescent onset in relation to desistance of transgender identity' (Section 4).
  • Small absolute numbers of detransition limiting statistical power: 'The detransition numbers reported in this study are too small to draw any conclusions' (Section 4).
  • Lack of cause-of-death data: 'Mortality data in GIRCA are automatically updated from the National Population Register; however, cause of death is not registered' (Section 2.4) and 'Our Norwegian study could not clarify mortality reasons among the referred' (Section 4).
  • Because of loss to follow-up and incomplete external treatment data, the authors acknowledge their detransition figure (2.3% of those who started GAHT) may be too low. They cite a Finnish nationwide register study finding a 7.9% discontinuation rate to support the concern that their number is probably an underestimate.
  • Potential selection bias due to referral requirements: 'the requirement of referrals from local child and adolescent psychiatric outpatient clinics (CAPOCs), which conduct initial assessments. This may reflect a higher intensity of GD in our sample' (Section 4), suggesting the sample may not be representative of all youth with gender incongruence.
  • Conflict of interest: Anne Waehre served as 'External referee of "The systematic knowledge overview of gender dysphoria from the Swedish National Board of Health and Welfare's review for medical and social evaluation"' during 2020-2022 (Conflict of Interest Statement), which could represent involvement in policy decisions that may align with the more restrictive treatment approach discussed in the paper.

Key Findings

  • Among 1,258 children and adolescents referred to Norway's national gender clinic from 2000-2020, 62% started gender-affirming hormone treatment (GAHT) and 11% received puberty blockers (GnRHa).
  • Nearly all (97%) of those who received puberty blockers went on to hormone treatment, raising questions about whether blockers allow for meaningful exploration of gender identity.
  • Eighteen individuals assigned female at birth (2.3% of those on GAHT) detransitioned after testosterone treatment, with most ceasing to identify as transgender entirely.
  • Because of loss to follow-up and incomplete external treatment data, the authors acknowledge their detransition figure (2.3% of those who started GAHT) may be too low. They cite a Finnish nationwide register study finding a 7.9% discontinuation rate to support the concern that their number is probably an underestimate.
  • About 22% of those who attended at least one appointment were discharged without any medical treatment, most commonly due to mental health concerns.
  • The study highlights significant shifts in Norwegian clinical practice over time, with declining use of puberty blockers in recent years amid growing international scrutiny of evidence for these treatments.

Abstract

Aim: We aimed to describe treatment trajectories, detransition and mortality rate among children and adolescents referred to the Norwegian National Center for Gender Incongruence (NCGI). Methods: The cohort included all 1258 persons under 18 years at referral to the NCGI from 2000 to 2020. Trajectories were registered until end of 2023. Results: In total, 861/1258 (68.4%) were assigned female gender at birth (AFAB). Mean age at referral was 14.4 years. Puberty suppression with gonadotropin-releasing hormone agonists (GnRHa) was initiated among 135/1258 (10.7%), significantly more persons assigned male gender at birth (AMAB) than AFAB (p < 0.001). Gender-affirming hormonal treatment (GAHT) was initiated in 783/1258 (62.2%). The continuation rate from GnRHa to GAHT was 97%. Discharge rate from NCGI without gender-affirming medical treatment among those who attended at least one appointment, was 264/1198 (22.0%). Eighteen AFAB detransitioned after initiated GAHT, eleven due to a cessation of transgender identity. Mortality rate in the cohort until end of 2023 was 11/1258 (0.9%). Conclusion: Different trajectories including medical pathways and assessments without gender-affirming treatment were observed. GAHT was initiated in 783/1258 (62.2%), including eighteen AFAB detransitioning after testosterone treatment. There was a high continuation rate from GnRHa to GAHT. Various trajectories highlights the need for long-term follow-up in care.

Summary

This Norwegian cohort study of 1,258 youth referred to the National Center for Gender Incongruence found that 22% were discharged without gender-affirming medical treatment. Of those who started testosterone, 18 females detransitioned (11 due to cessation of transgender identity), though this likely underestimates true detransition rates due to loss to follow-up—patients discontinuing treatment may disengage from care, and treatment outside the clinic system was only captured if clinicians were informed. The study highlights the high continuation rate from puberty blockers to hormones (97%), raising concerns about the pipeline effect, and underscores the need for long-term follow-up given highly variable follow-up durations (3–20+ years), incomplete capture of external treatment, and various treatment trajectories including detransition.

Conclusion

This study provides valuable insights to gender-affirming care for children and adolescents, owing to its large sample size, including all children and adolescents referred to a national gender clinic over two decades. The study reports varying trajectories, encompassing both medical pathways and assessments ended without gender-affirming medical treatment. Our findings highlight the necessity for long-term follow-up and support of people referred to gender clinics. There is a need for ongoing research on gender-affirming treatment in young people to evaluate the short- and long-term benefits and risks of early treatment interventions, as well as patient-reported outcome measures.