Treatment Persistence Was High When Hormone Therapy for Gender Incongruence Included Comprehensive Diagnoses and Interdisciplinary Care During Adolescence

There has been a global increase in young people seeking specialist treatment for gender incongruence [1]. For example, initial diagnoses of individuals aged 5–24 years increased eight-fold in Germany from 2013 to 2022. However, the low diagnostic persistence rate of less than 50% indicated the need for a standardised, multidisciplinary diagnostic process [2]. The 2024 Cass Review, commissioned by NHS England, recommended a cautious approach to medical interventions in adolescence. It also called for comprehensive diagnostics and robust long-term data on the outcomes of psychosocial and medical treatments. A standardised diagnostic procedure, based on international guidelines, is used at the Transgender Centre Innsbruck [1]. In Austria, child and adolescent psychiatric, psychodiagnostic and psychotherapeutic opinions are required before any medical interventions. Pubertal development can be inhibited by gonadotropin-releasing hormone analogues (GnRHa) from Tanner stage II onwards. At Innsbruck, GnRHa are also commonly used to suppress endogenous sex steroid production during gender-affirming hormone therapy (GAHT), including in adults. GAHT with oestrogen or testosterone may subsequently be initiated. A second opinion from a child and adolescent psychiatrist is required before GAHT starts, particularly if GnRHa therapy has already been used to suppress puberty. Psychotherapeutic support is recommended throughout the transition and is a prerequisite for starting GAHT. This retrospective, longitudinal cohort study assessed treatment persistence among adolescents following a comprehensive diagnostic procedure and interdisciplinary care. It was conducted at the University Clinics for Child and Adolescent Psychiatry, Gynaecological Endocrinology and Reproductive Medicine at the Transgender Centre Innsbruck from 1 February 2012 to 30 June 2023. The study was approved by the local ethics committee of the Medical University of Innsbruck (number 1347/2023) and followed all relevant guidelines and regulations. During the study, 144 adolescents had their first appointment at the Centre within 5 weeks of their 18th birthday. Of these, 42 were excluded: 16 only attended the child and adolescent psychiatry department, 12 did not start GAHT during the study period, 10 only attended once, one refused to take part, and one was abroad and unreachable for an extended period. Another two died by suicide. The final sample comprised 102 individuals. Data on 71 follow-up visits came from the patient documentation system, information on 10 patients came from the Austrian public electronic health record database, and we made telephone contact with 21. Informed consent was obtained as necessary. Most individuals were assigned female at birth (76.5%) and 23.5% were assigned male (Table 1). None had a sex development disorder. The mean age at first presentation was 16.3 years ±1.1. Those assigned female rather than male at birth presented at a slightly earlier mean age (16.2 vs. 16.6 years). The mean age at the start of GnRHa therapy was 17.1 ± 1.5 and it was 17.6 ± 1.3 years for GAHT. The average durations of GnRHa therapy for those assigned female and male at birth were 5.4 ± 7.3 (0–38) versus 3.4 ± 4.0 (1–15) months, respectively. The median follow-up time was 5.0 years (IQR 2.7 years). Three participants (2.9%) discontinued therapy, and all had been assigned female at birth. Two wanted to return to the gender they were assigned at birth, and one was satisfied with their current gender role and appearance and no longer wanted to take hormones. Two had undergone chest masculinisation, but none had undergone genital affirming surgery. One person broke off contact with the treatment team. A Norwegian study published in 2025 showed a similar detransition rate of 2.3% [3]. Our results show that treatment persistence among adolescents with gender incongruence was high following standardized diagnostic preparation before GAHT started. Most (97.1%) of those who had started GAHT were still using it after a mean of 4.1 (0.4–10.3) years. This suggests that our multi-stage diagnostic approach effectively identified persistent gender incongruence and facilitated stable treatment decisions. This naturalistic study provides rare follow-up data on treatment persistence among young people who received GAHT and adds to the limited evidence on treatment trajectories from adolescence to young adulthood. However, there were some limitations. First, data on 10.2% of the patients came from the public electronic health record database, which contained information on prescriptions, but not whether they were purchased or taken. A register-based study from Finland showed a higher discontinuation rate of around 8% when it assessed prescriptions that were purchased [4]. Second, we excluded 37 adolescents who had not started any medical interventions when the data were analyzed. It is unclear whether these individuals will eventually begin somatic treatment or ultimately decide against it. Our findings show that treatment persistence was high from adolescence to young adulthood when GAHT was preceded by a structured, multi-stage diagnostic process and included interdisciplinary care. Evidence suggests that suicide is generally rare among young people with gender incongruence when psychiatric morbidity is controlled for [5]. However, the two suicides in our cohort highlight that comorbid mental disorders are a significant clinical concern that must be addressed during an integrated diagnostic and treatment process. A careful diagnostic process may lead to more stable treatment outcomes and could explain our high persistence rate. Future research should combine extended follow-up periods with comprehensive assessments of treatment persistence, mental health, psychosocial functioning and the long-term consequences of medical interventions. Open Access funding provided by Medizinische Universitat Innsbruck/KEMÖ. The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.