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Origins of Gender Affirmation Surgery: The History of the First Gender Identity Clinic in the United States at Johns Hopkins
Abstract
Background:
Gender-affirming care, including surgery, has gained more attention recently as third-party payers increasingly recognize that care to address gender dysphoria is medically necessary. As more patients are covered by insurance, they become able to access care, and transgender cultural competence is becoming recognized as a consideration for health care providers. A growing number of academic medical institutions are beginning to offer focused gender-affirming medical and surgical care. In 2017, Johns Hopkins Medicine launched its new Center for Transgender Health. In this context, history and its lessons are important to consider. We sought to evaluate the operation of the first multidisciplinary Gender Identity Clinic in the United States at the Johns Hopkins Hospital, which helped pioneer what was then called "sex reassignment surgery."
Methods:
We evaluated the records of the medical archives of the Johns Hopkins University.
Results:
We report data on the beginning, aim, process, outcomes of the clinic, and the reasons behind its closure. This work reveals the function of, and the successes and challenges faced by, this pioneering clinic based on the official records of the hospital and mail correspondence among the founders of the clinic.
Conclusion:
This is the first study that highlights the role of the Gender Identity Clinic in establishing gender affirmation surgery and reveals the reasons of its closure.
... Subsequently, dedicated centers for trans medical and surgical care began to emerge in the 1950s. 9 These centers employed onerous invasive approaches to gender-affirming care, which would today be described as gatekeeping; one early leader in genderaffirming surgical care had nearly 1200 applications for gender-affirming surgeries, but only performed 23 (7 transgender women and 16 transgender men) between 1966 and 1972. 9 This approach to surgical care was evaluated by measuring the ''job, educational, marital, and domiciliary stability'' of trans persons who had received surgery and reportedly found no ''objective advantage in terms of social rehabilitation.'' ...
... 9 These centers employed onerous invasive approaches to gender-affirming care, which would today be described as gatekeeping; one early leader in genderaffirming surgical care had nearly 1200 applications for gender-affirming surgeries, but only performed 23 (7 transgender women and 16 transgender men) between 1966 and 1972. 9 This approach to surgical care was evaluated by measuring the ''job, educational, marital, and domiciliary stability'' of trans persons who had received surgery and reportedly found no ''objective advantage in terms of social rehabilitation.'' 10 Beyond inappropriate research methodologies, 9 researchers failed to acknowledge the role of systemic discrimination and gender nonaffirmation on the well-being of trans persons. ...
... 9 This approach to surgical care was evaluated by measuring the ''job, educational, marital, and domiciliary stability'' of trans persons who had received surgery and reportedly found no ''objective advantage in terms of social rehabilitation.'' 10 Beyond inappropriate research methodologies, 9 researchers failed to acknowledge the role of systemic discrimination and gender nonaffirmation on the well-being of trans persons. Instead, researchers focused on ''social rehabilitation'' that centers cisgender identities as the ideal and only valid gender experience. ...
To advance the fields of transgender health research and clinical care and center trans-led scholarship, there must be an acknowledgment of the consolidated power in cisgender hands and the subsequent need to redistribute such power to trans experts and burgeoning trans leaders. To redress the social structures that cause harm and limit opportunities for trans persons to lead, current cisgender leaders can take actions including deferring opportunities to trans persons to ensure a redistribution of power and resources to trans experts. This article presents necessary steps to recruit, collaborate, and elevate trans experts.
... Influenced by Dr. Benjamin Harris' "The Transsexual Phenomenon" [33], Johns Hopkins Hospital in Baltimore became the first academic institution in the USA to offer gender-affirming surgery [36]. Soon after, at least another 8 academic institutions opened transgender programs throughout the 1960-1970s (University of Minnesota, University of Washington, Northwestern/Cook County Health in Chicago, Stanford University, Cleveland Clinic, University of Colorado, Baptist Medical Center in Oklahoma City, and Washington University in St. Louis) [37]. ...
... Under his leadership, another Johns Hopkins psychiatrist, Dr. Jon Meyer, published a study of 50 patients which concluded that gender-affirming surgery did not provide "objective" benefit for transgender individuals [39]. This publication led to the sudden closure of the clinic in 1979 [36]. Interestingly, John Money, who believed that gender could be learned and who co-founded the Johns Hopkins gender clinic, publicly expressed opposition to Meyer's conclusions of his study [36]. ...
... This publication led to the sudden closure of the clinic in 1979 [36]. Interestingly, John Money, who believed that gender could be learned and who co-founded the Johns Hopkins gender clinic, publicly expressed opposition to Meyer's conclusions of his study [36]. ...
While individuals have demonstrated gender diversity throughout history, the use of medication and/or surgery to bring a person's physical sex characteristics into alignment with their gender identity is relatively recent, with origins in the first half of the 20th century. Adolescent gender-affirming care, however, did not emerge until the late 20th century and has been built upon pioneering work from the Netherlands, first published in 1998. Since that time, evolving protocols for gender-diverse adolescents have been incorporated into clinical practice guidelines and standards of care published by the Endocrine Society and World Professional Association for Transgender Health, respectively, and have been endorsed by major medical and mental health professional societies around the world. In addition, in recent decades, evidence has continued to emerge supporting the concept that gender identity is not simply a psychosocial construct but likely reflects a complex interplay of biological, environmental, and cultural factors. Notably, however, while there has been increased acceptance of gender diversity in some parts of the world, transgender adolescents and those who provide them with gender-affirming medical care, particularly in the USA, have been caught in the crosshairs of a culture war, with the risk of preventing access to care that published studies have indicated may be lifesaving. Despite such challenges and barriers to care, currently available evidence supports the benefits of an interdisciplinary model of gender-affirming medical care for transgender/gender-diverse adolescents. Further long-term safety and efficacy studies are needed to optimize such care.
... In 1966, John Hopkins University Hospital in Baltimore created the Gender Identity Clinic, the first gender-affirming care clinic in the United States (Siotos et al., 2019). Across the United States, health centers specifically designed for ...
... LGBTQIA2þ people continue to provide this specialized care (Siotos et al., 2019). Although many of these centers challenge the status quo in sexual and reproductive health care, a lack of trust and safety in care settings increases the likelihood that patients will conceal information from providers such as sexual orientation, gender identity, family and support systems, and relevant physical and mental health information or that they will avoid seeking health care altogether (Besse et al., 2020;Richardson et al., 2019). ...
... As of 2020, individuals who identify as transgender and gender diverse (TGD) have higher rates of being uninsured, 14%-19% when compared to the general population, 11%-17% [6,7]. While 30 states have detailed explicit coverage for transgender and gender non-binary (TGNB) people as of 2021, only 18 of these states provide coverage for GAS, with 13 states denying such coverage [8]. Therefore, it becomes imperative for plastic surgeons to be cognizant of the insurance coverage for procedures that fall under the umbrella of GAS. ...
... However, decisions on policy coverage are decided on a local level, and, as a result, coverage varies by state for GAS. A 2021 policy review by Gorbea et al. found that of the 50 states in the United States, only 30 addressed transgender non-binary people in their policies [8]. Despite inconsistent national coverage by Medicaid nationally, patients insured by CMS were more likely to have GAS than patients with other insurance plans [18,28]. ...
Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.
... The programs were highly selective, accepting only 1.2% of requests, 8.11 and had arduous requirements. 5,11 For instance, patients were required to be heterosexual and had to produce independent evidence of their cross-gender behavior. 11 Many TGNB people learned to ...
... 5,11 For instance, patients were required to be heterosexual and had to produce independent evidence of their cross-gender behavior. 11 Many TGNB people learned to ...
Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth, based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in The Standards of Care; international guidelines that help inform clinical decision-making. Historically, mental healthcare professionals (MHPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as our understanding of gender identity evolves, so does the relationship between the MHP and the surgeon. The role of the MHP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and their healthcare team. This article discusses the evolution of the relationship between the MHP and surgeon as well as providing insight into the history of this relationship.
... The rate of transgender individuals in the US population is estimated as 0.6%. 1 The first gender identity clinic in the United States was established at John Hopkins Hospital in 1966. 2 The number of persons seeking gender-affirming procedures (previously called "sex reassignment surgery") has increased dramatically since. 3 Transgender men have been reported to be twice as likely to seek gender-affirming surgery as transgender women, and subcutaneous mastectomy is generally the first surgery opted by transgender men. ...
... According to the proposed system, for each of the four classifications (I, IIa, IIb, III), a different minimal operation is possible: periareolar, nipple-areola complex on scar [Omega], spindle-shaped mastectomy with nipple-areola complex dermal flap, and complete mastectomy with free nipple-areola complex graft (Figs. [1][2][3][4]. We suggest that when the expected breast tissue size does not correspond with the excess of skin, the surgeon should rethink the type of operation and consider the given dimensions. ...
The purpose of mastectomy for the female-to-male transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique; these have generally been based on the degree of breast ptosis and the quality and elasticity of the skin. We present a series of subcutaneous mastectomies operated on by 1 surgeon during the last 2 decades. Based on our experience, we suggest a classification system for selecting surgical technique.
Methods:
Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. The data included background and surgery information. Pictures from the clinic's archive of the patients before, during, and after surgery were collected and analyzed.
Results:
In total, 220 mastectomies were performed on 110 patients aged 13.5-50 years (mean 22.5 ±6.1). The excision averaged 443 g per breast (range: 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included 2 hypertrophic scars, 6 hematomas requiring revision surgery, 3 wound dehiscences, and 3 cases of partial nipple necrosis.
Conclusions:
Analysis of the data led to a proposed classification for female-to-male transgender mastectomy (Wolf's classification), based on skin excess and the distance between the original and the planned position of the nipple-areola complex.
... Procedures within the spectrum of gender-affirming surgery encompass "facial surgeries" (e.g., facial feminization/masculinization, vocal cord surgery, laryngeal chondroplasty), "top surgeries" (e.g., breast augmentation, mastectomy), and "bottom surgeries" (e.g., vaginoplasty, orchiectomy, phalloplasty, vaginectomy/hysterectomy/salpingo-oophorectomy, metoidioplasty, scrotal reconstruction) (Siotos et al., 2019). ...
... 12 Gender-affirming surgery is becoming increasingly common, particularly as more evidence emerges regarding positive health outcomes and reduced negative health outcomes. 13,14 Relative to other surgical procedures, gender affirmation surgery is only recently reimbursed by Medicare. The Affordable Care Act of 2010 greatly expanded health care coverage for transgender and gender-diverse people. ...
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.
... At the same institute, patient Dora Richter received the first known gender confirmation surgery in 1931 [12,13]. In the United States, Johns Hopkins University became the first American school to open a medical program focusing on transgender medicine and research [12,14]. The Johns Hopkins program was ended in 1979, but in the same year, the World Professional Association for Transgender Health (WPATH), one of the most important organizations for researching and guiding transgender healthcare, was developed by endocrinologist Harry Benjamin [15]. ...
Background
The state of evidence-based transgender healthcare in the United States has been put at risk by the spread of misinformation harmful to transgender people. Health science librarians can alleviate the spread of misinformation by identifying and analyzing its flow through systems that affect access to healthcare.
Discussion
The author developed the theory of the Misinformation - Legislation Pipeline by studying the flow of anti-transgender misinformation from online echo chambers through a peer-reviewed article and into policy enacted to ban medical treatments for transgender people in the state of Florida. The analysis is precluded with a literature review of currently accepted best practices in transgender healthcare, after which, the author analyzes the key report leveraged by Florida's Department of Health in its ban. A critical analysis of the report is followed by a secondary analysis of the key peer-reviewed article upon which the Florida Medicaid authors relied to make the decision. The paper culminates with a summation of the trajectory of anti-transgender misinformation.
Conclusion
Misinformation plays a key role in producing legislation harmful to transgender people. Health science librarians have a role to play in identifying misinformation as it flows through the Misinformation - Legislation Pipeline and enacting key practices to identify, analyze, and oppose the spread of harmful misinformation.
... In 1966, the Johns Hopkins University opened the first gender identity clinic in the USA, but a narrow definition of 'transsexual' was applied only to those who reported gender dysphoria at an early age and who were heterosexual after transition. Due to the restrictive criteria, only 23 out of 1,200 surgery requests were accepted by 1972 (Siotos et al., 2019). As hormone therapy and surgical transition became more accessible to some transgender people, the use of 'transsexual' increased. ...
The lives of transgender older adults are rarely examined, and little is known about the critical life events and experiences of this population. Informed by the Iridescent Life Course, this study investigates how intersectionality, fluidity, context and power impact the life events and experiences of trans older adults by generation and gender. Utilising 2014 data from the National Health, Aging, and Sexuality/Gender Study: Aging with Pride (National Institutes of Health/National Institute on Aging funded), a national sample of LGBTQ+ individuals 50 years and older, living in the United States of America, were analysed to examine life events of 205 transgender older adults, including identity development, work, bias, kin relationships, social and community engagement, health and wellbeing. Ordinary least-squares regressions and logistics regressions are used to compare the life events between the generations then test the interaction effect of gender. Pride Generation more openly disclose their identities and are more likely to be employed and married compared to the Silenced Generation, who have more military service, higher rates of retirement, fewer same-sex marriages and more different-sex marriages. Invisible Generation, the oldest group, are more likely retired, have more children and are more likely engaged in the community compared to the Silenced Generation, who experienced more discrimination. Applying the Iridescent Life Course is instrumental in understanding older trans adults' lives through intersecting identities of both generation and gender. These insights have the potential to create a greater appreciation of how historical events shape differing generations of transgender people, creating an opportunity to link generations together.
... Money, who had gained notoriety in the fields of gender identity and sexual development through his work with intersex people, co-founded the Gender Identity Clinic at Johns Hopkins in 1966 [83]. A year later in 1967, Money was consulted by the parents of David Reimer, whose penis had been damaged beyond repair during a failed circumcision to correct his phimosis. ...
The term chimera refers to an organism with cell lines from two or more distinct zygotes. Human chimerism may occur naturally or artificially. Although rare, advancements in genetics and genomics have resulted in the identification of additional natural human chimeras. Three forms of naturally occurring chimerism have been documented in humans: blood group chimerism, microchimerism, and fusion chimerism. Fusion chimerism may occur through several means. Sex-chromosome discordant chimerism refers to individuals with both XX and XY cell lines. There is a large amount of phenotypic variability among 46,XX/46,XY chimeric individuals. The care of people with intersex traits or DSD (Disorders of Sexual Development) is controversial due in part to a history of unnecessary surgical intervention and power-imbalances between the intersex and medical communities. As more 46,XX/46,XY chimeric individuals with intersex traits or DSD are identified, the implications for their care will need to be clarified.
... Historically, the transgender experience was classified as a mental disease that was best treated with psychiatric modalities including conversion therapy, similar to the treatment of homosexuality at the time. 2,8,9 Individual providers in the early and mid-20th century realized that those modalities failed but that success could be achieved by aligning the phenotype to the gender identity rather than the other way around. 10,11 The Harry Benjamin International Gender Dysphoria Association was founded in 1979 as a professional society dedicated to assisting providers with guidelines around best practices. ...
The population of transgender patients seeking gender confirmation surgery for gender dysphoria is increasing in the United States. Facial gender confirmation surgery (FGCS) is one of the treatment modalities patients require and is often a combination of soft tissue and cranio-maxilla-facial procedures. Despite evidence of the efficacy of FGCS, there remains some extant controversies to address, such as reimbursement for these procedures, categorization of aesthetic versus functional surgery, and evaluation of outcomes. This review provides a discussion of these topics, as well as the historical and psychosocial issues specific to transgender patients that surgeons should know when providing FGCS. We provide practice pearls for providing affirming transgender healthcare, illustrative patient clinical vignettes, and a discussion of the Standards of Care of the World Professional Association for Transgender Health to help guide surgeons who are interested in providing FGCS to transgender patients.
... Serratus anterior adipofascial flap and vascularized rib flaps can be elevated on the same pedicle. [13,14] Dorsalis pedis fasciocutaneous flap has been also used in the reconstruction of the hand defects [15] with poor donor scar on the foot dorsum. ...
Background:
Reconstruction of the complex upper extremity defects is a challenging procedure for reconstructive surgeons because of the complex anatomical and functional structure of this region. In reconstruction, local and regional flap options involving the composite tissues are restricted. The posterior interosseous flap (PIO) has been presented 'in a single study' with a wide variety of uses, and in this study, the versatility of PIO has been tried to be emphasized by its multitude uses as well as its chance at adaptability to each case. Hence, due to this, the objective to highlight the versatile utility of the PIO flap in clinical practice and to present a good option for the reconstruction of complex upper limb defects for various cases have been targeted.
Methods:
We used 26 PIO flaps in 25 patients (18 male and seven female patients) with upper limb defects. The main etiological causes were burn contracture, traffic accident, firearm and acute burn injury. Twenty-two flaps were harvested as fasciocutaneous and four flaps as osteo-fasciocutaneous manner, which were applied to the metacarpal defects. In this study, 25 flaps were transferred as pedicled flaps, of which 23 and 2 flaps had reverse and antegrade blood flows, respectively, whereas one flap was used as a free flap.
Results:
The mean follow-up period was 14 months. All flaps except one, which had partial necrosis and secondary healed, survived completely. All patients were able to gain basic functions for daily routine activities in the late postoperative period. Patients and/or their parents were satisfied with the postoperative functional and aesthetic improvements.
Conclusion:
Many advantages of the PIO flap make it useful for the reconstruction of upper limb complex defects. It can be versatilely used based on changing its flow direction and enrichment of contents.
Trans health policy has a history of authorising members of various health professions to verify whether a person is psychiatrically distressed-yet-safe-enough to access requested gender-affirming medical technologies. However, ongoing concerns about an approach that attributes authority to psychiatric knowledges to determine access to care have generated alternative visions for depathologisation that redesign healthcare systems to meet rather than regulate requests for body modifications. This is not simply because pathologisation structures harmful practices and relations but also because it is part of a mechanism that helps secure colonial state power and maintains populations on stolen Indigenous lands. This chapter offers a critical history of care in the present. It examines how requests for gender-affirming medical technologies became mental health problems that often require psychiatric assessment and diagnosis to enable “treatment” of the body. This genealogy traces the conditions and contestation of care. It shows how colonially inflected rationales and practices of governing gender are overlaid with different strategies and tactics for governing access. Understanding how people with self-designated genders have become psychiatrised subjects of care within projects of settler colonialism is integral to dismantling an illness model and critically evaluating an ascendant model of rights in trans health.
Background
Gender affirmation surgeries (GASs) are procedures that help patients align their body and gender identity. European surgeons are widely credited with pioneering GAS surgical techniques in the 1930s, whereas knowledge of GAS in the United States (US) prior to the 1960s is sparser. This study explores the early leaders, techniques, and obstacles encountered by physicians performing GAS in the US in the 1950s to 1970s.
Methods
Archives from the Harry Benjamin Collection and Elmer Belt Papers were reviewed for patient, physician, and operative details.
Results
A total of 39 physician and academic collaborators and 72 patients were identified. Most physicians and academic collaborators were from the US (28/39, 71.8%) or Germany (3/39, 7.7%). Urology was the most common specialty (8/36, 22.2%), followed by plastic surgery (7/36, 19.4%) and psychiatry (5/36, 13.9%). Forty patients underwent GAS, of which the majority underwent vaginoplasty (31/40, 77.5%), orchiectomy (7/40, 17.5%), and penectomy without vaginoplasty (4/40, 10.0%). Belt preferred to implant testicles into the retroperitoneum rather than perform orchiectomies during his vaginoplasties, and vaginoplasty complications were commonly reported (13/31, 41.9%). Patients and providers faced challenges obtaining and providing GAS due to the indeterminate legal status of the procedures, shifting hospital policies, and discouragement from family and colleagues.
Conclusions
Despite records of professional, familial, and even legal censure, the legacy of these early physicians and patients persists in the continued practice and refinement of GAS surgical techniques, often through the same organizations that housed these early practitioners. This article seeks to deepen our understanding of the lives and professional struggles of these medical innovators, upon whose work the contemporary American practice of GAS is built.
Gender-affirming surgery is a medically necessary intervention for many transgender and gender diverse people. A multidisciplinary approach facilitates patient care and helps optimize outcomes. Current surgical interventions for transgender men include chest surgery (i.e., mastectomy), genital surgery (including metoidioplasty and phalloplasty), facial masculinization, and other body contouring procedures. Gender-affirming surgeons should be well-versed in the operative techniques for each of these procedures.
The University of Michigan has played an important role in advancing gender-affirming surgery programs in the United States. The University of Michigan was home to a little-known gender identity clinic shortly after the opening of the first such clinic at Johns Hopkins. Since 1995, the University of Michigan Comprehensive Services Program (UMCGSP) has been continually offering surgical services to transgender and gender diverse patients. Here, we present the history of both programs, drawn from program documents and oral history, and explore their implications for the future sustainability of gender-affirming surgery programs. The original gender identity clinic opened in 1968, and operated in a multidisciplinary fashion, similar to other clinics at the time. Eventually, the clinic was closed due to disinvestment and lack of sufficient providers to maintain the program, problems which are being increasingly recognized as barriers for similar programs. The modern program, UMCGSP is perhaps the longest continually running gender-affirming surgical program at an academic center. In spite of challenges, key investments in education, statewide community engagement, and the development of a comprehensive care model have helped UMCGSP avoid the pitfalls of the earlier clinic and remain relevant throughout its nearly 30-year history. In the face of rising challenges to gender-affirming care in the United States, much can be learned from the sustainability of the UMCGSP. Institutions seeking to maintain gender-affirming surgery programs should ensure the availability of comprehensive care and promote the education of the health care workforce.
The 2030 agenda for sustainable development and its pledge to ‘leave no one behind’ provides a renewed impetus for advancing health equity globally for transgender and other gender diverse (TGGD) people. It is estimated that in the United States (US), over 1.4 million adults collectively identify with TGGD. A growing number of children and adolescents in the US report having gender identities or expressions that differ from their birth-assigned gender or social and cultural gender norms. Many intersecting social challenges translate into medical challenges for TGGD people. Many TGGD people suffer from gender dysphoria, feeling that they are ‘trapped’ in the wrong body. Gender dysphoria and health outcomes improve with gender-affirming treatment including hormone therapy and gender-affirming surgical interventions. Evaluating barriers prohibiting TGGD individuals from pursuing gender-affirming medical and surgical services is a crucial first step for developing strategies to improve gender-affirming care services. The authors review barriers faced by the TGGD people at the individual, interpersonal, and structural levels while trying to access gender-affirming surgery in the US. They examine how TGGD community members and healthcare providers may differ in their understanding of surgical care barriers and the potential ways to address them.
Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.
This article explores the new surgical population of gender affirming surgery, specifically vaginal surgeries for transgender and gender diverse people. There are established perioperative rehabilitation guidelines for nearly all other surgeries. A growing population of people is seeking gender affirming healthcare which includes vaginal surgery. This article reviews the guidelines set forth by the World Professional Association for Transgender Health Standards of Care (Version 8), explores the occupational needs of this population, as well as provides suggestions for future versions of official documents of the American Occupational Therapy Association to provide more inclusive language for the unique needs of this population following surgery.
Johns Hopkins Hospital established the first gender-affirming surgery (GAS) clinic in the United States in 1966. Operating for more than 13 years, the clinic was abruptly closed in 1979. According to the hospital, the decision was made in response to objective evidence claiming that GAS was ineffective. However, this evidence directly contradicted many contemporaneous studies and faced immediate criticism from the scientific community. Despite this resistance, it took the hospital nearly 40 years to resume performing GAS. Scientific evidence-imbued in scandal, bias, and moralism-was instrumentalized to serve broader institutional interests. The burgeoning field of plastic surgery tethered and then untethered GAS from its auspices in response to poor technical outcomes and transphobia. No longer serving surgeons' interests, the clinic was marginalized to "barely minimal facilities" in 1974, five years before GAS was formally banned. Over the next 5 years, the clinic co-inhabited space with the Department of Obstetrics and Gynecology. Simultaneously, the Department of Obstetrics and Gynecology navigated scandals related to reproductive technology (namely, the Dalkon Shield [A.H. Robins] controversy) until the clinic space was demolished in 1979. The study that informed the GAS ban was preferentially funded in keeping with the political economy of biomedical research. This article presents a spatial argument for how the closure of the nation's first GAS clinic was not based in empirical data alone but was manipulated to fuel political and institutional agendas.
The surgical treatment of gender incongruence with gender affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women, as well as those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to our own mistakes during patient care. Based on the lessons learned from these experiences, we provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.
Background
Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.
Aim
The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.
Methods
Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.
Outcomes
Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.
Results
Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).
Clinical Implications
This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.
Strengths & Limitations
This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.
Conclusion
Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal.
Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;XX:XXX–XXX.
Transgender medicine has made great strides in the past century. Biomedical advances in the fields of reconstructive surgery, endocrinology, and pharmacology have expanded the possibilities for gender-affirming care, including surgeries and hormone replacement therapy. Given these impressive medical and technical advancements, it is crucial to analyze the ways in which gender-affirming care has been gatekept. Gatekeeping refers to the practice of limiting health resources and services for certain populations. Transgender individuals have historically and presently experienced gatekeeping of gender-affirming and transition-related services by medical professionals, academic institutions, and insurance providers. In this paper, I draw from archival and scholarly materials to analyze the extent to which transgender individuals experienced care refusals during the 1960’s and 70’s at university-based gender clinics in the United States. I argue that the gatekeeping of care was historically motivated by medical providers’ and gender clinics’ desire to produce productive, heteronormative citizens and that gatekeeping allowed medical providers to shape and alter transgender people’s medical narratives. Ultimately, this analysis locates current biomedical advances in transgender health and medicine in the context of a long history of care refusals, gatekeeping, and acts of resistance in which transgender people attempted to reclaim their narratives. I aim to illuminate the ways in which medical care was gatekept during the gender clinic era of the 1960’s and 70’s in the United States and argue that these practices shaped the kinds of medical narratives that transgender people tell in order to receive care.
Modern transgender and non-binary (TGNB) pediatric health care originated in the 1990s. This patient population is adversely affected by minority stress, victimization, mental health disparities, and barriers to health care With improving social and cultural support for TGNB identities and favorable evidence for affirming social and medical interventions, the need for pediatric gender services clinics has grown. Gender-affirming care requires collaboration between social and medical entities, including school personnel, community services, medical providers, and mental health professionals, which is best served within a multidisciplinary treatment model of care. This article provides an overview of the components within multidisciplinary pediatric gender clinics.
Background
Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature.
Methods
PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of “gender affirming,” “gender confirming,” “transgender,” and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized.
Results
Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery.
Conclusion
Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.
The term transgender youth commonly refers to those whose gender identity, or personal core sense of self as a particular gender, differs from their assigned sex at birth; this is often designated by what external genitalia are present. These youths are presenting to multidisciplinary clinics worldwide at exponentially higher rates than in decades past, and clinics themselves have grown in number to meet the specialized demands of these youth. Additionally, the scientific and medical community has moved towards understanding the construct of gender dimensionally (i.e., across a spectrum from male to female) as opposed to dichotomous or binary "male or female" categories. This is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5); in this publication, the diagnostic classification of gender dysphoria, GD, (which has two subtypes: childhood and adolescence/adulthood) provides a set of criteria that many transgender people meet. GD describes the affective distress that arises as a result of the incongruence between gender identity and sex anatomy. The DSM uses language to indicate that a person may identify as another gender instead of the other gender, which further captures the complexity of the human experience of gender. Also, research regarding how current adolescents are describing their identity development and experience along this spectrum within today's society is only now being addressed in the literature. Therefore, the clinical needs of the transgender population have outpaced medical training and scientific advancement, which has opened up gaps on how to define best practices. This article provides current concepts of evaluation and management for transgender persons with emphasis on hormonal therapy (i.e., puberty blockers and gender affirming hormone therapy). Other management issues are briefly considered including gender confirming surgery and changes in the face as well as voice.
Importance
Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States.
Objectives
To investigate the incidence and trends over time of gender-affirming surgical procedures and to analyze characteristics and payer status of transgender patients seeking these operations.
Design, Setting, and Participants
In this descriptive observational study from 2000 to 2014, data were analyzed from the National Inpatient Sample, a representative pool of inpatient visits across the United States. The initial analyses were done from June to August 2015. Patients of interest were identified by International Classification of Diseases, Ninth Revision, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation.
Main Outcomes and Measures
Demographics, health insurance plan, and type of surgery for patients who sought gender-affirming surgery were compared between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014.
Results
This study included 37 827 encounters (median [interquartile range] patient age, 38 [26-49] years) identified by a diagnosis code of transsexualism or gender identity disorder. Of all encounters, 4118 (10.9%) involved gender-affirming surgery. The incidence of genital surgery increased over time: in 2000-2005, 72.0% of patients who underwent gender-affirming procedures had genital surgery; in 2006-2011, 83.9% of patients who underwent gender-affirming procedures had genital surgery. Most patients (2319 of 4118 [56.3%]) undergoing these procedures were not covered by any health insurance plan. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased by 3-fold in 2014 (to 70) compared with 2012-2013 (from 25). No patients who underwent inpatient gender-affirming surgery died in the hospital.
Conclusions and Relevance
Most transgender patients in this national sample undergoing inpatient gender-affirming surgery were classified as self-pay; however, an increasing number of transgender patients are being covered by private insurance, Medicare, or Medicaid. As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them.
Gender dysphoria is associated with significant health disparity. Gender services perform specialised activities such as diagnosis, endocrine management and liaison with surgical services. Although providing these specialised transition services appears to be safe and improves well-being, significant health disparity remains. Engaging primary care providers is an important part of any strategy to improve the health care of transgender people. The relationships between gender dysphoria and a range of primary care issues such as mental health, cardiovascular disease and cancer are explored.
We assessed the outcomes of gender affirming surgery (GAS or sex reassignment surgery) four to six years after first clinical contact, and the associations between postoperative (dis)satisfaction and Quality of Life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with Gender Identity Disorder (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale) and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94-100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR = 6.07). Satisfied respondents' QoL scores were similar to reference values; dissatisfied or regretful respondents' scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.
Importance:
The Institute of Medicine and The Joint Commission recommend routine documentation of patients' sexual orientation in health care settings. Currently, very few health care systems collect these data since patient preferences and health care professionals' support regarding collection of data about patient sexual orientation are unknown.
Objective:
To identify the optimal patient-centered approach to collect sexual orientation data in the emergency department (ED) in the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity study.
Design, setting, and participants:
An exploratory, sequential, mixed-methods design was used first to evaluate qualitative interviews conducted in the Baltimore, Maryland, and Washington, DC, areas. Fifty-three patients and 26 health care professionals participated in the qualitative interviews. Interviews were followed by a national online survey, in which 1516 (potential) patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) participated. Survey participants were recruited using random digit dialing and address-based sampling techniques.
Main outcomes and measures:
Qualitative interviews were used to obtain the perspectives of patients and health care professionals on sexual orientation data collection, and a quantitative survey was used to gauge patients' and health care professionals' willingness to provide or obtain sexual orientation information.
Results:
Mean (SD) age of patient and clinician participants was 49 (16.4) and 51 (9.4) years, respectively. Qualitative interviews suggested that patients were less likely to refuse to provide sexual orientation than providers expected. Nationally, 154 patients (10.3%) reported that they would refuse to provide sexual orientation; however, 333 (77.8%) of all clinicians thought patients would refuse to provide sexual orientation. After adjustment for demographic characteristics, only bisexual patients had increased odds of refusing to provide sexual orientation compared with heterosexual patients (odds ratio, 2.40; 95% CI, 1.26-4.56).
Conclusions and relevance:
Patients and health care professionals have discordant views on routine collection of data on sexual orientation. A minority of patients would refuse to provide sexual orientation. Implementation of a standardized, patient-centered approach for routine collection of sexual orientation data is required on a national scale to help to identify and address health disparities among lesbian, gay, and bisexual populations.
In this review, we introduce the topic of transgender medicine, aimed at the non-specialist clinician working in the UK. Appropriate terminology is provided alongside practical advice on how to appropriately care for transgender people. We offer a brief theoretical discussion on transgenderism and consider how it relates to broader understandings of both gender and disease. In respect to epidemiology, while it is difficult to assess the exact size of the transgender population in the UK, population surveys suggest a prevalence of between 0.2 and 0.6% in adults, with rates of referrals to gender identity clinics in the UK increasing yearly. We outline the legal framework that protects the rights of transgender people, showing that is not legal for physicians to deny transgender people access to services based on their personal beliefs. Being transgender is often, although not always, associated with gender dysphoria, a potentially disabling condition in which the discordance between a person's natal sex (that assigned to them at birth) and gender identity results in distress, with high associated rates of self-harm, suicidality and functional impairment. We show that gender reassignment can be a safe and effective treatment for gender dysphoria with counselling, exogenous hormones and surgery being the mainstay of treatment. The role of the general practitioner in the management of transgender patients is discussed and we consider whether hormone therapy should be initiated in primary care in the absence of specialist advice, as is suggested by recent General Medical Council guidance.
Purpose:
Research suggests that LGBT populations experience barriers to healthcare. Organizations such as the Institute of Medicine recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare, to reduce LGBT disparities. We explore patient views regarding the importance of SO/GI collection, and patient and provider views on risks and benefits of routine SO/GI collection in various settings.
Methods:
We surveyed LGBT/non-LGBT patients and providers on their views on SO/GI collection. Weighted data were analyzed with descriptive statistics; content analysis was conducted with open-ended responses.
Results:
One-half of the 1516 patients and 60% of 429 providers were female; 64% of patients and 71% of providers were White. Eighty percent of providers felt that collecting SO data would offend patients, whereas only 11% of patients reported that they would be offended. Patients rated it as more important for primary care providers to know the SO of all patients compared with emergency department (ED) providers knowing the SO of all patients (41.3% vs. 31.6%; P < 0.001). Patients commonly perceived individualized care as an SO/GI disclosure benefit, whereas providers perceived patient-provider interaction improvement as the main benefit. Patient comments cited bias/discrimination risk most frequently (49.7%; N = 781), whereas provider comments cited patient discomfort/offense most frequently (54.5%; N = 433).
Conclusion:
Patients see the importance of SO/GI more in primary care than ED settings. However, many LGBT patients seek ED care due to factors including uninsurance; therefore, the ED may represent an initial point of contact for SO/GI collection. Therefore, patient-centered approaches to collecting SO/GI are needed. Patients and providers differed in perceived risks and benefits to routine SO/GI collection. Provider training in LGBT health may address patients' bias/discrimination concerns, and ultimately reduce LGBT health disparities.
Importance:
In 2014, the US Department of Health and Human Services decided that its 1981 exclusion of transsexual surgical treatments from Medicare coverage was based on outdated, incomplete, and biased science and did not reflect current evidence or standards of care, and the exclusion was therefore lifted. As a direct result of this decision, surgeons nationwide are seeing an increase in consultations for surgical therapy to help transgender and gender-nonconforming individuals. Although some clinicians may have the technical training for such surgical procedures, in many cases, they may not have a full understanding of the complex and comprehensive care required to provide optimal health care for transgender individuals.
Observations:
Gender confirmation surgery is a developing field in the United States and other areas of the world. The World Professional Association for Transgender Health started a global education initiative intended to provide surgeons and other health care professionals with the necessary background knowledge to understand and treat this patient population. This article provides an overview of best practices as set forth in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health, including mental health, endocrinology, and surgery for trans women and trans men.
Conclusions and relevance:
Experts in each aspect of transgender health have summarized the content of the global education initiative in this article. It provides valuable information to surgeons of all disciplines and other health care professionals to help guide the treatment and management of transgender individuals.
Background. Transgender individuals have a gender identity that differs from the sex they were assigned at birth. The population size of transgender individuals in the United States is not well-known, in part because official records, including the US Census, do not include data on gender identity. Population surveys today more often collect transgender-inclusive gender-identity data, and secular trends in culture and the media have created a somewhat more favorable environment for transgender people.
Objectives. To estimate the current population size of transgender individuals in the United States and evaluate any trend over time.
Search methods. In June and July 2016, we searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and Web of Science for national surveys, as well as “gray” literature, through an Internet search. We limited the search to 2006 through 2016.
Selection criteria. We selected population-based surveys that used probability sampling and included self-reported transgender-identity data.
Data collection and analysis. We used random-effects meta-analysis to pool eligible surveys and used meta-regression to address our hypothesis that the transgender population size estimate would increase over time. We used subsample and leave-one-out analysis to assess for bias.
Main results. Our meta-regression model, based on 12 surveys covering 2007 to 2015, explained 62.5% of model heterogeneity, with a significant effect for each unit increase in survey year (F = 17.122; df = 1,10; b = 0.026%; P = .002). Extrapolating these results to 2016 suggested a current US population size of 390 adults per 100 000, or almost 1 million adults nationally. This estimate may be more indicative for younger adults, who represented more than 50% of the respondents in our analysis.
Authors’ conclusions. Future national surveys are likely to observe higher numbers of transgender people. The large variety in questions used to ask about transgender identity may account for residual heterogeneity in our models.
Public health implications. Under- or nonrepresentation of transgender individuals in population surveys is a barrier to understanding social determinants and health disparities faced by this population. We recommend using standardized questions to identify respondents with transgender and nonbinary gender identities, which will allow a more accurate population size estimate.
Purpose of review:
This article describes methodological challenges, gaps, and opportunities in US transgender health research.
Recent findings:
Lack of large prospective observational studies and intervention trials, limited data on risks and benefits of sex affirmation (e.g., hormones and surgical interventions), and inconsistent use of definitions across studies hinder evidence-based care for transgender people. Systematic high-quality observational and intervention-testing studies may be carried out using several approaches, including general population-based, health systems-based, clinic-based, venue-based, and hybrid designs. Each of these approaches has its strength and limitations; however, harmonization of research efforts is needed. Ongoing development of evidence-based clinical recommendations will benefit from a series of observational and intervention studies aimed at identification, recruitment, and follow-up of transgender people of different ages, from different racial, ethnic, and socioeconomic backgrounds and with diverse gender identities.
Summary:
Transgender health research faces challenges that include standardization of lexicon, agreed upon population definitions, study design, sampling, measurement, outcome ascertainment, and sample size. Application of existing and new methods is needed to fill existing gaps, increase the scientific rigor and reach of transgender health research, and inform evidence-based prevention and care for this underserved population.
Background:
Recently, the Massachusetts Group Insurance Commission (GIC) prioritized research on the implications of a clause expressly prohibiting the denial of health insurance coverage for transgender-related services. These medically necessary services include primary and preventive care as well as transitional therapy.
Objective:
To analyze the cost-effectiveness of insurance coverage for medically necessary transgender-related services.
Design:
Markov model with 5- and 10-year time horizons from a U.S. societal perspective, discounted at 3 % (USD 2013). Data on outcomes were abstracted from the 2011 National Transgender Discrimination Survey (NTDS).
Patients:
U.S. transgender population starting before transitional therapy.
Interventions:
No health benefits compared to health insurance coverage for medically necessary services. This coverage can lead to hormone replacement therapy, sex reassignment surgery, or both.
Main measures:
Cost per quality-adjusted life year (QALY) for successful transition or negative outcomes (e.g. HIV, depression, suicidality, drug abuse, mortality) dependent on insurance coverage or no health benefit at a willingness-to-pay threshold of 23,619; 6.49 QALYs), insurance coverage for medically necessary services came at a greater cost and effectiveness (9314/QALY. The budget impact of this coverage is approximately 10,000-22,000 and the cost of provider coverage is $2175/year, these additional expenses hold good value for reducing the risk of negative endpoints -HIV, depression, suicidality, and drug abuse. Results were robust to uncertainty. The probabilistic sensitivity analysis showed that provider coverage was cost-effective in 85 % of simulations.
Conclusions:
Health insurance coverage for the U.S. transgender population is affordable and cost-effective, and has a low budget impact on U.S. society. Organizations such as the GIC should consider these results when examining policies regarding coverage exclusions.
Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.
Learning objectives:
After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.
Background:
Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.
Methods:
The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.
Results:
Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.
Conclusions:
This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.
Transgender and gender-nonconforming individuals experience significant health disparities. They are more likely to use drugs and alcohol, smoke, be diagnosed with HIV infection or other sexually transmitted infections, and experience depression or attempt suicide. Many also experience discrimination within the health care system. Office-level strategies to create a safe and affirming space for gender-expansive patients include posting of a nondiscrimination statement, use of intake forms that ask about current gender identity and birth-assigned sex, provision of gender-neutral restrooms, and staff training in use of appropriate language. Hormone or surgical therapy can be initiated for patients with persistent gender dysphoria who are of age and have the capacity to make informed decisions, and have reasonable control of coexisting medical and psychiatric conditions. Estrogens, antiandrogens, and progestins are used for feminization, and testosterone for masculinization. Hormone treatment should be followed by careful monitoring for potential adverse effects. Surgical options include male-to-female and female-to-male procedures. The family physician may need to provide a referral letter, preoperative and postoperative examinations and care, and advocacy with health insurance providers. Preventive care for transgender patients includes counseling for cardiovascular health, cancer screening, provision of appropriate contraception, and screening for sexually transmitted infections.
Transgender people have a gender that is not in agreement with their birth sex. Previous barriers, including lack of provider knowledge, has created significant healthcare disparities for this population. Recent societal changes are increasing the numbers of transgender people seen by primary care. Ten key principles are provided to help primary practitioners create more welcoming environments and provide quality care to transgender patients. Overall, all members of the health care team (primary and specialty) need to become aware of the transition process and maintain communication regarding risks, benefits and goals. Transwomen (aka male to female) can be treated with estrogens, anti-androgens or a combination. Benefits include change in fat distribution, skin softening and breast development. Significant risks for thrombosis from estrogens have been linked to genetic mutations, smoking, prolonged inactivity and hormone formulation. Oral administration may provide increased risk over peripheral administration. Transmen (aka female to male) can be treated with peripheral testosterone preparations. Benefits include deepening of voice and development of facial and body hair with variable changes in muscle mass. Risks of testosterone appear to be less common than estrogen. Laboratory monitoring can guide treatment decisions and provide early detection of some complications. Monitoring of “existing” anatomy (either hormonally or surgically created or removed) is an important component of health care for transgender patients. Primary care providers should also be aware of resources in their community and on-line which can help patients optimize their transition.
The recent publication, Is It Okay To Ask: Transgender Patient Perspectives on Sexual Orientation and Gender Identity Collection in Healthcare, is significant in its discussion of circumstances affecting willingness of transgender patients to disclose gender identity and sexual orientation as well as the participants' focus on the need for improved LGBT education for medical staff. The authors also emphasize the importance of safe environments in primary care settings and emergency departments where providers may pose questions regarding intimate issues(1) . This article is protected by copyright. All rights reserved.
Background:
Surveys on quality of life (QOL) of male-to-female (MTF) transsexuals have found low QOL scores before and increased satisfaction scores after sex-reassignment surgery (SRS). To our knowledge, many of them lack standardized questionnaires and comparisons with normative data to evaluate different vaginoplasty techniques.
Aim:
To analyze patient satisfaction and QOL after SRS.
Methods:
Forty-seven patients participated in this study. All patients had surgery with our self-developed combined technique on average 19 months before the survey. They completed a self-developed indication-specific questionnaire concerning demographic and socioeconomic issues and postoperative satisfaction. Furthermore, a standardized self-assessment questionnaire on satisfaction and QOL (Fragen zur Lebenszufriedenheit(Module) [FLZ(M)]; Questions on Life Satisfaction(Modules)) was used. The FLZ(M) consists of three modules (general life satisfaction, satisfaction with health, and satisfaction with body image) with scores of weighted satisfaction for each item. Results of the general and health modules were compared with normative data.
Outcomes:
Demographics, QOL, general life satisfaction, satisfaction with health, and satisfaction with body image.
Results:
The self-developed indication-specific questionnaire showed that 91% experienced an improvement of QOL. All patients stated they would undergo SRS again and did not regret it at all. Patients stated their femininity significantly increased. For the FLZ(M), the sum score for general life satisfaction (P < .001) was?significantly lower than the normative data, whereas the sum score of the satisfaction with health module (P?= .038) did not reach statistical significance. The two modules also showed positive trends for different items. Values of the body image module showed a significant increase in satisfaction with breasts (P < .001) and genitals (P?= .002).
Clinical implications:
The findings of this survey emphasize the importance of SRS in the interdisciplinary gender-reassignment process. The detailed description of our combined technique could help to improve the surgical outcome and patient satisfaction of this complex and non-standardized surgery.
Strengths and limitations:
This is the first description of a new surgical technique (combined technique) for MTF SRS. QOL was assessed by a large number of patients by standardized questionnaires and could be compared with normative data. Because this is a retrospective study, we can draw only careful conclusions for pre- and postoperative changes.
Conclusion:
Our self-developed combined surgical technique seemed to have a positive influence on QOL after SRS. Satisfaction with breasts, genitals, and femininity increased significantly and show the importance of surgical treatment as a key therapeutic option for MTF transsexuals. Papadopulos NA, Lell? J-D, Zavlin D, et?al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med 2017;XX:XXX-XXX.
Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery (alternatively, gender reassignment surgery, sexual reassignment surgery, or gender-Affirming surgery). This review presents a robust overview of genital reconstruction in the female-To-male transgender patient-an operation that, historically, was seldom performed and has remained less surgically feasible than its counterpart (male-To-female genital reconstruction). However, as the visibility and public awareness of the trans community continues to increase, the demand for plastic surgeons equipped to perform these reconstructions is rising. The "ideal" neophallus is aesthetic, maintains tactile and erogenous sensibility, permits sexual function and standing urination, and possesses minimal donor-site and operative morbidity. This article reviews current techniques for surgical construction, including metoidioplasty and phalloplasty, with both pedicled and free flaps. Emphasis is placed on the variety of techniques available for constructing a functional neophallus and neourethra. Preparative procedures (such as vaginectomy, hysterectomy, and oophorectomy) and adjunctive reconstructive procedures (including scrotoplasty and genital prosthesis insertion) are also discussed.
Objective:
The National Academy of Medicine and Joint Commission recommend routine documentation of sexual orientation (SO) and gender identity (GI) in healthcare to address LGBT health disparities. We explored transgender patient-reported views on the importance of SO/GI collection, their willingness to disclose, and their perceived facilitators of SO/GI collection in primary care and Emergency Department (ED) settings.
Methods:
We recruited a national sample of self-identified transgender patients. Participants completed demographic questions, survey questions, and free response comments regarding their views of SO/GI collection. Data were analyzed using descriptive statistics; inductive content analysis was conducted with open-ended responses.
Results:
Patients mostly self-identified as Male gender (54.5%), White (58.4%), and sexual orientation other than Heterosexual, or LGB (33.7%; N=101). Patients felt it was more important for primary care providers to know their GI than SO (89.1% vs. 57%; p<.001); there was no difference among reported importance for ED providers to know the patients' SO versus GI. Females were more likely than males to report medical relevance to chief complaint as a facilitator to SO disclosure (89.1% vs. 80%; p=.02), and less likely to identify routine collection from all patients as a facilitator to GI disclosure (67.4% vs. 78.2%; p=.09). Qualitatively, many patients reported medical relevance to chief complaint and an LGBT-friendly environment would increase their SO/GI disclosure willingness. Patients also reported need for educating providers in LGBT health prior to implementing routine SO/GI collection.
Conclusions:
Patients see the importance of providing GI more than SO to providers. Findings also suggest that gender differences may exist in facilitators of SO/GI disclosure. Given the under-representation of transgender patients in healthcare, it is crucial for providers to address their concerns with SO/GI disclosure, which include LGBT education for medical staff and provision of a safe environment. This article is protected by copyright. All rights reserved.
Introduction
Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development.
Aims
(1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis.
Methods
A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors’ expertise.
Results
A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD.
Conclusions
Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.
Die Ausübungserklärung verweist ebenso auf die VSP Conditions und regelt die wirtschaftliche Realisierung der virtuellen Anteile im Exit-Fall.
This study assessed individual (ie, internalized transphobia) and structural forms of stigma as risk factors for suicide attempts among transgender adults. Internalized transphobia was assessed through a 26-item scale including four dimensions: pride, passing, alienation, and shame. State-level structural stigma was operationalized as a composite index, including density of same-sex couples; proportion of Gay-Straight Alliances per public high school; 5 policies related to sexual orientation discrimination; and aggregated public opinion toward homosexuality. Multivariable logistic generalized estimating equation models assessed associations of interest among an online sample of transgender adults (N = 1,229) representing 48 states and the District of Columbia. Lower levels of structural stigma were associated with fewer lifetime suicide attempts (AOR 0.96, 95% CI 0.92-0.997), and a higher score on the internalized transphobia scale was associated with greater lifetime suicide attempts (AOR 1.18, 95% CI 1.04-1.33). Addressing stigma at multiple levels is necessary to reduce the vulnerability of suicide attempts among transgender adults.
• Although medical interest in individuals adopting the dress and life-style of the opposite sex goes back to antiquity, surgical intervention is a product of the last 50 years. In the last 15 years, evaluation procedures and surgical techniques have been worked out. Extended evaluation, with a one- to two-year trial period prior to formal consideration of surgery, is accepted practice at reputable centers. Cosmetically satisfactory, and often functional, genitalia can be constructed. Less clear-cut, however, are the characteristics of the applicants for sex reassignment, the natural history of the compulsion toward surgery, and surgery's long-term effects. The characteristics of 50 applicants for sex reassignment, both operated and unoperated, are reviewed. The results of long-term follow-up are reported in terms of such indices as job, educational, marital, and domiciliary stability. Outcome data are discussed in terms of the adjustments of operated and unoperated patients.
When the practice of sex-change surgery first emerged back in the early 1970s, I would often remind its advocating psychiatrists that with other patients, alcoholics in particular, they would quote the Serenity Prayer, "God, give me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." Where did they get the idea that our sexual identity ("gender" was the term they preferred) as men or women was in the category of things that could be changed? Their regular response was to show me their patients. Men (and until recently they were all men) with whom I spoke before their surgery would tell me that their bodies and sexual identities were at variance. Those I met after surgery would tell me that the surgery and hormone treatments that had made them "women" had also made them happy and contented. None of these encounters were persuasive, however. The post-surgical subjects struck me as caricatures of women. They wore high heels, copious makeup, and flamboyant clothing; they spoke about how they found themselves able to give vent to their natural inclinations for peace, domesticity, and gentleness—but their large hands, prominent Adam's apples, and thick facial features were incongruous (and would become more so as they aged). Women psychiatrists whom I sent to talk with them would intuitively see through the disguise and the exaggerated postures. "Gals know gals," one said to me, "and that's a guy." The subjects before the surgery struck me as even more strange, as they struggled to convince anyone who might influence the decision for their surgery. First, they spent an unusual amount of time thinking and talking about sex and their sexual experiences; their sexual hungers and adventures seemed to preoccupy them. Second, discussion of babies or children provoked little interest from them; indeed, they seemed indifferent to children. But third, and most remarkable, many of these men-who-claimed-to-be-women reported that they found women sexually attractive and that they saw themselves as "lesbians." When I noted to their champions that their psychological leanings seemed more like those of men than of women, I would get various replies, mostly to the effect that in making such judgments I was drawing on sexual stereotypes.
Although medical interest in individuals adopting the dress and life-style of the opposite sex goes back to antiquity, surgical intervention is a product of the last 50 years. In the last 15 years, evaluation procedures and surgical techniques have been worked out. Extended evaluation, with a one- to two-year trial period prior to formal consideration of surgery, is accepted practice at reputable centers. Cosmetically satisfactory, and often functional, genitalia can be constructed. Less clear-cut however, are the characteristics of the applicants for sex reassignment, the natural history of the compulsion toward surgery, and surgery's long-term effects. The characteristics of 50 applicants for sex reassignment, both operated and unoperated, are reported in terms of such indices as job, education, marital, and domiciliary stability. Outcome are reviewed. The results of long-term follow up data are discussed in terms of the adjustments of operated and unoperated patients.
The evaluation and treatment of individuals with gender identity problems has resulted in an interesting and productive collaboration between several specialties of medicine. In particular, the psychiatrist and surgeon have joined hands in the management of these fascinating patients who feel they are trapped in the wrong body and insist upon correcting this cruel mistake of nature by undergoing sex reassignment surgery. Over the last two decades, some 40 centers have emerged in which interdisciplinary teams cooperate in the evaluation and treatment of these gender dysphoric patients. The model for this collaboration began at The Johns Hopkins Hospital, where the Gender Identity Clinic began its operation in 1965 (Edgerton, 1983; Pauly, 1983). This "gender identity movement" has brought together such unlikely collaborators as surgeons, endocrinologists, psychologists, psychiatrists, gynecologists, and research specialists into a mutually rewarding arena. This paper deals with the background and modern era of research into gender identity disorders and their evaluation and treatment. Finally, some data are presented on the outcome of sex reassignment surgery. This interdisciplinary collaboration has resulted in the birth of a new medical subspecialty, which deals with the study of gender identification and its disorders.
The increasing use of surgery for sex reassignment in the treatment of transsexualism is described. The author's early experience over a twenty-year period with the Gender Identity teams at The Johns Hopkins University and The University of Virginia is summarized. Many of the reasons for slow acceptance of this type of surgery by many members of the medical profession are analyzed. The satisfactory subjective results described by patients who have received sex reassignment continue to exceed the results obtained by other methods. The author concludes that further study of surgical treatment is justified, but that it should be limited to established multidisciplinary teams working in academic settings. Physicians are urged to withhold judgment on the role of surgery in gender disorders until they have had significant personal experience with these desperate and complex patients.
The selection of transsexuals for surgery must be based on the correct diagnosis, but it is also important that the patient be prepared preoperatively for the expected stress of surgery and postsurgical adjustments. This article shares the authors' experiences in running the Gender Identity Clinic of the University of Virginia Medical Center for the past 16 years.
The value in studying Dr. Harry Benjamin's first gender dysphoria patients is in learning how they described themselves--without any books to read, without any other source of information, assuming that he or she was alone and unlike anyone else in the world--and before hardly any literature on the subject had been published. Just as today, Benjamin's earliest patients came to him self-diagnosed. Even without the terminology currently available, their early descriptions of this unique phenomenon are identical with cross-gender identity patients who present themselves today: a recognition of the condition very early in their lives; the attempts at cross-dressing; the secrecy; the guilt; the unsuccessful attempts at suppressing desires and feelings; the episodic and continuous purging. These early individuals who suffered from gender conflicts had discovered Benjamin who would try to understand their unusual dilemma and be a barometer and a guide for the changes they would make. Their early individualistic perceptions provided insights that led to the birth of a new discipline. These 10 people must be lauded for their courage in seeking a description and a solution for a phenomenon that had no description and no treatment.
This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.
Reed Erickson and The Erickson Educational Foundation
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Two transsexuals reflect on university's pioneering gender dysphoria program
- D Lewy
Lewy D. Two transsexuals reflect on university's pioneering gender dysphoria program. Stanford Report. 2000; Available at: https://news.stanford.edu/news/2000/
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Center for Transgender Health
- Johns Hopkins Medicine
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www.hopkinsmedicine.org/center_transgender_health/index.html.
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