A review of gender affirmation surgery: What we know, and what we need to know

Analgesic benefits of regional anesthesia in the perioperative management of transition-related surgery: a systematic review

INTRODUCTION

Transition-related surgery is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients is nuanced and potentially complicated by higher rates of mood and substance use disorders. Regional anesthetic techniques are known to reduce pain severity and opioid requirements; however, little is known regarding the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery.

METHODS

We performed a systematic review of the literature to evaluate original reports characterizing the analgesic effectiveness of regional anesthetic techniques for patients undergoing chest and/or genital transition-related surgery. Our primary outcomes were pain severity and opioid requirements on the first postoperative day.

RESULTS

Of the 1863 records identified, 10 met criteria for inclusion and narrative synthesis. These included two randomized controlled trials, three cohort studies, and five case reports/series, comprising 293 patients. Four reports described 243 patients undergoing chest surgery, of whom 86% were transgender men undergoing mastectomy with pectoralis nerve blocks or local anesthetic instillation devices. The remaining six reports comprised 50 patients undergoing genital surgery, of whom 56% were transgender women undergoing vaginoplasty with erector spinae plane blocks or epidural anesthesia. Three studies directly compared regional techniques to parenteral analgesia alone. Two of these studies reported lower pain scores and opioid requirements on the first postoperative day with nerve blocks compared with none while the third study reported no difference between groups. Complications related to regional anesthetic techniques were rare among patients undergoing transition-related surgery.

DISCUSSION

Despite the ever-growing demand for transition-related surgery, the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery is very understudied and insufficient to guide clinical practice. Our systematic review of the literature serves to underscore regional anesthesia for transition-related surgery as a priority area for future research.

Along the Spectrum from Reduction to Mastectomy: Comparing the Opinions of an Online Transmasculine and Gender-Diverse Community on an Algorithmic Approach to Gender-Affirming Top Surgery

BACKGROUND

Gender-diverse patients often have unique preferences for top surgery that differ from those of binary transgender men. Yet, discussions around tailored surgical options remain limited. Social media platforms provide insights into the preferences of gender-diverse individuals who frequently turn to digital spaces for information and support. This study sought to explore the diverse needs of gender-diverse respondents and gather their feedback on a pictorial algorithm designed to assist with preoperative surgical decision-making.

METHODS

A cross-sectional survey was distributed on Reddit to individuals considering or having undergone masculinizing top surgery. The survey collected data on aesthetic preferences, comfort with surgical options, surgeon communication, and the need for non-standard surgical choices. A pictorial algorithm was used to evaluate its utility in enhancing preoperative discussions. Data were analyzed for demographic differences and preferences across transgender male, non-binary, and other gender-diverse (OGD) groups.

RESULTS

Of 799 respondents, 639 met the inclusion criteria. Non-binary and OGD respondents were older (p<0.0001) and had higher education levels (p<0.0001). These groups showed a higher preference for "non-standard" chest reconstruction (p=0.02), were less likely to want nipple-areola complex (NAC) reconstruction, and reported more frequent interactions where they educated their surgeons on options (p<0.0001) and greater comfort in these discussions (p=0.0002).

CONCLUSION

This study highlights the diverse preferences and needs of gender-diverse individuals seeking masculinizing top surgery. It underscores the importance of personalized care, with a structured communication tool and algorithm aiding better patient-provider alignment for more tailored surgical outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 .

Silicone deposition and adverse pulmonary events secondary to breast implant rupture

Silicone breast implants are common but may be associated with a number of complications including implant rupture. This case reports a 38-year-old woman with bilateral breast implants who presented with breast unevenness, triggering a cascade of investigations that identified implant rupture. A computed tomography scan of the thorax showed subpleural enhancing nodules in the left lung of equal density as the implants, repeat computed tomography thorax months later showed no interval changes. In this case, extracapsular rupture causing deposits of silicone via the lymphatic system into the lungs resulted in nodules visible on imaging. Reassuring radiological findings and lack of red flag symptoms led to radiological follow-up and avoided the need for invasive procedures such as biopsy. The authors aim to remind clinicians of the importance of maintaining a high index of clinical suspicion for implant-related pathology and to add to current literature regarding this rare complication.

Dermatological care of gender-diverse patients in Australia

In recent years, there has been an increasing recognition of the unique healthcare needs of gender-diverse patients in Australia. With the continuous growth of referrals to gender health services, there is an increased demand for specialised dermatological care. There is still a significant knowledge gap and a lack of guidelines specifically tailored to this patient group. In this article, we will provide a brief overview of the journey of Transgender and Gender Diverse (TGD) individuals as they embark on psychological and pharmacologic treatment for gender dysphoria in Australia. We endeavour to contribute to the existing body of knowledge by examining the evidence surrounding the treatment of skin, hair and nail issues for TGD patients. This article will outline how dermatologists can assist in the care of the gender-diverse patient. Although puberty blockade (stage 1 treatments) has minimal dermatological impact, gender-affirming pharmacotherapy (stage 2 treatments) can lead to many dermatological issues including acne, patterned hair loss (PHL) and dermatitis. The dermatologist may also play a role in stage 3 treatments which include surgical or procedural interventions for gender affirmation.

Nonbinary and Transgender Male Patient Preferences for Gender-Affirming Top Surgery

BACKGROUND

This study aimed to identify patient preferences and outcomes of chest masculinization surgery in patients identifying as nonbinary versus transgender (trans-) males.

METHODS

Patients who underwent chest masculinization (2003-2022) were included. Demographics, medical comorbidities, surgical approaches, complications, secondary procedures, and BODY-Q chest module survey responses were compared between cohorts.

RESULTS

Three hundred two patients were included. Thirteen percent identified as nonbinary and 87% as trans-male. The most common surgical approach in both groups was double incision with free nipple-areola graft (63% vs 71%, P = 0.33). Nonbinary patients more frequently opted for double incision without free nipple areola graft compared to trans-male patients (18% vs 2.7%, P < 0.001). Other unique surgical requests of nonbinary patients included nipple areola preservation and small breast mound preservation (5.2%) and balance between losing bulk and achieving a more androgynous appearance (5.3%). The survey response rate was 31% (93/302). Both groups reported improved quality of life postoperatively ( P = 0.16). Three nonbinary patients elected not to keep their nipple-areola complexes ( P = 0.005). Trans-male patients were more likely to report having a male chest as very important for their gender identity (82% vs 95%, P = 0.043). Nonbinary patients were less likely to prefer small nipples (82% vs 95%, P = 0.033) and 18% stated that they preferred no nipples (vs 2.7% trans-male patients, P < 0.001).

CONCLUSIONS

Nonbinary patients have distinct surgical preferences regarding nipple-areola complexes. Chest masculinization planning can differ for this group of patients compared to their trans-male counterparts.

Future directions in transmasculine genital gender-affirming surgery: tissue substitutes and transplant

PURPOSE OF REVIEW

The present study reviews contemporary literature focused on transplantation and tissue substitutes for the purposes of masculinizing genital gender affirming surgery. Additional background is provided for both topics to provide a more comprehensive understanding of the modern applications.

RECENT FINDINGS

Genitourinary vascularized composite allotransplantation has become a reality in recent years with several cases reported worldwide in cisgender men with promising reports of urinary and sexual function. A natural extension might be to apply these techniques to gender affirming surgery (GAS). Technical barriers include anatomic differences between vasculature supporting penoscrotal and vulvovaginal anatomy as well as size discrepancies between the corporal bodies which complicate the required anastomoses. Whether the smaller caliber of biologic female pelvic vasculature can support erection of a neophallus is another obstacle. Ethically, resource allocation, elective immunosuppression, society response to organ donation and gender identity, as well as the psychosocial safety of the patient given charged public opinion must all be considered.Tissue substitutes have long been used in urologic reconstruction but more recently applied to masculinizing gender affirmation surgery which has traditionally relied on autografting. The focus has been on restoring form and function to the donor site as well as facilitating treatment of urethral stricture and wound complications after phalloplasty. Furthermore, aesthetic applications have also been described, most recently for glans atrophy.

SUMMARY

The field of masculinizing gender affirmation surgery represents an exciting frontier for surgeons and patients alike. Given the relative nascency of the specialty and its propensity to draw techniques from various surgical disciplines there exists a unique opportunity for rapid innovation to overcome challenging problems posed by these complex procedures as evidenced by discussions around applying penile transplantation and the use of novel tissue grafting techniques.

The Impact of a Breast Cancer Risk Assessment on the Decision for Gender-Affirming Chest Masculinization Surgery in Transgender and Gender-Diverse Individuals: A Pilot Single-Arm Educational Intervention Trial

BACKGROUND

Persons assigned female or intersex at birth and identify as transgender and/or gender-diverse (TGD) may undergo gender-affirming chest masculinization surgery (GACMS); however, GACMS is not considered equivalent to risk-reducing mastectomies (RRM). This study aimed to estimate the prevalence of elevated breast cancer (BC) risk in TGD persons, compare self-perceived versus calculated risk, and determine how risk impacts the decision for GACMS versus RRM.

METHODS

A prospective single-arm pilot educational intervention trial was conducted in individuals assigned female or intersex at birth, age ≥ 18 years, considering GACMS, without a BC history or a known pathogenic variant. BC risk was calculated using the Tyrer-Cuzik (all) and Gail models (age ≥ 35 years). Elevated risk was defined as ≥ 17%.

RESULTS

Twenty-five (N = 25) participants were enrolled with a median age of 24.0 years (interquartile range, IQR 20.0-30.0 years). All were assigned female sex at birth, most (84%) were Non-Hispanic (NH)-White, 48% identified as transgender and 40% as nonbinary, and 52% had a first- and/or second-degree family member with BC. Thirteen (52%) had elevated risk (prevalence 95% confidence interval (CI) 31.3-72.2%). Median self-perceived risk was 12% versus 17.5% calculated risk (p = 0.60). Of the 13 with elevated risk, 5 (38.5%) underwent/are scheduled to undergo GACMS, 3 (23%) of whom underwent/are undergoing RRM.

CONCLUSIONS

Over half of the cohort had elevated risk, and most of those who moved forward with surgery chose to undergo RRM. A BC risk assessment should be performed for TGD persons considering GACMS. Future work is needed to examine BC incidence and collect patient-reported outcomes. Trial Registration Number ClinicalTrials.gov (No. NCT06239766).

Transgender lives at the population level: Evidence from Danish administrative data

This paper provides the first rigorous account of the diverse characteristics of transgender individuals at the population level, using data from Danish population registers. We observe three transgender subpopulations within the same national setting: all who changed thier legal sex (T-Legal, n = 1,995), all who have been assigned trans-related diagnostic codes (T-ICD, n = 1,594), and those who self-identified as transgender in a representative survey (T-Survey, n = 197, weighted n = 44,958). Results show significant differences in the subpopulations' backgrounds, family, education and labour market characteristics, and healthcare use. These differences extend beyond comparisons with the general population to great variations between each of the transgender subpopulations. Individuals with legal sex changes, and particularly those with trans-related diagnostic codes, face substantial disadvantages across various outcomes. Compared to the general population and the T-Survey subpopulation, the T-Legal subpopulation and the T-ICD subpopulation have significantly higher numbers of psychiatric hospital visits, lower educational attainment, lower annual earnings, and reduced employment rates, also when controlling for background characteristics. Earnings and employment rates remained significantly lower also when controlling for educational attainment. Our results show that the strategy chosen to identify trans individuals in population data has a great impact on the characteristics observed, and that trans individuals captured by surveys do not necessarily represent all transgender individuals, including those who seek to medically or legally transition. Furthermore, our results indicate that high numbers of trans individuals observed in surveys do not necessarily correspond to high demands for gender-affirming treatments or legal sex change. Finally, we show that transgender individuals who seek gender-affirming healthcare constitute a distinct and significantly disadvantaged group, also compared to other trans subpopulations.

Patient education and surgical decision-making in genital gender-affirming surgery

PURPOSE OF REVIEW

An update on the latest advances in surgical decision-making for genital gender-affirming surgery (GGAS), with an emphasis on patient education from three perspectives: surgeon-team perspectives, patient perspectives, and educational resources available to the public on social media.

RECENT FINDINGS

Transgender, nonbinary, and other culturally specific gender identities (TGNB) patients overwhelmingly desire an active role in the decision-making process. New developments in patient-engagement strategies help mitigate the harm of historical gatekeeping practices by centering the needs and experiences of TGNB patients to create a prioritized research agenda for GGAS effectiveness. Patient educational resources play an integral role in navigating the complexity of GGAS-surgical options, informing patients of the technical and logistical knowledge required for GGAS surgical decision-making. Peer support experiences are a critical facilitator for patient surgical decision-making, both for informed decision-making and for psychosocial support.

SUMMARY

Several developments have been made in examining shared-decision making, educational resources from the perspectives of both the surgical team and patients, and the role of social media in GGAS. Surgeons must continue to initiate robust conversations of patient goals, GGAS surgical options, the possible risk and benefit profiles of each option, and aftercare requirements, all while prioritizing patient-engagement strategies.

Temporary Declines and Demand Resurgence: Gender-Affirming Surgery Volume and Complication Trends During and After the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period.

METHODS

The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications.

RESULTS

Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications.

CONCLUSIONS

GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19.

IMPORTANT POINTS

During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

"I Had Attained the Identity I Had Long Desired": A Grounded Theory Study of Experiences of Transgender Men in Türkiye

Transgender individuals form a distinct community that often experiences marginalization within society. This marginalization is particularly pronounced in patriarchal countries, where transgender men encounter various challenges across psychological, medical, legal, and social domains during their transition. The study design to conduct a thorough analysis of the life experiences and perspectives of transgender men in Türkiye. It involved 15 participants and the collected data were subsequently analyzed using the constant comparative method, a key technique within grounded theory methodology. The coding process resulted in three main themes: "Realizing gender identity", "Impact of social support sources", and "The nature of being visible", and six sub-themes were formed, the core category being "… Despite the numerous challenges encountered along the way, when I gazed into the mirror, I realized I had attained the identity I had long desired". Transgender individuals in the study expressed encountering emotional, physical, and psychological challenges throughout their personal journeys. However, despite these difficulties, they reported experiencing a sense of satisfaction and contentment upon reaching the end of their transition process. It is recommended to implement counseling services specifically tailored for transgender individuals and their families and incorporate transgender-related content into the training programs of professionals working with transgender individuals.

The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

BACKGROUND

Many studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time.

METHODS

We conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada.  RESULTS: Eight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years. CONCLUSIONS : We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers.

Impact of Gender-confirming Chest Surgery on Sexual Health: A Prospective Study

Background

Few studies have evaluated the improvement of the sexual well-being of transgender patients after breast augmentation or bilateral mastectomy. This prospective study aims to assess the potential improvement in body awareness during sexual intercourse, as well as the nipple-areolar complex (NAC) sensitivity recovery after gender-confirming chest surgery.

Methods

From October 2019 up to April 2021, all transgender patients eligible for gender-confirming chest surgery in our institution were asked to fill out two questionnaires, namely BREAST-Q (a patient-reported outcome measure for use in reconstructive breast surgery and clinical practice) and Body Exposure during Sexual Activities Questionnaire (scientifically validated self-report assessments of body-image experiences in the context of sexual relations). The Semmes-Weinstein monofilament test was used to evaluate NAC sensitivity recovery. Different follow-ups were considered: preoperative and 4 and 12 months postoperative.

Results

Twenty-one transmasculine and 12 transfeminine patients met the inclusion criteria. For both groups, the preliminary 4-month postoperative evaluations showed significant improvement in psychological well-being and chest/breast satisfaction compared with preoperative values. Body awareness during sexual intercourse improved significantly at 4 months postoperative in the transmasculine groups (P ≤ 0.001) and at 12 months postoperative in the transfeminine group (P ≤ 0.01). No correlation between body awareness during sexual intercourse and NAC sensitivity was observed among either group, transmasculine and transfeminine patients.

Conclusions

Although aesthetic and psychological well-being increased quickly postoperatively, sexual health remained low among transfeminine patients until they completed their transition with vaginoplasty. NAC sensitivity recovery was found to not contribute to the improvement of the sexual health of transgender patients.

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.

Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review

INTRODUCTION

Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population.

METHODS

A systematic review of several databases was conducted. After compiling the articles, we extracted study characteristics. From the data set, weighted proportions were generated and analyzed.

RESULTS

A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the United States, 514 in European nations, 97 in Asian nations, which included only Thailand, and 19 in South American nations, which included only Brazil. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% while the prevalence of transmasculine regret was 0.8%.

CONCLUSIONS

Both transfeminine and transmasculine patients had significantly lower rates of regret in the United States when compared with the rest of the world. Our study largely excluded facial gender-affirming surgeries as most of its articles did not fall into our inclusion search criteria. To our knowledge, this is the most recent review performed on the topic of regret among gender-affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.

Systematic Review on Gender-Affirming Testosterone Therapy and the Risk of Breast Cancer: A Challenge for Physicians Treating Patients from Transgender and Gender-Diverse Populations

Conflicting evidence exists about the risk of breast cancer in transgender and gender-diverse (TGD) patients treated with testosterone. This review aimed to summarize current knowledge regarding the risk of breast cancer associated with gender-affirming testosterone treatment (GATT). A systematic literature search using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist was conducted in January 2023 through Ovid, Scopus, and Web of Science databases. English-language, peer-reviewed articles evaluating breast cancer in TGD patients after GATT that met the inclusion criteria were included. This review included 22 articles, with 14 case reports, 4 case series, and 4 retrospective cohort studies. The review identified 26 TGD patients who developed breast cancer post-GATT therapy, with inconclusive evidence on the relationship between testosterone and the risk of breast cancer in TGD patients. This uncertainty in part arises from the mechanisms governing testosterone's effects within breast tissue, with contrasting theories proposing both proliferative and antiproliferative impacts. Considering this ambiguity, it is imperative for healthcare providers to engage in informed discussions with patients prior to initiating hormone therapy to discuss potential adverse effects, including the possibility of breast cancer development in TGD individuals. Patient education and shared decision-making are essential components of responsible care in this context.

Gender and kidney transplantation

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

Gender dysphoria and gender-affirming surgery: The New York state experience

BACKGROUND

Transgender and gender nonconforming (TGNC) individuals experience incongruence between their self-identified gender versus their birth-assigned sex. In some cases, TGNC patients undergo gender-affirming surgical (GAS) procedures. Although GAS is an evolving surgical field, there is currently limited literature documenting patient characteristics and procedures. Addressing this knowledge gap, this retrospective cohort analysis described the characteristics of New York State's TGNC residents with gender dysphoria (GD) diagnosis, including patients undergoing at least one gender-affirming surgical procedure.

METHODS

Using the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2002 to 2018, we identified patients' first-time TCNC records and their risk characteristics. Patients who received GAS procedures were sub-classified as top-only, bottom-only, or combined top/bottom procedures and were compared with TGNC patients who did not receive GAS.

RESULTS

Of 24,615 records extracted from TGNC SPARCS database, 11,427 (46.4%) were transmasculine (female-to-male) and 13,188 (53.6%) were transfeminine (male-to-female). Overall, 2.73% of transgender patients received at least one GAS procedure. Of these patients, 78.2% had masculinizing and 21.8% had feminizing surgeries. After a diagnosis of GD, the positive predictors for a GAS-based procedure included female birth sex, pediatric age (<18 years) or older age (60+ years), commercial insurance coverage, and Hispanic race. In contrast, negative GAS predictors included male birth sex and government insurance coverage (i.e., Medicare and Medicaid).

CONCLUSIONS

Compared with transgender women, transgender men were more likely to receive at least one GAS procedure. Because the race, ethnicity, and payor status of TGNC patients can impact GAS treatment rates, additional research is warranted to examine post-diagnosis GAS treatment disparities among TGNC patients.

Preoperative hypocoagulative state is an independent risk factor for wound complications and infection in gender-affirming bottom surgeries

BACKGROUND

Bottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes.

METHOD

A retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls.

RESULTS

In this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01).

CONCLUSION

Preoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.

Penile Transplantation in Gender Affirmation Surgery: A Theoretical Feasibility Study

BACKGROUND

 It can be argued that individuals in the transgender and gender nonbinary (TGNB) community suffer from a similar impact on quality of life in the face of gender dysphoria, with psychosocial and physical consequences. Indications for penile allotransplantation for patients wishing to undergo gender affirmation surgery have yet to be elucidated, but technical lessons for feasibility can be gleaned from penis transplants that have already been performed on cisgender males to date.

METHODS

 This study investigates the theoretical feasibility for penile-to-clitoral transplantation, prior penile transplants, and current multidisciplinary gender affirmation health care modalities.

RESULTS

 Penile allotransplantation offers a potential solution for individuals in the TGNB community for a more aesthetic penis, improved erectile function without the need of a prosthesis, optimal somatic sensation, and improved urethral outcomes.

CONCLUSION

 Questions remain about ethics, patient eligibility, and immunosuppressive sequelae. Before these issues are addressed, feasibility of this procedure must be established.

Breast care considerations for transgender and gender-diverse patients

Transgender and gender-diverse (TGD) persons represent a small but growing population in the United States. Accessing inclusive, equitable, and evidence-based healthcare remains a challenge for this patient population. Many TGD persons seek gender-affirming care, including gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS), to help ameliorate the physical and mental aspects of their gender incongruence. Both GAHT and GAS induce clinically important histopathologic and anatomic changes in breast tissue. Consequently, breast care in TGD persons has become an increasingly recognized topic of importance in gender-affirming care. However, there remains a scarce but growing base of literature specifically addressing the unique healthcare needs of breast care in TGD patients. This article will review how to establish trusting patient-provider relationships for TGD patients, gender inclusivity in breast clinics and imaging centers, the influence of GAHT and GAS on breast tissue, breast cancer screening recommendations and barriers, and breast cancer risk and treatment considerations in TGD persons.

Moving toward targeted eating disorder care for transgender, non-binary, and gender expansive patients in the United States

OBJECTIVE

Literature suggests that transgender, non-binary, and/or gender expansive (TNG) people are more likely than cisgender peers to experience eating disorders (EDs) and engage in dangerous weight control behaviors. TNG individuals with EDs are dramatically higher risk for self-harm behaviors, suicidal ideation, and suicidal behaviors than cisgender peers with EDs or TNG peers without EDs, and often engage in ED symptoms/behaviors to alleviate gender dysphoria. Yet, no treatment paradigms have yet been adapted for TNG-specific ED care. This qualitative study aims to identify stakeholder needs from such care to inform future clinical interventions.

METHODS

We elicited patient (n = 12) and mental health clinician (n = 9) stakeholder needs and preferences regarding TNG-specific ED care. Semi-structured interview guides informed by the Consolidated Framework for Implementation Research (CFIR) and a behavioral insights framework, EAST, were developed to ensure uniform inclusion and sequencing of topics and allow for valid comparison across interviews. Using a rapid analysis procedure, we produced a descriptive analysis for each group identifying challenges of and opportunities in providing ED care for TNG adults.

RESULTS

Stakeholders expressed needs and preferences for TNG-specific treatment including that it be: (1) TNG-affirming, weight-inclusive, trauma-informed, and anti-racist; (2) delivered by an interdisciplinary team, including gender-affirming care clinicians; (3) focused on parsing gender dysphoria from other body image concerns, building distress tolerance, and working toward gender euphoria (rather than body acceptance).

DISCUSSION

Future work is needed exploring ED care delivery models that integrate gender-affirming care services with mental health care. Such models may improve TNG access to ED treatment and recovery.

PUBLIC SIGNIFICANCE

Transgender, non-binary, and/or gender expansive (TNG) experience disproportionately high rates of eating disorders and have unique barriers to accessing care. In individual interviews, TNG adults with eating disorders and mental health clinicians who provide psychotherapy for eating disorders voiced desire for greater availability of TNG-affirming, weight-inclusive eating disorder care, integrated with other gender-affirming care services. This informs future research developing eating disorder care for TNG individuals.

Patient Experiences and Provider Perspectives on Accessing Gender-Affirming Surgical Services in the Veterans Health Administration

BACKGROUND

Transgender and gender diverse (TGD) veterans have a greater prevalence of suicide morbidity and mortality than cisgender veterans. Gender-affirming surgery (GAS) has been shown to improve mental health for TGD veterans. In 2021, the Veterans Health Administration (VHA) announced the initiation of a rulemaking process to cover GAS for TGD patients.

OBJECTIVE

This study explores patients' and providers' perspectives about access to GAS and other gender-affirming medical interventions not offered in the VHA including barriers, facilitators, and clinical and policy recommendations.

PARTICIPANTS

TGD patients (n = 30) and VHA providers (n = 22).

APPROACH

Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data.

KEY RESULTS

VHA policy exclusions were the most cited barrier to GAS. Additional barriers included finding information about GAS, traveling long distances to non-VHA surgeons, out-of-pocket expenses, post-surgery home care, and psychological challenges related to the procedure. Factors facilitating access included surgical care information from peers and VHA providers coordinating care with non-VHA GAS providers. Pre- and post-operative care through the VHA also facilitated receiving surgery; however, patients and providers indicated that knowledge of these services is not widespread. Respondents recommended disseminating information about GAS-related care and resources to patients and providers to help patients navigate care. Additional recommendations included expanding access to TGD mental health specialists and establishing referrals to non-VHA GAS providers through transgender care coordinators. Finally, transfeminine patients expressed the importance of facial GAS and hair removal.

CONCLUSIONS

A policy change to include GAS in the VHA medical benefits package will allow the largest integrated healthcare system in the United States to provide evidence-based GAS services to TGD patients. For robust and consistent policy implementation, the VHA must better disseminate information about VHA-provided GAS-related care to TGD patients and providers while building capacity for GAS delivery.

Supporting gender-diverse young people: the role of the nurse

Gender-diverse individuals will need to access healthcare services for various reasons, with most of this care provided outside of specialist gender services. Nurses have an important role in advocating for the specific needs of gender-diverse individuals and providing person-centred care. Therefore, they have a responsibility to ensure their knowledge of appropriate terminology and gender-affirming interventions is up to date. This article provides information about gender diversity to enhance nurses' understanding of this area to enable them to care for gender-diverse people effectively and sensitively. While the focus of this article is on gender-diverse young people, the same principles can be applied across all age groups.

Gender Affirmation Surgery of the Face for the Transfeminine Patient

This article discusses the aspects of facial feminine affirmation surgery including forehead reconstruction, midface feminization, and lower face/neck feminization. We will present a brief history of gender affirmation. We discuss the anatomical differences between born XY males and XX females and discuss the subsequent procedures that aim at feminizing the face. The effects of silicone injections are also discussed as this was a trend in the past to feminize the face. Understandably so we discuss the anatomical differences as being a fluid expression and differences based on ethnic background.

"Coming Home to My Body": A Qualitative Exploration of Gender-Affirming Care-Seeking and Mental Health

Among transgender, non-binary, and/or gender expansive (TNG) persons, interest in medical and/or surgical forms of gender affirmation is heterogenous, as is access to those forms of medically necessary health care. Yet, the literature characterizing TNG persons' interest in medical and/or surgical gender-affirming care, barriers to accessing that care, and how societal narratives and expectations impact TNG individuals' self-image and mental health, as well as their personal choices regarding gender-affirming care remains sparse. Here we present qualitative research exploring TNG participants' interest in gender-affirming care and how such interventions impact identity formation. We conducted loosely structured interviews with a convenience sample of 54 TNG persons in the U.S. and Canada from Facebook pages used to recruit TNG research participants. One-hour interviews were conducted by an openly TNG researcher; participants were compensated. The most frequently sought gender-affirming care was hormone therapy, followed by chest ("top") surgery, genital ("bottom") surgery, electrolysis, breast augmentation, hysterectomy, and voice training. Less commonly desired interventions included fertility preservation, facial feminization/masculinization, and vocal surgery. Participants described four main categories of access barriers: financial (e.g., cost of medical/surgical care, inadequate insurance), logistical (e.g., no local providers, gatekeeping policies around body size and mental health, pandemic-related delays), personal fears about sub-optimal outcomes (e.g., complications, loss of sensation, undesired aesthetic and/or functional results), and societal discrimination (e.g., familial rejection, job loss, safety concerns). Participants reported primarily seeking this healthcare for social legibility, alleviating dysphoria/pursuing euphoria, and/or gender exploration. All who sought gender-affirming care reported improved mental health-including depression, anxiety, dissociation, and eating disorders-and social relationships, though many struggled to find TNG-competent mental health providers. This work provides key insights into how gender-affirming care can contribute to improving mental health for TNG communities, which will assist health providers in optimally treating TNG patients.

A Scoping Review of the Application of BREAST-Q in Surgical Research

Background

Collection of patient-reported outcome (PRO) data can facilitate cost-effective, evidence-based, and patient-centered care. The BREAST-Q has become the gold standard tool to measure PRO data in breast surgery. The last review of its application indicated that it was underutilized. Considering the evolution in breast surgery, the purpose of this study was to perform a scoping review of BREAST-Q application since 2015 and identify emerging trends and potential persistent gaps to guide patient-centered practice and future research in breast surgery.

Methods

We performed an electronic literature review to identify publications published in English that used the BREAST-Q to assess patient outcomes. We excluded validation studies, review papers, conference abstracts, discussions, comments, and/or responses to previously published papers.

Results

We identified 270 studies that met our inclusion criteria. Specific data was extracted to examine the evolution of the BREAST-Q application and examine clinical trends and research gaps.

Discussion

Despite a significant increase in BREAST-Q studies, gaps in the understanding of the patient experience remain. The BREAST-Q is uniquely designed to measure quality of life and satisfaction with outcome and care. The prospective collection of center-specific data for every type of breast surgery will generate important information for the provision of patient-centered and evidence-based care.

National Estimates of Gender-Affirming Surgery in the US

Importance

While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective

To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants

This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures

Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results

A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance

Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Feminization Rhinoplasty

This article provides a brief cross-cultural history of transgender, nonbinary, and other diverse gender identities, before exploring the background of gender-affirming care and facial feminization surgery in the United States. A variety of techniques for feminization rhinoplasty are discussed in detail. The authors provide insight into assessment and counseling of this unique patient population, timing of surgery, functional nasal considerations, and performing rhinoplasty in the context of other facial feminization procedures. Finally, complications of feminization rhinoplasty are identified and methods to prevent and treat such complications are enumerated.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

Masculinizing and defeminizing gender-affirming surgery

Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.

Non-typhoidal Salmonella soft-tissue infection after gender affirming subcutaneous mastectomy case report

We present a case of a 32-year-old transgender male who underwent chest masculinization, complicated by purulent soft tissue infection of bilateral chest incisions. Cultures tested positive for non-typhoidal Salmonella, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa. Herein, we discuss multiple factors contributing to the complexity of treating this patient's clinical course.

Effects of Gender Affirming Surgery on the Quality of Life of Transgender Women in Chiang Mai Province, Thailand

Gender affirming surgery (GAS) helps individuals to achieve a physical presence consistent with their gender identity. In this study, we explored the decision, expectation, experience, satisfaction, and quality of life (QOL) of transgender women (TGWs) who have undergone GAS and compared their QOL with transfeminine individuals (TFs) who have not and are seeking to do so in Thailand. The median overall QOL score of the TGWs who have undergone GAS was slightly higher than that of the TFs who have not (95 (92-103) vs. 92 (86-98); p = 0.003), which was also reflected in the specific domains of psychological health, social relationships, and environmental health, the exception being physical health. Not being financially prepared was the most relevant reason for delaying undergoing GAS among the TFs who have not undergone it and want to do so. In addition, more than half of the TGWs who have undergone GAS regretted not being socially accepted after surgery. Although the difference between the QOLs of the two groups is statistically significant, the clinical significance should be further investigated to provide more insight. In addition, the higher QOL of TGWs might not solely be due to having undergone GAS.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

BACKGROUND

Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI).

AIM

We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA.

OUTCOMES

Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty.

RESULTS

Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction.

CLINICAL TRANSLATION

The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery.

STRENGTHS & LIMITATIONS

This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center.

CONCLUSION

Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery

Purpose: Given the increasing frequency with which gender affirming surgery (GAS) is performed, understanding risk factors for poor outcomes is imperative. Recent investigations highlight inferior health outcomes experienced by Black transgender and gender expansive (TGE) individuals. Herein, we evaluate the relationship between race and postoperative outcomes in TGE patients undergoing GAS, utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: We conducted a retrospective review of ACS NSQIP from 2010 to 2018. Patients with a primary diagnosis of gender dysphoria undergoing GAS were identified and grouped by race. Patient characteristics and 30-day postoperative outcomes were recorded. Univariate analysis was used to compare patient characteristics and postoperative outcomes across groups. Multivariate logistic regression was used to determine independent predictors of complications. Results: We included 2308 patients (1780 White, 419 Black, 109 Asian). Gender, body mass index, smoking status, and type of surgery performed differed significantly between groups (p < 0.001). Univariate analysis revealed significant differences in 30-day readmission and organ space surgical site infection (SSI) across groups (p = 0.03). Multivariate logistic regression, adjusted for confounders, revealed that Black patients had higher odds of reoperation (odds ratio [OR] 1.82, p = 0.047), 30-day readmission (OR 2.46, p = 0.003), and organ space SSI (OR 4.65, p = 0.024) than White patients. Conclusion: We found that race was an independent predictor of important short-term postoperative outcomes in GAS. Inclusive clinical research, effective engagement with the TGE community, and surgery-specific enhanced recovery after surgery protocols may help address disparities, but we must acknowledge race as a social determinant of health.

Gender-Affirming Surgery: Perioperative Medical Care

OBJECTIVE

Gender-affirming surgeries are becoming increasingly common in the United States. For many transgender and gender-diverse patients, gender-affirming surgery is a critical aspect of their overall health and wellness and has a significant impact on their social functioning. Although often the role of the primary care provider, endocrinology specialists may also need to counsel their patients and collaborate with surgical teams.

METHODS

This narrative review provides an overview of the preoperative assessment and perioperative management for the most common gender-affirming surgeries.

RESULTS

Preoperative assessment prior to gender-affirming surgeries can resemble assessment for other surgeries.

CONCLUSION

In the absence of data specific to gender-affirming surgeries, risk stratification and amelioration must use surrogate data from other populations.

Facial Feminization Surgery: A Systematic Review of Perioperative Surgical Planning and Outcomes

Background:

Facial feminization is a critical step in a transfeminine patient’s surgical transition. However, the existing literature on the various types of feminization surgeries suffers from inadequate reporting on perioperative aspects of care, such as preoperative evaluation and postoperative outcomes. The aim of this study is to evaluate facial feminization surgery (FFS), preoperative planning, and patient reported outcomes after various types of procedures.

Methods:

An electronic database search of Ovid MEDLINE was completed according to PRISMA guidelines for articles pertaining to FFS. Study characteristics, operative information, and patient demographics were collected. Data concerning preoperative imaging, virtual simulation, postoperative complications, and patient-reported outcome measures (PROMs) were collected and analyzed for patterns.

Results:

A total of 22 papers representing 1302 patients were included for analysis. The most commonly discussed operations included upper face procedures, particularly of the forehead (17 studies, 77%). When discussed, preoperative planning for FFS included standard photography in 19 (86%) studies, advanced imaging, such as cephalometry or computed tomography, in 12 (55%) studies, and virtual simulation of surgical outcomes in four (18%) studies. Patient-centered outcomes, such as postoperative satisfaction, were described in 17 (77%) studies. Standardized PROMs were heterogenous across included studies with only 11 (50%) including at least one PROM.

Conclusions:

FFS is common, safe, and highly satisfying for transfeminine patients seeking surgical intervention for identity actualization. Future research concerning transgender care must evaluate advanced surgical planning and 3D simulation combined with more standardized assessment of PROMs to ensure high-quality analysis of patient satisfaction.

Creating Breast and Gynecologic Cancer Guidelines for Transgender Patients With BRCA Mutations

More than 1.5 million individuals in the United States identify as transgender. Transgender individuals have lower rates of health care utilization and higher rates of health care discrimination than cisgender patients. With a growing interest in providing comprehensive and compassionate care to the transgender community, there has been a concurrent increase in research on transgender health. However, lack of long-term data limits understanding the effects of hormone therapy on cancer risk factors in this population. This is particularly relevant for patients with hormonally mediated cancers and those at elevated risk from hereditary breast and ovarian cancer syndromes. Few cancer-screening and management guidelines currently exist for this population. Specific practices guided by the nuances of gender identity and gender-affirming care are essential to improve clinical management and to avoid further alienating a population that is already marginalized from the health care system. This commentary summarizes screening, management, and surveillance strategies devised for cisgender patients to offer corresponding recommendations tailored for transgender BRCA mutation carriers. In doing so, it highlights critical unanswered questions pertaining to the care of these patients. To address these questions, we must prioritize this population and adopt more inclusive frameworks in medicine and research.

Challenges in transgender health

Radix and Harris discuss the current state of transgender health and the challenges to equitable medical access experienced by transgender and gender-diverse patients. Transgender medicine has evolved significantly since the first clinical practice guidelines were developed more than 40 years ago, but important research gaps exist.