Half of transgender patients leave home country for surgery, study finds


Jae Downing, Ph.D., uses methodologies that avoid erasing transgender and gender-diverse people from research. This includes an inclusive approach to studying design and conducting research in a way that reflects the needs and issues of sexual and gender minorities. (OHSU/Casey Williamson)

In the United States, approximately half of transgender and gender-diverse patients who undergo gender-affirming genital surgery travel outside their home country to receive this care, and those who do travel pay almost 50% more in medical costs, according to new findings from researchers at Oregon Health & Science University, published in JAMA Surgery.

The OHSU-led study offers the first national estimate of the average cost of gender-affirming genital surgeries. Its findings can help patients and insurance companies better plan to receive or pay for such medically necessary surgical care, says the paper’s lead researcher, Jae Downing, Ph.D.assistant professor of health policy at Oregon Health & Science University-Portland State University School of Public Health.

“Travelling a long distance for a major procedure such as gender-affirming genital surgery places a heavy burden on patients,” says Downing. “We already knew that travel for health care requires patients to take time off work and pay for travel and accommodation themselves, and that this can make it difficult for providers to get follow-up care. trained professionals who understand the unique needs of each patient. Now, our study shows that traveling out of state also increases medical costs for trans and gender-diverse patients — even though the total cost of their surgery is largely the same.

Transgender and gender diverse people are assigned a sex at birth that differs from their gender identity. Many transgender patients seek medically necessary care from health professionals to affirm their gender. The care needs of each transgender patient are unique; some patients seek hormone therapy and others seek breast, face, or genital surgeries. Genital surgical care is complex, is carried out by specialized surgeons and may require several subsequent interventions.

To understand the cost of gender-affirming genital surgery, Downing and colleagues at OHSU and the University of Washington studied a research database containing information on commercial insurance claims in the United States. United for 129 million people between 2007 and 2019. In this dataset, 771 patients received feminizing genital surgery, known as vaginoplasty, or masculinizing genital surgery, known as phalloplasty.

For all gender-affirming genital procedures combined, 49% of patients traveled outside of their own state to receive surgical care. At the same time, whether a surgery was performed inside or outside the patient’s home state, there was no statistically significant difference in the total cost of each procedure.

To calculate out-of-pocket medical expenses, the researchers added coinsurance, copayments, and deductible insurance claim payments. They found that patients who traveled out of state for surgery paid an average of almost 50% more in fees than those who did not. The average out-of-state patient paid $2,645, compared to $1,781 for the average in-state patient.

The study also found that patients who live in the South more often travel far from their own state for gender-affirming genital surgery. For example, patients who live in the West were 36% less likely to travel outside their home country for surgery than those who live in the South.

As such, many patients may need to travel out of state for gender-affirming genital surgery because there are not enough surgeons providing this care to begin with, and the need to travel may be greater in the South because the shortage of gender-assertive genital surgeons is greater in that region, Downing and colleagues note. They cite a 2020 study that found there were only 11 surgeons providing such specialized care in the South, four of whom practiced in Florida.

Geolani Dy, MD, at OHSU Urology

Geolani Dy, MD (OHSU)

“Transgender and non-binary patients face huge barriers to accessing gender-affirming surgery, one barrier being the lack of skilled local surgeons and dedicated support teams to help patients navigate these care,” said Geolani Dy, MDcorresponding author of the study and assistant professor of urology and plastic and reconstructive surgery at the OHSU School of Medicine, which also offers vaginoplasties and other gender-affirming surgeries through the health program OHSU transgender.

“Patients and surgeons already know this well,” Dy continued, “and now this study helps quantify how much we need more gender-affirming surgeons.”

Researchers also found that only 1 in 100,000 patients had gender-affirming genital surgery paid for by their commercial health insurance provider in 2019, which equates to approximately 1,800 such surgeries covered nationwide. this year. Drawing on a separate 2021 study on bariatric surgery – which is also often not covered by insurance – the authors of this study found that in 2019, bariatric surgery was 20 times more likely to be be covered by insurance than gender-affirming genital surgery.

While approximately 0.6% to 3% of the US population may identify as transgender, 1 in 100,000 patients equates to approximately 0.001% of patients undergoing gender-affirming genital surgery covered by commercial insurance. Although not all transgender patients seek genital surgery, commercial insurance appears to largely cover those who do, Downing notes.

The researchers acknowledge that their study does not account for all out-of-pocket expenses; it only tracks eligible out-of-pocket medical expenses for which patients have submitted a claim to their private insurer, with no Medicare or Medicaid claims included. They also note that research is needed to understand how out-of-state travel affects surgical outcomes and to examine why patients travel out-of-state. Downing and Dy are seeking additional research funding to investigate some of these open questions.

Downing and his colleagues continued this study following their work with the Transgender and Non-Binary Allied Research Collective, or TRANS-ARC. A TRANS-ARC 2021 virtual summit of researchers, healthcare providers and patients prioritized several research topics related to gender-affirming surgical care, including how insurance coverage and out-of-pocket expenses affect surgical results.

This research was supported by internal funding from OHSU.

REFERENCE: Jae Downing, Sarah K. Holt, Michael Cunetta, John L. Gore, Geolani W. Dy, “Expenses and Out-of-Pocket Costs for Gender-Affirming Genital Surgery in the United States,” JAMA Surgery, July 6, 2022, doi :10.1001/jamasurg.2022.2606.


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