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

Educational Objective To identify the temporal trends in gender-affirming surgery and recognize the association between payer status and the patients seeking these operations.
1 Credit CME
Key Points

Question  What are the incidence of and trends in gender-affirming surgery over time in the United States?

Findings  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.

Meaning  As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them.


Importance  Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States.

Objectives  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.

Design, Setting, and Participants  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 International Classification of Diseases, Ninth Revision, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation.

Main Outcomes and Measures  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.

Results  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.

Conclusions and Relevance  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.

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Article Information

Accepted for Publication: December 24, 2017.

Corresponding Author: Brandyn D. Lau, MPH, CPH, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins University School of Medicine, 600 N Wolfe St, Radiology 127, Baltimore, MD 21287 (blau2@jhmi.edu).

Published Online: February 28, 2018. doi:10.1001/jamasurg.2017.6231

Author Contributions: Mr Canner and Dr Harfouch contributed equally and should be considered as co–first authors. Mr Canner and Mr Lau had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Canner, Kodadek, Pelaez, Offodile, Haider, Lau.

Acquisition, analysis, or interpretation of data: Canner, Harfouch, Kodadek, Coon, Haider, Lau.

Drafting of the manuscript: Harfouch, Pelaez, Haider.

Critical revision of the manuscript for important intellectual content: Canner, Harfouch, Kodadek, Coon, Offodile, Lau.

Statistical analysis: Canner, Harfouch.

Administrative, technical, or material support: Canner, Harfouch, Pelaez, Haider, Lau.

Study supervision: Offodile, Lau.

Conflict of Interest Disclosures: Dr Haider and Mr Lau reported being supported by contract AD-1306-03980 from the Patient-Centered Outcomes Research Institute (PCORI). Mr Lau reported being supported by contracts CE-12-11-4489 and DI-1603-34596 from the PCORI, grant 1R01HS024547 from the Agency for Healthcare Research and Quality, the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant, and grant R21HL129028 from the National Institutes of Health/National Heart, Lung, and Blood Institute. No other disclosures were reported.

Disclaimer: Dr Haider is the Deputy Editor for JAMA Surgery but was not involved in the editorial review or decision process.

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