Four of the region’s largest academic medical centers have opened or will soon open transgender surgery programs. | Courtesy of NYU Langone Health Transgender programs flourish following New York Medicaid coverage

Gaines Blasdel, a Washington, D.C., native who was assigned female at birth, began hormone therapy seven years ago at the age of 18.

At 19, Blasdel underwent chest masculinization surgery with financial support from his brothers and father. But like most transgender people, Blasdel believed genital surgery — also known as bottom surgery — was simply out of reach.


After all, in 2010, most insurance plans did not cover the operation and no hospital in New York performed the surgery. That meant even people who could get covered, or could pay cash, had to move to another city for a few months to be near their surgeons while they recuperated. The closest hospital that performed a phalloplasty — the construction of a penis with erotic sensation — was 800 miles away in Chicago.

In short, the surgery was beyond Blasdel’s means — and the means of all but the most well-heeled New Yorkers.

“The only people who could access these surgeries were people who did this instead of buying a house,” Blasdel said.

But that began to change in 2015, when New York became the ninth state to allow its Medicaid program to cover gender affirmation surgery. Private insurers were beginning to cover it as well. Suddenly, there was a payment model that could support New York hospitals’ investments in transgender surgery programs.

The result has been a host of new, more affordable options for transgender people seeking surgery. Mount Sinai Health System became the first academic medical center to open a program in March 2016, and NYU Langone Health soon followed — that’s where Blasdel underwent a phalloplasty in September.

“It was awesome,” Blasdel said. “The first couple days in the hospital, I was like, ‘yes!’ It was just really great to know I got exactly what I wanted.”

The Cuomo administration’s decision to have Medicaid cover transgender surgery created a surge in demand, and four of the region’s largest academic medical centers — Mount Sinai, NYU Langone, Montefiore and Northwell — have opened or will soon open programs.

For a population that’s disproportionately low-income, decisions by New York and other states to allow Medicaid coverage of transgender procedures has been a game changer. In 2015, New York Medicaid paid for 115 procedures for those with gender dysphoria. In 2016, the number more than doubled to 257.

“I’m afraid to take vacation,” said Jess Ting, director of surgery at the Center for Transgender Medicine and Surgery at Mount Sinai. He is on pace to perform about 250 this year, and the waiting list at Mount Sinai is so long that another surgeon, currently a Mount Sinai fellow, will be brought on board next summer. “I’m afraid to take a sick day, because that means someone can’t have their surgery.”

“The need is incredible,” Ting said as he sat in his scrubs — and choked up — shortly after completing male-to-female surgery on a 78-year-old patient at Beth Israel Medical Center, a patient who had been living as a woman for many decades, and had known she had the wrong genitalia since she was 5 years old. When they first met, Ting said, she was so nervous she could barely speak, afraid that after all these years she’d be told that she was now too old for the surgery.

Perhaps not surprisingly, the trend reflects the political and policy divide surrounding transgender rights. Of the 15 state Medicaid programs that cover gender reassignment surgery — New Hampshire being the most recent — all are states that generally vote Democratic and, with the exception of Illinois and Colorado, all are along the coasts.

And amid the Trump administration’s desire to have states take a greater control of their Medicaid programs, it is unlikely that red-blue divide will change any time soon.

As with reproductive rights, where a person lives will likely determine their ability to access transgender surgery.

“I think that we will see for some time to come that there are inequities among the states,” said Jillian Weiss, executive director of the Transgender Legal Defense & Education Fund. “It takes a long time for a society to change and to recognize the importance of civil rights for people, and the importance of health care.”

"Medicaid is the government’s provision of services to those who can’t otherwise afford them,” Weiss said. “It also is the state’s announcement of whether this kind of health care is something that they consider to be important for people.”

Avoiding 'terrible outcomes'

The Williams Institute at the UCLA School of Law estimates that 0.6 percent of the population identify as transgender. The New York metro region has approximately 20 million people so, statistically speaking, there are roughly 120,000, of all ages and ethnic backgrounds, who identify as transgender.

But for a surgery that costs tens of thousands of dollars, money is obviously an issue. A 2011 National Transgender Discrimination Survey found that transgender people are four times more likely than the general population to be living below the poverty line.

“Before Medicaid covered these operations, patients would go to unlicensed providers and they’d get silicone oil injected into their breasts to make breasts,” Ting said. “Some patients would auto-amputate their own penises. They would travel to Mexico to very shady surgeons, whoever they could afford and end up with terrible outcomes.”

Poor outcomes weren’t limited to shady providers operating out of Mexican storefronts. With so few providers in the United States and patients having to travel so far, complications were alarmingly frequent, said Lee Zhao, assistant professor of urology and co-director of the transgender reconstructive surgery program at NYU Langone Health. Patients with complications were so frequently referred to him that he decided to help start his own program.

In the wake of the Cuomo administration’s decision, NYU Langone hired Rachel Bluebond-Langner, a plastic surgeon from the University of Maryland School of Medicine, to be co-director of the program with Zhao. They performed their first vaginoplasty and phalloplasty procedures in January.

"One great benefit of insurance paying for this is surgeons were previously constrained by hospital resources and what they could do in an outpatient setting,” Zhao said. “The latest and greatest advances in medical technology were not applied to gender affirming surgery before insurance paid for it. Now we can use the exact same technology that we’d use for a prostate operation or a heart valve operation, And apply it to this field. So I think outcomes will improve because of that.”

NYU Langone was the first hospital in New York to use robotics for transgender surgery, allowing for better visualization and decreased blood loss. That helps with, among other things, a cleaner resection of the vagina.

"It’s used in every other pelvic operation,” NYU Langone’s Bluebond-Langer said.

The sudden flourishing of transgender programs is not without precedent. Policy at the state and federal level often drives industry development. Ambulatory surgery centers in New York grew at a rapid clip following the passage of 2008 state law that required physicians to obtain new accreditation if they wanted to continue to perform medical procedures in their offices using moderate or deep sedation.

The shift toward population health payment models — the kind that encourage health systems to keep patients under their umbrella — also encourage health systems to offer nearly every service a patient might need. That’s why New York recently saw two medical centers apply to open heart transplant units, the first such applications in more than 20 years. No health system wants to be a patient’s primary care provider, responsible for a patient’s overall health, and then see that patient have a complicated surgery performed somewhere else.

Life-altering consequences

A state’s decision to have Medicaid cover these procedures can be life-altering or even lifesaving.

Nathan Levitt, a family nurse practitioner and member of the transgender community who works with transgender patients at NYU Langone, said he has colleagues who committed suicide because they felt they’d never be able to have surgery.

“That’s the extreme,” he said. “But [I know] other people who have gone into so much depression, who don’t feel like they can leave their house, feeling isolated, feeling like they can’t interact, make friends, certainly date because they don’t feel comfortable in their bodies. I didn’t think this would ever get covered. I certainly never thought Medicaid would.”

Female to male transition is more prone to complications, which mostly relate to the urinary tract. The female urethra points down so when the transition is performed the vagina must be excised while the urethra is lengthened and pointed up. That’s a challenge because of fluid dynamics. Urine hits the reconstructed tissue. It can leak through the suture lines resulting in a fistula, or scar tissue can form.

“Can you imagine having an operation to make someone the way they always imagined and then they become incontinent afterwards,” Zhao said. “It’s a devastating problem.”

For decades, imagine was all a person could do.

Now, told their surgery date, and able, after decades, to put an "X" on a calendar, a countdown to a dream, many patients are overcome with emotion, Bluebond-Langner said.

“There are tears of joy,” she said. “And they will say, ‘I never in my lifetime thought this would be a possibility. I thought I’d go to the nursing home being misgendered, being made fun of.’”

Beth Drzewiecki, a urologist at Montefiore and assistant professor of urology at the Albert Einstein College of Medicine, said patients are often so elated to have the body they’ve always felt they should that, they tell her, they have hundreds of photos of their new vaginas on their cell phones.

Learning lessons in Europe

New York surgeons have traveled to Europe for first-hand experience.

Montefiore surgeons spent two weeks in Gent, Belgium this past April, studying under Stan Monstrey, now a member of Mount Sinai’s international visiting faculty. The Bronx hospital performed its first transgender surgery in May and has performed five more since.

In September, a Northwell Health team went to Belgrade, Serbia, to study under Miroslav Djordjevic, a professor of urology and surgery at the University of Belgrade’s School of Medicine.

Djordjevic operated every day for a week and the Northwell physicians watched his every move. Soon, they will be in the cadaver lab, practicing on real, albeit expired, bodies.

“We’re going to go through the operation,” said Adam Perry, a surgeon, helping to start Northwell’s program, “so we can demonstrate in practice what we learned.”

Northwell hopes to open its program in mid-2018.

None of this would have been possible without Medicaid and commercial insurance moving to cover the surgery, Perry said.

“It has to be funded somehow," he said. “If it’s not funded by insurance, patients have to pay for it out of their own pocket.”

Hospitals can’t afford to create programs around a handful of patients. They can’t invest in recruiting new physicians or devote the operating-room space, or buy new equipment.

“It’s a big investment and a big commitment of resources,” Perry said. “Without reliable, sustainable investment, I don’t see this happening — not on this scale.”

Transgender surgery is becoming a hot topic at urologic conferences as well, Drzewiecki said, which she attributed to insurance coverage.

“Now that it can be covered and it’s accessible to patients, they are demanding it,” she said.

A 'center of innovation'

When it comes to genital surgery, outcomes, broadly speaking, are about sensation, aesthetics, urination and sexual intercourse.

Another benefit of having surgical programs close to where a patient lives is that health systems can offer social support, which can be critical, Bluebond-Langer said. Vaginoplasties, for example, require the patient to dilate four times a day for the first year because the new vagina has a tendency to close as the body can treat it like a wound.

“If they are living in a home with a lot of other people, with no private space or limited access to shower, these are things you want to know,” she said. “Not to deny them surgery but to assess prior to surgery and change. Get them into a better housing situation, get them support get them connected into the community with people who can help them.”

All the academic medical centers expect to expand their programs in the coming years.

“There is plenty of work for all of us,” Blueblood-Langer said. “I think you’ll see us all standing and still have waiting lists.”

Ting said that in five years he’d like to have five surgeons operating five days a week, doing research, publishing results.

New York, Northwell’s Perry said, could be the epicenter of care for the transgender community.

“It’s relatively new but I think New York is a center of innovation,” Perry said. “Transgender surgery is still in its infancy. I think it is going to start to go mainstream and when it does there is going to be a lot of innovation and advancement. I think New York is the perfect place for transgender surgery, for being advanced and being innovative.”