Nearly 50 percent of transgender people travel outside of their state of residence to get gender-affirming genital surgeries, according to a new study from Oregon Health and Science University (OHSU). The percentage could increase as more states put bans against gender-affirming healthcare for trans people in place, the study’s authors say.

The study, published Wednesday in JAMA Surgery, looked at 771 transgender patients who had a vaginoplasty or phalloplasty between 2007 and 2019. It found that 49 percent left their state of residence to get the procedure. People who lived in southern states were more likely to have to leave their home states in order to receive the surgery.

That’s because there’s a lack of surgeons who provide such care in the South. A 2020 studyfound that just 11 doctors in the South could provide such surgeries, and four of the doctors resided in Florida.

The number of such doctors could decrease as more Southern states ban gender-affirming care for trans youth. Genital surgeries aren’t typically performed on young trans people, but some doctors could choose to locate their practices outside of states with such bans in place because the bans increase doctors’ legal and financial liabilities if they treat young patients.

Of additional concern, the OHSU study found trans people who left their states to get surgery ended up paying up to 50 percent more in out-of-pocket medical expenses than those who were able to obtain surgeries in their home states. This included costs for post-surgical visits and foll0w-up care.

Only one of the 771 patients included in the study had their surgery paid for by their commercial health insurance provider, The Hill noted. This suggests that the life-saving surgical procedures may not be affordable for many trans people. Trans people living in transphobic states will face even greater financial and time costs just to receive gender-affirming care.

“We already knew that traveling for health care requires patients to take time off work and pay for travel and lodging on their own, and that it can make receiving follow-up care from qualified providers who are familiar with each patient’s unique needs challenging,” Jae Downing,  the study’s lead author, said in a press release.

“This study helps quantify how severely we need more gender-affirming surgeons,” Geolani Dy, an assistant professor of urology and plastic and reconstructive surgery at OHSU School of Medicine, added.