Abstract
This cohort study assessed the use of preoperative hair removal among transgender individuals assigned male sex at birth enrolled in Oregon’s Medicaid program and their clinicians.
Hair removal can be a critical component of the gender-affirmation process for transgender patients and is often required before vaginoplasty or phalloplasty to prevent postoperative complications.1 In 2015, Oregon was one of the first of 22 states (plus Washington, DC and Puerto Rico) to cover gender-affirming surgeries in their Medicaid program.2 As of January 2020, Oregon is 1 of 6 states covering hair removal (electrolysis in October 2015 and laser procedures in October 2016) as part of presurgical preparation for genital or chest surgeries.3,4 Oregon’s plan covers these services without cost-sharing and requires procedures to be performed by board-certified dermatologists or other health care professionals licensed to perform hair removal.5 Little is known about use of electrolysis hair removal (EHR) and laser hair removal (LHR) once covered. This study describes hair removal for transgender individuals assigned male sex at birth (MSAB) in Oregon’s Medicaid program from 2015 to 2018.
Methods
We used 2015 to 2018 Oregon Medicaid claims for enrollees aged 18 to 64 years. Transgender beneficiaries who received at least 1 gender identity-related diagnosis were included (International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes F64.0-F64.9, Z87.890; International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 302.0, 302.51, 302.52, 302.53, 302.6, 302.85). Current Procedure Terminology (CPT), ICD Procedure Coding System, Healthcare Common Procedure Coding System, and national drug codes were used to infer MSAB and identify feminizing top surgery (FTS, ie, breast augmentation) and vaginoplasty. Hair removal covered under Oregon Medicaid policy was identified by presence of EHR (CPT 17380) or LHR (CPT 17110, 17111) claims. This study was approved by the institutional review board of Oregon Health & Sciences University and informed consent was waived because all data used were deidentified.
Results
Overall, 167 (12.2%) of the 1372 MSAB transgender beneficiaries had at least 1 hair removal claim paid by Medicaid (Table 1). Among those with hair removal, 32 (19.1%) had a vaginoplasty, 29 (17.4%) received FTS, and 106 (63.5%) had not yet received a surgery. Vaginoplasty and FTS recipients had similar demographics. Those without surgery were younger, non-White, and resided outside the Portland metro area.
Table 1. Characteristics of 167 Transgender Beneficiaries Assigned Male Sex at Birth With Hair Removal Paid for by Medicaid, 2015 to 2018.
| Characteristic | No. (%) | ||
|---|---|---|---|
| Vaginoplastya | Top surgeryb | No surgery | |
| Totalc | 32 (19.1) | 29 (17.4) | 106 (63.5) |
| Demographics | |||
| Age at last hair removal claim, median (IQR), y | 38.5 (31.0-43.3) | 38.0 (32.5-45.0) | 31.0 (26.5-41.0) |
| Reside in Portland metro aread | 22 (68.8) | 21 (72.4) | 65 (61.3) |
| Non-Hispanic White | 20 (62.5) | 20 (67.0) | 67 (63.2) |
| Non-White race or Hispanic ethnicity | 4 (12.5) | 3 (10.3) | 16 (15.1) |
| Unknown race/ethnicity | 8 (25.0) | 6 (20.7) | 23 (21.7) |
| Laser hair removal | 10 (31.3) | 19 (65.5) | 43 (40.6) |
| No. of visits, median (IQR)e | 6.0 (1.0-8.0) | 2.0 (1.0-3.0) | 3.0 (1.0-5.5) |
| Duration of procedures, median (IQR), mof | 5.3 (0-8.6) | 1.7 (0-4.6) | 3.9 (0-7.0) |
| Electrolysis | 27 (84.4) | 20 (69.0) | 63 (59.4) |
| No. of visits, median (IQR) | 35.0 (16.5-50.0) | 15.0 (9.5-19.5) | 9.0 (4.0-24.5) |
| Duration of procedures, median (IQR), mo | 12.7 (9.8-16.4) | 4.1 (2.2-5.6) | 5.7 (1.4-11.4) |
| Specialty of hair removal cliniciang | |||
| Dermatologyh | 6 (18.8) | 10 (34.5) | 69 (65.1) |
| Specialisti | 27 (84.4) | 20 (69.0) | 59 (55.7) |
| Otherj | 9 (28.1) | 13 (44.8) | 42 (39.6) |
Abbreviation: IQR, interquartile range.
Thirty-two of 42 beneficiaries receiving vaginoplasty had hair removal.
Twenty-nine out of 116 receiving a top surgery had hair removal.
Ninety-eight received electrolysis only, 54 received laser hair removal only, and 15 received both electrolysis and laser hair removal.
Portland metro area includes Multnomah, Clackamas, and Washington counties.
Sum of the days of claims.
Months between the first and last observed hair removal claim.
Beneficiaries may have more than 1 clinician; thus, numbers do not sum to 100.
Taxonomy code: 207N00000X.
Clinicians who are trained on a specific piece of equipment or technical procedure (taxonomy codes: 225500000X; 174400000X; 246Z00000X).
Any other taxonomy code not listed.
Among vaginoplasty recipients, 10 (31.3%) used LHR (6 visits over 5.3 months), and 27 (84.4%) used EHR (35 visits over 12.7 months). Among FTS recipients, 19 (65.5%) used LHR (2 visits over 1.7 months), and 20 (69.0%) used EHR (15 visits over 4.1 months). Dermatologists were seen by 6 (18.8%) of vaginoplasty recipients, 10 (34.5%) of FTS recipients, and 69 (65.1%) of those who had not yet received surgery. Other specialists were seen by 27 (84%) vaginoplasty recipients, 20 (69%) FTS recipients, and 59 (59%) who had not yet received surgery.
Beneficiaries accessed care from 9 EHR and 32 LHR clinicians (Table 2). Six (18.5%) LHR clinicians were dermatologists. Most EHR clinicians were electrologists located in a nonmedical practice setting who were licensed as medical clinicians after October of 2015.
Table 2. Clinicians Performing Electrolysis and Laser Hair Removal for Transgender Medicaid Beneficiaries Assigned Male Sex at Birth In Oregon , 2012 to 2018.
| Variable | No. (%) | |
|---|---|---|
| Electrolysis (n = 9) | Laser hair removal (n = 32) | |
| Specialty | ||
| Dermatologist | 3 (33.3) | 6 (18.7) |
| Specialista | 6 (66.7) | 0 |
| Other | 0 | 26 (81.3) |
| Practice in Portland metrob | 4 (44.4) | 20 (62.5) |
| Nonmedical practice settingc | 5 (55.5) | 0 |
None of the specialists had active National Provider Identifier numbers until after coverage of services in October 2015.
Portland metro area includes Multnomah, Clackamas, and Washington counties.
Practice addresses were matched with data from Google Maps.
Discussion
This study assessed use of preoperative hair removal among MSAB transgender individuals enrolled in Oregon’s Medicaid program and their clinicians. Dermatologists provided hair removal services at a higher rate to individuals who had not yet received a surgery compared with those with vaginoplasties or FTS. Accessing care with dermatologists rather than other types of clinicians may have been more difficult.
Most insurance plans that cover hair removal do not cover electrolysis performed outside of a medical setting,1 yet Oregon’s Medicaid recipients received electrolysis from clinicians not located in a medical setting. Limitations of this study include inability to identify the body site of hair removal and intraoperative hair removal techniques, exclusion of phalloplasty due to small sample sizes, single-state design, and the inability to identify why some beneficiaries received both LHR and EHR. Coverage and access to preoperative hair removal services are critical for individuals undergoing gender-affirming surgeries, and considered medically necessary by the American Academy of Dermatology.3
References
- 1.Marks DH, Peebles JK, Dommasch E. Hair reduction for transgender persons: what dermatologists should know and how they can help. JAMA Dermatol. 2019;155(5):525-526. doi: 10.1001/jamadermatol.2019.0149 [DOI] [PubMed] [Google Scholar]
- 2.Map LP. Healthcare Laws and Policies: Medicaid Coverage for Transition-Related Care. Updated October 20, 2020. Accessed November, 2, 2020, 2020. https://www.lgbtmap.org/img/maps/citations-medicaid.pdf
- 3.Thoreson N, Marks DH, Peebles JK, King DS, Dommasch E. Health Insurance Coverage of Permanent Hair Removal in Transgender and Gender-Minority Patients. JAMA Dermatol. 2020;156(5):561-565. doi: 10.1001/jamadermatol.2020.0480 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Oregon Health Authority OHERC. Prioritized List of Health Services. 2016. Accessed August 1, 2020. https://www.oregon.gov/oha/HPA/DSI-HERC/PrioritizedList/10-1-2016%20Prioritized%20List%20of%20Health%20Services.pdf [Google Scholar]
- 5.Oregon Health Authority. Board of Electrologists and Body Art Practitioners - Electrologists - License Information. 2018. Accessed August 1, 2020. https://www.oregon.gov/oha/PH/HLO/Pages/Board-Body-Art-Practitioners.aspx
