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Marano AA, Miller AS, Castillo W, Reisner SL, Schechter LS, Coon D. Social and Systemic Barriers to Transition-Related Surgical Procedures for Transgender Americans. LGBT Health 2024. [PMID: 38848247 DOI: 10.1089/lgbt.2023.0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Purpose: Transgender and gender-diverse (TGD) individuals in the United States face disproportionate barriers to health care access. This study compared characteristics of individuals who have and have not undergone gender-affirming surgery with the goal of identifying social and systemic barriers to transition-related surgery. Methods: Data were extracted from the 2015 United States Transgender Survey, a cross-sectional nonprobability sample of nearly 28,000 TGD adults. The primary outcome was having undergone gender-affirming surgery. Multivariable logistic regression models were constructed to determine correlates of receipt of gender-affirming surgery. A subgroup analysis was performed to explore differences by insurance types regarding coverage of surgical procedures and presence of in-network providers. Results: In total, 6009 (21.7%) participants underwent transition-related procedures. Increased odds of undergoing surgery were associated with older age, living in congruent gender, higher education attainment, and greater income. Decreased odds were linked with male sex assignment at birth, first recognizing TGD status at older ages, living in states without trans-protective health laws, no close transgender-knowledgeable health care provider, nonbinary status, and identifying as sexual minority. Residing in states without trans-protective health laws correlated with increased surgery denials over the previous 12-month period. Compared to White TGD individuals, TGD individuals who were Black, Latinx, or Another Race were significantly more likely to encounter health equity-related barriers to surgery. Conclusions: Gender-affirming surgery access is differentially distributed across demographic and modifiable equity-related factors amenable to interventions. Efforts are needed to address the number and geographic distribution of transgender health-competent providers, improve TGD legal protections, and increase access to health insurance for minority TGD individuals, who are disproportionately under/uninsured.
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Affiliation(s)
- Andrew A Marano
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amitai S Miller
- Harvard Medical School, Boston, Massachusetts, USA
- Harvard University John F. Kennedy School of Government, Cambridge, Massachusetts, USA
| | - Wendy Castillo
- Princeton School of Public and International Affairs, Princeton University, Princeton, New Jersey, USA
| | - Sari L Reisner
- Division of Endocrinology, Diabetes, and Hypertension. Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- The Fenway Institute, Fenway Health, Boston, Massachusetts, USA
| | - Loren S Schechter
- Division of Plastic Surgery, Department of Surgery, Rush University, Chicago, Illinois, USA
| | - Devin Coon
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Schrup S, Hanley M, May E, Ziegelmann M, Gross MS. The limited public information on private health insurance coverage of common sexual health services. Int J Impot Res 2024:10.1038/s41443-024-00882-x. [PMID: 38632434 DOI: 10.1038/s41443-024-00882-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/21/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Sarah Schrup
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA.
| | - Meg Hanley
- Division of Urology, University of Colorado, Aurora, CO, USA
| | - Emily May
- Division of Urology, UConn Health, Farmington, CT, USA
| | | | - Martin S Gross
- Section of Urology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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3
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Baugher AR, Olansky E, Sutter L, Cha S, Lewis R, Morris E, Agnew-Brune C, Trujillo L, Respress E, Lee K. Prevalence of Discrimination and the Association Between Employment Discrimination and Health Care Access and Use - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020. MMWR Suppl 2024; 73:51-60. [PMID: 38261571 PMCID: PMC10826684 DOI: 10.15585/mmwr.su7301a6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
Transgender women experience discrimination in many settings, including in employment. Because employment and health insurance are intertwined in the United States, employment discrimination might be related to lower health insurance coverage and health care use, including gender-affirming care. This analysis used data from transgender women (N = 1,608) in seven urban areas in the United States collected during 2019-2020 to present the prevalence of six discrimination types (employment, housing, bathroom, businesses, health care, and abuse) and to measure the association between employment discrimination (defined as trouble getting a job or fired due to being transgender) and sociodemographic characteristics, health care access, and health care use. Log-linked Poisson regression models were conducted to estimate adjusted prevalence ratios and 95% CIs. Seven in 10 transgender women experienced at least one type of discrimination during the past 12 months. During the same period, 9.9% of transgender women were fired and 32.4% had trouble getting a job because of being transgender. Employment discrimination was associated with younger age and lower socioeconomic status. Having trouble getting a job was associated with health care access and health care use factors, including having no health insurance or having Medicaid only, having an unmet medical need because of cost, never having transgender-specific care, and having an unmet need for gender-affirming procedures. These findings suggest that employment discrimination contributes to transgender women's economic marginalization and their ability to obtain adequate health insurance coverage and achieve their transition goals. These findings might help guide efforts that protect transgender women's right to pursue their work, health, and life goals without discrimination.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - National HIV Behavioral Surveillance Among Transgender Women Study Group
- Division of HIV Prevention, National Center for HIV, Viral Hepatitis, STD, and TB Prevention, CDC, Atlanta, Georgia; Social & Scientific Systems, Inc., Silver Spring, Maryland; ICF, Fairfax, Virginia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
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4
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Abstract
Insurance coverage of gender-affirming surgeries including facial and vocal feminization surgery remains a challenge for many patients, physicians, and practice administrators. These challenges range from disparities in coverage for commercial versus public insurance carriers, in network versus out of network benefits, preauthorization struggles, and the lack of standard coverage policies. This article aims to describe the insurance coverage and approval challenges related to facial feminization surgery and to provide guidance for surgeons and their practice administrators on how to obtain successful preauthorization/predetermination, single case agreements, and proper claim adjudication.
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Affiliation(s)
- Jacob E Kuperstock
- Department of Facial Plastic and Reconstructive Surgery, Otolaryngology Associates, PC, 3801 University Drive, Suite 100, Fairfax, VA 22030, USA.
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5
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Patel H, Camacho JM, Salehi N, Garakani R, Friedman L, Reid CM. Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis. Cureus 2023; 15:e36849. [PMID: 37123806 PMCID: PMC10142323 DOI: 10.7759/cureus.36849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.
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Affiliation(s)
- Heli Patel
- Department of Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Davie, USA
| | - Justin M Camacho
- Department of Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Neeku Salehi
- Department of Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Romina Garakani
- Department of Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Leigh Friedman
- Department of Medicine, Drexel University College of Medicine, Philadelphia, USA
| | - Chris M Reid
- Department of Plastic Surgery, University of California San Diego, San Diego, USA
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Maisner RS, Kapadia K, Berlin R, Lee ES. Is #Gender Affirmation Surgery Trending? An Analysis of Plastic Surgery Residency Social Media Content. Transgend Health 2023. [DOI: 10.1089/trgh.2021.0215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Affiliation(s)
- Rose S. Maisner
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kailash Kapadia
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Ryan Berlin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Edward S. Lee
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Santosa KB. Commentary on: The Effect of Preoperative Gender Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation. Aesthet Surg J 2022; 42:1017-1018. [PMID: 35768169 DOI: 10.1093/asj/sjac153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Boskey ER, Mehra G, Jolly D, Ganor O. Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty. J Sex Med 2022; 19:1055-1059. [PMID: 35410843 DOI: 10.1016/j.jsxm.2022.03.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/09/2022] [Accepted: 03/13/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Transgender men who undergo gender-affirming phalloplasty have limited options for attaining sufficient rigidity for sexual penetration. AIM The goal of this study was to understand interest in and concerns about internal erectile prostheses among transgender men who had undergone phalloplasty. METHODS As part of a pilot study of an external erectile device, transgender men (n = 15) were surveyed about their interest in, and concerns about, getting an internal prosthesis. Descriptive analyses were performed for structured questions and content analysis was used to analyze open responses. OUTCOMES Measured outcomes included closed- and open-ended questions assessing patient attitudes about internal erectile prostheses. RESULTS Before starting the study, approximately half the men stated they were interested in getting an internal device, 20% said they weren't, and 33% said they didn't know. More than half of this postphalloplasty population stated they were somewhat or very concerned about the need for additional surgery (73%), side effects (pain, damage to the phallus; 100%), and the risk of device failure (100%). An additional 47% stated they were somewhat or very concerned about cost and 33% stated they were somewhat or very concerned about finding a surgeon. CLINICAL IMPLICATIONS There is a need to develop appropriate alternatives to current internal prostheses for penetrative function after phalloplasty. STRENGTHS & LIMITATIONS Generalizability of results is limited by the fact that data are from men who had enrolled in a pilot study to test an external erectile prosthesis, and as such were explicitly interested in exploring nonsurgical alternatives to attain an erection. The combination of quantitative and qualitative data demonstrates that transgender men's concerns about internal prostheses are grounded in the current evidence. CONCLUSION Transgender men who have undergone phalloplasty have substantial concerns about the risks of getting an internal prosthesis and there is significant interest in alternatives to current devices. Boskey ER, Mehra G, Jolly D, et al. Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty. J Sex Med 2022;19:1055-1059.
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Affiliation(s)
| | | | - Divya Jolly
- Boston Children's Hospital, Center for Gender Surgery, Boston, MA, USA
| | - Oren Ganor
- Boston Children's Hospital, Center for Gender Surgery, Boston, MA, USA
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9
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Guelbert C. Nursing considerations for transgender men. Nursing 2022; 52:18-22. [PMID: 34879048 DOI: 10.1097/01.nurse.0000803428.47117.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Caring for transgender men requires adequate knowledge about gender transitioning. This article discusses surgical procedures, hormonal therapy, and other nursing actions related to transgender patients' physical and psychological health, privacy, and health promotion.
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Affiliation(s)
- Christopher Guelbert
- Christopher Guelbert is an assistant professor in the Goldfarb School of Nursing at Barnes-Jewish College in St. Louis, Mo
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10
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Building a gender-affirming surgery service: The fundamentals. Surgery 2021; 171:498-503. [PMID: 34593253 DOI: 10.1016/j.surg.2021.08.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/04/2021] [Accepted: 08/24/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success. METHODS In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service. RESULTS A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services. CONCLUSION Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.
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Khetpal S, Lopez J, Redett RJ, Steinbacher DM. Health Equity and Healthcare Disparities in Plastic Surgery: What We Can Do. J Plast Reconstr Aesthet Surg 2021; 74:3251-3259. [PMID: 34257031 DOI: 10.1016/j.bjps.2021.05.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022]
Abstract
Amidst the unexpected losses and challenges of 2020, healthcare disparities and health equity have presided as noteworthy topics of national discussion among healthcare workers, governmental officials, and society at large. Health equity, defined as the opportunity for everyone to be as healthy as possible, may be achieved through the alleviation of healthcare disparities. Healthcare disparities are defined as "preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations." While these concepts may be perceived as a departure from the core responsibility of plastic surgeons, it is of paramount importance to recognize how race, socioeconomic status (SES), and physical environment impact access to care, surgical outcomes, and postoperative recovery for vulnerable populations. In this communication, our purpose is two-fold: 1) to elucidate the existent healthcare disparities and associations with race and SES in craniofacial, trauma, breast, hand, and gender-affirming reconstruction; and 2) provide tangible recommendations to incorporate the concepts of health equity and healthcare disparities in clinical, research, community, and recruitment settings for plastic surgeons. Through such knowledge, plastic surgeons may glean important insights that may enhance the delivery of equitable and accessible care for patients.
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Affiliation(s)
- Sumun Khetpal
- Division of Plastic Surgery, Yale School of Medicine, New Haven, CT
| | - Joseph Lopez
- Division of Plastic Surgery, Yale School of Medicine, New Haven, CT
| | - Richard J Redett
- Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, MD
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Hassan O, Sun D, Jha P. Imaging in Gender Affirmation Surgery. Curr Urol Rep 2021; 22:14. [PMID: 33515366 PMCID: PMC7847456 DOI: 10.1007/s11934-020-01029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose of Review This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation. Recent Findings The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Summary Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.
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Affiliation(s)
- Omar Hassan
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA.
| | - Derek Sun
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| | - Priyanka Jha
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
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