How We Analyzed the Impact of State Bans on Gender-Affirming Care

This article was produced as part of the USC Annenberg Center for Health Journalism’s 2023 Data Fellowship.

To get a better understanding of how gender-affirming care for youths is being impacted by state bans, MedPage Today analyzed prescription data from Symphony Health, which captures 85% of retail pharmacy prescriptions and three-quarters of specialty and mail-order prescriptions in the U.S.

We chose to focus on puberty-blocking drugs as an imperfect proxy for access to gender-affirming care. While this care encompasses much more than these drugs -- including consultations with a clinician, counseling, discussions with family, lab tests, hormone replacement therapy (HRT), among other services -- they would be the most useful indicator given the limitations of the dataset.

For instance, the Symphony Health database links prescriptions to providers, not patients, and subsequently does not include indications or diagnoses associated with these prescribed drugs, like gender dysphoria. It would be difficult, perhaps more so than with puberty-blocking medications, to separate out hormones used for HRT versus other indications in minors.

We focused on gonadotropin-releasing hormone (GNrH) agonists, which are prescribed to block the onset of puberty. These include leuprolide acetate, histrelin, and triptorelin, all under various brand names and strengths. They are generally administered in the doctor's office via intramuscular injection once every 3 or 6 months. Sometimes, they are also given via an implant in the upper arm.

The number of youths under 18 with a diagnosis of gender dysphoria is small -- 42,167 in 2021, according to a Komodo Health analysis for Reuters. That's a small proportion of the 72 million children under age 18 in the U.S.

Among those with gender dysphoria, the number who elect to delay puberty is even smaller -- only around 1,390, the same analysis found. About three times that number initiate hormone treatment.

Our analysis dealt with a tiny number of patients on puberty-blocking medications. Statistically speaking, changes in such small numbers can be unreliable when assessing national and state trends.

GNrH agonists also are prescribed for other conditions, like central precocious puberty, growth disorders, or endometriosis in people under 18. Yet these other conditions are rare. If GNrH agonists prescribed for other conditions remained somewhat constant over time, any noticeable changes might be due to changes in prescription patterns of the same drugs for gender-affirming care.

To narrow our search to GNrH agonists prescribed to youths under 18, we limited our prescription data search to the following specialties:

• Pediatrics
• Pediatric endocrinology
• Adolescent medicine
• Child psychiatry
• Pediatric surgery
• Pediatric urology

Thus, prescriptions may be unaccounted for if they were administered by a non-pediatric specialist like a family medicine doctor or a nurse practitioner.

In our analysis of states that implemented bans of gender-affirming care for youth, we focused on 11 states with "effective" and enforceable bans, meaning they were not being blocked by courts and had specified penalties for providers or others. For each state, we compared the number of prescriptions in the 4 months preceding the month the ban went into effect with the 4 months after the month the ban went into effect. Four months on either side of a ban (spanning 9 months total per state) allowed us to look at the biggest number of states without further shortening the time frame.

We could only look at 2 years' worth of data, so some states that had a ban take effect closer to the end of 2023 did not allow enough time after their ban took effect for us to analyze them.

Of the 24 states that passed some kind of ban or restriction on gender-affirming care for youth, we included:

1. Alabama
2. Utah
3. Mississippi
4. Iowa
5. Kentucky
6. Oklahoma
7. Georgia
8. South Dakota
9. Tennessee
10. North Carolina
11. Missouri

We looked at total prescriptions and new prescriptions, by both the number of prescriptions, and by the doses of the drug. However, because these drugs are normally physician-administered in an office setting, some prescriptions may be equal to one dose.

Jae Corman, PhD, head of analytics and research at FOLX Health, and Anna Schoenbrunner, MD, of the Ohio State University Medical Center in Columbus, Ohio, provided research support for the data analysis.

Comment