Incidence and Factors Associated With Acne Among Transgender Patients Receiving Masculinizing Hormone Therapy.

Importance: Acne is a common condition among transgender patients receiving masculinizing hormone therapy (MHT), but the incident risk and predictors of developing acne in this population have not yet been studied on a large scale. Objective: To assess risk of acne among a large population of transgender patients receiving MHT and clinical risk factors for acne diagnosis. Design, Setting, and Participants: A retrospective cohort study that included 988 patients who started MHT between January 1, 2014, and December 31, 2017, with at least 1 year of follow-up was performed. Data analysis was conducted from September 1 to 15, 2019. Data were obtained using electronic health records from a community health center serving the sexual and gender minority community. The population included every patient who began receiving MHT during the study period who was aged 18 years or older at the time of MHT initiation and whose assigned sex at birth was female. Main Outcomes and Measures: The main outcome was acne defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification codes for acne. Overall prevalence and incidence proportions over 2 years after initiation of MHT were calculated. Baseline demographic and clinical characteristics were collected at the time of MHT initiation. A series of univariate analyses for all factors was calculated to test for an association with acne diagnosis, followed by multivariate analyses to test for independent predictors. Results: For 988 patients (median age, 25.8 years; interquartile range, 20.8-28.2 years), there was an overall acne prevalence of 31.1% (n = 307). The 1-year post-MHT acne incidence proportion was 19.0% and the 2-year incidence proportion was 25.1%. A younger age at MHT initiation was associated with a higher likelihood of developing acne, with a median of 22.4 years (interquartile range, 19.7-25.6 years) among patients who developed acne vs 24.7 years (interquartile range, 21.3-29.4 years) among patients who did not (P = .002). Conclusions and Relevance: Acne is a common condition among transgender patients on MHT, with a prevalence increasing from 6.3% to 31.1% following MHT initiation. Patients aged 18 to 21 years appear to be the most likely to develop acne after MHT initiation.

Health Insurance Coverage of Permanent Hair Removal in Transgender and Gender-Minority Patients.

Importance: Hair removal can be an essential component of the gender affirmation process for gender-minority (GM) patients whose outward appearance does not align with their gender identity. Objective: To examine the health insurance policies in the Affordable Care Act (ACA) marketplace and Medicaid policies for coverage of permanent hair removal for transgender and GM patients and to correlate the policies in each state with statewide protections of coverage for gender-affirming care. Design and Setting: Private health insurance policies available on the ACA marketplace and statewide Medicaid policies were examined in a cross-sectional study from September 1 to October 31, 2019, and January 17 to 30, 2020. Policies were assessed for coverage of permanent hair removal. Language concerning hair removal was found in each policy's medical or clinical coverage guidelines and separated into general categories. Main Outcomes and Measures: Logistic regression analyses were performed to compare Medicaid policies and ACA policies in states with and without transgender protections. Results: A total of 174 policies were analyzed, including 123 private insurance policies and 51 statewide Medicaid policies. Of these policies, 8 (4.6%) permitted the coverage of permanent hair removal without explicit restrictions. The remaining 166 policies (95.4%) broadly excluded or did not mention gender-affirming care; prohibited coverage of hair removal or did not mention it; or only permitted coverage of hair removal preoperatively for genital surgery. The ACA marketplace policies in states without transgender care protections were less likely to cover hair removal without restrictions than ACA policies in states with protections (2 of 85 policies [2.4%] in states without transgender care protections vs 5 of 38 policies [13.2%] in states with transgender care protections), and Medicaid policies were less likely to cover preoperative or nonsurgical hair removal compared with ACA policies (6 of 51 Medicaid policies [11.8%] vs 47 of 123 ACA policies [38.2%]). Conclusions and Relevance: Despite adoption of statewide restrictions on GM health care exclusions by several states, most Medicaid and ACA policies examined in this study did not cover permanent hair removal for transgender patients. Many GM patients seeking hair removal may be required to pay out-of-pocket costs, which could be a barrier for gender-affirming care.