Gender-affirming surgery (GAS) in the U.S. nearly tripled from 2016 to 2019, a longitudinal study found.

The number of gender-affirming procedures rose from 4,552 in 2016 to 13,011 in 2019, reported Jason Wright, MD, of Columbia University College of Physicians and Surgeons in New York City. It dropped slightly to 12,818 procedures in 2020, likely due to declines in elective surgery during the COVID-19 pandemic.

“Consistent with prior studies, we identified a remarkable increase in the number of GAS procedures performed over time,” Wright and colleagues wrote in JAMA Network Open.

The rise may be due in part to federal and state laws requiring coverage of transition-related care, although insurance coverage of specific procedures is variable, the researchers noted. The trend “suggests that there will be a greater need for clinicians knowledgeable in the care of transgender individuals and with the requisite expertise to perform GAS procedures,” they wrote.

“Anecdotally, it has seemed that there has been greater interest in gender-affirming surgery among patients and requests are increasing,” Wright wrote in an email to MedPage Today. “However, there has been little objective data to document these trends.”

The finding confirms the general beliefs of people working in the field, Devin O’Brien-Coon, MD, MS, of Brigham and Women’s Hospital in Boston, told MedPage Today.

“I think that the absolute numbers are probably not entirely something that can be super-reliable” because of the way the national databases keep records, noted O’Brien-Coon, who wasn’t involved with the study. For example, if the self-reported sex of the patient and the procedure did not match in the database, the type of procedure was not specified and the entry marked “inconsistent,” making it difficult to count or verify which procedures were related to gender transition.

“So, it’s probably reliable for telling you there is an X percentage change between the years more than it’s reliable for ‘there are this many cases this year,'” O’Brien-Coon said.

“The general take is, it’s less about the population as a whole has shifted … and more about, more of them [people seeking GAS] feel comfortable being publicly out with who they are,” he observed. “The biggest thing is, probably, not specifically excluded from the healthcare system.”

In their analysis, Wright and co-authors evaluated data from the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample from 2016 to 2020. They selected patients with ICD-10 diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment and used procedure codes to identify encounters for GAS, including breast and chest procedures, Genital Reconstructive Surgeries, and other facial and cosmetic surgical procedures.

The researchers identified 48,019 procedures in the samples. Most were for patients 19-30 years old (25,099 procedures), followed by patients ages 31-40 (10,476 procedures) and ages 41-50 (4,359 procedures). Patients 12-18 years old had 3,678 procedures during the study period.

The most common surgeries were breast and chest procedures at 56.6%. About a third of surgeries (35.1%) were genital reconstruction, and 13.9% were facial and cosmetic procedures. Breast reconstruction was the most common breast and chest surgery, hysterectomy the most common genital reconstructive procedure, and liposuction the most common facial and cosmetic procedure.

Breast and chest surgeries and genital procedures rose until 2019 and declined in 2020, while facial and cosmetic procedures increased consistently through 2020.

In younger patients, breast and chest procedures made up the greatest portion of gender-affirming surgeries. Genital reconstructive surgeries were performed in 11% of patients 12-18 years old, compared with 58.4% of patients 61-70 years old.

Gender was self-reported in the samples; 31.7% were male and 54.7% were female. Most patients (65.1%) were white. Most (60.5%) were privately insured and 25.3% were Medicaid recipients. About two-thirds (65.9%) of patients in the samples underwent one procedure, and 27.9% underwent two.

Study limitations included the possible under-capture of both transgender individuals and GAS procedures in the samples, the researchers said.