“Early on we recognized there’s been a lot of work on health disparities having to do with age, race and so on that get collected in health-care settings,” said Brandyn Lau, an assistant professor of surgery and health sciences informatics at the Johns Hopkins University School of Medicine. “One of the things we need to know is whether [lesbian, gay and transgender] patients are getting the same care.”
Lau and other researchers from Johns Hopkins Medicine and Harvard University analyzed 15 years of data from the National Inpatient Sample, a collection of hospital inpatient information from across the country, and found a total of 4,118 gender-affirming surgeries.
The majority of the surgeries that occurred between 2000 and 2011 involved patients not covered by health insurance. About half of the transgender patients in the study paid out of pocket between 2000 and 2005. That number rose to 65 percent between 2006 and 2011. However, the trend reversed between 2012 and 2014, with the number plummeting to 39 percent. Much of that decrease, the study's authors say, is because of Medicare and Medicaid. In May 2014, Medicare ended its 33-year ban on transgender surgeries.
Loren Schechter, who specializes in transgender surgeries, says he does about 300 procedures a year, whereas it was only about 50 in 2000. The plastic surgeon also accepts Medicare, which others do not.
“I would say 85 to 90 percent of [my] procedures are covered now by insurance,” he said.
Virtually every major medical association in the United States has described transition-related surgeries as “medically necessary” for both the physical and mental health of transgender people. They also have stipulated that health insurance coverage for such operations should be no less available than it is for other types of surgery.
In the United States, there has been substantial growth in the number and types of insurance coverage for transgender surgical procedures over the past 10 years. These include not only Medicare, but state-sponsored private plans and employment insurance coverage.
“These changes are driven by a growing expert consensus on the medical necessity of gender transition, new legal interpretations prohibiting insurance discrimination against transgender people, and mounting evidence that transgender-inclusive coverage is cost-effective,” Kellan Baker of the Johns Hopkins Bloomberg School of Public Health wrote in the New England Journal of Medicine last year.
Few studies have been done in the United States looking at outcomes of surgeries for transgender men and women. Many more, however, and much larger ones, have been conducted in Europe. In 2014, a study published in Deutsches Arzteblatt, the German Medical Association's official bilingual science journal, found that 90.2 percent of 119 transgender women said that “their expectations for life as a woman were fulfilled postoperatively.”
Section 1557 of the Affordable Care Act barred discrimination on the basis of gender identity and helped ensure that more transgender men and women would be covered for surgical procedures, including genital reconstruction. Health-care advocates are concerned that the Trump administration's Department of Health and Human Services will not enforce this policy.
“There's going to be rough sailing ahead,” Schechter said. “There is concern in the community and among providers that many of the gains already made are in jeopardy.”