Reassignment Surgery Research Articles

Toward informed consent: Canadian providers’ perspectives on presurgical mental health assessments for gender-affirming surgeries.

Toward informed consent: Canadian providers’ perspectives on presurgical mental health assessments for gender-affirming surgeries.

P194 VERY LOW-DOSE CYPROTERONE ACETATE (12.5 MG/DAY) IS EFFECTIVE AS ANDROGEN BLOCKER; WELL TOLERATED AND NOT ASSOCIATED WITH HYPERTENSION DEVELOPMENT IN YOUNG FEMALE TRANSGENDER PEOPLE

Background and Objective: Cyproterone acetate (CPA) has serious adverse effects (hyperprolactinemia, obesity, depression, thrombogenesis, liver toxicity, meningioma…) but the optimal dose has not been established. CPA is associated with a high risk of hypertension development, even with doses as low as 25 mg/day. We sought to establish if a very low CPA dose (12.5 mg/day) is effective as antiandrogen, its side effect profile, and if it is associated with hypertension development. Methods: Consecutive non-orchidectomized transgender women <30 years were offered CPA 12.5 mg/day instead of the regular 50-100 mg/day dose, along with estradiol (individually titrated); CPA dose was increased to 25 (eventually 50) mg/day if plasma testosterone was >2 nmol/L or there was clinical hyperandrogenism. Body weight, blood pressure, AST, ALT, GGT, prolactin, FSH, LH, estradiol and testosterone were monitored. A matched group of patients with LHRH agonist as antiandrogen plus estradiol served as control. Hypertension was diagnosed according to the current ESH guidelines. All patients gave informed consent. Results: 39 patients were recruited, median follow-up was 2.3 years. 32 were maintained on CPA 12.5 mg/day, two increased to 25 mg/day, one to 50 mg/day, two withdrew due to gender-affirming surgery; one was lost to follow-up. There were no serious side effects or related withdrawals. The control group included 35 patients without significant differences at baseline. Suppression of testosterone, LH and FSH were effective and comparable with the control group but a moderate increase in prolactin was observed (26±12 to 38±22 ng/mL, p=0.034). Neither group had changes in liver enzymes. Blood pressure and body weight did not increase significantly in either group; the incidence of hypertension was low in both groups (1 patient each). Conclusions: Very low-dose CPA was effective and well tolerated as antiandrogen in a large majority of our patients. While CPA is reportedly associated with a striking dose-dependent increase in the incidence of hypertension in the 25-100 mg/day dose-range, the 12.5 mg/day dose appears to be safer.

The Role of Gender-Affirming Surgery and Hormone Therapy in the Development of Substance Use and Psychological Disorders in Assigned Males at Birth with Gender Dysphoria

The Role of Gender-Affirming Surgery and Hormone Therapy in the Development of Substance Use and Psychological Disorders in Assigned Males at Birth with Gender Dysphoria

The use of peritoneum in female genital gender-affirming surgery: A systematic review

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen.Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty.Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8 cm and width of 3.5 cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty.This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.

ASO Visual Abstract: The Impact of a Breast Cancer Risk Assessment on the Decision for Gender-Affirming Chest Masculinization Surgery in Transgender and Gender-Diverse Individuals-A Pilot Single-Arm Educational Intervention Trial.

ASO Visual Abstract: The Impact of a Breast Cancer Risk Assessment on the Decision for Gender-Affirming Chest Masculinization Surgery in Transgender and Gender-Diverse Individuals-A Pilot Single-Arm Educational Intervention Trial.

Evaluating quality, understandability, and actionability of YouTube content for gender affirming surgery: Metoidioplasty.

The purpose of this study is to evaluate YouTube content about metoidioplasty on completeness of perioperative information, actionability, understandability, degree of misinformation, quality, and presence of commercial bias. A YouTube search for "Metoidioplasty" was conducted and the first 100 video results were watched by five independent reviewers. Videos in English <30 minutes in length were included and videos primarily showing surgical footage were excluded. Videos were evaluated between January 2022 and June 2022. Each video was evaluated for presenter demographics, channel/video statistics, and whether it covered topics including anatomy, treatment options, outcomes, procedure risks, and misinformation, and whether it had a clickbait title. Calculated scores for validated DISCERN and Patient Education Materials Assessment Tool (PEMAT) metrics were the primary outcome variables used to quantify quality, actionability, and understandability. For PEMAT, a cutoff of 75% was used to differentiate between "poor" versus "good/sufficient." Multivariate and univariate logistic regressions were performed to assess correlations among primary outcome variables and other variables. Of the 79 videos analyzed, 24% (n=19) were of high quality; 99% (n=78) had poor understandability and 100% (n=79%) had poor actionability. Patients/consumers were the most common publisher type (n=71, 90%). This study demonstrates metoidioplasty content available on YouTube is not comprehensive and is of poor quality, and poor actionability and understandability, demonstrating a clear need for more relevant, accessible, comprehensible, and accurate content.

Gender Reassignment and the Role of the Laboratory in Monitoring Gender-Affirming Hormone Therapy.

Transgender people experience distress due to gender incongruence (i.e., a discrepancy between their gender identity and sex assigned at birth). Gender-affirming hormone treatment (GAHT) is a part of gender reassignment treatment. The therapeutic goals of the treatment are to develop the physical characteristics of the affirmed gender as far as possible. Guidelines have been developed for GAHT, which recommend dosage as well as different formulations of oestrogen and testosterone for treatment. Questions arise about the metabolic side effects of hormone treatment. Establishing reference ranges for common analytes in transgender individuals remains a task for laboratory medicine. It has been suggested once GAHT is commenced, the reference ranges for affirmed gender are reported for red blood cells, haemoglobin and haematocrit. For transgender assigned-female-at-birth (AFAB) people, testosterone concentrations are recommended to be within the reference interval established for cisgender men and for transgender assigned-male-at-birth (AMAB) people, estradiol concentrations are within the reference range for cisgender women. Sex-specific reference ranges are available for certain laboratory tests, and these may be organ (e.g., heart)-specific. Transgender-specific reference ranges may be a requirement for such tests. Laboratories may need to make decisions on how to report other tests in the transgender population, e.g., eGFR. Interpretation of further tests (e.g., reproductive hormones) can be individualized depending on clinical information. Electronic medical record systems require fields for gender identity/biological sex at birth so that laboratory results can be flagged appropriately. In this review, we aim to summarise the current position of the role of the laboratory in the clinical care of the transgender individual. Prior to the review, we will summarise the genetics of sex determination, the aetiology of gender incongruence, and the recommendations for GAHT and monitoring for the transgender population.

Variant genital gender-affirming surgery: a systematic review.

To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes. A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist. In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias. This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

Reconstructive surgery of difficult urethrocutaneous fistula following gender-affirming surgery.

In Japan, transgender individuals have historically had limited therapeutic options, prompting many to seek gender-affirming surgeries in private or foreign clinics because of restricted access to public hospitals. This has led to challenges for patients undergoing surgery. A transgender man underwent surgery at a private clinic and experienced recurrent complications. Subsequent examination at another clinic and our hospital revealed limited medical records, complicating our understanding of this case. After a detailed investigation, the urethrocutaneous and urethrovaginal fistulas were identified and addressed by joint urologists and plastic surgeons, resulting in no recurrence after 1 year. This case underscores the importance of thorough preoperative assessment with a flexible mindset, emphasizing the need to avoid being misled by inadequate records or appearances in complication management of gender-affirming surgery. Collaborative efforts among healthcare professionals based on comprehensive evaluations lead to safer complication treatments.

Gender-affirming surgeries and patient-reported outcomes in gender binary versus non-binary and genderqueer-identifying individuals

Background Approximately 25%–50% of transgender and gender diverse (TGD) individuals identify as non-binary and/or genderqueer (NBGQ), yet understanding of the role of genital gender-affirming surgeries (GAS) and the overall outcomes of gender-affirming treatment in this group is limited. Aim Comparing the choice of gender-affirming surgical treatments and patient-reported outcomes between binary and NBGQ TGD individuals. Methods We conducted a cross-sectional online survey including 171 participants who completed at least 80% of their medical transition and had undergone GAS (based on self-report). Participants were grouped as binary transgender (n = 151) or NBGQ (n = 20) based on self-reported gender identity. Main outcomes included the propensity for genital GAS in NBGQ individuals compared to binary peers. Patient-reported outcomes, such as gender congruence, body satisfaction, life satisfaction, self-esteem, and mental health, were compared between groups. Analyses were conducted accounting for potential confounding factors including age, sex assigned at birth, and level of social support. Results NBGQ individuals reported a lower likelihood of having received genital GAS compared to binary-identifying participants (55.0% vs. 84.1%; OR = 0.23; p = .002), also after correcting for confounding factors, such as sex assigned at birth (OR = 0.28; p = .03; 95% CI 0.09–0.90). Patient-reported outcomes indicated poorer post-treatment body satisfaction and gender recognition, self-esteem, life satisfaction, and mental health in the NBGQ group (small to large effect sizes). Discussion The study emphasizes the differences in treatment characteristics of NBGQ individuals undergoing gender-affirming surgical care, related to both surgeries received and (poorer) patient-reported outcomes. These findings underscore the importance of individualized and equitable care in TGD healthcare to improve overall health outcomes.

Mandibular Gender Dimorphism: The Utility of Artificial Intelligence and Statistical Shape Modeling in Skeletal Facial Analysis.

In gender-affirming surgery, facial skeletal dimorphism is an important topic for every craniofacial surgeon. Few cephalometric studies have assessed this topic; however, they fall short to provide skeletal contour insights that direct surgical planning. Herein, we propose statistical shape modeling (SSM) as a novel tool for investigating mandibular dimorphism for young white individuals. A single-center, retrospective study was performed using computed tomography (CT) scans of white individuals, aged 20 to 39 years old. AI-assisted, three-dimensional (3D) mandibles were reconstructed in Materialise Mimics v25.0. We used SSM to generate average 3D models for both genders. Relevant manual anthropometric measurements were taken for the SSMs and individual mandibles. Contour disparities were then represented using 3D overlays and heatmaps. Statistical analyses were performed using unpaired student t testing or Wilcoxon signed rank testing with 95% confidence interval as deemed appropriate by population-level normality assessment. Ninety-eight patients (53 females, 45 males) were included. Male mandibles showed greater bigonial width, intercondylar width, ramus height, and body length [p<0.005]. There was no statistically significant difference in the gonial angle measurements [p=0.62]. All relevant manual individual measurements demonstrated excellent concordance to their SSM counterparts. The 3D overlays of SSMs revealed squarer male chins with more lateral but less anterior projection than their female counterparts. Also, the female mandibles showed smoother transition at the gonial angle. SSM provides a novel tool to objectively evaluate volumetric and contour dimorphisms between genders. Moreover, this method can be automated, allowing for expedited comparisons between populations of interest compared to manual assessment. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . Bullet points about the importance of this work: Advancing Anthropometric Assessment: Statistical shape modeling (SSM) offers a cutting-edge approach to visualizing gender-specific skeletal anatomic differences for aesthetic and gender-affirming facial surgery. Expediting Comparative Analysis: The workflow established in this paper streamlines the evaluative process, enabling rapid morphologic comparisons between populations. Patient-Centered Care: This study establishes a foundation for the development of SSMs in individualized operative planning.

Lessons learned from the Sexual Medicine Society of North America fellowship bootcamp.

Sexual Medicine Society of North America (SMSNA) fellowships offer variable experience in sexual health domains: erectile dysfunction, Peyronie's disease, male infertility, male hypogonadism (low testosterone), reconstruction (including male incontinence), benign prostatic hyperplasia, gender affirmation surgery, sexual mental health, and female sexual dysfunction. To evaluate baseline and postbootcamp understanding and trust in these domains. In 2023, 28 of 31 urologists currently enrolled in SMSNA-endorsed fellowships participated in a 3.5-day training bootcamp in Minneapolis, Minnesota. Participants were asked to complete pre- and postbootcamp surveys. The bootcamp curriculum offered American Urological Association guidelines and case-based lectures, hands-on clinical training with cadavers (penile surgery) and models (collagenase training), and interaction with industry. Changes in knowledge, independence, and trust in performing the procedures, as well as billing issues and feedback for future bootcamps. Prebootcamp surveys revealed vastly varied residency experience. Reported time with an expert faculty member was greatest for benign prostatic hyperplasia and least for female sexual dysfunction, gender affirmation surgery, and low testosterone. The lowest prebootcamp confidence in performing surgery independently was for penile grafting procedures and elevating the neurovascular bundle. Postbootcamp results revealed several areas of significant improvement in confidence (P ≤ .03): intralesional injections for Peyronie's disease, manual modeling, penile plication, penile grafting procedures, and elevating the neurovascular bundle. There was a trend for improved confidence with the insertion of inflatable (P = .05) and semirigid (P = .08) penile prostheses. Nonsignificant improvement occurred in artificial urinary sphincter surgery (P = .12). Participants graded the bootcamp very highly and requested that next year's bootcamp have more content on female sexual dysfunction, male incontinence, and low testosterone, as well as more hands-on skills sessions and case-based lecture formats. Offering a bootcamp with hands-on instruction could significantly improve urologists' knowledge and confidence. As the main strength, this study was the first specialized bootcamp for urologists in the subject of men's health, taking into account hands-on and cadaver laboratories, as well as highlighting industrial and pharmaceutical products. The small sample size was the major limitation. Current SMSNA fellows present with varied levels of experience and confidence across sexual health domains. Notable confidence improvements were seen with topics that combined didactic lectures with hands-on trainings.

Health care needs and barriers to care among the transgender population: a study from western Rajasthan

BackgroundTransgender people comprise an estimated 0.3–0.5% (25 million) of the global population. The public health agenda focuses on understanding and improving the health and well-being of gender minorities. Transgender (TG) persons often have complex healthcare needs and suffer significant health disparities in multiple arenas. The international literature suggests that this community is at a higher risk of depression, and other mental health problems, including HIV. Many transgender people experience gender dysphoria and seek specific medical needs such as sex reassignment surgeries, implants, hormonal therapies, etc., but are unable to access these services due to financial or social reasons. The objective of this study was to assess the healthcare needs and associated barriers experienced by transgender people in Western Rajasthan. Methodology: A qualitative study was carried out in which multilevel stakeholder interviews were conducted using interview and focus group discussion guides. Data was analyzed using the qualitative thematic analysis technique. Results: Findings reveal that transgender people have expressed their need to access health services for general health needs, including but not limited to mental health, non-communicable diseases, and infectious diseases. Barriers to healthcare services were identified on 3 levels: health system, social and personal. Health system barriers include policy, accessibility, affordability, and acceptability issues. Social factors such as inadequate housing, education, and job opportunities also play an important role in affecting the individual’s health-seeking behavior. The knowledge of healthcare providers in this context was also limited in context of health insurance schemes, package of services available for transgenders and the importance of gender sensitive healthcare. Conclusion: Transgender people expressed the need for mental health services, programs targeting nutritional improvement, gender-affirmation procedures besides regular screening of non-communicable diseases as operational for males and females. Levels of barriers have been identified at various levels ranging from absence of targeted policies to individual behavior.

The Role of Sex and Gender in Transgender Bone and Other Musculoskeletal Health.

Musculoskeletal changes occur with gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS) used in the care of transgender adolescents and adults. Survey results have shown that orthopaedic surgeons desire to care for transgender individuals but express concern over a knowledge deficit. This article reviews the physiology and pathophysiology that may occur with GAHT and GAS. Transgender women have lower bone mineral density (BMD) prior to GAHT than cisgender men. Limited fracture data would suggest that transgender women >50 years of age have fracture rates similar to those of cisgender women. Transgender men have normal BMD prior to GAHT and are not at an increased risk for fracture compared with cisgender women. The use of puberty-blocking medications in the care of transgender youth does result in a decline in BMD, which returns to baseline with GAHT, but the effect of delaying puberty on maximal BMD and the lifetime fracture risk are unknown. At present, dual x-ray absorptiometry (DXA) is used to measure BMD and assess fracture risk. Attention should be paid to using the appropriate reference group in the interpretation of DXA for transgender individuals. Promote musculoskeletal health by ensuring appropriate calcium, vitamin D, weight-bearing activity, and a healthy lifestyle. Adherence to GAHT needs to be encouraged to avoid bone loss. Data with regard to therapy for osteoporosis in transgender patients have been lacking, but, at present, use of available therapies is expected to be effective. Information with regard to differences in other musculoskeletal health issues such as joint injuries has been lacking in transgender individuals.

Discontinuing hormonal gender reassignment: a nationwide register study

BackgroundWith increasing numbers of people seeking medical gender reassignment, the scientific community has become increasingly aware of the issue of detransitioning from social, hormonal or even surgical gender reassignment (GR). This study aimed to assess the proportion of patients who discontinued their established hormonal gender transition and the risk factors for discontinuation.MethodsA nationwide register-based follow-up was conducted. Data were analysed via cross-tabulations with chi-square statistics and t tests/ANOVAs. Multivariate analyses were performed via Cox regression, which accounts for differences in follow-up times.ResultsOf the 1,359 subjects who had undergone hormonal GR in Finland from 1996 to 2019, 7.9% discontinued their established hormonal treatment during an average follow-up of 8.5 years. The risk for discontinuing hormonal GR was greater among later cohorts. The hazard ratio was 2.7 (95% confidence interval 1.1–6.1) among those who had accessed gender identity services from 2013 to 2019 compared with those who had come to contact from 1996 to 2005. Discontinuing also appeared to be emerging earlier among those who had entered the process in later years.ConclusionsThe risk of discontinuing established medical GR has increased alongside the increase in the number of patients seeking and proceeding to medical GR. The threshold to initiate medical GR may have lowered, resulting in a greater risk of unbalanced treatment decisions.Trial registration number (TRN)Not applicable (the paper does not present a clinical trial).

Enhanced Recovery After Gender-Affirming Surgery.

Enhanced Recovery After Gender-Affirming Surgery.

Mapping ethical, legal, and social implications (ELSI) of fertility preservation.

The study examines the ethical, legal, and social implications of fertility preservation, highlighting its importance across oncofertility, elective egg freezing, and posthumous assisted reproduction, as well as its impact on transgender individuals undergoing gender-affirming surgeries. A comprehensive analysis of 600 articles, focusing on a diverse range of disciplines, including bioethics, psychology, and sociology, to explore public and healthcare professionals' knowledge, patient experiences, and regulatory constraints. The body of literature is growing, indicating increasing recognition of FP's significance. Key themes included the centrality of counseling and informed decision-making, especially in oncofertility and EEF, and ethical debates surrounding informed consent and the autonomy of involved individuals. The analysis underscored a western-centric bias in current research, emphasizing the need for more inclusive and culturally sensitive studies. The study calls for a nuanced understanding of FP, advocating for policies that consider ethical, cultural, and social dimensions. It suggests the necessity for interdisciplinary research to address identified gaps, particularly in understanding non-Western perspectives and ensuring equitable access to FP services globally. Moreover, the review emphasizes the importance of integrating patient-centric approaches and ethical frameworks to guide FP practices and policies, ensuring they respect diverse values and meet individuals' needs.

Patient-Reported Preoperative Depression as a Predictor of Psychosocial Outcomes After Gender-Affirming Facial Feminization Surgery.

To understand psychosocial functioning before and after gender-affirming facial feminization surgery (FFS) as well as identify predictors of postoperative psychosocial functioning. Few investigations have rigorously explored the impact of gender-affirming FFS on psychosocial functioning in transgender and gender non-binary (TGNB) individuals. This knowledge gap hinders the identification of methods to optimize mental health quality-of-life outcomes after FFS and carries repercussions for access to care. Adult TGNB participants awaiting gender-affirming FFS were prospectively enrolled and administered Patient-Reported Outcomes Measurement Information System (PROMIS) instruments assessing anxiety, anger, depression, global mental and physical health, positive affect, emotional support, social isolation, companionship, and meaning and purpose before and 3-6 months after FFS. Paired t-tests compared pre- and postoperative scores. Multivariable linear models identified predictors of postoperative psychosocial outcomes. Among the domains, psychosocial scores improved for anxiety, depression, global mental health, social isolation, and positive affect after FFS. When accounting for potential variables contributing to postoperative psychosocial scores including other gender-affirming surgeries, hormone therapy duration, and private versus public insurance type, we found that preoperative depression scores independently predicted the variance in all other postoperative scores with global mental health (β=-0.52, 95%CI -0.58--0.31 P<0.001), anxiety (β=0.40, 95% CI 0.21-0.51, P<0.001), and meaning and purpose (β=-0.52, 95% CI -0.78--0.42 P<0.001) as the strongest models. This study suggests that gender-affirming FFS improves psychosocial functioning; however, such improvements are highly influenced by the baseline psychological functioning of each individual. These findings indicate that preoperative psychological functioning may be a potential avenue for improving outcomes after FFS via perioperative psychological interventions.

Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran

BackgroundGender dysphoria, characterized by a misalignment between one’s gender identity and assigned sex, propels individuals towards medical interventions like gender reassignment surgery (GRS) to harmonize their bodies with their gender. This process aims to enhance overall quality of life (QoL), functioning, and body image. Recognizing the importance of cultivating a positive body image for transgender individuals navigating societal norms, this narrative highlights the ongoing debate surrounding QoL post-GRS. In response, our study is outlined, aiming to scrutinize QoL and self-image among transgender men post-GRS, offering valuable insights into societal perceptions and psychological well-being in this context.MethodThis cross-sectional survey focused on transgender men aged 15 to 35 who underwent gender reassignment surgery (GRS) in 2018–2022 in Shiraz, Iran. Participants, after passing psychiatric evaluations, completed World Health Organization Quality of Life (WHOQOL-100) questionnaires pre- and at least one-year post-surgery. The scores of the Brief-WHOQOL questionnaire were evaluated in four domains of physical health, psychological health, social relationships, and environmental health.ResultsA total of 60 individual who underwent GRS completed our questionnaire. The average age of the patients was 24.1 ± 3.8 years. Following GRS, the most increase was observed in the psychological factor (by 25.6%). The increase in score was statistically significant in all subgroups (P < 0.001) after operation. Urban living location had a significant association with higher increase in physical health (P < 0.010), psychological health (P = 0.005), and environmental health (P = 0.012) after GRS. In regards to physical health, the low socioeconomic group had a significantly less physical score improvement in QoL compared to the moderate group (P = 0.024) following GRS. In regards to environmental health, the high socioeconomic groups had significantly higher improvement in QoL compared to the low (P = 0.006) and moderate (P < 0.001) group after operation.ConclusionThe results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients hailing from low socioeconomic backgrounds and rural areas.

The landscape of Medicare policies for gender-affirming surgeries in Canada: an environmental scan

BackgroundMany studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time.MethodsWe conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada. ResultsEight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years.Conclusions We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers.