CEO Rosalind Brewer, speaking during Walgreens’ fourth-quarter earnings call, said the company has seen a "tightening in the labor market" for pharmacists and pharmacy technicians, creating staffing shortages in some of its markets.
Walgreens CFO James Kehoe also noted the issue, saying, "Scripts remain challenged by temporary reductions in store operating hours due to staffing shortages."
"Scripts were up, softer than expected, 1.4% in fiscal year 2022," Brewer noted during the call.
"We are focusing investments to return about 3,000 stores to normal operating hours, which I expect will drive script volume recovery as we move through fiscal year 2023," she added. "We’re seeing positive staffing trends with 11 straight weeks of net pharmacists headcount increases."
The company has also opened eight "automated micro-fulfillment centers" that support some 1,800 Walgreens stores and use robotics to complete some pharmacy-related tasks, the CEO said during the earnings call.
"Our pace is somewhat slower than expected in part due to supply-side construction delays, but I’m pleased with the performance of the centers we do have up and running," she said.
In August, the Wall Street Journal reported the company was offering signing bonuses of up to $75,000 to pharmacists in certain U.S. markets to help address the staffing shortage. To receive the bonus, newly-hired pharmacists reportedly must remain working at Walgreens for at least 12 months.
For the fourth quarter, Walgreens posted $32.4 billion in sales, down slightly from $34.26 billion during the same period last year. It posted a net loss of $415 million.
The company's U.S. retail pharmacy comparable prescriptions dropped 3.5%, and its comparable prescriptions, excluding immunizations, fell 0.1% in the fourth quarter compared to the same quarter last year. The quarter’s total filled prescriptions, including immunizations and adjusted to 30-day equivalents, was 298.7 million, a 4.4% decrease, the company said in its earnings release.
Its total fiscal 2022 sales increased slightly from 2021, rising to $132.7 billion from $132.5 billion.
Ira, an older, soft-spoken homeless man, recently went to the Downtown Austin Community Court to see if he was eligible for free housing. One of my friends, a fellow researcher, accompanied him. Ira answered questions about his background, including about whether he had had run-ins with the law or a history of drug abuse. After the interview, the social worker at the court told Ira that his problems were not severe enough to get housing. Dejected, Ira joked, “If only I would have been a drug addict.” The social worker shrugged and responded that the community court’s housing program “takes a lot of things into consideration, but yeah.”
Today, drug abuse is not a barrier for homeless people seeking housing and welfare. In fact, many policies make drug abuse a prerequisite for services. Federal, state, and local programs give addicts more funds and assistance than nonaddicts. And other favors go to homeless individuals who can prove that they’re engaging in criminal activity.
The government claims that it is trying to support the most vulnerable people, which means finding those with the most problems. But it has come to regard those problems as immutable, in need of a constant flow of funding. The government ignores how, by rewarding destructive behavior, it makes it harder for people to get their lives together—and thus, how it is encouraging the very problems that it claims to be solving.
Most Americans recognize that subsidizing drug abuse and crime is a terrible idea. In the 1990s, the public forced Congress to end similar, older programs. But the bureaucracy and the advocates have found ways to resurrect such policies—and expand them. For many welfare programs today, the deserving recipients are no longer those with the most setbacks or the least income but those maintaining the worst addictions and committing the most crimes. If anyone wonders why, say, Los Angeles suffers around 2,000 homeless deaths a year—quadruple the level of about a decade ago—and if anyone wonders why drug abuse and violence are the overwhelming killers of the homeless, one reason is that the government is paying them to kill themselves and one another.
We have seen the lamentable effects of subsidizing addiction before. From 1972 to 1996, the government defined addiction to drugs and alcohol as a disability, which meant that an addict could get a monthly disability check. If you could prove to a federal bureaucrat that you had a crippling drug dependence, the government would pay you enough to feed yourself and your habit. If you got clean, it would declare you recovered and cancel your payments. The incentives, as economists say, were perverse.
Congress created Supplemental Security Income (SSI) in 1972 to combine disability payments for the poor into a single program. Representative Hugh Carey, a New York Democrat, was worried about his own state’s then-unique disability program, which funded heroin addicts—not because he wanted to end it but because he wanted federal taxpayers to pay for it. He succeeded in getting drug and alcohol addiction included as a disability in the House of Representatives’ SSI bill. Senator Harold Hughes, a Democrat from Iowa and a recovering alcoholic, understood the dangers of subsidizing addiction and got it excluded from the Senate’s version. Yet Carey triumphed over Hughes in the congressional conference committee. Soon, about 10,000 addicts were receiving SSI checks—almost all of them from New York’s welfare rolls.
In its early years, the addiction program remained limited in scope. The Social Security Administration, more at ease cutting checks for the elderly than administering a complicated welfare scheme, disfavored it. But a 1984 congressional expansion of disability benefits, and some new court rulings, added more drug abusers to the caseload. Then, in 1989, the federal government began spending tens of millions of dollars in outreach to get people on the disability rolls, focusing on the homeless, whose frequent addiction woes provided an easy route to benefits. Soon, 250,000 addicts were on the rolls.
Americans would eventually reject the experiment. Newspaper reports told of addicts dying the day the latest SSI check arrived. An episode of NBC’s Dateline showcased a recovered alcoholic, who observed that the federal checks to addicts were “killing them on the installment plan.” CBS’s 60 Minutes ran a devastating piece featuring an addiction specialist who fretted that the federal government was “enabling” addiction and discouraging treatment. In 1996, a recently elected Republican majority, with the help of many Democrats, ended the SSI addiction program.
Academics and many welfare bureaucrats were outraged. They spent years finding ways to skirt the law and restore addiction as a route to secure benefits. They have succeeded.
One way that addicts have secured benefits is through new homelessness programs. The HEARTH Act, signed by President Obama in 2009, reorganized homelessness spending to emphasize giving permanent homes to the chronically homeless—those on the streets for more than a year and with a disability. This was known as the Housing First philosophy. Without any seeming debate, Congress adopted the bureaucracy’s own definition of disability, which included “substance use disorder.”
The Department of Housing and Urban Development told local governments to devise a single ranking to determine which homeless people get free or subsidized housing. Those with “significant health or behavioral health challenges,” such as “substance use disorders,” should get an advantage, HUD said. In a new twist on the old disability programs, the federal government also began making criminality a favorable condition for benefits. One of its housing-voucher programs for the homeless, HUD said, should prioritize those with “criminal records” and those with “high utilization of crisis services,” such as “jails.”
The HUD mandates led a nonprofit group, OrgCode, to create the infelicitously named Vulnerability Index–Service Prioritization Decision Assistance Tool, or VI-SPDAT (pronounced vee-eye spi-dat), which local governments nationwide adopted. In a typical VI-SPDAT survey for single homeless adults, a homeless person can accumulate “points” toward free housing. He can get a point if he has “run drugs for someone” or “shared a needle.” He gets another point if his drug abuse got him evicted from an apartment. There’s another bonus point for taking medication other than “the way the doctor prescribed,” or selling the medication. For crime, the system awards a point if the homeless person has tried to harm someone in the last year, another for being the “alleged perpetrator of a crime,” and yet another for landing in a drunk tank, jail, or prison. If the person does enough drugs and commits enough crimes, he can get six total points. With enough time on the streets, he can get to the necessary eight points toward a free house, without showing any other issues, apart from criminal behavior and drug abuse.
For families—almost always, single mothers—the scoring system rewards both drug and child abuse. Beyond the usual substance-use points, mothers get a point if children are frequently truant. They get a bonus point if their child spends two or more hours per day without any responsible adult around. Incredibly, a mother can also get a bonus point if child protective services has removed one or more of her kids. Having “two or more planned activities each week,” such as going to the library or park, is a negative on their benefits score.
Abenefits system that rewards drug abuse, crime, and child abuse should collapse after public exposure, right? Yet the system came under attack only after tenuous accusations of racism. Activists argued that not enough minorities were getting into housing. Earlier this year, the creator of VI-SPDAT issued a mea culpa,calling for an end to the putatively racist program and for accelerating “activities to improve approaches that further promote racial and gender equity.” Though the Fair Housing Act forbids rewarding housing based on race, HUD in 2020 had already said that cities should change their scoring system to “dismantle embedded racism in [scoring] and prioritization processes” and find ways to get more minorities enrolled.
Now, as a consequence, many states and cities provide their own scoring systems, often after adjusting the scoring to emphasize questions to which black people are, supposedly, more likely to answer yes. Under the Massachusetts “Vulnerability Assessment Tool,” a homeless individual gets four points for agreeing that “I am currently using alcohol or drugs and not in recovery” but only one point if he has “been in recovery for more than one year.” The individual gets an extra two points if he has had an overdose or alcohol poisoning in the past 12 months. In Tacoma, Washington, the government says that the scoring system should focus on getting housing for those with “active substance use,” “frequent criminal justice interactions,” and, ideally, a “felony.” San Francisco asks if applicants have “ever had to use violence to keep yourself safe”; answering affirmatively yields bonus points for a new house. In all these places, getting into recovery or refraining from violence is almost fatal for an applicant’s chances for housing and benefits.
The homeless can accelerate their benefits by committing new crimes. Many cities have created “specialty courts” to deal with the particular problems of the addicted, the mentally ill, and the homeless. While some of these institutions use the power of mandated treatment to change lives, others have become another means to distribute funds to criminals. (See “Keeping the Mentally Ill Out of Jail,” Autumn 2018.) If you’re homeless in Austin and commit an offense such as trying to sell drugs, you will get assigned to the Downtown Austin Community Court. According to internal documents, your supposed “punishment” will be “access to basic needs, social services, and other resources,” so as to “address the root causes” of your situation. Your community service requirement will be met by the time you spend applying for welfare. Your assigned case managers will help you with those applications and also serve as chauffeurs, driving you to meetings and appointments. A single criminal act can open up various new benefits. As one news report says, the court wants to be “more of a social service organization than a court of law.”
In San Francisco, similarly, the CONNECT program will let anyone charged with crimes vaguely associated with homelessness, such as “defecating in public,” “aggressive soliciting,” “drinking in public,” “fighting,” or even plain “destruction of property” to receive, instead of punishment, “supportive housing, case management, medical services, family & employment programs,” and “meals service.”
The government’s effort to give housing priority to addicts and criminals is even more damaging because the current Housing First model discourages treatment for addiction or other problems. The idea behind Housing First, also known as permanent supportive housing, was that homeless people needed “low barriers” to get off the street and into housing; any mandates for treatment, on this view, would discourage homeless applicants.
Housing First is now official federal policy, and every local homelessness group receiving federal funds has to adopt it. HUD tells these groups that mandates for addiction services “should be rare and minimal if used at all.” The head of a major nonprofit providing housing for Native Americans in Arizona told me that many of her homeless clients suffered severe alcohol problems, but the federal government upbraided her when she tried to require minimal treatment in exchange for housing. The Tacoma homeless-services center warns that housing “may not be restricted based on . . . current sobriety,” willingness “to participate in substance abuse treatment or counseling,” or even “goal setting” of any sort. In exchange for free housing, then, the government expects less than nothing from its clients.
Some Housing First programs don’t just disdain treatment; they actively encourage drug abuse. One Pennsylvania program, Pathways to Housing, for example, provides homeless addicts with free apartments (“fully furnished units chosen by the participants”)—as well as a needle exchange and necessary drug paraphernalia.
It’s not surprising that housing filled with criminal addicts under zero requirements for treatment attracts problems. A San Francisco Chronicle investigationreported that in 2020–21, at least 166 people in the city’s permanent supportive housing program overdosed. This represented 14 percent of all overdoses in San Francisco during that period, even though these houses held less than 1 percent of the city’s population. One resident, Joel Yates, described what happened when he moved from a recovery house, which required sobriety, to a low-barrier supportive-housing unit: he quickly bumped into a neighbor on his floor who was smoking crack—and Yates relapsed.
The only reasons the number of overdoses in San Francisco housing is not higher is that, first, the city doesn’t track all overdoses, and, second, it has installed hallway Narcan dispensers to help revive overdosed residents. The horrific results of these programs confirm recent studies that show that the homeless placed in supportive housing are more likely to abuse drugs and alcohol than those left on the streets. And these grim findings dovetail with decades’ worth of research showing that boosting income to addicts increases their drug consumption and the likelihood of relapse. A free house frees addicts from lots of other expenses.
The drug-abuse problem in these units has gotten so bad that the federal government awarded the largest homeless-housing provider, CSH, almost $4 million to research “overdose prevention practices in permanent supportive housing.” The outcome of the research, by the very definition of permanent supportive housing, cannot be to discourage drug abuse.
Deserving recipients in many social-services programs are no longer those with the most setbacks or the least income but those with the worst addictions and who commit the most crimes. (ROBERTO E. ROSALES/ALBUQUERQUE JOURNAL/ZUMA WIRE/ALAMY LIVE NEWS)
Activists, bureaucrats, and judges have begun chipping away at legal restrictions on addiction subsidies in other programs. In 2007, the federal government released an article titled “Documenting Disability for Persons with Substance Use Disorders & Co-Occurring Impairments,” which explains ways to get SSI disability payments for addicts, while avoiding the formal ban. The article claims that a profound difference exists “between the [ban on addiction funding] and scientific understanding of addiction,” which suggests that the right approach should be to provide indefinite checks to drug abusers. The article claims, without concrete evidence, that the 1990s-era cutoff led to more addicts in jail and restricted access to treatment. It also explains how to demonstrate to welfare officials that an applicant’s addiction was a manifestation of other, fundable disabilities, using lines such as the “patient’s cocaine use clearly exacerbates his underlying psychiatric conditions.”
Psychiatric ills have become the easiest way to get addicts back on disability. After the cutoff of addiction funding in 1996, the percentage of SSI awards based on psychiatric diagnoses soared, to more than a third of the total, often with “co-occurring” addiction as a secondary disability. The increase in mental diagnoses absorbed almost half of the addicts who had been kicked off the rolls. In contrast to the bureaucracy’s claims of harm, a National Bureau of Economic Research paper found “appreciable increases in labor-force participation and current employment” for addicts removed from the rolls in the first years, but noted that, in the longer run, disability checks “returned to earlier levels, and the short-run gains in labor market outcomes waned.”
The federal Substance Abuse and Mental Health Services Administration, SAMHSA, a hotbed of activism, runs several programs designed to get benefits to addicts. One, SSI Outreach, Access, and Recovery, seeks to enroll individuals with “substance use disorders” for disability. Its literature trumpets the ways its disability applications get flagged by the bureaucracy for quicker and more positive treatment and reports that 71 percent of its applications are approved—twice the rate of all applicants. Another SAMHSA program, Grants for the Benefit of Homeless Individuals, tries to connect “clients who experience substance use disorders,” along with other mental-health problems, to everything from Medicaid to SSI to food stamps.
In 1990, a bipartisan majority in Congress forbade the Veterans Administration from giving disability to people based on their drug and alcohol addictions. But activists convinced the administration that if a “primary” injury, such as a leg wound, led to the “secondary” problem of drug abuse, the addiction garnered extra benefits. The 2001 federal court case of Allen v. Principi argued that substance abuse was often a sign of a psychiatric disorder and thus should be positive evidence of disability when awarding benefits. Now, despite earlier, broad-based concerns that the government was feeding veterans’ addictions, the government is again paying for drug and alcohol abuse among a vulnerable population.
In line with the medicalization of every aspect of modern life, federal Medicaid dollars for indigent health care are now used for housing the homeless, and specifically for drug addicts. Connecticut and Florida use Medicaid funds to help those with both mental health and addiction disorders find a place to live and help them keep their current housing. Florida says that its goal is to keep people with substance-abuse disorders in “sustainable housing through improved supports.” North Dakota says that its special Medicaid program for the disabled provides housing support to those with “alcohol abuse,” “cannabis abuse,” “cocaine abuse,” “hallucinogen abuse,” “opioid abuse” and the all-encompassing “other stimulant abuse,” as long as these are accompanied by a “drug-induced mood disorder.” Los Angeles uses Medicaid and other funds to support the most incorrigible addicts. A homeless drug abuser in LA won’t get special help if she overdosed only twice last year—but if she had three or more overdoses, she can get free “transportation, childcare support, establishment of benefits,” as well as assistance in receiving “SSI, SSDI, CAPI, CalFresh, and General Relief” funds.
These programs are in addition to the general cash provision for the homeless, which itself has deleterious consequences. Many cities like New York and San Francisco phased out such cash programs about 20 years ago (the latter under then-mayor Gavin Newsom’s Care Not Cash program), due to concerns about the money fueling alcohol and drug abuse, but they’ve now come back into vogue. One “old-school junkie” told former California gubernatorial candidate Michael Shellenberger about all the funds he gets to abuse drugs and live in the City by the Bay—over $600 in cash and $200 in food stamps a month. “I get paid to be homeless in San Francisco.”
The “harm reduction” approach to dealing with addiction began with the simple idea that clean needles could prevent the spread of blood-borne diseases such as HIV or hepatitis among intravenous drug users. But it has morphed into yet another source of addiction subsidies. Earlier harm-reduction activists backed needle exchanges, where addicts brought in dirty needles to trade in for clean ones. But now, government programs hand out dozens of free needles to anyone who asks. Cities like Seattle and San Francisco moved to providing free glass pipes for meth or free foil and cookers for heroin, usually focused (again) on the homeless. The putative health benefits of new glass pipes and foil have never been clearly explained.
Since 1988, federal law has prohibited the funding of needles for illegal drugs. But in 2015, Congress allowed funding for all aspects of needle programs except the needles themselves. Instead of the simple needle exchanges that some politicians wanted to support, the bureaucracy recommended supporting programs that offered as many free needles as possible. The Centers for Disease Control and Prevention says that “although restrictive syringe distribution approaches such as 1:1 exchange may seem desirable,” they are “not recommended.” Instead, they note that providing people up to 30 syringes a month may be helpful. President Biden’s stimulus act provided funds for many types of “syringe service programs and other harm reduction” initiatives without any of the usual restrictions, and that led the bureaucracy to try to maximize free drug supplies. SAMHSA offered a $30 million grant program to distribute, among other harm-reduction tools, “smoking kits/supplies” for those smoking crack and methamphetamine. The grant prioritized smoking-kit distribution in poor and minority communities. What was once a wild conspiracy theory about the U.S. government encouraging crack use among African-American city-dwellers is now a publicly stated policy.
The harm-reduction programs have extended their ambit to sustaining anyone with an addiction. According to financial statements, St. Ann’s Corner of Harm Reduction, in the Bronx, received over $3.2 million in government grants and contracts in 2020. Though this was slightly more than it spent on all its programs that year, much of that spending went to general lifestyle support. An academic study of an unnamed, government-funded Bronx harm-reduction center noted that it offered free food, clothing, backpacks, and MetroCards to attract “clients” from three “competing” needle programs. As the study noted, the center’s funding was “based upon the volume of individuals served.” The center paid regular income to “peer” counselors—individuals with a current or past drug addiction who advise other addicts, though what a current drug abuser could tell another, besides how to score, was unclear. Those addicts passed over for the coveted peer positions told the academic researcher that they would “take [their] talents” to other needle programs. The center also became a useful place to fence stolen goods, with employees purchasing some of the contraband themselves, the study noted.
Some cities have found even more direct ways to subsidize addiction. San Francisco famously provided alcohol, marijuana, and cigarettes to homeless addicts when it put them in free hotel rooms during the Covid lockdowns. The city also laid out in the hotel lobbies the usual assortment of free needles, rubber tourniquets for injections, cookers for heroin, and glass pipes for methamphetamine and crack. The city said that these supplies were necessary to keep the homeless in the hotels and protect them from the effects of Covid. And it worked: San Francisco did not see a single homeless death from Covid in the pandemic’s first year. Yet overall homeless deaths were double any previous year in the city’s history; more than 80 percent were substance overdoses.
A Los Angeles center for “harm reduction”—an approach that began on a principle of prevention but has morphed into yet another source of addiction subsidies (AL SEIB/LOS ANGELES TIMES/GETTY IMAGES)
Over the past century, elites have tried to redefine all crimes and all social problems as illnesses. The goal has been to remove any sense of personal responsibility and to attribute every problem either to biology or society.
Addiction, of course, isan illness. It hijacks the brain and turns a human into a vessel seeking just one thing: a fix. But indulging that addiction isa choice. It must be if we are going to encourage addicts to take steps toward their own recovery. Twelve-step programs require a person to “make a decision” to stop abusing substances. Yet the government ignores choice and pretends that continued self-abuse is inevitable. It enables addiction instead of fighting it.
We know that current policies don’t work. Drug overdoses have risen 500 percent in just two decades. More than 100,000 Americans overdosed last year, the vast majority from opioids. More drug abuse has been accompanied by more violence and crime, as well as increases in homelessness, especially on the street. Many cities have seen a doubling in annual homeless deaths just over the last five years. Earlier fears about heroin or the crack epidemic pale in comparison with the modern blight.
Thankfully, some efforts promote better decisions. The bipartisan 2018 Support for Patients and Communities Act created the Recovery Housing Program, which houses sober individuals, recovering from an addiction, for up to two years. The program should bolster nonprofits like Oxford House, which allows recovering addicts to live together in small, suburban houses and help one another on the path to recovery. All clients in Oxford House must work and stay clean. Conditioning more housing and services on sobriety would be the best possible incentive for personal change. But such programs remain the exception.
In the 1990s, the public learned about destructive programs that funded drug abuse, and it struck back with laws and prohibitions. Yet new programs, often sneaked in by the bureaucracy, have reversed this trend and instead are encouraging what the law forbids. Then and now, most Americans understand the obvious: the government shouldn’t be supporting drug abuse and crime. The taxpayer should not feed such habits or make it harder for addicts to get clean. In a better world, the government would help damaged individuals to move ahead with their lives. But today, as Ira and other homeless people know, the government is helping them kill themselves on the public dime.
Thousands of children in the United States now openly identify as a gender different from the one they were assigned at birth, their numbers surging amid growing recognition of transgender identity and rights even as they face persistent prejudice and discrimination.
As the number of transgender children has grown, so has their access to gender-affirming care, much of it provided at scores of clinics at major hospitals.
Reliable counts of adolescents receiving gender-affirming treatment have long been guesswork – until now. Reuters worked with health technology company Komodo Health Inc to identify how many youths have sought and received care. The data show that more and more families across the country are grappling with profound questions about what type of care to pursue for their children, placing them at the center of a vitriolic national political debate over what it means to protect youth who identify as transgender.
Diagnoses of youths with gender dysphoria surge
In 2021, about 42,000 children and teens across the United States received a diagnosis of gender dysphoria, nearly triple the number in 2017, according to data Komodo compiled for Reuters. Gender dysphoria is defined as the distress caused by a discrepancy between a person’s gender identity and the one assigned to them at birth.
Overall, the analysis found that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Reuters found similar trends when it requested state-level data on diagnoses among children covered by Medicaid, the public insurance program for lower-income families.
Gender-affirming care for youths takes several forms, from social recognition of a preferred name and pronouns to medical interventions such as hormone therapy and, sometimes, surgery. A small but increasing number of U.S. children diagnosed with gender dysphoria are choosing medical interventions to express their identity and help alleviate their distress.
These medical treatments don’t begin until the onset of puberty, typically around age 10 or 11.
For children at this age and stage of development, puberty-blocking medications are an option. These drugs, known as GnRH agonists, suppress the release of the sex hormones testosterone and estrogen. The U.S. Food and Drug Administration has approved the drugs to treat prostate cancer, endometriosis and central precocious puberty, but not gender dysphoria. Their off-label use in gender-affirming care, while legal, lacks the support of clinical trials to establish their safety for such treatment.
Over the last five years, there were at least 4,780 adolescents who started on puberty blockers and had a prior gender dysphoria diagnosis.
This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.
By suppressing sex hormones, puberty-blocking medications stop the onset of secondary sex characteristics, such as breast development and menstruation in adolescents assigned female at birth. For those assigned male at birth, the drugs inhibit development of a deeper voice and an Adam’s apple and growth of facial and body hair. They also limit growth of genitalia.
Without puberty blockers, such physical changes can cause severe distress in many transgender children. If an adolescent stops the medication, puberty resumes.
The medications are administered as injections, typically every few months, or through an implant under the skin of the upper arm.
After suppressing puberty, a child may pursue hormone treatments to initiate a puberty that aligns with their gender identity. Those for whom the opportunity to block puberty has already passed or who declined the option may also pursue hormone therapy.
At least 14,726 minors started hormone treatment with a prior gender dysphoria diagnosis from 2017 through 2021, according to the Komodo analysis.
Hormones – testosterone for adolescents assigned female at birth and estrogen for those assigned male – promote development of secondary sex characteristics. Adolescents assigned female at birth who take testosterone may notice that fat is redistributed from the hips and thighs to the abdomen. Arms and legs may appear more muscular. The brow and jawline may become more pronounced. Body hair may coarsen and thicken. Teens assigned male at birth who take estrogen may notice the hair on their body softens and thins. Fat may be redistributed from the abdomen to the buttocks and thighs. Their testicles may shrink and sex drive diminish. Some changes from hormone treatment are permanent.
Hormones are taken in a variety of ways: injections, pills, patches and gels. Some minors will continue to take hormones for many years well into adulthood, or they may stop if they achieve the physical traits they want.
Hormone treatment may leave an adolescent infertile, especially if the child also took puberty blockers at an early age. That and other potential side effects are not well-studied, experts say.
The ultimate step in gender-affirming medical treatment is surgery, which is uncommon in patients under age 18. Some children’s hospitals and gender clinics don’t offer surgery to minors, requiring that they be adults before deciding on procedures that are irreversible and carry a heightened risk of complications.
The Komodo analysis of insurance claims found 56 genital surgeries among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. Among teens, “top surgery” to remove breasts is more common. In the three years ending in 2021, at least 776 mastectomies were performed in the United States on patients ages 13 to 17 with a gender dysphoria diagnosis, according to Komodo’s data analysis of insurance claims. This tally does not include procedures that were paid for out of pocket.
A note on the data
Komodo’s analysis draws on full or partial health insurance claims for about 330 million U.S. patients over the five years from 2017 to 2021, including patients covered by private health plans and public insurance like Medicaid. The data include roughly 40 million patients annually, ages 6 through 17, and comprise health insurance claims that document diagnoses and procedures administered by U.S. clinicians and facilities.
To determine the number of new patients who initiated puberty blockers or hormones, or who received an initial dysphoria diagnosis, Komodo looked back at least one year prior in each patient’s record. For the surgery data, Komodo counted multiple procedures on a single day as one procedure.
For the analysis of pediatric patients initiating puberty blockers or hormones, Komodo searched for patients with a prior gender dysphoria diagnosis. Patients with a diagnosis of central precocious puberty were removed. A total of 17,683 patients, ages 6 through 17, with a prior gender dysphoria diagnosis initiated either puberty blockers or hormones or both during the five-year period. Of these, 4,780 patients had initiated puberty blockers and 14,726 patients had initiated hormone treatment.
