Gender-Affirming Surgery Price Transparency and Online Information Availability in US Hospitals.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

Current studies show that about half of transgender and gender-diverse (TGD) people wish to have children in the future. TGD patients who pursue gender-affirmation interventions must be aware of the impact that various treatments can have on fertility, as gender-affirming care through medical or surgical treatment can limit or alter reproductive potential. Many medical professional societies encourage providers to educate and counsel patients about the consequences of treatment and viable options for fertility preservation (FP) as early as possible, though patients may not be aware of all the family formation methods available. There is a significant need for a tool that thoroughly details not only the various opportunities for parenthood but the perceived cost, rates of success, and risks associated with each option. A fertility decision-aid would allow for a more robust informed consent process and shared decision-making for all individuals pursuing gender-affirming care.

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

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. 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. TGD patients (n = 30) and VHA providers (n = 22). Semi-structured telephone interviews conducted from August 2019 through January 2020. Two TGD analysts used conventional and directed content analysis to code transcribed data. 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. 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.

An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients

Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS. Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion. A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship. A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.

The use of social media is a growing trend among plastic and reconstructive surgery residency programs. Given the visual focus, compared to other social media apps, it is no surprise that Instagram is the dominant social media platform for plastic and reconstructive surgery residency programs. Currently, over 85 percent of plastic and reconstructive surgery residency programs maintain Instagram accounts, underscoring increased interest in using social media to promote their programs and educate the public.1 Now, in the coronavirus disease of 2019 era, social media presence is even more vital, as most communication, subinternships, and interviews will be virtual for the 2021 Match. Plastic and reconstructive surgery residency applicants have shown high levels of engagement with various social media platforms; Instagram is the most heavily used.2 However, there are no studies that investigate plastic and reconstructive surgery residency program Instagram engagement data and correlate post characteristics to the degree of engagement from the general social media community. Engagement analytics are commonly used by businesses, including plastic surgeons, to gauge how well they connect with their target audience.3,4 These data include information on impressions (number of times a post was viewed), interactions (number of actions taken directly from a post, including website clicks, e-mails, profile visits, and hyperlink clicks), reach (number of unique accounts that viewed a single post), and follows (number of new followers received from a post).3 Impressions and reach tell a user how many times a post has been viewed in total and how many unique accounts have viewed the post regardless of whether the post was "liked."3 Therefore, a post may not receive a large number of likes but may have high viewership, which can still mean valuable face time with the target audience for name recognition, recruitment, and branding. We searched Instagram in April of 2020 for all accounts associated with United States Plastic Surgery Residency programs. Four accounts—@harvard_plastic_surgery, @hopkinsplasticsurgery, @umichplasticsurgery, and @stanfordplastic—all had greater than 2500 followers. This was a higher number of followers compared to all other plastic and reconstructive surgery program accounts; the fifth most followed account had 2050 followers. Insight data, provided by Instagram for all "business" accounts, from each selected account were collected for posts between July of 2017 and May of 2020. Data from 832 posts were organized by type of media, number of images/videos, post content (Fig. 1), and tags, and then analyzed for correlations to different engagement fields.Fig. 1.: Number of posts including a category of content. Top categories included national conferences and resident life.Our study showed that certain post content helps drive higher engagement statistics, including operative cases, resident life, outdoor scenery, and awards/accolades. The most significant relative increase in engagement statistics occurs with posts regarding operative cases and resident life (inside/outside the hospital) (Fig. 2).Fig. 2.: Analysis of percentage change in likes relative to post content. *Statistically significant (p < 0.05). Operative cases and awards/accolades had the highest significant relative increase. National conference content was the only category to show a significant relative decrease of likes.Based on the data collected in this study, the ideal social media posts contain two facets: (1) posts with content showing residents and attending physicians operating, receiving awards/accolades, and enjoying life outside the hospital; and (2) posts where individuals and organizations are tagged. The general public, along with medical/plastic surgery professionals, appears to desire a glimpse into the operating room, a previous black box for many, and peek behind the scrub cap and mask of the surgeons.4 Interestingly, we found that national conferences were the most common content on the four accounts, but demonstrated significantly worse engagement data across all categories. This highlights a disconnect between what surgeons and surgical residents may think is interesting (research, presenting at conferences) and what the general public views as stimulating. This information can be important to programs looking to increase social media engagement and expand their social media followers in a short period. Of course, this information must be confined within the ethical and moral standards of the field. Studies within plastic and reconstructive surgery show more social media use among private practice surgeons compared to reconstructive/academic surgeons.4 However, most hospitals have a Web-based social media presence and use it for hospital promotion, education, community partnership, and fundraising purposes.5 Being "social media literate" and being able to cultivate an online presence and community will likely be increasingly vital in the academic setting. Plastic and reconstructive surgery residency social media accounts are important not only for branding, social network cultivation, and resident recruitment, but also as a tool to teach the next generation of plastic surgeons proper and ethical social media use. Plastic and reconstructive surgery residents have been found to have a much higher use of social media compared to practicing plastic surgeons.4 This trend will most likely continue as residents grow into young surgeons. Further prospective investigation into other plastic and reconstructive surgery residency Instagram accounts would further identify well-received and popular content. Programs can use these data to optimize engagement of their target audience and capitalize on this social media opportunity. DISCLOSURE Dr. Eberlin is a consultant for AxoGen, Integra, Checkpoint, and Tissium. Dr. Leto Barone is the founder and chief medical officer of ReconstratA, LLC. The remaining authors have no financial disclosures to report.

Over 1.4 million American adults identify as transgender or nonbinary. Of these transgender persons, up to half will seek gender-affirmation surgery. The literature is void regarding the current state of gender-affirming surgical training provided to plastic surgery residents. This study reviews the quantity and type of transgender surgical education in American plastic surgery residency programs. We performed a cross-sectional analysis on all accredited independent and integrated plastic surgery residency programs. Information on program curricula was collected from official program websites and email or telephone interviews with program coordinators. Education was categorized into didactic, clinical, or elective. Programs were classified according to geography and affiliation with a "Leaders in LGBT Healthcare" center. This study included 130 programs. While 58% of programs provided clinical training (n=75), significantly fewer had didactic teaching (n=50, 38%; p<0.003). One in five programs (n=15, 20%) that provided clinical training had a dedicated rotation. Programs affiliated with "Leaders in LGBT Healthcare" centers were significantly more likely to provide both didactic (n=33, n=17; p=0.031) and clinical training (n=48, n=27; p=0.006). Forty-two percent (n=54) of programs had no formal gender-affirmation surgery education and no scheduled elective time to acquire it. Despite the growing demand for gender-affirmation surgery, a large percentage of plastic surgery residency programs do not have didactic or clinical training and no elective means by which to acquire it. Institutional features, including "Leader in LGBT Healthcare Equality" status and geographic location, can significantly influence the type of gender transition education in residency.

As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.

The growing and interdisciplinary field of transgender health.

Gender-affirming surgery (GAS) can be an important part of comprehensive care for transgender and gender diverse (TGD) individuals, but this care is not provided by the Department of Veterans Affairs (VA) because of an exclusion in the medical benefits package. To describe the receipt of GAS by veterans and assess the associations between key sociodemographic characteristics and receipt of chest ("top") and genital ("bottom") surgeries. Cross-sectional national survey (the GendeR Affirming Care Evaluation (GRACE)), among TGD Veterans conducted between September 2022 and July 2023. A total of 6653 Veterans (54% response rate) completed the survey. Self-reported "top" and "bottom" GAS were key outcomes. Covariates included gender identity, sex assigned at birth, age, race, ethnicity, income, employment status, education, relationship status, sexual orientation, and geographic region. Among all respondents, 39% had ≥ 1 GAS. Among the 4430 veterans interested in top surgery, 38% received it; 23% of 3911 veterans interested in bottom surgery had received it. In multivariable models, older age (50 + vs. 18-39) was associated with higher receipt of top and bottom surgery while nonbinary gender identity (vs. binary gender identity), lower household income (< $50,000 vs. > $75,000), less education (less than a college graduate vs. Master's degree or more), sexual orientations other than heterosexual, and residing in a region other than the Pacific were associated with lower receipt of top and bottom surgery. Individuals assigned male (vs. assigned female) at birth had lower receipt of top surgery and higher receipt of bottom surgery. GAS receipt was low and there were important disparities by gender, sex, income, education, sexual orientation, and region. By removing the exclusion to providing GAS, VA could reduce barriers to accessing GAS and decrease disparities among TGD veterans.

BackgroundThere is a growing awareness surrounding gender diversity and the critical need for more robust research and evidence to guide gender-affirming healthcare, including gender-affirming hormone therapy (GAHT). Research priorities are often determined by clinicians and researchers; we lack data about the transgender and gender diverse (TGD) community's priorities for research.ObjectiveTo determine the research priorities of adult TGD patients who receive care at a multidisciplinary gender-affirming clinical program at a tertiary academic medical center.Design/MethodsIRB-approved electronic surveys were sent to 719 patients who sought care from the program in the last year. Participants were asked to rank research topics within six domains based on the importance of the topic to their care: 1) care access/utilization within the program, 2) GAHT impacts on the body, 3) GAHT concerns/potential adverse effects, 4) gender-affirming surgeries, 5) mental health, and 6) navigating healthcare/work/school, with 6-7 choices in each category, including a free text option to fill out their own research priority.Results135 individuals consented and responded to the survey (19% response rate). Almost half were aged 18-29 years (45%), and several were aged 50 years or older (16%). Nearly all identified as white (92%). Participants were able to check more than one response for these demographics: feminine gender identity (55%; inclusive of female, transgender female, and/or transfeminine); masculine gender identity (37%; inclusive of male, transgender male, and/or transmasculine), nonbinary (25%), and/or something else (25%).The top two research priorities (by % respondents ranking the topic as most important) within each of the six domains were: 1) care access/utilization within the program: have insurance coverage for gender-affirming care (66%), have gender-affirming surgery (33%); 2) GAHT impacts on the body: overall feminizing/masculinizing effects (81%), mental health/mood (69%); 3) GAHT concerns/potential adverse effects: heart health (54%), blood clots/stroke (47%); 4) gender-affirming surgeries: common complications (57%), post-op sexual function/pleasure (51%); 5) mental health: GAHT (59%) and surgeries (46%) impact on suicide risk; and 6) navigating healthcare/work/school: barriers to accessing care (61%), training community providers (58%). Fertility was ranked as the least important research priority. Research on the discontinuation of gender-affirming interventions and regret in getting gender-affirming surgery were also ranked as low priorities.ConclusionsTGD adults receiving care at a tertiary academic medical center ranked GAHT's effects on overall feminization/masculinization, mental health/suicide risk, common surgery complications, and cardiovascular health as top research priorities. They also indicated a desire for more research on barriers to accessing care, especially insurance coverage and provider education. Compared to other topics, fertility was ranked as the least important research priority. The TGD community's research priorities should be used to inform TGD health funding and researcher priorities to ensure that research evidence leads to improvements in patient-centered gender-affirming care.Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

The persistence of health care disparities along racial and ethnic lines highlights the complex and multifactorial nature of this national concern. The paucity of physicians ethnically underrepresented in medicine to treat an ever-growing heterogeneous population inherently contributes to these ongoing disparities. The authors proposed an approach to improve the representation of physicians underrepresented in medicine in their plastic surgery residency program. With a renewed commitment to ethnic diversity and inclusion, a multifaceted recruitment and retention approach was implemented at the University of Pennsylvania plastic and reconstructive surgery residency program from 2015 to 2020 (5 academic years). A retrospective review of the demographics of the program's residents was then assessed over the past 9 academic years for comparison (2011 to 2020). The representation of underrepresented-in-medicine residents within the plastic and reconstructive surgery residency program steadily increased with the implementation of this multifaceted approach, reaching an unprecedented high. Currently, 29 percent of all residents are underrepresented in medicine and 29 percent are female, some of whom are also underrepresented in medicine. Although the female representation is on par with the national average, the underrepresented-in-medicine representation is far greater than the national average. As a result of this multifaceted approach, the representation of African American and Latino plastic surgery residents at the University of Pennsylvania now far exceeds current national averages. Unfortunately, the representation of Native American and Alaskan Natives is still lacking, despite the program's broadened recruitment efforts. The success of this experience describes a successful strategy that institutions can implement to enhance underrepresented-in-medicine representation among its plastic surgery trainees.

Disclosure: J.M. Taormina: None. A.H. Gilden: None. S.J. Iwamoto: None. Introduction: Obesity prevalence is higher in transgender and gender diverse (TGD) adults compared to the general population. TGD people experience gender minority stress and disparities in lifestyle factors, socioeconomic status and medical comorbidities that likely contribute to excess weight. Gender-affirming hormone therapy (GAHT) has also been associated with increased body weight; oral estrogen with an antiandrogen is associated with increased fat mass and decreased lean mass. Many surgery centers enforce body mass index (BMI) requirements for gender-affirming surgeries (GAS) that limit access for TGD patients with obesity. The most effective and affirming weight management strategies for TGD patients have yet to be determined. Bariatric surgery has been identified as a treatment to address obesity prior to GAS; however, surgical weight loss can delay GAS for 3 years. While anti-obesity medications (AOMs) are effective, literature is needed supporting their use in TGD patients prior to GAS. Clinical Case: We report the case of a 40-year-old transgender woman with BMI 39.6 kg/m2, prediabetes, mixed hyperlipidemia, hypertension, non-alcoholic steatohepatitis (NASH) and congenital solitary kidney who presented for weight loss to qualify for gender-affirming bilateral breast augmentation. Her surgeon required a presurgical BMI &amp;lt;35.0 kg/m2. She had no prior GAS or bariatric procedures. She was taking intramuscular estradiol valerate, oral progesterone, spironolactone, and omeprazole without a history of prior AOM use. She was counseled on lifestyle modification, including recommendations for a reduced calorie diet, regular aerobic and resistance physical activity and sleep hygiene. Given history of prediabetes and NASH and superior mean weight loss with semaglutide compared to other FDA-approved AOMs, she was started on semaglutide 0.25 mg subcutaneously weekly with monthly dose escalation. In 3 months, she lost 17.7 kg or 13.9% total body weight with BMI 34.1 kg/m2. Complications addressed during treatment included acute kidney injury from poor water intake as a potential medication side effect; medication supply issues; limited engagement in physical activity due to lack of social safety, body dysmorphia and wish to limit upper body muscle mass for her desired body contour. Clinical Lessons: This case highlights (1) the need for increased access to affirming weight management services for TGD patients with obesity pursuing GAS and (2) the potential role of AOMs in assisting TGD patients in reaching presurgical BMI targets. Whether BMI requirements for GAS lead to improved surgical outcomes needs additional research. Perspectives on and the impacts of BMI requirements for GAS deserve exploration. Further studies are also needed to evaluate the needs of TGD patients in weight loss interventions and the effects of weight loss and AOMs on GAHT management. Presentation: Saturday, June 17, 2023

The purpose of this Web-based survey was to elucidate the current perspectives of plastic surgery residency program directors on training residents to perform gender-affirming surgery. Web-based surveys were distributed to 79 plastic surgery program directors. Demographic information and perspectives on training of gender-affirming surgery in plastic surgery residency were queried. Of 79 distributed surveys, there were 43 responses (54 percent). Overall, program directors reported that their trainees were prepared to address plastic surgery-related transgender concerns (67 percent), and believe plastic surgeons are the most appropriate specialty referral for each type of gender-affirming surgery (top/chest, 98 percent; facial, 95 percent; and bottom/genital, 79 percent). Ninety-three percent of program directors noted that transgender surgery is becoming more accepted and/or practiced in their referral area, with 26 percent reporting a dedicated clinic experience. There was a mixed response on the need for additional fellowship training for gender-affirming surgery. Residents are exposed to significantly more bottom (p = 0.0018), top (p = 0.0013), and facial operations (p = 0.00005) if they rotate through a "gender" clinic. Of the queried program directors, the majority feel their residents are well-trained in gender-affirming surgery. However, residents have more clinical exposure in facial and top (chest) gender-affirming surgery as compared to bottom (genital) surgery. Although most program directors agree that plastic surgeons are the most important referral for top, bottom, and facial operations, there is less consensus over the role of fellowship training. Most program directors reported a desire to devote additional CME time to the topic in the coming years.