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.

The Impact of COVID-19 on Rates of Pressure Injuries Among Hospitalized Patients across the US.

OBJECTIVE: To determine the impact of the COVID-19 pandemic on hospital-acquired pressure injury (HAPI) rates and composition of HAPI stages among hospitalized patients across the US. METHODS: Using encounter-level data from a nationwide healthcare insurance claims database, the authors conducted a retrospective cohort study and an interrupted time-series analysis to determine HAPI rates among hospitalized patients within 90 days of admission before (January 2018 to February 2020) and after (March 2020 to December 2020) the onset of the COVID-19 pandemic. Of 3,418,438 adult patients assessed for inclusion in the study, 1,750,494 met the inclusion criteria. Outcomes measured included the presence of a HAPI within 90 days of admission and HAPI stage based on the International Classification of Diseases, 10th Revision diagnosis codes. RESULTS: The authors identified HAPIs in 59,175 episodes of care, representing 59,019 unique patients and corresponding to an overall HAPI rate of 2.65%. Baseline characteristics did not vary significantly across the two time periods. Further, HAPI rates were consistent across the time periods analyzed with no significant differences in rates following the onset of the pandemic (P = .303). Composition of HAPI stages remained consistent across the pandemic (unspecified, stages 1-4, Ps = .62, .80, .22, .23, and .52, respectively) except for a significant decrease in unstageable/deep tissue pressure injuries (-0.088%, P = .0134). CONCLUSIONS: Although hospital resources were strained at the peak of the COVID-19 pandemic, no differences were identified in HAPI rates among the study's cohort of privately insured patients.

BMI is Not Associated with Chest-Specific Body Image, Complications or Revisions in Gender-Affirming Mastectomy: A Single-Center Cross-Sectional Study.

OBJECTIVE: To analyze the impact of Body Mass Index (BMI) on clinical and patient-reported outcomes following gender-affirming mastectomy (GM). BACKGROUND: BMI is a barrier for obese patients seeking GM despite increasing evidence that it is safe in this population. Currently little is known about the impact of BMI on chest-specific body image and satisfaction following GM. METHODS: This single-center, cross-sectional study included individuals 18 years and older who underwent GM between 1990-2020 and were at least 2 years post-operative. Patient-reported chest-specific body image was measured using the BODY-Q and Gender Congruence and Life Satisfaction (GCLS) chest subscales. Satisfaction was measured using the Holmes-Rovner Satisfaction with Decision (SWD) scale. Clinical and demographic variables were identified from chart review. Bivariate analysis was performed to determine if BMI was associated with chest-specific body image, satisfaction, complications within 30 days or revisions in GM. RESULTS: Two hundred twenty-seven individuals meeting eligibility criteria were contacted to participate and one hundred thirty-seven responded (60.4% response rate). The mean age was 29.1 (SD=9.0) and mean BMI was 30.9 (SD=8.0), with 26.4% (N=60) of the cohort having a BMI>35. Chest-specific body image, and satisfaction with decision did not vary by BMI or breast resection weight. Complications and revisions were not associated with BMI. CONCLUSION: Individuals undergoing GM reported high rates of satisfaction following GM regardless of BMI. Complication and revision rates did not vary significantly by BMI or breast resection weight. Surgeons should re-evaluate the role BMI plays in patient selection and counseling for GM.

Travel distance and national access to gender-affirming surgery.

BACKGROUND: Gender-affirming surgery is unequally distributed across the United States due to resource allocation, state-based regulations, and the availability of trained physicians. Many individuals seeking gender-affirming surgery travel vast distances to receive care. This study aims to quantify the distances that individuals travel to receive gender-affirming surgery based on procedure type and patient home-of-record location. METHODS: Patients in the Optum Clinformatics Data Mart who underwent gender-affirming surgery were identified via Current Procedural Terminology codes. Data on patient demographics, procedural care, and location of patient and provider were collected. To be included, a patient had to meet diagnostic criteria to receive gender-affirming surgery and have a recorded surgical procedure reimbursed as part of gender-affirming surgery per the Centers for Medicare and Medicaid Services guidelines. Patients residing or receiving care outside the continental United States were excluded. Distances between the ZIP Code of each patient's home of record and the location where the gender-affirming surgery was performed were calculated via the Google Maps Distance Matrix API. Distance traveled for gender-affirming surgery by patient state and gender-affirming surgery procedure were determined. Multivariate linear regression analysis determined predictors of distance traveled for gender-affirming surgery, whereas multivariate logistic regression identified variables associated with an increased likelihood of out-of-state travel to gender-affirming surgery. RESULTS: Across 86 million longitudinal patient records, the study population included 2,743 records corresponding to 1,735 patients who received gender-affirming surgery between January 2003 and June 2020. The median distance traveled for gender-affirming surgery was 191 miles (mean: 391.5), and 36.0% of patients traveled out of their state of residence. Every patient from West Virginia, Wyoming, South Dakota, Mississippi, and Delaware traveled out of state for gender-affirming surgery. Patients with homes of record in California (18.4%), Massachusetts (20.7%), and Oregon (19.0%) were the least likely to travel out-of-state for gender-affirming surgery out of states with more than 10 gender-affirming surgery encounters. The main predictors for out-of-state travel included both feminizing and masculinizing genital surgery, as well as an insurance coverage with increased provider options. Additionally, patients traveled shorter distances for gender-affirming surgery after the post-2014 Affordable Care Act expansion compared to pre-2014. CONCLUSION: Patients receiving gender-affirming surgery in the United States travel great distances for their care, often receiving their care from out-of-state providers. Restrictive guidelines imposed by state laws on both the access to and provision of gender-affirming surgery compound the myriad of common difficulties that patients face. It is imperative to discuss potential factors that may mitigate these barriers for those who require gender-affirming surgery.

Strengthening Association through Causal Inference.

SUMMARY: Understanding causal association and inference is critical to study health risks, treatment effectiveness, and the impact of health care interventions. Although defining causality has traditionally been limited to rigorous, experimental contexts, techniques to estimate causality from observational data are highly valuable for clinical questions in which randomization may not be feasible or appropriate. In this review, the authors highlight several methodologic options to deduce causality from observational data, including regression discontinuity, interrupted time series, and difference-in-differences approaches. Understanding the potential applications, assumptions, and limitations of quasi-experimental methods for observational data can expand our interpretation of causal relationships for surgical conditions.

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy.

Importance: There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments. Objective: To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy. Design, Setting, and Participants: For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020. Exposure: Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy. Main Outcomes and Measures: Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders. Results: A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses. Conclusions and Relevance: In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

State Restrictions and Geographic Access to Gender-Affirming Care for Transgender Youth.

This study estimates changes in geographic access and drive times to gender clinics following legislation enacted to restrict puberty-suppressing medications and hormones for those younger than 18 years.

Rectal Injury during Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management.

BACKGROUND: Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. METHODS: Adult patients who underwent PIV at the authors' institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. RESULTS: Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. CONCLUSION: The authors' algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Gender Affirming Mastectomy Improves Quality of Life in Transmasculine Patients: A Single-center Prospective Study.

OBJECTIVE: To determine the impact of gender-affirming mastectomy on depression, anxiety, and body image. BACKGROUND: There are many cross-sectional and ad-hoc studies demonstrating the benefits of gender-affirming surgery. There are few prospective investigations of patient-reported outcomes in gender-affirming surgery using validated instruments. METHODS: In this prospective study, patients presenting to the University of Michigan for gender-affirming Mastectomy were surveyed preoperatively and 6-months postoperatively. Primary outcomes were patient-reported measurements of anxiety measured by General Anxiety Disorder-7, depression measured by Patient Health Questionnaire-9, body image measured by BODY-Q and Body Image Quality of Life Index, psychosocial and sexual functioning measured by BREAST-Q, and satisfaction with decision measured by BREAST-Q. Linear regression analysis was used to control for presence of complication and existing history of mental health conditions. RESULTS: A total of 70 patients completed the study. The average age of participants was 26.7. The mean Patient Health Questionnaire-9 score pre-operatively was 7.8 and postoperatively was 5.4 ( P =0.001). The mean preoperative and postoperative General Anxiety Disorder-7 scores were 7.6 and 4.6, respectively ( P <0.001). There were significant improvements in both psychosocial (35 to 79.2, P <0.001) and sexual (33.9 to 67.2, P< 0.001) functioning related to chest appearance as measured by the BREAST-Q and global psychosocial functioning (-15.6 to +32, P <0.001) as measured by the Body Image Quality of Life Index. Satisfaction with chest contour (14.3 to 93.8, P <0.001) and nipple appearance (29.3 to 85.9, P <0.001) measured by the BODY-Q significantly improved. Patients had a mean satisfaction with outcome score of 93.1. CONCLUSIONS: Patients undergoing gender-affirming mastectomy in this single-center prospective study reported significant improvements in anxiety, depression, body image, psychosocial, and sexual functioning after this procedure. Patients were extremely satisfied with the decision to undergo this operation.

Treatment Preferences and Gender Affirmation of Nonbinary and Transgender People in a National Probability Sample.

Although visibility of nonbinary gender identities continues to improve in the United States, there is still a paucity of medical literature on the unique needs and experiences of nonbinary individuals. Using the TransPop survey, we compared gender-affirming treatment preferences and societal affirmation among nonbinary individuals, transmen, and transwomen using bivariate analysis and multivariable linear regression. Nonbinary individuals had or desired surgery and hormones at lower rates compared with binary transgender individuals. Nonbinary respondents had lower rates of adjusted and nonadjusted societal affirmation. This study showed variation in both treatment preferences and societal affirmation, which should be considered in clinical care and research studies clustering transgender and nonbinary individuals in analysis.

Common Revisions after Penile Inversion Vaginoplasty: Techniques and Clinical Outcomes.

SUMMARY: Up to one-third of patients are reported to undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty. The most commonly performed revisions are posterior introital web release, clitoroplasty, labiaplasty, and urethroplasty. To illustrate effective strategies for each of these revisions, this Video Plus article reviews the case of a 32-year-old transgender woman undergoing revision surgery to correct functionally limiting posterior introital webbing and to improve clitoral and labial appearance. Intraoperative steps and postoperative considerations are detailed in the accompanying videos.

An Evaluation of Racial Diversity in Craniofacial Surgery Literature.

ABSTRACT: Implicit bias can lead to discrimination of certain populations within healthcare. Representation in medical literature is no exception and it is hypothesized that images with lighter skin tone are more prevalent than darker skin tones in craniofacial literature. Clinical photographs and figure graphics from 5 journals were examined for pre-defined years. Annals of Plastic Surgery, Aesthetic Surgery Journal, Journal of Craniofacial Surgery, Journal of Plastic, Reconstructive and Aesthetic Surgery, and Plastic and Reconstructive Surgery journals were reviewed. All craniofacial-focused articles containing at least one color image depicting human skin were included. 10,477 images and 627 graphics were evaluated using the Fitzpatrick scale as a guide. Most journals trended toward broader inclusion of nonwhite photographs and graphics over time. In 2016, 47% of articles published in Journal of Craniofacial Surgery included nonwhite images compared to Annals of Plastic Surgery (16%), Aesthetic Surgery Journal (40%), Journal of Plastic, Reconstructive and Aesthetic Surgery (25%), and Plastic and Reconstructive Surgery (7%). Comparison of domestic and international publications demonstrated that author's country of origin impacted the percentage of nonwhite clinical photographs for most journals. Comparisons of publications by country demonstrated increased diversity in Asia and the Middle East for clinical photographs but not graphics. The frequency of nonwhite figure graphics was staggeringly low, identified in only 18 articles across all journals and years. Craniofacial literature more commonly reflects white skin tones. The trend over time suggests increasing inclusion of racial diversity in clinical photographs; however, figure graphics remain less racially diverse. Time, country of origin, and publishing journal appear to play a role.

Factors Associated With State-Specific Medicaid Expansion and Receipt of Autologous Breast Reconstruction Among Patients Undergoing Mastectomy.

Importance: Despite demonstrated psychosocial benefits, autologous breast reconstruction remains underutilized. An analysis of the association between Medicaid expansion and autologous breast reconstruction has yet to be performed. Objective: To compare autologous breast reconstruction rates and determine the association between Medicaid expansion and breast reconstruction. Design, Setting, and Participants: A retrospective cross-sectional study was performed using the State Inpatient Database from January 1, 2012, through September 30, 2015, and included 51 340 patients. Patients were identified using the International Classification of Diseases, Ninth Revision, codes for breast cancer, mastectomy, and autologous breast reconstruction. Data from states that expanded Medicaid (New Jersey, New York, and Washington) were compared with states that did not expand Medicaid (Florida, North Carolina, and Wisconsin). Data were analyzed from June 1, 2020, through February 28, 2021. Exposures: The Patient Protection and Affordable Care Act's Medicaid expansion was implemented in 2014; the preexpansion period ranged from 2012 to 2013 (2 years), whereas the postexpansion period ranged from 2014 to 2015 quarter 3 (1.75 years). Main Outcomes and Measures: Primary outcomes included use of autologous breast reconstruction before and after expansion. Independent covariates included patient demographics, comorbidities, and state of residence. Results: Among 45 850 patients who underwent mastectomy and 9215 patients who received autologous breast reconstruction, 36 777 (67%) were White and 32 205 (59%) had private insurance. The use of immediate or delayed autologous reconstruction increased from 18.1% (4951 of 27 290) to 23.0% (4264 of 18 560) throughout the study period. Compared with 2012, the odds of reconstruction were 64% higher in 2015 (odds ratio [OR], 1.64; 95% CI, 1.48-1.80; P < .001). African American (OR, 1.43; 95% CI, 1.33-1.55; P < .001) and Hispanic (OR, 1.44; 95% CI, 1.31-1.60; P < .001) patients had higher odds of reconstruction compared with White patients regardless of state of residence. However, Medicaid expansion was associated with a 28% decrease in the odds of reconstruction (OR, 0.72; 95% CI, 0.61-0.87; P < .001) for African American patients, a 40% decrease (OR, 0.60; 95% CI, 0.50-0.74; P < .001) for Hispanic patients, and 20% decrease (OR, 0.80; 95% CI, 0.67-0.96; P = .01) for patients with Asian, Native American, or other minority race/ethnicity. Medicaid expansion was not associated with changes in the odds of reconstruction for White patients. Conclusions and Relevance: In this cross-sectional study, although the odds of receiving autologous breast reconstruction increased annually, Medicaid expansion was associated with decreased odds of reconstruction for African American patients, Hispanic patients, and other patients of color.