Craniofacial Reconstructive Surgery Improves Appearance Congruence in Male-to-Female Transsexual Patients

Analysis of Cephalometric Differences of the Midface and Upper Face in Males and Females: A Radiographic Study

Gender affirmation facial surgery (GAFS) is an important component in treating gender dysphoria among transgender individuals by addressing gender incongruence of the face. There is a paucity of literature describing objective characterizations of the anatomic differences between male and female faces. In this study, cephalometric measurements were taken on routine CT imaging performed on cisgender patients between 2017 and 2020. Specifically defined cephalometric landmarks of the upper and midface were measured and compared between male and female cohorts. Thirty-eight patients, 19 male and 19 female, were identified for this study. Significant differences were identified in the frontal prominence, orbital size, malar height, bizygomatic width, nose, and upper lip, with moderate rates of specificity for each gender. Some important ratios are also presented. Differences in the malar region and the orbit highlight the importance of these areas as a point of focus for GAFS. These cephalometric findings provide objective evidence and parameters for perceived anatomic differences in male and female faces. In addition, they help both corroborate current surgical techniques as well as guide future approaches to GAFS.

Facial Masculinization Surgery: An Analysis of Interest Trends Using Search Term Analysis

INTRODUCTION

Facial masculinization surgery (FMS) is increasingly popular among cisgender and transgender men. The benefits of FMS are focused on facial identity and have been proven to decrease gender dysphoria in this population. Previous research showed increasing interest in gender affirmation surgery and facial feminization surgery, but the prevalence of FMS has not been explored. It is difficult to find these data based on surgical records alone because institutions do not have standardized methods of reporting and lack publications in the field. Our study aimed to analyze public interest in FMS by using worldwide Google Trends to quantify these trends.

METHODS

A worldwide Google Trends search was completed from January 1, 2008, to December 31, 2022, for terms focused on FMS. Then, search terms were analyzed for nonfacial masculinization procedures and were aggregated. Lastly, a PubMed search was conducted for the terms "transgender" and "facial masculinization" from January 1, 2008, to December 31 st , 2022, to compare publication rates.

RESULTS

Our data showed an increasing interest in FMS through Google search trends since the year 2008. A similar trend was demonstrated for non-FMS gender-affirming terms. PubMed analysis showed "transgender" medicine publishing rates were approximately 39.65 times greater than "facial masculinization" publishing rates, although "facial masculinization" medicine did produce a positive trend over the study period of approximately 4 publications per year. The medical literature on transgender surgeries rapidly outpaces publications specifically focusing on FMS.

CONCLUSION

Our study showed increasing interest in gender affirmation surgery over time, particularly FMS. These increasing trends should encourage greater scientific exploration of FMS and research to properly quantify and assess surgical outcomes in this special population. Additional educational interventions for both the general public and medical providers, to increase awareness of unique challenges that impact this community and highlight changes in health care coverage over time, should be created to keep pace with increasing patient demand and address the physical, systemic, and psychosocial issues faced by people who identify as transgender.

Transition Milestones, Psychological Distress, and Suicidal Ideation Among Transgender Adults: A Structural Equation Analysis

PURPOSE

This paper examines the relationships among transition milestones (i.e., transition-related events in transgender persons' lives that demarcate their life circumstances before vs. afte a milestone was reached), psychological distress, and suicidal ideation in a large sample of transgender adults.

METHODS

Data from the 2015 U.S. National Transgender Survey were used to examine 11 specific transition milestones in a sample of 27,715 transgender Americans aged 18 or older. The Kessler-6 scale was used to measure psychological distress and a dichotomous measure of suicidal ideation during the past year was the other main outcome measure. Covariates in the multivariate analysis included demographic measures, variables assessing support and discrimination, and 11 transition milestones.

RESULTS

Bivariate analyses revealed that, in almost all instances, reaching specific transition milestones led to reduced psychological distress and diminished odds of suicidal ideation. Multivariate analysis revealed that psychological distress was a strong predictor of suicidal ideation, but transition milestones were not retained in the final model. Structural equation analysis showed that three specific transition milestones (namely, changing one's name and/or gender on legal documents, taking gender-affirming hormones, having had any gender-conforming surgical procedures) influenced suicidal ideation indirectly, through their direct impact on psychological distress.

CONCLUSIONS

Reaching specific transition milestones plays an important role in many transgender adults' lives, and may be highly beneficial in helping them to reduce psychological distress. This, in turn, is likely to have a positive impact upon their likelihood of contemplating suicide.

A scoping review of the research literature on eating and body image for transgender and nonbinary adults

BACKGROUND

Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.

AIMS

This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.

RESULTS

After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.

CONCLUSIONS

Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.

(De-)centralized health care delivery, surgical outcome, and psychosocial health of transgender and gender-diverse people undergoing vaginoplasty: results of a retrospective, single-center study

PURPOSE

Previous research on genital gender-affirming surgery lacked to build a framework that took various surrounding factors into account. E.g., transgender health care services are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). The present study investigated the effects of different structural and clinical aspects of gender-affirming genital surgery on psychosocial outcomes.

METHODS

We surveyed former transgender and gender-diverse people who completed a vaginoplasty between 2014 and 2018. 45 participants were included in the study. We calculated hierarchical linear regression analyses to assess the relationship between psychosocial outcome measures (gender congruence, mental health, quality of life) and different aspects of gender-affirming genital surgery (e.g., setting of service delivery). To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identify predictors that are actually related to the outcomes.

RESULTS

A non-responder analysis revealed no systematic bias in the recruitment procedure. Treatment satisfaction was a significant predictor for gender congruence. Moreover, we found the setting of service delivery (centralized, decentralized) to predict psychological health and the physical health dimension of quality of life. The effect sizes of our models were moderate to high, and models explained up to 26% of the total variance with a power up to 0.83.

CONCLUSION

The present study is an exploratory attempt into the manifold relationships between treatment-related factors (e.g., aesthetic outcome), the setting of service delivery, and their effects on gender-affirming genital surgery.

Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes

OBJECTIVE

This study investigates the effect of gender-affirming facial feminization surgery (FFS) on psychosocial outcomes in patients with gender dysphoria.

BACKGROUND

Comprehensive analyses of psychosocial outcomes after gender-affirming FFS are absent in the literature resulting in a paucity of information on the impact of FFS on quality of life as well as ramifications in health insurance coverage of FFS.

METHODS

Scores from 11 validated, quantitative instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) assessing anxiety, anger, depression, global mental health, global physical health, satisfaction with sex life, positive affect, emotional support, social isolation, companionship, and meaning and purpose. Patients within the preoperative group (pre-FFS) were evaluated >30 days before surgery and patients within the postoperative group (post-FFS) were evaluated ≥10 weeks after surgery.

RESULTS

A total of 169 patients [mean (SD) age, 33.5 (10.8) years] were included. Compared with the pre-FFS group (n=107), the post-FFS group (n=62) reported improved scores anxiety (56.8±8.8 vs 60.1±7.9, P =0.01), anger (47.4±7.6 vs 51.2±9.6, P =0.01), depression (52.2±9.2 vs 57.0±8.9, P =0.001), positive affect (46.6±8.9 vs 42.9±8.7, P =0.01), meaning and purpose (49.9±10.7 vs 46.2±10.5, P =0.03), global mental health (46.7±7.6 vs 43.1±9.2, P =0.01), and social isolation (52.2±7.5 vs 55.4±7.4, P =0.01). Multivariable analysis to account for the effects of other gender-affirming surgeries, hormone therapy duration, preexisting mental health diagnoses, socioeconomic disparities, and patient-reported quality of social relationships on psychosocial functioning demonstrated that completion of FFS was independently predictive of improved scores.

CONCLUSIONS

Gender-affirming FFS improves the quality of life by multiple psychosocial domains in transfeminine patients.

Perceived Gender Transition Progress, Gender Congruence, and Mental Health Symptoms Among Transgender Adolescents

PURPOSE

Transgender adolescents (TGAs) have high risk for experiencing mental health problems, but little is known about how aspects of gender identity relate to their mental health symptoms. Evidence from child and adult samples of transgender individuals indicates making progress in gender transition milestones and higher levels of congruence between gender identity and gender expression are related to fewer mental health problems. We examined associations between perceived transition progress, gender congruence, and mental health symptoms in a diverse, nationwide sample of TGAs.

METHODS

TGAs (n = 1,943) participated in a cross-sectional online survey. Perceived gender transition progress, gender congruence, and depressive and anxiety symptoms were assessed. Path analysis was conducted to examine whether transition progress was related to mental health symptoms via higher levels of gender congruence.

RESULTS

Most TGAs had undertaken at least one social transition step (98%), but only 11% had taken medical transition steps. Higher gender congruence was associated with lower mental health symptoms. Greater transition progress was associated with higher gender congruence, and perceived transition progress evidenced negative indirect associations with mental health symptoms. TGAs identifying with binary identities (transmasculine and transfeminine youth) reported lower levels of transition progress and gender congruence compared to other subgroups of TGAs.

DISCUSSION

Higher levels of perceived transition progress and gender congruence are related to lower mental health symptoms among TGAs. Mental health interventions tailored to the unique developmental needs of TGAs are needed given high risk for mental health problems within this population, and interventions addressing transition progress and gender congruence should be examined.

Gender-Affirming Facial Feminization Surgery at a Public, Safety-Net Hospital: A Single-Center Early Experience

BACKGROUND

Facial feminization surgery (FFS) remains inaccessible to many transgender patients. Zuckerberg San Francisco General Hospital (ZSFG) was among the first public, safety-net hospitals to perform FFS. The purpose of this study is to examine the postoperative outcomes of patients who underwent FFS at ZSFG and describe barriers to providing FFS in a public hospital setting.

METHODS

A retrospective review identified patients who underwent FFS at ZSFG. Demographic data, comorbidity profiles, postoperative outcomes, and hospital utilization data were collected from the medical records. FACE-Q modules (scored 0-100) were used to survey patient satisfaction at least 1 year postoperatively.

RESULTS

Seventeen patients underwent comprehensive FFS surgery at ZSFG. The median age was 41 years [interquartile range (IQR): 38-55], median body mass index was 26.4 (IQR: 24.1-31.3). Patients underwent a median of 9 procedures, the most common of which included frontal cranioplasty (n=13, 77%), open brow lift (n=13, 77%), rhinoplasty (n=12, 71%), and mandible contouring (n=12, 71%). There were no complications, readmissions, or reoperations within 30 days. Patients reported high satisfaction with the surgical outcome (median: 87, IQR: 87-100), excellent postoperative psychological functioning (median: 100, IQR: 88-100), and low levels of appearance-related distress (median: 3, IQR: 0-35). An estimated 243 operating room hours and 51 inpatient bed days were required to cover all FFS procedures.

CONCLUSIONS

Performing FFS in a public, safety-net hospital was associated with zero postoperative complications, few revision procedures, and excellent patient satisfaction. Limited operating room hours and inpatient availability represented barriers to providing FFS in this setting.

Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium

BACKGROUND

Increasing societal acceptance of transgender people has led to broader availability of gender surgery and rapid growth in transition-related operations. Facial gender surgery aims to modify patients' facial features to be more congruent with their physical expression of gender, reducing gender dysphoria and improving quality of life. Growth in research and technique evolution has not kept pace with growth in clinical volume. Therefore, the first International Facial Gender Symposium was held at Johns Hopkins University in 2019, convening surgeons who perform facial gender surgery to share ideas and assess the state of clinical evidence.

METHODS

To review the literature on facial gender surgery, the authors developed a search strategy for seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) through May of 2019, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines.

RESULTS

Based on the English language literature and clinical experience, the authors suggest guidelines for screening, management, and appropriate surgical technique for patients undergoing facial gender surgery. They highlight facial gender surgery as a medically necessary intervention and identify shortcomings in current guidelines.

CONCLUSIONS

Facial gender surgery represents a complex array of craniofacial and soft-tissue procedures that require application of advanced skills and decision-making. Facial gender operations are not cosmetic, are medically necessary, and require development of new CPT codes specific to facial gender surgery. It is imperative to create educational programs and methods to define sufficient training for facial gender surgery surgeons. Research priorities include better procedural outcomes data, more quality-of-life studies, and insight into variation in both patient and procedural subgroups.

Necessity of facial contouring in feminization surgery for Chinese transgender females

Background

An increasing number of transgender females are suffering from a critical gender dysphoria, which often presents as depression and self-destructive behavior. Facial feminization surgery (FFS) is an effective method to alleviate symptoms of gender dysphoria, which could be more important than genital reassignment surgery for Chinese. Facial contour surgery is perceived as an ordinary FFS for the Chinese women to improve their facial appearance. The zygoma and jaw are key areas for feminizing the facial contour. This study mainly emphasized the necessity of FFS and discussed the importance of facial contour surgery of Chinese individuals.

Methods

The differences of facial contour before and after FFS in terms of skeletal and soft tissue were analyzed. The pre- and postoperative images were evaluated for feminization. The results of the full suite of measurements were compared to reveal the effective change of FFS. Furthermore, a surgery satisfaction survey was conducted among these patients after recovery.

Results

All the patients expressed their satisfaction with the reduction in the intergonial width as well as the middle face prominence. All the facial contour ratios changed significantly after surgery in both hard tissue and soft tissue.

Conclusions

Facial contour surgery is crucial to changing one's facial appearance and sex impression, which significantly alleviates gender dysphoria.

Narrative review of facial gender surgery: approaches and techniques for the frontal sinus and upper third of the face

Facial gender confirmation surgery (FGCS) is a series of procedures which seek to harmonize a patient's face with his/her self-image and gender identity. Originally described in San Francisco in the 1980s, FGCS has evolved to encompass all elements of the craniofacial skeleton and facial soft tissue. This field in plastic and reconstructive surgery has quickly gained more attention in the past decade due to the pioneering work of groups around the world along with increased social acceptance and medical care of the transgender community. This narrative review focuses on the upper third of the face. Key differences in the forehead and the hairline of cis men and women are discussed which inform pharmacologic and surgical interventions. Hairline modifying therapies including pharmacotherapy and hair transplantation are explained. Virtual surgical planning (VSP), a tool broadly used in surgical fields, has a special role in FGCS and we offer advice in using VSP when addressing the frontal sinus. Use of VSP allows the surgeon to provide reproducible and accurate results. We then discuss the history of the frontal sinus setback and offer our algorithmic approach to recontouring the forehead with detailed description of the operative steps and decision making. Finally, postoperative care and complications considered.

A French Translation of the Transgender Congruence Scale: Validation and Associations with Distress, Well-Being, and Perceived Transition Status

Purpose: Disparities in psychosocial functioning between transgender and cisgender populations highlight the importance of validating measures assessing mechanisms of resilience for transgender and nonbinary people. Gender congruence is an important mechanism of resilience, as it focuses on the individual's own gender objectives. Moreover, research increasingly links gender congruence to psychosocial functioning and well-being. The goals of the current study were to validate a French-language version of the Transgender Congruence Scale and examine how this scale was associated with life satisfaction, psychological distress, and perceived transition status. Methods: Individuals (N=179) with a variety of transgender and nonbinary gender identities living in Quebec, Canada, were recruited online. They completed the Transgender Congruence Scale, as well as measures of transition status, psychological distress, and life satisfaction. Results: A two-factor model (assessing appearance congruence and identity congruence, respectively) was supported in the current sample. The French translation of the Transgender Congruence Scale showed good reliability and validity, similar to those found with the original English language version of the measure. Higher scores on both subscales, as well as the total scale, were associated with better psychosocial functioning and self-defined transition status. Discussion: Findings linked both appearance and identity congruence to psychosocial outcomes and supported the validity of this French version of the Transgender Congruence Scale. With potential clinical or research applications, the Transgender Congruence Scale is a brief and psychometrically sound measure of an important resilience construct for gender minority individuals that can now be used with Francophone populations.

The Health Burden of Transfeminine Facial Gender Dysphoria: An Analysis of Public Perception

Objectives/Hypothesis: The face is a major communicator of gender identity. Transfeminine individuals report debilitating quality-of-life deficits as a result of their gender dysphoria, which may be addressed with feminizing therapies. We aimed to quantify the potential impact of facial gender dysphoria experienced by transfeminine patients, as well as associated treatments, including feminizing facial gender surgery, through validated health state utility measures. Methods: A transfeminine patient volunteer who underwent head and neck gender-affirming treatments was consented for research use of perioperative photographs. These media aided in the description of two transfeminine health states, pre- and postfacial feminization facial gender dysphoria. Monocular blindness and binocular blindness were two health state controls. General population adults rated these four health states through visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO), which were used to calculate the quality-adjusted life years (QALYs). Results: Survey respondents totaled 206 with a mean (standard deviation [SD]) age of 35.8 (11.9) years. Mean (SD) health utility measures included 0.75 (0.22) QALYs for VAS, 0.82 (0.19) QALYS for SG, 0.79 (0.21) QALYS for TTO for pretreatment facial gender dysphoria, and 0.81 (0.21), 0.86 (0.19), 0.83 (0.20) QALYS for postgender-affirming treatments for facial gender dysphoria. The health utility scores for the postgender-affirming treatments for facial gender dysphoria (+0.06 VAS, p = 0.005) were significantly improved compared with the pretreatment state. Conclusions: To our knowledge, this study is the first to examine how the general population perceives the health burden of facial gender dysphoria experienced by transfeminine patients. Facial gender dysphoria is perceived to have a negative impact on health states, not dissimilar to monocular blindness in our sample. Feminizing facial gender surgery appears to significantly increase health utility measures.

A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS.

Midfacial Bony Remodeling

Craniofacial procedures to the midface in conjunction with work to the upper face and skull, and if needed the lower jaw, are a permanent and effective way to achieve feminization of the face in transgender patients. Although the surgery is more complex than other procedures, it should be considered for select patients. Further improvement of cosmesis may be considered a separate surgical entity and is not limited in scope or time by having undergone midface osteotomies. When carefully planned, bony surgery to the midface is safe and results in long-term predictive results and a favorable appearance as the patient ages."

Facial Feminization Surgery: The Ethics of Gatekeeping in Transgender Health

The lack of access to gender-affirming surgery represents a significant unmet health care need within the transgender community, frequently resulting in depression and self-destructive behavior. While some transgender people may have access to gender reassignment surgery (GRS), an overwhelming majority cannot afford facial feminization surgery (FFS). The former may be covered as a "medical necessity," but FFS is considered "cosmetic" and excluded from insurance coverage. This demarcation between "necessity" and "cosmetic" in transgender health care based on specific body parts is in direct opposition to the scientific community's understanding of gender dysphoria and professional guidelines for transgender health. GRS affects one's ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one's quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs.