Gender-Affirming Chest Reconstruction Among Transgender and Gender-Diverse Adolescents in the US From 2016 to 2019

Abstract

This cross-sectional study examines the incidence, demographic characteristics, and cost associated with masculinizing and feminizing chest surgical procedures among individuals younger than 18 years.

Thirty-five state legislatures have introduced more than 100 bills that limit or prohibit access to medically necessary gender-affirming care for transgender and gender-diverse (TGD) youth, resulting in poor mental and physical health outcomes.¹ Approximately 300 000 adolescents between 13 and 17 years of age identify as transgender.² Among TGD individuals experiencing gender dysphoria, gender-affirming surgery may improve functioning and mental health.³ However, there is a paucity of information regarding gender-affirming surgery in adolescent populations. Reconstructive genital surgery is typically not performed in adolescents, but masculinizing chest reconstruction (eg, mastectomy) and feminizing chest reconstruction (eg, augmentation mammaplasty) may be performed in outpatient and ambulatory surgery settings.⁴ We investigated the incidence, demographic characteristics, and spending related to ambulatory gender-affirming chest reconstruction in adolescents using nationally representative data from 2016 to 2019.

Methods

Using the Nationwide Ambulatory Surgery Sample, we identified patients with an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis code of gender dysphoria who underwent chest reconstruction (eAppendix in the Supplement). The Nationwide Ambulatory Surgery Sample is an all-payer database that captures ambulatory surgery encounters performed in the US. Vanderbilt University Institutional Review Board deemed this study to be exempt from review and waived the informed consent requirement because the study is retrospective. We followed the STROBE reporting guideline.

Encounters for patients younger than 18 years between 2016 and 2019 were included. Demographic and clinical characteristics were recorded for each encounter. Race and ethnicity were collected from hospital records only in 2019, the last year of available data. Total charges were adjusted for inflation, and observations were weighted to be nationally representative. Changes in patterns over the study period were compared using Pearson χ² tests with Rao-Scott correction for categorical variables and linear regression for continuous variables. Analyses were computed in Stata, version 17 (StataCorp LLC), and statistical significance was defined as a 2-sided α < .05. Data were analyzed from January 15 to May 11, 2022.

Results

A weighted estimate of 1130 encounters (1114 [98.6%] masculinizing and 16 [1.4%] feminizing) for chest reconstruction were included. Between 2016 and 2019, the annual number of gender-affirming chest surgeries increased by 389% (100 in 2016 vs 489 in 2019; P < .001) (Figure).

Figure. Temporal Trends in Ambulatory Gender-Affirming Chest Reconstruction in Adolescents From 2016 to 2019.

Most gender-affirming chest surgeries were covered by private health insurance (61.1%; 95% CI, 52.0%-69.4%) (Table). There was no significant change in health insurance coverage during the study period. The median (range) age for gender-affirming chest reconstruction was 16 (12-17) years. Of the patients who underwent chest reconstruction in 2019, 2.7% (95% CI, 1.5%-4.8%) were Black, 2.5% (95% CI, 1.4%-4.7%) were Asian or Pacific Islander, 12.2% (95% CI, 8.9%-16.4%) were Hispanic, 0.5% (95% CI, 0.1%-1.8%) were Native American, 77.9% (95% CI, 73.1%-82.1%) were White individuals, and 4.2% (95% CI, 2.2%-7.9%) were categorized under other race and ethnicity.

Table. Characteristics of Transgender and Gender-Diverse Youth Who Underwent Ambulatory Gender-Affirming Chest Reconstruction From 2016 to 2019^a.

Characteristic	No. (%) [95% CI]b
Unweighted sample size	829
Age category, y
≤14	42 (5.5) [3.6-8.4]
15	131 (16.0) [13.7-18.6]
16	291 (34.5) [31.0-38.2]
17	365 (44.0) [40.3-47.9]
Race and ethnicityc
Asian or Pacific Islander	9 (2.5) [1.4-4.7]
Black	10 (2.7) [1.5-4.8]
Hispanic	41 (12.2) [8.9-16.4]
Native American	2 (0.5) [0.1-1.8]
White	279 (77.9) [73.1-82.1]
Otherd	13 (4.2) [2.2-7.9]
Expected primary payer
Public health insurancee	135 (16.5) [12.0-22.1]
Private health insurance	495 (61.1) [52.0-69.4]
Self-pay	134 (15.8) [11.2-21.8]
Otherf	65 (6.7) [2.6-16.1]
Patient location
Counties with >1 million population	561 (68.0) [62.3-73.3]
Counties with 250 000-999 999 population	179 (21.9) [17.5-27.0]
Counties with <250 000 population	87 (9.8) [6.8-14.0]
Missing data	2 (0.3) [0.1-1.1]
Median income, $
1-47 999	65 (7.7) [5.8-10.1]
48 000-60 999	114 (13.3) [10.3-16.9]
61 000-81 999	235 (27.8) [23.7-32.3]
≥82 000	408 (50.3) [43.4-57.2]
Missing data	7 (1.0) [0.4-2.1]
Hormone therapy	170 (19.9) [14.8-26.1]
Comorbidities
Anxiety	179 (21.1) [16.6-26.4]
Asthma	77 (9.3) [7.0-12.2]
Depression	138 (16.2) [12.2-21.2]
Diabetes	2 (0.2) [0.1-0.9]
History of tobacco use disorder	14 (1.6) [0.7-3.6]
Hypertension	3 (0.3) [0.1-1.1]
Obesity	34 (4.2) [2.9-6.2]
Total charges, median (IQR), $g	29 886 (21 285-45 147)

^a Data were obtained from the 2016-2019 Nationwide Ambulatory Surgery Sample.

^b Percentages were calculated using survey weights.

^c Race and ethnicity were collected from hospital records in 2019 only.

^d Included multiple races.

^e Public health insurance included Medicare and Medicaid.

^f Included no charge or other expected primary payers.

^g Adjusted for inflation.

Most adolescents who underwent chest surgery during the study (50.3%; 95% CI, 43.4%-57.2%) had a family income of $82 000 or more. The median (IQR) total charges for chest reconstruction were $29 886 ($21 285-$45 147), which did not change during the study period.

Psychiatric conditions were the most common comorbidities, 21.1% of patients (95% CI, 16.6%-26.4%) had anxiety and 16.2% (95% CI, 12.2%-21.2%) had depression. Only 19.9% (95% CI, 14.8%-26.1%) of adolescents who underwent chest reconstruction used gender-affirming hormone therapy.

Discussion

To our knowledge, this study is the largest investigation to date of gender-affirming chest reconstruction in a pediatric population. The results demonstrate substantial increases in gender-affirming chest reconstruction for adolescents. Most TGD adolescents had either public or private health insurance coverage for these procedures, contrasting with the predominance of self-payers reported in earlier studies on TGD adults.⁵ Adolescents undergoing gender-affirming chest reconstruction may use hormone therapy, but most in this study were not in accordance with data from the 2015 US Transgender Survey.⁶ Study limitations include the reliability of diagnosis codes in identifying TGD patients, sampling error, and the absence of cost-to-charge ratio data.

Supplement.

eAppendix. Gender Dysphoria Diagnosis Codes and Current Procedural Terminology (CPT) Codes Analyzed