8/28 - What Do We Know About Differences In Access to Care And Surgery Complications for Black Transgender People?

August 28, 2023

Everyone at QueerDoc fits somewhere in the LGBTQ+ broadband. One of the reasons QueerDoc exists is healthcare discrimination and our mission to cure it. But, let’s face it, we’re mostly white, and while we have experienced discrimination as patients, our personal experiences can only inform so much of what we do. Medical discrimination is layered and complex, and racial bias is heavy in that mix. Collectively, we have access to a lot of education, including medical academic libraries: one thing we can do is use those resources to identify ways that can help our patients access care and improve their outcomes.

We wish to thank Justice Roe Williams (he/him) for his guidance, training, and support as we strive to identify and deconstruct how personal and systemic biases influence our work so that we can do more dismantling of how cishet white supremacist patriarchal culture works in medicine. Justice uses his former experiences as a Trans Health Navigator at Fenway Health in Boston, MA, and his current expertise as a certified personal trainer to inform both his activism and his work as a DEI consultant in the health and wellness industries. Justice is the executive director of Fitness4AllBodies and an editor of Deconstructing the Fitness Industrial Complex: How to Resist, Disrupt, and Reclaim What It Means To Be Fit in American Culture.

The heart of this blog is about differences in surgical outcomes for Black trans patients and potential ways to lessen the risk of complications. If you don’t want to read all the way through, here’s the scoop: it appears that, although overall complication rates are not much different across races, Black patients have higher rates of reoperation and readmission than white patients, and researchers think that’s due to hematomas, which are serious bruises at incision sites. Black patients might not be more likely to get hematomas, but care teams might be less likely to notice them and act quickly to prevent further complications because care teams aren’t familiar with what bruising looks like in darker skin. We share some hematoma risk factor information at the end of this blog and have put together a checklist for talking with your surgeon about hematomas.

But, unfamiliarity with how bruising and healing happen in darker skin is a symptom of systemic factors that impact overall access to gender affirming care. So let’s talk about some of those, too:

Access to Care:

It’s really hard to get surgery without insurance. There are systemic barriers to getting both healthcare and insurance that disproportionally impact Black and trans people.

Statistically, both Black and trans people in the U.S. have higher rates of unemployment or under-employment, lower total incomes, and fewer actual healthcare facilities or providers in their communities compared to white and cis people. Jobs that are available may not provide employer-sponsored health insurance.

If you’re interested in some in-depth reading, the Center for American Progress put out a really good (but academic) white paper on healthcare discrimination and barriers to insurance for transgender and gender non-conforming people. You can also check out their short form fact sheet.

The 2015 U.S. Trans Survey is one of the only big datasets that helps us understand how racism and transphobia intersect in trans-specific healthcare.

For the respondents of the U.S. Trans Survey, factors that impacted access to healthcare included:

Income. The higher your income, the less likely you are to be denied care.
Education. The more formal education you have obtained, the less likely you are to be denied care.
Race. Biracial or multiracial transgender people were more likely to be denied both trans-specific and general care compared to other minority groups. Black transgender people were less likely to be denied trans-specific care than other minority groups, but more likely to be denied general care compared to Latino/a/Hispanic and Asian/Native Hawaiian/Pacific Islander respondents. All minority respondents were more likely to be denied care compared to white respondents.
Age. There was greater access to care among those 18-24. Those 24-44 and 45 and up were more likely to be denied care.
Disability. Disability increased the rate of denial. The authors do not provide additional information.
Gender identity. Genderqueer and nonbinary individuals were less likely to be denied care compared to binary transgender individuals. This may be a reflection of presentation, requested care, being out to providers, or other factors.1

All of these identities can stack and can run smack into individual providers with biases and shortcomings in medical education that further impact access to care.

Location and Politics Also Play a Huge Role in Access to Care and Insurance

The ACA has made a huge difference in access to insurance.

The number of uninsured nonelderly adults (so, not eligible for Medicare) drastically changed when the Affordable Care Act (ACA) was signed into law.

Prior to the ACA law in 2010, there were 46.5 million uninsured nonelderly adults in the United States. That number dropped to 28.9 million in 2019 and 27.5 million in 2021.2 That’s nearly twenty million more adults getting insurance in ten years. Uninsured rates have decreased across racial, ethnic, age, and income groups since the passage of the ACA.3

In 2021 POC made up 45.1% of the nonelderly US population, but 61.3% of the nonelderly uninsured population.

For Black nonelderly adults, this is how the rates of not having insurance changed after the ACA:

2013 – 21%
2016 – 13%
2021 – 10.9% 2

For Black trans adults (from the 2015 U.S. Trans Survey, Report on the Experiences of Black Respondents):

2015 – 20% of Black respondents to the U.S. Trans Survey did not have health insurance compared to 14% of all respondents. The overall rate of uninsurance in the U.S. at the time was 11% and the rate among Black people was 13%. Transgender people were more likely to be uninsured than cis people, and Black transgender people were more likely than transgender people as a whole to be uninsured.

Did Your State Opt-In to Expanded Medicaid Requirements? Does Your State Legally Protect Gender Affirming Care?

The ACA allowed each state to decide whether or not to raise the income limits for Medicaid eligibility. Overall, states that opted to expand their Medicaid eligibility rules saw more people getting insurance. About twice as many: the uninsured rate in non-expansion states is 15.1% compared to 7.7% in expansion states.

Along with more people gaining access to insurance due to the ACA and Medicaid expansion, executive actions in the Obama and Biden presidencies added policies that prohibited discrimination and required coverage for gender affirming care to insurance requirements.

Do You Like Maps?

The Movement Advancement Project is a fantastic resource for visual data about protective and restrictive state-level policies about gender affirming care. Here are some of the results of their work:

States With Medicare Coverage for Gender Affirming Care:

States Which Ban Exclusions Of Trans Care:

Movement Advancement Project map indicating states that insurance nondiscrimination laws protecting gender affirming care. The majority of highest protection states are in the west (WA, OR, CA, NV,) on the Great Lakes (MN, WI, IL, MI, NY) and northeast (VT, NY, ME.) Highest protection states/locations also include CO, DE, Washington, D.C., and PR. | access

When we tie these maps with one of the states that opted in to Medicaid Expansion (so more people were eligible for insurance) it is clear that states with expanded access also tend to cover gender affirming care and protect access to that care. This one is from KFF.org:

Map of the United States indicating states with opted to expand Medicaid. States which adopted and expanded Medicaid are in dark blue, while states which did not adopt expansion are in orange. The majority of non-adopter states are in the south and southeast: TN, MS, AL, GA, SC, FL, along with WY, WI, KS, and TX. | access

The really big thing here, however, is that the majority of the U.S. Black population lives in states that did not expand Medicaid, do not include gender affirming care in Medicaid coverage, and do not protect access to care. Some, as we all know from these last several months of state bans, actively work against access to gender affirming care. It might not follow that the majority of Black trans people also live in these states, but it does seem likely that Black trans people are disproportionally affected by state policies that create barriers to care.

U.S. Black Population, 2020 Census:

Map of the United States indicating the % of population by state that is African American/Black. Darker green states have a higher percentage of Black/African American residents. There is a clear preponderance of darker green (higher % of population) in the south and southeast, and in the mid-Atlantic states. via Wikipedia. | access

A recap:

Black and trans people are less likely to have jobs that provide insurance or sufficient income to be able to purchase private insurance Access to state-based insurance that covers gender affirming care is highly dependent on location.

All this adds up to less access to surgery.

Okay, Now Let’s Talk About What Happens After Surgery

Most 20th and 21st-century medical research has been done on white, cis, and usually male patients. There are a lot of reasons why this is, including bias affecting which patients get enrolled in studies, systemic factors which impact if patients stay in studies or are lost to follow-up, available funding and research opportunities for scientists, patient distrust of research opportunities due to historical wrongs, and basic assumptions that studying one group of people is applicable to other groups of people. There also tend to be fewer studies available as the population being studied gets smaller. It’s also harder to draw conclusions about studies when the number of people in the study is small.

For our needs, we’re interested in:

Surgical outcomes and complications by race.
Surgical outcomes and complications by gender.
Surgical outcomes and complications by race and by gender.

Check out our references and citations at the end of this blog for the studies we reviewed when researching this blog, and if you’re unable to get a copy of the articles we reference, let us know at info@queerdoc.com!

What Does The Research Say?

The first part of this blog talked about access to insurance. There is research (out of Veterans Affairs hospitals) that when access to care, including postoperative care, is equalized, survival rates are equalized. These studies looked at mortality after cancer surgeries, so it isn’t an exact comparison to gender affirming surgeries, but it is an important finding: if insurance/coverage is equal, patient outcomes appear to be more equal, too.4

What Do The Studies That Look At Race and Gender Affirming Surgeries Say?

Odds for Reoperation and Readmission

Article: Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery, LGBT Health, 2022, Vol 9, No 5.

This study of 2308 trans patients found that Black adults were more likely to need readmission or reoperation in the 30 days post gender affirming surgery and were more likely to develop an internal surgical site infection compared to white patients.

Article: Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries, Annals of Surgery, July 2023

This study specifically looks at outcomes in chest surgeries and found that there was no difference in overall complication rates for both chest-flattening and chest-augmenting surgeries by race. They also noted low rates of severe complications. However, they did find differences in specific complications:

Black patients obtaining chest-flattening surgeries had a higher rate of unplanned readmissions and mild complications compared to white patients.

Black patients obtaining chest-augmenting surgeries were more likely to have superficial infections and unplanned reoperation. The most common reason for readmission and reoperation was hematoma: wound bruising where blood pools under the skin.

But WHY?

The authors propose that the differences in hematomas needing reoperation is due to less familiarity with darker skin:

Postsurgical hematomas are often initially recognized through a combination of worsening discomfort and observable changes in skin color and appearance. Doctors may have less practice and expertise identifying these changes in a timely manner for patients with darker skin, and may also be worse at pain assessment in Black patients and other people of color.5
Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries. Annals of Surgery, July 2023

Hematomas are common complications in breast augmentations. There is some evidence to indicate that the technique and placement of the implant affect hematoma risk. Hematomas appear to be more likely when the submuscular/dual-plane approach is used and when the implant pocket is manually created (read more about pocket and surgical techniques in our augmentation blog.) Drains also appear to increase hematoma risk, while compression garments/surgical bras post-surgery decrease the risk of hematoma.6

We don’t know of any studies looking at other gender affirming surgery outcomes by race in detail. But, as superficial infection, hematoma, and wound dehiscence (when the edges of the wound don’t seal, or come apart after surgery) are also common complications for bottom surgeries, we think the same important question applies: how much does the care team know about healing in darker skin?

Specific Strategies For Lowering Hematoma Risk

Our recommendations:

Your Stay:

Do you have a friend or family member who could act as your advocate if you have concerns and they are not being treated seriously enough?
Know the signs of hematoma:
- Discoloration around the incision that looks similar to a bruise
- Swelling, especially sudden or uneven
- Pain
- If you are concerned about a potential hematoma, consider taking pictures to document skin changes
Risk factors for hematoma include:
- Age – older patients have a higher risk of hematoma
- Hypertension
- Medications (aspirin, NSAIDs, SSRIs, blood thinners)
  - Discuss stopping these medications with your surgeon and care team at least two weeks prior to surgery and waiting at least two weeks after surgery before resuming.
Undergoing more than one procedure in one surgery session
Vomiting 6

Your Surgeon: Download our Questions For My Surgeon About Racial Disparities in Care and Hematoma Risk

Questions For My Surgeon and Care Team About Racial Disparities in Care Download

For more information on risk factors for negative surgical outcomes, read our BMI and Gender Affirming Surgery blog.

Read our blog on checking out your surgeon and hospital’s safety ratings for information on how to get the scoop on outcomes and other patient safety measures.

This blog was originally much longer, but pages of data on systemic factors that influence access to care and access to insurance, even when you’re super nerdy about gender affirming care, don’t always make the best blog, so we cut it out. We would love to know if you’d like to know more about it all, about your experiences accessing healthcare, and any stories, good, or bad, about surgery that you would like to share. Trans stories are life-saving. You can find us at info@queerdoc.com.

There are no simple answers to systemic inequality. However, there are resources that can help with access to healthcare. Are we missing a group that provides healthcare support services to Black and trans people? Please let us know at info@queerdoc.com.

Services specific to Black trans folk:

BTAC Healthcare Services – (September 2024 – service may be down, but you can contact Black Trans Advocacy Committee to request information.)
For The Gworls
Black Transmen, INC,
Black Transwomen, Inc.
Black Trans Mx.
Black Trans Travel Fund
Trans Women of Color Collective: the Black Trans Health Initiative
National Black Justice Coalition

Other services:

Campaign for Southern Equality
Trans Empowerment Project
Trans Lifeline’s Microgrants
Elevated Access (supports travel for healthcare, but will need a referral)
Point of Pride grants

Sources, References, and Citations

Research about how surgical outcomes and complications differ by race:

Research about differences in complications and outcomes for similar procedures between cisgender and transgender patients:

Research about differences in outcomes for transgender patients by race:

Citations in the Blog

Healthcare Experiences of Transgender People of Color. Howard, S.D., Lee, K.L., Nathan, A.G. et al., J GEN INTERN MED 34, 2068–2074 (2019). https://doi.org/10.1007/s11606-019-05179-0
Key Facts about the Uninsured Population, Jennifer Tolbert, Patrick Drake, Anthony Damico, 12/19/2022, KFF
High Stakes for the Health of Sexual and Gender Minority Patients of Color. Judy Y. Tan, Ph.D., Arshiya A. Baig, M.D., M.P., and Marshall H. Chin, M.D., M.P., Division of Prevention Science, Department of Medicine, University of California San Francisco, San Francisco,CA, USA; Department of Medicine, University of Chicago, Chicago, IL, USA.
Racial Disparities in Surgical Care and Outcomes in the United States: A Comprehensive Review of Patient, Provider, and Systemic Factors, Adil H. Haider, Valerie K. Scott, Karim A. Rehman, Catherine Velopulos, Jessica M. Bentley, Edward E. Cornwell, Waddah Al-Refaie, Journal of the American College of Surgeons, Volume 216, Issue 3, 2013, Pages 482-492.e12,https://doi.org/10.1016/j.jamcollsurg.2012.11.014.
Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries. Annals of Surgery, Jolly, D., Boskey, E. R., & Ganor, O. (2023). Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries. Annals of Surgery, 278(1), e196–e202. https://doi.org/10.1097/SLA.0000000000005512
Hematomas in Aesthetic Surgery, Aesthetic Surgery Journal, Volume 38, Issue 9, September 2018, Pages 1013–1025, https://doi.org/10.1093/asj/sjx236

8/28 - What Do We Know About Differences In Access to Care And Surgery Complications for Black Transgender People?

Access to Care:

Location and Politics Also Play a Huge Role in Access to Care and Insurance

The ACA has made a huge difference in access to insurance.