Background : California law ensures insurance coverage of medically necessary transgender health care. Unfortunately, uninsured transgender patients have no such access to care. To best improve transgender health disparities, the Department of Public Health of San Francisco County received funding to establish a gender health program for under- and uninsured transgender patients. Herein we present our hallmark experience in establishing a government funded transgender surgery program for uninsured patients in San Francisco, the first of its kind in the United States.
Methods : The Gender Health SF (GHSF) Program operates in accordance with the WPATH SOC (World Professional Association for Transgender Health Standards of Care). In addition, GHSF specifically requires referrals from a PCP who has treated the patient continuously for at least one year. A formal assessment is generated, and the patient is assigned a patient navigator (trans individuals who have undergone surgery) to assist in assembling the required documentation, as well as provide support, education, and encouragement. When patients are deemed stable from a medical, psychological, and social standpoint, they are referred for surgical evaluation.
Results : A retrospective review of patient outcomes (via EMR, electronic medical record) and quality-improvement patient survey data was performed. Since the origin of the GHSF program in 2013, 351 surgical cases have been completed (genital surgeries and select other procedures were referred to outside providers. Feminizing mammoplasties were the modal surgery (150 cases), with 109 vaginoplasties and 59 gender affirming mastectomies as the second and third most common gender affirming procedures performed. Comprehensive facial feminization is growing most rapidly, with 12 cases in 2017, and 30 in 2018. Clinical outcomes data for a single surgeon were reviewed. This surgeon completed 93 primary feminizing mammoplasties; there were no surgical site infections, and one revision was performed to correct minor postoperative asymmetry. Of the 28 gender affirming mastectomies performed, one patient had partial nipple loss due to persistent tobacco use, and three minor scar revisions were performed on other patients. Of 183 survey respondents, 97.8% felt “very” or “completely” prepared for surgery, reflecting the effectiveness of our pre-operative screening and education/support programs. 91.8% of respondents noted satisfaction with surgery, with 76% noting “complete/extreme” satisfaction.
Conclusions : Key components to success in providing transgender surgical care for uninsured patients include the requirement of a stable PCP for referrals and a Peer Navigator. Complication rates for chest and breast surgeries in this public health sample mirror those previously reported in the private population, and our preliminary satisfaction data confirms effective quality outcomes. Most remarkably, because patients referred through this program must establish stable social circumstance to qualify for surgery, we have seen an unprecedented improvement in functional societal roles as these motivated patients seek stable jobs, housing, and health maintenance. Further data review is in progress to quantify the long term psychosocial benefits not only on an individual basis, but for society at large. Our program has established that public funding can effectively improve health disparities in uninsured transgender patients with notably low complications and very high patient satisfaction.