Values and Evidence in Gender-Affirming Care.

This commentary responds to the article "What Is the Aim of Pediatric 'Gender-Affirming' Care?," by Moti Gorin, in the same issue of the journal. Gender-affirming care is often treated as exceptional and subject to heightened scrutiny. This exceptionalization results in its being held to stricter evidentiary standards than other forms of medical interventions are. But values and value judgments are inextricable from the practice of evidence-based medicine. For gender-affirming care, values shape what counts as "strong" evidence, whether the legitimacy of transgender identity is assumed versus treated as something to be investigated, how to characterize the testimonial accounts of trans and gender-nonconforming patients, and more. We argue that these kinds of questions are part of the practice of medicine, not exceptional to transgender people and gender-affirming care. However, litigation of evidence for gender-affirming care in state and national policy underscores the moral urgency of thinking carefully about what values ought to guide evidence.

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today.

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.