D. Dai1, B. Charlton2, E. Boskey3, L. Hughes4, J. Hughto5, E. J. Orav6, J. Figueroa1 1Harvard T.H. Chan School of Public Health, Department Of Health Policy And Management, Boston, MA, USA 2Harvard Medical School and Harvard Pilgrim Health Care Institute, Department Of Population Medicine, Boston, MA, USA 3Boston Children’s Hospital, Division Of Gynecology, Boston, MA, USA 4Harvard T.H. Chan School of Public Health, Departments Of Behavioral And Social Sciences And Epidemiology, Boston, MA, USA 5Brown School of Public Health, Department Of Behavioral And Social Sciences And Epidemiology, Boston, MA, USA 6Harvard T. H. Chan School of Public Health, Department Of Biostatistics, Boston, MA, USA
Introduction:
Recently, there has been an increase in legislative efforts restricting gender-affirming care for transgender and gender diverse (TGD) minors stemming from concerns that TGD people, specifically minors, are commonly utilizing gender-affirming surgeries (GAS). However, under stringent clinical standards, the use of GAS by TGD minors is expected to be exceedingly low. Because there are no prior national empirical characterizations, we evaluated the extent to which TGD minors and adults received GAS. We also compared the relative use of breast reduction surgery by TGD people and cisgender males given that breast reduction can be considered GAS and covered by insurance for both groups, but is only under regulatory consideration for TGD people.
Methods:
We used the Real-World Data from Inovalon Insights from 2019, which captured medical claims of insured populations. We identified TGD people who received a GAS using validated sets of diagnostic and procedural codes. We then calculated the rate of GAS with a TGD-related diagnosis per 100k total people across age groups. Next, we compared the proportion of breast reductions utilized by cisgender males— defined as males without a TGD-related diagnosis— and TGD people. Across this study, surgeries on intersex people and those with specific medical indications for surgery (e.g., cancer) were excluded.
Results:
The sample included 47.4M insured adults and 22.8M insured minors, of which 3.8M minors were aged 15–17, 2.7M were aged 13–14, and 16.3M were aged ≤12. The rate of undergoing GAS with a TGD-related diagnosis was 4.7 per 100k total adults compared to 1.8 per 100k minors aged 15–17, 0.1 per 100k minors aged 13–14, and 0 surgeries among minors aged ≤12. Of GAS among adults and minors with a TGD-related diagnosis respectively, 58% and 94% were chest-related surgeries.
Of the 450 breast reductions among cisgender male and TGD adults, 78% were performed on cisgender males; and of the 116 breast reductions among cisgender male and TGD minors, 97% were performed on cisgender male minors.
Conclusion:
Among a national insured population in 2019, there were no gender-affirming surgeries conducted on TGD minors aged 12 years and younger, and surgeries on TGD minors older than 12 were rare. Low utilization likely reflects adherence to stringent clinical standards of care. Additionally, when considering breast reductions—a procedure that can be considered gender-affirming when used by cisgender males or TGD people—we found that the vast majority were performed on cisgender males. Taken together, these findings suggest that concerns around high rates of utilization of gender-affirming surgery, specifically on TGD minors, are unwarranted.
