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LaValley MN, Diaddigo SE, Asadourian PA, Feuer GB, Warner PE, Rohde CH. National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery. Plast Reconstr Surg 2024; 153:1433-1440. [PMID: 37815328 DOI: 10.1097/prs.0000000000011123] [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: 10/11/2023]
Abstract
BACKGROUND Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage. METHODS Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions. RESULTS Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS. CONCLUSIONS Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.
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Affiliation(s)
- Myles N LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Sarah E Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paul A Asadourian
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Grant B Feuer
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paige E Warner
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Christine H Rohde
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
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Chin MG, LaGuardia JS, Morgan KBJ, Ngo H, Moghadam S, Huang KX, Bedar M, Cronin BJ, Kwan D, Lee JC. United States Health Policies on Gender-Affirming Care in 2022. Plast Reconstr Surg 2024; 153:462e-473e. [PMID: 37092963 DOI: 10.1097/prs.0000000000010594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Within the United States, access to gender-affirming operations covered by health insurance has increased dramatically over the past decade. However, the perpetually changing landscape and inconsistencies of individual state health policies governing private and public insurance coverage present a lack of clarity for reconstructive surgeons and other physicians attempting to provide gender-affirming care. This work systematically reviewed the current U.S. health policies for both private insurance and Medicaid on a state-by-state basis. METHODS Individual state health policies in effect as of August of 2022 on gender-affirming care were reviewed using the LexisNexis legal database, state legislature publications, and Medicaid manuals. Primary outcomes were categorization of policies as protective, restrictive, or unclear for each state. Secondary outcomes included analyses of demographics covered by current health policies and geographic differences. RESULTS Protective state-level health policies related to gender-affirming care were present in approximately half of the nation for both private insurance (49.0%) and Medicaid (52.9%). Explicitly restrictive policies were found in 5.9% and 17.6% of states for private insurance and Medicaid, respectively. Regionally, the Northeast and West had the highest rates of protective policies, whereas the Midwest and South had the highest rates of restrictive policies on gender-affirming care. CONCLUSIONS State-level health policies on gender-affirming care vary significantly across the United States with regional associations. Clarity in the current and evolving state-specific health policies governing gender-affirming care is essential for surgeons and physicians caring for transgender and gender-diverse individuals.
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Affiliation(s)
- Madeline G Chin
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
- Division of Plastic and Reconstructive Surgery, Warren Alpert Medical School of Brown University
| | - Jonnby S LaGuardia
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | | | | | - Shahrzad Moghadam
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Kelly X Huang
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Meiwand Bedar
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Brendan J Cronin
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Daniel Kwan
- Division of Plastic and Reconstructive Surgery, Warren Alpert Medical School of Brown University
| | - Justine C Lee
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
- UCLA Gender Health Program, University of California, Los Angeles
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Mackie AS, Bravo-Jaimes K, Keir M, Sillman C, Kovacs AH. Access to Specialized Care Across the Lifespan in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:267-282. [PMID: 38161668 PMCID: PMC10755796 DOI: 10.1016/j.cjcpc.2023.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/05/2023] [Indexed: 01/03/2024]
Abstract
Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.
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Affiliation(s)
- Andrew S. Mackie
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Katia Bravo-Jaimes
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle Keir
- Southern Alberta Adult Congenital Heart Clinic, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Sillman
- Adult Congenital Heart Disease Program, Sutter Heart and Vascular Institute, Sacramento, California, USA
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Unreasonable Expectations: A Call for Training and Educational Transparency in Gender-affirming Surgery. Plast Reconstr Surg Glob Open 2023; 11:e4734. [PMID: 36699231 PMCID: PMC9833440 DOI: 10.1097/gox.0000000000004734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/08/2022] [Indexed: 01/13/2023]
Abstract
Although in most areas of practice, there is a reasonable expectation that doctors are sufficiently trained to offer care, this is not true in the case of gender-affirming procedures, which are not required learning in any surgical residency. At the current time, the field of gender surgery is too rapidly evolving, with available resources too scarce for fellowship or residency training to be a realistic requirement for offering these procedures, as the demand already outstrips the available workforce. However, patients are currently given too little information about surgeons' history with these procedures to provide truly informed consent. There is, as such, an ethical mandate to mold the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care.
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Mehra G, Boskey ER, Ganor O. The Quality and Utility of Referral Letters for Gender-Affirming Surgery. Transgend Health 2022; 7:497-504. [PMID: 36644120 PMCID: PMC9829156 DOI: 10.1089/trgh.2021.0057] [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: 01/18/2023] Open
Abstract
Purpose The World Professional Association for Transgender Health (WPATH) recommends referral by a mental health professional for gender-affirming chest and genital surgeries. However, several transgender health guidelines propose an informed consent model of care to respect patient autonomy. This research aimed to understand, characterize, and asses the quality of information gathered through referral letters for patients consulting for gender-affirming surgeries. Methods A retrospective review of electronic medical records (EMRs), including referral letters from behavioral health (BH) and primary care providers (PCPs), was conducted for patients seeking chest or genital surgery by a single surgeon between 2017 and 2019. Data were abstracted manually and included medical and gender history and documentation of WPATH-recommended surgical criteria. Results A total of 233 patient records, including 171 PCP letters and 231 BH letters, were reviewed. With respect to documentation of surgical criteria, 92% of BH letters documented a diagnosis of gender dysphoria, 63% ability to provide informed consent, and 51% management of BH comorbidities. More than half of individuals with chronic physical health conditions did not have those conditions documented in their referral letters. Similarly, BH letters often failed to document BH diagnoses endorsed by patients. For example, while 80% of patients endorsed a diagnosis of anxiety, more than half did not have it documented in their letters. Overall, greater than half of diagnoses across BH conditions were only documented as present in the EMR. Conclusion Referral letters only variably documented WPATH-recommended surgical criteria and did not reliably document physical and mental health comorbidities. Our research suggests that multidisciplinary pre-surgical assessment may be more useful than referral letters in some settings.
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Affiliation(s)
| | - Elizabeth R. Boskey
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Legislations Mandating Insurance Coverage Are Highly Effective in Delivering Surgical Care of Transgender Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4496. [PMID: 36061492 PMCID: PMC9433082 DOI: 10.1097/gox.0000000000004496] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/22/2022] [Indexed: 11/26/2022]
Abstract
Although gender-affirming surgery is increasingly performed, few studies have examined any temporal correlation between legislations mandating transgender care and the actuation of such surgical care.
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Kang CO, Kim E, Cuccolo N, Dagi A, Luther L, Veeramani A, Boskey ER, Lee B, Taghinia AH, Ganor O. A Critical Assessment of the Transgender Health Care Workforce in the United States and the Capacity to Deliver Gender-Affirming Bottom Surgery. Ann Plast Surg 2022; 89:100-104. [PMID: 35749813 DOI: 10.1097/sap.0000000000003113] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Gender-affirming surgery is a critical component of transgender health care, but access information is limited. The study aim was to assess workforce capacity to perform gender affirming bottom surgeries (GABSs) in the United States. METHODS A questionnaire was administered via email, phone call, or fax from February to May 2020 to 86 practices identified as performing GABS by searching 10 Web-based databases with standardized keywords. Questions assessed training capacity, surgical capacity, and surgeon experience. RESULTS Thirty-two of 86 practices responded, 20 met the inclusion criteria. Practices were identified in 15 states, with an average 2.4 (SD, 1.3) surgeons performing GABS per year. States with the greatest number of total providers offering GABS were Illinois (n = 21), Texas (n = 10), and Massachusetts (n = 13). No significant correlation between number of GABS types offered and geographic population density (r = -0.40, P = 0.08), or between number of providers and geographic population density (r = 0.19, P = 0.44). Vaginoplasty was most frequently performed, with the longest waitlists and highest number of waitlist additions per month. Phalloplasty was the second most common procedure, and waitlist additions per month exceeded provider capacity to perform the procedure. Most surgeons performing GABS were plastic surgeons and urologists, whereas obstetricians/gynecologists performed the majority of hysterectomies. CONCLUSIONS This study demonstrated a shortage of providers with requisite training and experience to provide GABS. Although more robust studies are needed to better characterize the relationship between the number of patients seeking GABS and available providers, these findings indicate a need for improved training.
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Affiliation(s)
- Christine O Kang
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Erin Kim
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Nicholas Cuccolo
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York University Grossman School of Medicine, New York, NY
| | - Alexander Dagi
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | | | - Anamika Veeramani
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elizabeth R Boskey
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Bernard Lee
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Amir H Taghinia
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Van Gerwen OT, Aryanpour Z, Selph JP, Muzny CA. Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review. Int J STD AIDS 2022; 33:106-113. [PMID: 34615399 PMCID: PMC9713597 DOI: 10.1177/09564624211046997] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.
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Affiliation(s)
- Olivia T Van Gerwen
- Department of Medicine, Division of Infectious Diseases, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zain Aryanpour
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
| | - John P Selph
- Department of Urology, 9968University of Alabama at Birmingham, Birmingham, AL, USA.Increase
| | - Christina A Muzny
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
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Ganor O, Jolly D, Boskey ER. Nonsensical Coding of Gender-Affirming Procedures: A Need for Transgender-Specific Procedure Codes. J Am Coll Surg 2022; 234:250-251. [PMID: 35213450 DOI: 10.1097/xcs.0000000000000015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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