Excess costs of transgender and gender-diverse people with gender incongruence and gender dysphoria compared with people from the general population in Germany: a secondary analysis using data from a randomised controlled trial and a representative telephone survey.

Abstract

For transgender and gender-diverse (TGD) people, it is known that there is a lack of healthcare professionals with experience in trans healthcare. This may result in either inadequate provision of healthcare or in an increased seeking of adequate trans healthcare. Little is known about healthcare services utilisation and resulting costs in treatment-seeking TGD people with gender incongruence or gender dysphoria (GIC/GD). Therefore, the aim of this study was to determine the excess costs associated with GIC/GD in Germany. In a secondary analysis, baseline data of a randomised controlled trial with a sample of TGD people with GIC/GD were combined with data of a telephone survey conducted in a representative sample of the general German population. The data sets were matched using entropy balancing. Self-reported healthcare services utilisation was valued by standardised unit costs for the German healthcare system, and absenteeism from work and unemployment were valued with the gross hourly wage of persons in manufacturing and services sectors. TGD people with GIC/GD living at least 50 km outside Hamburg in the federal state Bremen, Mecklenburg-Western Pomerania, Lower Saxony or Schleswig Holstein and the German general adult population. Treatment-seeking TGD people with GIC/GD (n=167) and people of the general German population (n=2811). 6-month excess healthcare costs and indirect costs from a societal perspective were calculated for the year 2020 using two-part models with logit specification for the first part and a generalised linear model with gamma family and log link function for the second part. The total 6-month excess costs associated with GIC/GD from a societal perspective were estimated to be €672 (95% CI: €-3315 to €4657; p=0.741) per person. The direct excess healthcare costs were estimated to be €2 (€-1115 to €1119; p=0.977) and the indirect excess costs due to absenteeism from work and unemployment were €669 (€-3031 to €4370; p=0.723) per person. The total excess costs associated with GIC/GD in trans men, trans women and non-binary people were estimated to be €-5572 (€-12 232 to €1088), €4238 (€-1694 to €10 170) and €3041 (€-4268 to €10 351) per person (all with p>0.05), respectively. The total 6-month costs in TGD people with GIC/GD did not differ statistically significantly from the costs in the general German population. Indirect excess costs due to absenteeism from work accounted for the largest part of the excess costs associated with GIC/GD, yet with wide 95% CIs. Potential causes of absenteeism from work, such as experienced or expected discrimination, need to be identified and addressed so that TGD people can experience a healthy work environment. NCT04290286.