Balkan Em, Babbs Gray, Meyers David J, Kelly Patrick J A, Yee Kim, Pletta David R, Shireman Theresa I, Alpert Ash B, Baker Kellan E, Hughto Jaclyn M W
Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island.
The Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island.
JAMA Netw Open. 2025 May 1;8(5):e258072. doi: 10.1001/jamanetworkopen.2025.8072.
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.
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.
Race and ethnicity, Medicare-Medicaid dual status, age, original reason for Medicare entitlement, geographic area, and chronic conditions.
Descriptive analyses and generalized estimating equations were used to assess gender-affirming surgical procedures and beneficiary characteristics associated with surgical procedures.
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.
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.
医疗保险按个案为性别肯定手术提供覆盖。接受性别肯定手术的医疗保险受益人的比例尚不清楚。
研究医疗保险受益人性别肯定手术的频率和趋势。
设计、设置和参与者：这项横断面研究使用全国医疗保险数据，分析了2016年1月1日至2020年2月29日期间跨性别和性别多样化受益人性别肯定手术的使用情况，以及未被认定为跨性别的受益人类似手术的使用情况。通过基于索赔的算法识别跨性别医疗保险受益人；使用倾向得分匹配法选择非跨性别个体。分析于2022年11月至2024年10月进行。
种族和民族、医疗保险-医疗补助双重身份、年龄、医疗保险资格的原始原因、地理区域和慢性病。
使用描述性分析和广义估计方程来评估性别肯定手术以及与手术相关的受益人特征。
本研究纳入了跨性别个体（平均[标准差]年龄，60.0[18.6]岁；43.2%为女性向男性转变者，33.0%为男性向女性转变者，23.9%为性别未分类者）和未被认定为跨性别的个体（平均[标准差]年龄，62.7[21.0]岁；55.5%为女性，44.5%为男性）。在总计142703人年中，有2156例跨性别个体在日历年至少接受了1次性别肯定手术。接受至少1次手术的个体比例从2016年和2017年的2.1%至2.2%降至2018年和2019年的1.4%。不同受益人特征的手术情况存在很大差异。接受手术的跨性别受益人更年轻（31 - 40岁与61 - 65岁：调整优势比[AOR]，1.91[95%置信区间，1.55 - 2.34]），医疗补助参保率更高（AOR，1.14[95%置信区间，1.02 - 1.26]），慢性病发生率更高（≥10种疾病与0种疾病：AOR，2.10[95%置信区间，1.79 - 2.46]），与未接受手术者相比，居住在西海岸（阿拉斯加、爱达荷、俄勒冈和华盛顿）的居民比例高于东北部（康涅狄格、缅因、马萨诸塞、新罕布什尔、罗德岛和佛蒙特）（AOR，1.30[95%置信区间，1.05 - 1.61]）。在地理上，将东北部与东南部（阿拉巴马、佛罗里达、佐治亚、肯塔基、密西西比、北卡罗来纳、南卡罗来纳和田纳西）进行比较时差异最大（AOR，0.70[95%置信区间，0.58 - 0.86]；P < .001），与南部其他地区（阿肯色、路易斯安那、新墨西哥、俄克拉何马和得克萨斯）比较时差异也很大（AOR，0.56[95%置信区间，0.44 - 0.71]；P < .001）。对于未被认定为跨性别的个体，各地区接受手术的情况没有显著差异。
这项对医疗保险计划的横断面研究发现，性别肯定手术非常罕见，尤其是对于年龄较大、未同时参加医疗保险和医疗补助以及居住在南部的人。尽管跨性别医疗保险受益人在接受性别肯定手术方面存在实质性的地区差异，但未被认定为跨性别的受益人没有地区差异。有必要进一步研究以探讨跨性别和性别多样化受益人在获得性别肯定手术方面的障碍。
