Gender-Affirming Medications Among Transgender Adolescents in the US, 2018-2022

Abstract

This cross-sectional study explores the receipt of gender-affirming medications among transgender and gender-diverse adolescents in the US, analyzing these rates by age and sex assigned at birth.

More than 300 000 adolescents aged 13 to 17 years (1.4%) identify as transgender and gender diverse (TGD) in the US.¹ Some adolescents who identify as TGD require medical interventions, including gonadotropin-releasing hormone (GnRH) agonists to delay gender-incongruent puberty and gender-affirming hormones (testosterone/estrogen), which are associated with improved psychological functioning.² Despite its safety and effectiveness, gender-affirming medical care for adolescents who identify as TGD is a polarizing topic, with nearly half of US states enacting laws to limit access.³ Advocates of these restrictive laws argue that rates of gender-affirming care are too high. Research published in 2024 documented that the receipt of gender-affirming surgical procedures is rare among adolescents,⁴ but the frequency of puberty blockers and gender-affirming hormone use is not well understood. Because age and experience of puberty onset varies by sex assigned at birth and dictates the course of care, it is important to analyze these rates by age and sex assigned at birth. This study filled this gap by using private insurance data across all 50 states.

Methods

This cross-sectional study used 2018 to 2022 data from the Merative MarketScan Research Database, which includes private insurance claims (eMethods in Supplement 1). This study was approved by the Harvard Pilgrim Health Care Institutional Review Board and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Informed consent was not required because the data were deidentified. To capture the range of ages at which puberty begins,⁵ we identified adolescents who identify as TGD aged 8 to 17 years who received puberty blockers (GnRH agonists) or gender-affirming hormones, using diagnostic, drug, and procedural codes (eg, receipt of exogenous hormones, histrelin implant, diagnosis of gender identity disorder) (eTable in Supplement 1). We calculated the rate of adolescents with a TGD-related diagnosis who received this care per 100 000 total adolescents enrolled in insurance by age and sex assigned at birth. We then used the Wald method to calculate 95% CIs. We used the sex recorded at the earliest enrollment as a proxy for sex assigned at birth. Analyses were performed with SAS version 3.7 Enterprise edition (SAS Institute) in August 2024.

Results

The sample included 5 155 282 adolescents, yielding 11 879 766 person-years of data. The rate of receiving puberty blockers among adolescents was 20.81 (95% CI, 19.04-22.59) per 100 000 adolescents assigned female at birth (AFAB) and 15.22 (95% CI, 13.73-16.71) per 100 000 adolescents assigned male at birth (AMAB). Before age 14 years, the rate of receiving puberty blockers to AFAB adolescents was slightly higher than AMAB adolescents (Figure). The rate of receiving hormones was 49.9 (95% CI, 47.14-52.65) and 25.34 (95% CI, 23.42-27.27) per 100 000 AFAB and AMAB adolescents, respectively. Hormone receipt rates increased after age 14 years, but remained low, peaking at age 17 years at 140.16 (95% CI, 128.01-152.32) per 100 000 for AFAB adolescents and 82.42 (95% CI, 73.25-91.59) per 100 000 among AMAB adolescents. Notably, no adolescents younger than 12 years received a hormone prescription.

Figure. Gender-Affirming Medication Receipt per 100 000 Enrolled Adolescents by Age and Sex Assigned at Birth, 2018-2022.

To be included in the numerator, enrollees must have had a transgender and gender diverse–related diagnosis before age 18 years. The Wald method was used to calculate 95% CIs (shading). The maximum rate for estrogen (assigned male at birth [AMAB]) was 82; testosterone (assigned female at birth [AFAB]), 140; puberty blockers (AMAB), 15; and puberty blockers (AFAB), 21.

Discussion

In this cross-sectional population of insured adolescents from 2018 to 2022, receipt of puberty blockers and hormones was rare. The higher rates of puberty blocker and hormone receipt at younger ages among AFAB relative to AMAB adolescents align with their earlier onset of puberty and the current standards of care.⁶ This study is limited by its reliance on claims data, which may misclassify adolescents who identify as TGD and receipt of care; it also cannot determine if their use is for gender affirmation or other reasons and excludes other gender-affirming medications (eg, antiandrogens, progesterone). These data are most generalizable to those with private insurance in large group plans, likely reflecting greater access to gender-affirming care. Thus, these rates may be the highest estimates, with lower rates expected among those with less comprehensive private insurance, Medicaid recipients, and the uninsured.

Supplement 1.

eMethods

eTable 1. Diagnosis, Prescription, Procedure Codes

Supplement 2.

Data Sharing Statement