87%使用青春期阻斷劑的荷蘭青少年轉用異性荷爾蒙；3.5%因焦慮緩解而停止

因性別焦慮接受促性腺激素釋放激素類似物治療的青少年的軌跡

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

在萊頓門診年齡夠大且青春期已進行到一定程度的 214 名青少年中，143 人（67%）被判定適合使用青春期阻斷劑，他們全部在 2010 年 11 月至 2018 年 1 月間開始。
125 人（87%）在使用阻斷劑的典型 10 個月後接續使用跨性別荷爾蒙；5 人仍太年輕不能使用荷爾蒙，6 人轉到了其他門診。
九名青少年（6%）停用阻斷劑。其中四人仍想要性別治療，因副作用、情緒問題或實際原因而停用；一人重新開始，三人後來開始使用荷爾蒙或停經藥物。
五名青少年（3.5%）不再想要性別治療。他們的原因包括覺得自己是非二元性別、戀愛，以及妨礙探索自身感受的個人或家庭問題。
20 名青少年繼續使用阻斷劑的時間超過門診計畫所需，最常見的原因是不穩定的家庭或社交生活、自閉症或憂鬱等其他狀況，或實際原因。
開始使用的典型年齡，跨性別女孩為 15 歲，跨性別男孩為 16 歲，因此許多人是在青春期後期或之後才開始，此時阻斷劑在身體上作用不大。
作者承認，他們的研究無法顯示阻斷劑本身是否使性別焦慮更可能持續。

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