How Many Clicks Does it Take? Examining the Ease of Finding Gender-Affirming Surgery Information on U.S. Hospital Websites

SDCC 

Purpose
Transgender and gender-diverse (TGD) individuals face many barriers that impede their access to gender-affirming surgery (GAS).1 Prior research has highlighted difficulty in searching for GAS providers and locating information about GAS, with considerable webpage inconsistencies and omission of online information.2,3 As TGD people increasingly rely on the internet when searching for GAS content,4 we investigated the accessibility of online GAS information relative to three of the most common, non-GAS procedures.

Methods
The sample included the 100 largest U.S. hospitals by inpatient beds. The three most common surgeries in adults, hip arthroplasty, knee arthroplasty, and cesarean sections were used as comparative search terms. GAS-terms were: gender affirmation surgery, gender-affirming surgery, gender confirmation surgery, gender-confirming surgery, gender reassignment surgery, top surgery, chest masculinization, facial feminization, metoidioplasty, phalloplasty, and vaginoplasty. Non-GAS terms were: Cesarean section, C-section, knee replacement, knee arthroplasty, hip replacement, and hip arthroplasty.

Beginning at the hospital's homepage, each linked webpage was clicked by a Python puppeteer. Each link on subsequent webpages was then followed until 2500 links had been accessed. At each hyperlinked page, TGD terms and comparative non-GAS terms were identified. Information on states' bans on insurance exclusions for TGD-related care was gathered from the Movement Advancement Project.5 We used T-tests, chi-squared tests, and Fisher's exact tests to assess associations between variables.

Results
Out of the top 100 hospitals, 82 had websites that could be scraped for key terms. All 82 hospitals' websites had non-GAS terms while only 34 (41.5%) had GAS terms. When averaging the minimum number of followed links needed from each hospital to reach a given term, there was a significant increase in average minimum number of links for GAS terms compared to non-GAS terms (2.56 links vs. 1.74 links; p = 0.005).

Out of the 20 states that had hospitals with GAS terms on their website, 11 states had laws which proscribed against private insurance transgender discrimination. Hospitals in states with these protective laws were more likely to provide information about GAS, with 57.6% (n = 19/33 ) in these states displaying GAS content compared to 30.6% (n = 15/49) in states without such laws (p = 0.015). However, there was no statistically significant difference in the average minimum number of followed links needed to find GAS terms between states that had and did not have protective laws (2.4 clicks vs. 2.8 clicks; p = 0.43).

Conclusions
The study reveals disparities in the availability of GAS and the ease of access to GAS information online. The association between transgender-protective laws and offering GAS online GAS content suggests that these laws may foster an environment where hospitals are encouraged to offer GAS or are more willing to disclose that their surgeons perform GAS. Future efforts are needed to increase GAS capacity building around the country, and hospitals should become more transparent about their GAS offerings.

References:

1. Puckett JA, Cleary P, Rossman K, Newcomb ME, Mustanski B. Barriers to Gender-Affirming Care for Transgender and Gender Nonconforming Individuals. Sex Res Social Policy. 2018;15(1):48-59. doi:10.1007/s13178-017-0295-8
2. Evans YN, Gridley SJ, Crouch J, et al. Understanding Online Resource Use by Transgender Youth and Caregivers: A Qualitative Study. Transgend Health. 2017;2(1):129-139. doi:10.1089/trgh.2017.0011
3. Cohen W, Maisner RS, Mansukhani PA, Keith J. Barriers To Finding A Gender Affirming Surgeon. Aesthetic Plast Surg. 2020;44(6):2300-2307. doi:10.1007/s00266-020-01883-z
4. El-Hadi H, Stone J, Temple-Oberle C, Harrop AR. Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care. Plast Surg (Oakv). 2018;26(4):263-268. doi:10.1177/2292550318767437
5. Movement Advancement Project. Healthcare laws and policies. Boulder, CO; 2024. Available from: https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies [Last accessed: February 15, 2024].

Gender Affirmation

PSTM 2024