Objective:
While gender-affirming surgeries are becoming more widely performed, few studies have examined any temporal correlation between legislations mandating transgender care and the actuation of such surgical care.
Methods:
-Retrospective review of the National Inpatient Sample (NIS) database from 2000 to 2018
-Diametrically opposite regions (Divisions 1 & 2 vs. Divisions 6 & 7) were selected and compared.
-Division 1 & 2 states mandate explicit inclusion of gender-affirming care.
-Division 6 & 7 states mandate explicit exclusion or have no explicit statement of gender-affirming care.
-We segregated all major payers in NIS into two groups:
1.those impacted by state-specific legislature, (Medicaid and private insurance)
2.those not impacted by state-specific legislature, (Medicare and self-pay)
Statistics:
-Annual temporal trend analysis utilized
-A smoothed linear regression model
-A non-parametric Mann-Kendall trend test
-Interrupted time series analyses
-Impact of policy change mandating transgender care
-Segmental regression to estimate the longitudinal impact after 2015
Results:
-In states with explicit inclusion of gender-affirming care, a significant increase in the number of patients on state-dependent insurance receiving gender affirming surgeries occurred when states began mandating care and thereafter.
-This significance was not seen in any regions among patients under non-state-dependent payers.
Regions of Insurance Coverage:
Hospital census divisions as categorized by the National Inpatient Sample database
Interrupted Time Series Analysis:
A significant increase in the number of patients covered under state legislation-dependent insurance (Medicaid and private insurance) receiving gender affirming surgeries around the time during which state legislations began mandating care and in the years thereafter (both p<0.01).
Conclusions:
-The impact of expansion of coverage for gender-affirming surgery on its utility within specific regions of the United States cannot be understated.
-Within a geographical region, only the population covered by state-specific insurance carriers exhibited any uptick in utilization of transgender surgical care if there were state legislative mandates in place.
-A direct correlation was seen between the utility of gender-affirming surgery and the enactment of legislation ensuring coverage of these surgeries.
-Transgender patients may be less likely to receive gender-affirming surgery simply due to their state’s legislature.
-More work must be done to ensure that transgender patients are not disadvantaged simply due to the state in which they reside and its corresponding legislature.
