Little is known about the cost of gender-affirming surgeries (GAS) in the United States (US). The aims of this study were to characterize the national trends of GAS cost and to examine demographics associated with potential differences in cost from 2012 - 2019 in the US.

This retrospective, serial cross-sectional study utilized the National Inpatient Sample from the Healthcare Cost and Utilization Project, which captures nationally representative inpatient visits in the US. Inclusion criteria were records from 2012 - 2019 that indicated at least 18 years of age at time of admission, with gender-diverse (GD) diagnoses and GAS procedures that were identified using ICD-9 and ICD-10 codes. Among these records, demographics, utilization, and cost in inflation-adjusted, 2022 US dollars were collected. Excluding records with no cost data, median and mean cost were calculated, and a multivariable regression model was created to examine key drivers associated with potential differences in cost. Data were analyzed in R.

Of an overall weighted estimate of 70,590 records with a GD diagnosis code, 6,325 (9.0%) underwent GAS. Among these records, the median age was 34 years and the median length of stay (LOS) was 3 days. The majority indicated male sex (54.9%) and White race (67.6%), underwent genital surgery (81.5%), had private insurance (56.7%), and underwent GAS in a hospital located in the West (50.5%). The overall median cost of GAS was $22,267 (IQR $12,163 - $32,431) and remained relatively stable from 2012 - 2019. The overall mean cost was $24,834 (± $1,310) and increased 35% from 2012 – 2019 (Figure 1). The cost of genital GAS remained relatively stable over time, except the highest quartile group where rising costs are noted, and its utilization increased 6 –7-fold over time. GAS utilization in non-White records increased 7 – 8-fold over time; compared to 2012 when only 25% of GAS was utilized by non-White records, this proportion rose to 32% in 2019. Utilization by records with Medicaid and Medicare are most robust in 2014 – 2019 and increased 6 – 7-fold during this time. On multivariable analyses, shorter LOS and hospital location outside the West were associated with lower costs (p<0.001). Records indicating male sex and non-White race were associated with higher costs (p<0.05).

This study found that while the median cost of GAS has remained stable over time, the mean cost has increased. The utilization of GAS increased over time, especially in records that indicated public insurance and non-White race, suggesting that access to GAS has increased. Variations in GAS costs may be driven by LOS, hospital location, sex, and race, which may be influenced by geographic variations in labor costs and the social determinants of health that this study was not able to control for. Further studies are needed to understand reasons for potential differences in cost by demographics, the increase in cost for the highest quartile of genital GAS, and trends in facial and vocal GAS performed in outpatient settings that this data do not capture.

As demand for GAS increases with variations in cost by several demographic variables, there will likely be a need to evaluate health policies to increase GAS coverage and access.

Continence 7S1 (2023) 101027
DOI: 10.1016/j.cont.2023.101027