National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery

Shifting Paradigms: A Deep Dive Into Public Perceptions of Gender-affirming Surgery

Background

Given the growing demand for gender-affirming surgery (GAS) in recent years, it is essential to explore the public perceptions of GAS. Understanding the public's opinions and attitudes toward GAS will provide valuable insights for shaping educational initiatives to enhance public knowledge and awareness.

Methods

This cross-sectional study used the Prolific Academic platform to distribute an online survey among adult participants residing in the United States in August 2023.

Results

Of 1005 completed survey responses, 50% of respondents were 41 years of age or older, 51% were women, and 73% were White. A total of 18% identified as part of the LGBTQIA+ community, and most (37%) resided in the southern United States. The majority of participants (78%) did not personally know anyone who underwent GAS, and 74% believed that plastic surgeons mainly perform GAS. Only 22% felt healthcare professionals were well qualified to provide gender-affirming care. Media's effect on GAS acceptance was assessed to be mostly negative (33%) or very negative (12%). About 33% favored both public and private health insurance coverage for GAS, whereas 35% opposed insurance coverage. Most respondents strongly agreed (32% and 34%) or agreed (33% and 37%) that GAS aligns with gender identity and improves mental health. Regarding minimum age, most partakers (43%) supported 18 years, whereas 38% endorsed 21 years.

Conclusions

This study sheds light on the public perceptions of GAS. These insights underscore the need for targeted educational efforts to increase awareness, rectify misconceptions, and promote a deeper understanding of GAS within society.

Surgical Treatment of Transgender and Gender-Diverse Individuals and Health Outcomes

Gender affirming surgeries are procedures that are used by transgender and gender diverse individuals to align their bodies to their gender identities. These have been shown to improve the mental health and wellbeing of those individuals who choose to access them. Rates of regret associated with gender affirming surgeries are low, and in addition to improving mental health and quality of life, these procedures have the potential to make it safer for transgender and gender diverse people to move through the world. This article provides a narrative review that places gender affirming surgeries in the current sociopolitical context of the United States. It describes common types of gender affirming surgery, protocols for surgical assessment, and the risks and benefits of surgery.

Medicaid coverage for gender-affirming surgery: A state-by-state review

OBJECTIVE

To systematically review Medicaid policies state-by-state for gender-affirming surgery coverage.

DATA SOURCES AND STUDY SETTING

Primary data were collected for each US state utilizing the LexisNexis legal database, state legislature publications, and Medicaid manuals.

STUDY DESIGN

A cross-sectional study evaluating Medicaid coverage for numerous gender-affirming surgeries.

DATA COLLECTION/EXTRACTION METHODS

We previously reported on state health policies that protect gender-affirming care under Medicaid coverage. Building upon our prior work, we systematically assessed the 27 states with protective policies to determine coverage for each type of gender-affirming surgery. We analyzed Medicaid coverage for gender-affirming surgeries in four domains: chest, genital, craniofacial and neck reconstruction, and miscellaneous procedures. Medicaid coverage for each type of surgery was categorized as explicitly covered, explicitly noncovered, or not described.

PRINCIPAL FINDINGS

Among the 27 states with protective Medicaid policies, 17 states (63.0%) provided explicit coverage for at least one gender-affirming chest procedure and at least one gender-affirming genital procedure, while only eight states (29.6%) provided explicit coverage for at least one craniofacial and neck procedure (p = 0.04). Coverage for specific surgical procedures within these three anatomical domains varied. The most common explicitly covered procedures were breast reduction/mastectomy and hysterectomy (n = 17, 63.0%). The most common explicitly noncovered surgery was reversal surgery (n = 12, 44.4%). Several states did not describe the specific surgical procedures covered; thus, final coverage rates are indeterminate.

CONCLUSIONS

In 2022, 52.9% of states had health policies that protected gender-affirming care under Medicaid; however, coverage for various gender-affirming surgical procedures remains both variable and occasionally unspecified. When specified, craniofacial and neck reconstruction is the least covered anatomical area compared with chest and genital reconstruction.

Nonsurgical Interventions for Gender-Affirming Facial Feminization: A Scoping Review

Importance: Systematic review will improve understanding of nonsurgical facial feminization techniques, which are useful alternatives or adjuncts to surgical gender affirmation. Objective: To determine the effectiveness of nonsurgical facial feminization techniques in patients seeking gender-affirming feminization by reviewing the literature for patient-reported, subjective, and objective outcomes of feminization. Evidence Review: A comprehensive database search was conducted through July 28, 2022. A total of 264 titles and abstracts were screened by two independent reviewers in Covidence. Of all, 48 met the inclusion criteria for full-text review, and 20 articles were included in the final data extraction. Findings: The most described nonsurgical facial feminization techniques were neurotoxins, fillers, and hair removal. Techniques were derived from cisgender cosmetic procedures to achieve feminine qualities. The most common study type was expert opinion or literature reviews. There were only two studies that analyzed measurable nonsurgical facial feminization techniques. Conclusions and Relevance: There is a lack of high-quality prospective research and randomized, controlled trials specific to the transgender patient population that evaluate outcomes, patient satisfaction, or complications. Such studies are needed to inform evidence-based practices.

Insights Into Facial Surgery Trends in the United States in the Setting of Gender Dysphoria: A National Analysis From 2012 to 2019

INTRODUCTION

Over the past decade, there has been an improvement in access to gender-affirming surgical care for the transgender population. Even with improvements, this population continues with a high level of inequity among access to specialized surgical care. While multiple studies have previously focused on trends among top and bottom surgery, this study provides trends specifically among facial gender affirmation surgery (FGAS) within the United States.

METHODS

The National Inpatient Sample (NIS) was utilized to identify patients who underwent FGAS from 2012 to 2019. The diagnostic codes for gender identity disorder and gender dysphoria were used to identify the desired patient population. CPT coding released in a medical policy for transgender care coverage was used to identify those who underwent FGAS. Frequency distributions from the patient population were analyzed to determine differences among characteristics.

RESULTS

In total, 660 patients underwent FGAS from 2012 to 2019. The incidence of FGAS has increased by 1433%. Geographically, FGAS was more likely to be performed in the West and Northeast geographical regions (P<0.0001). There was a statistically significant difference in hospital length of stay and the total number of charges when stratified by race (P<0.0001 and P=0.0003), hospital location (P<0.0001 and <0.0001), and insurance type (P<0.0001 and <0.0001). The largest cohort of patients paid out-of-pocket (P<0.0001).

CONCLUSIONS

FGAS is one of the fastest-growing GAS procedures. Currently, FGAS procedures are not equally distributed, with higher concentrations occurring among wealthier, white individuals in certain geographical regions. Future studies are warranted to understand further trends within FGAS.

Does every transgender person want gender affirming surgery? A survey of transgender individuals in the Midwestern United States

Gender-affirming surgery (GAS) is a highly personalized decision for transgender and gender diverse (TGD) individuals. However, the proportion of TGD individuals who desire GAS is unknown. A questionnaire was created after identifying themes surrounding experiences with gender-affirming medical care by community focus groups. Respondents who reported medically transitioning and who had undergone GAS were compared to those without prior GAS. From 88 completed surveys, 18 (20.5%) individuals did not wish to undergo GAS. Of those medically transitioning and desiring GAS, 15.2% (9/59) desired GAS but had not received it yet, with 6.7% (6/9) identifying as non-binary. Individuals who had not had GAS were more likely to earn under $15,000 annually, compared to $25,000-49,000 in the GAS group (p = 0.01). There was no significant difference in educational level (p = 0.32) or insurance status (p = 0.33). Of TGD individuals who desire GAS, out-of-pocket expenses such as hair removal, opaque insurance policies, lack of social support, and access to gender-affirming providers can hinder the transition process. Understanding barriers and rationales for pursuing GAS can provide targets for improving healthcare delivery to this diverse population.

FACE-Q Satisfaction Ratings Are Higher After Facial Feminization Surgery Than Hormone Replacement Therapy Alone

Purpose

Facial feminization surgery (FFS) is associated with improved psychological outcomes in transgender patients. We aimed to evaluate the impact of FFS on patient satisfaction with facial appearance using validated, patient-reported outcome tools.

Methods

Patients were recruited to complete a FACE-Q survey at least 6 months after their FFS. FACE-Q modules used included "Satisfaction with Facial Appearance Overall," "Facial Attributes" (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), "Decision," "Outcomes," "Psychological Function," and "Social Function." "Satisfaction with Facial Appearance Overall" was compared to FACE-Q outcomes in transgender patients on hormone replacement therapy (HRT), alone.

Results

Twenty-three patients completed the survey. Rhinoplasty was the most common procedure (82.6%). Insurance was rated as a major barrier in 50% of patients. "Satisfaction with Facial Appearance Overall" using the FACE-Q was 69.3, with "Psychological Function" rated at 73.7 and "Social Function" rated at 76.1. FFS was associated with a higher overall satisfaction in facial appearance compared to patients on HRT for 3 months (69.3 vs. 48.5, p<0.01) and 12 months, alone (69.3 vs. 54.4, p<0.001). Wait time for FFS of less than a year (β=-20.4, p=0.04) and undergoing FFS at a younger age (β=-1.4, p<0.001) were independently associated with higher satisfaction scores in overall facial appearance.

Conclusions

FFS is associated with greater satisfaction with overall facial appearance, especially compared to transgender patients only on HRT. Insurance was the greatest barrier to receiving FFS. Improved access to surgery is needed to yield higher overall satisfaction with facial appearance.

Health Disparities Research in Facial Plastic and Reconstructive Surgery: A Scoping Review

OBJECTIVE

Health disparities contribute significantly to disease, health outcomes, and access to care. Little is known about the state of health disparities in facial plastic and reconstructive surgery (FPRS). This scoping review aims to synthesize the existing disparities research in FPRS and guide future disparities-related efforts.

DATA SOURCES

PubMed, Embase, Web of Science.

REVIEW METHODS

We conducted a scoping review in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist. Our search included all years through March 03, 2023. All peer-reviewed primary literature of any design related to disparities in FPRS was eligible for inclusion.

RESULTS

Of the 12283 unique abstracts identified, 215 studies underwent full-text review, and 108 remained for final review. The most frequently examined topics were cleft lip and palate (40.7%), facial trauma (29.6%), and gender affirmation (9.3%). There was limited coverage of other areas. Consideration of race/ethnicity (68.5%), socioeconomic status (65.7%), and gender/sex (40.7%) were most common. Social capital (0%), religion, occupation, and features of relationships were least discussed (0.01% each). The majority of studies were published after 2018 (59.2%) and were of nonprospective designs (95.4%). Most studies focused on disparity detection (80.6%) and few focused on understanding (13.9%) or reducing disparities (5.6%).

CONCLUSION

This study captures the existing literature on health disparities in FPRS. Studies are concentrated in a few areas of FPRS and are primarily in the detecting phase of public health research. Our review highlights several gaps and opportunities for future disparities-related focus.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Compared with previous literature, insurance coverage and criteria alignment are becoming more concordant with medical guidelines. However, significant barriers to care for GAS remain.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

United States Health Policies on Gender-Affirming Care in 2022

BACKGROUND

Within the United States, access to gender-affirming operations covered by health insurance has increased dramatically over the past decade. However, the perpetually changing landscape and inconsistencies of individual state health policies governing private and public insurance coverage present a lack of clarity for reconstructive surgeons and other physicians attempting to provide gender-affirming care. This work systematically reviewed the current U.S. health policies for both private insurance and Medicaid on a state-by-state basis.

METHODS

Individual state health policies in effect as of August of 2022 on gender-affirming care were reviewed using the LexisNexis legal database, state legislature publications, and Medicaid manuals. Primary outcomes were categorization of policies as protective, restrictive, or unclear for each state. Secondary outcomes included analyses of demographics covered by current health policies and geographic differences.

RESULTS

Protective state-level health policies related to gender-affirming care were present in approximately half of the nation for both private insurance (49.0%) and Medicaid (52.9%). Explicitly restrictive policies were found in 5.9% and 17.6% of states for private insurance and Medicaid, respectively. Regionally, the Northeast and West had the highest rates of protective policies, whereas the Midwest and South had the highest rates of restrictive policies on gender-affirming care.

CONCLUSIONS

State-level health policies on gender-affirming care vary significantly across the United States with regional associations. Clarity in the current and evolving state-specific health policies governing gender-affirming care is essential for surgeons and physicians caring for transgender and gender-diverse individuals.

Quality of life outcomes in patients undergoing facial gender affirming surgery: A systematic review and meta-analysis

Background: Facial gender-affirming surgery (FGAS), one of many transition-related surgeries (TRSs), "feminizes" the faces of transgender and gender diverse (TGD) patients undergoing transition. However, it is difficult to demonstrate the medical necessity of FGAS in terms of postoperative quality of life (QoL) outcomes due to a lack of standardized assessment tools. Thus, FGAS remains largely unsubsidized in North America. Methods: A systematic review of online databases was conducted according to PRISMA guidelines. Screening and quality assessment was conducted by two independent blinded reviewers (KJ and GR). For statistical analysis, data from different Likert-scale-like questionnaires were extracted and coalesced into three-point scales on a data table of seven QoL domains; "Pre-" and "Postoperative femininity," "Psychological satisfaction," "Social Integration and Functioning," "Aesthetic Satisfaction," "Physical Health," and "Satisfaction with Surgical Results." Results: From 2000 to 2022, 1837 patients and 3886 procedures from 19 studies were included. Weighted averages across all QoL domains reflected statistically significant improvement compared to neutral following FGAS (p < 0.001). Three studies used the same questionnaire, which showed that out of all eight questions regarding facial appearance, FGAS patients most strongly agreed the surgery was important to their ability to live as a woman (mean = 4.56/5, n = 137). Secondary outcomes showed the most common complications were hardware palpability (3.45%, n = 145) and aberrant scarring (2.17%, n = 423) with an overall revision rate of 2.17% (n = 423). The most common procedure was fronto-orbital remodeling. Conclusion: FGAS significantly improves QoL with minimal risk to life and supports the literature in defining FGAS as a medically necessary procedure comparable to other TRSs.

Quantifying Facial Feminization Surgery's Impact: Focus on Patient Facial Satisfaction

Background

Facial feminization surgery (FFS) has been associated with improving gender dysphoria in transgender patients. This study aimed to quantify the impact of surgery on patient facial satisfaction, using the FACE-Q and a quality-of-life (QoL) survey.

Methods

Transgender female patients were recruited to complete the FACE-Q and the World Health Organization's QoL Scale-Short Form (WHOQOL-BREF) if they were planning to or had undergone FFS at our institution. FACE-Q modules completed included "Satisfaction with Facial Appearance Overall," individual facial attributes (forehead/eyebrows, nose, cheeks, cheekbone, chin, jawline, and neck), and the WHOQOL-BREF, which assesses patient QoL through four domains (physical, psychological, social relations, and environment). Both matched and unmatched analyses of preoperative versus postoperative cohorts were performed.

Results

Overall, 48 patients participated in our study and completed 31 FACE-Q surveys preoperatively and 37 postoperatively. On average, patients were 37.2 ± 12.5 years old. FACE-Q scores increased significantly for all facial attributes and for Satisfaction with Facial Appearance Overall between cohorts (P < 0.05). The facial attribute with the greatest increase in satisfaction was the jawline, followed by the nose. The WHOQOL-BREF's psychological and physical domains both improved significantly (P < 0.05). Wait time for surgery of less than 6 months (b = 22.42, P = 0.02) was associated with higher overall facial satisfaction, whereas age at surgery (b = -1.04, P < 0.01) was associated with lower overall facial satisfaction.

Conclusions

Transgender female patients experienced significant improvements in facial satisfaction and QoL after FFS. Undergoing surgery at a younger age and shorter wait times for surgery were associated with increased overall facial satisfaction.

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.

Preparing for Facial Feminization Surgery

Preparing for facial feminization surgery (FFS) or gender-affirming facial surgery is a daunting task. Patients do extensive research online to see what FFS means. Oftentimes it is the patients who are educating their physicians when discussing medical clearance or the esteemed "therapy letter." The therapy letter is a letter that details the support for surgery in a stable patient and reaffirms the need to have FFS in a person diagnosed with gender dysphoria. This typically follows the World Professional Association for Transgender Health standards-of-care guidelines. Besides having the therapy letter, patients must be counseled on concurrent mental health illnesses.

Getting to Yes: Navigating the Insurance Gauntlet

Insurance coverage of gender-affirming surgeries including facial and vocal feminization surgery remains a challenge for many patients, physicians, and practice administrators. These challenges range from disparities in coverage for commercial versus public insurance carriers, in network versus out of network benefits, preauthorization struggles, and the lack of standard coverage policies. This article aims to describe the insurance coverage and approval challenges related to facial feminization surgery and to provide guidance for surgeons and their practice administrators on how to obtain successful preauthorization/predetermination, single case agreements, and proper claim adjudication.

Quality and Readability of Accessible Facial Feminization Literature: Where Can We Improve?

BACKGROUND

Facial feminization surgery (FFS) consists of multiple, complex procedures. Well-informed patients have been shown to have better outcomes and expectations. However, there is limited data evaluating FFS patient-oriented material online. This study aims to evaluate the quality and readability of FFS literature online.

METHODS

Facial feminization surgery-related terms were queried in Google with location, cookies, and user account information disabled. Websites were analyzed for readability using Flesch Reading Ease and Flesch-Kincaid Reading Grade Level, suitability using the suitability assessment of materials (SAM), and quality using the DISCERN scale. Unpaired t tests and χ2 tests were used to compare the websites of community-based and academic or public institutions.

RESULTS

One hundred twenty websites met inclusion criteria (71 community-based and 49 academic). The average reading grade level was 11.68 ± 1.71. The average SAM score was 53.11 ± 11.75, denoting adequate readability. Only 16.67% of websites contained visual aids to assist in explaining procedures and benefits. Overall, 68.33% of websites' DISCERN score was rated very poor or poor, whereas only 8.33% were rated as good. The following DISCERN elements had the lowest scores across all graded websites: "clear source and date of information," "details of additional source of support," "refers to areas of uncertainty," and "describes risks of each treatment." Websites published by community-based institutions were significantly better in describing how FFS works and the benefits of each procedure. Academic sites overall were less biased (4.84 vs 4.62, P = 0.03) and provided additional sources of support (2.35 vs 1.32, P = <0.001).

CONCLUSIONS

Online FFS patient resources should be written at a more inclusive reading level and should increase the use of pictorial aids to improve patient comprehension. Facial feminization surgery patient resources were significantly above the recommended sixth grade reading level for health literature. Academic and community-based institutions should include more information about procedural risks and limitations in surgical outcomes to ensure a broader scope of understanding.

Sex Differences in Adult Facial Three-Dimensional Morphology: Application to Gender-Affirming Facial Surgery

Background: Gender-affirming facial surgery (GFS) is pursued by transgender individuals who desire facial features that better reflect their gender identity. Currently, there are a few objective guidelines to justify and facilitate effective surgical decision making. Objective: To quantify the effect of sex on adult facial size and shape through an analysis of three-dimensional (3D) facial surface images. Materials and Methods: Facial measurements were obtained by registering an atlas facial surface to 3D surface scans of 545 males and 1028 females older than 20 years of age. The differences between male and female faces were analyzed and visualized for a set of predefined surgically relevant facial regions. Results: On average, male faces are 7.3% larger than female faces (Cohen's D = 2.17). Sex is associated with significant facial shape differences (p < 0.0001) in the entire face as well as in each sub-region considered in this study. The facial regions in which sex has the largest effect on shape are the brow, jaw, nose, and cheek. Conclusions: These findings provide biologic data-driven anatomic guidance and justification for GFS, particularly forehead contouring cranioplasty, mandible and chin alterations, rhinoplasty, and cheek modifications.

Limited Access to Facial Feminization Geographically Despite Nationwide Expansion of Other Gender-Affirming Surgeries

Facial feminization surgery (FFS) is an integral aspect of gender-affirming surgery (GAS) for individuals seeking to align secondary sex characteristics and gender identity. Despite the importance of FFS in treating gender dysphoria, current trends and prevalence remain unknown. We sought to examine trends in GAS and FFS and investigate the payer status of facial feminization procedures in the United States.

Methods

Data was extracted from the National Inpatient Sample from 2008 to 2017 by using International Classification of Diseases Ninth or Tenth diagnosis codes for gender identity disorder and procedure codes for FFS.

Results

From 2008 to 2017, 3015 patients underwent GAS. The yearly number of cases increased as did the average cost of GAS, which rose from $13,657 in 2008 to $50,789 in 2017. From 2015 to 2017, when FFS data was available, 110 of 1215 (9.1%) GAS patients had FFS. Most were non-Hispanic White (66.7%) or Black (23.8%). Fifty percent of FFS cases occurred in the West, followed by the Northeast (31.8%), South (13.6%), and Midwest (4.8%) (P = 0.015). By payer the cases were, 36.4% self-pay, 31.8% Medicaid, and 27.3% private insurance (P < 0.0001). Approximately, 18% of patients undergoing male-to-female transition received FFS.

Conclusions

From 2008 to 2017, GAS cases increased nationwide while the average cost of surgery rose steeply. FFS cases were primarily in the Western and Northeast United States. Despite high cost, roughly 18% of transgender women in our sample received FFS, highlighting the importance of FFS in gender transition.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

BACKGROUND

Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.

AIM

The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.

METHODS

Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.

OUTCOMES

Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.

RESULTS

Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).

CLINICAL IMPLICATIONS

This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.

STRENGTHS & LIMITATIONS

This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.

CONCLUSION

Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

Gender-Affirming Facial Surgery: Experiences and Outcomes at an Academic Center

Background: Gender-affirming facial surgery (GFS) is becoming more widely available for transgender individuals, but data on surgical approaches and outcomes remain limited. Methods: Retrospective analysis of surgical outcomes among consecutive GFS cases performed at a tertiary care academic center between March 2016 and August 2020. Results: Seventy-seven patients underwent 109 surgeries, including 478 individual procedures. The median age was 42 years. Ninety-five percent of patients had public health insurance. Two-stage GFS was often used in older patients (p = 0.001), with the first stage involving bone and cartilaginous alterations, and the second stage involving soft tissue procedures. Mean hospital stay after first-stage GFS was 1.2 days, with 70% discharged on postoperative day 1. Mean follow-up was 11.3 months. Among 66 patients with at least 1 month of follow-up, all complications were minor and included surgical site infection (5%), dehiscence (3.0%), seroma (3%), and medical complications (6%). Thirty-day hospital readmission rate was 1.5%. Conclusions: There are unique surgical approaches for GFS, which demonstrate low complication and readmission rates. Understanding these approaches and outcomes may help guide preoperative patient consultations and clinical decision making.

An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know

Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.