How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers

Abstract

Introduction In the United States, 1.4–1.65 million people identify as transgender, many of whom will seek genital gender-affirming surgery (GAS). The number of surgeons, geographic proximity thereof, and exclusionary insurance policies has limited patient access to genital GAS. Aim To assess the accessibility of both feminizing and masculinizing genital GAS (vaginoplasty, metoidioplasty, and phalloplasty) by identifying the location of GAS surgeons, health insurance, or payment forms accepted. Methods Between February and April 2018, genital GAS surgeons were identified via Google search. Surgeons’ offices were contacted by telephone or e-mail. Main Outcome Measure We queried the type of genital GAS performed, the health insurance or payment forms accepted, and the type of medical practice (academic, private, or group managed-care practice). Results We identified 96 surgeons across 64 individual medical centers offering genital GAS. The survey response rate was 83.3%. Only 61 of 80 (76.3%) surgeons across 38 of 53 (72%) locations confirmed offering genital GAS. Only 20 (40%) U.S. states had at least one genital GAS provider. 30 of 38 (79%) locations reported accepting any form of insurance. Only 24 of 38 (63%) locations (14 academic; 10 private/group) accepted Medicaid ( P = .016); 18 of 38 (47%) locations (13 academic; 5 private/group) accepted Medicare ( P = .001). Clinical Translation Reconciliation of the public policies regarding insurance coverage for GAS with the actual practices of the providers is necessary for improving access to GAS for transgender individuals. Strengths & Limitations We purposefully used a methodology mirroring how a patient would find GAS surgeons, which also accounts for key limitations: only surgeons whose services were featured on the internet were identified. We could not verify the services or insurance-related information surgeons reported. Conclusion This study suggests that access to genital GAS is significantly limited by the number of providers and the uneven geographic distribution across the United States, in which only 20 of 50 U.S. states have at least one genital GAS surgeon. Feldman AT, Chen A, Poudrier G, et al. How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers. Sex Med 2020;8:664–672.

Gender-Affirming Surgeries

“…2 However, only a few states have laws protecting LGBTQ patients from insurance coverage discrimination. 2,6 Not only is insurance coverage a challenge but also a vastly uneven geographic distribution of institutions performing GASs. 6 (Fig.…”

“…2,6 Not only is insurance coverage a challenge but also a vastly uneven geographic distribution of institutions performing GASs. 6 (Fig. 5).…”

“…The Healthcare Rights Law in 2016, a regulation issued by the US Department of Health and Human Services, prohibits any transgender exclusions in healthcare coverage plans and must provide the same coverage for a specific procedure that would be covered for a cisgender person 2 . However, only a few states have laws protecting LGBTQ patients from insurance coverage discrimination 2,6 . Not only is insurance coverage a challenge but also a vastly uneven geographic distribution of institutions performing GASs 6 .…”

Gender-Affirming Surgeries in Transgender and Gender Diverse Adolescent and Young Adults: A Pediatric and Adolescent Gynecology Primer

“…For those who are above the age of majority, having surgery before aging out of parental health insurance may be important, because not all insurance companies cover gender affirmation procedures. 20 AYA are likely to have different support structures than older surgical patients. For some it will carry elements of greater stability, but for others it will not.…”

The History of Gender-Affirming Vaginoplasty Technique

“…15 This resulted in a confused, hostile atmosphere for transgender healthcare in the United States and accordingly the growth of the field plateaued and was effectively stifled for at least 3 decades. 15,16 Expert transgender healthcare providers, who saw patients benefit from gender-affirmative social transition, hormones and surgery debated the opposition camp, asking the critical question: "what meaningful alternative help have you been able to offer the transsexual patient?" 17 Eventually, the answer from the opposition to this question became apparent, they had no meaningful alternative to the affirmative treatment pathway.…”