National Estimates of Gender-Affirming Surgery in the US

Exploring the evolution of facial feminization and masculinization surgery: a bibliometric analysis and visualization study

BACKGROUND

This study aims to conduct a bibliometric analysis of the current literature related to facial feminization surgery (FFS) and facial masculinization surgery (FMS) to understand the patterns, trends, and evolution of research topics. In addition, it aims to objectively identify the important articles that constitute the primary backbone of the FFS/FMS literature and provide a resource for education and new studies in this emerging field.

RESULTS

Using the principles of the Leiden Manifesto, 384 publications from the Web of Science from 1987 to 2023 were analyzed. The analysis included cross-country collaboration, keyword trends, affiliations, co-citation networks, and clustering. The results showed an increasing trend in FFS/FMS publications, with the USA leading in both publications (n = 238) and citations (n = 2420). The most cited journal was the Journal of Plastic and Reconstructive Surgery. The results indicate a high growth rate, with an H-index of 34 and an average citation of 11.41 per article. Co-occurrence analysis revealed evolving keywords such as "forehead" (n = 52) and "quality of life" (n = 44). The timeline view illustrated the terms reflecting current areas of interest such as #patient satisfaction and #gender-affirming care.

CONCLUSION

The study reveals the influence of countries, institutions, authors, and emerging trends, supporting the anticipation that FFS/FMS will be a critical field of study in the future. The findings contribute to understanding the global landscape of FFS/FMS research, facilitating informed decision-making for researchers, and clinicians in the field of maxillofacial surgery.

Anesthesia for gender-affirming surgery: a practical review

PURPOSE OF REVIEW

Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients.

RECENT FINDINGS

Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional.

SUMMARY

Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.

Sexual Health for Transgender and Gender Diverse Individuals: Routine Examination, Sexually-Transmitted Infection Screening, and Prevention

Gynecologists play a critical role in the office evaluation of transgender and gender diverse individuals. This includes the provision of essential healthcare services including the treatment and prevention of human immunodeficiency virus and sexually-transmitted infections and screening for human papillomavirus infection-related diseases and cancers. Caring for patients who identify as transgender or gender diverse (TGD) and who have undergone gender-affirming surgical treatments is challenging due in part to clinical gaps in knowledge resulting from insufficient training and educational resources. A patient-centered approach to the care of TGD individuals requires knowledge of the general principles of affirming, holistic care with attention to the risk factors, and anatomic considerations unique to this population. This review aims to provide basic knowledge needed for the successful gynecologic evaluation of a gender diverse patient.

Policy and laboratory practice: How quality control procedures for genetic testing perpetuate biological essentialism and discrimination against transgender, gender diverse, and intersex people

Transgender, gender diverse, and intersex (TGDI) individuals face significant health disparities due to individual and systemic experiences of discrimination, impacting their access to healthcare. While clinical genetic testing has become increasingly accessible to the general population, the field of clinical genetics perpetuates a narrative of biological essentialism, which creates barriers for TGDI patients. Biological essentialism upholds that sex is a binary, fixed, and innate characteristic, a misconception that has been historically weaponized against the TGDI community in both individual experiences of discrimination and anti-trans legislation, among other systemic forms of oppression. Rejecting this discriminatory framework requires careful consideration of, and changes to, long-established practices that often go unquestioned, such as quality control metrics in genetic testing, in order to improve TGDI patients' outcomes and access to genetic services. The sex-check, comparing an individuals reported sex against their sex chromosomes, is an example of how laboratory genetics practices reinforce the narrative that sex is determined purely by chromosomal composition. Additionally, the sex-check "outs" TGDI people in clinical settings, creating a discriminatory and unsafe environment for these patients. Alternative quality control procedures and inclusive practices, such as clearer delineation of sex and gender on test requisition forms, are proposed to improve TGDI patient experiences. Genetic counselors and other clinical providers have a responsibility to address historical discrimination and advocate for changes to laboratory practice, so as to create affirming experiences for TGDI patients.

Health Care Utilization During the First 5½ Years of Authorized Service by Transgender U.S. Service Members (2016-2021)

Purpose: This study examined the utilization of gender-affirming health care by active-duty service members during the initial 5½ years that transgender and gender-diverse (TGD) individuals were authorized to serve in the U.S. military. The aim of this study was to inform policy discussions regarding inclusion of TGD individuals in the military. Methods: We conducted a retrospective cohort study using administrative health care data from the Military Data Repository (MDR). We assessed the association of demographic factors with the utilization of gender-affirming medical and surgical care. We calculated the incidence rate of initial TGD-related encounters and new prescriptions for gender-affirming hormones among Defense Department Service members between July 2016 and December 2021. Results: We identified 2481 service members with an initial health care encounter with an associated TGD-related diagnosis. More than half (53%) of these service members started gender-affirming hormones, and 14% underwent gender-affirming surgery. Mastectomies and hysterectomies accounted for more than 70% of surgeries. Service members made 3.22 initial encounters with a TGD-related diagnosis per 10,000 service members per year, with an overrepresentation of service members who were designated female in the MDR (8.62), junior enlisted (4.98), and young (4.64). Individuals designated female in the MDR comprised 17% of all service members but accounted for 46% of initial encounters, 51% of new prescriptions, and 73% of surgeries. Conclusion: The study revealed a higher-than-expected number of service members seeking gender-affirming care, particularly among service members designated female in the MDR. Military Health System clinicians provided most of this care, which may mitigate the cost of delivering this essential medical care.

Characteristics of a transgender and gender-diverse patient population in Utah: Use of electronic health records to advance clinical and health equity research

Transgender and gender-diverse (TGD) people, individuals whose gender identity differs from their sex assigned at birth, face unique challenges in accessing gender-affirming care and often experience disparities in a variety of health outcomes. Clinical research on TGD health is limited by a lack of standardization on how to best identify these individuals. The objective of this retrospective cohort analysis was to accurately identify and describe TGD adults and their use of gender-affirming care from 2003-2023 in a healthcare system in Utah, United States. International Classification of Disease (ICD)-9 and 10 codes and surgical procedure codes, along with sexual orientation and gender identity data were used to develop a dataset of 4,587 TGD adults. During this time frame, 2,985 adults received gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS) within one healthcare system. There was no significant difference in race or ethnicity between TGD adults who received GAHT and/or GAS compared to TGD adults who did not receive such care. TGD adults who received GAHT and/or GAS were more likely to have commercial insurance coverage, and adults from rural communities were underrepresented. Patients seeking estradiol-based GAHT tended to be older than those seeking testosterone-based GAHT. The first GAS occurred in 2013, and uptake of GAS have doubled since 2018. This study provides a methodology to identify and examine TGD patients in other health systems and offers insights into emerging trends and access to gender-affirming care.

Gender-Affirming Care for Older Transgender and Gender Diverse Adults

In the United States, it is estimated that 0.3% of Americans aged 65 and older, or almost 172,000 individuals, identify as transgender. Aging comes with a unique set of challenges and experiences for this population, including health care disparities, mental health concerns, and social isolation. It is crucial for clinicians to use a patient-centered and trauma-informed care approach to address their specific needs and provide evidence-based quality health care, including preventive screenings, mental health support, and advocating for legal protections.

No Bones About It: Sex Is Binary

Anthropologists have led the way in formulating techniques that reveal skeletal differences between males and females. Understanding of physical differences in the pelvis related to childbirth, hormonal impacts on bones, and extensive comparative studies have provided anthropologists with an array of traits and measurements that help them estimate sex using just bones. Forensic anthropologists and bioarcheologists are improving their ability to differentiate males and females by increasing research on a variety of postcranial bones and through the use of molecular data, especially new methods called proteomics, to identify sex in prepubescent juveniles. As remains from more cultures and time periods are studied, sex identification will continue to improve, because skeletal sex differences are in large part biologically determined. Yet, anthropologists have also been at the forefront of arguing that sex lies on a spectrum. Anthropologists who view sex as on a spectrum may deter sex identification progress; from their perspective, an individual of an undetermined sex may just be a nonbinary individual. Anthropologists who consider sex is on a spectrum are coming to this conclusion in part because they are looking for anatomical ideals, mistaking pathology for variation, and confusing independent variables with dependent variables. Nonetheless, anthropologists need to continue to improve sex identification techniques to reconstruct the past accurately, which may reveal less strict sex roles than previously presumed and help with the identification of crime victims. Forensic anthropologists should also increase their efforts to identify whether individuals have undergone medical procedures intended to change one's gender due to the current rise in transitioning individuals.

Gender Affirmation Surgery-related Hashtag Utilization on Instagram: Implications for Education and Patient Care

Background

Gender-affirmation surgery (GAS) allows for transgender and nonconforming patients to achieve a more congruent physical appearance and alleviate dysphoria. Social media, such as Instagram, has adopted an increasingly important role in plastic and reconstructive surgery, and understanding trends and usage related to GAS can have significant implications for patient education and outreach. As such, this cross-sectional study aims to address the following questions related to GAS-related content available on Instagram: (1) Who is posting this content? (2) What specific hashtags are they using? and (3) What are the implications behind these posts?

Methods

This study analyzed 22 GAS-related hashtags on Instagram. Content analysis was then used to evaluate the "top" 15 posts (n = 330) associated with each hashtag.

Results

A total of 425,607 posts were associated with the 22 hashtags queried. #topsurgery had the highest number of associated posts (n = 279,480), followed by #ftmtopsurgery (n = 41,769) and #vaginoplasty (n = 39,737). Of the "top" 330 posts, 299 were not duplicates. Plastic surgeons eligible for membership in the American Society of Plastic Surgeons accounted for only 1.7% of "top" posts (n = 5); noneligible physicians accounted for 6.0% of posts (n = 18). Patients accounted for the majority of the "top" posts sampled (n = 236; 79.9%).

Conclusions

When used appropriately, social media can be a powerful tool for spreading awareness on procedures and educating patients. Although there is a paucity of plastic surgeons posting GAS-related content on Instagram, patients are playing an important role in disseminating information.

Adolescent gender dysphoria management: position paper from the Italian Academy of Pediatrics, the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, the Italian Society of Adolescent Medicine and the Italian Society of Child and Adolescent Neuropsychiatry

BACKGROUND

In response to the imperative need for standardized support for adolescent Gender Dysphoria (GD), the Italian Academy of Pediatrics, in collaboration with the Italian Society of Pediatrics, the Italian Society for Pediatric Endocrinology and Diabetes, Italian Society of Adolescent Medicine and Italian Society of Child and Adolescent Neuropsychiatry is drafting a position paper. The purpose of this paper is to convey the author's opinion on the topic, offering foundational information on potential aspects of gender-affirming care and emphasizing the care and protection of children and adolescents with GD.

MAIN BODY

Recognizing that adolescents may choose interventions based on their unique needs and goals and understanding that every individual within this group has a distinct trajectory, it is crucial to ensure that each one is welcomed and supported. The approach to managing individuals with GD is a multi-stage process involving a multidisciplinary team throughout all phases. Decisions regarding treatment should be reached collaboratively by healthcare professionals and the family, while considering the unique needs and circumstances of the individual and be guided by scientific evidence rather than biases or ideologies. Politicians and high court judges should address discrimination based on gender identity in legislation and support service development that aligns with the needs of young people. It is essential to establish accredited multidisciplinary centers equipped with the requisite skills and experience to effectively manage adolescents with GD, thereby ensuring the delivery of high-quality care.

CONCLUSION

Maintaining an evidence-based approach is essential to safeguard the well-being of transgender and gender diverse adolescents.

Gender affirming care for the minimally invasive gynecologic surgeon

PURPOSE OF REVIEW

Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists.

RECENT FINDINGS

The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure.

SUMMARY

Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

Peri-surgical imaging of intersex and gender diverse youths

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Neovaginal Human Papilloma Virus-Related Squamous Cell Carcinoma in a Transgender Woman

This case series discusses a human papilloma virus (HPV)–related neovaginal squamous cell carcinoma in a transgender woman and the need for formal gynecologic screening recommendations.

Isolated and combined breast augmentation in transgender patients: Multi-institutional insights into early outcomes and risk factors

BACKGROUND

The increasing demand for gender-affirming surgery (GAS) in transgender and gender-diverse healthcare highlights the importance of breast augmentation surgery (BAS) for transfeminine patients. Despite its significance, there is a lack of research on postoperative outcomes of BAS.

METHODS

We analyzed the multi-institutional American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) (2008-2021) database to identify female transgender individuals (TGIs) who underwent BAS surgery, both isolated and combined with concurrent GAS procedures. We evaluated 30-day outcomes, including the incidence of mortality, reoperation, readmission as well as surgical and medical complication occurrence.

RESULTS

Of 1699 female TGIs, 92% underwent isolated BAS and 7.7% underwent combined BAS. The mean age and body mass index (BMI) were 36 ± 12 years and 27 ± 6.6 kg/m2, respectively. Isolated BAS showed a 2.8% complication rate, while combined BAS had a higher rate with 9.1%. Specifically, all complications occurred in patients undergoing BAS with concurrent genitourinary surgery (n = 85; 14%), whereas no adverse events were recorded after combined BAS and facial feminization (n = 19) or chondrolaryngoplasty (n = 19). In patients seeking combined BAS, advanced age (p = 0.05) and nicotine abuse (p = 0.004) were identified as risk factors predisposing to adverse events, whereas American Society of Anesthesiology class 1 was found to be protective (p = 0.02).

CONCLUSIONS

Isolated BAS in TGIs demonstrates a positive safety profile. Combined surgeries, particularly with genitourinary procedures, pose higher risks. Identifying risk factors such as smoking and advanced age is crucial for patient selection and surgical planning. These findings can aid in refining patient eligibility and inform surgical decision-making for BAS.

[Psychiatric, socio-legal and perioperative aspects of vaginoplasty]

The number of scientific papers on gender-confirming surgeries as well as the surgeries themselves have increased by leaps and bounds in recent years. This leads to sometimes considerable waiting times for people seeking treatment. Social media and the internet do not always provide reliable and high-quality information. Therefore, it is necessary that both surgically and conservatively active urologists are familiar with topics regarding transgender persons. The establishment of structured training, the guarantee of minimum quality standards in the treatment of transgender persons and the further education and training of medical staff pose particular challenges. The German Society for Urology (DGU) and the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) have already founded their own working groups on the surgical side, which coordinate their work. Under the auspices of the professional societies DGU and DGPRÄC, a guideline on surgical procedures for gender incongruence was developed under the umbrella of the AWMF ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften") which is currently being finalised. For a long time, the health care of transgender people has been moving in a field of tension between the right of self-determination of those seeking treatment, on the one hand, and the fear of making the wrong medical decisions, on the other. In contrast to most other conditions in urology, the goal of treatment is largely determined by the person seeking treatment and does not necessarily follow predetermined schedules or content. The treatment should primarily aim at reducing the individual's suffering and promoting quality of life.