Many trans patients must travel out of state for surgery

Seeking gender-affirming surgery can mean a long drive and increased costs, according to new research.

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Over half of the transgender and gender-diverse individuals in the United States who elect to seek gender-affirming surgery must travel outside their home states for that care and pay up to 50% more than an in-state patient would, according to a report published in JAMA Surgery.

“The team was looking for all barriers to care in this population. We found costs ended up being a huge barrier,” said contributing author Sarah Holt, an epidemiologist in the Department of Urology at the University of Washington School of Medicine.

She said she hopes the findings demonstrate the need for transgender care in all states and helps patients and insurers plan around current realities.

Researchers from UW Medicine and Oregon Health & Sciences University examined a database of 129 million patients who received care from 2007 to 2019 in the U.S.. Using procedure codes from a national insurance database, the investigators focused on feminizing genital surgeries (vaginoplasties) and masculinizing genital surgeries (phalloplasties). The team identified 771 patients who underwent either procedure and who were also covered by commercial insurance.

Among the 609 people who underwent vaginoplasty (creation of a vagina by using existing genital tissue), 41% did so in their state of residency, according to insurance data, and 56% of the patients underwent surgery outside their state. Among the 162 patients who underwent phalloplasties, or the surgical creation of a penis, 50% underwent surgery outside their state of residence.

The average patient who traveled out- of- state paid $2,645, compared with $1,781 for the average in-state patient. Regional variation for out-of-pocket costs were dramatic, the authors noted: A phalloplasty in the South cost $4,391 but only $1,022 in Western states. Perhaps not surprisingly, patients who lived in the South were more likely to seek out-of-state care, and to pay more, than patients in other U.S. regions, the study showed. Travel and lodging expenses, as well as loss to wages from time off work, were not factored into the findings, Holt said. 

“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 study co-author Dr. Geolani Dy, an assistant professor of urology and of plastic and reconstructive surgery at the OHSU School of Medicine. 

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

The researchers acknowledged that their methodology did not calculate all out-of-pocket expenses, only allowable out-of-pocket medical expenses for which patients submitted a reimbursement request to their private insurer, with no Medicare or Medicaid claims included.

The authors also noted that more research is needed to understand the extent to which traveling out of state affects surgical outcomes and to examine why patients travel out of state. Jae Downing, lead author and assistant professor of health policy at OSHU, and Dy are pursuing additional funding to study these questions.

Content from OSHU's news release was included in this report. 

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