Clinical and Socio-Economic Determinants of Gender Affirmation Surgery
Victor Vakayil, MD, MS, MPH, Nicholas Kim, MD, Umar Choudry, MD.
University of Minnesota, Minneapolis, MN, USA.
PURPOSE:All transgender individuals do not undergo gender affirmation surgery(GAS). We characterize the demographic, clinical and socio-economic determinants of GAS. METHODS:We retrospectively analyzed the National Inpatient Sample from 1998-2015 to identify all individuals with a diagnosis of gender dysphoria using ICD-9/10 codes. Subsequently, patients were stratified into gender-specific, top(chest/breast) and lower(genital) surgical cohorts. Multi-level, mixed-effect, logistic regression models were constructed to estimate the independent, fixed-effects of various clinical, demographic, socio-economic factors, adjusting for geographical and institutional variation in healthcare as random effects. Additionally, we evaluated temporal trends in inpatient, transgender healthcare utilization.RESULTS:9483 transgender patients were identified over 17 years. Overall incidence of inpatient healthcare utilization significantly increased, 3.5 times from 1998(4.4/100,000 hospitalizations) to 2015(15.3 /100,000,P= 0.01), 11.1%(N=1131) of all encounters involved GAS. There was significant geographical variation with more than half the procedures being performed on the West coast(53%), at non-academic urban hospitals(51%); less than 13% were performed rurally. Lower household income(OR 0.6,P=0.002), presence of comorbidities such as AIDS(OR 0.1), depression(OR 0.7), alcohol and drug abuse(OR 0.1) were negative predictors of GAS, while increased age(OR 1.02) and private insurance status & self-pay(OR 3.4) were positive predictors. Trend analysis noted that mean patient age for GAS decreased over the last 5 years, while federal and private insurance coverage increased.
CONCLUSION:Increased inpatient health utilization rates, coupled with increased insurance coverage may increase the demand for GAS. Various clinical and socio-economic factors affect transgender health & contribute to their decision to surgically transition. Understanding these factors will help improve the care they receive.
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