World Professional Association For Transgender Health Research Articles

Urological focus on gender affirmation surgery.

Gender affirmation surgery plays an important role in the treatment of gender dysphoria. These procedures play a vital role in aligning individuals' physical characteristics with their gender identity, resulting in improved mental health and overall wellbeing. This article provides an overview of genital gender affirmation surgeries, focusing on the available options and appropriate referral criteria for general practitioners and surgeons. Gender affirmation surgery necessitates a multidisciplinary approach, emphasising patient readiness, clear surgical preferences, hormonal transition and modifiable risk factors. The two primary methods for assessing patient appropriateness, the World Professional Association for Transgender Health (WPATH) guidelines and the informed consent model, are discussed. This article summarises surgical options for both trans-male and trans-female individuals, outlining procedures, benefits and potential complications. Gender affirmation surgery is set to play an increasingly important role in the management of gender dysphoria. By understanding the available options and referral processes, primary care physicians will be able to optimise care for these patients.

(040) Anterolateral Thigh Flap Phalloplasty: Outcomes Following Genital Gender Affirmation Surgery

Abstract Introduction Genital gender affirmation surgery (gGAS) is a key part of the management of patients with gender dysphoria. The anterolateral thigh (ALT) free flap was proposed as an alternative to the more common radial forearm free flap (RFFP) phalloplasty due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap offers greater security of vascular supply for suitable patients, and if suitable and desired the flap can be formed with an integrated urethra, facilitating voiding while standing. Objective The aim of the study is to report the contemporary surgical and functional outcomes of ALT phalloplasty. Methods All individuals undergoing ALT flap phalloplasty for genital gender affirmation surgery (GAS) between 2009 and 2023 nationwide were included. Individuals were managed in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care version 7. Data were extracted from a prospectively collected single surgeon database and medical records. Functional outcomes were assessed by non-validated questionnaire. Statistical analysis included Mann-Whitney, chi-squared, Fisher’s exact and unpaired T tests. Results Surgical outcomes: A total of 87 patients were included in the study. More than half (45, 51.7%) had an integrated urethra. The median length of stay following surgery was six days (IQR 6-7). Eleven patients (12.6%) had a 30-day Clavien-Dindo 3b complication or greater. Three patients (3.4%) experienced total flap loss. A further three patients (3.4%) had partial flap loss. Three patients (3.4%) required a salvage phalloplasty later. Thirteen patients (out of 42, 31.0%) without an integrated urethra went onto have a free flap urethroplasty. Functional outcomes: Thirty-nine individuals (44.8%) completed the patient reported outcomes questionnaire. Most patients (77%) were generally satisfied with their phalloplasty. More than half (56%) with an erectile device used their phallus for penetrative intercourse, while one in five reported experiencing orgasm using their phallus alone. Following urethral lengthening, all respondents were able to void standing. There was no significant difference in mean satisfaction scores for those with an integrated urethra compared to those without (4.18/5 vs 3.82/5, p=.45), as well as between those with or without an erectile device, respectively (3.78/5 vs 4.10/5, p=.26). Conclusions This study is one of the largest single centre cohorts of ALT flap phalloplasty reported to date. It further supports the use of the ALT flap as one of the main genital GAS options for transmen. Over half of the patients studied had an integrated urethra, the gold standard for urethral lengthening. Patient reported functional outcomes were promising, with similar scores regardless of urethral lengthening or erectile device insertion. Disclosure No.

Transgender women’s perspectives on mental health care related to vaginoplasty for gender affirmation

PurposeThis study aimed to describe patient experiences and attitudes about the role of the mental health professional as it relates to pursuing gender affirmation surgery.MethodsThis was a mixed-models study with semi-structured interviews. Participants who presented for gender affirming vaginoplasty and had completed pre-surgical requirements but had not yet had the procedure were invited to participate in the study. Semi-structured phone interviews were conducted from November 2019 and December 2020 until saturation of themes was achieved at a sample size of 14. Interviews were then transcribed verbatim and coded by theme. Qualitative analysis was performed using a grounded theory approach.ResultsAlmost half of the patients did not identify any barriers to obtaining mental health care, but a majority brought up concerns for less advantaged peers, with less access to resources. Some patients also felt that there was benefit to be obtained from the mental health care required before going through with surgery, while others felt the requirements were discriminatory. Finally, a large proportion of our participants reported concerns with the role of mental health care and the requirements set forth by the World Professional Association for Transgender Health (WPATH), and patients gave suggestions for future improvements including decreasing barriers to care while rethinking how guidelines impact patients.ConclusionThere are many competing goals to balance when it comes to the guidelines for gender affirmation surgery, and patients had differing and complex relationships with mental health care and the pre-surgical process.

Hysterectomy and Oophorectomy for Transgender Patients: Preoperative and Intraoperative Considerations

ObjectiveTo review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender patients. DesignStepwise demonstration of techniques with narrated video footage. SettingApproximately 0.3% of hysterectomies performed annually in the United States are for transgender men. While some transgender men choose hysterectomy for the same indications as cisgender women, the most prevalent diagnosis for the performed surgeries is gender dysphoria.1 Hysterectomy with or without oophorectomy can be offered to patients who have met the World Professional Association for Transgender Health (WPATH) criteria.2 InterventionsImportant perioperative counseling points for transgender patients include: establishing terminology for relevant anatomy as well as the patient's name and pronouns; if applicable, discussing options for fertility preservation if the patient desires biological children3,4 and discussing the use of hormone therapy post-oophorectomy to reduce the loss of bone density;5,6 and reviewing intraoperative and postoperative expectations.When performing an oophorectomy on a transgender patient for gender affirmation, it is especially important to minimize the risk for ovarian remnant syndrome and the need for additional surgery, such as due to persistent menstruation. The performance of a two-layer vaginal cuff closure should be considered to reduce the risk of vaginal cuff complications, which is preferable for patients whose pelvic organs cause gender dysphoria.7,8 ConclusionSpecial considerations outlined in this video and the WPATH guidelines should be reviewed by gynecologic surgeons to minimize transgender patients’ experiences of gender dysphoria before, during, and after surgery.

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 (TGD) individuals who desire it, the aim of this study is to assess the concordance of insurance criteria for GAS with the most recent World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (SOC-8). Insurance policies for coverage of gender-affirming genital ("bottom surgery"), chest ("top surgery"), and facial reconstruction from companies representing 80% of the market coverage in each state were evaluated. Policies were classified into three categories: no-coverage (NC), case-by-case (CC), and preauthorization (PA). Among PA policies, criteria for coverage of specific surgeries were analyzed for adherence to WPATH SOC-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 was for hormone therapy, being required for at least 12 months prior to surgery in the majority of surveyed policies. Many specific procedures and treatments were excluded, especially facial GAS with cosmetic overlap. Additionally, reversal and revisionary surgeries were covered in less than 25% of policies. Compared to previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care are still present for GAS.

The Limited Coverage of Facial Feminization Surgery in the United States: A Literature Review of Policy Constraints and Implications.

There is a literature gap regarding facial feminization surgery (FFS) access and coverage. Our goal is to compile information from previous studies and assess the current policy landscape for these surgeries in the US. We also explored why some policies do not cover them, identify states with better coverage, and determine the most covered procedures. PubMed, Medline, Embase, and Scopus were searched for studies that reviewed policies on FFS coverage. Studies on surgical techniques or other gender-affirming surgeries (GASs) that did not involve FFS were excluded. Seven studies were included for analysis. In 2014, the Department of Human Health Services (HHS) lifted the transgender exclusion policy, leading to an increase in policies regarding GASs for both private and state insurance. However, there are differences in medical necessity requirements among policies, which may not align with the World Professional Association for Transgender Health (WPATH) criteria. States that prohibit exclusion tend to offer better coverage for FFS. These states are mainly located in the western and northeast regions, whereas states in the southern and middle east regions have less coverage. Among the procedures, chondrolaryngoplasty is the most covered, while facial and cervical rhytidectomy are the least covered. To enhance transgender care, it is crucial to reach a consensus on how to offer coverage for facial feminization surgery. However, there is a lack of adequate research on this topic, and there is a need for resources and tools to assess the results of FFS procedures. One significant constraint of this study is that it does not provide a systematic review of the literature.

(473) Simultaneous Multidisciplinary Gender Affirming Surgery during COVID-19: Improving Access to Care for Military Patients

Abstract Introduction Access to surgical care for the transgender population has been a persistent challenge. Frequently cited barriers include long waiting lists, strict insurance prior authorization protocols, surgeon scarcity, financial cost, and social stigma. These issues have been magnified throughout the COVID-19 pandemic response, as the diversion of resources has led to the postponement of surgeries deemed “routine” or “non-essential.” Many medical societies and healthcare organizations have classified gender-affirming surgery (GAS) as such despite the World Professional Association for Transgender Health (WPATH) defining surgical care for gender dysphoric individuals as medical necessity. Unfortunately, delays in care for this population contribute to prolonged mental health distress. Another important barrier to access centers on the issue of surgical timing. Many patients cannot afford to postpone school and work obligations to undergo multiple surgeries each with long recovery times. Furthermore, staffing shortages nationwide have limited operating room (OR) availability. To respond to these issues, our center organized a multidisciplinary collaboration among various surgical subspecialties to perform simultaneous GASs (e.g., top and bottom surgeries). In this way, the patient can undergo multiple GASs in a single procedure, thus limiting anesthesia exposure, expediting postoperative recovery, improving patient satisfaction and maximizing limited healthcare resources. Objective To describe a multidisciplinary model for GAS involving simultaneous top and bottom surgery to improve access to care for the transgender population in a resource-limited environment. Methods Case report describing successful multidisciplinary surgical management of a transgender female desiring multiple simultaneous GAS. Results Patient is a 24-year-old active duty transgender female who met WPATH criteria for top and bottom surgery. She desired numerous procedures including simple orchiectomy, breast implants and facial feminization. Given our limited OR availability during COVID-19, the decision was made to perform all of these surgeries under the same anesthetic. She 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. Patient was discharged on post-op day 1 and had an uneventful recovery without surgical or anesthetic complications. Conclusions Simultaneous GAS is an effective approach to improve access to care during the COVID-19 pandemic. A single anesthetic enables the patients to achieve their surgical goals sooner and to lessen their overall recovery time compared to staged procedures. Disclosure No

Introduction to healthcare for transgender and gender-diverse people.

This editorial provides a broad introduction to transgender health for transgender and gender-diverse people. Following a brief description of the history of transgender and gender-diverse people, the development of medical treatment is discussed, together with the use of appropriate terminology and language. The content largely draws attention to the guidance in the Standards of Care for the Health of Transgender and Gender Diverse People Version 8 developed by the World Professional Association for Transgender Health (WPATH) and published in 2022. Further key areas addressed are as follows. • The use of names and pronouns. • Population estimates of transgender and gender diverse people. • Diagnostic classification systems in transgender health. • A wide range of gender-affirming medical interventions, including hormones and surgeries. • Ethical considerations for research with transgender and gender diverse populations.

Ethical Need for a Fertility Decision-Aid for Transgender Adults of Reproductive Age

Ethical Need for a Fertility Decision-Aid for Transgender Adults of Reproductive Age

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

Current challenges faced by transgender and gender-diverse patients and providers in anesthesiology.

(In)Equality and Beyond: Achieving Justice in Gender-Affirming Hormone Initiation.

The World Professional Association for Transgender Health (WPATH) is an international organization that aims to advocate for transgender and gender-diverse (TGD) people by promoting safe and effective ways to access and deliver healthcare to maximize psychological health and well-being. One way this is achieved is through the WPATH's published Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, a set of guidelines for gender-affirming care that is based on the available science and expert consensus. In anticipation of the release of updated guidelines (Standards of Care Version 8) in 2022 the Radcliffe Institute for Advanced Study at Harvard University hosted an Exploratory Seminar in December 2021 that brought together experts from the United States, Mexico, and the United Kingdom to share knowledge across disciplines in order to propose revisions to the WPATH's updated guidelines. This article shares the workgroup's high-level consensus and recommendations.

7578 Hysterectomy with or without Oophorectomy for Transgender Male Patients: Preoperative and Intraoperative Considerations

<h3>Study Objective</h3> To review the preoperative and intraoperative considerations for gynecologic surgeons when performing hysterectomy with or without oophorectomy for transgender male patients. <h3>Design</h3> Stepwise demonstration of techniques with narrated video footage. <h3>Setting</h3> Approximately 0.3% of hysterectomies performed annually in the U.S. are for transgender male patients, most commonly to alleviate gender dysphoria. A hysterectomy with or without oophorectomy can be offered to patients who have met criteria outlined by the World Professional Association for Transgender Health (WPATH) guidelines. <h3>Patients or Participants</h3> Transgender male patients seeking hysterectomy with or without oophorectomy. <h3>Interventions</h3> Important perioperative counseling points for transgender male patients include: •Establishing terminology to minimize gender dysphoria •Discussing options for fertility preservation •Discussing the importance of continuing testosterone therapy post-oophorectomy to reduce the loss of bone density •Reviewing intraoperative and postoperative expectations Important intraoperative considerations for the performance of safe and effective hysterectomy with or without oophorectomy for transgender male patients include: •Maintaining a margin of at least 2 cm between the surgical instrument and the ovary during coagulation and transection of the infundibulopelvic ligament to prevent ovarian remnant syndrome •Performance of a two-layer vaginal cuff closure to reduce the risk of vaginal cuff complications <h3>Measurements and Main Results</h3> The patients recovered well without any postoperative complications. <h3>Conclusion</h3> In conclusion, it is essential to minimize the patient's experience of gender dysphoria by providing gender-affirming care before, during and after surgery. In particular, the surgeon should take care to perform oophorectomy with an adequate margin to minimize the risk of ovarian remnant syndrome and use a two-layer laparoscopic vaginal cuff closure to decrease the risk of vaginal cuff complications.

Working with Transgender Adolescents: Essential Guidelines and Applications

Background: There has been a rise in the numbers of adolescents identifying as transgender and seeking medical treatment for gender dysphoria. While gender clinics are developing across the country, not all transgender adolescents have access to these centers. There is, therefore, an increased need for other clinicians to be aware of interventions and guidelines to help transgender youth and their families. Objective: The aim of this article is to provide an overview of current literature and guidelines for treating transgender adolescents with gender dysphoria. Methods: Using keywords “gender”, “gender dysphoria”, “transgender”, “trans*”, “adolescent trans*”, the authors searched PubMed to gather current literature on treating transgender adolescents. Additionally, sources from primary transgender resources online were obtained, including current endocrine and psychological guidelines. Results: This article discusses important gender concepts that are relevant to treating all transgender individuals. It describes models of engagement with transgender adolescents seeking treatment, including assenting and consenting to medical intervention. Finally, we discuss the assessment of transgender adolescents’ needs and present an overview of the various guidelines outlining both non-medical and medical interventions targeted to treat gender dysphoria in this population. Conclusions: Knowledge of treating adolescents with gender dysphoria is imperative as gender dysphoria presents more commonly in practice. Multidisciplinary collaboration is required to provide comprehensive treatment to this population. Guidelines from professional organizations such as the World Professional Association for Transgender Health and the Endocrine Society provide instructions for clinical practice while the evidence base in this field continues to expand.

ODP415 Inclusion Health Clinic: Gender-Affirming Hormone Therapy &amp; Surgery Booklet and Review of Efficacy in Patient-Provider Encounters

Abstract While gender-inclusive health has been a growing field, comprehensive information on the topic has lacked for both patients and providers. The "Inclusion Health Clinic (IHC) Gender-Affirming Hormone Therapy &amp; Surgery" booklet, modelled after other Froedtert Health resources and created using guidelines from Endocrine Society, University of California, San Francisco, and World Professional Association for Transgender Health (WPATH), was introduced to IHC on April 28, 2021. Its goal was to facilitate patient-provider relationships through sharing clinical knowledge and practice preferences with patients as well as to assist providers in communicating concepts to individuals seeking advice and care. Booklet efficacy was analyzed through anonymous surveys self-selected among transgender and gender-nonconforming patients seen at Inclusion Health Clinic. Regardless of gender identity or new patient status, 100% of survey respondents found the booklet useful in generating a productive conversation. For numerical questions, averages for all data sets were above 4. 0/5. 0: ease of navigation was rated highest (4.75 +/- .24), followed by scope of care (4.25 +/- .34), and lastly the booklet's utility in explaining concepts (4.15 +/- .36). For qualitative responses, respondents found the most value in pages related to hormone therapy and surgery. Data from the survey was primarily used to improve the booklet; this revision is projected to be distributed to IHC in Spring 2022. The aspiration is for the booklet to evolve as care for the LGBTQ+ population advances, and that it will continue to serve as a relevant and useful source of information on gender-affirming health needs. Presentation: No date and time listed

76. Robot-assisted Vaginoplasty: A Multidisciplinary Technique for Gender Affirmation

Background: Gender affirming trans female bottom surgery is critical in treating gender dysphoria but can result in complications such as stricture/stenosis development, neovaginal prolapse, and rectal injury. The authors describe a multidisciplinary robot-assisted technique incorporating a free peritoneal graft to alleviate these complications. Methods: Patients who met the World Professional Association for Transgender Health (WPATH) criteria for bottom surgery, underwent robotic-assisted penile inversion vaginoplasty with senior author (J.D.K), and had at least three months of follow-up were included in the study. Patients undergoing zero-depth vaginoplasty or revision vaginoplasty were excluded. The free peritoneal graft is harvested robotically and used as a strip of mucosal-like tissue for a more anatomic neovagina and sutured to scrotal skin grafts over a vaginal conformer. The construct is sutured to the remaining penile shaft skin and then then inverted and passed through the perineal body into the robotically-created space. The apex of the neovaginal lining created by the skin graft-peritoneal graft construct is then sutured to the peritoneal reflection with barbed suture in two layers intra-corporally via the robot. Results: Thirty-eight patients were included in our study. Average age at the time of initial consult was 31 years. All patients were on hormone therapy and 42% of patients had previously undergone top surgery. The average length of follow-up was 230 days. The most common complication was stricture/stenosis secondary to non-compliance with post-operative dilation protocol. Eight patients (21%) experienced stricture, four of which were managed with aggressive dilation. Three patients required surgical revision and one patient did not require any intervention. Seven patients (18%) experienced wound dehiscence with four patients requiring operative repair. Four patients (11%) developed labial banding/webbing that required revision. Other complications included one hematoma, one infection, and two episodes of post-operative bleeding. Eleven patients (29%) developed symptomatic granulation tissue during the healing process that was treated with silver nitrate application and resolved with time. Lastly, two patients (5%) had labial asymmetry that did not interfere with function, but who desired revision for cosmesis. Eighty-four percent of patients used Soul Source vaginal dilators (Sour Source Therapeutic, North Hollywood, CA) post-operatively and of those patients 53% could dilate with the orange dilator (the largest, 1 1/2 inch diameter), 13% with teal (1 3/8 inch diameter), 16% with blue (1 ¼ inch diameter) and 19% with purple (1 1/8 inch diameter). All dilators are 9 inches in length. Patients are cleared for sexual intercourse three months after surgery. Many patients had return of sensation to light touch of the neo-clitoris and were able to achieve organism through direct neo-clitoral stimulation. Conclusion: With experience and an interdisciplinary team, robotic-assisted vaginoplasty with free peritoneal grafting is safe and effective with a low complication rate and high neo-vaginal patency rate. Many patients report successful penetrative intercourse and the ability to achieve orgasm post-operatively.

National Trends in Gender-Affirming Surgical Procedures: A Google Trends Analysis.

Background: There has been a significant increase in the volume of gender-affirming surgical (GAS) procedures over the past decade. The objective of this paper is to use online search data from Google Trends (GT) to describe national search trends for GAS procedures.Methods: GT was queried for search terms relating to GAS from January 2004 to February 2021. The 19 selected keywords covered a broad range of GAS topics. United States (US) search interest was collected as relative search volumes (RSVs) and then analyzed by geographic region. The number of plastic surgery providers offering GAS and academic surgery centers was collected from the World Professional Association for Transgender Health (WPATH) and Trans-health.com. RSVs were analyzed by metro area to determine the relationship between search demand and personal income. State Medicaid policies for transgender health services were also collected.Results: All search terms demonstrated a positive increase in RSVs over time except “sex reassignment surgery” and “penectomy”. The Mountain/Pacific and East South Central/West South Central had the greatest search volume for GAS and most providers offering care. The East South Central/West South Central region​​ ranked last for providers offering care, despite the relatively high search interest. This region also had no states with explicit Medicaid policies covering gender-affirming care. Metro areas in the top five for RSV but bottom quartile for per capita personal income were identified.Conclusions: Online search interest for GAS-related terms has increased. Search interest for GAS has regional variation and did not show a specific pattern with provider availability.

Requirement of Mental-health Referral Letters for Staged and Revision Genital Gender-Affirming Surgeries: An Unsanctioned Barrier to Care

ABSTRACT Introduction The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental-health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health-insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. Objective This study investigates insurance requirements for referral letters and their negative impact on care. Methods We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral-letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. Results Nearly all reviewed U.S. health-insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral-letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Conclusions Insurance companies’ requirements for referral letters impede care and contradict WPATH guidelines. We advocate that referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral-letter requirements for secondary surgeries provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients’ surgical readiness. Significant changes in mental-health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document. Disclosure No

50. Transgender Health Provider Consent Practices

Recommendations from the Endocrine Society and the World Professional Association for Transgender Health (WPATH) provide guidance on how and when to prescribe pubertal suppression (PS) and/or gender affirming hormones (GAH) to transgender (TG) minors seeking medical interventions. These guidelines emphasize the importance of mental health professional (MHP) involvement and parental consent but fail to address scenarios that may complicate the informed consent process e.g., MHP letters may be difficult to obtain, parents may not always be supportive, and adolescents may have variable decision-making capacity.

Gender-Affirming Hormone Therapy for the Trans, Gender Diverse, and Nonbinary Community: Coordinating World Professional Association for Transgender Health and Informed Consent Models of Care.

Before commencing gender-affirming hormone therapy, people undergo assessments through the World Professional Association for Transgender Health (WPATH) model (typically with a mental health clinician), or an informed consent (IC) model (without a formal mental health assessment). Despite growing demand, these remain poorly coordinated in Australia. We aimed to compare clients attending WPATH and IC services; compare binary and nonbinary clients; and characterize clients with psychiatric diagnoses or longer assessments. Cross-sectional audit of clients approved for gender-affirming treatment (March 2017-2019) at a specialist clinic (WPATH model, n=212) or a primary care clinic (IC model, n=265). Sociodemographic, mental health, and clinical data were collected from electronic records, and analyzed with pairwise comparisons and multivariable regression. WPATH model clients had more psychiatric diagnoses (mean 1.4 vs. 1.1, p<0.001) and longer assessments for hormones (median 5 vs. 2 sessions, p<0.001) than IC model clients. More IC model clients than WPATH model clients were nonbinary (27% vs. 15%, p=0.016). Nonbinary clients had more psychiatric diagnoses (mean 1.7 vs. 1.1, p<0.001) and longer IC assessments (median 3 vs. 2 sessions, p<0.001) than binary clients. Total psychiatric diagnoses were associated with nonbinary identities (β 0.7, p=0.001) and health care cards (β 0.4, p=0.017); depression diagnoses were associated with regional/remote residence (adjusted odds ratio [aOR] 2.2, p=0.011); and anxiety disorders were associated with nonbinary identities (aOR 2.8, p=0.012) and inversely associated with employment (aOR 0.5, p=0.016). WPATH model clients are more likely to have binary identities, mental health diagnoses, and longer assessments than IC model clients. Better coordination is needed to ensure timely gender-affirming care.

The Quality and Utility of Referral Letters for Gender-Affirming Surgery.

The World Professional Association for Transgender Health (WPATH) recommends referral by a mental health professional for gender-affirming chest and genital surgeries. However, several transgender health guidelines propose an informed consent model of care to respect patient autonomy. This research aimed to understand, characterize, and asses the quality of information gathered through referral letters for patients consulting for gender-affirming surgeries. A retrospective review of electronic medical records (EMRs), including referral letters from behavioral health (BH) and primary care providers (PCPs), was conducted for patients seeking chest or genital surgery by a single surgeon between 2017 and 2019. Data were abstracted manually and included medical and gender history and documentation of WPATH-recommended surgical criteria. A total of 233 patient records, including 171 PCP letters and 231 BH letters, were reviewed. With respect to documentation of surgical criteria, 92% of BH letters documented a diagnosis of gender dysphoria, 63% ability to provide informed consent, and 51% management of BH comorbidities. More than half of individuals with chronic physical health conditions did not have those conditions documented in their referral letters. Similarly, BH letters often failed to document BH diagnoses endorsed by patients. For example, while 80% of patients endorsed a diagnosis of anxiety, more than half did not have it documented in their letters. Overall, greater than half of diagnoses across BH conditions were only documented as present in the EMR. Referral letters only variably documented WPATH-recommended surgical criteria and did not reliably document physical and mental health comorbidities. Our research suggests that multidisciplinary pre-surgical assessment may be more useful than referral letters in some settings.