Trans Patients Often Have to Travel Out of State for Care: Study

Most patients undergoing genital gender-affirming surgery do so outside their home states, resulting in higher costs for the procedures, according to a study published online in JAMA Surgery.

The study by Oregon Health & Science University is the first to offer a national estimate of exactly how much gender-affirming genital surgeries costs, according to its researchers.

They found that about half of transgender and gender-diverse patients who undergo gender-affirming genital surgery travel outside their state to receive treatment, and they spend about 50 percent more on out-of-pocket medical expenses when they travel.

Jae Downing, the paper's lead researcher and an assistant professor of health policy at the Oregon Health & Science University-Portland State University School of Public Health, said the findings of this study can be used by patients and insurance companies to plan how to receive or cover this surgically necessary treatment.

Downing and their colleagues examined whether the out-of-pocket and total costs of gender-affirming surgery differed depending on whether the procedure was performed in their state or outside. In addition, the team compared out-of-pocket and total costs for commercially insured patients. There were 771 patients undergoing genital surgery (609 vaginoplasties; 162 phalloplasties).

Forty-one percent and 56 percent of vaginoplasty patients underwent surgery in and outside their state of residency. Similarly, 41 percent and 50 percent underwent phalloplasty surgery in and outside their state of residence. The facility or residence information was missing for three and nine percent of vaginoplasties and phalloplasties, respectively.

Patients who underwent procedures outside the state of residence had 49 percent higher out-of-pocket expenses than those who underwent procedures in their state of residence, the study found.

Downing said traveling to a distant location for a significant procedure like gender-affirming genital surgery is burdensome for patients.

"We already knew that traveling for health care requires patients to take time off work and pay for travel and lodging on their own," Downing told the university. "And that it can make receiving follow-up care from qualified providers who are familiar with each patient's unique needs challenging. Now, our study shows that traveling out of state also increases out-of-pocket medical expenses for trans and gender-diverse patients -- even though their surgery's total cost is largely the same."

Often, transgender patients seek medically necessary care from health professionals to affirm their gender identity. Transgender patients have different care needs -- some require hormone therapy, while others need genital surgery.

Gender-affirming genital surgery is complex and requires specialized surgeons and multiple procedures. Since there aren't enough surgeons who offer gender-affirming genital surgery in their state, many patients may need to travel outside their state to do so. Downing and colleagues note that the need to travel may be most significant in the South since fewer gender-affirming genital surgeons exist in that region.

An estimate from 2020 indicates that there are only 11 surgeons who offer this type of specialized care in the South, with four surgeons in Florida.

Patients in the West were 36 percent less likely to travel for surgery out of their home state than those in the South.

"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 Dr. Geolani Dy, the study's corresponding author.

Through the OHSU Transgender Health Program, Dy provides vaginoplasty and other gender-affirming surgeries as an assistant professor of urology and plastic and reconstructive surgery.

"Patients and surgeons already know this well," Dy told OHSU, "and now this study helps quantify how severely we need more gender-affirming surgeons."

The researchers conducted this study as part of their work with the research group Transgender and Non-Binary Allied Research Collective, or TRANS-ARC.

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