Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus.
The Ohio State University College of Medicine, Columbus.
JAMA. 2023 Mar 14;329(10):819-826. doi: 10.1001/jama.2023.0878.
Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies.
To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents.
DESIGN, SETTING, AND PARTICIPANTS: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019.
California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013.
Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure.
A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001).
Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.
重要性：性别肯定手术通常对性别多样化或性别不适的患者有益。通过限制立法和保险政策，获得性别肯定手术的机会往往受到限制。
目的：研究 2013 年加利福尼亚州实施的《保险性别非歧视法》（该法禁止保险公司和健康计划根据患者的性别、性别、性别认同或性别表达来限制福利）与加利福尼亚州居民接受性别肯定手术之间的关联。
设计、地点和参与者：对 2005 年至 2019 年期间接受性别肯定手术（面部、胸部和生殖器手术）的跨性别和性别多样化患者进行的人口流行病学研究。在 2013 年 7 月《保险性别非歧视法》实施之前和之后，加利福尼亚州与华盛顿州和亚利桑那州（选择这两个州是因为地理位置相似，并且与加利福尼亚州一样在 2014 年 1 月 1 日扩大了医疗补助）相比，加利福尼亚州利用性别肯定手术的情况进行了比较。最后一次随访日期为 2019 年 12 月 31 日。
暴露情况：加利福尼亚州的《保险性别非歧视法》于 2013 年 7 月 9 日实施。
主要结果和措施：接受性别肯定手术，定义为至少进行 1 次面部、胸部或生殖器手术。
结果：共有 25252 名患者（加利福尼亚州：n=17934[71%]；对照组：n=7328[29%]）被诊断为性别焦虑症。中位数年龄在加利福尼亚州为 34.0 岁（无论是否接受性别肯定手术），对照组中接受性别肯定手术的患者为 39 岁（IQR，28-49 岁），对照组中未接受性别肯定手术的患者为 36 岁（IQR，22-56 岁）。在研究期间，有 2918 例（11.6%）入院患者至少进行了 1 次性别肯定手术-加利福尼亚州 2715 例（15.1%），对照组 203 例（2.8%）。加利福尼亚州与对照组相比，在 2013 年 7 月第三季度性别肯定手术数量呈显著增加，与《保险性别非歧视法》的实施时间一致（P<.001）。该政策的实施与加利福尼亚州与对照组相比，接受保险的患者（13.4%[95%CI，11.5%-15.4%]；P<.001）中接受性别肯定手术的概率绝对增加了 12.1%（95%CI，10.3%-13.9%），但在自付患者中并未增加（-22.6%[95%CI，-32.8%至-12.5%]；P<.001）。
结论和相关性：加利福尼亚州实施《保险性别非歧视法》后，加利福尼亚州接受性别肯定手术的人数与华盛顿州和亚利桑那州（对照组）相比显著增加。这些数据可能为州立法工作提供信息，以制定防止州居民（包括跨性别和性别多样化患者）在健康保险方面受到歧视的政策。
