Providing gender-affirming medical care to adolescents has become one of the most heavily debated medical topics in the public sphere.
Medical interventions once widely presented by most major medical groups as unequivocally beneficial and even lifesaving for young people with gender dysphoria have come under sustained scrutiny as emerging evidence has called the certainty of these claims into question and trans issues have become more politically polarizing and salient.
A central component of gender affirming care is the provision of masculinizing and feminizing hormone therapy, which can induce the secondary sex characteristics typical of the sex with which the young person identifies while suppressing the progression of the sex characteristics associated with their birth sex. For young people with persistent gender incongruence, these changes may produce greater visual and bodily congruence with their preferred sex. This has been associated with improved mental health and decreased stigmatization and may be particularly impactful when treatment begins before natal puberty has produced pronounced and difficult-to-conceal physical features.
Demand for gender-affirming care in Canada has risen substantially since the early 2000s. As with elsewhere in the Western world, this increase has been driven by those assigned female at birth (AFAB), whereas earlier cohorts presenting to pediatric gender clinics were more evenly divided between AFAB and assigned male at birth (AMAB) adolescents. Data from Canadian clinics now show that AFAB adolescents account for nearly three quarters of all new referrals. A rise in care-seeking by gender incongruent youth can potentially cause an increase in hormone use if assessment and treatment protocols have not become more strict over time. Hormone interventions are a highly consequential: the physical changes it promotes are difficult or impossible to reverse and its long-term health impacts are not well characterized.
We also lack high-quality evidence on the overall impact of hormone therapy on the long-term quality of life for young people with gender dysphoria. While numerous studies have reported improvements in dysphoria, depression, anxiety and suicidality after young people begin hormones, the generalizability of these studies is limited by retrospective designs, selection bias, short follow-up, loss of participants and the absence of appropriate comparison groups. Follow-up often ends when patients leave pediatric care, making it difficult to assess long-term outcomes into adulthood. Recent population-based studies, while limited in their ability to precisely measure psychological well-being, have not conclusively shown meaningful reductions in long-term use of mental health care services or a decrease in the risk of suicide.
There is also increasing visibility of detransitioners, who often express considerable regret about their transitions, and in particular the irreversible physical changes associated with hormonal and surgical intervention. While a recent Canadian study suggested less than 3 per cent of adolescents started on hormonal therapies detransition prior to adulthood, this may fail to detect those who desist from their transitions later in adulthood.
However, despite rapidly changing care seeking and uncertainty around the balance of benefits and harms, we have remarkably sparse data on how hormones are being prescribed to Canadian adolescents, and how their use is changing over time.
Outside of Alberta, Canadian guidance and statutes allow physicians broad discretion in prescribing hormones to adolescents with gender dysphoria, even while many other jurisdictions, including the United Kingdom, much of the United States, Sweden and Finland, have restricted or prohibited their use in adolescents, often citing uncertainty about the balance of benefits and harms and concerns about young people’s ability to appreciate the consequentiality of their decisions.
A recent American study using data from Oregon offers some indication of what may be happening. Oregon is a socially progressive state on trans issues, including mandating coverage of hormone therapy for both private and state-run health insurance plans, and thus may provide relevant insights on hormone use in Canada.
This study assessed administrative claims data from more than 850,000 adolescents in Oregon covered by both public and private insurance and found that approximately one in 241 AFAB adolescents was receiving testosterone by age 17 while about one in 630 AMAB adolescents received estrogen prior to adulthood. The prevalence of hormone use among Oregon adolescents increased approximately ninefold between 2016 and 2023.
Notably, the prevalence of hormone use in Oregon was nearly twice as high as seen in an analysis performed only one year earlier across a more politically and geographically diverse cross-section of the U.S. A recent non-peer analysis performed by the Manhattan Institute, a conservative think tank that has advocated against the use of hormonal therapies for young people with gender dysphoria, showed that Oregon had the second highest prevalence of gender dysphoria diagnosis among young people of all U.S. states, and that there was a broad correlation between a state’s social progressiveness and the likelihood of adolescents being diagnosed with gender dysphoria.
Though we do not have direct Canadian data, should we be alarmed if our data were to show similarly that hormone use has increased at this rate over the last decade, and that approximately 0.4 per cent of AFAB adolescents are receiving testosterone and 0.15 per cent of AMAB adolescents are receiving estrogen?
That depends on whether the rise represents a health-care system meeting the needs of a population that benefits from this care or overdiagnosis and overtreatment with an intervention that can cause serious harms. There may be additional concerns about the profound disparity in hormone use between AFABs and AMABs, especially if the impacts of treatment also differ between them.
Trans supporting physicians, researchers and advocates have tended to favour the former explanation. In their assessment, decreased stigmatization around trans issues and improved access to care has allowed young people – who would have in the past kept their gender incongruence hidden or unexamined – to be more open about their gender issues, thus driving the increase in trans identification and care-seeking.
While this explanation almost certainly is part of the story, it does not fully explain why the increase in trans identification and care-seeking among adolescents has been driven disproportionately by AFABs, often with shorter periods of apparent gender incongruence and with high burdens of psychological comorbidities.
Several other explanations have been proposed, including changing cultural narratives, peer and online influences and the use of gender incongruence as a framework through which some adolescents interpret their broader distress.
However, if there were an emergent form of gender dysphoria affecting adolescent AFABs, it may not share the same history as was seen in older cohorts, where dysphoria that persisted into or developed during adolescence was largely presumed to be unrelenting in the absence of pursuing transition. If it were more likely to resolve spontaneously without medical intervention or with psychological support alone in this contemporary cohort, then it raises concern about possible overtreatment, especially given the irreversible nature of changes brought on by hormone therapy.
And indeed, it does appear that AFABs, and particularly those with shorter histories of transition and greater burdens of psychiatric illness, are over-represented among regretful detransitioners. This is especially critical when considering that testosterone therapy causes irreversible signs of masculinization within months of onset, specifically voice deepening, facial hair development and clitoral enlargement. In contrast, the visible effects of estrogen such as breast growth develop more gradually, and although these changes may also be permanent, they tend to be easier to obscure.
There is a corresponding asymmetry in the consequences of delaying the initiation of hormone therapy. AFAB adolescents typically enter natal puberty earlier and frequently present for treatment after breast development and other female-typical pubertal changes are often well established. For AMAB adolescents, the effects of continuing endogenous testosterone exposure continue to accumulate throughout adolescence. Further masculinization of the voice, face and body cannot subsequently be reversed by estrogen and may make achieving visual congruence as female considerably more difficult if hormone therapy is delayed. In that sense, AFABs are more likely to bear the excess costs and consequences of overtreatment while potentially being less negatively impacted over the long term if treatment is deferred or delayed.
Despite this, no guidelines currently suggest that natal sex should be taken into consideration regarding clinical decision-making regarding diagnosis and the initiation of hormonal treatment.
Taken together, these uncertainties raise questions about whether current approaches in Canada are adequately calibrated to the population now seeking treatment, and whether this is being somewhat driven by our failure to consider the greater capacity for overdiagnosis among AFABs.
It may be more prudent to begin with a non-coercive outcome-neutral exploratory approach rather than proceeding immediately to hormones in late-presenting AFAB adolescents with substantial psychiatric comorbidity, a short history of gender incongruence and/or uncertainty about the sources of dysphoria.
Greater confidence may be warranted when dysphoria is longstanding, the young person is well integrated in the opposite gender role, and where allowing a birth-sex consistent puberty to continue can reasonably be expected to produce substantial distress, which may be more of an issue in AMABs. Puberty blockers, while controversial in their own right, may still have a role in delaying consequential natal sex typical bodily changes while assessment continues, so long as this time is used for meaningful exploration of the underlying distress and does not merely function as an uncontested path to hormone therapy.
Most importantly, the Canadian health-care community and those living with gender incongruence and dysphoria – as well as their families – have a compelling interest in better understanding how young people who receive these interventions are managing in the short and long term. Our research community needs to prioritize leveraging existing data sources and better track outcomes on treatment continuation, physical health, mental health, social functioning, regret and detransition well into adulthood.
In addition, if there are identifiable and modifiable influences in the social environment that are contributing to the development of gender dysphoria among youth, clinicians should be open to addressing those influences rather than assuming that medical transition is necessarily the appropriate response.
Canadian clinicians still have the privilege of practising largely without governmental or regulatory interference. Proactively developing more discerning, sex-sensitive approaches to assessment and sex-specific treatment thresholds, while systematically tracking long-term outcomes, may make it less likely that legislators will impose blunt policies driven more by politics than evidence.
