An unexpected announcement from President Donald Trump has propelled discussions on the costs and complications of transgender medical care into the mainstream.
In a series of Tweets earlier this summer, the President declared his intention to expel all transgender individuals serving in the US military, citing “tremendous medical costs” as a primary factor in his decision. Along with several political opponents and critics in the lay press, numerous health associations released condemning statements the same day arguing that the president’s claims were unsubstantiated.
“There is no medically valid reason to exclude transgender individuals from military service,” David O Barbe, MD, president of the American Medical Association, said in a statement released the day of President Trump’s announcement. “The financial cost … should not be used as an excuse to deny patriotic Americans an opportunity to serve their country.”
“Many thousands of dollars have already been spent studying this matter,” Gail Knudson, MD, president of the World Professional Association for Transgender Health, said in the organization’s statement. “There’s no appreciable increase in cost associated with allowing transgender people to serve openly.”
Among the most recent of these studies was a 2016 analysis conducted by the RAND Corporation. The corporation estimated that only 2450 of the 1.3 million active-component service members were transgender, and of these 29 to 129 active members would seek transition-related care that could disrupt their service. Further, they wrote that extending gender transition-related health care coverage to these personnel would increase costs by $2.4 million to $8.4 million annually—a 0.04% to 0.13% increase in health care expenditures for active military members.
“I don’t think [the statement] was grounded in reality of what the individuals who are in the military are really costing people.” Ruben Hopwood, PhD, coordinator of the Trans Health Program at Fenway Health, said in an interview. “The military spends more on Viagra than it spends on treating trans people that are in the military. That's what I find laughable about it.”
Small budget impact
Disproportionate views on the prevalence of transgender persons and the cost of their care also extends into the general population, Dr Hopwood said. While empirical data on the demographics of transgender persons in the United States is generally unavailable due to difficulties stemming from discrimination, estimates from various surveys suggest 1% to 3% of the population has ever experienced a form of gender dysphoria, and only 0.5% has sought dysphoria treatment.
“They get a lot of attention because it's kind of sensationalistic, and that's how our society thrives,” he said. “It's a skewed view of the very tiny population.”
The primary additional needs of gender-affirming care are hormone therapy, psychological care and surgical procedures, First Report Managed Care Editorial Advisory Board member Larry Hsu, MD, Medical Director of the Hawaii Medical Service Association, said in an interview. Although each of these treatments come with their own costs, he said that their impact is still minimal when considering the size of this population.
"I can reasonably state that the cost per unit per patient is not that significant,” he said. “It pales by multiple factors compared to other disorders. This is not a budget breaker.”
Approximately 75% to 78% of individuals seeking gender dysphoria care will pursue hormone treatments, which are generally continued for the duration of a transgender patient’s life, Dr Hopwood said. The prices for these will vary by delivery method, he continued, with oral estrogen costing $20 monthly, injectable estrogen roughly $150 to $200 monthly, and accompanying spironolactone $10 to $20 monthly. For transgender men’s hormone therapies, testosterone injections typically cost $80 monthly (but may vary based on state supply regulations), testosterone patches more than $300 monthly, and testosterone gels between $300 to $350 monthly.
“As far as medications go ... those are super cheap,” Dr Hopwood said. “But you do have a lifetime of them, so people starting them in their 20s and 30s ... are going to be using them for a long, extended time period.”
Surgeries, on the other hand, are characterized by a larger one-time cost. These procedures are most often sought by transgender males, Dr Hopwood said, with the most common being chest reconstructions costing between $9000 and $10,000. Whereas survey data cited by Dr Hopwood suggest that 40% of transgender males have already had this procedure, only 3% reported undergoing a metoidioplasty ($50,000-$60,000) and 2% reported having a phalloplasty ($50,000-$300,000). Hysterectomies ($10,000) were also reported by 20% of transgender men, although Dr Hopwood said that many of those seeking the procedure do so out of medical concern.
Although some may view certain gender-affirming surgeries for transgender women as cosmetic, Hopwood said that many of these procedures are especially necessary for women as they are much more likely to face discrimination or violence based on their presentation. Breast augmentation surgeries can cost anywhere from $5000 to $10,000 and are sought by more than half of transgender women, he said. Facial feminization surgeries could be as expensive as $40,000 or as little as $3000 depending on the patient’s preexisting facial bone structure. For sexual organ surgeries, vaginoplasties ($30,000 to $50,000) were reported among approximately one-fifth of transgender women, while labioplasties ($4,000 to $5,000; sometimes included with vaginoplasty) and orchiectomies ($4000 to $6000) alone were less common. Dr Hopwood noted that some transgender women will also seek hair removal, non-breast implants, tracheal shaves or liposuction to better fit in with the general population, although these surgeries are much less likely to be covered by insurance policies.
Nearly all of these considerations must be considered alongside psychological care for depression, anxiety, suicide risk, and other mental health issues that more frequently affect transgendered persons, Dr Hsu said. In addition, these patients are required to visit a psychological health expert prior to starting hormone therapy or gender-affirming surgeries, Dr Hopwood explained, with sign-offs from two experts often required for sexual genital surgery.
Attention to comorbidities will also become more imperative as a transgender patient ages, Barney Spivack, MD, national medical director of Medicare case and condition management at OptumHealth, and First Report Managed Care Editorial Advisory Board member said. Along with the typical gamut of chronic diseases, he noted that prostate, breast, cervical, and anal cancers could require special attention, alongside side effects of and reactions to hormone therapy.
But in spite of these additional costs, Drs Hsu and Hopwood both stressed that their impact pales in comparison to the expensive routine therapies necessary for other large patient subpopulations
“The cost overall is pretty negligible,” Dr Hopwood said. “In single sections it's going to be kind of high, but certainly less expensive than HIV and cancer treatment, and we treat that routinely. It's got to be put into perspective, and the sensational part about who is being treated has to be removed from the equation for people to think clearly and really look at things without all of the kneejerk visceral reactions that come into play.”
Barriers to basic care
Hormones, surgery, and counseling may be the first issues raised when discussing transgender care, but oftentimes it is the lack standard care that most greatly affects this population and, as a result, drains resources from health care systems down the road.
"We've still got humans that need preventative primary and the same care as absolutely every other person—the basic care is absolutely required,” Dr Hopwood said. “The problem is that the basic care is often what is being denied, and treated as part of this 'you're costing me money.' But we don't treat anybody else that way with basic preventative care."
Under the Affordable Care Act’s non-discrimination provision (Section 1557)—which received a final ruling on May 13, 2016 but as of now is partially enjoined by a US District Court—any health program, insurer or other activity that receives support from HHS may not discriminate on the basis of a race, color, sex and other patient characteristics. While the provision ensures care for transgender persons, Dr Spivack said, it is not a sure bet that providers or insurers will support every treatment.
“The main point is that coverage for health services has to be appropriately provided regardless of sex assigned at birth, gender identity, or recorded gender,” he said. “But just because there’s a nondiscrimination mandate, that does not mean that everything is covered.”
Hopwood said that depending on the state, most if not all care related to gender dysphoria will be denied by insurers. The result, he said, is that cervical cancer, breast cancer screenings, or other care tangentially related to sex may be routinely denied for many transgender patients. In addition, infrequent coverage of mental health care for gender identity or dysphoria forces many patients to either hide their orientation, or to forego care and grow into a more substantial burden.
“The number one cost and drag on health care, on systems, is major depression and the cost of disability for people who cannot get up and go to work,” Dr Hopwood said. “The effect (of transition care) is that you take people who are otherwise going to be living off of disability and public services and you get them back into productive adult participation in a society.”
Lack of treatment or coverage could lead these patients to seek their own care from less reputable sources, warned Dr Hopwood and Caitlin Leach, PharmD, clinical pharmacist at Park Pharmacy, Maryland, and lecturer on transgender topics at the School of Pharmacy at University of Maryland.
“There's a lot happening that forces patients to turn to silicone ‘pumping parties,’ where needles may be shared,” Dr Leach said in an interview. “People are pumping silicone, which is incredibly dangerous, or there are hormones that they might acquire from non-pharmacy sources. That's going to put them at a huge risk for complications and potentially ED visits, which we already know are very expensive and a burden to the health care system.”
“It's just horrible for people, and they don't have any other options for healthy care,” Dr Hopwood said. “But they sure do show up with the infections, with the loose stuff floating through their hearts and lungs. The care [becomes] catastrophic care, and it costs way more than it would have just cost to do the implants.”
Increased awareness could change care
Growing awareness of transgender persons in mainstream culture could have a modest effect on the future of care, as those experiencing gender dysphoria increasingly step forward. Dr Hsu explained that his health system had recently noticed a small bump in the number of transgender cases—a change that he labeled the “Bruce Jenner effect.” Dr Leach said that she hoped more providers would gain experience and become more comfortable treating transgender patients over time, with the eventual goals of reducing discrimination from providers and convincing insurers of the importance of transition care coverage.
“I know a lot of physicians will disagree with me that it's not their job to become activists, but I do think... we need to get involved with discussions on insurance coverage and advocating to other care providers,” she said.
While Dr Hopwood said that he did not believe the total number of patients experiencing gender dysphoria would change, he anticipated that growing awareness could lead these patients to seek care at a much younger age. Such a trend, he explained, could lead to greater costs for health care systems due to the many additional years that a patient would be seeking regular hormone treatment.
Even if these numbers were to see a slight increase, however, the experts said that their stance on the overall impact of providing transgender care would remain the same.
“While there are some larger costs in the 3 to 5 year time period, the long-term cost... is not a budget-buster,” Hsu said. “CFOs should not be losing sleep about this cost.”