Transgender surgery - Knowledge gap among physicians impacting patient care

Defining Preferred Esthetics of the Ideal Phallus via Crowdsource Survey

OBJECTIVE

To describe phalloplasty subunits and determine the preferred crowdsourced esthetics. Esthetic ideals are often used to guide reconstruction, and there has been an increase in the number of gender-affirming surgeries and reconstructive phalloplasties performed. However, there is a paucity of literature describing ideal phalloplasty esthetics.

METHODS

Phallus esthetic subunits were defined, and a split testing-based survey was used. Subjects were solicited via Craigslist, Amazon Mechanical Turk, and Reddit and distributed among health care co-workers. Computer-generated images with variable ratios of glans, corona, and shaft were provided and respondents were asked to select the most esthetically pleasing photo. Demographic information was gathered. Univariate and multivariate regression were performed.

RESULTS

A total of 1029 people responded to the survey request and 909 people (88.3%) completed the entire survey. There were 440 respondents who self-identified as male, 334 female, 92 transgender male, and 25 transgender female. The health care field was the profession for 55.4%. Health care providers had 65.3% higher odds of preferring the longer shaft length-to-width ratio, 30.3% less odds of preferring a bilateral taper of the glans, and 48.4% less odds of preferring an angulated shaft compared to non-health care providers (P = .006, P = .021, P <.001, respectively). When compared to males, transgender females were more than 13 times likely to prefer an angulated glans corona junction (P = .008).

CONCLUSION

The ideal phallic esthetic varies by individual, and there were statistically significant preferences across age, education, health care status, gender, and sexual orientation. This study can serve as a guide on phalloplasties for patients and gender-affirming surgeons.

Bilateral Urinary Stones in a Transgender Woman: A Case Report in Lebanon

This case report presents a 38-year-old transgender woman, assigned male at birth, who presented with severe right flank pain associated with nausea and hematuria. After previously undergoing gender-affirming surgeries, including abdominoplasty, liposuction, breast augmentation, and reconstructive vaginal surgery, the patient developed bilateral ureteral and kidney stones leading to significant hydronephrosis. Bilateral double J insertion was performed following a computed tomography (CT) Uroscan. This was followed by flexible ureteroscopy and laser fragmentation of the stone bilaterally. The patient's anatomy was remarkable for the presence of neovagina and prostate. This case highlights the unique challenges and considerations in managing genitourinary complications in transgender individuals. The literature is limited in the Middle East concerning transgender individuals, hence the need to conduct further research and compile comprehensive case reports on transgender individuals in the Middle East in order to establish a robust database and draw meaningful epidemiological conclusions.

TransCare Initiative: An Institutional Knowledge-to-Action Project for Surgery and Gender Equity Education

BACKGROUND

The transgender/gender nonconforming (TGNC) population is growing exponentially, but surgeon education has not advanced accordingly. Our objective was to assess department-wide understanding, awareness, and comfort in treating TGNC patients and identify specific gaps in education and training needs.

METHODS

A survey covering 4 domains (personal perceptions; prior healthcare training/experience; comfort providing care; barriers to access) regarding TGNC patients was distributed to surgery faculty and trainees at an urban referral center. The survey contained 24 5-point Likert scale and 6 multiple choice demographic items. There was a 4-week response window. Descriptive statistics assessed the relative frequency of responses. The main outcome measures were the gaps and variation in each domain.

RESULTS

There was a 47.59% (89/187) response rate and split evenly between trainees and attendings. Over half (51.21%, n = 44) reported formal TGNC training, mainly in medical school (27.5%, n = 22). Most knew (72.41%, n = 63) and had experience caring for TGNC patients (74.71%, n = 65). There was disparity understanding general concepts, with disagreement on definitions (8.99%, n = 8) and gender choice (14%, n = 12). Most reported comfort with communication, and could initiate conversations on pronouns (75.6%, n = 65) and gender identity (71.7%, n = 65). Over 40% could not complete a comprehensive history and admitted discomfort performing physical exams. Despite this, 88.51% (n = 77) felt they could provide an adequate level of care. Most respondents recognized unique TGNC health risks (91.86%, n = 79) and access barriers (82.76%, n = 72), including providers' lack of TGNC cultural competency (82.76%, n = 72).

CONCLUSION

Disparities existed across all domains needed for inclusive TGNC surgical care. Respondents were aware of unique health needs and barriers to access. Provider self-perceived experience did not match the knowledge and skill required to provide optimal care for TGNC patients.

Emergency care considerations for transgender and gender diverse youth: a review to improve health trajectories

PURPOSE OF REVIEW

Transgender and Gender Diverse (TGD) youth represent a growing subset of pediatric patients who are at increased risk for harmful health outcomes. Consideration of these risks during emergency encounters may decrease these undesired, sometimes fatal, adverse events.

RECENT FINDINGS

Gender affirmative care of TGD youth is considered a basic healthcare right as noted by several academic societies including the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the American Psychological Association [1-3] ( Table 1 ). Withholding gender affirmative care can lead to undesired health outcomes including but not limited to an increased incidence of mood disorders, self-injurious behavior, suicidal ideation, sexually transmitted diseases, and delayed presentations of treatable illness. TGD youth often access acute care settings, yet many feel apprehensive due to prior negative experiences or fear of discrimination. Practitioners are also often unaware as to how to effectively provide this type of healthcare.

SUMMARY

Acute care settings provide a unique and impactful environment to provide evidence-based, gender-affirming care that can make patients feel validated, mitigate future care avoidance, and minimize negative downstream health effects. In this review, we have consolidated high yield health considerations regarding TGD youth for acute care and emergency providers to deliver optimal care for this population.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.