In the U.S., where gender-affirming genital surgery is performed, about half of transgender and gender-diverse patients travel to states outside their home countries to receive this care, and those who travel pay nearly 50 percent more out-of-pocket medical bills.New findings by researchers at Oregon Health and Science University, published in American Medical Association Surgery.
The OHSU-led study is the first to produce a national estimate of the average cost of sex-confirming genital surgery. The paper’s lead investigator said its findings could help patients and insurers better plan to receive or cover this medically necessary surgical care, Dr. Jae TangningAssistant Professor of Health Policy Oregon Health and Science University – Portland State University School of Public Health.
“Traveling long distances for major procedures such as gender-affirming genital surgery can be very taxing for patients,” Downing said. “We already know that traveling for health care requires patients to take time off and pay for travel and lodging themselves, and that this can be costly. Getting follow-up care with qualified providers familiar with each patient’s unique needs is challenging. Now, our research shows that interstate travel also increases out-of-pocket costs for transgender and gender-diverse patients—despite the total cost of their surgery basically the same.”
Transgender and gender-diverse people are assigned a gender different from their gender identity at birth. Many transgender patients seek necessary medical care from health professionals to confirm their gender. The care needs of each transgender patient are unique; some seek hormone therapy, while others seek chest, facial, or genital surgery. Genital surgical care is complex, led by a specialist surgeon, and may require multiple follow-up procedures.
To understand the cost of gender-confirming genital surgery, Downing and colleagues from OHSU and the University of Washington examined a research database containing information on 129 million U.S. commercial insurance claims between 2007 and 2019. In this dataset, 771 patients underwent feminizing genital surgery, known as vaginoplasty, or masculinizing genital surgery, known as phalloplasty.
Of all gender-confirmed genital surgeries, 49 percent traveled outside of the state for surgery. At the same time, there was no statistically significant difference in the total cost per procedure whether the procedure was performed inside or outside the patient’s hometown.
To calculate out-of-pocket medical costs, researchers added coinsurance, copayments, and deductibles from insurance claims. They found that patients who traveled abroad for surgery paid, on average, nearly 50 percent more out-of-pocket than those who did not travel. Out-of-state patients paid an average of $2,645, while in-state patients paid an average of $1,781.
The study also showed that patients living in the South more often left their state for gender-affirming genital surgery. For example, patients living in the West were 36 percent less likely to leave their hometown for surgery than those living in the South.
As a result, many patients may need to leave their state for gender-confirming genital surgery because there are not enough surgeons to provide this care in the first place, and travel may be greatest in the South because of gender shortages – Downing and colleagues noted , the region is more sure of reproductive surgeons.they point to a Study in 2020 Only 11 surgeons were found to provide this specialty care in the South, with 4 practicing in Florida.
“Transgender and nonbinary patients face significant barriers to undergoing gender-affirming surgery, one of which is the lack of locally qualified surgeons and dedicated support teams to help patients with this care,” said Geolani Dy, MDthe study’s corresponding author and assistant professor of urology and plastic and reconstructive surgery at the OHSU School of Medicine, who also passed OHSU Transgender Health Program.
“Patients and surgeons have been well aware of this,” Dy continued, “and now this study helps quantify the severity of our need for more gender-affirming surgeons.”
The researchers also found that only 1 in 100,000 patients underwent gender-affirming genital surgery paid for by their commercial health insurance provider in 2019, which equates to about 1,800 such procedures covered nationwide that year.from a drawing A separate 2021 study Regarding bariatric surgery — which isn’t often covered by insurance either — the study’s authors found that in 2019, bariatric surgery was 20 times more likely to be covered by insurance than gender-affirming genital surgery.
Although estimated 0.6% to 3% In the US population, 1 in 100,000 patients may identify as transgender, which equates to approximately 0.001% of patients undergoing commercial insurance-covered sex-affirming genital surgery. Downing noted that while not all transgender patients seek genital surgery, commercial insurance appears to greatly cover those who do.
The researchers acknowledge that their study did not account for all out-of-pocket costs. It only tracks allowed out-of-pocket medical expenses for which patients submit reimbursement requests to their private insurance companies, excluding Medicare or Medicaid claims. They also noted that research is needed to understand the extent to which departures affect surgical outcomes and to examine the reasons for patients’ departures. Downing and Dy are seeking additional research funding to study some of these open questions.
Downing and colleagues conducted this study because they worked with Transgender and Nonbinary Related Research Collective, or TRANS-ARC. The 2021 virtual summit for TRANS-ARC researchers, healthcare providers and patients prioritized several research topics related to gender-affirming surgical care, including how insurance coverage and out-of-pocket costs affect surgical outcomes.
This research was supported by OHSU internal funding.
References: Jae Downing, Sarah K. Holt, Michael Cunetta, John L. Gore, Geolani W. Dy, “Expenditure and out-of-pocket costs of genital sex confirmation surgery in the United States,” JAMA Surgery, July 6, 2022, doi: 10.1001/jamasurg.2022.2606.