Gender-Affirming Care in Plastic Surgery Training: Moving beyond Metrics of Exposure.

Abstract

Transgender and gender-diverse individuals have always existed, thus there has always been a need for gender-affirming care. Only recently has the broader medical community acknowledged the harm in not offering these services. Plastic surgeons are at the forefront of the surgical care of this community due to the operative flexibility and diverse skill set needed to address multiple anatomic areas of desired affirmation, including the face, chest, body, and genitals. The volume of gender affirmation surgeries has increased 3.67-fold from 2000 to 2014 and continues to expand.1 The historical lack of access to these surgeries, combined with an exponentially growing demand, has resulted in a huge number of patients waiting for surgical care from only a handful of experienced surgeons. Although it is critical that the medical necessity of gender-affirming care has been recognized and that coverage has increased, the effort to effectively care for the transgender and gender-diverse community will remain inadequate without a greater availability of meaningful training to produce a sufficient number of competent surgeons. Residency programs have made meaningful strides in offering more accessible and competent gender-affirming training, but there is significant room and need for further improvement. Two recent studies published in Plastic and Reconstructive Surgery have examined plastic surgery residents’ training in transgender and gender-diverse care. In a survey of program directors, 67 percent described their trainees as prepared to address plastic surgery–related care for transgender and gender-diverse patients but reported only 28 percent of their residents had exposure to genital surgery and 56 percent had exposure to facial surgery.2 In a national survey of plastic surgery residents, 64.6 percent of residents stated they had “[received] education or exposure to the care of transgender patients,” but there were significant differences in exposure by region.3 The metrics used in these studies to assess the current state of gender-affirming surgery training were largely limited to measurements of exposure, rather than competency and actual experience in clinical and operative care. The World Professional Association for Transgender Health’s recommendations for clinical training encompass a far greater breadth of experience beyond surface-level exposure.4 Although residents train in many areas involved in gender affirmation, these surgical techniques are often highly complex and take significant training and experience to master, especially given the profound psychosocial implications for patients. Surgical providers must have a robust understanding of the perioperative experience of patients to achieve safe, successful outcomes. Gender-affirming surgery is an evolving area of subspecialization that should be given the same priority as any other subspecialty in plastic surgery. As more individuals seek gender-affirming procedures, plastic surgery trainees will benefit from additional training tailored to transgender and gender-diverse patients, with 71.9 percent of residents endorsing the necessity for fellowship training in gender-affirming surgery.3 Moving beyond metrics of exposure to national training guidelines for plastic surgery residents on the clinical skills and competencies needed to care for transgender and gender-diverse patients is both a necessary step and our responsibility to help alleviate and address the inequities facing transgender and gender-diverse patients. DISCLOSURE The authors have no financial interests to disclose. No funding was received for this article. Nicolas A. Leighton, B.A.The George Washington University HospitalWashington, D.C. Mandi Pratt-Chapman, Ph.D.The George Washington UniversityGW Cancer CenterWashington, D.C. Blair R. Peters, M.D.Department of SurgeryDivision of Plastic and Reconstructive SurgeryDepartment of UrologyOregon Health and Sciences UniversityPortland, Ore.