Trends in the use of Puberty Blockers among Transgender Children in the United States

Research Article

J Pediatri Endocrinol. 2017; 2(2): 1020.

Trends in the use of Puberty Blockers among Transgender Children in the United States

Lopez CMD*, Solomon S, Boulware RA, Cowles DE, Ozgediz DH, Stitelman MG, Caty ER and Christison L

Department of Surgery, Section of Pediatric Surgery, Yale University School of Medicine, USA

*Corresponding author: Lopez CMD, Department of Surgery, Section of Pediatric Surgery, Yale University School of Medicine, USA

Received: November 11, 2017; Accepted: December 22, 2017; Published: December 29, 2017

Abstract

Objective: To identify national trends in the utilization of histrelin acetate implants among transgender children in the United States

Methods: We analyzed demographic, diagnostic, and treatment data from 2004 to 2016 on the use of Histrelin Acetate reported to the Pediatric Health Information System (PHIS) to determine the temporal trends in its use for transgender-related billing diagnoses, e.g. “Gender Identity Disorder.”Demographic and payer status data on this patient population was also collected.

Results: Between 2004 and 2016, the annual number of implants placed for a transgender related diagnosis increased from 0 to 63. The average age for placement was 14 years. Compared to natal females, natal males were more likely to receive implants (57 versus 46) and more likely to have implants placed at an older age (62% of natal males versus 50% of natal females were>13 years; p<0.04).The majority of children were white non-Hispanic (white: 60, minority: 21). When compared to the distribution of patients treated for precocious puberty (white: 1428, minority: 1421), white non-Hispanic patients were more likely to be treated with a histrelin acetate implant for a transgender related diagnosis than minority patients (p<0.001). This disparity was present even among minority patients with commercial insurance (p<0.001).

Conclusion: Utilization of histrelin acetate implants among transgender children has increased dramatically. Compared to natal females, natal males are more likely to receive implants and also more likely to receive implants at an older age. Treated transgender patients are more likely to be white when compared to the larger cohort of patients being treated with histrelinacetate for Central Precocious Puberty (CPP), thus identifying a potential racial disparity in access to medically appropriate transgender care.

Keywords: Transgender children; Histrelin acetate; Disparities; Race; Payer status

Introduction

Long-acting gonadotropin releasing hormone analogues (GnRHa’s), often referred to as “puberty blockers”, to suppress endogenous sex hormone production are FDA-approved for the treatment of Central Precocious Puberty (CPP). In recent years, however, the use of these agents has expanded to include a growing number of transgender children. In Tran’s youth, GnRHa therapy suppresses normally timed pubertal development. In these individuals, the onset of pubertal progression and the resultant phenotypic acquisition of secondary sex characteristics has been shown to be associated with increased anxiety, depression, and gender dysphoria [1]. Moreover, many of these changes have limited reversibility, decreasing the subsequent effectiveness of cross hormone therapy.

The most commonly used medications for pubertal suppression are leuprolide acetate injections (Lupron; AbbVie, Chicago, IL) andhistrelin acetate subcutaneous implant (Supprelin, Vantas; Endo Pharmaceuticals, Malvern, PA). The safety and efficacy of these agents have been reported in a number of populations and both regimens are recommended in the World Professional Organization for Transgender Health Standards of Care and the Endocrine Society Guidelines [2-7].

While appropriate medical intervention along with an affirming environment has been shown to result in improved health outcomes for transgender individuals, national survey data on the number of transgender children remains elusive andtrends in the utilization of hormone suppressing therapies in this population have not previously been described [1-4].

We conducted a study to analyze the temporal trends in the number of histrelin acetate implants placed in children in the United States for a transgender-related diagnosis and to examine differences in its utilization among transfemale (natal male) and transmale (natal female) individuals.

Methods

Study population and design

The study was a retrospective data analysis using the Pediatric Health and Information System (PHIS) database, a comprehensive pediatric database operated by the Children’s Hospital Association. The database includes clinical, demographic, and financial details of more than six million patients in 43 US children’s hospitals, including data from major US centers with specialized pediatric gender clinics [8]. The diagnostic codes for Gender Identity Disorder (ICD-10 F64.00) and Sexual and Gender Identity Disorders/Gender Dysphoria (ICD-9 302.00) were used as a proxy for transgender status. The PHIS database was searched for patients who were admitted for placement of a histrelin acetate implant (CPT 11981) in association with a principle diagnosis of F64.00 and 302.00 from 2004 to 2016. Patients younger than 19 years of age were included in the study. The age at admission, utilization of histrelin acetate, age at implant placement, natal sex, and the hospital of admission were obtained. For comparison, PHIS data on patients admitted for placement of a histrelin acetate implant (CPT 11981) in association with a diagnosis of precocious puberty (ICD-10 E30.1; ICD-9 259.1) was also gathered. This study was submitted and approved by the hospital’s institutional review board (HIC# 2000021331).

Pilot validation of search criteria

Medical records of patients admitted to Yale New Haven Children’s Hospital from February 2014 to June 2017 for surgical placement of a histrelin acetate implant were identified. A total of 92 patient cases (n=2 Transyouth, n=81CPP, n=1 Pituitary Dwarfism, n=1 Short Stature, n=7 Other) were manually reviewed to identify transgender children and associated ICD diagnostic codes. ICD codes for Gender Identity Disorder (ICD-10 F64.00) and Sexual and Gender Identity Disorders/Gender Dysphoria (ICD-9 302.00) correctly identified transgender children.

Statistical analysis

A thorough analysis of demographics associated with histrelin acetate use in the pediatric transgender population was conducted. Continuous data were summarized with means and standard deviations. Proportions were compared using the fisher exact twotailed tests. The p value was set at 0.05.

Results

The population of children undergoing histrelin acetate implants for a transgender-related diagnosis included 92 unique patients from 12 hospitals. The population of children undergoing histrelin acetate implants for precocious puberty included 2240 unique patients from 34 hospitals.

Notable temporal differences were found with regard to the incidence of histrelin acetate use for a transgender-related diagnosis, including a tenfold increase in the annual number of implants from 2014 to 2016, while the number of implants placed for CPP essentially remained unchanged (Table 1) of the 92 transgender patients identified, there were 39 natal females, 52 natal males, and one patient whose natal sex was unknown. The average age at the time of implant placement for transgender children was 14 years (range 8.8 to 18.8 years), whereas the average among children with CPP was 8.5 years (range 1 to 16.8 years). There were more treated transfemales. Compared to transmales, transfemales were more likely to have implants paced at an older age (62% transfemales/natal males versus 50% transmales/natal females individuals were >13 years; P < 0.04).

Citation: Lopez CMD, Solomon S, Boulware RA, Cowles DE, Ozgediz DH, Stitelman MG, et al. Trends in the use of Puberty Blockers among Transgender Children in the United States. J Pediatri Endocrinol. 2017; 2(2): 1020..