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Stoody VB, Glick HR, Murphey AC, Sturza JM, Selkie EM. A Content Analysis of Transgender Health and Wellness Themes Shared Through Social Media. Clin Pediatr (Phila) 2024; 63:1352-1363. [PMID: 38135918 DOI: 10.1177/00099228231219499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Transgender and gender-diverse (TGD) adolescents experience limited access to gender-affirming care (GAC) and information and use social media platforms for informational and social support. We conducted conventional content analysis of posts on the platform, Tumblr and applied univariate statistics to characterize health and wellness themes represented by this content. Content was predominantly transmasculine-relevant. Posts addressing the trans health care paradigm often co-occurred with content referencing affirmation logs, the physical and emotional impact of affirmation, surgery, and unspecified medical interventions. Gender-affirming hormone therapy was the most prevalent intervention referenced in posts related to non-professional/non-licensed medical care and advice requests. Transgender and gender-diverse youth-serving individuals can use this information to mitigate harm, enhance patient education, and improve the overall well-being of TGD youth. Further research is needed to characterize the effect of content encountered on social media on pediatric patient experiences and on outcomes of GAC.
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Affiliation(s)
- Vishvanie B Stoody
- Division of Adolescent Medicine, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hannah R Glick
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Annie C Murphey
- Section of Emergency Medicine, The University of Chicago, Chicago, IL, USA
| | - Julie M Sturza
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ellen M Selkie
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Cummings O, Iheanacho F, Gibson J, Araia E, Ademuwagun L, Charvis JS, Tanzer J, McIntire D, Kalliainen L. An Evaluation of the Presence of Diversity, Equity, and Inclusion Information on Plastic Surgery Residency Program Websites. Ann Plast Surg 2024; 93:149-152. [PMID: 39023406 DOI: 10.1097/sap.0000000000004015] [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: 07/20/2024]
Abstract
BACKGROUND Increasing the diversity of plastic surgery trainees is an important step in providing optimal care for our increasingly diverse patient populations. Given that information presented on residency programs' websites can strongly influence applicants' decisions to apply to or rank a program, demonstrating a commitment to diversity, equity, and inclusion (DEI) on program websites may aid in recruiting applicants with URM background. METHODS Using 8 DEI-related criteria, we evaluated the websites of 103 plastic surgery residency programs for the presence of DEI-related content during the month of June 2022. Each program was evaluated by 2 individual graders. We analyzed the data with confirmatory factor analysis in R using the Lavaan package. RESULTS On average, programs fulfilled 2.1 ± 1.6 of the metrics with a range of 0-7 fulfilled per program. Our model revealed that the criteria were a high-quality (P < 0.0001) measure of DEI-related metrics. There was a significant association between program size and presence of DEI-related criteria (linear 0.039; quadratic -0.005; both P < 0.01), such that mid-sized programs (16-18 residents) had the highest quality of DEI advertising compared to both small and large programs. Programs associated with a USNWR Top 20 Hospital were less likely to achieve high level of DEI-related criteria than other programs (P < 0.0001). CONCLUSION Mid-sized programs had greater DEI quality on their websites, while smaller and larger programs similarly had poorer assessed quality. There is room for all programs to improve the presence of DEI-related material on their websites, especially related to care of transgender populations.
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Affiliation(s)
- Olivia Cummings
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | - Franklin Iheanacho
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | - Jasmine Gibson
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | - Ermias Araia
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | - Lydia Ademuwagun
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | | | - Joshua Tanzer
- Department of Psychology, University of Rhode Island, Kingston, RI
| | - Damon McIntire
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
| | - Loree Kalliainen
- From the Department of Surgery, The Warren Alpert Medical School of Brown University, Providence
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Ferrin PC, Pua E, Isbester K, Peters BR. Factors Affecting the Choice to Forgo Nipple Grafts in Gender-Affirming Chest Surgery. Ann Plast Surg 2024; 93:189-193. [PMID: 38833665 DOI: 10.1097/sap.0000000000004004] [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: 06/06/2024]
Abstract
INTRODUCTION Some patients pursuing gender-affirming mastectomy prefer to forgo autologous nipple and areolar reconstruction, instead choosing a "no nipple" option. The objective of this study is to evaluate the motives and influences contributing to this decision. METHODS A retrospective survey-based study of patients undergoing gender-affirming mastectomy over a 4.6-year period was conducted. All patients were offered nipple and areolar reconstruction. A survey was distributed to those who elected to forgo nipple and areolar reconstruction exploring the factors influencing that choice and postoperative satisfaction. RESULTS Five hundred thirty-six patients underwent gender-affirming mastectomy and 13% chose to forgo nipple and areolar reconstruction. The survey response rate was 72%. Most respondents identified as nonbinary (48%) or transmasculine (42%). Body image, defined in the context of this study as an improvement in body image satisfaction due to achievement of a more gender-congruent appearance, was the most highly cited and most heavily weighted decision-making factor. Concerns about nipple graft outcomes were frequently cited as important but carried less weight. There were no differences between transmasculine and nonbinary patients in terms of motivations for choosing this surgical option. Fifty-eight percent of respondents pursued or planned to pursue chest tattoos, whereas 42% preferred no further chest modifications. Patient satisfaction was high postoperatively (98%), and 82% of respondents would choose to forgo nipple and areolar reconstruction again even if surgical outcomes of free nipple grafts were improved. CONCLUSIONS Gender-affirming mastectomy without nipple and areolar reconstruction was requested by 13% of patients presenting for gender-affirming chest surgery over the study period and had high postoperative satisfaction among patients who chose this option. This modification of gender-affirming mastectomy is a variation that surgical teams should be aware of. Many reasons to forgo nipple preservation were cited, most of which related to body image. Secondary factors were easier recovery and/or concern about outcomes of free nipple grafts. Many patients wished information about this surgical option was more widely available.
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Affiliation(s)
- Peter C Ferrin
- From the Department of Surgery, Oregon Health and Science University
| | - Ezra Pua
- Oregon Health and Science University School of Medicine
| | - Kelsey Isbester
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University
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Moghadam S, Khetpal S, Ozaki W. Use of Titanium Mesh During Frontal Sinus Setback in Facial Feminization Surgery: Clinical Outcomes and Perspectives. J Craniofac Surg 2024; 35:1338-1341. [PMID: 38830026 DOI: 10.1097/scs.0000000000010350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024] Open
Abstract
Brow position, hairline shape, and forehead projection may confer cis-feminine identity, and facial feminization surgery (FFS) can improve gender dysphoria among transfeminine patients. Depending on the Ousterhout classification, burring, osteotomy, anterior frontal sinus setback, and augmentation, with subsequent fixation via metal or bioabsorbable plates, can address forehead projection. However, titanium mesh, often used in frontal sinus fracture repair, has not been described for forehead contouring in FFS. The purpose of this study was to study clinical outcomes associated with the use of titanium mesh for the stabilization of bone following anterior frontal sinus setback. A retrospective cohort study of trans-female and nonbinary patients undergoing primary FFS by our senior author between January 2021 and February 2023 was performed. Variables collected include demographics, Ousterhout classification, operative details, complications, and follow-up duration. Patients with prior FFS or facial trauma were excluded. Data were analyzed using SPSS, (IBM, Armonk, NY). Forty-three transfeminine patients were included for analysis. The cohort had an average age of 33.0±8.7 years and a median follow-up time of 3.0 months (IQR = 1.0-7.0). Among our cohort, 26 patients (60.5%) received titanium mesh and 17 patients (39.5%) underwent burring only for forehead contouring. There were no reported complications (ie, infection, hardware extrusion, or mucocele formation) or a need for forehead revisions among the entire cohort regardless of the frontal sinus reconstruction material utilized. Clinical outcomes were favorable among patients receiving titanium mesh anterior table fixation during FFS. Titanium mesh can be considered as an additional technique for frontal bossing reduction and anterior table fixation in FFS.
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Affiliation(s)
- Shahrzad Moghadam
- From the Department of Surgery, Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
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Turan Ş, Özulucan MT, Karataş U, Kavla Y, Koyuncu O, Durcan E, Durcan G, Bağhaki S. The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth. Qual Life Res 2024; 33:1937-1947. [PMID: 38656406 PMCID: PMC11176246 DOI: 10.1007/s11136-024-03664-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB). METHODS In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr). RESULTS We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group. CONCLUSION Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.
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Affiliation(s)
- Şenol Turan
- Department of Psychiatry, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye.
| | - Mahmut Taha Özulucan
- Graduate School of Health Science, Neuroscience PhD Program, Koç University, Istanbul, Türkiye
| | - Uğur Karataş
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Yasin Kavla
- Department of Psychiatry, Hınıs State Hospital, Erzurum, Türkiye
| | - Oğuzhan Koyuncu
- Department of Child and Adolescent Psychiatry, Medeniyet University, Istanbul, Türkiye
| | - Emre Durcan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Gizem Durcan
- Department of Child and Adolescent Psychiatry, Istanbul University-Cerrahpasa, Istanbul, Türkiye
| | - Semih Bağhaki
- Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye
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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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LaGuardia JS, Chin MG, Fadich S, Morgan KBJ, Ngo HH, Bedar M, Moghadam S, Huang KX, Mallory C, Lee JC. Medicaid coverage for gender-affirming surgery: A state-by-state review. Health Serv Res 2024. [PMID: 38881495 DOI: 10.1111/1475-6773.14338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024] Open
Abstract
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.
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Affiliation(s)
- Jonnby S LaGuardia
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | - Madeline G Chin
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | - Sarah Fadich
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | | | - Halena H Ngo
- Harvard Law School, Cambridge, Massachusetts, USA
| | - Meiwand Bedar
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | - Shahrzad Moghadam
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | - Kelly X Huang
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
| | - Christy Mallory
- Williams Institute, University of California Los Angeles School of Law, Los Angeles, California, USA
| | - Justine C Lee
- Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California, USA
- UCLA Gender Health Program, Los Angeles, California, USA
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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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Sanchez K, Tollinche L, Reece-Nguyen T. Anesthesia for gender-affirming surgery: a practical review. Curr Opin Anaesthesiol 2024; 37:292-298. [PMID: 38390936 DOI: 10.1097/aco.0000000000001366] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW Gender-affirming surgery (GAS) is an effective, well studied, and often necessary component of gender-affirming care and mitigation of gender dysphoria for transgender and gender-diverse (TGD) individuals. GAS is categorized as chest surgeries, genitourinary surgeries, facial feminization/masculinization, and vocal phonosurgery. Despite increased incidence of GAS during recent years, there is a gap in knowledge and training on perioperative care for TGD patients. RECENT FINDINGS Our review discusses the relevant anesthetic considerations for the most common GAS, which often involve highly specialized surgical techniques that have unique implications for the anesthesia professional. SUMMARY Anesthesiology professionals must attend to the surgical and anesthetic nuances of various GAS procedures. However, as many considerations are based on common practice, research is warranted on anesthetic implications and outcomes of GAS.
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Affiliation(s)
- Kyle Sanchez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Luis Tollinche
- Department of Anesthesiology and Pain Medicine, MetroHealth Medical System of Case Western Reserve University, Cleveland, Ohio
| | - Travis Reece-Nguyen
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford Medicine, Stanford, California, USA
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Shue S, Joo A, Xu J, Gu G, Camargo A, Bronson I, Lister R, Hawley N, Morrison DA, McIntyre JK. Comparing Gender Congruency in Nonsurgical versus Postsurgical Top Surgery Patients: A Prospective Survey Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5925. [PMID: 38903139 PMCID: PMC11186809 DOI: 10.1097/gox.0000000000005925] [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: 11/03/2023] [Accepted: 05/01/2024] [Indexed: 06/22/2024]
Abstract
Background Gender dysphoria can result in reduced quality of life. Treatments include hormone replacement therapy (HRT) and gender-affirming surgery. Our study compared congruency, satisfaction, and discrimination in patients who underwent top surgery and HRT versus HRT alone. We hypothesized improved outcomes in top surgery patients but that lack of access is a common barrier. Methods Transgender and nonbinary subjects who underwent at least 6 months of HRT were recruited and answered questions on gender congruency, discrimination, and barriers to care. Surgical patients were asked about postoperative satisfaction using the BREAST-Q. A Mann-Whitney test compared survey responses between study arms. Results One hundred twelve eligible subjects completed the survey. Surgical subjects answered significantly more positively (P < 0.001) on all questions regarding gender congruency. The greatest difference was observed in how subjects' physical bodies represented their gender identity, where the surgery group rated higher on the five-point Likert scale by 2.0 points (P < 0.001). Surgical patients also reported less violence, verbal abuse, and discrimination (P < 0.003). Within the hormone arm, 87.1% stated desire for surgery and 62.5% declared barriers to surgery, with cost and insurance coverage representing the most common barriers. Finally, surgical subjects reported high satisfaction on the BREAST-Q, scoring more than 3.0 in all categories of breast augmentation and more than 2.6 for breast reduction on a four-point Likert scale. Conclusions Top surgery, in addition to HRT, significantly improves gender congruency and decreases discrimination and abuse, compared with HRT alone. Unfortunately, barriers including cost and lack of insurance continue to be obstacles for care.
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Affiliation(s)
- Shirley Shue
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Alex Joo
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Jing Xu
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Garrick Gu
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Anthony Camargo
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Isaac Bronson
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Rachel Lister
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | - Nathan Hawley
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
| | | | - Joyce K. McIntyre
- From the Division of Plastic Surgery, University of Massachusetts Chan Medical School
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11
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LaValley MN, Diaddigo SE, Asadourian PA, Feuer GB, Warner PE, Rohde CH. National Legislative Favorability and Insurance Coverage for Adult and Adolescent Gender-Affirming Surgery. Plast Reconstr Surg 2024; 153:1433-1440. [PMID: 37815328 DOI: 10.1097/prs.0000000000011123] [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: 10/11/2023]
Abstract
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.
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Affiliation(s)
- Myles N LaValley
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Sarah E Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paul A Asadourian
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Grant B Feuer
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Paige E Warner
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
| | - Christine H Rohde
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital/Columbia University Medical Center
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12
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Ren T, Galenchik-Chan A, Erlichman Z, Krajewski A. Prevalence of Regret in Gender-Affirming Surgery: A Systematic Review. Ann Plast Surg 2024; 92:597-602. [PMID: 38685500 DOI: 10.1097/sap.0000000000003895] [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: 05/02/2024]
Abstract
INTRODUCTION Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population. METHODS A systematic review of several databases was conducted. After compiling the articles, we extracted study characteristics. From the data set, weighted proportions were generated and analyzed. RESULTS A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the United States, 514 in European nations, 97 in Asian nations, which included only Thailand, and 19 in South American nations, which included only Brazil. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% while the prevalence of transmasculine regret was 0.8%. CONCLUSIONS Both transfeminine and transmasculine patients had significantly lower rates of regret in the United States when compared with the rest of the world. Our study largely excluded facial gender-affirming surgeries as most of its articles did not fall into our inclusion search criteria. To our knowledge, this is the most recent review performed on the topic of regret among gender-affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.
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Affiliation(s)
- Thomas Ren
- From the Stony Brook University Hospital
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13
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Cordero JJ, Alaniz L, Kalavacherla S, Tholpady SS, Chu MW. Trends of Medicare Reimbursement Rates for Gender-Affirming Surgery Procedures. Ann Plast Surg 2024; 92:S366-S370. [PMID: 38689421 DOI: 10.1097/sap.0000000000003799] [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: 05/02/2024]
Abstract
BACKGROUND Awareness of Medicare reimbursement is important for gender-affirming surgeons who treat transgender patients with Medicare. In 2014, Medicare began to provide coverage for medically necessary transition-related surgery. The purpose of this study was to analyze trends in Medicare reimbursement rates for gender-affirming surgery procedures from 2014 to 2022. METHODS The Medicare Physician Fee Schedule Look-Up Tool provided by the Centers for Medicare and Medicaid Services was used, and the Current Procedural Terminology codes for 43 gender-affirming surgery services were obtained. Monetary units, conversion factors, relative value units (RVUs) for work, facility, and malpractice costs for 30 transmasculine and 13 transfeminine procedures were analyzed. Descriptive statistics were performed to account for inflation and to determine the relative differences between 2014 and 2022. RESULTS For all gender-affirming surgery procedures covered by Medicare, the average relative difference of monetary units decreased by 2.99% between 2014 and 2022. On average, there was a 3.97% decrease of work-based RVU charges for transmasculine procedures and a 1.73% decrease of work-based RVU charges for transfeminine procedures. After adjusting for inflation, the average relative difference of monetary units for all gender-affirming surgery procedures decreased by 23.42% between 2014 and 2022. CONCLUSIONS Reimbursement rates for gender-affirming surgery procedures covered under Medicare have decreased over the observed period, and trends in reimbursement rates have not kept up with consumer price index inflation. Gender-affirming surgeons should be conscious of these changes in reimbursement rates and advocate for fairer compensation to promote medical care among an underserved population.
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Affiliation(s)
- Justin J Cordero
- From the School of Medicine, University of California Riverside, Riverside
| | | | | | - Sunil S Tholpady
- Division of Plastic and Reconstructive Surgery, Indiana University, Indianapolis, IN
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Christiano JG, Punekar I, Patel A, McGregor HA, Moskow M, Anson E. Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria. Transgend Health 2024; 9:143-150. [PMID: 38585246 PMCID: PMC10998022 DOI: 10.1089/trgh.2022.0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future. Methods Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts. Results Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team. Conclusion This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.
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Affiliation(s)
- Jose G. Christiano
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Imran Punekar
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Alap Patel
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | | | - Marian Moskow
- University of Rochester School of Nursing, Rochester, New York, USA
| | - Elizabeth Anson
- University of Rochester School of Nursing, Rochester, New York, USA
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15
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Wallace AB, Song S, Yeh P, Kim EA. The Effect of Pectoral Nerve Blocks on Opioid Use and Postoperative Pain in Masculinizing Mastectomy: A Randomized Controlled Trial. Plast Reconstr Surg 2024; 153:570-577. [PMID: 37220393 DOI: 10.1097/prs.0000000000010707] [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: 05/25/2023]
Abstract
BACKGROUND Bilateral masculinizing mastectomy is the most common gender-affirmation operation performed. Currently, there is lack of data regarding intraoperative and postoperative pain control for this population. It is the authors' aim to study the effects of the pectoral nerve (Pecs) I and II regional nerve blocks in patients undergoing masculinizing mastectomy. METHODS A randomized, double-blind, placebo-controlled trial was performed. Patients undergoing bilateral gender-affirmation mastectomy were randomized to receive either a Pecs block with ropivacaine or placebo injection. The patient, surgeon, and anesthesia team were blinded to the allocation. Intraoperative and postoperative opioid requirements were collected and recorded as morphine milligram equivalents (MME). Participants recorded postoperative pain scores at specific time points on the day of surgery through postoperative day 7. RESULTS Fifty patients were enrolled between July of 2020 and February of 2022. Twenty-seven were randomized to the intervention group and 23 to the control group, with 43 patients undergoing analysis. There was no significant difference in intraoperative MME between the Pecs block group and the control group (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point. CONCLUSIONS There was no significant reduction in opioid consumption or postoperative pain scores in patients undergoing bilateral gender-affirmation mastectomy who received a regional anesthetic when compared with placebo. In addition, a postoperative opioid-sparing approach may be appropriate for patients undergoing bilateral masculinizing mastectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, I.
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Affiliation(s)
- Adam B Wallace
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Siyou Song
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Peter Yeh
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
| | - Esther A Kim
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco
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16
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Johnson A, McClurg AB, Baldino J, Das R, Carey ET. Fertility preservation choices and decisional regret after gender-affirming surgery in transgender men or gender nonbinary persons. F S Rep 2024; 5:87-94. [PMID: 38524213 PMCID: PMC10958706 DOI: 10.1016/j.xfre.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/06/2023] [Accepted: 12/12/2023] [Indexed: 03/26/2024] Open
Abstract
Objective To investigate the prevalence of decisional regret regarding preoperative fertility preservation choices after gender-affirming surgery or removal of reproductive organs. Design Cross-sectional. Setting University-based pratice. Patients A total of 57 survey respondents identifying as transgender men or gender nonbinary with a history of gender-affirming surgery or removal of reproductive organs between 2014 and 2023 with the University of North Carolina Minimally Invasive Gynecology division. Intervention Survey or questionnaire. Main Outcome Measures The prevalence and severity of decisional regret regarding preoperative fertility preservation choices were measured with the use of the validated decisional regret scale (DRS) (scored 0-100). Secondary outcomes included patient-reported barriers to pursuing reproductive endocrinology and infertility consultation and fertility preservation treatment. Results The survey response rate was 50.9% (57/112). "Mild" to "severe" decisional regret was reported by 38.6% (n = 22) of survey respondents, with DRS scores among all respondents ranging from 0-85. Higher median DRS scores were associated with patient-reported inadequacy of preoperative fertility counseling regarding implications of surgery on future fertility or family-building (0 vs. 50) and fertility preservation options (0 vs. 12.5). No desire for future fertility at the time of fertility counseling was the most frequent reason (68.4%) for declining a referral to reproductive endocrinology and infertility for additional fertility preservation discussion. Conclusions Decisional regret regarding preoperative fertility preservation choices is experienced among transgender men or gender nonbinary persons after gender-affirming surgery or the removal of reproductive organs. Preoperative, patient-centered fertility counseling and fertility preservation treatments should be provided to reduce the risk of future regret.
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Affiliation(s)
- Austin Johnson
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington
| | - Asha B. McClurg
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Janine Baldino
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Rajeshree Das
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin T. Carey
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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17
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Das RK, Galdyn I, McCaffrey RL, Drolet BC, Al Kassis S. Geographic Differences in Patient Demographics and Performance of Gender-Affirming Surgery From 2016 to 2019. Aesthet Surg J 2024; 44:NP209-NP217. [PMID: 37995314 DOI: 10.1093/asj/sjad353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 11/12/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Although legislation prohibiting gender identity discrimination in health insurance has shown some improvement in insurance coverage for gender-affirming surgery (GAS), recent bills criminalizing GAS providers in the South and Midwest regions pose threats to patient care. OBJECTIVES To investigate the influence of US census region on patient demographics and GAS rates in the ambulatory surgery setting. METHODS Individuals with gender dysphoria who underwent GAS in the ambulatory setting from 2016 to 2019 were identified in the Nationwide Ambulatory Surgery Sample (NASS) with billing codes. Demographic and clinical characteristics were analyzed and stratified by US census region. RESULTS The data set included a weighted estimate of 33,174 encounters with 72.8% (95% CI, 69.1-76.2) for chest reconstruction; 24.1% (95% CI, 20.9-27.5) for surgery on the genitals and reproductive organs; and 6.0% (95% CI, 4.6-7.8) for facial surgery. Overall, the rates of GAS increased by 187%, from 4320 encounters in 2016 to 12,396 encounters in 2019. In the Midwest, GAS increased by 257% compared to 203% in the Northeast, 218% in the South, and 154% in the West. Compared to patients in the West, those in other regions had higher odds of anxiety and depression (odds ratio, 1.57; 95% CI, 1.09-2.26; P < .05) and were more likely to have lower incomes than other ambulatory surgery patients in the region (P < .001). CONCLUSIONS Between 2016 and 2019, there was substantial growth of GAS in the Midwest, South, and Northeast. Regional differences in insurance coverage, socioeconomic status, availability of facial surgery, and comorbidities were observed. LEVEL OF EVIDENCE: 2
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Adidharma L, Adidharma W, Latack KR, Moog D, Morrison SD, Wilkins EG. Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites. Transgend Health 2024; 9:83-91. [PMID: 38312453 PMCID: PMC10835154 DOI: 10.1089/trgh.2021.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Purpose The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions. Methods In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed. Results We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012). Conclusion Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.
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Affiliation(s)
- Lingga Adidharma
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Widya Adidharma
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Kyle R Latack
- Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Dominic Moog
- School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Shane D Morrison
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Edwin G Wilkins
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Ha A, Garoosi K, Hale E, Higuchi T, Winocour J, Mathes DW, Kaoutzanis C. Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021. Indian J Plast Surg 2024; 57:47-53. [PMID: 38450014 PMCID: PMC10914541 DOI: 10.1055/s-0043-1778096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
Introduction: In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods: We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results: We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion: In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.
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Affiliation(s)
- Ally Ha
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Anschutz Medical Campus, Aurora, Colorado
| | - Kassra Garoosi
- University of Colorado School of Medicine, Aurora, Colorado
| | - Elijah Hale
- University of Colorado School of Medicine, Aurora, Colorado
| | - Ty Higuchi
- Department of Surgery, Division of Urology, Anschutz Medical Campus, Aurora, Colorado
| | - Julian Winocour
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Anschutz Medical Campus, Aurora, Colorado
| | - David W. Mathes
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Anschutz Medical Campus, Aurora, Colorado
| | - Christodoulos Kaoutzanis
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Anschutz Medical Campus, Aurora, Colorado
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20
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Krakowsky Y, Shah G, Nguyen ALV, Kavanagh AG, Potter E, Remondini T, Goldsher YW, Millman A. Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know. BJU Int 2024; 133:124-131. [PMID: 38060336 DOI: 10.1111/bju.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.
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Affiliation(s)
- Yonah Krakowsky
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gresha Shah
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
| | - Anna-Lisa V Nguyen
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alex G Kavanagh
- Gender Surgery Program of British Columbia, Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emery Potter
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Taylor Remondini
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Wilk Goldsher
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Millman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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21
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Diaddigo SE, Asadourian PA, Lavalley MN, Marano AA, Rohde CH. Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data. Ann Plast Surg 2024; 92:253-257. [PMID: 38198631 DOI: 10.1097/sap.0000000000003735] [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: 01/12/2024]
Abstract
BACKGROUND Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population. METHODS Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications. RESULTS A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008). CONCLUSIONS Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.
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Affiliation(s)
- Sarah E Diaddigo
- From the Division of Plastic and Reconstructive Surgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY
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22
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Chin MG, LaGuardia JS, Morgan KBJ, Ngo H, Moghadam S, Huang KX, Bedar M, Cronin BJ, Kwan D, Lee JC. United States Health Policies on Gender-Affirming Care in 2022. Plast Reconstr Surg 2024; 153:462e-473e. [PMID: 37092963 DOI: 10.1097/prs.0000000000010594] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Madeline G Chin
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
- Division of Plastic and Reconstructive Surgery, Warren Alpert Medical School of Brown University
| | - Jonnby S LaGuardia
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | | | | | - Shahrzad Moghadam
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Kelly X Huang
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Meiwand Bedar
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Brendan J Cronin
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
| | - Daniel Kwan
- Division of Plastic and Reconstructive Surgery, Warren Alpert Medical School of Brown University
| | - Justine C Lee
- From the Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, David Geffen School of Medicine
- UCLA Gender Health Program, University of California, Los Angeles
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23
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Das RK, Remy K, McCarty JC, Valerio IL, Austen WG, Carruthers KH. A Relative Value Unit-Based Model for Targeted Nipple-Areola Complex Neurotization in Gender-Affirming Mastectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5605. [PMID: 38333028 PMCID: PMC10852362 DOI: 10.1097/gox.0000000000005605] [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: 11/03/2023] [Accepted: 12/15/2023] [Indexed: 02/10/2024]
Abstract
Background For transmasculine individuals, double-incision mastectomy with free nipple grafts is the most common procedure for gender-affirming chest masculinization. However, patients report decreased sensation postoperatively. Direct coaptation of intercostal nerves to the nipple-areolar complex (NAC) is an experimental technique that may preserve postoperative sensation, yet whether reimbursements and billing codes incentivize hospital systems and surgeons to offer this procedure lacks clarity. Methods A retrospective cross-sectional analysis of fiscal year 2023 Medicare physician fee schedule values was performed for neurotization procedures employing Current Procedural Terminology codes specified by prior studies for neurotization of the NAC. Additionally, operative times for gender-affirming mastectomy at a single center were examined to compare efficiency between procedures with and without neurotization included. Results A total of 29 encounters were included in the study, with 11 (37.9%) receiving neurotization. The mean operating time was 100.3 minutes (95% CI, 89.2-111.5) without neurotization and 154.2 minutes (95% CI, 139.9-168.4) with neurotization. In 2023, the average work relative value units (wRVUs) for neurotization procedures was 13.38. Efficiency for gender-affirming mastectomy was 0.23 wRVUs per minute without neurotization and 0.24 wRVUs per minute with neurotization, yielding a difference of 0.01 wRVUs per minute. Conclusions Neurotization of the NAC during double-incision mastectomy with free nipple grafts is an experimental technique that may improve patient sensation after surgery. Current reimbursement policy appropriately values the additional operative time associated with neurotization relative to gender-affirming mastectomy alone.
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Affiliation(s)
- Rishub K. Das
- From Division of Plastic and Reconstructive Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Katya Remy
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Justin C. McCarty
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Ian L. Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - William G. Austen
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Katherine H. Carruthers
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Siotos C, Underhill JM, Sykes J, Jones KB, Schechter L, Dorafshar AH, Hamidian Jahromi A. Trends of Medicare reimbursement rates for gender affirmation procedures. J Sex Med 2024; 21:181-191. [PMID: 38055925 DOI: 10.1093/jsxmed/qdad160] [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: 07/14/2023] [Revised: 08/28/2023] [Accepted: 10/24/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. AIM This article evaluates trends in Medicare reimbursement for gender affirmation procedures. METHODS The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. OUTCOME The main outcome was inflation-adjusted difference of charges from 2014 to 2021. RESULTS Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. CLINICAL IMPLICATIONS Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. STRENGTHS AND LIMITATIONS Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. CONCLUSIONS From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.
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Affiliation(s)
- Charalampos Siotos
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, United States
| | - Joshua M Underhill
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, United States
| | - Jennifer Sykes
- Division of Plastic and Reconstructive Surgery, Temple University Hospital, Philadelphia, PA 19140, United States
| | - Kody B Jones
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, United States
| | - Loren Schechter
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, United States
| | - Amir H Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL 60607, United States
| | - Alireza Hamidian Jahromi
- Division of Plastic and Reconstructive Surgery, Temple University Hospital, Philadelphia, PA 19140, United States
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Castaneda PR, Zaliznyak M, Sandhu SS, Cook-Wiens G, Smith SM, Mallavarapu S, Garcia MM. Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine. J Sex Med 2024; 21:175-180. [PMID: 38112322 DOI: 10.1093/jsxmed/qdad147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 10/06/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited. AIM To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth. METHODS There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model. OUTCOMES We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW). RESULTS TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models. CLINICAL IMPLICATIONS When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety. STRENGTHS AND LIMITATIONS To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions. CONCLUSION Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.
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Affiliation(s)
- Peris R Castaneda
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Michael Zaliznyak
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- School of Medicine, Saint Louis University, St Louis, MO 63104, United States
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA 90048, United States
| | - Sandeep S Sandhu
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA 90048, United States
| | - Galen Cook-Wiens
- Department of Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
| | - Shannon M Smith
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA 90048, United States
| | - Samhita Mallavarapu
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA 90048, United States
| | - Maurice M Garcia
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA 90048, United States
- Departments of Urology and Anatomy, University of California San Francisco, San Francisco, CA 94143, United States
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Rochlin DH, Lin W, Reitz RJ, Chen M, Buntic R, Watt A, Safa B. Phalloplasty Flap Salvage Using a Superficial Circumflex Iliac Artery Perforator Propeller Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5522. [PMID: 38288417 PMCID: PMC10817080 DOI: 10.1097/gox.0000000000005522] [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: 05/08/2023] [Accepted: 11/08/2023] [Indexed: 01/31/2024]
Abstract
Background Partial phalloplasty flap loss presents an evolving challenge, largely due to the complex demands required for both aesthetics and function. We describe our novel experience using the superficial circumflex iliac perforator (SCIP) propeller flap for neophallus salvage when skin grafting alone provides insufficient soft tissue bulk or coverage. Methods We retrospectively reviewed patients who underwent SCIP propeller flap reconstruction after phalloplasty partial flap loss. After suprafascial dissection, superficial circumflex iliac vessel perforator(s) were isolated toward the femoral origin. The flap was rotated 180 degrees and inset into the ventral or distal neophallus depending on the region of flap loss. If glans reconstruction was required, the flap was tubularized before inset. Division and inset were performed at a second stage, followed by subsequent glansplasty, urethral creation, and/or penile implant placement. Results SCIP propeller flap reconstruction was performed for four patients after one to six debridements at a mean of 6.5 (range 1.0-19.2) months following the initial phalloplasty. Three patients had lost the ventral phallus due to venous insufficiency, arterial insufficiency, and excessive postoperative swelling, respectively. The fourth patient experienced near-total loss of the glans following penile implant insertion. Division and inset was performed at an average of 7.5 (range 5.0-12.0) weeks after SCIP flap. There were no complications related to SCIP flap viability. Conclusion The SCIP propeller flap allows salvage of partial flap loss following phalloplasty by providing thin, pliable soft tissue bulk and skin coverage with minimal donor site morbidity, without the need for microsurgery, allowing progression with subsequent reconstructive stages.
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Affiliation(s)
- Danielle H. Rochlin
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, Calif
| | | | - Robert J. Reitz
- From the Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, Calif
| | - Mang Chen
- G.U. Recon Clinic, San Francisco, Calif
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Reeves K, Job S, Blackwell C, Sanchez K, Carter S, Taliaferro L. Provider cultural competence and humility in healthcare interactions with transgender and nonbinary young adults. J Nurs Scholarsh 2024; 56:18-30. [PMID: 38228567 DOI: 10.1111/jnu.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 02/27/2023] [Accepted: 04/19/2023] [Indexed: 01/18/2024]
Abstract
PURPOSE Transgender and nonbinary (TGNB) patients experience many barriers when seeking quality healthcare services, including ineffective communication and negative relationships with their providers as well as a lack of provider competence (including knowledge, training, and experience) and humility (engagement in the process of self-reflection and self-critique) in treating TGNB individuals. The purpose of this qualitative study was to identify factors associated with cultural competence and humility that facilitate and impede effective relationships between TGNB young adults and their healthcare providers. METHODS Data came from individual interviews with 60 young adults aged 18 to 24 from Florida who self-identified as transgender or nonbinary. We analyzed the data using inductive thematic approaches, and a feminist perspective, to identify themes associated with patient-provider relationships. CONCLUSIONS We identified 4 themes related to patient-provider relationships: (1) Participants indicated effective patient-provider communication and relationships are facilitated by providers requesting and utilizing TGNB patients' correct names and personal pronouns. (2) Participant narratives conveyed their preferences that providers "follow their lead" in terms of how they described their own anatomy, reinforcing the utility of cultural humility as an approach for interactions with TGNB patients (3) Participants discussed the detrimental effects of TGNB patients having to educate their own providers about their identities and needs, suggesting clinicians' competence regarding gender diversity is paramount to fostering and maintaining patient comfort. (4) Finally, participants' responses indicated concerns regarding the confidentiality and privacy of the information they provided to their providers, suggesting a lack of trust detrimental to the process of building rapport between patients and their providers. CLINICAL RELEVANCE Our findings indicate balancing the use of cultural humility and cultural competence during clinical encounters with TGNB young adults can enhance patients' experiences seeking healthcare. Nursing education is often devoid of focus on caring for transgender and nonbinary persons. Additional provider training and education on approaching clinical encounters with TGNB patients with cultural humility and competence should improve patient-provider communication and relationships, leading to a higher quality of patient care.
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Affiliation(s)
- Karli Reeves
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Sarah Job
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Christopher Blackwell
- Department of Nursing Practice, College of Nursing, University of Central Florida, Orlando, Florida, USA
| | - Kyle Sanchez
- College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Shannon Carter
- Department of Sociology, College of Sciences, University of Central Florida, Orlando, Florida, USA
| | - Lindsay Taliaferro
- Department of Population Health Sciences, College of Medicine, University of Central Florida, Orlando, Florida, USA
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Boonipat T, Sanchez Figueroa NG, Huang T, Martinez-Jorge J. The impact of chest contouring aesthetics outcomes: a pilot eye tracking study. Case Reports Plast Surg Hand Surg 2023; 11:2287027. [PMID: 38179208 PMCID: PMC10763852 DOI: 10.1080/23320885.2023.2287027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/13/2023] [Indexed: 01/06/2024]
Abstract
Eye-tracking technology was used to assess aesthetic surgical outcomes in transgender and gender diverse patients who are assigned female at birth and who seek gender affirming chest surgery. Post-surgery, observers focused more on scars than on the nipple-areolar complex. Ratings for similarity to cis-male chests significantly increased. This series highlights the objective evaluation of visual perception and masculinity assessments using eye-tracking.
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Affiliation(s)
- Thanapoom Boonipat
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Tony Huang
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jorys Martinez-Jorge
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
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29
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Rezaei SJ, Miranda N, Bene NC, Ganor O. The Current State of Transgender Health Curricula in Graduate Surgical Education: A Systematic Review of Survey Data. JOURNAL OF SURGICAL EDUCATION 2023; 80:1826-1835. [PMID: 37658003 DOI: 10.1016/j.jsurg.2023.08.007] [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: 03/08/2023] [Revised: 06/29/2023] [Accepted: 08/02/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES Transgender and gender diverse (TGD) individuals in the U.S. face significant healthcare disparities, which can be further exacerbated by providers' unfamiliarity with this population's specific needs. ACGME currently does not have requirements for gender-affirming surgery (GAS) in the residency programs of surgical specialties that are responsible for providing this care. This systematic review evaluates gender-affirming care (GAC) and GAS training in surgical residency programs in the U.S. through the analysis of survey respondent data. METHODS Six databases (PubMed, Embase, Web of Science and Scopus, Cochrane Library and Google Scholar) were searched in December 2022 and May 2023. The search process ultimately yielded 22 survey-based studies, published between 2015 and 2023, with responses from 3020 respondents (2582 trainees and/or attending physicians, 438 program directors). RESULTS Six different surgical specialties were the focus of included studies, and common questions revolved around GAS training availability, comfort in treating TGD patients, and the importance of GAS in graduate surgical education (GSE). Less than half of trainees indicated that they received some form of previous GAC or GAS training, and less than half of program directors indicated that their residency or fellowship program offered such training. CONCLUSIONS While comfort levels around treating TGD patients ranged, the studies indicated an overall perceived importance of GAS training. These findings highlight the need to incorporate GAS training into graduate surgical education to improve access to and quality of care for TGD patients.
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Affiliation(s)
- Shawheen J Rezaei
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; Stanford University School of Medicine, Stanford, California.
| | - Noah Miranda
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; UMass Chan Medical School, Worcester, Massachusetts
| | - Nicholas C Bene
- Division of Plastic Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Harvard Medical School, Boston, Massachusetts
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30
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Winayanuwattikun W, Vachiramon V, Rattananukrom T, Palakornkitti P, Sitpahul N. Efficacy of Botulinum Toxin Type A for Prevention of Post-Mastectomy Scar in Transmen: A Prospective, Randomized Study. Toxins (Basel) 2023; 15:636. [PMID: 37999499 PMCID: PMC10680993 DOI: 10.3390/toxins15110636] [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: 09/25/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Subcutaneous mastectomies in transmen have been gaining popularity. However, post-operative scars are an inevitable consequence. Recently, Botulinum neurotoxin A (BoNT-A) has shown positive effects in scar prevention. The objective of this study is to investigate the effectiveness of BoNT-A in scar prevention. METHODS Fifteen patients who had undergone subcutaneous mastectomy were included. At 14 days post-surgery, either incoBoNT-A or a placebo was injected into the scar on each side. The primary outcome assessment measured the scar's severity using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). The secondary outcome assessment evaluated the scar's color using a standard measurement device. Outcome assessments were conducted until 6 months post-surgery. RESULTS There were significantly lower VSS scores in the BoNT-A group compared to the placebo at the end of the study (7.43 ± 0.26 vs. 8.82 ± 0.26, p < 0.001). The objective assessment revealed a statistically significant decrease in redness values in the BoNT-A group compared to the placebo at 3 and 6 months. CONCLUSION BoNT-A has demonstrated effectiveness in scar prevention by reducing the severity of postoperative scar formation and improving overall scar appearance.
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Affiliation(s)
- Waranaree Winayanuwattikun
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (W.W.); (T.R.); (P.P.)
| | - Vasanop Vachiramon
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (W.W.); (T.R.); (P.P.)
| | - Teerapong Rattananukrom
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (W.W.); (T.R.); (P.P.)
| | - Pasita Palakornkitti
- Division of Dermatology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; (W.W.); (T.R.); (P.P.)
| | - Ngamcherd Sitpahul
- Department of Plastic and Maxillofacial Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
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Togioka BM, Harriman KA, Ye S, Berli J. Frequency and Characteristics of Postoperative Neuropathy in Individuals on Gender-Affirming Hormone Therapy Undergoing Gender Affirmation Surgery: A Retrospective Cohort Study. Cureus 2023; 15:e47988. [PMID: 38034215 PMCID: PMC10686520 DOI: 10.7759/cureus.47988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction Gender affirmation surgery includes procedures of the face, larynx, chest, reproductive system, external genitalia, and adipose tissue performed to ameliorate incongruence between gender identity and phenotype. The annual number of gender affirmation surgeries performed in the United States has increased significantly. There have been no investigations into the frequency of peripheral neuropathy after gender affirmation surgery, which is an important topic, given transgender individuals are at increased risk for delaying necessary medical care. After appreciating a number of cases of postoperative neuropathy in our clinical practice, we hypothesized that gender affirmation surgery is a high-risk procedure for postoperative neuropathy. Methods We conducted a one-year, monocentric, retrospective cohort study utilizing clinical data of individuals on gender-affirming hormone therapy undergoing gender-affirmation surgery under general anesthesia. The study included transgender women, assigned male at birth, receiving antiandrogen, progesterone, or estrogen therapy (target range plasma estradiol concentration 90-200 pg/ml) and transgender men, assigned female at birth, receiving antiestrogen or testosterone therapy (target range plasma testosterone concentration 320-1000 ng/dl). The primary objective was to estimate the incidence of postoperative peripheral neuropathy, defined as new numbness, paresthesia, neuropathic pain, or muscle weakness occurring in a peripheral innervation territory. Secondary objectives were to summarize the clinical presentation of neuropathy and investigate for associations between procedure characteristics and neuropathy. Results We identified nine cases of postoperative peripheral nerve injury in 232 consecutive gender affirmation procedures establishing an incidence of 3.9%. All injuries were associated with surgery longer than six hours and were characterized by sensory deficits including numbness 89% (8/9) and tingling 56% (5/9), which were diagnosed by postoperative day one. Conclusions Our results suggest that gender affirmation surgery is a high-risk procedure for postoperative neuropathy, with an incidence similar to other high-risk procedures, and an incidence that is higher than the general surgical population. However, given this has not been previously reported and our study includes a heterogenous population from a single institution, our results should be considered hypothesis generating. Additional studies that include multiple institutions are needed to confirm our findings and identify modifiable risk factors for postoperative neuropathy.
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Affiliation(s)
- Brandon M Togioka
- Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, USA
| | | | - Shangyuan Ye
- Biostatistics, Oregon Health & Science University, Portland, USA
| | - Jens Berli
- Plastic Surgery, Oregon Health & Science University, Portland, USA
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Aryanpour Z, Min-Tran D, Ghafoor E, Wojcik C, Peters BR. Are We Teaching Evidence-Based and Inclusive Practices in Gender-Affirming Care? Perspectives From Plastic Surgery In-Service Examinations. J Grad Med Educ 2023; 15:587-591. [PMID: 37781442 PMCID: PMC10539137 DOI: 10.4300/jgme-d-22-00611.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 04/03/2023] [Accepted: 07/05/2023] [Indexed: 10/03/2023] Open
Abstract
Background Resident physicians take annual in-service examinations (ISEs) as part of continuing medical education, which set educational priorities, allow for formative feedback, and guide preparation for final board examinations. Gender-affirming care is provided in many specialties but has been an underrepresented area in medical education. Plastic surgeons provide a large portion of gender-affirming surgical care. Educational gaps in standardized ISEs may contribute to ongoing health care disparities for transgender and gender diverse people. Objective To evaluate the quality of content pertaining to gender-affirming surgery (GAS) on plastic surgery ISEs. Methods Plastic surgery ISEs from years 2012 to 2020 were accessed online through the American Council of Academic Plastic Surgeons website in June 2022. All 5 gender diverse authors analyzed examinations for the presence of GAS questions; identified questions were analyzed for quantity, organization based on content category, affirming language, and accuracy against current guidelines. Results Of 1959 ISE questions available for review, 11 GAS questions were identified for a total frequency of 0.56%. Most GAS questions (6 of 11, 55%) were miscategorized. Inappropriate language, including misgendering of patients, occurred in 7 of 11 (64%) questions. No questions discussed GAS beyond chest or genital surgery, or common variations of these procedures. Transgender identities were represented as only binary, with no mention of nonbinary or gender-fluid individuals. Conclusions Our study illustrates that there are significant gaps in educational content pertaining to gender-affirming care on plastic surgery ISEs.
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Affiliation(s)
- Zain Aryanpour
- Zain Aryanpour, MD, is a PGY-2 Resident, Department of Surgery, University of Colorado, Anschutz Medical Campus
| | - Dominic Min-Tran
- Dominic Min-Tran, BS, is a Fourth-Year Medical Student, University of Washington School of Medicine
| | - Essie Ghafoor
- Essie Ghafoor, BS, is a Fourth-Year Medical Student, University of Illinois at Chicago School of Medicine
| | - Christopher Wojcik
- Christopher Wojcik, DO, is a PGY-2 Resident, Department of Surgery, University of Colorado, Anschutz Medical Campus; and
| | - Blair R. Peters
- Blair R. Peters, MD, is Assistant Professor, Division of Plastic & Reconstructive Surgery, Department of Surgery, and Department of Urology, Oregon Health & Science University
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Colman DE, Beltran TG, Weber JM, Erkanli A, Robinson WR, Myers ER, Gray BA. Patient and Surgery Characteristics of Inpatient Hysterectomies Among Transgender Individuals. LGBT Health 2023; 10:544-551. [PMID: 37252769 PMCID: PMC10574525 DOI: 10.1089/lgbt.2022.0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Purpose: The purpose of this study is to estimate population-based rates of inpatient hysterectomy and accompanying bilateral salpingo-oophorectomy by indication and evaluate surgical patient characteristics by indication, year, patient age, and hospital location. Methods: We used 2016 and 2017 cross-sectional data from the Nationwide Inpatient Sample to estimate the hysterectomy rate for individuals aged 18-54 years with a primary indication for gender-affirming care (GAC) compared to other indications. Outcome measures were population-based rates for inpatient hysterectomy and bilateral salpingo-oophorectomy by indication. Results: The population-based rate of inpatient hysterectomy for GAC per 100,000 was 0.05 (95% confidence interval [CI] = 0.02-0.09) in 2016 and 0.09 (95% CI = 0.03-0.15) in 2017. For comparison, the rates per 100,000 for fibroids were 85.76 in 2016 and 73.25 in 2017. Rates of bilateral salpingo-oophorectomy in the setting of hysterectomy were higher in the GAC group (86.4%) than in comparison groups (22.7%-44.1% for all other benign indications, 77.4% for cancer) across all age ranges. A higher rate of hysterectomies performed for GAC was done laparoscopically or robotically (63.6%) than other indications, and none was done vaginally, as opposed to comparison groups (0.7%-9.8%). Conclusion: The population-based rate for GAC was higher in 2017 compared to 2016 and low compared to other hysterectomy indications. Rates of concomitant bilateral salpingo-oophorectomy were more prevalent for GAC than for other indications at similar ages. The patients in the GAC group tended to be younger, insured, and most procedures occurred in the Northeast (45.5%) and West (36.4%).
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Affiliation(s)
- Drew E. Colman
- Department of Combined Internal Medicine and Pediatrics, Los Angeles County+University of Southern California Medical Center, Los Angeles, California, USA
| | - Theo G. Beltran
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jeremy M. Weber
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Alaattin Erkanli
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Whitney R. Robinson
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Evan R. Myers
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Beverly A. Gray
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
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Hassan B, Zeitouni F, Ascha M, Sanders R, Liang F. Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors. Cureus 2023; 15:e45948. [PMID: 37885491 PMCID: PMC10599689 DOI: 10.7759/cureus.45948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors. METHODS We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years. RESULTS A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each). CONCLUSIONS AND RELEVANCE GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.
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Affiliation(s)
- Bashar Hassan
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Ferris Zeitouni
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, USA
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Mona Ascha
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Renata Sanders
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
| | - Fan Liang
- Center for Transgender and Gender Expansive Health, Johns Hopkins University, Baltimore, USA
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Wang F, Cheng T, Chemakin K, Rothchild E, Ricci JA. TransTok - An analysis of surgical gender affirmation content on TikTok. J Plast Reconstr Aesthet Surg 2023; 84:214-222. [PMID: 37339546 DOI: 10.1016/j.bjps.2023.05.038] [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: 01/24/2023] [Accepted: 05/15/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE Social media platforms are popular sources of medical information but may harbor harmful misinformation. This study aims to evaluate the effect of TikTok on the transgender population, which may be more likely to seek information from non-traditional sources because of high medical mistrust. METHODS Twenty gender affirmation related hashtags were queried, with the top 25 videos per hashtag included for analysis. Videos were categorized based on the content and creator. Variables included likes, comments, shares, and video views. All "educational" videos were analyzed for reliability of information using a modified DISCERN (mDISCERN) score and the Patient Education Materials Assessment Tool (PMAT). Kruskal-Wallis H tests, Mann-Whitney U tests, and simple linear regression models were used in analysis. RESULTS A total of 429 videos amassed 571,434,231 views, 108,050,498 likes, 2,151,572 comments, and 190,9744 shares. Patients were the majority of content creators (74.88%), with patient experiences being the majority of videos (36.07%). Non-physician creators had significantly higher likes and comments when compared to physicians (6185 vs. 1645, p = 0.028; 108 vs. 47, p = 0.016 respectively). Sixty "educational" videos were included in information reliability analysis. There were no significant differences between video characteristics of different content creators, even after stratifying according to physician status. Significant differences were observed in the reliability of information according to PMAT and mDISCERN scores, with physician created videos being significantly higher rated than non-physician created videos (0.90 vs. 0.84, p < 0.001; 3 vs. 2, p < 0.001, respectively). CONCLUSION Lower quality information is associated with non-physician content creators. We encourage physicians to be continuously involved in creating quality information on TikTok.
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Affiliation(s)
- Fei Wang
- The Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Tiffany Cheng
- The Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Katherine Chemakin
- The Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Evan Rothchild
- The Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Joseph A Ricci
- The Department of Surgery, Division of Plastic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA.
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Batur AF, Sun H, Pope R, Banik S, Mishra K, Gupta S. A comprehensive analysis of YouTube videos on gender affirmation surgery. Int Urogynecol J 2023; 34:2275-2283. [PMID: 37103618 DOI: 10.1007/s00192-023-05542-0] [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: 02/02/2023] [Accepted: 03/26/2023] [Indexed: 04/28/2023]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to comprehensively analyze YouTube™ videos focusing on genital gender-affirmation surgery (GAS) from the perspective of urologists and gynecologists and to utilize results to create educational videos for transgender individuals with accurate and engaging content. METHODS A YouTube search was performed using the keywords "Metoidioplasty," "Phalloplasty," "Gender affirmation surgery," "Transgender surgery," "Vaginoplasty," and "Male-to-female surgery." Video results that were duplicated, non-English, of low relevance, non-audio, and/or short duration (under 2 min) were excluded. The upload source was classified as university/nonprofit physician or organization, health information websites, medical advertisement/for-profit organizations, or individual patient experience. Viewer engagement metrics were obtained for each video. Each video was evaluated using the DISCERN, Global Quality Score (GQS), and Patient Education Materials Assessment Tool for audio-visual content (PEMAT A-V) tools. RESULTS A total of 273 videos were evaluated. Viewer engagement metrics of videos from the patient experience group were higher than those of both universities/nonprofit physicians and medical advertisement/for-profit groups. DISCERN and GQS scores were significantly lower in videos uploaded by the patient experience group than in each of the other upload sources. More videos covered female-to-male (FtM) transition (168, 61.5%) than covered male-to-female (MtF; 71, 26.0%), and both (34, 12.5%). MtF transition videos had significantly higher total view counts than videos from the other groups (p<0.001). The like counts of videos were significantly higher in both MtF transition and FtM transition groups than for videos explaining both types of transition within the same video. The total DISCERN score was significantly lower in FtM transition videos than in the other content groups. Two educational videos were prepared, informed by the tools and results of this study, and hosted on YouTube. CONCLUSIONS The findings suggest that genital GAS videos with less technical content have higher audience engagement. This information should be used to aid medical organizations when creating YouTube content to provide accurate information to larger audiences in the transgender community.
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Affiliation(s)
- Ali Furkan Batur
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA.
- Department of Urology, Selcuk University School of Medicine, Konya, Turkey.
| | - Helen Sun
- Urology Institute, Case Western Reserve University/University Hospitals Cleveland, Cleveland, OH, USA
| | - Rachel Pope
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Swagata Banik
- Department of Public Health and Prevention Science, School of Health Sciences, Baldwin Wallace University, Berea, OH, USA
| | - Kirtishri Mishra
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA
| | - Shubham Gupta
- Urology Institute, University Hospitals Cleveland Medical Center, 11100 Euclid Avenue, Cleveland, OH, USA
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Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National Estimates of Gender-Affirming Surgery in the US. JAMA Netw Open 2023; 6:e2330348. [PMID: 37610753 PMCID: PMC10448302 DOI: 10.1001/jamanetworkopen.2023.30348] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/15/2023] [Indexed: 08/24/2023] Open
Abstract
Importance While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited. Objective To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups. Design, Setting, and Participants This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified. Main Outcome Measures Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed. Results A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients. Conclusions and Relevance Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.
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Affiliation(s)
- Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Yukio Suzuki
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Koji Matsuo
- Department of Obstetrics and Gynecology, University of Southern California, Los Angeles
| | - Dawn L. Hershman
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
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Price R, Debryn D, Mukerji S, Nozari A, Spiegel JH, Kim E. No Thromboembolic Complications After Facial Feminization Surgery in Transgender Patients Utilizing Estrogen Therapy: A Retrospective Cohort Study. Transgend Health 2023; 8:344-351. [PMID: 37525836 PMCID: PMC10387159 DOI: 10.1089/trgh.2021.0170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Estrogen therapy is associated with an increased risk of venous thromboembolism (VTE). A large proportion of transfeminine patients use estrogen therapy before undergoing gender-affirming surgery. Many surgeons implement the discontinuation of hormone therapy before surgery. This study sought to evaluate the perioperative risk of VTE in transfeminine patients undergoing the procedure of facial feminization. Methods Retrospective chart reviews were performed of all patients who underwent facial feminization by a single surgeon at an urban academic institution from 2014 to 2020. Patient characteristics including comorbidities, Caprini score, VTE chemoprophylaxis, and perioperative hormone therapy management were reviewed. The incidences of VTE during perioperative hospital stay and within 1 week and 6 months after the surgical procedure were examined. Results There were 296 facial feminization procedures performed on 282 distinct patients who met criteria for inclusion in the study. Hormone therapy was prescribed to 83.6% of patients, 69.5% of whom reported that they held these medications before the procedure. Of those holding, 84.1% of patients reported they discontinued these medications between 2 and 4 weeks. No patients received VTE chemoprophylaxis. There were 0 VTE incidents during the patients' perioperative period up to 6 months postprocedure. Conclusion Our findings support that transfeminine patients who use estrogen hormone therapy are at a minimal risk to experience VTE when undergoing facial feminization procedures. Future directions include evaluating the psychologic effect of discontinuing hormone therapy to help guide perioperative decision making.
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Affiliation(s)
- Ryan Price
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Deen Debryn
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Shivali Mukerji
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Ala Nozari
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Jeffrey H. Spiegel
- Department of Otolaryngology—Head and Neck Surgery, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Eugene Kim
- Department of Anesthesiology, Boston Medical Center, Boston, Massachusetts, USA
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Jolly D, Boskey ER, Ganor O. Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries. Ann Surg 2023; 278:e196-e202. [PMID: 35762604 DOI: 10.1097/sla.0000000000005512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries. BACKGROUND Little is currently known about how race may affect the outcomes of gender-affirming surgeries. METHODS We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression. RESULTS There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers. CONCLUSIONS Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries.
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Affiliation(s)
- Divya Jolly
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
| | - Elizabeth R Boskey
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, MA
- Department of Surgery, Harvard Medical School, Boston, MA
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Song S, Kim EA. Double-incision mastectomy after reduction mammaplasty for persistent gender dysphoria: a case report. Case Reports Plast Surg Hand Surg 2023; 10:2222826. [PMID: 37351526 PMCID: PMC10283411 DOI: 10.1080/23320885.2023.2222826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 06/03/2023] [Indexed: 06/24/2023]
Abstract
Most patients undergo just one type of gender-affirming top surgery, but some will have a double-incision mastectomy after reduction mammaplasty. We describe a 46-year-old transgender man who requested a flatter chest after undergoing reduction mammoplasty the previous year. We also provide three considerations to guide surgical decision-making in this situation.
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Affiliation(s)
- Siyou Song
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Esther A. Kim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
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Seay K, Shih K, Kredentser A, Wu D, Schmidt E. Endometrial cancer in a transgender male: A rare case and review of the literature. Gynecol Oncol Rep 2023; 47:101199. [PMID: 37251786 PMCID: PMC10209109 DOI: 10.1016/j.gore.2023.101199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Endometrial cancer is the most common gynecological malignancy in the United States. Despite the high prevalence amongst cisgender females the prevalence of this gynecological malignancy in transgender men has not been clearly identified. To date, only four reported cases have been described in the literature. Case A 36-year-old nulliparous assigned female at birth, transgender premenopausal male underwent a laparoscopic total hysterectomy, bilateral salpingo-oophorectomy, sentinel lymph node mapping and omental biopsy after having an endometrial biopsy that demonstrated well differential endometroid adenocarcinoma. He had been on testosterone therapy for at least five years prior to presenting to his gynecologist with the chief complaint of vaginal bleeding. Final pathology showed FIGO Stage 1A endometroid endometrial carcinoma. Conclusion This case report adds to the body of literature demonstrating that transgender men can develop endometrial carcinoma while on exogenous testosterone therapy. In addition, this report illustrates the importance of routine gynecological care in the transgender patient population.
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Affiliation(s)
- Kieran Seay
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, United States
| | - Karin Shih
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, United States
| | - Ariel Kredentser
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, United States
| | - Dongling Wu
- Pathology and Laboratory Medicine, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, United States
| | - Elizabeth Schmidt
- Division of Family Planning, Department of Obstetrics and Gynecology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Long Island, NY, United States
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Ho I, Raymer C, Isakov R. A novel and easily reproducible technique for determining nipple placement in chest masculinization surgery. J Plast Reconstr Aesthet Surg 2023; 83:358-360. [PMID: 37302241 DOI: 10.1016/j.bjps.2023.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/10/2023] [Accepted: 05/25/2023] [Indexed: 06/13/2023]
Affiliation(s)
- Isabel Ho
- Department of Plastic Surgery, Cleveland Clinic Foundation, United States of America; Case Western Reserve University School of Medicine, United States of America.
| | - Charles Raymer
- Department of Plastic Surgery, Cleveland Clinic Foundation, United States of America
| | - Raymond Isakov
- Department of Plastic Surgery, Cleveland Clinic Foundation, United States of America
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Saxena N, Jolly D, Wu CA, Boskey ER, Ganor O. Comparing Scrotoplasty Complication Rates in Transgender and Cisgender Men: An ACS NSQIP Study. JPRAS Open 2023; 36:55-61. [PMID: 37139354 PMCID: PMC10149324 DOI: 10.1016/j.jpra.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older (M trans = 38 years (SD:14), M cis = 53 years (SD: 15)) and had higher BMI than the transgender cohort (M trans = 26.9 (SD: 5.5), M cis = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health (p = 0.001), and were more likely to have hypertension (p = 0.001) and diabetes (p = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time (M trans = 303 min (SD: 155), M cis = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty (p = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender patients.
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Schoenbrunner A, Beckmeyer A, Kunnath N, Ibrahim A, Pawlik TM, Venkataramani A, Kuzon WM, Diaz A. Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery. JAMA 2023; 329:819-826. [PMID: 36917051 PMCID: PMC10015311 DOI: 10.1001/jama.2023.0878] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/03/2023] [Indexed: 03/15/2023]
Abstract
Importance Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.
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Affiliation(s)
- Anna Schoenbrunner
- Department of Plastic and Reconstructive Surgery, The Ohio State University, Columbus
| | | | - Nicholas Kunnath
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
| | - Andrew Ibrahim
- Department of Surgery, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Taubman College of Architecture and Urban Planning, University of Michigan, Ann Arbor
| | | | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia
- Opportunity for Health Labs, University of Pennsylvania, Philadelphia
| | | | - Adrian Diaz
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Department of Surgery, The Ohio State University, Columbus
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Gender Affirming Mastectomy Improves Quality of Life in Transmasculine Patients: A Single-center Prospective Study. Ann Surg 2023; 277:e725-e729. [PMID: 34387203 DOI: 10.1097/sla.0000000000005158] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the impact of gender-affirming mastectomy on depression, anxiety, and body image. BACKGROUND There are many cross-sectional and ad-hoc studies demonstrating the benefits of gender-affirming surgery. There are few prospective investigations of patient-reported outcomes in gender-affirming surgery using validated instruments. METHODS In this prospective study, patients presenting to the University of Michigan for gender-affirming Mastectomy were surveyed preoperatively and 6-months postoperatively. Primary outcomes were patient-reported measurements of anxiety measured by General Anxiety Disorder-7, depression measured by Patient Health Questionnaire-9, body image measured by BODY-Q and Body Image Quality of Life Index, psychosocial and sexual functioning measured by BREAST-Q, and satisfaction with decision measured by BREAST-Q. Linear regression analysis was used to control for presence of complication and existing history of mental health conditions. RESULTS A total of 70 patients completed the study. The average age of participants was 26.7. The mean Patient Health Questionnaire-9 score pre-operatively was 7.8 and postoperatively was 5.4 ( P =0.001). The mean preoperative and postoperative General Anxiety Disorder-7 scores were 7.6 and 4.6, respectively ( P <0.001). There were significant improvements in both psychosocial (35 to 79.2, P <0.001) and sexual (33.9 to 67.2, P< 0.001) functioning related to chest appearance as measured by the BREAST-Q and global psychosocial functioning (-15.6 to +32, P <0.001) as measured by the Body Image Quality of Life Index. Satisfaction with chest contour (14.3 to 93.8, P <0.001) and nipple appearance (29.3 to 85.9, P <0.001) measured by the BODY-Q significantly improved. Patients had a mean satisfaction with outcome score of 93.1. CONCLUSIONS Patients undergoing gender-affirming mastectomy in this single-center prospective study reported significant improvements in anxiety, depression, body image, psychosocial, and sexual functioning after this procedure. Patients were extremely satisfied with the decision to undergo this operation.
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Villavisanis DF, Morales CZ, Blum JD, Llado-Farrulla M, Cho DY, Taylor JA, Losee JE. Lesbian, Gay, Bisexual, Transgender, and Queer Diversity and Inclusion in Plastic and Reconstructive Surgery: Taking "Pride" in Patient Care. Ann Plast Surg 2023; 90:113. [PMID: 36688852 DOI: 10.1097/sap.0000000000003366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jessica D Blum
- From the Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia
| | - Monica Llado-Farrulla
- Division of Plastic and Reconstructive Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Daniel Y Cho
- From the Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia
| | | | - Joseph E Losee
- Department of Plastic Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
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Iv Kyrazis CB, Stein EB, Carroll EF, Crissman HP, Kirkpatrick DL, Wasnik AP, Zavaletta V, Maturen KE. Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations. Radiographics 2023; 43:e220124. [PMID: 36602923 DOI: 10.1148/rg.220124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
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Affiliation(s)
- Crysta B Iv Kyrazis
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Erica B Stein
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Evelyn F Carroll
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Halley P Crissman
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Daniel L Kirkpatrick
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Ashish P Wasnik
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Vaz Zavaletta
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Katherine E Maturen
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
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Kaur MN, Gallo L, Wang Y, Rae C, McEvenue G, Semple J, Johnson N, Savard K, Pusic AL, Coon D, Klassen AF. Health State Utility Values in Patients Undergoing Chest Masculinization Surgery. J Plast Reconstr Aesthet Surg 2023; 81:26-33. [PMID: 37068381 DOI: 10.1016/j.bjps.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 01/18/2023] [Accepted: 02/03/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively. METHODS Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed. RESULTS A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01). CONCLUSION Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.
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Affiliation(s)
- Manraj N Kaur
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis S, Boston, MA 02116, USA.
| | - Lucas Gallo
- Department of Surgery, Division of Plastic Surgery, McMaster University, 1280 Main Street W, Hamilton, ON, Canada L8N 3Z5
| | - Yi Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street W, Hamilton, ON, Canada L8N 3Z5
| | - Charlene Rae
- Department of Pediatrics, McMaster University, 3N27, 1280 Main Street W, Hamilton, ON, Canada L8N 3Z5
| | - Giancarlo McEvenue
- Doctor Giancarlo Plastic Surgery Clinic, 4600 Linton Blvd, Suite 310, Delray Beach, FL 33445, USA
| | - John Semple
- Division of Plastic Surgery, Women's College Hospital, 76 Grenville St, Toronto, ON, Canada M5S 1B2
| | - Natasha Johnson
- Department of Pediatrics, McMaster University, 3N27, 1280 Main Street W, Hamilton, ON, Canada L8N 3Z5
| | - Kinusan Savard
- Fleming College, 599 Brealey Dr, Peterborough, ON, Canada K9J 7B1
| | - Andrea L Pusic
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis S, Boston, MA 02116, USA
| | - Devin Coon
- Brigham and Women's Hospital, Harvard Medical School, 75 Francis S, Boston, MA 02116, USA
| | - Anne F Klassen
- Department of Pediatrics, McMaster University, 3N27, 1280 Main Street W, Hamilton, ON, Canada L8N 3Z5
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Mishra K, Ferrando CA. Postoperative adverse events following gender-affirming vaginoplasty: an American College of Surgeons National Surgical Quality Improvement Program study. Am J Obstet Gynecol 2023; 228:564.e1-564.e8. [PMID: 36669553 DOI: 10.1016/j.ajog.2023.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND As a part of gender-affirming care, many transgender women undergo vaginoplasty surgery, which is increasingly being performed in the United States. There are considerable knowledge gaps about adverse events associated with vaginoplasty as most published articles report single-center results. OBJECTIVE This study aimed to describe severe and overall 30-day adverse events after gender-affirming vaginoplasty using a large multicenter database. STUDY DESIGN This was a retrospective cohort study of transgender women who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and procedure codes for male-to-female vaginoplasty. Adverse events at 30 days were identified, including unplanned reoperation or readmission, blood transfusion, wound dehiscence, surgical site infections, thromboembolic disease, sepsis, cerebrovascular or cardiac events, and urinary tract infection. Surgical procedures were further stratified by Clavien-Dindo grade, a standardized classification system for registering surgical complications. A score of 0 is given if there is no adverse event, whereas scores of 1 and 2 refer to deviations from the normal postoperative course, which may include additional pharmacologic treatment, bedside-managed wound complications, and blood transfusions. Clavien-Dindo grades of 3 to 4 include surgical interventions or life-threatening complications requiring intensive care unit management. A Clavien-Dindo grade of 5 is given for any complication resulting in death. RESULTS A total of 488 cases were eligible for inclusion in this study. The mean age of the cohort was 37.5 years, and race distribution was as follows: 71.1% White, 15.2% Black, 5.5% Asian or Pacific Islander, and 8.2% other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent nongenital surgery was performed in 17% of cases. The median operative time for all cases was 271 minutes (interquartile range, 214-344). There was no reported death in the 30-day period (Clavien-Dindo grade 5), and 27 cases (5.5%) had a Clavien-Dindo grade of 3 to 4. On multivariate analysis, body mass index and higher American Society of Anesthesiologists class were associated with higher odds of having a Clavien-Dindo grade of 3 to 4 (adjusted odds ratios, 2.9 [95% confidence interval, 1.32-4.21; P=.01] and 1.23 [95% confidence interval, 0.56-2.57; P=.05], respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 46 cases (9.0%). The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: body mass index (adjusted odds ratio, 9.81; 95% confidence interval, 1.77-22.13; P=.005), higher American Society of Anesthesiologists class (adjusted odds ratio, 3.23; 95% confidence interval, 1.23-9.03; P=.003), diabetes mellitus (adjusted odds ratio, 5.39; 95% confidence interval, 1.42-20.45; P=.006), and hypertension (adjusted odds ratio, 3.63; 95% confidence interval, 1.26-10.47; P=.01). The reoperation rate was 4.7% (n=23), with no significant patient factor associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma. CONCLUSION In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications were rare, occurring in 1 of 20 patients. Most patients experienced minor complications or no complication after surgery.
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Affiliation(s)
- Kavita Mishra
- Department of Obstetrics and Gynecology, Stanford Pelvic Health Center, Stanford University School of Medicine, Palo Alto, CA.
| | - Cecile A Ferrando
- Cleveland Clinic, Center for Urogynecology and Pelvic Reconstructive Surgery, Women's Health Institute, Cleveland, OH
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Song JY, Patel Y. Evaluation of Post-Menopausal Bleeding in Two Patients with Sigmoid Neovaginoplasty. CRSLS : MIS CASE REPORTS FROM SLS 2023; 9:JSLS.2022.00068. [PMID: 36712180 PMCID: PMC9840202 DOI: 10.4293/crsls.2022.00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Introduction Mayer-Rokitansky-Kuster-Hauser syndrome or vaginal agenesis, is the rare congenital absence of the vagina with varying degree of hypoplasia of the Mullerian duct system and uterine development. One of the reconstructive surgical options for a vaginoplasty involves the usage of the large bowel. Case Description We report two cases of patients who have had a sigmoid neovaginoplasty presenting many years later with postmenopausal bleeding. Discussion The authors describe the evaluation that can be performed by the gynecologist and gastroenterologist to initiate the work-up for this rare presentation.
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Affiliation(s)
- Jonathan Y. Song
- Department of Obstetrics and Gynecology, Division of Minimally Invasive Gynecologic Surgery, Northwestern Medicine Delnor Hospital, Geneva IL
| | - Yogesh Patel
- Department of Internal Medicine, Division of Gastroenterology Northwestern Medicine Delnor Hospital, Geneva IL
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