Gender confirmation surgery: diagnosis and management

Epidemiology

It is estimated that approximately 0.5%–1.3% of the population in the United States has gender dysphoria. In 2014, the prevalence of transgender individuals was estimated at 1.4 million, which was double the predicted estimate in 2011. This is consistent with other reports citing an increase in the number of patients (from 2000 to 2014) presenting with gender dysphoria. These findings are also consistent with the ASPS annual report indicating that 1759 transfeminine and 1497 transmasculine patients underwent gender confirmation surgery procedures in 2016. This represented an increase of 27% and 10%, respectively, when compared to the number of procedures performed in 2015. Historically, approximately three times as many individuals assigned male at birth as compared to individuals assigned female at birth sought genital surgery. This ratio may have existed for multiple reasons, including accessibility of surgeons, cost of surgical procedures, and available surgical options. However, with the increase in third party coverage as well as increased societal awareness and access to care, there has been a corresponding increase in the number of individuals assigned female at birth seeking gender confirmation surgery (GCS). In the senior author’s experience, the number of individuals assigned male at birth and the number of individuals assigned female at birth who seek GCS have equalized. Not all transgender individuals seek surgical intervention; surgical care is provided on an individualized basis in a manner consistent with the Standards of Care .

Change in coverage over time – Affordable Care Act

The increase in the number of surgical procedures has been partly attributed to an expansion of coverage by private insurers and government payors (Medicare and Medicaid). In 2014, the United States Department of Health and Human Services repealed the 1989 decision that banned Medicare reimbursement for gender confirming interventions. In addition, the nondiscrimination provision in the Health Program & Activities Provision of the Affordable Care Act forbade providers funded by the United States Department of Health and Human Services to deny healthcare based on gender identity ; this was an important step in allowing patients access to previously unaffordable and necessary surgical care. Many private insurers and state insurance plans quickly followed suit and expanded coverage for GCS. Despite this, transgender individuals, as compared to cisgender individuals, are still less likely to have health insurance. The 2015 US Transgender Survey reported that 55% of patients who sought surgery and 25% of those on hormones reported difficulty obtaining insurance coverage.

WPATH

The World Professional Association for Transgender Health (WPATH) is “an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect in transsexual and transgender health.” The vision of WPATH is “a world wherein transsexual, transgender, and gender nonconforming individuals benefit from access to evidence-based health care, social services, justice, and equality.” WPATH was formed in 1979 as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). Dr Harry Benjamin was one of the first physicians to care for transgender individuals. In 2007, HBIGDA underwent a name change to the World Professional Association for Transgender Health (WPATH). WPATH was instrumental in developing a framework for the multidisciplinary care of transgender individuals. One of WPATH’s main functions is to promote the highest standards of healthcare for individuals through the formulation of the “Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonbinary Individuals.” The guidelines were first published in 1979. The eighth version is currently in development, reflecting the evolution in care for transgender and gender diverse individuals. These flexible guidelines help frame the surgical management of transgender patients, with the goal of optimizing outcomes.

Expanded societal support/paradigm shift

The transgender population is often a marginalized and underserved group within the healthcare system. The Williams Institute reported that 33% of transgender individuals report a “bad experience” with healthcare. Experiences with transphobia, stigmatization, and microaggressions have been associated with many adverse healthcare outcomes. This, coupled with the fact that many healthcare providers are unfamiliar and unprepared to manage the healthcare needs of transgender individuals, has led many individuals to avoid medically necessary healthcare. Recently, there has been a paradigm shift; more transgender individuals are seeking medical care. In a recent survey of the general population in the United States, 60% of respondents aged 16–64 believed that the US was becoming more tolerant toward transgender individuals. The respondents also indicated that they want the US government to do more in terms of protection and support for the transgender community.

Terminology

When caring for transgender individuals, understanding the definitions of sex, gender, and sexual orientation are important. Gender and sex are distinct concepts that are often used interchangeably. Sex refers to the sex assigned at birth and is generally based on the anatomy of internal and external sex organs, hormones, and chromosomes. Gender is “socially, culturally and personally defined.” Psychosexual development and differentiation entails three major components:

• i.

  Gender identity , referring to one’s sense of belonging to the male or female sex category, both, or neither

• ii.

  Gender role , sexually dimorphic behaviors, and psychological characteristics within the population, such as toy preferences and mannerisms

• iii.

  Sexual orientation , one’s pattern of erotic responsiveness

As noted by the Institute of Medicine’s 2011 report, The Health of Lesbian, Gay, Bisexual, and Transgender People , “transgender people are defined according to their gender identity and presentation. This group encompasses individuals whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditionally associated with or typical for that sex (i.e., people identified as male at birth who subsequently identify as female, and people identified as female at birth who later identify as male), as well as other individuals who vary from or reject traditional cultural conceptualizations of gender in terms of the male–female dichotomy. The transgender population is diverse in gender identity, expression, and sexual orientation. Transgender individuals assigned male at birth are known as transgender women, or transwomen, while transgender individuals assigned female at birth are known as transgender men, or transmen. Some transgender individuals do not fit into either of these binary categories and may identify as non-binary, gender queer, or gender diverse. Previously, the term gender nonconformity was used to describe a difference between an individual’s gender identity, role, or expression and that of cultural norms; however, this term has generally been abandoned as it is deemed to be pejorative. Gender dysphoria describes the discomfort or distress experienced by an individual due to a discrepancy between one’s gender identity and the sex assigned at birth.

WPATH Standards of Care

WPATH developed the Standards of Care to help provide “the highest standards” of care for individuals. The Standards of Care state that the overarching treatment goal is “…lasting personal comfort with the gendered self, in order to maximize overall health, psychological well-being and self-fulfillment.” Toward this end, gender confirmation surgery provides the appropriate physical morphology and alleviates the extreme psychological discomfort of the patient. Furthermore, as discussed by Meyer et al . in 2001 and Cohen-Kettenis & Kuiper in 1984, adjusting the mind to the body is not an effective treatment, while adjusting the body to the mind is the best way to assist severely gender dysphoric persons. The Standards of Care , as outlined by WPATH, provide flexible guidelines to aid surgical management and optimize outcomes. The guidelines are flexible so as to meet the diverse healthcare needs of the transgender and gender diverse individuals. Table 14.1.1 outlines the Standards of Care for various gender confirmation surgeries. The Standards of Care are not intended as barriers to surgery, but rather as a means of identifying patients who would benefit from surgical management.

Mental health practitioners

Mental health practitioners play an important role in the evaluation of individuals experiencing gender dysphoria. Mental health professionals typically provide the diagnosis of gender dysphoria, assess for associated or co-occurring mental health diagnoses, and evaluate the patient’s personal support systems; all are key elements that can affect postoperative outcomes. The Standards of Care outline the need for the mental health professional to communicate their recommendations to the surgeon, often in the form of “referral letters”. Surgeons should be familiar with the Standards of Care and understand what constitutes an appropriate assessment ( Box 14.1.1 ).

Adolescent therapy

Over the past decade, an emerging area of clinical interest involves the treatment of transgender adolescents. Adolescents who identify as transgender overwhelmingly describe themselves as transgender as adults. Some adolescents consider the physical changes of puberty distressful, and may initiate treatment with puberty-suppressing medications, such as a gonadotropin releasing hormone (GnRH) analog. This helps to prevent (and/or delay) the development of irreversible secondary sex characteristics. The physical changes of puberty result from maturation of the hypothalamo-pituitary-gonadal axis and development of secondary sex characteristics. In individuals assigned female at birth, the first physical sign of puberty is often breast budding. In individuals assigned male at birth, an increase in testicular volume heralds the onset of puberty. Potential benefits of GnRH analogs include relief or amelioration of gender dysphoria and better psychological and physical outcomes. The hormonal changes are thought to be reversible. Many individuals choose to undergo mastectomy before the age of 18. While genital surgery is often performed after 18 years of age, some individuals do undergo genital gender confirming surgery prior to that. For individuals who have received pubertal blockers, modification of the surgical technique may be required.