The number of gender-affirming surgeries performed in the United States nearly tripled between 2016 and 2019, a trend driven in part by changes in federal and state laws mandating coverage of the procedures, a new study published in JAMA Network Open found.
Breast and chest surgeries were the most common procedures performed, and the number of surgical procedures carried out increased with age. The researchers said that in addition to legal shifts, the established safety of the surgeries and resulting increase in quality of life may also help explain the increase.
"The point of this is to raise awareness and to really document the patterns of care in the United States," said Jason Wright, MD, an associate professor at Columbia University Vagelos College of Physicians and Surgeons in New York City. "We hope that people understand that these procedures are being performed more commonly and they're out there."
A study published last year in JAMA Pediatrics found that the number of chest reconstruction surgeries among US adolescents rose fourfold between 2016 and 2019.
The new study included data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. More than 48,000 patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified. Age ranges were grouped as 12-18 (7.7%), 19-30 (52.3%), and 31-40 (21.8%).
The number of gender-affirming procedures rose from 4552 in 2016 to a peak of 13,011 in 2019. (A slight decline to 12,818 procedures in 2020 was attributed to the COVID-19 pandemic.) The surgeries were grouped into three categories: breast and chest procedures, which occurred in 56.6% of patients; genital reconstructive surgeries (35.1%), and other facial cosmetic procedures (13.9%).
"We really wanted to try to make this as representative as we could," Wright said. "I think this is really the best estimates that are available to date."
Chest and breast procedures made up a higher percentage of surgeries in younger patients, while genital surgical procedures made up a higher percentage in older patients. For example, patients aged 19-30 made up 59.1% of breast or chest surgeries and 44.2% of genital surgeries. However, those aged 31-40 accounted for 26.2% of genital surgeries and 18.1% of breast or chest surgeries. For ages 41-50, the spread was more than double, accounting for 12.8% of genital surgeries and only 6.1% of breast or chest surgeries, according to the researchers.
In addition to more inclusive health insurance, Wright said the increase in these procedures can also be attributed to studies showing their safety and the long-term association with high patient satisfaction.
Kevin Wang, MD, medical director of Providence–Swedish Health Services' LGBTQIA+ program in Seattle, agreed that changes in health insurance coverage for gender-affirming surgery likely account in part for their increase. But he added that more clinicians are performing these procedures.
He said gender-affirming surgeries improve quality of life for the people who undergo them. The American Academy of Pediatrics has said it would be conducting a thorough review of the effects of transgender care on youth. A 2018 policy statement from the group said transgender youth should "have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space."
Wright cited several limitations to his group's study that may result in the under-capture of transgender individuals and gender-affirming surgery, including this one in particular: even though the study captured inpatient and ambulatory surgical procedures in large, nationwide datasets, a small number of the procedures could have been performed in other settings.
Guiding a patient through gender-affirming care and surgical procedures can be an arduous process, including understanding their goals, using hormone therapy, and making referrals to specialists. Wang said he works to maximize his patients' physical, mental, and emotional health, and helps them understand the risks.
He cited the double standard of a cisgender woman wanting breast augmentation without justification, but someone who identifies as transgender has many more boxes to check — for example, seeing a behavior health specialist to demonstrate they understand the risks and securing a letter of support from their primary care physician to undergo a similar procedure.
"It's just interesting how the transgender community has to jump through so many more barriers and hoops for affirming, life-saving procedures where you have other people who are doing it for aesthetic purposes and do not require any type of authorization," Wang said.
Wright said he hopes the findings call attention to the need for more professionals working in the gender-affirming care field.
"I think for the medical community, it's important to raise the idea that these procedures are becoming more common," Wright said. "We are going to need specialists who have expertise in transgender care and surgeons who have the ability to perform these operations. Hopefully, this sheds light on the resources that are going to be required to care for these patients going forward."
Wright reported receiving grants from Merck and personal fees from UpToDate outside the submitted work. No other disclosures were reported.
JAMA Netw Open. Published online August 23, 2023. Full text
Robert Fulton is a journalist living in California.
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Cite this: Gender-Affirming Surgeries Nearly Tripled Between 2016 and 2019: Study - Medscape - Aug 29, 2023.