Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

BACKGROUND: The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. OBJECTIVES: This study investigates insurance requirements for referral letters and their negative impact on care. MATERIALS AND METHODS: We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. RESULTS: Nearly all reviewed U.S. health insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. DISCUSSION AND CONCLUSION: Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.

Intersecting Experiences of Healthcare Denials Among Transgender and Nonbinary Patients.

INTRODUCTION: Transgender and nonbinary individuals experience high levels of health disparities and are more likely to experience denials of health care than their cisgender (nontransgender) counterparts. There is a lack of evidence on how healthcare denials vary by gender identity and other intersecting identity characteristics in the transgender and nonbinary populations. METHODS: Using data from the 2015 U.S. Trans Survey (n=27,715), multivariate logistic regressions were used to analyze (in 2019) the increased likelihood of experiencing denials of trans-related care and standard care across socioeconomic and identity characteristics among the transgender and nonbinary population, including race, age, educational attainment, disability, income, and gender identity. RESULTS: Almost 8% of the participants had been denied trans-specific health care, and >3% had been refused general health care. Transgender (compared with nonbinary), older, biracial, or multiracial, and lower-income participants, as well as those with less than a high school diploma and those with disabilities, were significantly more likely to experience refusal of care in general or trans-specific healthcare settings. CONCLUSIONS: There is a need for better training of healthcare providers to be inclusive and reduce denial rates of their transgender and nonbinary patients. However, it is also clear that current rates of denial must be considered through a whole-person lens, considering the experience of concurrent oppressed identities and recognizing the increased risk those with multiple marginalized identities experience in being denied needed health care.

Increasing normality-persisting barriers: Current socio-demographic characteristics of 350 individuals diagnosed with gender dysphoria.

INTRODUCTION: The number of individuals requesting medical treatment for gender dysphoria has increased significantly within the past years. Our purpose was to examine current biographic and socio-demographic characteristics and aspects of legal gender reassignment. DESIGN: Medical files from n = 350 individuals of a German Endocrine outpatient clinic were collected from 2009 to 2017 and analysed retrospectively. RESULTS: Ratio of transwomen to transmen equates to 1:1.89 with a remarkable increase of transmen by the year 2013, showing a reversal of gender distribution compared with previous studies for the first time. Use of illegal substances or self-initiated hormone therapy was rare (4.6 and 2.1%). Satisfaction with gender-affirming hormone therapy was significantly higher in transmen than in transwomen (100% vs 96.2%, P = .005). Use of antidepressants declined significantly after onset of hormone treatment in transmen (13% vs 7%; P = .007). The number of individuals with a graduation diploma was only about half as high as in the general population (14.3% vs 27.3%), whereas unemployment rate was more than twice as high (14% vs 6.9%). Median latency between application for legal gender reassignment and definitive court decision was 9 months. CONCLUSIONS: Our data provide possible indications for a decline of psychosocial burden in individuals diagnosed with gender dysphoria over the last years. However, affected individuals are still limited in their occupational and financial opportunities as well as by a complex and expensive procedure of legal gender reassignment in Germany.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

Transgender Medicare Beneficiaries and Chronic Conditions: Exploring Fee-for-Service Claims Data.

PURPOSE: Data on the health and well-being of the transgender population are limited. However, using claims data we can identify transgender Medicare beneficiaries (TMBs) with high confidence. We seek to describe the TMB population and provide comparisons of chronic disease burden between TMBs and cisgender Medicare beneficiaries (CMBs), thus laying a foundation for national level TMB health disparity research. METHODS: Using a previously validated claims algorithm based on ICD-9-CM codes relating to transsexualism and gender identity disorder, we identified a cohort of TMBs using Medicare Fee-for-Service (FFS) claims data. We then describe the demographic characteristics and chronic disease burden of TMBs (N = 7454) and CMBs (N = 39,136,229). RESULTS: Compared to CMBs, a greater observed proportion of TMBs are young (under age 65) and Black, although these differences vary by entitlement. Regardless of entitlement, TMBs have more chronic conditions than CMBs, and more TMBs have been diagnosed with asthma, autism spectrum disorder, chronic obstructive pulmonary disease, depression, hepatitis, HIV, schizophrenia, and substance use disorders. TMBs also have higher observed rates of potentially disabling mental health and neurological/chronic pain conditions, as well as obesity and other liver conditions (nonhepatitis), compared to CMBs. CONCLUSION: This is the first systematic look at chronic disease burden in the transgender population using Medicare FFS claims data. We found that TMBs experience multiple chronic conditions at higher rates than CMBs, regardless of Medicare entitlement. TMBs under age 65 show an already heavy chronic disease burden which will only be exacerbated with age.

Coverage for Gender-Affirming Care: Making Health Insurance Work for Transgender Americans.

Many transgender Americans continue to remain uninsured or are underinsured because of payers' refusal to cover medically necessary, gender-affirming healthcare services-such as hormone therapy, mental health counseling, and reconstructive surgeries. Coverage refusal results in higher costs and poor health outcomes among transgender people who cannot access gender-affirming care. Research into the value of health insurance coverage for gender-affirming care for transgender individuals shows that the health benefits far outweigh the costs of insuring transition procedures. Although the Affordable Care Act explicitly protects health insurance for transgender individuals, these laws are being threatened; therefore, this article reviews their importance to transgender-inclusive healthcare coverage.

The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual.

INTRODUCTION: In the UK, funding for a bilateral mastectomy (BLM) and associated chest recontouring for female-to-male transsexuals (trans men) has been rejected by some funding authorities on a number of unsustainable grounds. METHODS: As funding is increasingly an important area for both surgeons and referrers, we undertook a review of the small amount of literature pertaining to this issue and considered it in light of our clinical experience of this group. FINDINGS: The literature showed that BLM is necessary for trans men to live safely and effectively in their reassigned gender role, and further that it acts as a prophylaxis against distress, ameliorates extant distress as well as providing improved quality of life and global functioning for this patient group.

Self-castration by a transsexual woman: financial and psychological costs: a case report.

INTRODUCTION: The out-of-pocket cost for an elective orchiectomy, which is often not covered by health insurance, is a significant barrier to male-to-female transsexuals ready to proceed with their physical transition. This and other barriers (lack of access to a surgeon willing to perform the operation, waiting times, and underlying psychological and psychiatric conditions) lead a subset of transsexual women to attempt self-castration. Little information has been published on the financial costs and implications of self-castration to both patients and health care systems. AIM: We compare the financial and psychological costs of elective surgical orchiectomy vs. self-castration in the case of a transsexual woman in her 40s. METHODS: We interviewed the patient and her providers and obtained financial information from local reimbursement and billing specialists. RESULTS: After experiencing minor hemorrhage following the self-castration, our patient presented to the emergency department and underwent a bilateral inguinal exploration, ligation and removal of bilateral spermatic cords, and complicated scrotal exploration, debridement, and closure. She was admitted to the psychiatric service for a hospital stay of three days. The total bill was U.S. $14,923, which would compare with U.S. $4,000 for an elective outpatient orchiectomy in the patient's geographical area. CONCLUSIONS: From a financial standpoint, an elective orchiectomy could have cost the health care system significantly less than a hospital admission with its associated additional costs. From a patient safety standpoint, elective orchiectomy is preferable to self-castration which carries significant risks such as hemorrhage, disfigurement, infection, urinary fistulae, and nerve damage. Healthcare providers of transsexual women should carefully explore patient attitudes toward self-castration and work toward improving access to elective orchiectomy to reduce the number of self-castrations and costs to the overall health care system. Further research on the financial implications of self-castration from different health care systems and from a series of patients is needed.

Female and male transgender quality of life: socioeconomic and medical differences.

INTRODUCTION: Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status. AIM: First, to assess health-related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data. METHODS: One hundred forty-eight current and former transgender patients of a gender identity clinic participated in a large QOL study. MAIN OUTCOMES MEASURES: Health-related QOL was measured using the Short Form 36-Item Questionnaire. RESULTS: The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health-related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single. CONCLUSIONS: Specific social indicators are important in relation to health-related QOL of transgenders in a context of qualitative and adequate medical care.