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New England Section of the American Urological Association

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Evaluating a Rural Transgender and Gender Diverse Population and Interest in Genital Gender Confirming Surgery
Amanda R. Swanton, MD/PhD, Ella A. Damiano, MD, John F. Nigriny, MD, Benjamin Boh, DO, MS, John H. Turco, MD, William Bihrle, III, MD, Rachel A. Moses, MD, MPH.
Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.

Introduction: In addition to the multiple psychosocial and health disparities faced by transgender and gender diverse persons (TGGD) seeking hormonal and surgical interventions, those living in rural areas face additional barriers to healthcare. The 2015 U.S. Transgender Survey revealed up to 25% of respondents had undergone genital gender confirmation surgery (GCS): 10% TGGD female and 2% of TGGD male respondents. Little is published regarding the transition related health care utilization for TGGD persons from rural areas. We sought to evaluate such a population.
Materials & Methods: This is a single center descriptive study evaluating a population of TGGD persons seeking gender related care in a rural academic hospital between September 2015 and February of 2020. The electronic medical record was reviewed to identify TGGD persons carrying ICD-10 and F64 CPT codes delineating “gender identity disorder” or “gender dysphoria”. Patient variables including age, gender assigned at birth, use of hormones, history of GCS, and home zip code were abstracted through administrative data and retrospective chart review. Of those patients who had not previously undergone GCS, a granular chart review was performed to capture documented interest in pursuing GCS. Patient variables were tabulated using R, and comparisons were made using chi-squared tests. Zip codes were used to determine if patients resided in rural versus metropolitan locations. Results: During this time period, 1466 patients were identified with gender identity CPT codes; 43 patients were excluded due to the patient being deceased or suspected coding errors. Of the 1423 patients included in the final analysis, 837 (59%) of patients were assigned female sex and 586 (41%) were assigned male sex at birth. Though most patients were between the ages of 18-60, 279 (20%) were younger than 18 and 45 (3%) were 65 or older. Hormone use was documented in 1036 (73%) of patients, including 588 (70%) TGGD males and 448 (76%) TGGD females (p = 0.012). Genital reconstruction was documented in only 42 (3%) of patients, including 6 (1%) TGGD males and 36 (6%) TGGD females (p <0.001). Of those who had not received genital reconstruction, 100 (7%) patients had a documented interest in the medical record, including 21 (3%) TGGD males and 79 (14%) TGGD females (p <0.001). The hospital drew patients from a large, multi-state region with 817 (57%) patients coming from rural zip codes.
Conclusions: A large number of TGGD persons from surrounding rural and metropolitan areas sought gender health care at this rural academic medical center, predominately adolescents and young adults, with a slightly higher proportion of TGGD males. The majority of patients receive hormone therapy. While a relatively small proportion have undergone genital gender confirming surgery, nearly 10% of patients had a documented interest in GCS which due to the limitations of the study, may be an under-estimation in this population. Further research is needed to determine transition related surgical healthcare needs of this population and to further develop rural comprehensive gender health programs.


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