Transgender and gender diverse (TGD) individuals do not identify with their gender assigned at birth. The term TGD is used to allow the inclusion of a broad spectrum of gender identities for people who do not identify with their gender assigned at birth but might also not necessarily identify with the term “transgender” (e.g. non-binary, genderqueer, or agender individuals). An incongruence between gender assigned at birth and gender identity can lead to gender dysphoria (GD), which is associated with clinically significant distress and impairment in social, occupational, or other important areas of functioning, according to the DSM-5 (1). GD, besides being an inherently distressing experience, can also be understood within the framework of minority stress, associated with experiences of discrimination, exclusion, victimization, and internalized as well as external stigmatization (2, 3). It is thus unsurprising that GD is frequently associated with co-occurring mental health conditions such as depression, anxiety, eating disorders, self-harm, and suicidality (4–8). In order to alleviate GD, TGD persons may seek gender-affirming medical treatment (GAMT) such as hormone therapy or surgery to better align their physical appearance with their gender identity (9). Apart from GAMT, social support (such as supportive environments, social transitioning, and legal gender recognition), community involvement, psychotherapy, counselling, as well as education about and advocacy for TGD are also important strategies to decrease suffering caused by GD (10–14).

The proportion of gender diversity in the general population is difficult to assess. According to the World Professional Association for Transgender Health (WPATH) Standards of care (SOC) 8, survey-based studies of children and adolescents estimate proportions of around 1.3 % identifying as transgender (15), and 2.7 - 8,4% as TGD or gender non-conforming (16, 17). The development of secondary sex characteristics during puberty can come with significant distress for TGD adolescents (18). Gender-affirming hormone therapy (GAHT) can allow TGD adolescents to undergo pubertal development that better correlates with their gender identity. This has been shown to improve psychological well-being (19), psychosocial functioning (20), mental health outcomes (21, 22) and body satisfaction (23) in TGD adolescents. However, GAHT negatively impacts fertility (24) and potential adverse effects of long-term GAHT are not yet fully researched yet (25, 26).

GAMT for children and adolescents was established in the Netherlands towards the end of the 20th century, and most current guidelines are based on the so-called “Dutch Protocol” – a combination of gonadotropin releasing analogue (GnRHa) to suppress endogenous puberty starting as early as Tanner Stage 2-3, and gender-affirming hormone therapy with sex steroids in accordance with gender identity starting around the age of 16 (27). In Vienna, as seen in other centers worldwide, demand for GAMT in children and adolescents has increased significantly over the past decade (18, 28–30). The University Clinic for Pediatric and Adolescent Healthcare at the Vienna General Hospital began seeing gender incongruent adolescents in 2008 and has since provided consultation for over 300 children and adolescents. While research on transgender health has increased in the last years, data on the medical treatment of TGD youth is still scarce and difficult to compare, as different countries and health care systems differ in their diagnostic process, legal framework, and access to GAMT. In the European context, there is a notable paucity on data about TGD youth from central Europe. The objective of this retrospective study was to describe patient characteristics, clinical management, treatment trajectories, fertility preservation and legal gender marker changes in Austrian TGD youth.

The present analysis describes treatment trajectories of children and adolescents who presented with gender incongruence at the pediatric clinic of Vienna University Hospital from 2008 to 2022. As in other gender clinics worldwide (18, 28–30), we observed a significant increase in the number of children and adolescents with gender incongruence and GD seeking gender-affirming care in recent years. The ratio of AMAB to AFAB individuals shifted from 1.55:1 in 2008-2015 to 1:3 in the years 2016-2022. This trend has also been observed in other gender identity clinics such as Amsterdam (18) and Valencia (37), albeit less pronounced than in Finland, where an AMAB to AFAB ratio of 1:5.2 was described in 2017 (29). A US-based study looking at gender identity data in an electronic health record database in Iowa described an AMAB to AFAB ratio of 1:5 in 12-17 year-old TGD individuals (38). A 2022 investigation based on a survey conducted across 16 states found AMAB to AFAB ratios of 1:1.5 to 1:2 in TGD US-American adolescents (39). As only a small number of pediatric TGD individuals ends up seeking GAMT, this discrepancy between data from self-report surveys and clinical records requires further investigation, and could reflect the influence of sociocultural factors on referral patterns (40).

The age at first visit (with a median of 15.8 years) at our clinic was significantly higher than in the Amsterdam cohort (11.5 years for AMABs, and 14.1 years for AFABs) (18), but similar to Israeli (28) and Finnish (29) cohorts (both 15,5 years), as well as a UK cohort with a mean age of 15.4 years (36).

Gender affirming treatment trajectories were comparable to other transgender youth cohorts. Of the eligible individuals, 89% (186/207), amounting to 60% of the entire Austrian cohort, started GAMT in the pediatric setting. In the Amsterdam cohort of Loos et. al., 63% of eligible individuals received GnRHa (18), in the Canadian cohort described Bauer et al. 62,4% of the entire study population received GAMT (41), and in the Israeli cohort of Segev-Becker et al., it was 80% (28). Comparison between different cohorts is complicated by variations in eligibility criteria for GAMT (that are at times not described in detail), as well as different health care systems and associated paths individuals must navigate to access GAMT.

No explicit regrets or treatment discontinuations of GAMT were noted in the pediatric setting, but four individuals (2.3%) who started treatment with GnRHa were lost to follow up and show no records of receiving subsequent hormone therapy in either the pediatric or the adult outpatient clinic at Vienna University Hospital. Two individuals were identified who discontinued treatment as young adults: one who detransitioned permanently, and one who considered a detransition, but subsequently restarted treatment. Feelings of regret about having received gender affirming treatment were not noted in either of their case files. The comprehensive mental health assessment conducted by three independent mental health professionals prior to therapy initiation might have contributed to the low detransition and regret rates in our cohort.

Surgery before the age of 18 was not performed routinely. The most frequent surgery was chest masculinization surgery, performed on less than a fifth of underage AFAB individuals receiving GAMT, whereas in a Dutch cohort almost 80% of eligible individuals underwent chest masculinization surgery (18). Chest masculinization surgery in adolescents is associated with significantly reduced gender dysphoria and very low regret rates (42), and has seen an increase in demand in recent years, in adults (43) as well as in adolescents (44). Low surgery rates in our cohort could be connected to relatively high age at hormone therapy initiation (median age 16.7), and the fact that at least 12 months of hormone therapy with sex steroids are recommended before gender affirming surgery (9). Another factor influencing surgery rates could be the generally reduced number of elective surgeries performed during and after the Covid-19 pandemic, as most surgeries in our cohort were performed in 2019 and 2020, with very low numbers in 2021 and 2022.

Fertility preservation rates were very low, with only six individuals undergoing cryopreservation, corresponding to five of the 42 AMAB individuals (11%) and one of the 121 AFAB individual receiving GAMT (0.8%). Low fertility preservation rates are also described in other studies (45–47), which are discordant with the reported desire for biological children in TGD individuals (24). Fertility preservation and possible effects of gender-affirming treatment on fertility are discussed routinely prior to any treatment start as part of the consent discussion, but Vienna University Hospital currently does not offer specialized fertility consultations for transgender adolescents. However, even centers offering specialized consultations still had similarly low fertility preservation rates (47). When considering these low rates, multiple factors should be considered: while the majority of TGD adolescents express a desire for future children (48.7%–67%), only a fraction is interested in having biological children (9%-35%) and most are interested in adoption (70-80%) (24). However, in an Australian Study investigating TGD parenthood, most had become parents via their partner giving birth (64%), 28% had given birth themselves, and only 5% and 3% were step- or foster parents respectively (48). To fulfill their desire for children, most TGD people have to overcome many barriers, even more so when pursuing biological offspring (24). More emphasis should be placed on improved access to fertility counseling and fertility preservation. Currently, neither procedural nor storage costs are covered by Austrian state health insurance. This creates an immense financial barrier for fertility treatment and should be addressed at a policy level to provide best possible care for all transgender children and adolescents. Insurance coverage of fertility preservation related costs might also increase fertility preservation utilization (24).

This study is, to our knowledge, the first study also reporting on changes to legal gender markers in TGD youth. Legal gender recognition is associated with improved mental health, and subsequently decreased levels of distress and suicidality (49–51). For context, it is important to note that in Austria, barriers to legal gender recognition for Austrian citizens are lower than barriers to GAMT, requiring only one mental health assessment presented to a local register office or municipal administration (52). In TGD youth, guardian approval is also necessary for legal gender recognition. Two thirds of our cohort of TGD youth changed their LGM, superseding the number of GAMT treatment initiations. While LGM changes were more common in those receiving GAMT (86.6%), more than a third of individuals who did not receive GAMT during the observational period of this study changed their LGM. This suggests that legal gender recognition can be an important aspect of affirming TGD young people’s gender identity, regardless of medical treatment initiation. More investigations into legal gender recognition in TGD youth and the impact on psychosociological wellbeing are required - especially since LGM change is a non-invasive, fully reversible measure that can aid in the alleviation of GD.

The number of transgender and gender diverse youth seeking gender affirming medical treatment in Austria increased over the last fifteen years, but has seemed to plateau between 2019 and 2022. This is the first study reporting treatment trajectories, fertility preservation and legal gender recognition rates in TGD youth in Austria. While most youth presented in middle adolescence (median age 15.8 years), GAMT rates were high, with 89% of eligible youth starting GAMT in the pediatric setting. There were no treatment discontinuations. Gender affirming surgery rates were relatively low, with chest masculinization surgery in 16.6% of AFAB individuals and breast augmentation in 3.7% of AMAB individuals. Fertility preservation rates were low. Legal gender recognition was very common in our TGD cohort, with the number of LGM changes superseding that of GAMT initiation rates. Prospective investigations into long-term treatment adherence, treatment satisfaction, somatic and mental health of children and adolescents with gender dysphoria, as well as the significance of legal gender recognition in TGD adolescents are needed.

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Ethikkommission der Medizinischen Universität Wien. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants’ legal guardians/next of kin in accordance with the national legislation and institutional requirements.

JS: Conceptualization, Data curation, Investigation, Visualization, Writing – original draft. SK: Conceptualization, Data curation, Formal 1nalysis, Project administration, Writing – review & editing. UK: Data curation, Writing – review & editing. JO: Software, Supervision, Validation, Writing – original draft, Writing – review & editing. SR: Conceptualization, Methodology, Writing – review & editing.