Gender-Affirming Surgery Gets a Boost After California Law Kicked In

Gender-affirming surgeries in California increased sharply compared with nearby states following California's passage of the Insurance Gender Nondiscrimination Act, which was implemented in July 2013, according to a population epidemiology study.

From that point through the end of 2019, the probability of a transgender or gender-diverse patient undergoing gender-affirming surgery in California increased by 12.1% compared with Arizona and Washington, which were used as control states (95% CI 10.3-13.9, P<0.001), reported Anna Schoenbrunner, MD, of the Ohio State University in Columbus, and colleagues.

This difference following implementation of the law -- which prohibits insurers and health plans in California from limiting benefits based on a patient's sex, gender, gender identity, or gender expression -- was observed only for patients with private insurance or Medicaid, but not self-pay patients, the group detailed in JAMA.

"We actually saw that there were fewer people paying out of pocket in the self-pay group and more being insured," Schoenbrunner told MedPage Today. "So, to me, that indicates that the policy, in addition to the Affordable Care Act with Medicaid expansion, is effective in the sense that more people are being insured, and those insurers are covering these procedures."

Of the nearly 18,000 patients with gender dysphoria from California during the full study period from 2005 to 2019, 5.1% of insured patients underwent gender-affirming surgeries in the period before the law's implementation (2005 to June 2013) versus 16% afterward. In the control states, these rates were 3.4% and 1.7%, respectively, for the two periods.

"I think the findings are robust enough and ... the timing of it is so coincidental with the passage of the policy that it's really hard to argue that there may be something else going on here besides the policy," co-author Adrian Diaz, MD, MPH, also of the Ohio State University, told MedPage Today.

The 2013 California policy stemmed from a practice by insurers being able to deny a prior authorization for gender-affirming surgeries, even if physicians determined the surgeries to be medically necessary. A 2013 article in the Hastings Women Law Journal noted that insurance companies routinely classify transgender status as a preexisting condition exempt from treatment, or classify gender-confirming treatments as "cosmetic or elective because they seek to change anatomy that is considered normal and functional."

Similarly, the Transgender Law Center noted "an alarmingly high rate" of transgender patients denied coverage for essential healthcare, with 15% denied gender-specific care such as Pap smears or prostate exams because the patients were transgender. Under the new policy, "California health plans and insurers cannot arbitrarily deny medically necessary services provided to other policy holders or members simply because the patient is transgender," the center explained.

But 27 states still have no law that provides LGBTQ inclusive insurance protections, and Arkansas explicitly permits this insurance discrimination, according to the Movement Advancement Project. "California is just one state, and these patients are all across the country," said Diaz. "So we do need more states that are willing to protect the rights of these patients."

"It's actually quite a ... hopeful study in some sense," Schoenbrunner said of the findings. "We can see that there have been some efforts made in some states to improve and protect access to this care, and that the effect is as intended, meaning that more patients are able to access the surgical gender-affirming care that they need."

The study population included 17,934 adult patients from California and 7,328 from the control states with a gender dysphoria diagnosis, who were admitted to a hospital in their state for any reason, and were residents of their respective state.

Of those, 2,715 in California had at least one gender-affirming surgery -- defined as undergoing at least one facial, chest, or genital procedure -- from 2005 to 2019, with 2,384 occurring after the law's implementation and 331 during the pre-implementation period (2005 to June 2013). In control states, a total of 203 surgeries occurred, with a similar number for the two periods (101 and 102).

Following implementation of the law, the number of gender-affirming surgeries in California increased to 5.7 per quarter (95% CI 5.3-6.2), as compared with 0.41 surgeries per quarter (95% CI 0.24-0.57) in the control states.

The study used data from the California Department of Health Care Access and Information discharge database and Healthcare Cost and Utilization Project State Inpatient Database for Washington and Arizona. In California, the median age for those who did and did not undergo surgery was 34, and a higher proportion of those who underwent surgery reported their sex as female (56.4%). In Arizona and Washington, patients who underwent surgery had a higher median age at 39, and those who did not had a median age of 36.

Limitations of the study, the researchers said, included administrative data confounders like noncoded procedures or gender dysphoria diagnoses, any general underreporting of diagnosis and surgery because of the general controversy over this area of care, and evaluation of a single state that can't be generalized to others.

In addition, the team noted, the states' databases were different, the number of centers offering gender-affirming surgeries differed by state, there was a lack of information about whether or not residents of those three states traveled to other states to receive care, and what the authors called "ecological trends independent of nondiscrimination legislation as gender diversity becomes more recognized in society, especially in states like California."

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