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BACKGROUND: The COVID-19 pandemic prompted surgical volume reductions due to lockdown measures. This study evaluates COVID-19's impact on gender-affirming surgery (GAS) volume and complications from the pandemic onset through the recovery period. METHODS: The 2019-2021 National Surgical Quality Improvement Program databases were queried for transgender or gender-diverse patients using ICD-10 codes. Five time periods were analyzed: Pre-pandemic, Immediate pre-pandemic and COVID-19 outbreak, Initial COVID-19 peak, Pre-COVID-19 vaccine, and Post-vaccine release. Complications included reoperation, urinary tract infections, and wound complications. Multivariate logistic regressions assessed factors associated with undergoing surgery during the initial COVID-19 peak and experiencing surgical complications. RESULTS: Out of 2,963,230 patients, 4637 underwent GAS between 2019 and 2021. Chest feminizing and masculinizing procedures comprised 60.1% of all GAS. During the initial COVID-19 peak, all GAS surgeries nearly halved, with breast augmentations dropping to 15.3% of pre-pandemic volumes. White patients constituted a significantly higher proportion of GAS patients during the initial COVID-19 peak than in 2019 (74.7% vs. 61.0%, p = 0.014). Post-vaccine, GAS levels surged, exceeding pre-pandemic volumes by 45.5% and initial peak levels by 188.5%. The overall complication rate was 4.9%, and was significantly associated with older age, increased operative time, feminizing and masculinizing genital surgeries, and hysterectomies. The initial COVID-19 peak showed no significant correlations with surgical complications. CONCLUSIONS: GAS volume temporarily decreased during the initial COVID-19 outbreak and has since rebounded and surpassed pre-pandemic levels, corresponding with past-decade trends. Complication risks remained consistent despite the pandemic, though the results highlight potentially significant race-based disparities in GAS access during COVID-19. IMPORTANT POINTS: During the COVID-19 pandemic, public health measures led to severe volume reductions in gender-affirming surgical (GAS) procedures. Since the initial COVID-19 peak, GAS volumes have fully recovered and surpassed pre-pandemic volumes. Surgical complication rates for various GAS procedures were within expected ranges, emphasizing the overall safety of these surgeries. The study's results highlight racial disparities in undergoing GAS during the COVID-19 pandemic, with White patients disproportionately represented among those who had surgery during the COVID-19 lockdown. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .
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Purpose: Transgender and gender-diverse (TGD) individuals in the United States face disproportionate barriers to health care access. This study compared characteristics of individuals who have and have not undergone gender-affirming surgery with the goal of identifying social and systemic barriers to transition-related surgery. Methods: Data were extracted from the 2015 United States Transgender Survey, a cross-sectional nonprobability sample of nearly 28,000 TGD adults. The primary outcome was having undergone gender-affirming surgery. Multivariable logistic regression models were constructed to determine correlates of receipt of gender-affirming surgery. A subgroup analysis was performed to explore differences by insurance types regarding coverage of surgical procedures and presence of in-network providers. Results: In total, 6009 (21.7%) participants underwent transition-related procedures. Increased odds of undergoing surgery were associated with older age, living in congruent gender, higher education attainment, and greater income. Decreased odds were linked with male sex assignment at birth, first recognizing TGD status at older ages, living in states without trans-protective health laws, no close transgender-knowledgeable health care provider, nonbinary status, and identifying as sexual minority. Residing in states without trans-protective health laws correlated with increased surgery denials over the previous 12-month period. Compared to White TGD individuals, TGD individuals who were Black, Latinx, or Another Race were significantly more likely to encounter health equity-related barriers to surgery. Conclusions: Gender-affirming surgery access is differentially distributed across demographic and modifiable equity-related factors amenable to interventions. Efforts are needed to address the number and geographic distribution of transgender health-competent providers, improve TGD legal protections, and increase access to health insurance for minority TGD individuals, who are disproportionately under/uninsured.
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OBJECTIVE: To the evaluate the readability and comprehensiveness of genitourinary and sexual health-related patient-reported outcomes (PROMs) used in gender-affirming care. METHODS: Common PROMs that measure genitourinary and sexual health-related outcomes in gender-affirming care literature were identified from six recent systematic reviews. Readability analysis was completed at the level of individual items and full scale using established readability assessment tool, including Flesch Kincaid Grade Level (FKGL), Gunning Fog Score (GF), Coleman Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG) Index. The concepts measured by the PROMs were evaluated for comprehensiveness. RESULTS: Twenty-five PROMs were included, of which 12 assessed genitourinary outcomes and 13 assessed sexual health outcomes. A total of seven genitourinary domains and eight sexual health domains were identified during concept mapping. Readability analysis showed a median PROM grade level of 9.0 and 9.5 in genitourinary and sexual PROMs, respectively. The Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction v2.0 had the lowest median reading grade level of 5.7, and the Female Sexual Function Index has the highest median reading grade level of 13.9. No single PROM was found to be comprehensive. Multiple PROMs contained double-barreled items or used outdated terminology. CONCLUSION: Most PROMs used in the genital gender-affirming literature failed to meet the readability recommendations for patient-facing material and were culturally unfit for use in transgender and gender-diverse individuals. None of the PROMs were found to be comprehensive for evaluating outcomes of gender-affirming care. Validated gender-affirming care-specific PROMs that are comprehensible, comprehensive, and relevant are urgently needed.
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Objective: Nerve scarring after traumatic or iatrogenic exposure can lead to impaired function and pain. Nerve-adjacent biomaterials promoting a regenerative tissue response may help reduce perineural fibrosis. Our prior work suggests that testosterone may promote fibrotic skin scarring, but it is unknown how testosterone alters nerve fibrosis or shifts the response to biomaterials. Approach: Sterilized Lewis rats received either testosterone cypionate (+T) or placebo (-T) biweekly. Fifteen days later, wounds were created over the sciatic nerve and covered with an acellular matrix (AM) or closed via primary closure (PC). At day 42, force gauge testing measured the force required to mobilize the nerve, and wound tissue was analyzed. Results: Nerve mobilization force was greater in +T versus -T wounds (p < 0.01). Nerves tore before gliding in 60% of +T versus 6% of -T rats. Epidermal gap (p < 0.01), scar width (p < 0.01), and cross-sectional scar tissue area (p = 0.02) were greater in +T versus -T rats. +T versus -T rats expressed less Col-3 (p = 0.02) and CD68 (p = 0.02). Nerve mobilization force trended nonsignificantly higher for PC versus AM wounds and for +T versus -T wounds within the AM cohort. Innovation: Testosterone increases nerve tethering in the wound healing milieu, altering repair and immune cell balances. Conclusion: Testosterone significantly increases the force required to mobilize nerves in wound beds and elevates histological markers of scarring, suggesting that testosterone-induced inflammation may increase perineural adhesion. Testosterone may reduce the potential anti-tethering protective effect of AM. Androgen receptor antagonism may represent a therapeutic target to reduce scar-related nerve morbidity.
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Cobertura del Seguro , Cirugía de Reasignación de Sexo , Humanos , Cobertura del Seguro/legislación & jurisprudencia , Cobertura del Seguro/estadística & datos numéricos , Cobertura del Seguro/economía , Cirugía de Reasignación de Sexo/legislación & jurisprudencia , Cirugía de Reasignación de Sexo/economía , Adolescente , Adulto , Femenino , Masculino , Estados Unidos , Personas Transgénero/legislación & jurisprudenciaRESUMEN
Gender affirmation is standard medical care, and community input is an essential component of patient-centered care. This study shares how our organization assessed patients' perceptions of health care organizations that provide gender-affirming care. Building on qualitative interview data, we distributed an online survey via a lesbian-gaybisexual-transgender-queer research firm. The survey was completed by 314 transgender individuals residing in 37 U.S. states and territories. Most respondents (69%) reported negative experiences seeking health care. Patients would travel long distances for competent providers and were more willing to seek care from an institution actively working to change a formerly negative reputation. Patients described high-quality organizations as prioritizing staff training (95.5%), having inclusive policies (93.3%), and hiring expert staff (86.0%). Programs should ensure cultural competency training for all staff. They should recruit and retain providers skilled in transgender medicine, especially trans-identified providers. Patient experience and reputation in the community influence where patients seek care.
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Atención Dirigida al Paciente , Personas Transgénero , Humanos , Personas Transgénero/psicología , Atención Dirigida al Paciente/organización & administración , Femenino , Masculino , Adulto , Persona de Mediana Edad , Estados Unidos , Adulto Joven , Aceptación de la Atención de Salud , Encuestas y CuestionariosRESUMEN
Hypertrophic scarring is a major source of morbidity. Sex hormones are not classically considered modulators of scarring. However, based on increased frequency of hypertrophic scarring in patients on testosterone, we hypothesized that androgenic steroids induce abnormal scarring and developed a preclinical porcine model to explore these effects. Mini-swine underwent castration, received no testosterone (noT) or biweekly testosterone therapy (+T), and underwent excisional wounding. To create a delayed wound healing model, a subset of wounds were re-excised at 2 weeks. Scars from postoperative day 42 (POD42) and delayed wounds (POD28) were harvested 6 weeks after initial wounding for analysis via histology, bulk RNA-seq, and mechanical testing. Histologic analysis of scars from +T animals showed increased mean fibrosis area (16 mm2noT, 28 mm2+T; p = .007) and thickness (0.246 mm2noT, 0.406 mm2+T; p < .001) compared to noT. XX+T and XY+T scars had greater tensile burst strength (p = .024 and p = .013, respectively) compared to noT swine. Color deconvolution analysis revealed greater deposition of type I and type III collagen as well as increased collagen type I:III ratio in +T scars. Dermatopathologist histology scoring showed that +T exposure was associated with worse overall scarring (p < .05). Gene ontology analysis found that testosterone exposure was associated with upregulation of cellular metabolism and immune response gene sets, while testosterone upregulated pathways related to keratinization and laminin formation on pathway analysis. In conclusion, we developed a preclinical porcine model to study the effects of the sex hormone testosterone on scarring. Testosterone induces increased scar tissue deposition and appears to increase physical strength of scars via supraphysiologic deposition of collagen and other ECM factors. The increased burst strength seen in both XX and XY animals suggests that hormone administration has a strong influence on scar mechanical properties independent of chromosomal sex. Anti-androgen topical therapies may be a promising future area of research.
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Cicatriz Hipertrófica , Humanos , Porcinos , Animales , Matriz Extracelular , Testosterona/farmacología , Colágeno Tipo I , LamininaRESUMEN
OBJECTIVE: To describe the current Medicaid coverage landscape for gender-affirming surgery across the United States at the procedure level and identify factors associated with coverage. BACKGROUND: Medicaid coverage for gender-affirming surgery differs by state, despite a federal ban on gender identity-based discrimination in health insurance. States that cover gender-affirming surgery also differ in which procedures are included in Medicaid coverage, leading to confusion among patients and clinicians. METHODS: State Medicaid policies in 2021 for gender-affirming surgery were queried for each of the 50 states and the District of Columbia (D.C.). State partisanship, state-level Medicaid protections, and coverage of gender-affirming procedures in 2021 were recorded. The linear correlation between electorate partisanship and total procedures covered was assessed. Pairwise t tests were used to compare coverage based on state partisanship and the presence or absence of state-level Medicaid protections. RESULTS: Medicaid coverage for gender-affirming surgery was covered in 30 states and Washington, D.C. The most commonly covered procedures were genital surgeries and mastectomy (n = 31), followed by breast augmentation (n = 21), facial feminization (n = 12), and voice modification surgery (n = 4). More procedures were covered in Democrat-controlled or leaning states, as well as in states with explicit protections for gender-affirming care in Medicaid coverage. CONCLUSIONS: Medicaid coverage for gender-affirming surgery is patchwork across the United States and is especially poor for facial and voice surgeries. Our study provides a convenient reference for patients and surgeons detailing which gender-affirming surgical procedures are covered by Medicaid within each state.
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Neoplasias de la Mama , Cirugía de Reasignación de Sexo , Personas Transgénero , Humanos , Masculino , Femenino , Estados Unidos , Medicaid , Identidad de Género , Cobertura del Seguro , Mastectomía , WashingtónRESUMEN
Purpose: Transgender and gender diverse (TGD) patients experience challenges in health care settings, including stigma, lack of culturally competent providers, and suboptimal gender-affirming care. However, differences in patient satisfaction between TGD patients compared with cisgender patients have been inadequately studied. This study aimed to assess such differences in patient satisfaction with care received in a large academic medical care system in Boston, Massachusetts. Methods: Routine patient satisfaction surveys were fielded from January to December 2021 and were summarized. Logistic regression models compared low net promoter scores (NPS; ≤6) between gender identity groups (cisgender women, transmasculine and nonbinary/genderqueer people assigned female at birth [AFAB], transfeminine and nonbinary/genderqueer people assigned male at birth) relative to cisgender men, adjusting for age, race, ethnicity, education, inpatient/outpatient service delivery, and distance from medical center. Results: Of 94,810 patients, 246 (0.3%) were TGD and 94,549 (99.7%) were cisgender. The mean age was 58.3 years (standard deviation = 16.6). Of the total sample, 17.0% of patients were people of color, 6.6% were Hispanic/Latinx, 48.6% were college graduates, and 2.6% had received inpatient care. In general, patient satisfaction with health care received was lower for TGD patients than for cisgender patients (7.3% vs. 4.5% reporting low NPS; adjusted odds ratio [aOR] = 1.14; 95% confidence interval [CI] = 0.70-1.85). Transmasculine and nonbinary/genderqueer patients AFAB had elevated odds of low NPS compared with cisgender men (8.8% vs. 3.6%; aOR = 1.71; 95% CI = 1.02-2.89). Conclusion: Future research is warranted to better understand factors driving lower ratings among TGD patients. Health care quality improvement efforts are needed to address gender identity inequities in care.
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Personas Transgénero , Transexualidad , Recién Nacido , Humanos , Femenino , Masculino , Persona de Mediana Edad , Identidad de Género , Satisfacción del Paciente , EtnicidadRESUMEN
BACKGROUND: Phalloplasty is among the most complex and technically demanding reconstructive surgeries. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There is little published on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap. METHODS: A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of two high-volume phalloplasty teams (Johns Hopkins/Brigham & Women's Hospital and GU Recon/Buncke Clinic) in treating patients with severe post-surgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision. RESULTS: Common complications of phalloplasty include urethral strictures and fistulae, diverticula, excess bulk, phalloplasty malposition, hypertrophic/keloidal scarring, and partial/total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus. CONCLUSIONS: Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications following phalloplasty.
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Importance: Sociodemographic and health characteristics of patients undergoing gender-affirming surgery (GAS) are currently unknown. Understanding these patient characteristics is vital to optimizing patient-centered care for transgender patients. Objective: To determine sociodemographic characteristics for the transgender population undergoing GAS. Collected sociodemographic information included the following: age, race/ethnicity, body metrics, hormone replacement therapy administration and duration, substance use, psychiatric comorbidities, and medical comorbidities. Evidence Review: A search of seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) was used to find all articles on GAS from inception through May 2019. The 15,190 articles were then subjected to two levels of screening, and articles unrelated to gender-affirming care, unavailable in English, n<5, and with no outcomes reporting were excluded. Textbook chapters and letters were also excluded. Findings: A total of 406 studies were fully extracted, with 307 studies reporting age (n=22,727 patients), 19 reporting race/ethnicity (n=1184), 74 reporting body metrics (body mass index [BMI] n=6852, height n=416, and weight n=475), 58 reporting hormone therapies (n=5104), 56 reporting substance use (n=1146), 44 reporting psychiatric comorbidities (n=574), and 47 reporting medical comorbidities (n=573). From the 406 studies, 80 were done in the United States. Regarding U.S. studies, 59 studies reported age (n=5365), 10 reported race/ethnicity (n=709), 22 reported body metrics (BMI n=2519), 18 reported hormone therapies (n=3285), 15 reported substance use (n=478), 44 reported psychiatric comorbidities (n=394), and 47 reported medical comorbidities (n=293). Age was the most reported characteristic, reported in 75.62% of studies (73.75% of U.S. studies). Race/ethnicity was the least commonly reported data, reported in 4.68% of studies (12.50% of U.S. studies). Conclusions and Relevance: The type of sociodemographic information reported by GAS studies is inconsistently reported. To improve patient-centered care for transgender patients, further work is needed to create a standardization of collected sociodemographic information.
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Penile inversion vaginoplasty is the most common gender-affirming genital surgery performed around the world. Although individual centers have published their experiences, expert consensus is generally lacking. Methods: Semistructured interviews were performed with 17 experienced gender surgeons representing a diverse mix of specialties, experience, and countries regarding their patient selection, preoperative management, vaginoplasty techniques, complication management, and postoperative protocols. Results: There is significant consistency in practices across some aspects of vaginoplasty. However, key areas of clinical heterogeneity are also present and include use of extragenital tissue for vaginal canal/apex creation, creation of the clitoral hood and inner labia minora, elevation of the neoclitoral neurovascular bundle, and perioperative hormone management. Pathway length of stay is highly variable (1-9 days). Lastly, some surgeons are moving toward continuation or partial reduction of estrogen in the perioperative period instead of cessation. Conclusions: With a broad study of surgeon practices, and encompassing most of the high-volume vaginoplasty centers in Europe and North America, we found key areas of practice variation that represent areas of priority for future research to address. Further multi-institutional and prospective studies that incorporate patient-reported outcomes are necessary to further our understanding of these procedures.
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BACKGROUND: Chest masculinization surgery is the most common gender-affirming procedure performed in transgender and gender-diverse individuals. While evidence on the health-related quality of life (HRQL) impact of chest masculinization is starting to emerge, data on health state utility values (HSUVs) associated with the surgery is largely missing. The objectives of this study were to estimate the HSUVs using EQ-5D for patients seeking chest masculinization surgery and assess the determinants of EQ-5D score at 6 months postoperatively. METHODS: Patients seeking chest masculinization at a single community plastic surgery clinic by 2 surgeons completed 3 patient-reported outcome measures - EQ-5D-3L, Patient Health Questionnaire (PHQ)-9, and BODY-Q Chest module - preoperatively and postoperatively at 6 weeks and 6-months. Friedman test was used to assess the differences in PROM scores at the 3 timepoints. Simple and backward stepwise regression analyses of 6-month postoperative EQ-5D scores were performed. RESULTS: A total of 113 patients (mean [SD] age, 25.7 [6.9] years) were included. The mean [SD] EQ-5D scores at preoperative, postoperative 6 weeks and 6 months were 0.81 [0.15], 0.84 [0.15] and 0.87 [0.12], respectively. Postoperatively, problems were most frequently reported in the dimensions "pain/discomfort" and "anxiety/depression". Preoperative PHQ-9 score was a predictor of 6-month postoperative EQ-5D scores following simple (p < 0.01) and backward stepwise linear regression analysis (p < 0.01). CONCLUSION: Chest masculinization was associated with an improvement in overall HRL at 6 months postoperatively; however, this did not achieve statistical significance. Preoperative depression severity was a significant determinant of postoperative HRL. Consequently, additional support must be offered to patients who have a higher level of preoperative depression.
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Calidad de Vida , Procedimientos Quirúrgicos Torácicos , Humanos , Adulto , Encuestas y Cuestionarios , Dolor , Análisis de Regresión , Estado de SaludRESUMEN
SUMMARY: Facial feminization surgery covers a broad spectrum of procedures across both hard and soft tissues. Despite the fact that this is a decidedly predictable surgery, because of the high demand for the procedures, a growing number of patients are requiring revision surgery, whether to correct unexpected results or to treat mid-term to long-term functional and aesthetic complications. This Special Topic article categorizes unsatisfactory outcomes encountered after forehead surgery, lower jaw surgery, and thyroid chondroplasty; key steps to avoid these pitfalls; and strategies for structured analysis and operative planning in revision cases.
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Procedimientos de Cirugía Plástica , Humanos , Masculino , Cara/cirugía , Frente/cirugía , Huesos Faciales/cirugía , Feminización/cirugíaRESUMEN
PURPOSE: To quantify changes in extraocular muscle (EOM) cross-sectional areas (CSA) on orbital imaging in patients with thyroid eye disease before and after teprotumumab treatment, and assess for correlation with clinical outcomes. METHODS: This retrospective study included thyroid eye disease patients treated with teprotumumab who had pre- and post-treatment CT imaging. Reformatted oblique coronal images were created for each orbit in a plane perpendicular to the optic nerve. EOM CSA measurements were performed by 2 radiographic reviewers and averaged. Primary outcomes included change in ratio of total EOM to orbit CSA, and of each individual muscle group to orbit CSA, before and after treatment. Secondary outcomes included subanalysis based on age (≥40, <40 years) and Clinical Activity Score (CAS) (≥4, <4), and comparison with clinical outcomes including CAS, Hertel exophthalmometry, Gorman diplopia score, and extraocular motility. RESULTS: Forty-eight orbits of 24 patients (16 female, mean age 57.9 years) were included. There was a significant reduction in the total EOM to orbit CSA ratio ( p < 0.01) and for each individual rectus muscle to orbit CSA ratio ( p < 0.01 for all groups). Total EOM to orbit CSA ratios were reduced for 21 patients (87.5%); this was statistically significant in 13 patients (54.2%). There was significant improvement in CAS, proptosis, diplopia, and EOM motility ( p < 0.01 for all categories). There was a significant correlation between reduction of EOM CSA, and reduction of diplopia ( p < 0.01) and EOM motility ( p < 0.01). CONCLUSIONS: EOM CSA is significantly reduced following treatment with teprotumumab, and correlates with clinical findings including improvement in extraocular motility and diplopia.
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Oftalmopatía de Graves , Músculos Oculomotores , Humanos , Femenino , Persona de Mediana Edad , Adulto , Músculos Oculomotores/diagnóstico por imagen , Oftalmopatía de Graves/diagnóstico , Oftalmopatía de Graves/tratamiento farmacológico , Diplopía/inducido químicamente , Diplopía/diagnóstico , Diplopía/tratamiento farmacológico , Estudios Retrospectivos , ÓrbitaRESUMEN
OBJECTIVE: To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging. MATERIALS AND METHODS: Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening. RESULTS: Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging. CONCLUSION: We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients.
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Uretra , Estrechez Uretral , Femenino , Humanos , Uretra/diagnóstico por imagen , Uretra/cirugía , Estrechez Uretral/diagnóstico por imagen , Estrechez Uretral/cirugía , Estrechez Uretral/epidemiología , Faloplastia , Estudios Retrospectivos , Tomografía Computarizada por Rayos XRESUMEN
Gender-affirming care for transgender and gender diverse (TGD) individuals is a multidisciplinary endeavor that requires organized efforts of many specialized practitioners. TGD individuals experience many health care barriers, including the scarcity of multidisciplinary teams formed to coordinate and deliver complex care in an efficient and affirming way. The Johns Hopkins Center for Transgender Health was founded in 2017 with the mission of decreasing health disparities and improving the health of the TGD community. The authors present their experience building the center around a service line model in which patients have 1 point of contact, they are tracked throughout the care process, and the multidepartmental practitioners involved in their care are aligned. This model allowed for a patient-centered experience in which all involved disciplines were seamlessly integrated and the patient could navigate easily among them. With the structure and mission in place, the next challenge was to develop an infrastructure for culturally competent care. Through competency training and adjustment of systems-based logistics, measures were put in place to prevent traumatic experiences, such as misgendering, use of culturally inappropriate vocabulary, and use of incorrect names. Partnerships among colleagues in the fields of plastic surgery, urology, gynecology, otolaryngology, anesthesia, psychiatry/mental health, internal medicine, endocrinology, fertility, nursing, social work, speech therapy, and pediatrics/adolescent care were necessary to provide the appropriate breadth of services to care for TGD patients. Since its inception, the center has seen steady and continual growth, with more than 2,800 patients in its first 5 years. By sharing their experience in creating and developing a center of excellence, the authors hope to provide a blueprint for others to expand health care quality and access for TGD individuals.
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Endocrinología , Ginecología , Personas Transgénero , Adolescente , Humanos , Niño , Personas Transgénero/psicología , Identidad de Género , Atención a la SaludRESUMEN
OBJECTIVE: Accumulating evidence demonstrates that gender affirming hormone therapy (GAHT) improves mental health outcomes in transgender persons. Data specific to the risks associated with GAHT for transgender persons continue to emerge, allowing for improvements in understanding, predicting, and mitigating adverse outcomes while informing discussion about desired effects. Of particular concern is the risk of venous thromboembolism (VTE) in the context of both longitudinal GAHT and the perioperative setting. Combining what is known about the risk of VTE in cisgender individuals on hormone therapy (HT) with the evidence for transgender persons receiving HT allows for an informed approach to assess underlying risk and improve care in the transgender community. OBSERVATIONS: Hormone formulation, dosing, route, and duration of therapy can impact thromboembolic risk, with transdermal estrogen formulations having the lowest risk. There are no existing risk scores for VTE that consider HT as a possible risk factor. Risk assessment for recurrent VTE and bleeding tendencies using current scores may be helpful when assessing individual risk. Gender affirming surgeries present unique perioperative concerns, and certain procedures include a high likelihood that patients will be on exogenous estrogens at the time of surgery, potentially increasing thromboembolic risk. CONCLUSIONS AND RELEVANCE: Withholding GAHT due to potential adverse events may cause negative impacts for individual patients. Providers should be knowledgeable about the management of HT in transgender individuals of all ages, as well as in the perioperative setting, to avoid periods in which transgender individuals are off GAHT. Treatment decisions for both anticoagulation and HT should be individualized and tailored to patients' overall goals and desired outcomes, given that the physical and mental health benefits of gender affirming care may outweigh the risk of VTE.