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.

Keywords: Genital Gender Affirming Surgery; Phalloplasty; Transgender; Vaginoplasty.

Figure 1

Geographic distribution of the number of medical centers (locations) in the United States providing gender affirming surgery (GAS). Locations are identified by city. No city had greater than 3 locations performing GAS.

Figure 2

U.S. Map of Medicaid/Medicare policy regarding insurance coverage for GAS and of survey data of respondents reporting acceptance of Medicare/Medicaid. Reported Policies: States whose Medicaid policy explicitly includes coverage for gender affirming surgery (GAS) (CA, CO, CT, DC, HI, IL, MD, MA, MN, MT, NV, NH, NJ, NY, OR, PA, RI, VT, and WA) (yellow). States where Medicaid policy explicitly excludes coverage of GAS (AL, GA, IA, ME, MO, NE, OH, TN, WI, and WY) (Red). States that have no explicit policy on genital GAS (AL, AZ, AK, DE, FL, ID, IN, KS, KY, LA, MI, MS, NM, NC, ND, OK, SC, SD, TX, UT, VA, and WV) (gray). Results from our study: States where Medicaid explicitly covers GAS and at least 1 provider in our survey reported accepting Medicaid reimbursement for genital GAS (CA, CT, MD, MA, MN, NJ, NY, NY, OR, and PA) (yellow with green vertical lines). States where Medicaid explicitly covers GAS, but our survey found no provider that accepts Medicaid for GAS (CO, DC, HI, MT, NV, NH, RI, VT, and WA) (yellow with red horizontal lines). States where Medicaid explicitly excludes GAS, but where our study identified 2 states with providers who reported that they accept Medicaid for GAS (OH, WI) (red with blue dots). States where Medicaid has no explicit policy on genital GAS, but where our survey identified 5 states with providers who reported that they accept Medicaid for GAS (FL, ID, MI, TX, and UT) (gray with green dots).