Socioeconomic Drivers of Gender Affirmation Surgery: An Analysis of the 2015 USTS Transgender Survey Database
Victor Vakayil, MBBS, MS, Zachary Miller, BS, Marie-Claire Buckley, MD, Umar Choudry, MD, Nicholas Kim, MD.
University Of Minnesota, Minneapolis, MN, USA.
PURPOSE: Gender affirmation surgery (GAS) can improve self-esteem, functioning, and quality of life among those with gender dysphoria. Despite these long-term benefits, some patients have not undergone GAS. Using a national database, we elucidate individual-level factors associated with surgical transitioning and evaluate socio-economic determinants of GAS.
METHODS: We abstracted data from the United States National Center for Transgender Equality's: 2015 Transgender Survey Public Use Dataset, which included over 27,700 respondents from all fifty states within the US. All respondents who self-identified as transgender or gender non-binary were included in our analysis and those who identified as cross-dressers were excluded. Individuals were compared after stratifying them into two cohorts; those who underwent GAS and those who did not. We performed a univariate analysis and constructed multilevel, logistic regression models to estimate the independent, fixed-effect of various clinical, demographic and socio-economic determinants, adjusting for geographical variation in healthcare as random-effects.
RESULTS: A total of 26,957 individuals were included in our analysis and overall 21.3% (N=5729) underwent GAS. Among those Assigned Female At Birth (AFAB, 58.7%, N=15,817), 21.8% (N=3314) underwent GAS, 73.6% (N=11,209) desired GAS, while 4.6% (N=708) categorically chose not to surgically transition. Among those Assigned Male At Birth (AMAB, 41.3%, N=11,140), 21.9% (N=2315) underwent GAS, 77.5% (N=8191) desired GAS, while 0.6%(N=60) chose not to surgically transition. Mastectomies (34.5%, N=2744), hysterectomies (12.8%, N=1021) and phalloplasties (2.5%, N=200) were the most common surgical procedures undergone by trans-men. Vaginoplasties (13.1%, N=1207), orchiectomies (11.5%, N=1062) and breast augmentation (9.3%, N=855) were the most common surgical procedures undergone by trans-women. We observed significant geographical clustering among individuals receiving GAS, with higher rates along the East and West coasts of the US (Z=2.2, P=0.029). On univariate analysis, those who had not surgically transitioned tended to be younger, of minority ethnicity, AFAB, and with poorer socio-economic indicators (all P <0.05). Multilevel analysis demonstrated increased age (OR=1.1, P<0.001), Caucasian race (OR=1.5, P=0.016), visual conformity (OR=2.0, P<0.001) and receiving psychotherapy (OR=1.8, P<0.001) and hormonal therapy (OR=2.1, P<0.001) to be independently associated with an increased odds of surgically transitioning, while a non-binary gender identity (OR=0.5, P<0.001), lower education and income (OR=0.6, P<0.001), lack of health insurance that covers GAS (OR=0.1, P<0.001), and a pansexual orientation (OR= 0.7, P<0.001) were independently associated with lower odds of surgically transitioning (Table 1).
CONCLUSION: Overall, 21.3% of respondents had undergone GAS, and greater than 97% of respondents desired some form of surgery for gender congruence. Only less than 3% of respondents indicated that they did not want any surgical therapy. We demonstrate that demographic and modifiable socio-economic drivers of healthcare can explain a significant amount of heterogeneity surrounding the variable rates of surgical transitioning. Targeting these factors, such as expanding insurance coverage and instituting appropriate healthcare policy will help improve the care we provide to this patient population.
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