Background

Thirty-seven percent of the 3066 adolescents and young adults (AYAs) in a newly-published JAMA Pediatrics cohort study started gender-affirming hormone therapy within 2 years of the initial gender dysphoria diagnosis, suggesting inequities in time to hormone treatment. Barrier reduction to care for transgender and gender-diverse AYAs is needed within the United States Military Health System.¹

According to the authors of the study, led by Evan R. Locke, MD, of the Department of Family Medicine, David Grant Medical Center, Travis Air Force Base, California, 1.6 million people aged 13 years or older in the United States are transgender or gender diverse. These adolescents can experience depression, anxiety, suicidal ideation, and risk-taking behavior if they are in unsupportive environments.¹

"Clinicians are uniquely positioned to support the health and well-being of transgender and gender-diverse AYAs by providing social support and prescribing developmentally appropriate, medically necessary medications when indicated," stated the study authors. They added that among those aged 14 to 22 years in this population who first received a diagnosis of gender dysphoria in adolescence, a better understanding of patterns of exogenous sex steroid hormone initiation could inform health systems policy, educational initiatives, legislation, and science research implementation. These actions can help ensure equitable care, "especially in the context of multiple forms of marginalization," stated the authors.^1,2

Study details and results

"The goal of the current study was to evaluate the proportion of AYAs who initiate exogenous sex steroid hormones, determine the time to medication initiation, and identify potential inequities in US military–affiliated adolescents with low- or no-cost health care who received a new diagnosis of gender dysphoria across a large health care system," added the investigative team.¹

In a retrospective cohort design that used TRICARE Prime billing and pharmacy data from the Military Health System Data Repository, patients aged 14 to 22 years who received a gender dysphoria diagnosis between September 1, 2016 and December 31, 2021, were included. Excluded were service members and their spouses. Data analysis occurred between August 30 and October 12, 2023.¹

The primary outcome was the time between inital diagnosis of gender dysphoira to the first prescription for gender-affirming hormone medication, within a 2-year time frame. Gender-affirming care could include medical, surgical, mental health, and non-medical services for transgender and nonbinary people according to the Office of Population Affairs.³

There were 3066 patients included in the study, with a median (IQR) age of 17 years (15-19). Of these patients, 74% had a first-assigned gender marker of female. According to an unadjusted survival model that accounted for censoring, 37% initiated therapy by 2 years (95% CI, 35%-39%). Per age-adjusted curves, the proportion of patients who initiated therapy by 2 years increased by age category¹:

• 14-16 years: 25%
• 17-18 years: 39%
• 19-22 years: 55%

Two-year adjusted probabilities and incidence rate ratios (IRRs) demonstrated that longer times to hormone initiation were experienced by adolescents aged 14 to 16 years ((IRR, 0.36; 95% CI, 0.30-0.44) and 17 to 18 years (IRR, 0.66; 95% CI, 0.54-0.79), compared to young adults who were aged 19 to 22 years and Black patients compared to White adolescents (IRR, 0.73; 95% CI, 0.54-0.99).

Related to military rank, senior officer, compared with junior enlisted insurance sponsor rank (IRR, 1.93; 95% CI, 1.04-3.55) was associated with shorter time to hormone initiation. Similarly, related to health care setting location, civilian compared with military health care setting (IRR, 1.21; 95% CI, 1.02-1.43) was associated with shorter time to hormone initiation).¹

Conclusion

Most AYAs with a gender dysphoria diagnosis did not initiate exogenous sex steroid hormone therapy within 2 years of diagnosis, leading the investigative team to conclude, "Inequities in time to treatment indicate the need to identify and reduce barriers to care."

References:

1. Locke ER, Highland KB, Thornton JA, et al. Time to gender-affirming hormone therapy among US military–affiliated adolescents and young adults. JAMA Pediatr. Published online August 19, 2024. doi:10.1001/jamapediatrics.2024.2835.
2. Meerwijk EL, Sevelius JM. Transgender population size in the United States: a meta-regression of population-based probability samples. Am J Public Health. 2017;107(2):e1-e8. doi:10.2105/AJPH.2016.303578.
3. Gender-affirming care and young people. Office of Population Affairs. Accessed August 19, 2024. https://opa.hhs.gov/sites/default/files/2022-03/gender-affirming-care-young-people-march-2022.pdf.