Management options for gender affirmation surgery of the breast

Gender identity and terminology

One’s gender identity refers to their experienced gender, or their core sense of being a man, a woman or neither. Gender incongruence, in turn, is an International Classification of Disease (v.11) diagnosis describing persistent incongruence between a person’s experienced gender and their assigned sex, which is typically determined at birth based on natal genitalia. In this sense transgender men are assigned a female gender at birth, but identify as men, and transgender women are assigned a male gender at birth but identify as women. People who experience their gender as non-binary (a term more widely replacing ‘gender nonconforming’) includes those who identify with parts of male and female genders, or identify with neither a male nor female gender. In this text, transmasculine is used to refer to transgender men and non-binary people who may seek a mastectomy. Transfeminine is used to refer to transgender women and non-binary people who may seek breast augmentation.

The aim of gender-affirming surgery is to better align a person’s phenotypic appearance with their identified gender. This can entail procedures that confer an overall more male or female phenotype throughout the body or other, more subtle, changes that exist along a spectrum. Rates of gender-affirming surgery have been steadily increasing in the US. The rise in these procedures can be attributed to increasing public understanding and acceptance of transgender and non-binary identities as well as increasing insurance coverage for gender-affirming surgeries. A landmark advance in this regard was the reversal of exclusion of gender-affirming surgery services from Medicare coverage in 2014.

For most patients, the goal of gender-affirming mastectomy is to removes most all breast tissue and re size the nipple–areola complex (NAC) to obtain a flat and often more masculine chest contour. This can be achieved using different incision patterns based on the individual’s anatomy and preference using a group of procedures often colloquially referred to as “top surgery” as well as “chest masculinization”. The latter term is preferably avoided as feminine and masculine norms are culturally determined and a fluid concept. Similarly, appropriate language and documentation should be used in reference to anatomic and technical descriptions. Such language is modeled throughout this text, for example, the term “chest” or “chest wall” cancer is used to refer to cancer arising from breast tissue in patients that have undergone gender-affirming mastectomy. Ideally, patient-specific identity terms should be removed from procedural description: i.e., “gender-affirming mastectomy” and not “transgender mastectomy” or “chest masculinization.” In the same sense, “cisgender” and “transgender” should be avoided when describing anatomy or organs of populations, as tissue does not have a gender identity. When referring to a specific patient’s anatomy, utilizing that patient’s gender identity or personally preferred language is always appropriate, i.e., “the transgender man’s ovary” if the patient identifies as a transgender man, or “the patient reports doing breast self-exams” if the patient describes their anatomy as a breast.

History

Standards of care

Surgeons providing gender-affirming care should follow the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC). Criteria for surgical treatment, including diagnosis of persistent gender dysphoria, should be documented in the preoperative evaluation. As with all procedures, patients should understand the potential risks, benefits and expected postoperative course of these procedures and should have the ability to make informed decisions and consent to treatment.

Patient undergoing gender-affirming mastectomy or breast augmentation require one referral letter from a qualified mental health professional according to the WPATH SOC. Individuals undergoing gender-affirming breast augmentation should ideally have a minimum of 12 months of continuous hormone therapy such that endogenous breast growth assists with surgical planning. Those undergoing gender-affirming mastectomy do not require preoperative hormone therapy. Box 16.1 summarizes preoperative WPATH SOC for patients undergoing gender-affirming mastectomy and breast augmentation. Copies of referral letters should be included in the medical record and sent to insurance as supporting documents for authorization.

Best practices

It is critical for all healthcare providers caring for transgender and non-binary individuals that they create a safe and affirming environment. Foremost, this entails not treating gender incongruence as a pathologic diagnosis, but instead applying gender identity as another demographic variable that is critical to the patient’s experience of surgery. Understanding and utilizing appropriate terminology and pronouns is a core component to the delivery of affirming care. Importantly, this also extends to communication and documentation within the medical record. Utilizing a two-step method by first asking a patient’s gender identity followed by their assigned sex at birth is a useful means of obtaining gender information.

We document patients’ chosen name, gender identity and pronouns throughout the electronic medical record including on case bookings, office visit summaries and operating room schedules. Organ inventories are also a useful means of recording organs that have been removed and those that remain. This documentation can help guide efficient preventative care and cancer screening in a trans- and gender non-binary affirming manner. Perioperative care should be inventoried for practices that have previously been sex specific and adjusted accordingly. For example, we request a urine pregnancy test for all patients who have retained a uterus and ovaries, and this is explained in the preoperative education visit.

Gender-affirming care is typically best provided by a multidisciplinary team, with close collaboration among surgeons, medical specialists, endocrinologists and mental health providers. This team can be within one center or practice, or can involve interprofessional collaboration with referring providers at external facilities. The healthcare facility or system must also support and facilitate an affirming environment. All healthcare personnel interacting with patients in this setting, from administrative staff to anesthesia, should be appropriately trained to deliver affirming care.

General preoperative considerations

A thorough history is an important component of the preoperative evaluation. Any prior surgical or non-surgical gender-affirming procedures are noted. Preventative health and prior cancer screening should be documented. Assessment of certain risk factors for complications such as high body mass index (BMI), medical comorbidities and smoking is critical. Active smokers are provided with cessation counseling and cotinine testing is done routinely to test for tobacco use prior to proceeding with surgery. A complete understanding of a patient’s overall health facilitates appropriate patient selection and counseling on potential risks of complications.

In addition to documentation of gender identity and pronouns, dates of social transition and initiation of hormone therapy should be noted. If the patient is on hormones, current hormone medications, dosages, prior medications and their hormone provider should also be obtained.

Mental health support is an important aspect of the entire spectrum of gender-affirming care. Psychiatric morbidity in the transgender and non-binary population stems from multiple sources including abuse, marginalization, rejection and discrimination. However, it is important not to stigmatize psychosocial issues. This can occur by pathologizing gender dysphoria, as well as by instituting psychotherapy requirements prior to surgical interventions. Such requirements are cautioned against by the WPATH SOC as they can actually serve as barriers to meaningful engagement. It is helpful to communicate to patients that the requirement for a mental health referral is not supposed to be a test of “true” gender identity (no such tests exist) or longitudinal psychotherapy, but ideally a holistic supportive space for psychosocial support and collaborative planning. Mental health providers should be advocates for psychosocial well-being, screen for potential morbidity, and offer mental health support to all patients. This support can be offered not only before surgery is scheduled, but also to assist with peri- and postoperative challenges if they arise. Having trusted referral relationships with mental health providers who have articulated this practice philosophy benefits patients.

Preoperative patient education is necessary for both gender-affirming mastectomy and breast augmentation. This conversation extends beyond the simple “risks and benefits” of each procedure, and should include a thorough discussion of all available treatment options (including doing nothing), the expected postoperative recovery, and the expected individualized postoperative outcomes. Preoperative discussions should not be a one-way conversation. If given the chance, patients may articulate an aesthetic vision which does not match expectations. The surgeon must listen to patient concerns and desires in order to establish an appropriate surgical plan together with the patient through a process of shared decision-making. Caregivers and sources of support during the recovery period should be identified preoperatively and the caregiver should be included in the care plan.

Finally, insurance coverage of gender-affirming procedures should be discussed with patients preoperatively. Since the reversal of Medicare exclusion of transgender surgical services in 2014, most federally subsidized health programs as well as third-party payer provide coverage for gender-affirming mastectomy and breast augmentation. Insurance providers should follow WPATH SOC, though may misinterpret or impose unnecessary additional barriers, which can be challenged or reversed. Thus, familiarity with these SOC and thorough documentation is critical to facilitating coverage. In the case that procedures are not covered by insurance, patients must understand the additional potential costs associated with surgeries, such as pathologic analysis of breast tissue sent from gender-affirming mastectomy specimens or revision surgery. Honest and frank conversation on these matters preoperatively can minimize confusion and frustration from these issues for both the patient and provider.