Contemporary nationwide estimates and socio-demographic associates of bottom gender affirmation surgical procedures among transgender persons with gender dysphoria

Abstract

ABSTRACT Introduction There is paucity of data for transgender persons who undergo genital or bottom gender-affirming surgery (GAS). Objective To provide nationwide estimates of frequency, length of stay, charges, and mortality for bottom GAS hospitalizations among transgender persons diagnosed with gender dysphoria and to characterize socio-demographic, clinical, and hospital-related characteristics of transgender persons with gender dysphoria (GD) who undergo GAS. Methods We analyzed the National Inpatient Sample (NIS) for years 2016 to 2018, representing 90% of all US hospitalizations. Utilizing International Classification of Disease (ICD) version 10 codes, we identified transgender persons with gender dysphoria with and without bottom GAS. Between these groups, we compared socio-demographic characteristics (age, administratively documented sex, race, median income for zip code, insurance type, US region) and comorbidity profiles via the Charlson Comorbidity Index (CCI - a composite score comprising age and 17 multi-system conditions). Mental health comorbidities and substance abuse disorders were also evaluated. We provide an account of hospital characteristics where GAS procedures were conducted along with estimates of charges, length of stay, and in-hospital mortality among GD patients with GAS. We utilized survey weights and reported nationally representative estimates as odds ratios (OR) and 95% confidence intervals (CI). Results The 2016 - 2018 NIS had 37,870 GD hospitalization encounters. The proportion of GD hospitalizations increased over the 3-year period, OR (CI): 1.55(1.43-1.68). From among these encounters, 2,925 (7.7) had at least one GAS procedure documented. The absolute count of GD hospitalizations with GAS also increased over 3 years. GD patients with GAS (37.4 years) (vs. no-GAS group - 31.6 years) were significantly older; OR (CI): 1.02(1.01-1.02), were more likely to be administratively documented as male; OR (CI): 1.62(1.02-2.58), and more likely to belong to a higher socio-economic group. GAS procedures were also associated with higher rates of private insurance (vs. Medicare); OR (CI): 3.17(2.16-4.66). GD patients who underwent GAS (vs. no-GAS) had significantly lower comorbidities, OR (CI) for low vs. high CCI: 2.28(1.32-3.93). Likewise, a lower proportion of GAS GD patients (vs. non-GAS GD) had documented substance abuse and mental health disorders. OR (CI) for alcohol abuse: 0.09(0.07–0.12), smoking: 0.44(0.35–0.56), drug use: 0.07(0.3–0.15), depression: 0.67(0.48–0.92), and psychosis: 0.23(0.14–0.37). Higher rates of GAS were observed in Western US region; OR (CI) vs. Midwest 5.90(2.89-12.04) and vs. South 3.58(1.52-8.44). GD GAS procedures were predominantly performed in urban hospitals with the mean hospital charges, mean length of stay, and proportional in-hospital mortality of $101,654, 4.3 days, and 0.3%, respectively. Conclusions Nationally, older GD patients who are privately insured, with lower systemic and mental comorbidities, and lower rates of substance abuse are more likely to undergo GAS, predominantly in the Western US. Current lack of data among transgender persons with gender dysphoria invites anecdotal experience to drive decision making, and better characterization of this population may optimize GAS outcomes. Disclosure Work supported by industry: no.