Project Summary An estimated 1.4 million Americans identify as transgender, defined as incongruence between one’s gender and their gender assigned at birth. For many transgender people, having primary and secondary sex characteristics that align with their gender is essential to mental, emotional, and physical wellbeing as well as their ability to meaningfully engage in social roles. Gender-affirming surgery allows patients to change their primary and secondary sex characteristics through a variety of operations, including vaginoplasty, phalloplasty, gender-affirming mastectomy, breast augmentation, and facial feminization. The number of individuals seeking gender-affirming procedures has increased dramatically in recent years, with over 8,000 gender-affirming procedures performed in the United States in 2017 alone. Despite their effectiveness, gender-affirming procedures are costly, and often prohibitively expensive for most patients without insurance coverage. Fortunately, many insurance carriers provide coverage for gender- affirming procedures, but most require prior authorization processes and do not offer uniform coverage for all types of procedures. Further, coverage for these procedures varies geographically, and depends on both state and federal legislation. As such, the effects of policy and payment models on the accessibility of gender- affirming surgery remains unclear. In this two-year study, we will quantitatively and qualitatively examine the impact of legislative measures and payment models on the rates of gender-affirming surgery. We specifically aim to: 1) assess the effect of payment models on access to these operations via the patient perspective and 2) utilize claims database analysis to determine the association of the enactment of the Affordable Care Act and rates of gender-affirming surgery. Results from this mixed-methods investigation are critical to evaluating the efficacy of policy affecting gender-affirming surgery and guide future legislation. The robust methodology proposed in this study alongside the rigorous coursework through the National Clinician Scholars Program will prepare Dr. Lane for a career as a surgeon-scientist with deep expertise in the application of health services research to enhance the care of transgender individuals.

Using both qualitative and quantitative methodology, we will examine patient-perceived and population-based barriers to gender affirming surgery. We will perform semi- structured interviews to evaluate financial toxicity as well as claims database analysis to determine the effect of insurance characteristics and federal policy on the rates of gender affirming surgery.