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Half of transgender patients leave home state for surgery – study

A similar study has unfortunately not been done in the Philippines, though the US study still highlights that “traveling a long distance for a major procedure such as gender-affirming genital surgery places a large burden on patients.”

Photo by Kelly Sikkema from Unsplash.com

About half of transgender and gender-diverse patients who undergo gender-affirming genital surgery travel outside their home state to receive this care, and those who travel pay nearly 50% more in out-of-pocket medical expenses.

This is according to a study – “Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the U.S.” by Jae Downing, Sarah K. Holt, Michael Cunetta, John L. Gore, and Geolani W. Dy – that appeared in JAMA Surgery.

A similar study has unfortunately not been done in the Philippines, though the U.S. study still highlights that “traveling a long distance for a major procedure such as gender-affirming genital surgery places a large burden on patients.”

“We already knew that traveling for health care requires patients to take time off work and pay for travel and lodging on their own, and that it can make receiving follow-up care from qualified providers who are familiar with each patient’s unique needs challenging. Now, (this) study shows that traveling out of state also increases out-of-pocket medical expenses for trans and gender-diverse patients — even though their surgery’s total cost is largely the same,” Downing said.

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. Each transgender patient’s care needs are unique; some patients seek hormone therapy and others seek surgeries for their chest, face or genitals. Genital surgical care is complex, is led by specialized surgeons and can require multiple, subsequent procedures.

To understand the cost of gender-affirming genital surgery, Downing and colleagues from OHSU and the University of Washington studied a research database containing US commercial insurance claim information for 129 million people between 2007 and 2019. Within that data set, 771 patients received a feminizing genital surgery, known as vaginoplasty, or a masculinizing genital surgery, known as phalloplasty. 

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

To calculate out-of-pocket medical expenses, the researchers added up coinsurance, copayments and deductible payments from insurance claims. They found the patients who traveled out of their state for surgery paid an average of nearly 50% more in out-of-pocket expenses than those who didn’t. The average out-of-state patient paid $2,645, compared with $1,781 for the average in-state patient. 

Many patients may also need to travel out of their state for gender-affirming genital surgery because there aren’t enough surgeons who provide this care to begin with.

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“Transgender and nonbinary patients experience enormous barriers to accessing gender-affirming surgery, with one barrier being the lack of local, qualified surgeons and dedicated support teams to help patients navigate this care,” said Geolani Dy, M.D., the study’s corresponding author and assistant professor of urology and of plastic and reconstructive surgery in the OHSU School of Medicine, who also provides vaginoplasty and other gender-affirming surgeries through the OHSU Transgender Health Program.

Researchers similarly found that just 1 in 100,000 patients had a gender-affirming genital surgery paid for by their commercial health insurance provider in 2019, which equates to about 1,800 such surgeries being covered nationwide that year. Drawing from a separate 2021 study on bariatric surgery — which also often isn’t covered by insurance — this study’s authors found that in 2019, bariatric surgery was 20 times more likely to be covered by insurance than gender-affirming genital surgery.

While an estimated 0.6% to 3% of the U.S. population may identify as transgender, 1 in 100,000 patients equates to about 0.001% of patients having gender-affirming genital surgery covered by commercial insurance. Although not all transgender patients seek genital surgery, commercial insurance appears to substantially undercover those who do, Downing noted.

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