Healthcare costs associated with gender dysphoria in children, adolescents and young adults in germany: A prevalence-based analysis using statutory health insurance data.

Background: In the past decade, there has been an increase in individuals presenting to healthcare services with gender dysphoria (GD), the psychological distress that may arise when an individual's birth-assigned sex does not align with his/her experienced gender. The current study aimed to analyze resource use and costs associated with prevalent GD in individuals aged 4 to 30 years.

Methods: The analysis was a prevalence-based cost study using data of the two largest German health insurance funds (BARMER and TK) from 2018, 2019, and 2020. Individuals with prevalent GD were identified based on ICD-10 diagnosis codes related to gender dysphoria. These were compared to a control group balanced for (1) age, birth-assigned sex, degree of urbanization, and (2) additionally for psychiatric diagnoses using entropy balancing. Outcomes of interest were total and sector-specific annual costs (outpatient, inpatient, medications) and health-related resource use (hospital days, defined daily doses of medications). Groups were compared stratified by age groups, birth-assigned sex, and for a subgroup of individuals with GD receiving hormonal therapy.

Results: Individuals with prevalent GD aged 4-30 years had higher average resource use and costs compared to controls, with little variation between years (e.g. difference in 2019 +€4,843 [95% confidence interval €4,306; €5,380], balanced for age, birth-assigned sex, degree of urbanization). The group difference was observed across age groups and healthcare sectors, with the largest differences found in somatic and psychiatric inpatient hospitalizations, and with psychiatric costs accounting for 50% of the total cost difference. Comparing individuals with GD receiving hormonal therapy with controls, the difference in total costs was similar, but the contribution of psychiatric costs was less pronounced (29%). The cost difference decreased considerably in all subgroups and sectors when psychiatric diagnoses were additionally balanced for.

Conclusions: Individuals with GD aged 4-30 years had higher annual resource use and costs than controls. Future studies analyzing resource use and costs over multiple years and examining the temporal association between GD and psychiatric disorders would allow a more accurate estimate of the costs directly attributable to GD.