Impact of State Legislation on Regional Availability of Gender-Affirming Surgeons in the United States

Provider scarcity is one of the principal barriers to gender-affirming care (GAC) in the United States, with poorly characterized geographic variation. State-level legislation governing access to gender-affirming surgery (GAS) provides a framework for examining how the regulatory environment correlates with surgeon availability. This study examined the geographic distribution of GAS surgeons across the United States and its association with state legislative classification.

Six provider databases were queried to identify surgeons offering gender-affirming procedures and their practice locations. Isochrone application programming interface (API) software mapped all counties within a 2-hour drive of each surgeon. Surgeon-to-transgender population ratios were calculated.

Surgeons per 10,000 transgender individuals ranged from 0 to 26.4 (national average 8.2). Chest surgery had the broadest access, with 65.4% of counties (83.9% of the population) within a 2-hour drive of at least one surgeon. Access declined substantially for more specialized procedures: 30.9% of counties (65.1% of the population) for facial feminization; 16.1% of counties (50.0% of the population) for chondrolaryngoplasty; and 15.0% of counties for vaginoplasty. Restrictive states averaged 5.91 surgeons per 10,000 transgender individuals, compared with 9.80 in neutral states and 10.83 in protective states; shield states averaged 7.65.

Access to GAS varies markedly by procedure type and state legislative category. Chest surgery has the widest geographic availability, while access to genital reconstruction and voice surgery remains critically limited. Surgeon density is significantly lower in restrictive states than in neutral or protective states, a pattern consistent across parametric and nonparametric analyses.