Centering Transgender and Nonbinary Voices in Genital Gender-Affirming Surgery Research Prioritization

Improving access for and experience of transgender and non-binary patients in clinical research: Insights from a transgender patient focus group and targeted literature reviews

INTRODUCTION

The transgender and non-binary communities make up a significant, growing proportion of the population, but, to date, few clinical trials report including transgender and non-binary individuals.

METHODS

As part of a mixed-method approach, multiple literature searches for articles published from January 2018 to July 2022 and a Patient Advisory Council (a semi-structured patient focus group) meeting were conducted to identify challenges faced by the transgender and non-binary communities when accessing healthcare and participating in clinical research. A set of guidelines to promote inclusivity in clinical research was developed using these findings.

RESULTS

During this time period, only 107 (0.08%) of 141,661 published articles of clinical trials reported participation of transgender or non-binary patients. A targeted search identified only 48 articles reporting specific barriers to inclusion in clinical research, while an expanded search identified 290 articles reporting barriers to healthcare access for transgender and non-binary patients. Several key considerations to promote study inclusivity emerged from the literature searches and Patient Advisory Council: adjust clinical protocols, informed consent documents, and data collection forms to distinguish sex assigned at birth from gender identity; involve members of the transgender and non-binary communities in research whenever possible; provide communication training to personnel involved in clinical research; and maximize accessibility for potential participants.

CONCLUSION

Future research on investigational drug dosing and drug interactions in transgender and non-binary patients, along with regulatory guidance, are recommended to ensure clinical trials' processes, designs, systems, and technologies are transgender and non-binary patient-friendly, inclusive, and welcoming.

Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US

Importance

Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level.

Objective

To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient's state of residence.

Design, Setting, and Participants

This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021.

Exposures

Vaginoplasty and phalloplasty.

Main Outcomes and Measures

The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models.

Results

The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence.

Conclusions and Relevance

In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.