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Littman AJ, Jeon A, Fort CL, Dashtestani K, Korpak A, Kauth MR, Shipherd JC, Jasuja GK, Wolfe HL, Neira PM, Caballero J, Garcia S, Williamson C, Collongues B, Simpson TL. Receipt of Gender-Affirming Surgeries Among Transgender and Gender Diverse Veterans. J Gen Intern Med 2024:10.1007/s11606-024-08917-1. [PMID: 39060784 DOI: 10.1007/s11606-024-08917-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package. OBJECTIVE To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries. DESIGN Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023. PARTICIPANTS A total of 6653 Veterans (54% response rate) completed the survey. MAIN MEASURES Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region. KEY RESULTS Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery. CONCLUSIONS GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.
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Affiliation(s)
- Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Amy Jeon
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Carolyn L Fort
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Krista Dashtestani
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anna Korpak
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Michael R Kauth
- Office of Patient Care Services, Department of Veterans Affairs, LGBTQ+ Health Program, Washington, DC, USA
- Department of Psychiatry, TH Chan School of Medicine, UMass Chan Medical School, Worcester, MA, USA
| | - Jillian C Shipherd
- Office of Patient Care Services, Department of Veterans Affairs, LGBTQ+ Health Program, Washington, DC, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Guneet K Jasuja
- Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
- Section of General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Hill L Wolfe
- VA Pain Research, Informatics, Multi-Morbidities, and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Paula M Neira
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, USA
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Josie Caballero
- National Center for Transgender Equality, Washington, DC, USA
- Transgender American Veterans Association, Washington, DC, USA
| | - Sady Garcia
- Transgender American Veterans Association, Washington, DC, USA
| | | | | | - Tracy L Simpson
- VA Puget Sound Center of Excellence in Substance Addiction Treatment and Education, Seattle, WA, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Park JB, Adebagbo OD, Escobar-Domingo MJ, Rahmani B, Tobin M, Yamin M, Lee D, Fanning JE, Prospero M, Cauley RP. Trends in Top Surgery Patient Characteristics, Wound Complications, and CPT Code Use by Plastic Surgeons: A Decade-Long Analysis. Ann Plast Surg 2024:00000637-990000000-00518. [PMID: 39016249 DOI: 10.1097/sap.0000000000004047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
BACKGROUND Gender-affirming top surgery is becoming increasingly common, with greater diversity in the patients receiving top surgery. The purpose of this study was to examine national trends in patient demographics, characteristics, wound complication rates, and concurrent procedures in patients receiving gender-affirming top surgeries. METHODS Patients with gender dysphoria who underwent breast procedures, including mastectomy, mastopexy, breast augmentation, or breast reduction by a plastic surgeon between 2013 and 2022, were identified from the American College of Surgeons National Surgical Quality Improvement Program database. These procedures were considered to be gender-affirming "top surgery." Univariate analyses were performed to examine trend changes in the patient population and types of additional procedures performed over the last decade. RESULTS There was a 38-fold increase in the number of patients who received top surgery during the most recent years compared to the first 2 years of the decade. Significantly more individuals receiving top surgery in recent years were nonbinary (P < 0.01). There was a significant decrease in percentage of active smokers (P < 0.01) while there was an increase in percentage of patients with diabetes (P = 0.03). While there was a significant increase in the number of obese patients receiving top surgery (P < 0.01), there were no differences in postoperative wound complications between the years. Significantly more patients received additional procedures (P < 0.01) and had about a 9-fold increase in distinct number of additional CPT codes from 2013-2014 to 2021-2022. CONCLUSIONS Our study found that there has been (1) a significant increase in the number of top surgery patients from 2013 to 2022 overall and (2) a particular increase in patients with preoperative comorbidities, such as a higher body mass index and diabetes. Understanding current and evolving trends in patients undergoing surgical treatment for gender dysphoria can inform individualized care plans that best serve the needs of patients and optimize overall outcomes.
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Affiliation(s)
- John B Park
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Maria J Escobar-Domingo
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Benjamin Rahmani
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Micaela Tobin
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mohammed Yamin
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Daniela Lee
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - James E Fanning
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Matthew Prospero
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ryan P Cauley
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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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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Gupta N, Alnaseri T, Slack G, DeLong M. Gender Affirmation Surgery-related Hashtag Utilization on Instagram: Implications for Education and Patient Care. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5841. [PMID: 38784826 PMCID: PMC11111395 DOI: 10.1097/gox.0000000000005841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 04/01/2024] [Indexed: 05/25/2024]
Abstract
Background Gender-affirmation surgery (GAS) allows for transgender and nonconforming patients to achieve a more congruent physical appearance and alleviate dysphoria. Social media, such as Instagram, has adopted an increasingly important role in plastic and reconstructive surgery, and understanding trends and usage related to GAS can have significant implications for patient education and outreach. As such, this cross-sectional study aims to address the following questions related to GAS-related content available on Instagram: (1) Who is posting this content? (2) What specific hashtags are they using? and (3) What are the implications behind these posts? Methods This study analyzed 22 GAS-related hashtags on Instagram. Content analysis was then used to evaluate the "top" 15 posts (n = 330) associated with each hashtag. Results A total of 425,607 posts were associated with the 22 hashtags queried. #topsurgery had the highest number of associated posts (n = 279,480), followed by #ftmtopsurgery (n = 41,769) and #vaginoplasty (n = 39,737). Of the "top" 330 posts, 299 were not duplicates. Plastic surgeons eligible for membership in the American Society of Plastic Surgeons accounted for only 1.7% of "top" posts (n = 5); noneligible physicians accounted for 6.0% of posts (n = 18). Patients accounted for the majority of the "top" posts sampled (n = 236; 79.9%). Conclusions When used appropriately, social media can be a powerful tool for spreading awareness on procedures and educating patients. Although there is a paucity of plastic surgeons posting GAS-related content on Instagram, patients are playing an important role in disseminating information.
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Affiliation(s)
- Nisha Gupta
- From the Georgetown University School of Medicine, Washington D.C
| | - Tahera Alnaseri
- Division of Plastic and Reconstructive Surgery, UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Ginger Slack
- Division of Plastic and Reconstructive Surgery, UCLA David Geffen School of Medicine, Los Angeles, Calif
| | - Michael DeLong
- Division of Plastic and Reconstructive Surgery, UCLA David Geffen School of Medicine, Los Angeles, Calif
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Bertrand AA, DeLong MR, McCleary SP, Nahabet EH, Slack GC, DaLio AL, Weimer AK, Kwan L, Bernacki J, Rudkin GH. Gender-Affirming Mastectomy: Psychosocial and Surgical Outcomes in Transgender Adults. J Am Coll Surg 2024; 238:890-899. [PMID: 38294149 DOI: 10.1097/xcs.0000000000000940] [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: 02/01/2024]
Abstract
BACKGROUND Limited literature exists examining the effects of gender-affirming mastectomy on transmasculine and nonbinary patients that is prospective and uses validated survey instruments. STUDY DESIGN The psychosocial functioning of transmasculine and nonbinary patients was compared between patients who underwent gender-affirming mastectomy and those who had not yet undergone surgery. Participants were enrolled in a single-site, combined study of surgical and psychosocial outcomes, including a cross-sectional cohort of preoperative and postoperative patients, as well as separate prospective cohort. Participants completed the BREAST-Q psychosocial and sexual well-being modules, the BODY-Q satisfaction with chest and nipples modules, the Body Image Quality of Life Inventory, the Transgender Congruence Scale, the Patient Health Questionnaire-9, and the Generalized Anxiety Disorder-7 scale before and after surgery. We also examined how patient demographic factors correlated with postoperative surgical and psychosocial outcomes. RESULTS A total of 111 transmasculine and nonbinary patients 18 to 63 years of age (mean ± SD 26.5 ± 8) underwent mastectomy and were included in the study. All were included in the cross-sectional cohort, and 20 were enrolled in the prospective cohort. More than one-third (34.2%) of patients were nonbinary. After surgery, psychosocial and sexual well-being, satisfaction, body image-related quality of life, and gender congruence were increased (p < 0.001) in both cohorts, and depression (p < 0.009 cross-sectional), and anxiety (p < 0.001 cross-sectional) were decreased. The most common adverse event was hypertrophic scarring, which occurred in 41 (36.9%) participants. CONCLUSIONS In this study of transmasculine and nonbinary adults, gender-affirming mastectomy was followed by substantial improvements in psychosocial functioning.
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Affiliation(s)
- A A Bertrand
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Michael R DeLong
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Sean P McCleary
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Edward H Nahabet
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Ginger C Slack
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Andrew L DaLio
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
| | - Amy K Weimer
- Departments of Internal Medicine (Weimer, Bernacki), University of California, Los Angeles, Los Angeles, CA
| | - Lorna Kwan
- Urology (Kwan), University of California, Los Angeles, Los Angeles, CA
| | - Jessica Bernacki
- Departments of Internal Medicine (Weimer, Bernacki), University of California, Los Angeles, Los Angeles, CA
| | - George H Rudkin
- From the Division of Plastic and Reconstructive Surgery (Bertrand, DeLong, McCleary, Nahabet, Slack, DaLio, Rudkin), University of California, Los Angeles, Los Angeles, CA
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6
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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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Kim EJ, Stearns SA, Bustos VP, Engmann T, Dowlatshahi AS, Lee BT, Cauley R. Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization. Ann Plast Surg 2024; 92:92-96. [PMID: 38117049 DOI: 10.1097/sap.0000000000003729] [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: 12/21/2023]
Abstract
PURPOSE The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS. METHODS This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians. RESULTS A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively). CONCLUSIONS There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.
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Affiliation(s)
- Erin J Kim
- From the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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8
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Shah NR, Cockrell HC, Keller NE, Diaz-Miron J, Meckmongkol TT, Yu P, Englum B, Richards MK, Martin K. Debunking Myths of Gender Informed Care: What Every Pediatric Surgeon Should Know. J Pediatr Surg 2023; 58:2286-2293. [PMID: 37690870 DOI: 10.1016/j.jpedsurg.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/09/2023] [Accepted: 08/13/2023] [Indexed: 09/12/2023]
Abstract
As the transgender population in the United States grows, gender-affirming care is becoming increasingly relevant to the practice of pediatric surgery. Medical care for the transgender and gender diverse population is a politically charged topic with significant complexity and opportunities for clarification. It is important for providers to better understand this population's unique health and social needs. This review aims to debunk long-standing myths regarding gender-affirming care and highlight the current therapeutic and legislative landscapes within the scope of pediatric surgical practice. LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Nikhil R Shah
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA.
| | - Hannah C Cockrell
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Noah E Keller
- Department of Pediatric Surgery, Roseville Medical Center, Roseville, CA, USA
| | - Jose Diaz-Miron
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Teerin T Meckmongkol
- Division of Pediatric Surgery, Nemours Children's Health Orlando, Orlando, FL, USA
| | - Peter Yu
- Division of General and Thoracic Surgery, Children's Hospital of Orange County, Orange CA, USA
| | - Brian Englum
- Division of Pediatric Surgery, University of Maryland Children's Hospital, Baltimore, MD, USA
| | - Morgan K Richards
- Division of Pediatric Surgery, St. Luke's Children's Hospital, Boise, ID, USA
| | - Kathryn Martin
- Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY, USA
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9
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Boyer TL, Wolfe HL, Littman AJ, Shipherd JC, Kauth MR, Blosnich JR. Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration. J Gen Intern Med 2023; 38:3549-3557. [PMID: 37670068 PMCID: PMC10713904 DOI: 10.1007/s11606-023-08389-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients. OBJECTIVE This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations. PARTICIPANTS TGD patients (n = 30) and VHA providers (n = 22). APPROACH Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. KEY RESULTS VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal. CONCLUSIONS A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Hill L Wolfe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Pain Research, Informatics, Multi-Morbidities, and Education Center, West Haven, CT, USA
- Biomedical Informatics & Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Jillian C Shipherd
- Lesbian, Gay, Bisexual, Transgender, and Queer Health Program, Veterans Health Administration, Washington, DC, USA
- National Center for PTSD, VA Boston Healthcare System, Boston, MA, USA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Michael R Kauth
- Lesbian, Gay, Bisexual, Transgender, and Queer Health Program, Veterans Health Administration, Washington, DC, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
| | - John R Blosnich
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
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10
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Torres Perez-Iglesias CA, Heyman A, Koh DJ, Medina N, Roh DS, Slama J. Technical and Clinical Differences Between Transgender and Cisgender Females Undergoing Breast Augmentation. Ann Plast Surg 2023; 91:534-539. [PMID: 37823620 DOI: 10.1097/sap.0000000000003706] [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: 10/13/2023]
Abstract
BACKGROUND Gender-affirming surgery is a quickly expanding field. However, it is facing a shortage of specialized surgeons for a population exceeding 1.4 million individuals. Many studies comparing outcomes between cisgender and transgender patients fail to describe the technical differences of the operation. Breast augmentation in the transgender female patient involves important anatomical, technical, and clinical features that differ from the cisgender female. In this study, we aimed to describe and compare these characteristics between these 2 groups to better inform the new generation of gender-affirming surgeons. METHODS A retrospective cohort study of patients who underwent primary breast augmentation between 2009 and 2019 at a specialized tertiary center for transgender care was performed. Mastopexy, secondary augmentation, and reconstructive procedures were excluded. Demographic, operative, and clinical data were collected from medical records. All patients had a minimum of 1 year of follow-up after the initial surgery. Bivariate analysis was performed. RESULTS A total of 250 cisgender females and 153 transgender females were included. The transgender group showed higher rates of smoking ( P < 0.0001), immunosuppression ( P < 0.0001), obesity ( P < 0.0001), mental health disorders ( P < 0.0001), and hypertension ( P = 0.002). Median base width ( P < 0.0001), sternal notch to nipple distance ( P < 0.0001), and implant size (500 mL [interquartile range, 425-600 mL] vs 350 mL [interquartile range, 325-385 mL]; P < 0.0001) were larger in transgender patients. Transgender patients also demonstrated a stronger correlation between implant size and body surface area ( r = 0.71, P < 0.0001). Readmission, reoperation, and complication rates were similar between the groups; however, transgender females had a higher incidence of surgical site infections (3.9% vs 0.4%, P < 0.013). Capsular contracture was the most common complication and indication for reoperation in both groups. CONCLUSIONS There are important anatomical, clinical, and technical differences between reconstructive gender-affirming breast augmentation in transgender female patients and cosmetic breast augmentation in the cisgender female. The gender-affirming surgeon must know these differences to provide the best quality of care and help patients achieve better congruence between their gender identity and body image.
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Affiliation(s)
| | | | | | - Nilton Medina
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Daniel S Roh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Jaromir Slama
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
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11
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Kim EJ, Stearns SA, Bustos VP, Dowlatshahi AS, Lee BT, Cauley R. Impact of financial well-being on gender affirmation surgery access and hospital course. J Plast Reconstr Aesthet Surg 2023; 85:174-181. [PMID: 37499558 DOI: 10.1016/j.bjps.2023.06.059] [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: 12/21/2022] [Revised: 06/11/2023] [Accepted: 06/22/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Although gender affirmation surgery (GAS) can effectively treat gender dysphoria, it remains one of the most expensive components of gender affirming care. This study aims to identify the impact of financial well-being on GAS access and hospital course in the United States. METHODS The National Inpatient Sample database was queried from 2012 to 2019. US transgender patients undergoing GAS were identified. Predictors included patient sociodemographic variables. Outcomes included hospitalization course variables. Regression modeling was used to assess the relationship between predictor and outcome variables. Significance was set at α = 0.05. RESULTS A total of 5620 weighted GAS encounters were identified (genital surgery 92.3%, chest surgery 16.6%). 1825 (32.5%) patients were in the highest income bracket, compared with 1120 (19.9%) patients in the lowest bracket. Higher income was associated with younger age at the time of GAS. Patients in the highest income quartile were also 3.7 times more likely to be funded by private insurance and self-pay options than those in the lowest income quartile (95% confidence interval [CI]: 3.1-4.4, p < 0.0001). Additionally, patients in the lowest income quartile were 4.2 times more likely to require either home healthcare or transfer to a nursing facility post discharge than those in the highest income quartile (95% CI: 3.1-5.8, p < 0.001). CONCLUSIONS To promote equitable care to transgender patients, efforts to reduce financial barriers to healthcare access are much needed, particularly through broader insurance coverage of GAS procedures. Broadly, our results highlight the impact of socioeconomic variables on healthcare access and outcomes.
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Affiliation(s)
- Erin J Kim
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Stephen A Stearns
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Valeria P Bustos
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Arriyan S Dowlatshahi
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Bernard T Lee
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ryan Cauley
- Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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12
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Hassan B, Zeitouni F, Ascha M, Sanders R, Liang F. Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors. Cureus 2023; 15:e45948. [PMID: 37885491 PMCID: PMC10599689 DOI: 10.7759/cureus.45948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors. METHODS We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years. RESULTS A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each). CONCLUSIONS AND RELEVANCE GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.
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Affiliation(s)
- Bashar Hassan
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Ferris Zeitouni
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Mona Ascha
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Renata Sanders
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Fan Liang
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
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13
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Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open 2023; 6:e2330348. [PMID: 37610753 PMCID: PMC10448302 DOI: 10.1001/jamanetworkopen.2023.30348] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/15/2023] [Indexed: 08/24/2023] Open
Abstract
Importance While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited. Objective To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups. Design, Setting, and Participants This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified. Main Outcome Measures Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed. Results A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [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. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients. Conclusions and Relevance Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.
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Affiliation(s)
- Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yukio Suzuki
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Dawn L. Hershman
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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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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15
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Kinney MK, Victor BG, Fortenberry JD. Conceptualizations of wellbeing among nonbinary individuals in the Midwestern United States: a photovoice study. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2023; 25:483-503. [PMID: 39055637 PMCID: PMC11268229 DOI: 10.1080/26895269.2023.2232351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Background: Traditionally, gender has been viewed through an essentialist lens with fixed biology-based traits or polarized gender norms between women and men. As awareness of gender diversity grows, increasingly more people are coming out as nonbinary - or not exclusively a man or woman. Little has been explored regarding experiences unique to nonbinary individuals, particularly beyond a focus on adverse risks and outcomes to understand their wellbeing. This article discusses gendered experiences and the construction of wellbeing among nonbinary individuals. Aim: The purpose of this study was to conceptualize wellbeing as a complex multidimensional phenomenon through nonbinary individuals' perspectives. Methods: A virtual PhotoVoice study was conducted with 17 nonbinary adults in the Midwestern United States who participated in online group discussions and in-depth semi-structured interviews, which were analyzed with thematic analysis. Results: The analysis identified five core dimensions of nonbinary wellbeing: 1) Security, 2) Mental and physical health, 3) Autonomy, 4) Belonging, and 5) Gender positivity. Exemplary definitions of wellbeing are also presented. Discussion: Understanding how nonbinary individuals thrive challenges the framing of gender diverse experiences in adversity and presents a more holistic portrayal that community members and allies can strive toward. This study contributes an intersectional understanding of wellbeing in relation to identities of race, culture, age, disability, neurodiversity, and sociopolitical geographical context. The findings of this study can aid in practice, advocacy, and research to bolster the wellbeing of nonbinary people.
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Affiliation(s)
- M. Killian Kinney
- Claire Argow Social Work Program, Pacific University, Forest Grove, Oregon, USA
| | - Bryan G. Victor
- School of Social Work, Wayne State University, Detroit, Michigan, USA
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16
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Bruce H, Munday K, Kapp SK. Exploring the Experiences of Autistic Transgender and Non-Binary Adults in Seeking Gender Identity Health Care. AUTISM IN ADULTHOOD 2023; 5:191-203. [PMID: 37346990 PMCID: PMC10280216 DOI: 10.1089/aut.2023.0003] [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: 06/23/2023]
Abstract
Background This study sought to obtain an in-depth understanding of autistic transgender and/or non-binary adults' experiences in accessing, or trying to access, gender identity health care (GIH). To our knowledge, no prior study researched this topic. Methods Through semi-structured interviews, we obtained the first-hand experiences of 17 participants. H.B. (cisgender, non-autistic) conducted a reflexive thematic analysis using an inductive approach, in collaboration with K.M., an autistic transgender disability community researcher, and under the supervision of S.K.K., a cisgender autistic autism researcher. Results Thematic analysis determined that poor knowledge of professionals, accessibility issues, and bureaucratic and economic barriers impacted participants' experiences when accessing GIH. Participants experienced a perceived lack of professional knowledge around autism and gender diverse health care needs, limited communication methods and accommodations, and misdiagnosis of mental health difficulties. Accessibility issues included unmet sensory needs, disruption to routine, and a lack of local provision. Further, participants shared that they struggled with unclear processes, standardization of care, long waiting lists, and confusing or inaccessible insurance coverage. Recommendations for improvements highlighted the need to listen to service users to positively impact their experiences in accessing GIH. Conclusion This study suggests that more training needs to be given to health care providers and professionals around autistic experience to help improve providers' competence in communication and providing person-centered accommodations. More training around gender diverse identities is needed, as well as increased knowledge on the co-occurrence of autism and transgender/non-binary identities, to positively impact patient experiences and help improve access to care.
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Affiliation(s)
- Harley Bruce
- Department of Psychology, University of Portsmouth, Portsmouth, United Kingdom
| | - Katie Munday
- Department of Education and Sociology, University of Portsmouth, Portsmouth, United Kingdom
| | - Steven K. Kapp
- Department of Psychology, University of Portsmouth, Portsmouth, United Kingdom
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Lynne-Joseph A. "As a clinician, you have to be passionately involved": Advocacy and professional responsibility in gender-affirming healthcare. Soc Sci Med 2023; 321:115788. [PMID: 36842306 DOI: 10.1016/j.socscimed.2023.115788] [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: 10/14/2022] [Revised: 01/15/2023] [Accepted: 02/16/2023] [Indexed: 02/23/2023]
Abstract
Previous research has studied how clinicians such as physicians, nurses, social workers, and nutritionists understand advocacy as a professional responsibility. Analyses have typically focused on individual healthcare professions and have viewed ambiguity around the conceptualization of advocacy as detrimental. Little research has considered how multiple professions within a single field of healthcare interpret clinician advocacy, nor how ambiguity might be productive in a multidisciplinary field. This article addresses these gaps by utilizing science and technology studies scholarship on buzzwords to analyze how clinicians in the field of gender-affirming healthcare have come to understand advocacy as a professional responsibility despite significant ambiguity around the goals, tactics, and targets of advocacy. Gender-affirming healthcare refers to any kind of physical or mental healthcare that transgender and gender diverse (TGD) people obtain to affirm their gender identity. Drawing on interviews with 30 U.S. clinicians, observation of nine transgender health conferences, and content analysis of 202 professional journal articles and 11 professional association statements, I argue that ambiguity around advocacy has been key to its uptake as a responsibility across multiple professions in this field. Foregrounding interview data, I show how polysemy allows clinician respondents across professions to reassert their expertise as they delineate what constitutes good gender-affirming healthcare and defend the emergent field in three problem domains: health insurance, the marginalization of TGD people, and the legality of gender-affirming healthcare. I also demonstrate how theoretical work on buzzwords explains why three clinician respondents rejected advocacy as a professional responsibility.
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Affiliation(s)
- Alyssa Lynne-Joseph
- Wichita State University, Department of Sociology, 1845 Fairmount Street, Wichita, KS, 67260, USA.
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18
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Age-related Outcomes of Chest Masculinization Surgery: A Single-surgeon Retrospective Cohort Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4799. [PMID: 36845860 PMCID: PMC9945241 DOI: 10.1097/gox.0000000000004799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/06/2022] [Indexed: 02/22/2023]
Abstract
Many transmasculine individuals face chest dysphoria, an emotional distress associated with breast development. The definitive management for reduction of existing breast tissue and alleviation of chest dysphoria comes in the form of chest masculinization surgery. Over the years, a substantial increase in the number of youth seeking gender-affirming chest masculinization surgery was observed globally. The study was hypothesized to answer the question as to whether the age limit of chest masculinization surgery should be lowered to include adolescents. Methods A retrospective cohort study was conducted, based on the experience of a single surgeon over a period of 20 years. Results Two-hundred eight patients were included in this cohort. Patients were divided into two equal groups based on their age. No statistically significant differences between the groups were observed in terms of resected breast tissue (P = 0.62 and 0.30, for the right and left breast, accordingly), auxiliary liposuction (P = 0.30), liposuction volume (P = 0.20), procedure (P = 0.15), postoperative drains (P = 0.79), and surgery duration (P = 0.72). Statistically significant differences were found in the 18 years or younger group, with lower rates of complication (P < 0.001), lower rates of revision surgery (P = 0.025), and higher satisfaction rankings (P < 0.001). Apart from age, no other factors were found to potentially explain the different rates of complications between the age groups. Conclusion Patients aged 18 or younger opting for chest masculinization surgery experience fewer complications and revision procedures while having higher satisfaction rates with the surgical outcome.
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Ha M, Ngaage LM, Finkelstein ER, Klein M, Yanga A, Colohan SM, Nurudeen SM, Terhune JH, Slezak S, Rasko YM. Insurance Coverage of Prophylactic Mastectomies: A National Review of the United States. Clin Breast Cancer 2023; 23:211-218. [PMID: 36588087 DOI: 10.1016/j.clbc.2022.12.001] [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: 09/21/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Breast cancer is associated with a multitude of risk factors, such as genetic predisposition and mutations, family history, personal medical history, or previous radiotherapy. A prophylactic mastectomy (PM) may be considered a suitable risk-reducing procedure in some cases. However, there are significant discrepancies between national society recommendations and insurance company requirements for PM. MATERIALS AND METHODS The authors conducted a cross-sectional analysis of insurance policies for a PM. One-hundred companies were selected based on the greatest state enrolment and market share. Their policies were identified through a Web-based search and telephone interviews, and their medical necessity criteria were extracted. RESULTS Preauthorized coverage of PMs was provided by 39% of insurance policies (n = 39) and 5 indications were identified. There was consensus amongst these policies to cover a PM for BRCA1/2 mutations (n = 39, 100%), but was more variable for other genetic mutations (15%-90%). Coverage of PM for the remaining indications varied among insurers: previous radiotherapy (92%), pathological changes in the breast (3%-92%), personal history of cancer (64%) and family history risk factors (39%-51%). CONCLUSION There is a marked level of variability in both the indications and medical necessity criteria for PM insurance policies. The decision to undergo a PM must be carefully considered with a patient's care team and should not be affected by insurance coverage status.
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Affiliation(s)
- Michael Ha
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD
| | - Emily R Finkelstein
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Division of Plastic and Reconstructive Surgery, University of Miami Miller School of Medicine, Miami, FL.
| | - Marissa Klein
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Annie Yanga
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shannon M Colohan
- Division of Plastic Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Suliat M Nurudeen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Julia H Terhune
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Sheri Slezak
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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20
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Aryanpour Z, Nguyen CT, Blunck CK, Cooper KM, Kovac S, Ananthasekar S, Peters BR. Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022; 19:846-851. [PMID: 35288048 DOI: 10.1016/j.jsxm.2022.02.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care. AIM The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement. METHODS Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations. OUTCOMES Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes. RESULTS Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235). CLINICAL IMPLICATIONS This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions. STRENGTHS & LIMITATIONS This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality. CONCLUSION Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.
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Affiliation(s)
- Zain Aryanpour
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.
| | - Christine T Nguyen
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Conrad K Blunck
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Kasey M Cooper
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Stefan Kovac
- University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | | | - Blair R Peters
- Division of Plastic & Reconstructive Surgery, Oregon Health Sciences University, Portland, OR, USA; Department of Urology, Oregon Health Sciences University, Portland, OR, USA
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21
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Tang A, Hojilla JC, Jackson JE, Rothenberg KA, Gologorsky RC, Stram DA, Mooney CM, Hernandez SL, Yokoo KM. Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents. Ann Plast Surg 2022; 88:S325-S331. [PMID: 36248210 PMCID: PMC9555285 DOI: 10.1097/sap.0000000000003135] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
Background There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system. Methods Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth ages 12-17 within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using chi-squared tests. Results The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range 12-17) and the most common technique was double-incision (85%). For patients with greater than 1-year follow-up (n=137, 65.6%), at least one complication was found in 7.3% (n=10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9 % underwent revision (n=15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (p>0.05). Two patients (0.95%) had documented postoperative regret but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively. Conclusion Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.
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Affiliation(s)
- Annie Tang
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | | | - Jordan E Jackson
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Kara A Rothenberg
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Rebecca C Gologorsky
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | | | - Colin M Mooney
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland
| | - Stephanie L Hernandez
- Multispecialty Transition Department, Kaiser Permanente Northern California, Oakland
| | - Karen M Yokoo
- Department of Plastic Surgery, Kaiser Permanente Northern California, Richmond, CA
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22
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Stoehr JR, Hamidian Jahromi A, Hunter EL, Schechter LS. Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action. Transgend Health 2022; 7:117-126. [PMID: 36644513 PMCID: PMC9829135 DOI: 10.1089/trgh.2020.0136] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Telemedicine has facilitated the delivery of affordable and accessible health care. However, little has been discussed about its use in gender-affirming care (GAC). Telemedicine has the potential to overcome many barriers encountered by transgender individuals such as limited geographic access to care and financial constraints, which have both been exacerbated by the COVID-19 pandemic. Telemedicine may also enhance opportunities for training in gender-affirming surgery. A systematic review of the literature on telehealth and GAC was performed. Identified uses of telehealth included: an electronic teleconsultation service, a virtual peer health consultation service, and an open online course on LGBT+ rights and health care for health care providers and laypeople. As the medical and health care communities adjust to the new reality of health care, efforts should be made to effectively incorporate telemedicine into GAC.
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Affiliation(s)
- Jenna Rose Stoehr
- Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alireza Hamidian Jahromi
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois, USA.,The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois at Chicago, Illinois, USA
| | - Ezra Leigh Hunter
- The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois at Chicago, Illinois, USA
| | - Loren S. Schechter
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Illinois, USA.,The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois at Chicago, Illinois, USA.,Address correspondence to: Loren S. Schechter, MD, The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois at Chicago, 4646 N Marine Dr, Chicago, IL 60640, USA,
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23
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Gender-affirming Mastectomy with Concurrent Oncologic Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY - GLOBAL OPEN 2022; 10:e4092. [PMID: 35169524 PMCID: PMC8830861 DOI: 10.1097/gox.0000000000004092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 11/26/2022]
Abstract
Transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. Our center offers simultaneous oncologic mastectomy with gender-affirming reconstruction to patients who are diagnosed with breast cancer. This study is the first reported series of concurrent gender-affirming and oncologic mastectomies.
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24
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Klein M, Ha M, Yang A, Ngaage LM, Slezak S, Rasko Y. A National Review of Insurance Coverage of Noncancerous Breast Reconstruction. Ann Plast Surg 2021; 87:232-237. [PMID: 34397512 DOI: 10.1097/sap.0000000000002871] [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: 11/27/2022]
Abstract
BACKGROUND Breast reconstruction is commonly performed for a multitude of noncancerous indications, such as correction of congenital deformities, acquired tissue disease, burns, and trauma. However, breast reconstruction for noncancerous indications is often considered cosmetic or not explicitly mentioned in insurance policies. The goal of this study was to assess variability in insurance coverage of breast reconstruction for noncancerous indications. METHODS The authors conducted a cross-sectional analysis of 102 US insurance companies, including Medicare and Medicaid, for coverage of breast reconstruction for noncancerous indications (Poland syndrome, fibrocystic breast disease, burns and trauma). Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies. RESULTS Half of the insurers (49%, n = 50) had no policy for Poland syndrome, 46% (n = 47) had no policy for burns and trauma, and 82% (n = 84) had no policy for fibrocystic breast disease. Fifty-two percent (n = 22) of policies providing coverage for Poland syndrome, 24% (n = 13) of policies providing coverage for burns and trauma, and 58% (n = 7) of policies providing coverage for fibrocystic breast disease had specific, stringent criteria for medical necessity. Thirty-six percent (n = 15) of policies covering Poland syndrome, 47% (n = 26) of policies covering burns and trauma, and 33% (n = 4) of policies covering fibrocystic breast disease include coverage of the contralateral breast. CONCLUSIONS There is a paucity of publicly available information on insurance coverage of breast reconstruction for noncancerous indications and a lack of consensus between top US insurance companies on what constitutes medical necessity for surgical correction.
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Affiliation(s)
- Marissa Klein
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland
| | - Michael Ha
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland
| | - Annie Yang
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland
| | | | - Sheri Slezak
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland
| | - Yvonne Rasko
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland
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25
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Ngaage LM, Xue S, Borrelli MR, Safa B, Berli JU, Bluebond-Langner R, Rasko YM. Gender-Affirming Health Insurance Reform in the United States. Ann Plast Surg 2021; 87:119-122. [PMID: 33470627 DOI: 10.1097/sap.0000000000002674] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In May 2014, the US Department of Health and Human Services prohibited insurance discrimination of transgender individuals. Despite this, insurance plans often lack explicit guidelines on gender transition-related care and coverage of surgical procedures is extremely varied. We evaluated the evolution of insurance coverage of gender-affirming care following the 2014 legislative change. METHODS Insurance providers were selected based on company market share. We conducted a Web-based search and telephone interviews to identify the corresponding policies related to gender-affirming health care. We compared policy changes made before and after the 2014 US Department of Health and Human Services decision. RESULTS Of the 92 insurers surveyed, 7% did not have a policy, and 315 policy revisions were documented. After the legislation, a significantly higher proportion of policy revisions were related to coverage of services (36% vs 11%, P < 0.0001), removal of existing criteria significantly decreased (23% vs 49%, P = 0.0044), and addition of criteria unrelated to international standards sharply increased (32% vs 2%, P = 0.0002). This resulted in reduced coverage of facial feminization, hair transplantation, laryngochondroplasty, and voice modification surgery. However, nipple reconstruction experienced increased coverage. The percentage of revisions to add preauthorization criteria to meet international standards (49% vs 45%, P = 0.6714) or to change terminology (37% vs 27%, P = 0.1055) were similar before and after the legislation. CONCLUSIONS After the transformative legislation in 2014, an increasing number of insurance companies established gender transition-related policies. As more patients seek gender-affirming care, insurers deviate from international guidelines and create additional benchmarks that may act as barriers to care.
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Affiliation(s)
- Ledibabari Mildred Ngaage
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Shan Xue
- Medical College of Georgia, Atlanta, GA
| | | | - Bauback Safa
- Department of Plastic Surgery, The Buncke Clinic, San Francisco, CA
| | - Jens U Berli
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR
| | - Rachel Bluebond-Langner
- Department of Plastic and Reconstructive Surgery, New York University Langone Health, New York City, NY
| | - Yvonne M Rasko
- From the Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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26
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Kirkland A, Talesh S, Perone AK. Transition Coverage and Clarity in Self-Insured Corporate Health Insurance Benefit Plans. Transgend Health 2021; 6:207-216. [PMID: 34414277 PMCID: PMC8364000 DOI: 10.1089/trgh.2020.0067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: While many health insurance plans now cover at least some gender-affirming care for transgender persons, no study to date has examined contract language about gender-affirming care in self-insured corporate plans. We sought to evaluate private company offerings from the perspective of an employee, analyzing clarity as well as what gender-affirming care is covered or excluded. Methods: We coded 435 health insurance contracts from 40 U.S. self-insured corporations from 2019 for inclusion of 52 coverage aspects from the World Professional Association for Transgender Health (WPATH) recommendations. We categorize contracts by clarity of the document and its inclusions and exclusions, and compare each company's contract ratings to their 2019 Human Rights Campaign (HRC) Workplace Equality Index rating. Results: Findings reveal higher levels of total exclusions in contracts (9% here vs. 3% found in prior studies of more highly regulated plans), as well as extensive variation in clarity, coverage specifications, and types of exclusions. Facial confirmation surgery procedures are commonly excluded even in plans that affirm the WPATH guidelines. Twenty-five percent of the companies in the study offered at least one contract with a categorical exclusion. HRC ratings did not match up to our ratings of gender-affirming coverage. Conclusion: Legal complexity has resulted in a patchwork of continued health insurance exclusions of gender-affirming care even as coverage has expanded. Lack of transparency and clarity also contributes to challenges in understanding one's own coverage as well as mapping the national picture of transgender inclusion in health care plans.
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Affiliation(s)
- Anna Kirkland
- Arthur F. Thurnau Professor of Women's and Gender Studies and Director, Institute for Research on Women and Gender, Political Science, Sociology, and Health Management and Policy (by courtesy), University of Michigan, Ann Arbor, Michigan, USA
- *Address correspondence to: Anna Kirkland, JD, PhD, Arthur F. Thurnau Professor of Women's and Gender Studies and Director, Institute for Research on Women and Gender, Political Science, Sociology, and Health Management and Policy (by courtesy), University of Michigan, 204 South State Street, Ann Arbor, MI 48109-1382, USA,
| | - Shauhin Talesh
- Professor of Law, Criminology, Law & Society, and Sociology, University of California, Irvine, California, USA
| | - Angela K. Perone
- Doctoral candidate, School of Social Work and Sociology, University of Michigan, Ann Arbor, Michigan, USA
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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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28
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Scalia P, Tighe KM, Elwyn G, Bagley PJ, Blunt HB, Boh B, Walters OC, Moses RA. A systematic review of decision aids for gender affirming therapy. Transl Androl Urol 2021; 10:2574-2582. [PMID: 34295744 PMCID: PMC8261453 DOI: 10.21037/tau-20-1000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/17/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Transgender and gender diverse (TGD) persons considering gender affirming therapy have to make many complex medical decisions, potentially without understanding the associated harms or benefits of hormonal and surgical interventions. Further, clinicians are often unaware of how best to communicate information to persons seeking gender affirming therapy. Patient decision aids have been developed to provide evidence-based information as a way to help people make decisions in collaboration with their clinicians. It is unclear whether such tools exist for persons seeking gender affirming therapy. The objective of our systematic review is to search for and determine the quality of any existing patient decision aids developed for TGD persons considering gender affirming therapy, and the outcomes associated with their use. METHODS We adapted a search strategy for databases using two key concepts "decision support intervention/patient decision aid" and "transgender". We also conducted a brief online search of Google and abstracts from relevant conferences to identify any tools not published in the academic literature. Following study selection and data extraction, we used the International Patient Decision Aid Standards instrument (IPDASi) to assess the quality of patient decision aids, and the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) checklist to assess the quality of evaluations. RESULTS We identified 762 studies; none were identified from Google or conference content. One tool met our inclusion criteria: an online, pre-encounter patient decision aid for transmasculine genital gender-affirming surgery developed in Amsterdam, translated in English and Dutch. The tool met all the IPDASi qualifying criteria, and scored a 17/28 on the certification criteria, and 57/112 on the quality criteria. The efficacy of the patient decision aid has not been evaluated. CONCLUSIONS Despite multiple decisions required for gender affirming therapies, only one patient decision aid has been developed for transmasculine genital reconstruction. Further research is required to develop patient decision aids for the multiple decision points along the gender affirming journey.
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Affiliation(s)
- Peter Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Katherine M. Tighe
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | | | | | - Benjamin Boh
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Political Advocacy from Plastic Surgery Trainees in the United States. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3590. [PMID: 34036027 PMCID: PMC8140763 DOI: 10.1097/gox.0000000000003590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/01/2021] [Indexed: 11/30/2022]
Abstract
Legislature directly impacts the practice of physicians across multiple specialties. The goal of our study is to investigate the political engagement and opinions of plastic surgery trainees, and how they perceive legislation impacts future practice.
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30
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Non-surgical Correction of Congenital Ear Anomalies: A Review of the Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3554. [PMID: 33912373 PMCID: PMC8078268 DOI: 10.1097/gox.0000000000003554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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31
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Sergi FD, Wilson EC. Filler Use Among Trans Women: Correlates of Feminizing Subcutaneous Injections and Their Health Consequences. Transgend Health 2021; 6:82-90. [PMID: 33937525 DOI: 10.1089/trgh.2020.0035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Purpose: Subcutaneous injections, or "fillers," are used illicitly and in large quantities by trans women for feminization. They are associated with severe complications, but data on their use are limited, especially in places with widespread access to safe gender-affirming care. Our analysis seeks to assess the prevalence, correlates, and complications of filler use to inform prevention and treatment. Methods: A secondary analysis of cross-sectional survey data from the Trans* National Study conducted from May 2016 to December 2017 of 631 adult trans women in the San Francisco Bay Area, California, recruited using respondent-driven sampling. Results: Around 65/631 participants (10.3%) reported filler use. Filler use was highest among Latinas (21.3% vs. 3.8% among whites, p<0.001), high school graduates (22.6% vs. 1.7% among college graduates, p<0.001), and those with a history of being undocumented (31.7% vs. 16.3% among documented immigrants and 6.4% among U.S. natives, p<0.001). Filler users had higher odds of engaging in sex work ever (odds ratio [OR] 3.3, p<0.001) and in the last 6 months (OR 2.00, p=0.049). The majority of filler users (78.5%) reported a physical complication, including infectious and inflammatory responses, coagulopathies, and neuropathies. Conclusion: Filler use was high among participants, despite availability of gender-affirming care and prevalence of complications. Filler use was highest among those with social, economic, and political vulnerabilities. Thus, filler use might be associated with structural factors that reduce access to safer methods of feminization. Addressing these factors, increasing access to safe gender-affirming care, and developing protocols for filler-related complications are needed.
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Affiliation(s)
- Francesco D Sergi
- School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Erin C Wilson
- San Francisco Department of Public Health, San Francisco, California, USA
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32
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Bekeny JC, Zolper EG, Manrique OJ, Fan KL, Del Corral G. Breast augmentation in the transgender patient: narrative review of current techniques and complications. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:611. [PMID: 33987309 PMCID: PMC8105870 DOI: 10.21037/atm-20-5087] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/29/2021] [Indexed: 11/06/2022]
Abstract
Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.
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Affiliation(s)
- Jenna C. Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth G. Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
- MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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33
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Gorbea E, Gidumal S, Kozato A, Pang JH, Safer JD, Rosenberg J. Insurance Coverage of Facial Gender Affirmation Surgery: A Review of Medicaid and Commercial Insurance. Otolaryngol Head Neck Surg 2021; 165:791-797. [PMID: 33722109 DOI: 10.1177/0194599821997734] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To provide a portrait of gender affirmation surgery (GAS) insurance coverage across the United States, with attention to procedures of the head and neck. STUDY DESIGN Systematic review. SETTING Policy review of US medical insurance companies. METHODS State policies on transgender care for Medicaid insurance providers were collected for all 50 states. Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined. The largest medical insurance companies in the United States were identified using the National Association of Insurance Commissioners Market Share report. Policies of the top 49 primary commercial medical insurance companies were examined. RESULTS Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17%). Thirteen states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy. Ninety-two percent of commercial medical insurance providers had a published policy on GAS coverage. Genital reconstruction was described as a medically necessary aspect of transgender care in 100% of the commercial policies reviewed. Ninety-three percent discussed coverage of FGAS, but 51% considered these procedures cosmetic. Thyroid chondroplasty (20%) was the most commonly covered FGAS procedure. Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13% of the medical policies reviewed. CONCLUSION While certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers, potentially limiting patient access. LEVEL OF EVIDENCE Level V.
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Affiliation(s)
- Enrique Gorbea
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunder Gidumal
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Aki Kozato
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Henry Pang
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Surgery, Division of Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Rosenberg
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Center for Transgender Medicine and Surgery, Mount Sinai Health System and Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Mehringer JE, Harrison JB, Quain KM, Shea JA, Hawkins LA, Dowshen NL. Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics 2021; 147:peds.2020-013300. [PMID: 33536330 DOI: 10.1542/peds.2020-013300] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Transmasculine individuals, those assigned female sex at birth but who identify as masculine, have high rates of suicidal behavior and often suffer from chest dysphoria (discomfort and distress from unwanted breast development). Growing numbers of transmasculine youth are pursuing definitive treatment with masculinizing chest surgery (MCS), and adult studies reveal marked benefits of MCS, although little is known about the impact of chest dysphoria on transmasculine youth or the optimal timing of MCS. In this study, we aimed to explore youth experiences of chest dysphoria and the impact of MCS. METHODS Transmasculine youth aged 13 to 21 were recruited from a pediatric hospital-based gender clinic. Participants completed a semistructured qualitative interview exploring the experience of chest dysphoria and thoughts about or experiences with MCS. Interview transcripts were coded by 3 investigators employing modified grounded theory, with the median interrater reliability at κ = 0.92. RESULTS Subjects (N = 30) were a mean age of 17.5 years, and 47% had undergone MCS. Youth reported that chest dysphoria triggered strong negative emotions and suicidal ideation, caused a myriad of functional limitations, and was inadequately relieved by testosterone therapy alone. All post-MCS youth reported near or total resolution of chest dysphoria, lack of regret, and improved quality of life and functioning. CONCLUSIONS We observed consensus that chest dysphoria is a major source of distress and can be functionally disabling to transmasculine youth. MCS performed during adolescence, including before age 18, can alleviate suffering and improve functioning. Additional research is needed to develop patient-reported outcome measures to assess the impact of chest dysphoria and MCS.
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Affiliation(s)
- Jamie E Mehringer
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York;
| | | | - Kit M Quain
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | - Linda A Hawkins
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Nadia L Dowshen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.,Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Beyond the Hernia Repair: A Review of the Insurance Coverage of Critical Adjuncts in Abdominal Wall Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3309. [PMID: 33425617 PMCID: PMC7787284 DOI: 10.1097/gox.0000000000003309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/26/2020] [Indexed: 01/30/2023]
Abstract
The prevalence of complex abdominal wall defects continues to rise, which necessitates increasingly sophisticated medical and surgical management. Insurance coverage for reconstructive surgery varies due to differing interpretations of medical necessity. The authors sought to characterize the current insurance landscape for a subset of key adjunctive procedures in abdominal wall reconstruction, including component separation and simultaneous ventral hernia repair with panniculectomy (SVHR-P) or abdominoplasty (SVHR-A), and synthesize a set of reporting recommendations based on insurer criteria. Methods Insurance companies were selected based on their national and state market share. Preauthorization criteria, preauthorization lists, and medical/clinical policies by each company for component separation, SVRH-P, and SVRH-A were examined. Coverage criteria were abstracted and analyzed. Results Fifty insurance companies were included in the study. Only 1 company had clear approval criteria for component separation, while 38 cover it on a case-by-case basis. Four companies had clear approval policies for SVHR-P, 4 cover them on an individual case basis, and 28 flatly do not cover SVHR-P. Similarly, 3 companies had clear approval policies for SVHR-A, 6 cover them case by case, and 33 do not cover SVHR-A. Conclusions Component separation and soft tissue contouring are important adjunctive AWR procedures with efficacy supported by peer-reviewed literature. The variability in SVHR-P and SVHR-A coverage likely decreases access to these procedures even when there are established medical indications. The authors recommend standardization of coverage criteria for component separation, given that differing interpretations of medical necessity increase the likelihood of insurance denials.
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Panagiotakopoulos L, Chulani V, Koyama A, Childress K, Forcier M, Grimsby G, Greenberg K. The effect of early puberty suppression on treatment options and outcomes in transgender patients. Nat Rev Urol 2020; 17:626-636. [PMID: 32968238 DOI: 10.1038/s41585-020-0372-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 12/17/2022]
Abstract
In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.
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Affiliation(s)
| | - Veenod Chulani
- Department of Paediatrics, Chief of Adolescent Medicine, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Atsuko Koyama
- Department of Paediatrics, Emory University, Atlanta, GA, USA
| | | | - Michelle Forcier
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA.,Division of Adolescent Medicine, Hasbro Children's Hospital, Providence, RI, USA
| | - Gwen Grimsby
- Division of Adolescent Medicine, Departments of Paediatrics and Obstetrics/Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Katherine Greenberg
- Division of Paediatric Urology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Gadkaree SK, DeVore EK, Richburg K, Lee LN, Derakhshan A, McCarty JC, Seth R, Shaye DA. National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery. Facial Plast Surg Aesthet Med 2020; 23:270-277. [PMID: 32865436 DOI: 10.1089/fpsam.2020.0226] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% (n = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures (p = 0.043), whereas those in restrictive states offered less overall coverage (p = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.
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Affiliation(s)
- Shekhar K Gadkaree
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Elliana Kirsh DeVore
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Kayla Richburg
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Linda N Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Adeeb Derakhshan
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin C McCarty
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Seth
- Department of Otolaryngology-Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - David A Shaye
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
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Navigating the Insurance Landscape for Coverage of Reduction Mammaplasty. Plast Reconstr Surg 2020; 146:539e-547e. [DOI: 10.1097/prs.0000000000007241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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DeVore EK, Gadkaree SK, Richburg K, Banaszak EM, Wang TV, Naunheim MR, Shaye DA. Coverage for Gender-Affirming Voice Surgery and Therapy for Transgender Individuals. Laryngoscope 2020; 131:E896-E902. [PMID: 32776558 DOI: 10.1002/lary.28986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/22/2020] [Accepted: 07/10/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine insurance coverage for gender-affirming surgery and voice therapy for individuals who seek to align their voice with their gender identity, and to analyze differences based on state-by-state transgender equality. STUDY DESIGN Cross-sectional study. METHODS Policies from the top three commercial insurers per state in 2019 were reviewed. Coverage status was determined by web-based search, telephone interviews, and email inquiries. A state-by-state equality score was calculated based on the number of laws and policies relating to the transgender community. Correlation between number of preauthorized procedures and state equality scores was assessed. RESULTS Of the 150 insurance companies reviewed, only four (2.7%) held favorable policies, whereas 113 (75.8%) provided no coverage. Endoscopic surgery, open surgery, individual voice therapy, and group voice therapy interventions were equally excluded (n = 93, 62.4%). Coverage was not correlated with laws driving transgender equality (P = .782). CONCLUSIONS Gender-affirming voice interventions are seldom covered by commercial insurance companies. Despite established medical necessity and years of experience in practice, gender-affirming interventions for voice have not yet been fully considered by third-party payors. Further investigation regarding cost-effectiveness and treatment efficacy is warranted to improve insurance coverage of voice-related gender-affirming care. LEVEL OF EVIDENCE NA Laryngoscope, 131:E896-E902, 2021.
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Affiliation(s)
- Elliana K DeVore
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Shekhar K Gadkaree
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Kayla Richburg
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Elizabeth M Banaszak
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Tiffany V Wang
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Matthew R Naunheim
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - David A Shaye
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
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Ngaage LM, McGlone KL, Xue S, Knighton BJ, Benzel CA, Rada EM, Coon D, Berli J, Rasko YM. Gender Surgery Beyond Chest and Genitals: Current Insurance Landscape. Aesthet Surg J 2020; 40:NP202-NP210. [PMID: 31883267 DOI: 10.1093/asj/sjz262] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Plastic surgery plays an essential role in the treatment of gender dysphoria. International standards of care currently consider genital and chest surgeries to be medically necessary. Ancillary procedures such as facial surgery, chondrolaryngoplasty, hair restoration/removal, and body contouring are considered cosmetic surgeries except in individual circumstances. OBJECTIVE The authors sought to assess the frequency of coverage provision for ancillary transition-related surgeries through a cross-sectional analysis of US insurance policies. METHODS The authors selected insurance companies based on state enrollment data and market share. Policies were identified through web-based search and telephone interviews. A list of eligible procedures was compiled and grouped into 5 categories: body masculinization, body feminization, facial procedures, hair restoration/removal, and chondrolaryngoplasty. Medical necessity criteria from publicly accessible policies were then abstracted. RESULTS Sixty-one insurance companies held an established policy. One-third of these policies offered favorable coverage for at least 1 ancillary procedure. Chondrolaryngoplasty was the most covered category (26%, n = 16), whereas body masculinization was the least covered (8%, n = 5). Almost two-thirds of the companies with favorable policies listed coverage criteria. We identified 4 recurring requirements: age, hormone therapy, continuous living in a congruent gender role, and referral from a mental health professional. CONCLUSIONS There is a low prevalence of US insurance coverage for ancillary gender surgeries and wide variability in coverage criteria. Reevaluation of ancillary transition-related procedures from cosmetic to medically necessary based on clinical judgement or establishment of defined coverage criteria may augment coverage and better address the needs of transgender patients.
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Affiliation(s)
- Ledibabari M Ngaage
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | | | - Shan Xue
- Medical College of Georgia, Augusta, GA
| | | | | | - Erin M Rada
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jens Berli
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR
| | - Yvonne M Rasko
- Division of Plastic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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