29%的性別診所青少年改變了對醫療過渡的看法

跨性別和性別多元青少年在性別相關醫療請求上的變化

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

在 68 名曾要求使用跨性別荷爾蒙和／或手術的青少年中，有 20 人（29%）在追蹤期間改變了要求。
非二元性別的青少年在改變者中占比較高（改變者 20 人中有 9 人，未改變者 48 人中有 6 人）。年齡、自閉症和出生性別沒有明顯差異。
20 次改變中有 17 次（85%）發生在任何治療開始之前。最常見的模式（9 名年輕人，45%）是要求治療、撤回要求，之後又再次提出。
有 5 名年輕人（改變者的四分之一）撤回要求後，在追蹤期間沒有再提出，另有 1 人只是「考慮」未來接受治療。
有 3 人在開始使用荷爾蒙後改變：兩人在達成目標後停用，一人停用並表示後悔，同時也有嚴重的精神疾病。
改變者中有 9 人（45%）也描述了性別認同的改變，最常見的是從跨性別男性或跨性別女性變成非二元性別。有一名年輕人的認同曾經過認同出生性別的階段，最後才確定為跨性別男性。
原因分為兩類：仍在探索自己的性別（想要更多生活經驗、探索認同），以及來自他人的壓力（缺乏支持、擔心出櫃、感受到同儕壓力）。

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