Just Read: Temporal Trends in Gender-Affirming Surgery Among Transgender Patients, Insights from Study Authors, Evidence that Providing Medical care is more Cost-effective than Denying It

This paper, published in JAMA Surgery last week, provides important evidence of the value of providing medically-necessary care to people who are trasngender or gender nonconforming.

The primary importance of this paper is

This is the first study to our knowledge that broadly evaluates national temporal trends in gender-affirming surgery for transgender patients in the United States.Citation: Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg [Internet]. 2018 Feb 28; Available from: http://archsurg.jamanetwork.com/article.aspx?doi=10.1001/jamasurg.2017.6231

The significant number of inpatient admissions for mental health

The importance to physicians and the people we serve is the above plus the data in Table 1: “Characteristics of Patients Who Have a Diagnosis Code for Transsexualism or Gender Identity Disorder in the National Inpatient Sample”

Of the 37,827 inpatient encounters in the sample, 14,128, or 40.5 % are for Mental Health. This dwarfs the number for actual treatment-related reasons, such as gender affirming surgery. Additionally:

  • 1038 (3 %) for substance abuse
  • 871 (2.5 %) for HIV
  • 1262 (3.6%) for Poison/Suicide

These 17,299 inpatient admissions could very well be preventable with appropriate science-based medical care. It’s been established that

Spending more time and money on denying care rather than providing it

As the heading says, this is what I have observed over the past 6 years in conversations with physicians and other health professionals. This approach is unnecessary, wasteful, and affects everyone in the health system and society.

My communication with one of the study authors

I thank the authors for providing data that demonstrates the impact, and also for being available to me with questions. I contacted study author Brandyn D. Lau, MPH, CPH,
Assistant Professor of Radiology and Radiological Science & Health Sciences Informatics (@LauzeeTweet), who was kind enough to provide this helpful background to the team’s work:

Thank you so much for your kind words and for highlighting this work! We were very excited by these findings, but also recognize that there’s a real need to do a better job of collecting information to more fully assess the health needs of the communities and identify specific opportunities to improve the quality of care we provide.

In healthcare to date, we have largely missed the opportunity assess and improve care for sexual and gender minority patients because we don’t routinely collect information about sexual orientation and gender identity. In the current study, we used diagnosis codes (i.e. gender identity disorder and/or transsexualism) to identify the population, which is unfortunate that we would have to use a surrogate indicator and potentially giving the wrong impression that we endorse pathologizing gender identity. Clearly there will be no diagnosis code to identify a patient’s sexual orientation and, as a gay man and as a quality improvement researcher, I wish that sexual orientation (in addition to gender identity) would be routinely collected so that we can explore broadly differences in care among sexual and gender minority patients. My hope is that this study calls on the health care community to do a better job of collecting all demographics, including gender identity and sexual orientation, to comprehensively assess the current state of care and identify opportunities to improve care quality for patients moving forward.

To your question, the biggest challenge with using this type of cross sectional data is that we have no idea what transition-related care, if any, patients were getting other than patients who were admitted for gender-affirming surgery. The dataset does not include any information about medication (e.g. hormones) and does not include reliable information about history of gender-affirming surgical procedures. I completely agree that the 40% of admissions being associated with mental health is a call to ensure that we are providing high-quality comprehensive care, including transition-related care, for trans patients. That being said, inclusion in this dataset required that a provider actively document GID or TS as a diagnosis during the visit, so the numbers that we see likely underrepresent the truth. I am absolutely excited that headway has been made to improve access to transition-related care. We owe it to the patients, to the communities to do a better job of collecting more robust data about processes, clinical outcomes, and patient-reported outcomes to identify specific opportunities to improve care and to measure our performance in healthcare settings to hold ourselves accountable for providing the highest quality patient-centered care.Personal email communication

And this

I completely agree, and am optimistic and excited for the next study (or next 10 studies) to hopefully show shifts in trans patients from getting inpatient mental health care to getting primary care and medically necessary transition-related care.Personal email communication

This visual shows what this means:

I completely agree with Brandyn, I am also glass 3/4 full, the future = all genders respected and represented, and this century is my favorite one so far 🙂 .

Citation: Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, et al. Temporal Trends in Gender-Affirming Surgery Among Transgender Patients in the United States. JAMA Surg [Internet]. 2018 Feb 28; Available from: http://archsurg.jamanetwork.com/article.aspx?doi=10.1001/jamasurg.2017.6231

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Ted Eytan, MD