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.