Prospective Patient-reported Psychosocial Outcomes of Facial Feminization Surgery

Abstract

PURPOSE: Gender affirming surgery is an essential component in the treatment of gender dysphoria. While health insurance plans have deemed several gender-affirming surgeries as medically necessary, facial reconstructive procedures continue to be debated due to a deficiency of high-level evidence for quality-of-life improvements. As face perception neural networks allow for immediate gender identification, facial gender-affirming surgery is frequently the first and most important surgery for many patients with gender dysphoria, particularly in the transfeminine population. In this work, we administer a battery of validated, quantitative patient-reported outcomes measures examining the psychosocial functioning of a cross-section of transgender patients who have or have not received facial feminization surgery (FFS). METHODS: In total, 96 patients (age 33.07 ± 10.60 years) receiving an FFS consultation at the University of California, Los Angeles were prospectively enrolled from 2019 to 2021 and administered 11 adult Patient-Reported Outcomes Measurement Information System item banks, including version 1.0 anxiety short form 8a, version 1.1 anger short form 5a, version 1.0 depression short form 8b, version 1.2 global health form, version 2.0 satisfaction with sex life form, version 1.0 positive affect short form 15a, version 1.0 meaning and purpose short form 4a, version 2.0 emotional support short form 4a, version 2.0 companionship short form 4a, and version 2.0 social isolation short form 4a. Descriptive statistics and linear regression analyses were performed. RESULTS: Patients who received FFS (assessed 236.35 ± 143.30 days postoperatively) demonstrated improvements in anxiety, anger, depressive symptoms, sex life, positive affect, emotional support, and meaning and purpose instrument scores. Because psychosocial functioning is likely to be influenced by multiple factors, we developed a linear regression model to understand whether FFS would be an independent predictor of psychosocial scores. Other predictors included were the presence or absence of other gender affirming surgery, binary or non-binary gender identity, duration of hormone treatment, age at the time of assessment, and global health scores as a measure of baseline health. For anxiety scores, this model accounted for 36.6% of the variance [F(6,78) = 7.512, P < 0.001], and for anger scores, this model accounted for 23.2% of the variance [F(6,78) = 3.919, P = 0.02]. The completion of FFS independently predicted lower anxiety scores (beta = −0.197, P = 0.04) and lower anger scores (beta = −0.219, P = 0.04). With the exception of global health, no other variables were significantly predictive of either anxiety or anger scores. CONCLUSIONS: Our prospective, cross-sectional assessment of psychosocial outcomes demonstrated a global improvement in psychosocial functioning in patients who have received FFS. The linear regression model that includes other potential predictors of variance in scores such as other gender affirming surgery, age, and duration of hormone therapy demonstrated that completion of FFS was an independent predictor of lower anxiety and anger scores. This work is the first Level II evidence study in quality of life of outcomes for patients who have undergone FFS and it is also the first study utilizing robust, validated instruments for assessment. Future directions of this work include longitudinal analyses of patient outcomes after FFS.