Reassignment Surgery Research Articles

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State.

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State.

Danish Prostate Cancer Consortium Study 1 (DPCC-1) protocol: Multicentre prospective validation of the urine-based three-microRNA biomarker model uCaP

IntroductionThe primary objective of the Danish Prostate Cancer Consortium Study 1 (DPCC-1) is to provide validation for a novel urine-based microRNA biomarker, called uCaP, for a diagnosis of prostate cancer.Methods...

Frequency and Characteristics of Postoperative Neuropathy in Individuals on Gender-Affirming Hormone Therapy Undergoing Gender Affirmation Surgery: A Retrospective Cohort Study.

Introduction Gender affirmation surgery includes procedures of the face, larynx, chest, reproductive system, external genitalia, and adipose tissue performed to ameliorate incongruence between gender identity and phenotype. The annual number of gender affirmation surgeries performed in the United States has increased significantly. There have been no investigations into the frequency of peripheral neuropathy after gender affirmation surgery, which is an important topic, given transgender individuals are at increased risk for delaying necessary medical care. After appreciating a number of cases of postoperative neuropathy in our clinical practice, we hypothesized that gender affirmation surgery is a high-risk procedure for postoperative neuropathy. Methods We conducted a one-year, monocentric, retrospective cohort study utilizing clinical data of individuals on gender-affirming hormone therapy undergoing gender-affirmation surgery under general anesthesia. The study included transgender women, assigned male at birth, receiving antiandrogen, progesterone, or estrogen therapy (target range plasma estradiol concentration 90-200 pg/ml) and transgender men, assigned female at birth, receiving antiestrogen or testosterone therapy (target range plasma testosterone concentration 320-1000 ng/dl). The primary objective was to estimate the incidence of postoperative peripheral neuropathy, defined as new numbness, paresthesia, neuropathic pain, or muscle weakness occurring in a peripheral innervation territory. Secondary objectives were to summarize the clinical presentation of neuropathy and investigate for associations between procedure characteristics and neuropathy. Results We identified nine cases of postoperative peripheral nerve injury in 232 consecutive gender affirmation procedures establishing an incidence of 3.9%. All injuries were associated with surgery longer than six hours and were characterized by sensory deficits including numbness 89% (8/9) and tingling 56% (5/9), which were diagnosed by postoperative day one. Conclusions Our results suggest that gender affirmation surgery is a high-risk procedure for postoperative neuropathy, with an incidence similar to other high-risk procedures, and an incidence that is higher than the general surgical population. However, given this has not been previously reported and our study includes a heterogenous population from a single institution, our results should be considered hypothesis generating. Additional studies that include multiple institutions are needed to confirm our findings and identify modifiable risk factors for postoperative neuropathy.

Rethinking Gender Recognition in Hong Kong and the Way Forward

This article considers Hong Kong’s (“HK”) current approach in requiring trans to undergo full sex-reassignment surgery (“SRS”) before they can change their gender indicated on their Hong Kong identity cards. Through reflecting upon international and comparative case law, this article first examines how HK’s current approach confers limited protection towards trans’ fundamental rights as against foreign jurisdictions. This article then examines whether the United Kingdom’s (“UK”) Gender Recognition Act 2004 (“GRA”), which was described as a “compelling” model by the Hong Kong Court of Final Appeal, confers a higher degree of protection towards trans people. This article concludes by advocating for the elimination of the full SRS requirement as a prerequisite for gender recognition in HK.

Robotics in genital gender-affirming surgery

Gender-affirming genital surgery includes a constellation of pelvic procedures that can help feminize or masculinize the genitalia. Technological advances in robotic surgery can aid surgical access to and visualization of the pelvis, thereby facilitating certain procedures. In this scoping review, we will discuss the developing role of the robot in genital affirming genital surgery. Indications, techniques, and outcomes using the robot in both feminizing and masculinizing genital procedures will be reviewed.

Crowdsourcing Your Gender Journey: Analyzing Trends and Predictors of Success for Gender-Affirming Surgery GoFundMe Campaigns in the United States

Crowdsourcing Your Gender Journey: Analyzing Trends and Predictors of Success for Gender-Affirming Surgery GoFundMe Campaigns in the United States

Concordance of National Insurance Criteria with WPATH Standards of Care for Gender-Affirming Surgery.

Given that gender-affirming surgery (GAS) is considered medically necessary for transgender and gender-diverse individuals who desire it, the aim of this study was to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Insurance policies for coverage of gender-affirming genital surgery ("bottom surgery"), chest surgery ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into 3 categories: no coverage, case by case, or preauthorization. Among preauthorization policies, criteria for coverage of specific procedures were analyzed for adherence to the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Bottom-surgery policies were most concordant for age and gender dysphoria criteria, and transmasculine top surgery policies were most concordant for hormone therapy, continuous living in a congruent gender role, and referral criteria. Transfeminine top surgery criteria were more restrictive than transmasculine criteria. The most discordant criteria were for hormone therapy, being required for at least 12 months before surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Reversal and revisionary procedures were covered by less than 25% of policies. Compared with previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care for GAS remain.

A multimetric health literacy analysis of online gender affirmation surgery materials: From facial to genital surgery

The transgender patient population is expanding, and gender affirming surgery (GAS) volume is increasing. Accurate, comprehensive, and easily navigable resources on GAS are lacking. We aim to evaluate the readability of online materials for specific gender affirming surgical procedures to identify mechanisms of improving information access for transgender patients. "Facial feminization", "facial masculinization", "MTF breast augmentation", "FTM chest masculinization", "MTF vaginoplasty", "metoidioplasty", and "FTM phalloplasty" were searched on Google. Per keyword, the first 75 text-containing results were included. Text was analyzed for reading difficulty using the Flesch-Kincaid Reading-Ease (FKRE) test and grade level using the Flesch-Kincaid Grade Level (FKGL) formula, Gunning Fog Index (GFI), Simple Measure of Gobbledygook (SMOG), and Coleman-Liau Index (CLI). Scores were compared using independent t-and ANOVA tests (α=0.05). Mean readability scores (FKRE 37.44) and grade-levels (FKGL 12.87, GFI 15.61, SMOG 11.91, CLI 15.00) correlated with college-level difficulty. Masculinizing surgical materials were more difficult to read than feminizing ones (p≤0.023). Top surgery materials were easier to read than facial and genital surgery materials (p≤0.013). Specifically, chest masculinization resources were more difficult to read than those for breast augmentation (p≤0.006). No differences were found between facial feminization and masculinization surgery resources, nor between resources for different gender affirming genital surgeries. Online GAS materials are written above the recommended 6th grade reading-level, with resources for transgender men being significantly more challenging to understand. Improving readability of online resources can help overcome barriers to care for the transgender patient population.

Travel distance and national access to gender-affirming surgery

BackgroundGender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location. MethodsPatients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient’s home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery. ResultsAcross 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014. ConclusionPatients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.

Performing (Trans)Woman Identity through Nirvana: A Study of Hijra Life Narratives

This paper extensively studies the significance of nirvana in the lives of hijra transwomen at the personal, social as well as cultural levels. Life writings of hijras from India so far published in English are taken as the primary source of study. Hijras constitute one of the uniquely organised transgender communities worldwide, with a distinct historical legacy and sociocultural characteristics of their own. Nirvana, in the hijra parlance, refers to the shedding of male genital organs and attainment of (trans)woman’s body through castration coupled with an elaborate set of rituals. It plays an eminent role in authenticating hijra identity by the virtue of its corporeal visibility and ritualistic connotations. Castration, the core treatment in gender-affirmation or sex reassignment surgery, happens to be the crucially inevitable procedure in nirvana process. Hijra life narratives document their innate desire and anxiety for nirvana, preparations for sex reassignment surgery with community support, painful and brutal experience of surviving castration surgery, postoperative care and rituals within the hijra community, and ultimate pleasure of attaining nirvana. This paper employs Judith Butler’s theories on gender performativity, and the interconnectedness between biological sex and social gender to investigate the lived experiences of hijras for unearthing the significance of nirvana. The study concludes that nirvana becomes an agency for resisting oppression and stigma for the hijra transwomen. It further establishes how nirvana authenticates their (trans)womanhood, while also bestowing them with the power to bless others with fertility.

National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery.

Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage. Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions. Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS. Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap.

SAT677 Use Of An Anti-obesity Medication In A Transgender Woman Pursuing Body Mass Index Requirements For Gender-affirming Surgery

Abstract 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 <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

SAT408 Assessment Of Family Planning Readiness In Transgender Youth

Abstract Disclosure: R.S. Conard: None. L.J. Folsom: None. Background: Transgender individuals identify with a gender incongruent with the sex assigned at birth. Some seek medical care in the form of gender affirming hormone therapy (GAHT) or gender affirming surgery (GAS). GAHT initiated in adolescence may include GnRH analogues and cross-sex hormones. Barriers to family planning in this population include low utilization of cryopreservation and decisional regret. There is a paucity of data on the risk of infertility with GAHT, and on to what degree transgender adolescents feel informed about fertility and family planning options. Objective: To assess knowledge regarding options for family planning and fertility preservation in transgender adolescents treated with GAHT in a pediatric endocrinology gender clinic. The goal is to enhance patient education about potential effects of GAHT on fertility and options for family planning. Methods: 41 adolescent patients aged 10 years and older treated with GAHT in an urban outpatient pediatric endocrinology clinic were surveyed from January to June 2022. Survey questions were multiple choice, Likert scale, and open-ended. To be included participants were at least 10 years of age, actively followed in the clinic, and receiving GAHT at time of enrollment. Results: 41 participants completed the survey. Four (10%) expressed interest in discussing family planning with their provider at the time of survey completion. 18 (45%) were open to discussion in the future; 16 (39%) were not interested at all. 13 (32.5%) participants were planning for future parenthood, and 16 (40%) participants were undecided. Of those interested in parenthood 7 (53.8%) planned to adopt or foster. Barriers to family planning expressed included financial concerns, potential need to pause GAHT, and social stigma of transgender parenthood. 20 (50%) participants reported prior family planning discussion with their endocrinologist. Conclusion: Despite routine family planning discussions documented during visits, these may not be optimally impactful given that 50% of participants did not recall the conversations. Family planning appears to be of lower priority in this population as most desired to postpone discussions with their provider despite undergoing treatment that could influence fertility. Our findings indicate it is essential to actively identify methods to engage transgender youth in discussions related to family planning during GAHT. Presentation: Saturday, June 17, 2023

Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience.

Regret after Gender-Affirming Surgery: A Multidisciplinary Approach to a Multifaceted Patient Experience.

Quality Assessment of Online Resources for Gender-affirming Surgery.

As visibility of the transgender patient population and utilization of online resources increases, it is imperative that web-based gender-affirming surgery (GAS) materials for patients are readable, accessible, and of high quality. A search trends analysis was performed to determine frequency of GAS-related searches over time. The top 100 most common results for GAS-related terms were analyzed using six readability formulas. Accessibility of patient-facing GAS sources was determined by categorizing types of search results. Frequency of article types was compared in low- and high-population dense areas. Quality was assigned to GAS web-based sources using the DISCERN score. Search engine trend data demonstrates increasing occurrence of searches related to GAS. Readability scores of the top 100 online sources for GAS were discovered to exceed recommended levels for patient proficiency. Availability of patient-facing online information related to GAS was found to be 60%, followed by information provided by insurance companies (17%). Differences in availability of online resources in varying dense cities were found to be minimal. The average quality of sources determined by the DISCERN score was found to be 3, indicating "potential important shortcomings." Despite increasing demand for web-based GAS information, the readability of online resources related to GAS was found to be significantly greater than the grade level of proficiency recommended for patients. A high number of nonpatient-facing search results appear in response to GAS search terms. Quality sources are still difficult for patients to find, as search results have a high incidence of low-quality resources.

Are We Teaching Evidence-Based and Inclusive Practices in Gender-Affirming Care? Perspectives From Plastic Surgery In-Service Examinations.

Background Resident physicians take annual in-service examinations (ISEs) as part of continuing medical education, which set educational priorities, allow for formative feedback, and guide preparation for final board examinations. Gender-affirming care is provided in many specialties but has been an underrepresented area in medical education. Plastic surgeons provide a large portion of gender-affirming surgical care. Educational gaps in standardized ISEs may contribute to ongoing health care disparities for transgender and gender diverse people. Objective To evaluate the quality of content pertaining to gender-affirming surgery (GAS) on plastic surgery ISEs. Methods Plastic surgery ISEs from years 2012 to 2020 were accessed online through the American Council of Academic Plastic Surgeons website in June 2022. All 5 gender diverse authors analyzed examinations for the presence of GAS questions; identified questions were analyzed for quantity, organization based on content category, affirming language, and accuracy against current guidelines. Results Of 1959 ISE questions available for review, 11 GAS questions were identified for a total frequency of 0.56%. Most GAS questions (6 of 11, 55%) were miscategorized. Inappropriate language, including misgendering of patients, occurred in 7 of 11 (64%) questions. No questions discussed GAS beyond chest or genital surgery, or common variations of these procedures. Transgender identities were represented as only binary, with no mention of nonbinary or gender-fluid individuals. Conclusions Our study illustrates that there are significant gaps in educational content pertaining to gender-affirming care on plastic surgery ISEs.

Transgender health is a vital component in healthcare

Abstract The term “transgender” is used to describe individuals whose innate sense of one’s own gender, expression or behavior is not in alignment with the sociocultural expectations emerging from the gender assigned to them at birth, legally and medically. The term encompasses such a wide spectrum of gender identities and expressions that it has not been possible to completely understand the dynamics of a “transgender” individual’s experiences. A transgender faces injustice and discrimination at every turn in life. They are victims of sexual abuse, violence, social stigma and harassment, intense poverty, substance abuse, and overall poor physical and mental health. A transgender has both routine healthcare needs like the rest of the population and unique healthcare needs such as gender-affirming hormone therapy and surgeries. A transgender-friendly healthcare system with healthcare staff competent in knowledge and interest in transgender care is the need of the hour to address the health concerns of this population.

WPATH Standards for Providing Gender Reassignment Care

WPATH Standards for Providing Gender Reassignment Care

Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization andMedical Readiness forMilitary Patients.

Access to surgical care for gender-affirming surgery (GAS) has been a persistent challenge within the DoD due to long waiting lists, strict insurance requirements, and surgeon/subspecialty scarcity. These issues were magnified during the COVID-19 pandemic response, as limited resources led to postponement of "elective" surgeries. To remedy this, our center organized a multidisciplinary collaboration to perform simultaneous GAS. This model is necessary to optimize the quality-of-life and medical readiness for a particularly marginalized population within the U.S. Military who now constitute roughly 1% of all active duty personnel. In addition, one-stage surgery provides a feasible solution to streamlining care and decreasing DoD personnel health care costs. We present a case describing successful multidisciplinary surgical management of a transgender woman desiring multiple GASs. We include a comparative, cost-benefit analysis to emphasize the advantages of single-stage over multistage surgeries. Our patient is a 24-year-old active duty transgender female who underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Our patient was discharged on post-operative day 1 and had an uneventful recovery without complications. Keys to successful implementation included the judicious, coordinated use of local analgesia as well as the organization of separate operating room bedside tables and scrub techs for each team. Total convalescent leave time and temporary profile duration were reduced by 50% relative to the staged approach: 4 weeks and 3 months versus 8 weeks and 6 months, respectively. Of note, anesthesia provider fees total ∼$8,213 when surgeries are performed as three separate events. For one-stage surgery, anesthesia fees amount to only $1,063 (assuming ∼10 hour anesthesia time with a CRNA provider). Our case study demonstrates that one-stage multidisciplinary surgery can be accomplished without added risk to the patient. Judicious surgical planning, including having surgeons operating at the same time, reduces operative time and provides for efficient operating room utilization. Simultaneous GAS is an effective approach to improve access to surgical care for transgender patients. A single anesthetic enables patients to achieve their surgical goals sooner and to lessen their overall recovery time. This allows service members to return to duty sooner, supporting the Defense Health Agency mission to ensure a medically-ready force. This model should become the standard within MTFs across the DoD, as it promotes improved quality-of-life for patients, decreases personnel costs, and ensures medical readiness.

Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors.

Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors. We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatricdatabase, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years. A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each). GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.