New Criteria for Sex Reassignment Surgery: WPATHStandards of Care, Version 7,Revisited

Gender-Affirming Surgeries: A National Surgical Quality Improvement Project Database Analyzing Demographics, Trends, and Outcomes

BACKGROUND

Gender affirmation surgery is an exponentially growing field within plastic surgery. The aim of our study is to analyze demographics, procedure type, trends, and outcomes in the surgical management of gender identity disorder in the past few years.

METHODS

The American College of Surgeons NSQIP database was queried for the years 2015 to 2019. International Classification of Diseases codes were used to identify all gender-affirming cases. Patients were categorized by procedure type using Current Procedural Terminology codes for feminizing/masculinizing top, bottom and head/neck procedures. Patient demographics, comorbidities, and postoperative complications were analyzed using SPSS statistics software. A comparative analysis was performed among the procedure type.

RESULTS

From 2015 to 2019, 4114 patients underwent a gender-affirming surgery (GAS) increasing the number of surgeries by over 400%, according to the NSQIP database. Demographics include age (mean = 32 years), body mass index (mean = 28 kg/m2), race (60% White, 22% unknown, 13% African American, 4% Asian, 1% other). Female to male procedures represented the most commonly performed (n = 2647; 64%), followed by male to female (n = 1278; 31%) with head/neck procedures representing 5% (n = 189) of all procedures. Top surgeries were also the most common (n = 2347, 57%), followed by bottom surgeries (n = 1578, 38%). The overall complication rate was 6% (n = 247), 2.1% (n = 4) for head/neck procedures, 8% (n = 134) for bottom procedures, and 3.5% (n = 84) for top surgeries.A reoperation within 30 days and related to the initial GAS occurred for 52 patients. Postoperative complication rates were statistically different between bottom surgeries compared with the top and head/neck procedure groups (P < 0.001). Increasing age and body mass index showed a significantly higher odds of having a complication.

CONCLUSIONS

Gender-affirming procedures have significantly increased over the past 5 years. Increased exposure through literature and research, as well as an improvement in social climates, including increasing insurance coverage have contributed to the expansion of these procedures. Low serious complication rates within 30 days prove GAS to be safe.

Readiness assessments for gender-affirming surgical treatments: A systematic scoping review of historical practices and changing ethical considerations

Transgender and gender diverse (TGD) are terms that refer to individuals whose gender identity differs from sex assigned at birth. TGD individuals may choose any variety of modifications to their gender expression including, but not limited to changing their name, clothing, or hairstyle, starting hormones, or undergoing surgery. Starting in the 1950s, surgeons and endocrinologists began treating what was then known as transsexualism with cross sex hormones and a variety of surgical procedures collectively known as sex reassignment surgery (SRS). Soon after, Harry Benjamin began work to develop standards of care that could be applied to these patients with some uniformity. These guidelines, published by the World Professional Association for Transgender Health (WPATH), are in their 8th iteration. Through each iteration there has been a requirement that patients requesting gender-affirming hormones (GAH) or gender-affirming surgery (GAS) undergo one or more detailed evaluations by a mental health provider through which they must obtain a "letter of readiness," placing mental health providers in the role of gatekeeper. WPATH specifies eligibility criteria for gender-affirming treatments and general guidelines for the content of letters, but does not include specific details about what must be included, leading to a lack of uniformity in how mental health providers approach performing evaluations and writing letters. This manuscript aims to review practices related to evaluations and letters of readiness for GAS in adults over time as the standards of care have evolved via a scoping review of the literature. We will place a particular emphasis on changing ethical considerations over time and the evolution of the model of care from gatekeeping to informed consent. To this end, we did an extensive review of the literature. We identified a trend across successive iterations of the guidelines in both reducing stigma against TGD individuals and shift in ethical considerations from "do no harm" to the core principle of patient autonomy. This has helped reduce barriers to care and connect more people who desire it to gender affirming care (GAC), but in these authors' opinions does not go far enough in reducing barriers.

Transgender men's fertility preservation: experiences, social support, and the quest for genetic parenthood

Transgender people assigned female at birth may undergo fertility preservation by egg or embryo freezing, usually prior to gender affirming treatment. In this binational ethnographic study, four transgender men were included as part of a larger comparative project on fertility preservation. In-depth ethnographic interviews allowed informants to talk freely about their fertility preservation experiences, and the circumstances that had enabled them to pursue this option. Prominent in men's accounts were the importance of genetic parenthood and the role of social support from others in the fertility preservation process. Indeed, in all cases, social support-from parents, siblings, partners, peers, physicians and employers-was critical, effectively enabling young transgender men to embark on their fertility preservation journeys and undergo the physically taxing process. This study illustrates the power of thriving through relationships that were critical in young transgender men's experiences of fertility preservation.

Ethical Issues Considered When Establishing a Pediatrics Gender Surgery Center

As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital's ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital's mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center's services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution.

Health care provider perceptions of fertility preservation barriers and challenges with transgender patients and families: qualitative responses to an international survey

PURPOSE

To examine provider perceptions of practice behaviors and barriers related to fertility counseling, fertility preservation, and family building among transgender patients.

METHODS

Participants were medical and mental health professionals who treat adult and youth transgender patients. Recruitment occurred online and in person, via professional listservs for transgender professionals, conferences, and gender clinics. From August-November 2017, 110 participants representing nine countries responded to four open-ended questions included on a survey related to provider practice behaviors and perceived barriers to fertility counseling, fertility preservation, and family building with transgender patients. Thematic coding analysis was used to identify themes.

RESULTS

Multiple themes were identified including the following: access and cost issues; urgency for gender-affirming treatment; patient maturity and inability to make future-oriented decisions; and provider-related challenges pertaining to knowledge, role, and general lack of information in the nascent field of transgender reproductive health.

CONCLUSION(S)

This study yielded insights into practice behaviors, challenges, and perceived barriers to fertility counseling with transgender individuals and can serve as a basis for intervention development to optimize clinical practices with this population.

Gender incongruence: a comparative study using ICD-10 and DSM-5 diagnostic criteria

OBJECTIVE

To compare the presence of criteria listed in the DSM-5 and ICD-10 diagnostic manuals in a Brazilian sample of transgender persons seeking health services specifically for physical transition.

METHODS

This multicenter cross-sectional study included a sample of 103 subjects who sought services for gender identity disorder in two main reference centers in Brazil. The method involved a structured interview encompassing the diagnostic criteria in the two manuals.

RESULTS

The results revealed that despite theoretical disagreement about the criteria, the manuals overlap regarding diagnosis confirmation; the DSM-5 was more inclusive (97.1%) than the ICD-10 (93.2%) in this population.

CONCLUSIONS

Although there is no consensus on diagnostic criteria on transgenderism in the diversity of social and cultural contexts, more comprehensive diagnostic criteria are evolving due to society's increasing inclusivity.

Barriers, Challenges, and Decision-Making in the Letter Writing Process for Gender Transition

This article addresses the challenges that clinicians face in writing letters of support for transgender and gender-diverse clients. It addresses common but challenging clinical representations to help the reader understand the nuances associated with writing letters. Three cases are presented. The first addresses systemic challenges, the second addresses management of care, and the third addresses co-occurring mental health concerns. Recommendations for practice are provided based on the experiences included within the 3 case examples.