Beyond a uniform transition: Distinct pathways of gender-affirming care in a multidisciplinary gender clinic

Background Gender-affirming care encompasses a wide range of medical, reproductive, legal, and psychosocial interventions. Although previous research has examined specific components of gender-affirming care, little is known about how these interventions cluster together in real-world clinical settings and whether distinct transition pathways emerge among individuals receiving gender-affirming care.Methods This retrospective cohort study analyzed clinical records of 401 adult transgender individuals who attended a hospital-based multidisciplinary gender clinic in Israel between 2020 and 2025. Latent Class Analysis (LCA) was used to identify transition pathways based on fertility preservation status, gender-affirming chest surgery, and legal gender marker change.Results Three classes were identified: (1) Fertility Preservation Pathway (23.69%), characterized by completed fertility preservation and limited surgical or legal interventions; (2) Mixed Medical Transition Pathway (33.17%), characterized by higher rates of chest surgery, legal gender marker change, longer treatment duration, and greater engagement with multiple transition-related interventions; and (3) Minimal Medical Intervention Pathway (43.14%), characterized by limited completed medical and legal interventions and a modest probability of fertility preservation referral. The Fertility Preservation Pathway was associated with younger age at transition initiation and a predominance of transfeminine individuals. The Mixed Medical Transition Pathway was characterized by higher rates of transmasculine individuals and longer treatment duration. The Minimal Medical Intervention Pathway included the highest proportion of nonbinary individuals and the lowest proportion of Jewish participants. No significant differences emerged across pathways in psychiatric comorbidities.Conclusions Findings highlight the heterogeneity of gender-affirming care trajectories and challenge assumptions of a uniform transition process. These results support individualized, multidisciplinary, and flexible models of gender-affirming care that are responsive to diverse patient goals and experiences.