Epidemiology and disparities of gender-affirming surgery in the United States

Several advances have been made to increase access to gender-affirming procedures across the country, yet it remains unknown whether these benefits are experienced disproportionately across demographics. The purpose of this study was to investigate the epidemiologic trends of gender-affirming surgery across the country over the past six years, as well as to analyze the racial and ethnic disparities in immediate postoperative complications for patients undergoing gender-affirming surgery nationwide.

Retrospective cohort study was conducted of gender-affirming procedures performed in the United States between 2015 and 2020 across 719 hospitals participating in the National Surgical Quality Improvement Program. Age at surgery, type of reconstruction, and postoperative complications were compared across demographic groups.

During the study interval, 4491 patients underwent gender-affirming surgery, including 71.1% (n=3221) masculinizing procedures and 28.3% (n=1270) feminizing procedures. Over the last five years, there has been a fourfold increase in gender-affirming surgery, from 299 per million to 1029 per million cases performed in the United States (p<.001). Transmasculine patients were ten years younger than transfeminine patients (p<.001). While masculinizing procedures were the most common across all demographics, Black and Hispanic patients were significantly more likely to undergo feminizing procedures than White patients (p<.001). Black patients were significantly older than White patients at the time of surgery. Black patients were significantly more likely than White patients to experience postoperative surgical complications (p=.039).

Racial and ethnic disparities exist in gender-affirming surgery preference, timing, and postoperative outcomes.