Trajectories of gender expansive behavior in children and adolescents: a time-to-event analysis in a large health system-based cohort Open Access

Wagner, Stephanie (Spring 2020)

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Objectives: Health care needs of transgender and gender diverse (TGD) children and adolescents is an increasingly important, but understudied, issue. Few studies have examined the likelihood of gender expansive behavior progressing to a TGD-specific diagnosis or gender affirming hormonal treatment (GAHT). This study aims to explore this using data from three geographically and demographically diverse integrated health care systems.

Methods: Electronic Health Records from 2006 to 2014 were used to ascertain study participants at Kaiser Permanente sites in Georgia, Northern California, and Southern California. Individuals were designated as having TGD status based on free-text keywords in clinical notes. Of 1,347 participants first presenting as TGD at age 3-17 years, 958 were enrolled without a TGD diagnosis and included in this analysis. Participants were followed until the event of interest (diagnostic code or first ordered GAHT prescription, analysis dependent), disenrollment from the health plan, or end of study follow-up (December 2014). Multivariable Cox proportional hazard models were used to compare incidence rates of events of interest across demographic groups with results expressed as hazard ratios (HR) and 95% confidence intervals (CI).

Results: Overall, 29% of participants received a TGD diagnosis and 25% were prescribed GAHT during follow-up. Approximately one quarter (24%) of TGD youth with male sex recorded at birth received a TGD diagnosis compared to one third (33%) of TGD youth who were recorded as female at birth (adjusted HR=1.3; 95% CI: 1.0, 1.7). TGD diagnosis was more common among those 15+ years at presentation when compared to those age 10-14 years and age 3-9 years (37% vs. 28% vs. 16%, respectively). Using the youngest group as reference, the adjusted HRs (95% CI) were 2.0 (1.3-3.0) for age 10-14 years and 2.7 (1.8-3.9) for age 15+ years. Racial/ethnic minorities were less likely to receive a diagnosis (26% vs. 33%) or be prescribed GAHT (21% vs. 29%) than their non-Hispanic white counterparts.

Conclusions: Rates of TGD-specific diagnosis and GAHT initiation in TGD youth differ significantly by age, sex recorded at birth, and race/ethnicity. These results have implications for future studies aimed at informing care of children with gender expansive behaviors.

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