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Rezaei SJ, Miller AS, Miranda N, Ganor O. Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes. BEHAVIORAL SCIENCES & THE LAW 2024; 42:588-606. [PMID: 38889084 DOI: 10.1002/bsl.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/25/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.
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Affiliation(s)
- Shawheen J Rezaei
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Amitai S Miller
- Harvard University John F. Kennedy School of Government, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Noah Miranda
- Stanford University School of Medicine, Stanford, California, USA
- UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
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McLaughlin MF, Rosser M, Song S, Mehta N, Terry MJ, Kim EA. Evaluating Access and Outcomes in Gender-affirming Breast Augmentation: A Comparative Study of a County Hospital and an Academic Center. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5972. [PMID: 39015360 PMCID: PMC11249717 DOI: 10.1097/gox.0000000000005972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/14/2024] [Indexed: 07/18/2024]
Abstract
Background Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center. Methods This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed. Results Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (P < 0.001), Spanish-speaking (P = 0.001), and to have obesity (P = 0.011) and HIV (P = 0.004). Patients at ZSFG took hormones for longer before surgical consultation (P < 0.001) but had shorter referral-to-surgery intervals (P = 0.024). Patients at ZSFG more frequently underwent a subglandular approach (P = 0.003) with longer operative times (P < 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (P = 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (P = 0.008). Conclusions County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.
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Affiliation(s)
- Matthew F. McLaughlin
- From the School of Medicine, University of California, San Francisco, San Francisco, Calif
| | - Mica Rosser
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Siyou Song
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Nina Mehta
- School of Medicine, University of North Carolina, Chapel Hill, Chapel Hill, N.C
| | - Michael J. Terry
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
| | - Esther A. Kim
- Division of Plastic and Reconstructive Surgery, University of California, San Francisco, San Francisco, Calif
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Liu C, Shahid M, Yu Q, Orra S, Ranganath B, Chao JW. Complications following Breast Augmentation in Transfeminine Individuals: A Systematic Review and Meta-Analysis. Plast Reconstr Surg 2024; 153:1240-1251. [PMID: 37189242 DOI: 10.1097/prs.0000000000010691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. Although adverse events among breast augmentation in cisgender women are well described, their relative incidence in transfeminine patients is less elucidated. This study aims to compare complication rates after breast augmentation between cisgender women and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals. METHODS PubMed, the Cochrane Library, and other resources were queried for studies published up to January of 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender women. RESULTS Within the transfeminine group, the pooled rate of capsular contracture was 3.62% (95% CI, 0.0038 to 0.0908); the hematoma/seroma rate was 0.63% (95% CI, 0.0014 to 0.0134); the infection incidence was 0.08% (95% CI, 0.0000 to 0.0054); and implant asymmetry rate was 3.89% (95% CI, 0.0149 to 0.0714). There was no statistical difference between rates of capsular contracture ( P = 0.41) and infection ( P = 0.71) between the transfeminine versus cisgender groups, whereas there were higher rates of hematoma/seroma ( P = 0.0095) and implant asymmetry/malposition ( P < 0.00001) in the transfeminine group. CONCLUSION Breast augmentation is an important procedure for gender affirmation and, in transfeminine individuals, carries relatively higher rates of postoperative hematoma and implant malposition relative to cisgender women.
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Affiliation(s)
- Chenyu Liu
- From the George Washington University School of Medicine and Health Sciences
| | | | - Qian Yu
- University of Chicago Medical Center
| | - Susan Orra
- Department of Plastic Surgery, Georgetown University
| | - Bharat Ranganath
- From the George Washington University School of Medicine and Health Sciences
| | - Jerry W Chao
- From the George Washington University School of Medicine and Health Sciences
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Torres Perez-Iglesias CA, Heyman A, Koh DJ, Medina N, Roh DS, Slama J. Technical and Clinical Differences Between Transgender and Cisgender Females Undergoing Breast Augmentation. Ann Plast Surg 2023; 91:534-539. [PMID: 37823620 DOI: 10.1097/sap.0000000000003706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Gender-affirming surgery is a quickly expanding field. However, it is facing a shortage of specialized surgeons for a population exceeding 1.4 million individuals. Many studies comparing outcomes between cisgender and transgender patients fail to describe the technical differences of the operation. Breast augmentation in the transgender female patient involves important anatomical, technical, and clinical features that differ from the cisgender female. In this study, we aimed to describe and compare these characteristics between these 2 groups to better inform the new generation of gender-affirming surgeons. METHODS A retrospective cohort study of patients who underwent primary breast augmentation between 2009 and 2019 at a specialized tertiary center for transgender care was performed. Mastopexy, secondary augmentation, and reconstructive procedures were excluded. Demographic, operative, and clinical data were collected from medical records. All patients had a minimum of 1 year of follow-up after the initial surgery. Bivariate analysis was performed. RESULTS A total of 250 cisgender females and 153 transgender females were included. The transgender group showed higher rates of smoking ( P < 0.0001), immunosuppression ( P < 0.0001), obesity ( P < 0.0001), mental health disorders ( P < 0.0001), and hypertension ( P = 0.002). Median base width ( P < 0.0001), sternal notch to nipple distance ( P < 0.0001), and implant size (500 mL [interquartile range, 425-600 mL] vs 350 mL [interquartile range, 325-385 mL]; P < 0.0001) were larger in transgender patients. Transgender patients also demonstrated a stronger correlation between implant size and body surface area ( r = 0.71, P < 0.0001). Readmission, reoperation, and complication rates were similar between the groups; however, transgender females had a higher incidence of surgical site infections (3.9% vs 0.4%, P < 0.013). Capsular contracture was the most common complication and indication for reoperation in both groups. CONCLUSIONS There are important anatomical, clinical, and technical differences between reconstructive gender-affirming breast augmentation in transgender female patients and cosmetic breast augmentation in the cisgender female. The gender-affirming surgeon must know these differences to provide the best quality of care and help patients achieve better congruence between their gender identity and body image.
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Affiliation(s)
| | | | | | - Nilton Medina
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Daniel S Roh
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
| | - Jaromir Slama
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Boston University School of Medicine, Boston, MA
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Chartier R, Herlin C, Sinna R. [Thoracic reassignment surgeries]. ANN CHIR PLAST ESTH 2023; 68:436-445. [PMID: 37596145 DOI: 10.1016/j.anplas.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/23/2023] [Indexed: 08/20/2023]
Abstract
Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.
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Affiliation(s)
- R Chartier
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France
| | - C Herlin
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Lapeyronie, CHRU de Montpellier, 34295 Montpellier, France
| | - R Sinna
- Service de chirurgie plastique, reconstructrice et esthétique, hôpital Nord, CHU Amiens Picardie, 80054 Amiens cedex 1, France.
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Kamran R, Jackman L, Chan C, Suk Y, Jacklin C, Deck E, Wietek N, Stepney M, Harrison C, Jain A, Rodrigues J. Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review. JAMA Netw Open 2023; 6:e236425. [PMID: 37010869 PMCID: PMC10071345 DOI: 10.1001/jamanetworkopen.2023.6425] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/12/2023] [Indexed: 04/04/2023] Open
Abstract
Importance Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy. Objective To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation. Evidence Review In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080). Findings In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate. Conclusions and Relevance In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.
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Affiliation(s)
- Rakhshan Kamran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Liam Jackman
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia Chan
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Yujin Suk
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Eve Deck
- Department of Family Medicine, Western University, London, Ontario, Canada
| | - Nina Wietek
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Melissa Stepney
- Centre for Academic Primary Care, University of Bristol, Bristol, United Kingdom
| | - Conrad Harrison
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Abhilash Jain
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jeremy Rodrigues
- Warwick Clinical Trials Unit, University of Warwick, Coventry, United Kingdom
- Department of Plastic Surgery, Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, Aylesbury, United Kingdom
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7
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Kamali A, Sackey H, Gran I, Sigurjónsson H, Farnebo F, Lundgren K, Granath F, Sommar P. Implant Attributes or Patient Characteristics? Factors Affecting Outcome after Breast Augmentation in Transgender Women. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4645. [PMID: 37731908 PMCID: PMC10508468 DOI: 10.1097/gox.0000000000004645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 09/02/2022] [Indexed: 09/22/2023]
Abstract
Implant-based breast augmentation is a valuable tool for treatment of gender dysphoria in transgender women. The aim was to assess whether implant attributes, plane selection, and patient characteristics had an impact on the surgical outcome, and to compare these parameters between transgender and cisgender breast augmentations. Methods A cohort of transgender women who underwent breast augmentation at our department during 2009-2018 were retrospectively studied. The cohort was also compared with a cohort of 12,884 mainly cisgender women registered in the Swedish breast implant registry (BRIMP) during 2014-2019. Results A total of 143 transgender individuals were included, with a median follow-up of 5.7 years. Complications occurred in 20 patients (14.0%), four patients (2.8%) underwent acute reoperation, and 20 patients (14.0%) had secondary corrections. No differences were seen in complication rates when comparing prepectoral with subpectoral placement (15.1% versus 12.9%; P = 0.81); size, less than 400 mL versus greater than or equal to 400 mL (14.7% versus 13.3%; P = 0.81), or the shape of the implants, round versus anatomic (10.7% versus 22.2%; P = 0.10). In comparison with the cohort from BRIMP, the transgender cohort had more round implants (72.0% versus 60.7%; P < 0.01), larger implants (44.1% had volumes of 400-599 mL, compared with 25.4%; P < 0.0001), and more prepectoral placement (51.0% versus 7.3%; P < 0.0001). The risk of reoperation less than 30 days was 1.2% in BRIMP and 2.8% in the transgender cohort (P = 0.08). Conclusions In transgender women, implants are often larger, round, and placed prepectoral' compared with cisgender women. Despite these differences, complication rates were equivalent. Implant attributes, surgical techniques, and patient characteristics were not independently associated with the rate of complications.
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Affiliation(s)
- Alexander Kamali
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Akademiskt Centrum Plastikkirurgi, Department of Plastic Surgery, Stockholm, Sweden
| | - Helena Sackey
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Isak Gran
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Hannes Sigurjónsson
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Filip Farnebo
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Kalle Lundgren
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Granath
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Pehr Sommar
- From the Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Reconstructive Plastic and Craniofacial Surgery, Karolinska University Hospital, Stockholm, Sweden
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Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrián TM, Allen LR, Azul D, Bagga H, Başar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitán L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:S1-S259. [PMID: 36238954 PMCID: PMC9553112 DOI: 10.1080/26895269.2022.2100644] [Citation(s) in RCA: 718] [Impact Index Per Article: 359.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
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Affiliation(s)
- E Coleman
- Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A E Radix
- Callen-Lorde Community Health Center, New York, NY, USA
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - W P Bouman
- Nottingham Centre for Transgender Health, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - G R Brown
- James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
- James H. Quillen VAMC, Johnson City, TN, USA
| | - A L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - M B Deutsch
- Department of Family & Community Medicine, University of California-San Francisco, San Francisco, CA, USA
- UCSF Gender Affirming Health Program, San Francisco, CA, USA
| | - R Ettner
- New Health Foundation Worldwide, Evanston, IL, USA
- Weiss Memorial Hospital, Chicago, IL, USA
| | - L Fraser
- Independent Practice, San Francisco, CA, USA
| | - M Goodman
- Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - J Green
- Independent Scholar, Vancouver, WA, USA
| | - A B Hancock
- The George Washington University, Washington, DC, USA
| | - T W Johnson
- Department of Anthropology, California State University, Chico, CA, USA
| | - D H Karasic
- University of California San Francisco, San Francisco, CA, USA
- Independent Practice at dankarasic.com
| | - G A Knudson
- University of British Columbia, Vancouver, Canada
- Vancouver Coastal Health, Vancouver, Canada
| | - S F Leibowitz
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - H F L Meyer-Bahlburg
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | - J Motmans
- Transgender Infopunt, Ghent University Hospital, Gent, Belgium
- Centre for Research on Culture and Gender, Ghent University, Gent, Belgium
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - T O Nieder
- University Medical Center Hamburg-Eppendorf, Interdisciplinary Transgender Health Care Center Hamburg, Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Hamburg, Germany
| | - S L Reisner
- Harvard Medical School, Boston, MA, USA
- Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - C Richards
- Regents University London, UK
- Tavistock and Portman NHS Foundation Trust, London, UK
| | | | - V Tangpricha
- Division of Endocrinology, Metabolism & Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Atlanta VA Medical Center, Decatur, GA, USA
| | - A C Tishelman
- Boston College, Department of Psychology and Neuroscience, Chestnut Hill, MA, USA
| | - M A A Van Trotsenburg
- Bureau GenderPRO, Vienna, Austria
- University Hospital Lilienfeld-St. Pölten, St. Pölten, Austria
| | - S Winter
- School of Population Health, Curtin University, Perth, WA, Australia
| | - K Ducheny
- Howard Brown Health, Chicago, IL, USA
| | - N J Adams
- University of Toronto, Ontario Institute for Studies in Education, Toronto, Canada
- Transgender Professional Association for Transgender Health (TPATH)
| | - T M Adrián
- Asamblea Nacional de Venezuela, Caracas, Venezuela
- Diverlex Diversidad e Igualdad a Través de la Ley, Caracas, Venezuela
| | - L R Allen
- University of Nevada, Las Vegas, NV, USA
| | - D Azul
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - H Bagga
- Monash Health Gender Clinic, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - K Başar
- Department of Psychiatry, Hacettepe University, Ankara, Turkey
| | - D S Bathory
- Independent Practice at Bathory International PLLC, Winston-Salem, NC, USA
| | - J J Belinky
- Durand Hospital, Guemes Clinic and Urological Center, Buenos Aires, Argentina
| | - D R Berg
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J U Berli
- Oregon Health & Science University, Portland, OR, USA
| | - R O Bluebond-Langner
- NYU Langone Health, New York, NY, USA
- Hansjörg Wyss Department of Plastic Surgery, New York, NY, USA
| | - M-B Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Plastic Surgery, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - M L Bowers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mills-Peninsula Medical Center, Burlingame, CA, USA
| | - P J Brassard
- GrS Montreal, Complexe CMC, Montreal, Quebec, Canada
- Université de Montreal, Quebec, Canada
| | - J Byrne
- University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - L Capitán
- The Facialteam Group, Marbella International Hospital, Marbella, Spain
| | | | - J M Carswell
- Harvard Medical School, Boston, MA, USA
- Boston's Children's Hospital, Boston, MA, USA
| | - S C Chang
- Independent Practice, Oakland, CA, USA
| | - G Chelvakumar
- Nationwide Children's Hospital, Columbus, OH, USA
- The Ohio State University, College of Medicine, Columbus, OH, USA
| | - T Corneil
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - K B Dalke
- Penn State Health, PA, USA
- Penn State College of Medicine, Hershey, PA, USA
| | - G De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
| | - E de Vries
- Nelson Mandela University, Gqeberha, South Africa
- University of Cape Town, Cape Town, South Africa
| | - M Den Heijer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Endocrinology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - A H Devor
- University of Victoria, Victoria, BC, Canada
| | - C Dhejne
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - A D'Marco
- UCTRANS-United Caribbean Trans Network, Nassau, The Bahamas
- D M A R C O Organization, Nassau, The Bahamas
| | - E K Edmiston
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - L Edwards-Leeper
- Pacific University, Hillsboro, OR, USA
- Independent Practice, Beaverton, OR, USA
| | - R Ehrbar
- Whitman Walker Health, Washington, DC, USA
- Independent Practice, Maryland, USA
| | - D Ehrensaft
- University of California San Francisco, San Francisco, CA, USA
| | - J Eisfeld
- Transvisie, Utrecht, The Netherlands
| | - E Elaut
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Clinical Experimental and Health Psychology, Ghent University, Gent, Belgium
| | - L Erickson-Schroth
- The Jed Foundation, New York, NY, USA
- Hetrick-Martin Institute, New York, NY, USA
| | - J L Feldman
- Institute for Sexual and Gender Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - A D Fisher
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | - M M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA, USA
| | - L Gijs
- Institute of Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | | | - B P Hall
- Duke University Medical Center, Durham, NC, USA
- Duke Adult Gender Medicine Clinic, Durham, NC, USA
| | - T L D Hardy
- Alberta Health Services, Edmonton, Alberta, Canada
- MacEwan University, Edmonton, Alberta, Canada
| | - M S Irwig
- Harvard Medical School, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - A C Janssen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - K Johnson
- RMIT University, Melbourne, Australia
- University of Brighton, Brighton, UK
| | - D T Klink
- Department of Pediatrics, Division of Pediatric Endocrinology, Ghent University Hospital, Gent, Belgium
- Division of Pediatric Endocrinology and Diabetes, ZNA Queen Paola Children's Hospital, Antwerp, Belgium
| | - B P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - L E Kuper
- Department of Psychiatry, Southwestern Medical Center, University of Texas, Dallas, TX, USA
- Department of Endocrinology, Children's Health, Dallas, TX, USA
| | - E J Kvach
- Denver Health, Denver, CO, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - M A Malouf
- Malouf Counseling and Consulting, Baltimore, MD, USA
| | - R Massey
- WPATH Global Education Institute
- Department of Psychiatry & Behavioral Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - T Mazur
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- John R. Oishei Children's Hospital, Buffalo, NY, USA
| | - C McLachlan
- Professional Association for Transgender Health, South Africa
- Gender DynamiX, Cape Town, South Africa
| | - S D Morrison
- Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, USA
- Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, WA, USA
| | - S W Mosser
- Gender Confirmation Center, San Francisco, CA, USA
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - P M Neira
- Johns Hopkins Center for Transgender Health, Baltimore, MD, USA
- Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, Baltimore, MD, USA
| | - U Nygren
- Division of Speech and Language Pathology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Speech and Language Pathology, Medical Unit, Karolinska University Hospital, Stockholm, Sweden
| | - J M Oates
- La Trobe University, Melbourne, Australia
- Melbourne Voice Analysis Centre, East Melbourne, Australia
| | - J Obedin-Maliver
- Stanford University School of Medicine, Department of Obstetrics and Gynecology, Palo Alto, CA, USA
- Department of Epidemiology and Population Health, Stanford, CA, USA
| | - G Pagkalos
- Independent PracticeThessaloniki, Greece
- Military Community Mental Health Center, 424 General Military Training Hospital, Thessaloniki, Greece
| | - J Patton
- Talkspace, New York, NY, USA
- CytiPsychological LLC, San Diego, CA, USA
| | - N Phanuphak
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - K Rachlin
- Independent Practice, New York, NY, USA
| | - T Reed
- Gender Identity Research and Education Society, Leatherhead, UK
| | - G N Rider
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - J Ristori
- Andrology, Women Endocrinology and Gender Incongruence, Careggi University Hospital, Florence, Italy
| | | | - S A Roberts
- Harvard Medical School, Boston, MA, USA
- Division of Endocrinology, Boston's Children's Hospital, Boston, MA, USA
| | - K A Rodriguez-Wallberg
- Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology-Pathology, Karolinska Institute, Stockholm, Sweden
| | - S M Rosenthal
- Division of Pediatric Endocrinology, UCSF, San Francisco, CA, USA
- UCSF Child and Adolescent Gender Center
| | - K Sabir
- FtM Phoenix Group, Krasnodar Krai, Russia
| | - J D Safer
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, USA
| | - A I Scheim
- Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
- Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, Ontario, Canada
| | - L J Seal
- Tavistock and Portman NHS Foundation Trust, London, UK
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - K Spencer
- National Center for Gender Spectrum Health, Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - C St Amand
- University of Houston, Houston, TX, USA
- Mayo Clinic, Rochester, MN, USA
| | - T D Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, , Amsterdam, Netherlands
| | - J F Strang
- Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine, Washington, DC, USA
| | - G B Taylor
- Atrium Health Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Charlotte, NC, USA
| | - K Tilleman
- Department for Reproductive Medicine, Ghent University Hospital, Gent, Belgium
| | - G G T'Sjoen
- Center for Sexology and Gender, Ghent University Hospital, Gent, Belgium
- Department of Endocrinology, Ghent University Hospital, Gent, Belgium
| | - L N Vala
- Independent Practice, Campbell, CA, USA
| | - N M Van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - J F Veale
- School of Psychology, University of Waikato/Te Whare Wānanga o Waikato, Hamilton/Kirikiriroa, New Zealand/Aotearoa
| | - J A Vencill
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - B Vincent
- Trans Learning Partnership at https://spectra-london.org.uk/trans-learning-partnership, UK
| | - L M Wesp
- College of Nursing, University of Wisconsin MilwaukeeMilwaukee, WI, USA
- Health Connections Inc., Glendale, WI, USA
| | - M A West
- North Memorial Health Hospital, Robbinsdale, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - J Arcelus
- School of Medicine, University of Nottingham, Nottingham, UK
- Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
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9
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Schoffer AK, Bittner AK, Hess J, Kimmig R, Hoffmann O. Complications and satisfaction in transwomen receiving breast augmentation: short- and long-term outcomes. Arch Gynecol Obstet 2022; 305:1517-1524. [PMID: 35597817 PMCID: PMC9166844 DOI: 10.1007/s00404-022-06603-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction with breast augmentation. METHODS This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which were operated at University Hospital Essen from 2007 to 2020. RESULTS 99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III-IV) in this population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life owing to breast augmentation. CONCLUSION Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in reducing gender dysphoria.
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Affiliation(s)
- A K Schoffer
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
| | - A K Bittner
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - J Hess
- Department of Urology, University Hospital Essen, Essen, Germany
| | - R Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - O Hoffmann
- Department of Gynecology and Obstetrics, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
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10
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Milionis C, Ilias I, Koukkou E. Progesterone in gender-affirming therapy of trans women. World J Biol Chem 2022; 13:66-71. [PMID: 35721880 PMCID: PMC10558402 DOI: 10.4331/wjbc.v13.i3.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/28/2022] [Accepted: 04/22/2022] [Indexed: 02/06/2023] Open
Abstract
Progesterone is an endogenous steroid hormone with an important role for the physiology of the female reproductive system and the mammary gland. It has additional significant actions in other tissues, such as the cardiovascular system, the central nervous system, and bones. The present article explores potential clinical implications from the addition of bioidentical progesterone to gender-affirming treatment of trans women. For this purpose, it provides an overview of the physiological action of progesterone in target tissues and speculates on possible benefits for gender transitioning. Progesterone is expected to exert moderate anti-androgen action through suppression of the hypothalamic-pituitary-gonadal axis and inhibition of the conversion of testosterone to dihydrotestosterone. It may also contribute to breast maturation. In the long-term, progesterone could prevent bone loss and protect cardiovascular health. The potential benefits are mainly inferred by extrapolating evidence from biological actions in cisgender women and medical assumptions and hence, clinicians need to be cautious when applying these data into practice. Further research is needed to ascertain the efficacy and safety of progesterone in current hormonal regimens.
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Affiliation(s)
- Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
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11
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Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:255-273. [PMID: 35799954 PMCID: PMC9255096 DOI: 10.1080/26895269.2022.2038334] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Many transgender women and men undergo gender-affirming surgeries. Existing work shows that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive quality of life outcomes. Less work, however, examines these outcomes in the longer-term. Aims To conduct a systematic literature review into the longer-term (i.e., ≥ 1 year) surgical satisfaction and quality of outcomes following various forms of gender-affirming surgery in transgender populations. Specifically, we aim to examine research on such outcomes at least one-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries. Methods Studies were identified through Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. We considered all studies published until October 2021. Two reviewers extracted data from suitable studies using Covidence. Both reviewers also independently assessed the identified studies' risk of bias and strength of evidence. Results Seventy-nine low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggest that most transgender patients are satisfied with surgical outcomes when assessed at least one-year post-surgery. Low quality research also indicates that transgender women and men typically report positive psychological and sexual wellbeing post-surgery, and similar wellbeing outcomes as those who have not had surgery. Discussion To the best of our knowledge, this literature review is the first to critically summarize and evaluate all published studies on the longer-term quality of life outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. While the results suggest promising surgical satisfaction and quality of life outcomes following surgery, many studies only draw on small samples, and most studies do not allow for causal conclusions. Further, few studies have compared surgical outcomes between transgender women and men. We conclude by offering concrete suggestions for future research.
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Affiliation(s)
- Christienne Javier
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
| | - Charlie R. Crimston
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
| | - Fiona Kate Barlow
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
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12
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Oles N, Darrach H, Landford W, Garza M, Twose C, Park CS, Tran P, Schechter LS, Lau B, Coon D. Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 1: Breast/Chest, Face, and Voice). Ann Surg 2022; 275:e52-e66. [PMID: 33443903 DOI: 10.1097/sla.0000000000004728] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To perform the first systematic review of all available gender-affirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. METHODS A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to assess currently reported complication, satisfaction, and other outcome rates. RESULTS Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. CONCLUSIONS This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have assembled a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to high-quality research where improvement efforts should be focused.
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Affiliation(s)
- Norah Oles
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Halley Darrach
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Wilmina Landford
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Matthew Garza
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Claire Twose
- Welch Medical Library, Johns Hopkins University, Baltimore, Maryland
| | - Chanjun S Park
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | - Phuong Tran
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
| | | | - Brandyn Lau
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Health Sciences Informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute for Patient Safety, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Devin Coon
- Department of Plastic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Center for Transgender Health, Johns Hopkins Medicine, Baltimore, Maryland
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13
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Sexual well-being in transgender patients: Could gender confirming-chest surgery be enough? J Plast Reconstr Aesthet Surg 2021; 74:3443-3476. [PMID: 34686457 DOI: 10.1016/j.bjps.2021.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/19/2021] [Indexed: 11/22/2022]
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14
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Wilhelmus Timmermans F, Elisabeth Mokken S, Scheffers B, Bouman MB, Mullender M, van de Grift T. An anthropometric evaluation of the augmented breast: differences between cis-and transgender women and possible clinical implications. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-021-01856-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Abstract
Background
The morphometric results after breast augmentations are generally understood to be clinically different between trans(gender) and cis(gender) women. The objective of this study was to establish these morphometric differences between the augmented breasts of trans and cis women and their implications for preoperative planning and expectation management of trans women.
Methods
A single-center, observational cross-sectional study was conducted. Three-dimensional images (VECTRA) of the chest were taken and used to measure preset morphometric parameters. Subsequently, several proportional morphometric outcome variables were calculated. We compared body, breast, and nipple dimensions and their interdependence between trans and cis women. The main outcome sets were (1) the relative dimensions of the chest, (2) the position of the breasts relative to the chest, (3) and the position of the nipple relative to the breast and nipple size.
Results
A total of 22 transgender and 22 cisgender women were included. The results showed that the breasts of the trans women were positioned more cranial. Furthermore, the nipple-areola complexes (NAC) were significantly smaller and positioned relatively more latero-cranial on the breasts.
Conclusions
Morphological characteristics of augmented breasts differ significantly between trans and cis women. The results of this study identified distinct differences between the augmented breasts of trans and cis women. Because of the apparent differences in results, surgical considerations, expectation management, and shared decision-making should play an even more pronounced role in breast augmentations in trans women.
Level of evidence: Level III, risk/prognostic study.
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15
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Sijben I, Timmermans FW, Lapid O, Bouman MB, van der Sluis WB. Long-term Follow-up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-year experience in Amsterdam. J Plast Reconstr Aesthet Surg 2021; 74:3158-3167. [PMID: 34020905 DOI: 10.1016/j.bjps.2021.03.107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/22/2021] [Accepted: 03/14/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years. METHODS All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure. RESULTS A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%), CONCLUSION: Implant-based breast augmentation is a safe procedure in transgender individuals.
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Affiliation(s)
- Isha Sijben
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Floyd W Timmermans
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Oren Lapid
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands
| | - Wouter B van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, location VUmc, Amsterdam, the Netherlands.
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16
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Bekeny JC, Zolper EG, Manrique OJ, Fan KL, Del Corral G. Breast augmentation in the transgender patient: narrative review of current techniques and complications. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:611. [PMID: 33987309 PMCID: PMC8105870 DOI: 10.21037/atm-20-5087] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 01/29/2021] [Indexed: 11/06/2022]
Abstract
Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.
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Affiliation(s)
- Jenna C. Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Elizabeth G. Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Oscar J. Manrique
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
- MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
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17
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Tirrell AR, Abu El Hawa A, Bekeny JC, Del Corral G. Outcomes in chest feminization patients with a history of illicit hormone use and silicone injections. Breast J 2021; 27:352-358. [PMID: 33578450 DOI: 10.1111/tbj.14178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023]
Abstract
Transfeminine patients facing barriers to gender confirming surgery sometimes pursue illicit feminization procedures such as "street" hormones and silicone injections. These procedures often yield complications and disfigurement, making surgeons and insurance companies wary of secondary breast reconstruction. This clinical series assesses illicit treatment among our transfeminine breast surgery patients and describes the presentation, surgical approaches, and outcomes of each patient. A retrospective review of transfeminine patients who underwent chest feminization surgery with a single provider between March 2018 and March 2020 identified patients with a history of illicit hormones or silicone injections. Demographics, comorbidities, preoperative diagnoses and symptoms, surgical details, and postoperative outcomes were collected. Patients were contacted for a follow-up survey concerning outcomes and satisfaction. Of the 41 transfeminine patients reviewed, eight (19.5%) had previous illicit treatment. Seven (17.1%) used non-prescribed hormones, and three (7.3%) received silicone breast injections. Two patients presented with symptoms from silicone injections; the remaining were asymptomatic. Six patients underwent subglandular breast augmentation, one had a reduction mammoplasty, and one underwent an implant exchange. Only one patient had postoperative complications that healed without surgical intervention. This series emphasizes the need to assess the prevalence of silicone injections and illicit hormone use among transgender chest feminization patients. The use of these substances was relatively high in our population compared to national averages; however, there is a low risk of postoperative complications. Providers may perform breast surgery in patients with a history of illicit augmentation practices after careful evaluation and surgical planning.
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Affiliation(s)
- Abigail R Tirrell
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Areeg Abu El Hawa
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
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18
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de Blok CJM, Dijkman BAM, Wiepjes CM, Staphorsius AS, Timmermans FW, Smit JM, Dreijerink KMA, den Heijer M. Sustained Breast Development and Breast Anthropometric Changes in 3 Years of Gender-Affirming Hormone Treatment. J Clin Endocrinol Metab 2021; 106:e782-e790. [PMID: 33206172 DOI: 10.1210/clinem/dgaa841] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT Breast development is important for most trans women. An important limitation of current breast development measurement methods is that these do not allow for 3D volume analyses. OBJECTIVES To examine breast development and change in anthropometry during the first 3 years of gender-affirming hormone treatment using 3D imaging. Associations with clinical or laboratory parameters and satisfaction with the gained breast development were also studied. DESIGN Prospective cohort study. SETTING Specialized tertiary gender identity clinic in Amsterdam, the Netherlands. PARTICIPANTS Participants were 69 adult trans women with a median age of 26 years (interquartile range, 21-38). INTERVENTIONS Gender-affirming hormone treatment. MAIN OUTCOME MEASURES Volumetric and anthropometric breast development and satisfaction. RESULTS Breast volume increased by 72 cc (95% confidence interval [CI], 48-97) to 100 cc (standard deviation 48). This resulted in a cup-size <A-cup in 71% of the participants. Although the change in breast-chest difference plateaued after approximately 9 months, sustained increase in breast volume was observed during the 3-year observation period. Sternal notch to nipple distance increased by 1.3 cm (95% CI, 0.9-1.7) and internipple distance increased by 1.0 cm (95% CI, 0.4-1.5). At least 58% of trans women were satisfied with the gained breast size. CONCLUSIONS Sustained breast growth and development during hormone treatment was observed during the full 3-year observation period. The breasts of trans women are positioned more laterally and caudally on the chest compared with cis women. Although modest breast volumes were observed, breast development was satisfactory to most trans women.
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Affiliation(s)
- Christel J M de Blok
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Benthe A M Dijkman
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Annemieke S Staphorsius
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Floyd W Timmermans
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, HV, Amsterdam, the Netherlands
| | - Jan Maerten Smit
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Department of Plastic, Reconstructive, and Hand Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam Movement Sciences, HV, Amsterdam, the Netherlands
| | - Koen M A Dreijerink
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, HV, Amsterdam, the Netherlands
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19
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Use of the Subfascial Plane for Gender-affirming Breast Augmentation: A Case Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3362. [PMID: 33564588 PMCID: PMC7858195 DOI: 10.1097/gox.0000000000003362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/11/2020] [Indexed: 11/27/2022]
Abstract
Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population.
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20
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Epidemiologic Characteristics and Postoperative Complications following Augmentation Mammaplasty: Comparison of Transgender and Cisgender Females. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2461. [PMID: 31772890 PMCID: PMC6846310 DOI: 10.1097/gox.0000000000002461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/10/2019] [Indexed: 11/26/2022]
Abstract
Breast augmentation in transgender women can be an important first step in addressing gender incongruence and improving psychosocial functioning. The aim of this study was to compare postoperative outcomes of augmentation mammoplasty in transgender and cisgender females.
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