INTRODUCTION: Not all individuals referred to gender identity units receive gender-affirming medical treatment (GAMT). However, there is a paucity of literature examining the reasons for this. This study aimed to investigate the reasons for not initiating GAMT in individuals who initially reported gender identity concerns and requested body changes in a gender identity unit in Spain, all of whom underwent psychological assessment and counseling. MATERIAL AND METHODS: We retrospectively reviewed a total of 457 health histories and collected basic socio-demographic data and information on reasons for not initiating GAMT. This information was grouped into categories based on thematic similarity following consensus among the authors. RESULTS: We identified a total of 62 patients who did not start GAMT. A total of 26 were deemed ineligible for issues related to mental health, identity development, and inadequate understanding of the GAMT protocol. The remaining 36 patients were counseled and followed up for a mean of 8.4 months. We categorized the reasons for not starting GAMT into 4 groups: (A) failure to meet criteria for gender incongruence/dysphoria (four patients)
(B) premature termination of the assessment/counseling process (11 patients)
(C) gender identity-related doubts and/or desistance of the transgender identity (12 patients)
and (D) discontinued desire for GAMT (9 patients). CONCLUSIONS: GAMT is not the endpoint for all individuals seeking care, and reasons for not starting GAMT are heterogeneous and sometimes complex. Psychological assessment and counseling remain important features of quality gender-affirming care, and current debates about access to GAMT should take these experiences into account to better inform its future provision.