National Estimates of Gender-Affirming Surgery in the US

This cohort study examines trends in inpatient and outpatient gender-affirming surgical procedures in the US and explores the temporal trends in the types of procedures across age groups.


Introduction
Gender dysphoria is characterized as an incongruence between an individual's experienced or expressed gender and the gender that was assigned at birth. 1 Transgender individuals may pursue multiple treatments, including behavioral therapy, hormonal therapy, and gender-affirming surgery (GAS). 2 GAS encompasses a variety of procedures that align an individual patient's gender identity While numerous surgical interventions can be considered GAS, the procedures have been broadly classified as breast and chest surgical procedures, facial and cosmetic interventions, and genital reconstructive surgery. 2,4Prior studies [2][3][4][5][6][7] have shown that GAS is associated with improved quality of life, high rates of satisfaction, and a reduction in gender dysphoria.Furthermore, some studies have reported that GAS is associated with decreased depression and anxiety. 8Lastly, the procedures appear to be associated with acceptable morbidity and reasonable rates of perioperative complications. 2,4ven the benefits of GAS, the performance of GAS in the US has increased over time. 9The increase in GAS is likely due in part to federal and state laws requiring coverage of transition-related care, although actual insurance coverage of specific procedures is variable. 10,11While prior work has shown that the use of inpatient GAS has increased, national estimates of inpatient and outpatient GAS are lacking. 9This is important as many GAS procedures occur in ambulatory settings.We performed a population-based analysis to examine trends in GAS in the US and explored the temporal trends in the types of GAS performed across age groups.

Data Sources
To capture both inpatient and outpatient surgical procedures, we used data from the Nationwide Ambulatory Surgery Sample (NASS) and the National Inpatient Sample (NIS).NASS is an ambulatory surgery database and captures major ambulatory surgical procedures at nearly 2800 hospitalowned facilities from up to 35 states, approximating a 63% to 67% stratified sample of hospitalowned facilities.NIS comprehensively captures approximately 20% of inpatient hospital encounters from all community hospitals across 48 states participating in the Healthcare Cost and Utilization Project (HCUP), covering more than 97% of the US population.Both NIS and NASS contain weights that can be used to produce US population estimates. 12,13Informed consent was waived because data sources contain deidentified data, and the study was deemed exempt by the Columbia University institutional review board.This cohort study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Patients and Procedures
We selected patients of all ages with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) diagnosis codes for gender identity disorder or transsexualism (ICD-10 F64) or a personal history of sex reassignment (ICD-10 Z87.890) from 2016 to 2020 (eTable in Supplement 1).We first examined all hospital (NIS) and ambulatory surgical (NASS) encounters for patients with these codes and then analyzed encounters for GAS within this cohort.GAS was identified using ICD-10 procedure codes and Common Procedural Terminology codes and classified as breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures. 2,4Breast and chest surgical procedures encompassed breast reconstruction, mammoplasty and mastopexy, or nipple reconstruction.Genital reconstructive procedures included any surgical intervention of the male or female genital tract.Other facial and cosmetic procedures included cosmetic facial procedures and other cosmetic procedures including hair removal or transplantation, liposuction, and collagen injections (eTable in Supplement 1).
Patients might have undergone procedures from multiple different surgical groups.We measured the total number of procedures and the distribution of procedures within each procedural group.
Within the data sets, sex was based on patient self-report.The sex of patients in NIS who underwent inpatient surgery was classified as either male, female, missing, or inconsistent.The inconsistent classification denoted patients who underwent a procedure that was not consistent with the sex recorded on their medical record.Similar to prior analyses, patients in NIS with a sex variable not compatible with the procedure performed were classified as having undergone genital reconstructive surgery (GAS not otherwise specified). 9

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National Estimates of Gender-Affirming Surgery in the US

Covariates
Clinical variables in the analysis included patient clinical and demographic factors and hospital characteristics.Demographic characteristics included age at the time of surgery (12 to 18 years, 19 to 30 years, 31 to 40 years, 41 to 50 years, 51 to 60 years, 61 to 70 years, and older than 70 years), year of the procedure (2016-2020), and primary insurance coverage (private, Medicare, Medicaid, selfpay, and other).Race and ethnicity were only reported in NIS and were classified as White, Black, Hispanic and other.Race and ethnicity were considered in this study because prior studies have shown an association between race and GAS.The income status captured national quartiles of median household income based of a patient's zip code and was recorded as less than 25% (low), 26% to 50% (medium-low), 51% to 75% (medium-high), and 76% or more (high).The Elixhauser Comorbidity Index was estimated for each patient based on the codes for common medical comorbidities and weighted for a final score. 14Patients were classified as 0, 1, 2, or 3 or more.We separately reported coding for HIV and AIDS; substance abuse, including alcohol and drug abuse; and recorded mental health diagnoses, including depression and psychoses.Hospital characteristics included a composite of teaching status and location (rural, urban teaching, and urban nonteaching) and hospital region (Northeast, Midwest, South, and West).Hospital bed sizes were classified as small, medium, and large.The cutoffs were less than 100 (small), 100 to 299 (medium), and 300 or more (large) short-term acute care beds of the facilities from NASS and were varied based on region, urban-rural designation, and teaching status of the hospital from NIS. 8 Patients with missing data were classified as the unknown group and were included in the analysis.

Statistical Analysis
National estimates of the number of GAS procedures among all hospital encounters for patients with gender identity disorder were derived using discharge or encounter weight provided by the databases. 15The clinical and demographic characteristics of the patients undergoing GAS were reported descriptively.The number of encounters for gender identity disorder, the percentage of GAS procedures among those encounters, and the absolute number of each procedure performed over time were estimated.The difference by age group was examined and tested using Rao-Scott χ 2 test.All hypothesis tests were 2-sided, and P < .05 was considered statistically significant.All analyses were conducted using SAS version 9.4 (SAS Institute Inc).

Results
A total of 48 019 patients who underwent GAS were identified (Table 1 1).
The overall number of health system encounters for gender identity disorder rose from 13 855 in 2016 to 38 470 in 2020.Among encounters with a billing code for gender identity disorder, there was a consistent rise in the percentage that were for GAS from 4552 (32.9%) in 2016 to 13 011 (37.1%) in 2019, followed by a decline to 12 818 (33.3%) in 2020 (Figure 1 and eFigure in Supplement 1).
Among patients undergoing ambulatory surgical procedures, 37 394 (80.3%) of the surgical procedures included gender-affirming surgical procedures.For those with hospital admissions with gender identity disorder, 10 625 (11.8%) of admissions were for GAS.
Breast and chest procedures were most common and were performed for 27 187 patients (56.6%).Genital reconstruction was performed for 16 872 patients (35.1%), and other facial and cosmetic procedures for 6669 patients (13.9%) ( The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020 (Figure 1).Similar trends were noted for breast and chest surgical procedures as well as genital surgery, while the rate of other facial and cosmetic procedures increased consistently from 2016 to 2020.The distribution of the individual procedures performed in each class were largely similar across the years of analysis (Table 3).
When stratified by age, patients 19 to 30 years had the greatest number of procedures, 25 099 (Figure 2).There were 10 476 procedures performed in those aged 31 to 40 years and 4359 in those aged 41 to 50 years.Among patients younger than 19 years, 3678 GAS procedures were performed.
GAS was less common in those cohorts older than 50 years.Overall, the greatest number of breast

Table 1 .
Demographics of Transgender Patients Undergoing Gender-Affirming Surgery Overall and Stratified by Classes of Gender-Affirming Surgery (continued) Different cutoff was used to define bed size in inpatient encounters (National Inpatient Sample) and hospital ambulatory surgery encounters (Nationwide Ambulatory Surgery Sample).
a Race was only available in inpatient encounters (National Inpatient Sample).b

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Downloaded from jamanetwork.combyguest on 06/15/2024 and chest surgical procedures, genital surgical procedures, and facial and other cosmetic surgical procedures were performed in patients aged 19 to 30 years.When stratified by the type of procedure performed, breast and chest procedures made up the greatest percentage of the surgical interventions in younger patients while genital surgical procedures were greater in older patients (Figure2).Additionally, 3215 patients (87.4%) aged 12 to 18 years underwent GAS and had breast or chest procedures.This decreased to 16 067 patients