Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States

Abstract

<div class="section"> <a class="named-anchor" id="ab-soi170127-1"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e395">Question</h5> <p id="d1549595e397">What are the incidence of and trends in gender-affirming surgery over time in the United States? </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-2"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e400">Findings</h5> <p id="d1549595e402">In this population-based study of 37 827 gender-affirming surgical encounters, genital surgery increased over time and most patients undergoing these procedures were self-payers. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased from 2012 to 2014 by 3-fold. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-3"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e405">Meaning</h5> <p id="d1549595e407">As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-4"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e412">Importance</h5> <p id="d1549595e414">Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-5"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e417">Objectives</h5> <p id="d1549595e419">To investigate the incidence and trends over time of gender-affirming surgical procedures and to analyze characteristics and payer status of transgender patients seeking these operations. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-6"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e422">Design, Setting, and Participants</h5> <p id="d1549595e424">In this descriptive observational study from 2000 to 2014, data were analyzed from the National Inpatient Sample, a representative pool of inpatient visits across the United States. The initial analyses were done from June to August 2015. Patients of interest were identified by <i>International Classification of Diseases</i>, <i>Ninth Revision</i>, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-7"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e433">Main Outcomes and Measures</h5> <p id="d1549595e435">Demographics, health insurance plan, and type of surgery for patients who sought gender-affirming surgery were compared between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-8"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e438">Results</h5> <p id="d1549595e440">This study included 37 827 encounters (median [interquartile range] patient age, 38 [26-49] years) identified by a diagnosis code of transsexualism or gender identity disorder. Of all encounters, 4118 (10.9%) involved gender-affirming surgery. The incidence of genital surgery increased over time: in 2000-2005, 72.0% of patients who underwent gender-affirming procedures had genital surgery; in 2006-2011, 83.9% of patients who underwent gender-affirming procedures had genital surgery. Most patients (2319 of 4118 [56.3%]) undergoing these procedures were not covered by any health insurance plan. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased by 3-fold in 2014 (to 70) compared with 2012-2013 (from 25). No patients who underwent inpatient gender-affirming surgery died in the hospital. </p> </div><div class="section"> <a class="named-anchor" id="ab-soi170127-9"> <!-- named anchor --> </a> <h5 class="section-title" id="d1549595e443">Conclusions and Relevance</h5> <p id="d1549595e445">Most transgender patients in this national sample undergoing inpatient gender-affirming surgery were classified as self-pay; however, an increasing number of transgender patients are being covered by private insurance, Medicare, or Medicaid. As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them. </p> </div><p class="first" id="d1549595e448">This population-based study investigates the incidence and trends over time of gender-affirming surgical procedures in the United States and analyzes characteristics and payer status of transgender patients seeking these operations. </p>