37: Barriers to care and reproductive considerations for female-to-male transgender gender confirmation surgery

Abstract

The transgender population is one of the most marginalized and underserved populations in medicine. To provide the transgender community with adequate and compassionate care, it is important to identify barriers to gender confirming medical care. This study aimed to identify barriers to care for female-to-male transgender patients who desired gender confirmation surgery and to assess post-procedural satisfaction or regret, particularly with respect to fertility. We distributed an anonymous, cross-sectional survey to all female-to-male transgender patients who were at least 18 years old and underwent a total hysterectomy at our institution. Patients received surveys via email or paper from January through August 2017. We developed the survey to capture demographic characteristics, barriers to care, and experience before and after the surgery. We also used the validated Decision Regret Scale to assess feelings about having undergone the surgery; scores range from 0-100 with higher scores indicating more regret. Data are presented as median (interquartile range) or n proportion. A total of 91 surveys were distributed, and 48 (52.7%) were completed. Respondents were aware of their male gender by a median age of 14.0 (5.0-20.0) years and certain by age 21.5 (17.5-27.0). Sexual orientation was 50.0% heterosexual, 22.9% bisexual, 10.4% other, and 8.3% homosexual. Almost all respondents (93.8%) reported taking testosterone, but only 39.5% of those taking testosterone felt this was a prerequisite to surgery. The majority (75.0%) traveled less than 25 miles for their surgery and 95.8% reported that their insurance covered the procedure. The median time between the initial consultation and surgery was 6.5 (4.5-12.0) months. The most frequently cited barriers to surgical care were: stigma of being seen as a male patient in an obstetrics and gynecology practice (62.5%), insurance/financial support (48.7%), and difficulty taking time off from work (39.4%). The median score on the decision regret scale was 0.0/100 (0.0-5.0). Most (75.0%) respondents did not have children at the time of surgery and nine (20.5%) of these respondents planned to have children after surgery. Seven (77.8%) of those nine respondents planned to adopt or have their partner carry the pregnancy, while two (22.2%) planned to adopt or use a surrogate. Providers have expressed reservations to perform gender confirming surgery due to concern of patient regret for a permanent procedure with irreversible infertility. This study provides some reassurance in that none of the 48 participants expressed regret. The patients who did want to have future children all underwent the procedure with a plan. Diversity in sexual orientation was also present in this group with half of the participants identifying as bisexual, homosexual or other. Interestingly, in this study area where insurance covered the majority of the surgeries, the most frequently cited barrier to care was the stigma of being seen as a male patient in an ob-gyn practice. Changing clinical practice to decrease the perceived stigma is a major step to improve female-to-male transgender patients’ experience and willingness to access care.