Utilization and Costs of Gender-Affirming Care in a Commercially Insured Transgender Population

Gender-Affirming Surgery for Transgender and Gender Diverse Medicare Beneficiaries

Importance

Medicare covers gender-affirming surgical procedures on a case-by-case basis. The proportion of Medicare beneficiaries who receive gender-affirming surgical procedures is unknown.

Objective

To examine the frequency and trends of gender-affirming surgical procedures for Medicare beneficiaries.

Design, Setting, and Participants

This cross-sectional study used national Medicare data to analyze transgender and gender diverse beneficiaries' use of gender-affirming surgical procedures from January 1, 2016, to February 29, 2020, as well as use of the same surgical procedures by beneficiaries not identified as transgender. Transgender Medicare beneficiaries were identified using a claims-based algorithm; nontransgender individuals were selected using propensity score matching. Analyses were conducted from November 2022 through October 2024.

Exposures

Race and ethnicity, Medicare-Medicaid dual status, age, original reason for Medicare entitlement, geographic area, and chronic conditions.

Main Outcomes and Measures

Descriptive analyses and generalized estimating equations were used to assess gender-affirming surgical procedures and beneficiary characteristics associated with surgical procedures.

Results

This study included transgender individuals (mean [SD] age, 60.0 [18.6] years; 43.2% transfeminine individuals, 33.0% transmasculine individuals, and 23.9% individuals with unclassified gender) and individuals (mean [SD] age, 62.7 [21.0] years; 55.5% women and 44.5% men) not identified as transgender. Of 142 703 total person-years, there were 2156 instances of transgender individuals having at least 1 gender-affirming surgical procedure in the calendar year. The rate of individuals receiving at least 1 surgical procedure decreased from between 2.1% and 2.2% in 2016 and 2017 to 1.4% in 2018 and 2019. There was substantial variability in surgical procedures across beneficiary characteristics. Transgender beneficiaries who underwent surgery were younger (31-40 years vs 61-65 years: adjusted odds ratio [AOR], 1.91 [95% CI, 1.55-2.34]) and had higher enrollment in Medicaid (AOR, 1.14 [95% CI, 1.02-1.26]), higher rates of chronic conditions (≥10 conditions vs 0: AOR, 2.10 [95% CI, 1.79-2.46]), and higher proportions of residents on the West Coast (Alaska, Idaho, Oregon, and Washington) vs the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) (AOR, 1.30 [95% CI, 1.05-1.61]) compared with those who did not undergo surgery. Geographically, the largest difference was observed when comparing the Northeast with the Southeast (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee) (AOR, 0.70 [95% CI, 0.58-0.86]; P < .001) and other parts of the South (Arkansas, Louisiana, New Mexico, Oklahoma, and Texas) (AOR, 0.56 [95% CI, 0.44-0.71]; P < .001). There was no significant difference in receipt of surgical procedures across regions for those not identified as transgender.

Conclusions and Relevance

This cross-sectional study of the Medicare program found that gender-affirming surgical procedures were very rare, particularly for those who were older, were not dually enrolled in Medicare and Medicaid, and who resided in the South. Although there were substantive regional differences in receipt of gender-affirming surgical procedures among transgender Medicare beneficiaries, beneficiaries not identified as transgender did not experience regional differences. Further study is warranted to examine barriers to accessing gender-affirming surgery for transgender and gender diverse beneficiaries.

Utilization and Cost of Gender-affirming Surgery in the United States From 2012 to 2019

OBJECTIVE

To characterize the trends in and characteristics associated with the utilization and cost of gender-affirming surgery (GAS) in the United States from 2012 to 2019.

BACKGROUND

GAS is one option among gender-diverse (GD) people to transition from their biological anatomy to the anatomy congruent with their gender. Little is known about its utilization and cost trends and whether patient and hospital characteristics are associated with differences in utilization and cost.

METHODS

This serial cross-sectional study collected retrospective data from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), a representative pool of inpatient visits in the United States. Records from 2012 to 2019 that indicated ages 18 or older, GD diagnoses, and GAS procedures were identified using the International Classification of Diseases , Ninth and Tenth Revisions. Within this cohort, demographics, utilization, and cost were collected and analyzed using descriptive statistics and multivariable regression models.

RESULTS

A total of 6325 records with GD diagnoses and GAS procedures were identified. From 2012 to 2019, utilization increased by more than 5-fold (0.9-5.0 per 100,000 records among all records), and the mean, inflation-adjusted cost increased by 36% ($19,451 to $26,517). This cost trend was similar by type of surgery, and genital surgery had consistently higher costs than chest surgery from 2012 to 2019 (genital: $21,487-$26,712, chest: $13,238-$21,309). Lower odds of utilization were found in records with Medicaid (OR = 0.27, 95% CI [0.22-0.35], P <0.001) and Medicare (OR = 0.15, 95% CI [0.11-0.23], P <0.001) compared with private insurance, as well as those in the lowest income quartile (OR = 0.68, 95% CI [0.54-0.85], P <0.001) compared with the highest quartile. Lower costs were found in records that indicated hospital location in the Midwest (27% lower, 95% CI [0.61-0.87], P <0.001), Northeast (34% lower, 95% CI [0.55-0.80], P <0.001) and South (39% lower, 95% CI [0.53-0.71], P <0.001) compared with the West.

CONCLUSIONS

As demand for GAS increases with varying utilization and costs based on patient and hospital characteristics, there will likely be a need for more qualified surgeons, increased insurance coverage, and policies to ensure equitable access to GAS.

Communicating with transgender people within health care settings: clinical perspectives

Transgender persons need to regularly interact with health services and practitioners for both gender-transition purposes and routine care. Communication between clinicians and patients is a key element of health care. However, barriers to communication with transgender people in the health care context are usual. They typically include a lack of willingness among health staff to care for trans patients, an adherence to cisnormativity and misgendering by clinicians, and the existence of a displeasing climate during the interaction. Miscommunication generates a series of adverse consequences, including the avoidance of health care by patients and the social marginalization of transgender people. The implementation of novel health policies and organizational restructuring are important steps to create a safe environment for the trans population within health systems. Modification of administrative procedures as well as training and advice for health practitioners are also necessary to facilitate communication with trans people and improve health outcomes among this underprivileged population. The establishment of a society with equal rights among its members and a life without discriminations is the ultimate goal.

Systemic transphobia and ongoing barriers to healthcare for transgender and nonbinary people: A historical analysis of #TransHealthFail

Transgender (T+) people report negative healthcare experiences such as being misgendered, pathologizing gender, and gatekeeping care, as well as treatment refusal. Less is known about T+ patients' perceptions of interrelated factors associated with, and consequences of, negative experiences. The purpose of this analysis was to explore T+ patients' negative healthcare experiences through Twitter posts using the hashtag #transhealthfail. Publicly available Tweets published between July 2015 and November 2021 from US-based Twitter accounts were collected via Mozdeh. Tweets were deductively analyzed for content using a list of a-priori codes developed from existing literature. Additional codes were developed as new ideas emerged from the data. When possible, type of care location, providers interacted with, and initial reason for seeking care were extracted. Each Tweet was coded by at least two team members using NVivo12. A total of 1,340 tweets from 652 unique Twitter users were analyzed. Negative experiences were reported across healthcare settings and professional types, with physicians, nurses, and counselors/therapists being named most frequently. Primary antecedents of negative healthcare experiences and barriers to accessing care were related to health insurance issues and providers' lack of knowledge, discomfort, and binary gender beliefs. Negative healthcare interactions led T+ patients to perceive receiving a different standard of care and having unmet needs, which could lead to delaying/avoiding care in the future. As such, these results highlight the potential for direct and indirect harm related to providers' specific actions. Patient strategies to prevent and/or manage negative encounters and care facilitators were also identified. A multi-pronged approach addressing healthcare policy, improving knowledge and attitudes of healthcare providers and ancillary staff, and creating clinical settings that are physically and psychologically safe for T+ patients is critical to improving the healthcare experiences, and ultimately health, of T+ people.

Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature

The Cass Review's final report, published in April 2024, made recommendations to the UK's National Health Service regarding structuring of services for minors with gender-related distress. It recommended cautious use of hormonal interventions in this population and use of research protocols. Some clinician-researchers disagree with the Cass Review's recommendations and have written critiques. A critique of the Cass Review posted on Yale Law School's website in July 2024 has received extensive media coverage. Its references identified three other critiques. In these papers, there were multiple claims that were incorrect or that lacked essential clarification/contextualization. These claims involved (1) the Cass Review's contents and processes; (2) the pediatric transgender healthcare evidence base; (3) existing clinical practice guidelines, including claims that there is international medical consensus; (4) evidence-based medical practice and guideline development; and (5) conclusions regarding the validity of the Cass Review's findings. The Cass Review's careful, balanced investigations and judgments were a comprehensive, evidence-based response to the controversies in this pediatric clinical arena. Recently-published critiques of the Review have contained incorrect or inadequately contextualized claims. Because accurate information about medical interventions is essential to informed consent, it is important to correct errors in potentially influential publications.

Navigating payment and policy barriers to gender-affirming care for transmasculine individuals: A qualitative study and policy assessment

Over the past decade, access to and insurance coverage for gender-affirming medical and surgical treatment for transgender (trans) individuals in the U.S. has improved. Despite this, trans individuals continue to experience insurance-related barriers to gender-affirming care (GAC)-and in particular, transmasculine individuals may face gender-specific barriers resulting from regulations on masculinizing hormones. In this study, we interviewed transmasculine individuals from across the U.S. about their gender-affirming care experiences with a focus on insurance, payment and policy-related barriers to care. Interviews were conducted via video-conferencing software, analyzed using a codebook approach to thematic analysis, and contextualized within a broader analysis of the policy landscape dictating coverage for gender-affirming care. Participants reported insurance denials for gender-affirming care, as well as challenges with prior-authorization requirements, letter requirements, restrictive formulary lists and other challenges that complicated and/or barred access to care. Many discussed adaptive strategies to these challenges, which included utilizing community resources and knowledge, as well as receiving material support from family, friends, and partners, and developing technical and interpersonal savvy skills in response to insurance challenges. Participants expressed a range of emotional responses with regard to payment and related challenges, from annoyance and frustration to hopelessness. Our findings illuminate the persisting challenges that transmasculine individuals face when attempting to access and pay for gender-affirming care, despite improvements in insurance coverage and legal protections in recent years resulting from the Bostock ruling by the Supreme Court and the expansion of the ACA's Section 1557.

Five-Year Fracture Rate for Transgender and Gender Diverse Patients on Gender-Affirming Hormone Therapy

INTRODUCTION

Gender-affirming hormone therapy (GAHT) is a cornerstone of gender-affirming care for transgender and gender diverse (TGD) patients, with a direct biological role on bone metabolism. However, a paucity of data describes how GAHT influences fracture rate over time. The study's primary objective was to describe the 5-year all-cause fracture incidence rate (IR) among TGD patients initiating estrogen-based GAHT (E-GAHT) or testosterone-based GAHT (T-GAHT), compared with TGD patients not using GAHT (non-GAHT).

METHODS

This retrospective cohort study of TGD adults aged 18 to 65 years used insurance data from the Merative MarketScan Commercial Database (MarketScan) from January 1, 2009, to December 31, 2019. The main outcome was IR (IR with 95% confidence intervals [CIs]) of all-cause fracture after up to 5 years of follow-up. The IR ratio was estimated by comparing E-GAHT and T-GAHT groups with the non-GAHT group. Cox proportional hazards regression models estimated the hazard ratio (HR) of fracture after adjusting for age, comorbidity status using Charlson Comorbidity Index (CCI), recent fractures, and study start year.

RESULTS

Nine thousand six hundred ninety-six TGD adults (E-GAHT [n = 1,131]; T-GAHT [n = 1,046]; non-GAHT [n = 7,519]) were identified using clinical and enrollment criteria. No differences in age (mean age [SD], 33.4 [13.2] years, 30.8 [11.7] years, and 33.2 [13.6] years, respectively) and CCI (percent with CCI = 0 [%CCI = 3+]; 86.7% [2.2%], 84.9% [1.4%], and 85.3% [1.9%]) were observed by group. The fracture IR was 13.9 (95% CI, 9.1 to 18.8) for E-GAHT, 15.3 (95% CI, 10.1 to 20.4) for T-GAHT, and 19.2 (95% CI, 16.9 to 21.4) for non-GAHT. Compared with non-GAHT, the crude IR ratio and fully adjusted HR was 0.73 (95% CI, 0.51 to 1.04) and 0.71 (95% CI, 0.49 to 1.02), respectively, for E-GAHT and 0.80 (95% CI, 0.56 to 1.14) and 0.78 (95% CI, 0.55 to 1.12), respectively, for T-GAHT.

CONCLUSION

Based on United States commercial claims data, the use of GAHT was not associated with 5-year all-cause fracture IR.

LEVEL OF EVIDENCE

III.

Receipt of Gender-Affirming Surgeries Among Transgender and Gender Diverse Veterans

BACKGROUND

Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package.

OBJECTIVE

To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries.

DESIGN

Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023.

PARTICIPANTS

A total of 6653 Veterans (54% response rate) completed the survey.

MAIN MEASURES

Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region.

KEY RESULTS

Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery.

CONCLUSIONS

GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.

Impact of Anti-Discrimination Legislation on Access to Gender-affirming Care: A Commercial Claims Analysis

OBJECTIVE

To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services.

METHODS

We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services.

RESULTS

There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%).

CONCLUSION

Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services.

Association between genital gender-affirming surgery and psychiatric comorbidities in individuals with gender incongruence

BACKGROUND

Previous studies present mixed evidence on the relationship between psychiatric comorbidities and genital gender-affirming surgery (GGAS) in individuals with gender incongruence (GI).

AIM

This research aims to investigate the psychiatric comorbidity rates post-GGAS in the GI population-namely, depressive disorders, anxiety disorders, posttraumatic stress disorders, substance abuse disorder, and suicidality.

METHODS

Based on the TriNetX health care database, an international database with >250 million patients, a cross-sectional study was executed comparing psychiatric comorbidity rates among cases of GI with and without GGAS. Individuals were matched for demographic and health-related variables, which included history of cardiovascular disease, diabetes, and obesity.

OUTCOMES

The main focus was to establish the rates and changes in psychiatric comorbidities following GGAS.

RESULTS

Among individuals with GI, the study identified 4061 with GGAS and 100 097 without. At 1 year post-GGAS, there was a significant decrease in depression (odds ratio [OR], 0.748; 95% CI, 0.672-0.833; P < .0001), anxiety (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), substance use disorder (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), and suicidality (OR, 0.530; 95% CI, 0.425-0.661; P < .0001), and these reductions were maintained or improved on at 5 years, including posttraumatic stress disorder (OR, 0.831; 95% CI, 0.704-0.981; P = .028).

CLINICAL IMPLICATIONS

The findings indicate that GGAS may play a crucial role in diminishing psychiatric comorbidities among individuals with GI.

STRENGTHS AND LIMITATIONS

This is the largest known study to evaluate the effect of GGAS on psychiatric comorbidities in the GI population, offering robust evidence. The reliance on the precision of CPT and ICD-10 codes for data extraction poses a limitation due to potential coding inaccuracies.

CONCLUSION

The evidence suggests a significant association between GGAS and reduced psychiatric comorbidities in individuals with GI.

Shear wave elastography to assess stiffness of the human ovary and other reproductive tissues across the reproductive lifespan in health and disease†

The ovary is one of the first organs to show overt signs of aging in the human body, and ovarian aging is associated with a loss of gamete quality and quantity. The age-dependent decline in ovarian function contributes to infertility and an altered endocrine milieu, which has ramifications for overall health. The aging ovarian microenvironment becomes fibro-inflammatory and stiff with age, and this has implications for ovarian physiology and pathology, including follicle growth, gamete quality, ovulation dynamics, and ovarian cancer. Thus, developing a non-invasive tool to measure and monitor the stiffness of the human ovary would represent a major advance for female reproductive health and longevity. Shear wave elastography is a quantitative ultrasound imaging method for evaluation of soft tissue stiffness. Shear wave elastography has been used clinically in assessment of liver fibrosis and characterization of tendinopathies and various neoplasms in thyroid, breast, prostate, and lymph nodes as a non-invasive diagnostic and prognostic tool. In this study, we review the underlying principles of shear wave elastography and its current clinical uses outside the reproductive tract as well as its successful application of shear wave elastography to reproductive tissues, including the uterus and cervix. We also describe an emerging use of this technology in evaluation of human ovarian stiffness via transvaginal ultrasound. Establishing ovarian stiffness as a clinical biomarker of ovarian aging may have implications for predicting the ovarian reserve and outcomes of Assisted Reproductive Technologies as well as for the assessment of the efficacy of emerging therapeutics to extend reproductive longevity. This parameter may also have broad relevance in other conditions where ovarian stiffness and fibrosis may be implicated, such as polycystic ovarian syndrome, late off target effects of chemotherapy and radiation, premature ovarian insufficiency, conditions of differences of sexual development, and ovarian cancer. Summary sentence:  Shear Wave Elastography is a non-invasive technique to study human tissue stiffness, and here we review its clinical applications and implications for reproductive health and disease.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Health status of transgender people globally: A systematic review of research on disease burden and correlates

BACKGROUND AND OBJECTIVES

Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality.

DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS

We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis.

RESULTS

The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality.

CONCLUSIONS AND IMPLICATIONS

Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants.

REGISTRATION

PROSPERO CRD42021234043.

Compelling care: A grounded theory of transmasculine self-defense and collective protection at the clinic

Despite formidable inequities in health care systems, transgender people are accessing clinical services in record numbers and gaining recognition as a patient population. This article examines how transgender people are negotiating their care and, in so doing, challenging patterns of marginalization and exclusion. Interviews with twenty-six transmasculine adults were collected and analyzed in the context of a community-led initiative foregrounding low-income people and people of color in Los Angeles County using a constructivist grounded theory approach. Participants gained agency in clinical settings by compelling care, a grounded theory that explains how patients contest medical authority and shift power through everyday acts to defend themselves and future patients. Histories of mistreatment and unequal social power drive patients to engage with health care providers judiciously and with a sense of social responsibility. In tracing seemingly decentralized acts of self-defense (e.g., vetting providers, disrupting gender norms, directing treatment), the study shows how patients rely on community resources and marshal collective protection. The theory recasts patients as constitutive actors in a changing landscape of care and as integral to, and one of many fronts of, collective struggle. In turn, the study lends theoretical insights to anti-racist understandings of medical mistrust andoffers a depathologized framework toward the development of community-building health equity interventions.

Outcomes of Orchiectomy for Gender-affirming Surgery: A National Surgical Quality Improvement Program Study

OBJECTIVE

To identify perioperative outcomes of transgender orchiectomy (TGO) and to broadly compare outcomes of TGO to cisgender orchiectomy (CGO) for nononcologic indications.

METHODS

Using the National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2020, a retrospective study was performed on patients with ICD-9/10 codes for gender dysphoria, testicular torsion, and testicular pain who underwent simple orchiectomy. Demographics and surgical outcomes were summarized. Welch two-sample t test and chi-square test were used for group analysis. A trend analysis was performed for temporal trends of these surgeries.

RESULTS

246 patients underwent TGO and 997 patients underwent CGO (607 testicular torsion, 390 testicular pain). Overall complication rates between TGO and CGO did not differ for testicular torsion (3.7% vs 4.4%, P = .6) or testicular pain (3.7% vs 5.9%, P = .2). No differences in patient characteristics were seen within the TGO group when comparing those who experienced complications to those who didn't. From 2015 to 2020, TGO cases significantly increased by, on average, 9.5 cases per year (95% CI: 6.3-12.7, P = .001), while CGO had showed no significant temporal change.

CONCLUSION

Standalone TGO can be performed safely in an outpatient setting with an acceptable complication profile in medically diverse patients.

Quality of life of transgender people under the lens of social determinants of health: a scoping review protocol

INTRODUCTION

There is an urgent need for knowledge about the transgender population to inform the development of clinical protocols and training of health professionals on the unique issues affecting this population. Discussing transgender quality of life (QoL) through the lens of social determinants of health (SDOHs) would enable gender-specific health interventions. Here, we aimed to review the evidence on the QoL of transgender people from an SDOH perspective.

METHODS AND ANALYSIS

A scoping review (ScR) protocol following the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews statement and guided by the Joanna Briggs Institute was used. MEDLINE/PubMed, Cochrane Library, Embase, PsycINFO, Web of Science, Scopus and registry sites such as ClinicalTrials.gov and WHO ICTRP will be searched. Additional sources to be searched include ProQuest Dissertations/Theses Global, British Library, Google Scholar and Preprints for Health Sciences-medRXiv. Two independent researchers will carry out the selection, data charting and data synthesis. No date restriction will be applied in this ScR. The search will be restricted to articles published in English, Spanish and Portuguese. The results will be presented in tables, narrative summaries and graphs and will be graded on the type of data presented and the results. The search strategy will be updated in April 2023. The expected completion date of this ScR is July 2023.

ETHICS AND DISSEMINATION

This ScR protocol does not require ethical approval. Dissemination plans include peer-reviewed publications, conference presentations to be shared with experts in the field, and advisory groups to inform discussions on future research. It is hoped that our findings will be of interest to practitioners, researchers, stakeholders, public and private managers, and the general population concerned with this emerging public health issue.

TRIAL REGISTRATION NUMBER

osf.io/9ukz6.

EDITORS' INTRODUCTION: Transgender Health Equity and the Law

The sheer gamut of issues impacting transgender health equity may seem overwhelming. This article seeks to introduce readers to the breadth of topics addressed in this symposium edition, exemplifying that transgender health equity is a global issue that demands an interdisciplinary approach.