Thirty-five state legislatures have introduced more than 100 bills that limit or prohibit access to medically necessary gender-affirming care for transgender and gender-diverse (TGD) youth, resulting in poor mental and physical health outcomes.1 Approximately 300 000 adolescents between 13 and 17 years of age identify as transgender.2 Among TGD individuals experiencing gender dysphoria, gender-affirming surgery may improve functioning and mental health.3 However, there is a paucity of information regarding gender-affirming surgery in adolescent populations. Reconstructive genital surgery is typically not performed in adolescents, but masculinizing chest reconstruction (eg, mastectomy) and feminizing chest reconstruction (eg, augmentation mammaplasty) may be performed in outpatient and ambulatory surgery settings.4 We investigated the incidence, demographic characteristics, and spending related to ambulatory gender-affirming chest reconstruction in adolescents using nationally representative data from 2016 to 2019.
Using the Nationwide Ambulatory Surgery Sample, we identified patients with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of gender dysphoria who underwent chest reconstruction (eAppendix in the Supplement). The Nationwide Ambulatory Surgery Sample is an all-payer database that captures ambulatory surgery encounters performed in the US. Vanderbilt University Institutional Review Board deemed this study to be exempt from review and waived the informed consent requirement because the study is retrospective. We followed the STROBE reporting guideline.
Encounters for patients younger than 18 years between 2016 and 2019 were included. Demographic and clinical characteristics were recorded for each encounter. Race and ethnicity were collected from hospital records only in 2019, the last year of available data. Total charges were adjusted for inflation, and observations were weighted to be nationally representative. Changes in patterns over the study period were compared using Pearson χ2 tests with Rao-Scott correction for categorical variables and linear regression for continuous variables. Analyses were computed in Stata, version 17 (StataCorp LLC), and statistical significance was defined as a 2-sided α < .05. Data were analyzed from January 15 to May 11, 2022.
A weighted estimate of 1130 encounters (1114 [98.6%] masculinizing and 16 [1.4%] feminizing) for chest reconstruction were included. Between 2016 and 2019, the annual number of gender-affirming chest surgeries increased by 389% (100 in 2016 vs 489 in 2019; P < .001) (Figure).
Most gender-affirming chest surgeries were covered by private health insurance (61.1%; 95% CI, 52.0%-69.4%) (Table). There was no significant change in health insurance coverage during the study period. The median (range) age for gender-affirming chest reconstruction was 16 (12-17) years. Of the patients who underwent chest reconstruction in 2019, 2.7% (95% CI, 1.5%-4.8%) were Black, 2.5% (95% CI, 1.4%-4.7%) were Asian or Pacific Islander, 12.2% (95% CI, 8.9%-16.4%) were Hispanic, 0.5% (95% CI, 0.1%-1.8%) were Native American, 77.9% (95% CI, 73.1%-82.1%) were White individuals, and 4.2% (95% CI, 2.2%-7.9%) were categorized under other race and ethnicity.
Most adolescents who underwent chest surgery during the study (50.3%; 95% CI, 43.4%-57.2%) had a family income of $82 000 or more. The median (IQR) total charges for chest reconstruction were $29 886 ($21 285-$45 147), which did not change during the study period.
Psychiatric conditions were the most common comorbidities, 21.1% of patients (95% CI, 16.6%-26.4%) had anxiety and 16.2% (95% CI, 12.2%-21.2%) had depression. Only 19.9% (95% CI, 14.8%-26.1%) of adolescents who underwent chest reconstruction used gender-affirming hormone therapy.
To our knowledge, this study is the largest investigation to date of gender-affirming chest reconstruction in a pediatric population. The results demonstrate substantial increases in gender-affirming chest reconstruction for adolescents. Most TGD adolescents had either public or private health insurance coverage for these procedures, contrasting with the predominance of self-payers reported in earlier studies on TGD adults.5 Adolescents undergoing gender-affirming chest reconstruction may use hormone therapy, but most in this study were not in accordance with data from the 2015 US Transgender Survey.6 Study limitations include the reliability of diagnosis codes in identifying TGD patients, sampling error, and the absence of cost-to-charge ratio data.
Accepted for Publication: June 30, 2022.
Published Online: October 17, 2022. doi:10.1001/jamapediatrics.2022.3595
Corresponding Author: Rishub Karan Das, Vanderbilt University School of Medicine, 1161 21st Ave S, Nashville, TN 37212 (rishub.das@vanderbilt.edu).
Author Contributions: Mr Das had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Das, Perdikis, Al Kassis.
Acquisition, analysis, or interpretation of data: Das, Drolet.
Drafting of the manuscript: Das.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Das.
Supervision: Perdikis, Al Kassis, Drolet.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grant 5UL1TR002243-03 from the National Center for Advancing Translational Sciences Clinical and Translational Science Awards Program.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.