Gender-Affirming Care in a Public Health Payer System: A Cost-Utility Analysis of Top Surgery

Gender-affirming surgery can improve the mental and physical health of transgender and gender-diverse (TGD) adults. Examination of these effects through economic evaluation has yet to be conducted in a publicly funded health care system.

A Markov model was used to inform the cost-utility analysis over a 20-year time horizon. Uncertainty was assessed using probabilistic sensitivity analysis. The time horizon was varied in a scenario analysis. The analysis adopted the Ontario public payer perspective, with costs reported in 2024 Canadian dollars (CAD $1 = US $0.86 using Organisation for Economic Co-operation and Development 2022 purchasing power parities). Costs, utilities, and probability states were derived from health authority reports and the literature. The cohort included TGD adults in Ontario who desire top surgery. Top surgery was compared with no surgery. Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio were the primary outcome measures. Top surgery would be considered cost-effective if the incremental cost-effectiveness ratio was below the typical willingness-to-pay threshold of $50,000 per QALY (discounted at 1.5% per annum).

The cohort consisted of 1000 TGD individuals, representative of current Ontario top surgery waitlists. Top surgery was dominant (incremental cost -$2857, incremental effectiveness 0.59 QALY) compared with no surgery over a 20-year time horizon. Results were robust, with surgical intervention being cost-effective in 58% (dominant in 52%) of the 10,000 Monte Carlo simulations.

The findings suggest that top surgery is a cost-effective intervention at conventional willingness-to-pay thresholds. There may be a system-level benefit to providing access to care for waitlisted patients.