Online Crowdfunding Enables Patients' Access to Gender-Affirming Surgery

Abstract

Online crowdfunding allows transgender patients to fundraise for their surgeries or hormonal therapy. In this study, we updated the geographic trends in fundraising for gender-affirming surgery and sought to establish the factors influencing the amount raised per campaign. Campaigns were identified from GoFundMe. In total, 1010 crowdfunding campaigns were identified. The West had the highest proportion of campaigns (n=242, 34.6%). Controlling for each variable, we found that campaigns that raised the greatest amount of funds were associated with longer descriptions (p<0.0001, r=0.34), higher number of social media shares (p<0.0001, r=0.39), higher goal amount (p=0.041, r=0.19), and number of donors (p<0.0001, r=0.44).

Purpose

In the United States, ∼0.6% of the population identifies as gender-nonconforming or transgender.¹ In addition to being at increased risk for many health issues, transgender patients are less likely to be covered by health insurance, and coverage often lacks transgender-specific medical care.² According to the 2015 U.S. Transgender Survey, ∼55% of patients undergoing gender-affirming surgery reported difficulty obtaining health insurance coverage.³ Gender-affirming surgery can result in high financial burdens for transgender patients. Online medical crowdfunding, whereby patients recruit funding for medical care through advertising to potential donors using public campaigns on social media, has grown significantly in popularity over the past decade.⁴ This fundraising strategy is one method by which transgender patients may use to pay for their surgery or hormonal therapy. In this study, we updated the geographic trends in fundraising for gender-affirming surgery and sought to establish the factors influencing the amount raised per campaign.

Methods

Campaigns were identified from GoFundMe with the search term “Transgender surgery.” Duplicates, campaigns outside the United States, and those created by organizations (vs. patients) were excluded (Fig. 1). Data extracted from each campaign included title, description, amount raised, goal amount, number of social media shares, number of donors, and patient subregion (west, south, northeast, and midwest) and state location. The character number of each campaign description was used to assess for description length. Multivariable regression analysis, Pearson's correlation, and one-way analysis of variance were used for statistical analyses using R software (v.3.4.4). Campaign descriptions sentiment analysis and word cloud were done using the AFINN lexicon and the wordcloud2 package, respectively.

FIG. 1.

Campaign identification flowchart.

Results

In total,1010 crowdfunding campaigns were identified involving a total of 42,819 donors and $2,890,807 raised overall, and $2,860±213 raised per campaign. There was a statistically significant difference in number of campaigns adjusted for population size among the four main subregions of the United States (p<0.0001): the west had the highest proportion of campaigns (n=242, 34.6%). We found similar results at the state level (p<0.0001); after adjusting for population size, Vermont had the highest number of campaigns, followed by Washington, and then Oregon (14%, 5.3%, and 4.2%, respectively).

Controlling for each variable, the campaigns that secured the most funding were associated with longer descriptions (p<0.0001, r=0.34), higher number of social media shares (p<0.0001, r=0.39), higher goal amount to be raised, and greatest number of donors (p<0.0001, r=0.44) (Table 1). The most common words used in the most successful 25% of campaigns were “insurance,” “hard,” “pay,” and “dysphoria” (strong negative sentiments), and “love,” “support,” “help,” and “life” (strong positive sentiments; Fig. 2). Excluded organization-related campaigns fundraised for a variety of causes, including but not limited to housing, clothing, support after assault, trans/LGBTQ community organizations, food pantry, film production, transgender youth camps, and transgender-owned businesses.

Table 1.

Campaign Characteristics Associated with Increased Funding

	Correlation coefficient (r)	p
Description length	0.34	<0.0001
Number of social media shares	0.39	<0.0001
Goal amount	0.44	<0.0001

FIG. 2.

Word cloud representing the most commonly used words in campaign descriptions.

Discussion

In this study, we sought to establish what makes online gender-affirming campaigns successful. Our analysis of one of the main online fundraising platforms indicates patients from across the United States utilize online strategies to help raise the money required to undergo gender-affirming surgery. Most campaigns came from patients living in the west United States, indicating perhaps more surgeries in this region, more need for funding, or both. There is also increased access to Internet in the west, with more households in the west United States having computers and Internet access.⁵ At the state level, Vermont had the highest number of campaigns adjusted for population size. This is partly explained by its original state policy limiting gender-affirming surgery insurance coverage for youth under the age of 21 years.⁶ Washington and Oregon also had a greater number of campaigns than their neighboring states. This may be due to a greater transgender population to state population ratio when compared with neighboring states.³

Analysis of campaign characteristics highlighted that social media shares and donors were the two most important factors that independently predicted the chance of a successful campaign (i.e., a patient reaching a goal fund amount). There is likely an interaction between number of social media shares and pre-existing personal connections to donors. Indeed, those who routinely “blog” may have already recruited an online following, and this is a known theme in online medical crowdfunding campaigns.⁷ Analysis of all campaign descriptions using the AFINN and wordcloud2 packages showed that the most commonly used words were associated with low-strength sentiments (Fig. 2). In contrast, successful campaigns specifically exhibited strong positive and negative emotional sentiment in their descriptions. It is likely that an increased expression of emotion may have been more persuasive to prospective donors.⁸

As medical crowdfunding grows in popularity, plastic surgeons can expect its use to increase among transgender patients. Increased awareness among surgeons may allow further discussion about the feasibility of raising funds online with their patients. Furthermore, online crowdfunding not only creates a platform for patients to raise funds, but can also be an educational tool created by patients for patients. It is now commonplace for patients to use online platforms to describe their patient experience,⁹ and knowledge of unique patient experiences play an essential role in helping patients decide on and plan for gender-affirming surgery. One study found that most information on YouTube for transgender top surgery is disseminated through patient experience stories only, with very few unbiased videos by board-certified plastic surgeons explaining the risks, benefits, treatment options, and alternatives to surgery.¹⁰ With limited access to board-certified plastic surgeons performing gender-affirming surgery, online platforms may be the only resource available for patients.

Although the resources used in this study are powerful enough to establish certain correlations, inherent limitations arise with their use. Not all representative medical crowdfunding campaigns may be represented here since data were collected from a single website at one point in time. Supplemental information such as household income and patient demographic details were not available. In addition, donations accepted outside of the online fundraising campaigns could not be assessed. These variables may play an important role in the outcomes of the study. The AFINN lexicon provides excellent sentiment analysis, future studies could use machine learning and natural processing technique to further analyze campaign descriptions and titles.

Conclusion

In conclusion, our findings suggest that patients in the west seem to have the highest need for funding, as identified the highest number of GoFundMe campaigns. We also found the two most important factors for a successful campaign to be the number of donors and social media shares. Patients undergoing gender-affirming surgery may use online crowdfunding to cover the cost of their surgery. Plastic surgeons and primary care physicians will likely encounter medical crowdfunding with increased frequency as it continues to grow in popularity among their transgender patients. Increased awareness among physicians may allow further discussion about the feasibility of raising funds online with their patients.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Akiki RK, Borrelli MR, Kwan D (2021) Online crowdfunding enables patients' access to gender-affirming surgery, Transgender Health 6:5, 240–243, DOI: 10.1089/trgh.2020.0128.