Reassignment Surgery Research Articles

Images: Irregular sleep-wake rhythm disorder in transgender individuals.

Kokash A, Vendrame M. Images: irregular sleep-wake rhythm disorder in transgender individuals. J Clin Sleep Med. 2023;19(11):1981-1984.

An enhanced recovery after surgery protocol for facial feminization surgery reduces perioperative opioid usage, pain, and hospital stay

Prescription drug misuse in transgender individuals is estimated to be three times higher than that of the general population in the United States, suggesting that opioid-reduction strategies deserve significant consideration in gender-affirming surgeries. In this work, we describe the implementation of an enhanced recovery after surgery (ERAS) protocol to reduce opioid use after facial feminization surgery. A total of 79 patients who underwent single-stage facial feminization surgery before (n=38) or after (n=41) ERAS protocol implementation were included. Primary outcomes assessed were perioperative opioid consumption (morphine equivalent dose/kilogram, MED/kg), average patient-reported pain scores, and length of hospital stay. Comparisons between groups and multivariable linear regression analyses were conducted to define the contribution of the ERAS protocol to each of the three primary outcomes. Age, body mass index, mental health diagnoses, and length of surgery did not differ between pre-ERAS and ERAS groups. Compared to pre-ERAS patients, patients treated under the ERAS protocol consumed less opioids (median [interquartile range, IQR], 0.8 [0.5-1.1] versus 1.5 [1.0-2.1] MED/kg, p<0.001), reported lower pain scores (2.5±1.8 versus 3.7±1.6, p=0.002), and required a shorter hospital stay (median [IQR], 27.3 [26.3-49.8] versus 32.4 [24.8-39.1]h, p<0.001). When controlling for other contributing variables such as previous gender-affirming surgeries, mental health diagnoses, and length of surgery using multivariable linear regression analyses, ERAS protocol implementation independently predicted reduced opioid use, lower pain scores, and shorter hospital stay after facial feminization surgery. The current work details an ERAS protocol for facial feminization surgery that reduces perioperative opioid consumption, patient-reported pain scores, and hospital stays.

Assessment of deep plane facelift in facial feminization surgery: A prospective pilot study

Facial feminization surgery (FFS) is often the first procedure requested by patients wishing to undergo gender-affirming surgery. This study aims to evaluate the applicability and effectiveness of deep plane facelifts in FFS. The authors conducted a prospective study that included patients who requested a deep plane facelift as a standalone procedure to achieve a more feminine facial appearance as the only procedure of FFS. These patients underwent deep plane facelifts to achieve a more feminine oval face shape and increased tissue projection of the zygomatic-malar region. To assess the effectiveness of the procedure and patient satisfaction, the Face-Q scales, Face and Neck lift Objective Photo-Numerical Assessment Scale, the Satisfaction With Life Scale, and the Subjective Happiness Scale were applied preoperatively and one year after surgery. Thirty-six patients were included in the study. A statistically significant difference (p<0.005) was observed between pre and postoperative scores. The repositioning of the malar fat pads increased the malar volume, providing a more oval overall shape of the face, which is typically feminine. No major complications were observed. Despite our encouraging results, new studies with a larger sample of patients are needed to support the benefits of the deep plane facelift as part of FFS to elevate this technique from an ancillary to a routine procedure for patients undergoing gender affirmation surgery.

Outcomes of Orchiectomy for Gender-affirming Surgery: A National Surgical Quality Improvement Program Study

To identify perioperative outcomes of transgender orchiectomy (TGO) and to broadly compare outcomes of TGO to cisgender orchiectomy (CGO) for non-oncologic indications. Using the National Surgical Quality Improvement Program (NSQIP) database from 2010-2020, a retrospective study was performed on patients with ICD-9/10 codes for gender dysphoria, testicular torsion, and testicular pain who underwent simple orchiectomy. Demographics and surgical outcomes were summarized. Welch two sample t-test and Chi-square test were used for group analysis. A trend analysis was performed for temporal trends of these surgeries. 246 patients underwent TGO and 997 patients underwent CGO (607 testicular torsion, 390 testicular pain). Overall complication rates between TGO and CGO did not differ for testicular torsion (3.7% vs 4.4%, p=0.6) or testicular pain (3.7% vs 5.9%, p=0.2). No differences in patient characteristics were seen within the TGO group when comparing those who experienced complications to those who didn't. From 2015 to 2020, TGO cases significantly increased by, on average, 9.5 cases per year (95% CI: 6.3-12.7, p=0.001), while CGO had showed no significant temporal change. Standalone TGO can be performed safely in an outpatient setting with an acceptable complication profile in medically diverse patients.

Desire for Gender-Affirming Surgery in a Sample of Transgender and Gender Diverse Individuals in Late Adolescence Assigned Female at Birth

ObjectiveTo describe choices of transgender and gender diverse (TGD) late adolescents assigned female at birth regarding gender-affirming surgery (GAS). MethodsParticipants aged 18-21 completed an online survey that included demographic characteristics, surgical history, desire for GAS, and barriers to care. ResultsTwo hundred and sixty surveys were completed. Forty-three (16.7%) respondents had undergone GAS. Of those who had not, 178 (83%) planned to do so in the future, and 15 (7%) reported no desire to undergo GAS. One hundred and sixteen (54%) had not due to financial reasons, 54 (25%) due to insurance difficulties, and 28 (13%) because they were unable to find a surgeon. ConclusionTGD late adolescents assigned female at birth have varying desires for future GAS that align with their gender expression. They also face many barriers to care. It is important for health care providers to be aware of the unique desires of TGD adolescents, not assume any particular surgical path for gender affirmation, and acknowledge the barriers experienced.

Ensuring access to post-cancer breast reconstructions: COVID-19 lessons from the Dutch Breast Implant Registry

BackgroundCOVID-19 has impacted breast implant surgery for oncological and non-oncological patients worldwide. This population-based study aimed to evaluate the impact of the COVID-19 pandemic on access to reconstructive and cosmetic breast implant surgery in the Netherlands using real-world data to describe trends, and to identify lessons to prevent future capacity problems within (inter)national healthcare. MethodsThis longitudinal study included patients undergoing breast implant surgery from the mandatory nationwide Dutch Breast Implant Registry. For 2020, the first COVID-19 wave, intermediate period, and second wave were defined. We compared data from during the pandemic to a pre-pandemic (2019) reference year, assessing differences in the number of registered breast implants, and patient and surgery-related characteristics. ResultsA total of 34133 breast implants (17459 patients) were included. Compared to 2019, fewer implants were registered for post-cancer (n=484; -14.7%), cosmetic (n=480; -3.6%), and gender-affirming indications (n=104; -38.0%) during 2020. Fewer implants were registered in academic (n=196; -22.0%) and regional hospitals (n=1591; -16.5%), but more in private clinics (n=725; +10.1%). After the first wave, up to twice as many implants were registered in private clinics compared to 2019. No differences were found in characteristics of patients undergoing surgery in 2020 versus 2019. ConclusionHospital-based reconstructive and gender-affirming surgery were heavily impacted during the pandemic, while private-clinic-based cosmetic surgery quickly recovered. These outcomes are useful to fuel discussions about how healthcare could be reorganized in times of capacity problems. We suggest exploring options to deploy private clinics for ambulatory surgery aiming to keep hospital capacity available for acutely ill patients.

New research issues in the history of German sexology and sexual medicine

New research questions in the history of German sexology and sexual medicine include anew look at the Imperial and the Weimar Republic periods and Magnus Hirschfeld as aprotagonist, as well as the contemporary history of the discipline in the Federal Republic with the two formative institutes in Frankfurt (Volkmar Sigusch) and Hamburg (Eberhard Schorsch). In the post-war period, the tendency to try to solve social problems through endocrinological and surgical approaches continued. This included the (voluntary) castration of sex offenders, which has been regulated by law in the West Germany since 1969. Questions of gender identity do not only arise in the context of gender reassignment surgery. They also have high social relevance and have become increasingly politicized in recent years. These questions are also persistently relevant for urology and clinical sexual medicine.

Vulvoplastie chez les patientes en incongruence de genre

Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.

GrS Montréal : un hôpital privé spécialisé en chirurgie d’affirmation de genre au Canada

Gender dysphoria refers to the suffering an individual experiences when his or her sex at birth does not correspond to the expression of his or her gender. Gender-affirmation surgery is a procedure that can alleviate this suffering. For 20years, GrS Montreal has been Canada's only center dedicated exclusively to this type of surgery. Thanks to its expertise, quality of care, state-of-the-art infrastructure and convalescent home, GrS Montreal receives patients from all over the world. This article describes the particularities of this center and puts into perspective the evolution of this type of surgery.

Filling a gap in care: addressing obesity in transgender and gender diverse patients.

Transgender and gender diverse (TGD) adults are more likely to have obesity compared to cisgender peers. Based on surveys, the TGD population experiences disparities in healthy lifestyle behaviors (e.g., physical activity, screen time) compared to reference groups. They also face significant socioeconomic and healthcare barriers to accessing affirming care and gender minority stress, potentially contributing to increased weight. Gender-affirming hormone therapy is associated with changes in body composition and increased weight, which may impact cardiometabolic risk trajectory. Obesity can also be a barrier to gender-affirming surgeries, and affirming weight management services tailored to TGD patients are an important gap in healthcare to address. This Perspective briefly reviews current literature on the unique barriers experienced by TGD people and their identified needs regarding weight management interventions. It also suggests areas for future research to best fill this gap in healthcare and research while supporting the provision of lifesaving gender-affirming care.

Construction of Sensitive Labia Minora-Clitoris-Clitoral Hood Complex in Sex Reassignment Surgery in Circumcised Populations: Butterfly Flap.

The construction of the labia minora from preputial tissues in uncircumcised patients and the preservation of the sensitivity of the labia minora are not new ideas. However, evidently, this technique is designed for uncircumcised cases.There is no preputial tissue in the circumcised population. However, this tissue, whose inner and outer layers have different structures and appearances, is critical in the construction of the labia minora. Instead, there is an area of reepithelialization and reinnervation that heals secondarily or is closed primarily, depending on the circumcision. Also, this new skin area is devoid of the natural oily secretions of the prepuce. In addition, the removal of preputial tissue in circumcised individuals may cause uncertainty in terms of vascularity or sensitivity. In this study, we share our clinical experience regarding large labia minora creation (with preserved flap circulation without vaginal reconstruction concerns) and the use of most of the urethra as a mesh graft in the circumcised population. Between 2010 and 2022, 19 cases were operated on with this technique. All cases were primary interventions for male-to-female sex reassignment. Because this design of the sensitive inner surface of the labia minora, which ensured vascular safety, was not found in the literature, the design was named "butterfly flap" because of its shape. The area corresponding to both wings of the butterfly flap was evaluated with the Semmes Weinstein Monofilament test, with the patient's eyes closed, in the preoperative period. Likewise, the sensitivity of the inner surface of the labia minora in the first year of 10 patients who were able to attend follow-up clinical examination was evaluated with the same method. In our study, a clitoris and a labia minora with sensory innervation were obtained by elevating the superior 180-degree area of the neurovascular bundle surrounding the penis and using the butterfly flap we prepared in the area fed by this bundle. Fourteen cases stated that the sensation of the newly formed labia minora was erogenous and different from the tactile sensation on the body of the penis.

Transgender &amp; Fertility

TGD –Adults are transwomen and men with gender identity different from that assigned at birth. Unless they undergo sex reassignment surgery or medication their fertility is well preserved and they can reproduce. Presenting a case report of first transgender couple from Kerala, India with successful pregnancy and delivery.

Variability in Medicaid Coverage for Gender-affirming Surgeries Across U.S. States.

To describe the current Medicaid coverage landscape for gender-affirming surgery across the United States at the procedure level and identify factors associated with coverage. Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states and the District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. The linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t tests were used to compare coverage based on state partisanship and the presence or absence of state-level Medicaid protections. Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington, D.C. The most commonly covered procedures were genital surgeries and mastectomy (n = 31), followed by breast augmentation (n = 21), facial feminization (n = 12), and voice modification surgery (n = 4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.

Urine cytology in patients with gender confirmation surgery and hormone therapy: evaluation of urine cytology performance in an underserved patient population.

There is a practice gap and educational need regarding urine cytology (UC) performance in patients with history of gender confirmation surgery (GCS) and/or hormone therapy (HT). This potentially impacts diagnostic accuracy in this medically underserved population. We report a methodology that identifies relevant cases and evaluates the performance of UC in this cohort. Two institutional pathology archives from 2000 to 2021 were searched using relevant keywords to identify UC specimens from patients with GCS and/or HT for this retrospective study. For each specimen, patient demographics, relevant clinical history, and history of HT and/or GCS were noted. Each case was blindly reviewed by a cytopathologist according to The Paris System. A total of 32 UC specimens from 15 patients with history of GCS and/or HT were identified. There were 13 male to female and 2 female to male transgender patients. The original diagnosis was negative for high-grade urothelial carcinoma (NHGUC) in 24 of 32 (75%) and atypical urothelial cells (AUC) in 8 of 32 (25%) cases. The most common atypical features were irregular nuclear membranes and prominent small nucleoli in 7 of 8 (87.5%). Degenerative changes were present in 5 of 8 (62.5%). On re-review, with relevant clinical history, 100% of cases were re-classified as NHGUC. The original diagnosis of AUC in these cases likely reflects reactive changes post GCS and/or HT. This cohort may be at risk of AUC overdiagnosis, particularly if the pathologist is unaware of this clinical history. Pathologists need to recognize reactive cytomorphologic changes in these patients. Further multi-institutional studies are warranted to expand knowledge about UC performance in these patients.

Pain and Dysfunction Reported After Gender-Affirming Surgery: A Scoping Review.

The goal of this scoping review was to determine the types and rates of pain and dysfunction outcomes reported after gender-affirming surgical procedures. In addition, a summary of the involvement of conservative care reported in the literature was produced. A research librarian conducted searches through multiple databases from inception to 2021. Abstracts and full texts were reviewed by a team of at least 2 reviewers. Data were extracted from a custom survey and exported for summary. Thirty-one papers discussed masculinizing interventions, and 87 papers discussed feminizing procedures. Most of the studies emphasized surgical outcomes. Of the studies reporting pain or dysfunction, few standardized outcomes were used to collect information from patients. The pain was experienced across body regions after surgery for both feminizing and masculinizing procedures. Vaginal stenosis and incontinence were the most common complications reported. Patients were most often managed by physical therapists for vaginal stenosis or dyspareunia. Many published studies do not systematically collect specific or standardized information about pain and dysfunction after gender-affirming surgery. Of those studies that do report these outcomes, few detail the involvement of physical therapists in the recovery after surgery. Pain and urogenital dysfunction, often managed by physical therapists, occur after gender-affirming surgery, suggesting that physical therapists could have a larger role in the recovery of this patient population after surgery. The extent to which interventions used to manage these conditions in cisgender people will be equally effective in transgender people is unknown at this time. Future studies should use recognized measures to characterize patients' experiences with pain and dysfunction after surgery.

The Impact of Gender-affirming Surgeries on Suicide-related Outcomes: A Systematic Review

Aims: Being transgender has been linked to poor mental health indicators, especially those related to suicide. We aimed to review the impact of gender-affirming surgeries (GAS) on suicidal behavior in the transgender population. Method: An advanced search was conducted on PubMed until February 28, 2022, and a total of 11 studies were considered eligible. Data were extracted on the size of sample population, control group, type of procedure, means of assessment, duration of time between surgery and assessment, and suicide-related outcomes. The considered outcomes were suicidal ideation, suicide attempts, and death by suicide. Results: Five studies compared the same patients pre- and post-GAS, while six studies compared patients who underwent GAS with a group who did not. Overall, suicide-related outcomes were found to be less frequent in patients after GAS when compared to those same patients’ pre-GAS indicators. The two studies that used either the general population or matched age and sex controls found a much higher prevalence of suicide-related outcomes, specifically suicide attempts and death by suicide, in post-GAS patients than in control groups. However, the studies that compared the treatment groups with either patients in an earlier phase of the transition or those who desired but had not yet undergone surgery showed lower post-GAS suicide-related outcomes, including suicidal ideation and suicide attempts. Conclusions: Suicidal ideation was generally found to decrease post-GAS; results regarding suicide attempts were inconsistent, and there was insufficient data to draw any conclusion about the effects of GAS on death by suicide.

Gender Confirmation Surgery.

Gender Confirmation Surgery.

Gender-affirming microvascular breast reconstruction.

Gender-affirming surgery (GAS), including breast feminization, is requested and performed with increasing frequency. Transgender women may seek chest feminization surgery to address gender dysphoria, and such procedures have been shown to increase psychosocial and sexual well-being. Despite the potential effects of hormone therapy and androgen blockade on breast development, the results of glandular growth in adult transgender women are typically disappointing and are often inadequate to achieve the patient's goals. When evaluating options for breast construction, an implant-based approach meets the needs of most patients. However, patient choice, implant complications, acquired and congenital alterations of chest anatomy and the unique challenges of feminizing a natal male chest occasionally require consideration of other options. We review the few cases of gender-affirming breast reconstruction using autologous tissue published in the literature and summarize the senior author's approach and technique. We also review two cases of autologous chest feminization by the senior author. Ultimately, while implant-based reconstruction should continue to be the default procedure and offered to the majority of patients, several factors need to be considered when determining the optimal approach to breast feminization for a given patient. In patients with congenital or acquired deformities or a variety of factors where a reasonable outcome cannot be achieved with implants, autologous reconstruction should remain an option.

Mental Health Parity Arguments for Accessing Gender Affirmation Surgery.

Many insurers exclude coverage for transgender individuals. Litigation challenging these exclusions has increased. Most of these cases successfully advance equality claims by arguing that trans exclusions discriminate based on sex. That is, procedures performed on patients for reasons unrelated to gender affirming care are being denied to transgender individuals. There are, however, limitations to this argument. First, some courts may construe care narrowly and hold that some procedures are unique to gender affirming care that have no analog in other contexts. Second, a court that is hostile to the sex discrimination argument might hold that the denial does not arise from sex discrimination, but rather, because of the kind of diagnosis at issue. Further, the sex discrimination argument might force transgender individuals into making claims based on a binarized gender identity which may not conform with their lived experience.Claims based on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) can address these shortcomings. This Act prohibits insurers from discriminating against mental health diagnoses-for example, procedures that insurers cover because of medical or surgical diagnoses should alsobe covered if indicated for mental health diagnoses. Gender dysphoria is a recognized mental health diagnosis. Transgender individuals seeking gender affirming care arising from gender dysphoria can thus claim that exclusions of coverage violate the MHPAEA. Some transgender individuals might raise concerns that such an approach would lead to increased medicalization of trans identity. However, an MHPAEA claim would only appear in cases where a transgender individual is voluntarily submitting themselves to medical assistance in order to advance their own autonomy.

Analysis of Hairline and Forehead Sexual Dimorphic Aesthetics in 60 Celebrities Using Artificial Intelligence.

Thirty white female and 30 white male celebrities were included. Three full-face front-view photographs of each celebrity were evaluated by a facial analysis program, using Vision framework and MATLAB. After converting pixel distances to absolute distances, midline and lateral forehead heights were calculated and compared between men and women. Forehead height was similar between attractive men and women, but forehead width was shorter in women. Analysis of forehead height at various points along the hairline demonstrated that forehead measurements above the lateral brow and brow peak were significantly greater in men. Mean forehead height above the lateral eyebrow was 3.51 cm in women and 4.16 cm in men (P = 0.017). Forehead height above the eyebrow peak was 4.34 cm in women and 5.55 cm in men (P < 0.001). Medial forehead height was similar between men and women, indicating that the greatest difference in attractive male and female foreheads is in the lateral forehead and forehead width. Analysis of attractive white celebrities demonstrated no significant differences in central forehead heights between men and women. Forehead width and lateral forehead height were significantly smaller in women, with an overall downward slanting contour. Male hairlines were more horizontal and slanting upward laterally. These results have implications in facial rejuvenation and facial gender-affirming surgery.