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The Endocrine Society Guideline for Transgender Care and the World Professional Association for Transgender Health Standards of Care recommend the use of gonadotropin-releasing hormone analogues (GnRHa) as a treatment option for adolescents with gender dysphoria who have not completed puberty. These medications attenuate sex hormone production and pause development of secondary sex characteristics. The effects of GnRHa are reversible, allowing adolescents time to explore their gender identity before determining if they would benefit from interventions with partially irreversible effects, such as gender-affirming hormones. Critics of this approach have argued that starting GnRHa treatment will inevitably lead to the use of gender-affirming hormones, thus adolescents must understand the consequences of possible future irreversible treatments in order to assent to GnRHa treatment. We performed this study to assess the continuation rate of GnRHa treatment among transgender and gender-diverse (TGD) adolescents and the progression to gender-affirming hormones.
This is a secondary analysis of medical billing records from the United States Military Healthcare System from 2009-2018. Using pharmacy records and diagnostic codes, we identified TGD individuals who initiated GnRHa treatment prior to age 18 and between 30 days before their first visit and 90 days after their most recent visit that addressed gender dysphoria. We used Kaplan-Meyer analyses to estimate the proportion of patients who stopped GnRHa without starting gender-affirming hormones and the proportion who went on to initiate gender-affirming hormones. We explored the influence of demographic factors on these outcomes. IRB approved.
We identified 93 TGD adolescents who initiated GnRHa. The majority were transmasculine (58%) and had an enlisted (lower income) insurance sponsor (66% enlisted versus 34% officer). Average age at first gender dysphoria-related diagnosis was 13.5± 2.5 years (range: 5-18 years) and the average age at initiation of GnRHa was 13.9±2.5 years (range: 9-17 years). One year after starting GnRHa, 8.4% (95% CI: 1.0% – 15.8%) were no longer taking any gender-affirming medications (GnRHa and/or gender-affirming hormones). Over the first three years, none of the patients who started GnRHa between 15–17-years old had stopped gender-affirming medications compared with 10.6% of patients who started GnRHa between 9–14-years, though this difference did not reach statistical significance. Insurance sponsor’s rank (family income), birth-assigned sex, and the presence of mood disorders were not associated with cessation rates. Within 2 years of starting GnRHa, 83.2% (95%CI: 70.2 – 94.4%) of patients had started gender-affirming hormones; within 8 years of starting GnRHa, this number increased to 91.6% (95%CI 81.6 –100%). Younger patients had a greater delay in starting gender-affirming hormones. Insurance sponsor’s rank, birth-assigned sex, and the presence of mood disorders were not associated with initiation of gender-affirming hormones.
Contrary to concerns, GnRHa use did not inevitably lead to use of gender-affirming hormones. One out of twelve TGD adolescents who started GnRHa to address gender dysphoria subsequently stopped treatment.