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Breast anatomy and augmentation in transfeminine individuals
Augmentation mammaplasty, otherwise known as a breast augmentation, is one of the most common cosmetic procedures performed in cisgender females. Gynecologists routinely perform annual breast examinations and order screening mammography in cisgender women with breast implants. Similarly, there is an increasing number of transgender women seeking breast augmentation – with approximately 60%-70% of patients having desired or undergone the procedure.1 Consequently, these patients are instructed by their surgeons to follow up with gynecologists for annual examinations and screening. While there are many similarities in technique and procedure, there are nuances in patient demographics, anatomy, and surgical technique that obstetricians/gynecologists should be aware of when examining these patients or prior to referring them to a surgeon for augmentation.2
Many patients who are dissatisfied with breast size from hormone therapy alone will seek out augmentation mammaplasty. In patients taking estrogen for hormone therapy, breast growth will commence around 2-3 months and peak over 1-2 years.3 Unlike chest surgery for transmasculine individuals, it is recommended that transfeminine patients seeking breast augmentation wait a minimum of 12 months before to surgery to allow for maximum breast enlargement. As with breast growth in cisgender females, the extent of breast development is multifactorial and varies from individual to individual. Current literature does not suggest that estrogen type or dose affects the ultimate breast size; however, younger age, tissue sensitivity, and body weight may affect breast volume.3 Referral to a genetic counselor and preoperative imaging may be necessary if a patient has a history concerning for a genetic or familial predisposition to breast cancer.
Implant selection and placement is determined by a variety of factors. While the overall principles of augmentation mammaplasty are essentially the same, there are anatomic differences in transfeminine patients that surgeons must take into consideration at the time of the consultation and during the surgery itself. For example, the pectoralis major muscle is more defined, there is a longer sternal notch-to-nipple distance, the chest wall is broader and more barrel-shaped, and there is a shorter distance between the nipple and the inframammary crease.2-4 As a result of the broader chest wall, it is extremely difficult to achieve central cleavage even with larger implant selection. The surgeon must also ensure that the nipple and areola overlie the implant centrally. Medial placement of the implant will result in lateral displacement of the nipples, which can have an unsatisfactory cosmetic appearance.
Incision location can be axillary, inframammary, or even transareolar, although the latter is less common due to the smaller areolar size and larger implant choice.3 If the inframammary incision is used, it should be placed lower than the natural inframammary fold because the distance between the inferior areolar margin and inframammary fold is shorter and will expand after the implant is placed.4 While both saline and silicone implants are available, many surgeons (myself included), favor more form-stable silicone implants. Given the association between anaplastic large-cell lymphoma and textured implants, many surgeons also use nontextured, or smooth, cohesive gel silicone implants.5
Pocket selection of the implant itself can be subglandular – directly under the breast mound – or subpectoral – behind the pectoralis muscle. For patients with a pinch test of greater than 1.5 cm (outside of the area of the breast bud), good skin softening, and marked pectoralis hypertrophy, subglandular placement is reasonable.6 In thin patients with minimal breast development, subglandular placement can result in a “double-mound” appearance and can lead to visible implant edges on the periphery.6 Use of the subpectoral plane is more common and is associated with less implant visibility due to an increased amount of soft-tissue coverage and has lower rates of capsular contracture.4 However, due to the more robust pectoralis muscle in transfeminine patients, implant displacement can occur more frequently compared to subglandular placement. The surgeon and patient must have a thorough discussion about the location of the incision, implant material, and pocket placement along with the benefits and complications of the surgical plan.
Complications of augmentation mammaplasty are rare. However, when they occur it can include capsular contracture, breast asymmetry, hematoma formation, loss of nipple sensation, implant malposition, implant displacement below the inframammary crease, implant rupture, and need for revisional surgery.7 If an obstetrician/gynecologist observes any of the aforementioned findings in a postoperative patient, consultation and referral to a plastic surgeon is imperative.
Postoperative assessment and screening are mandatory in all patients who undergo breast augmentation. It is important for the gynecologist to note the incision placement, know the type of implant used (saline or silicone), and delineate where the implant was placed. If silicone implants are used, breast MRI is more sensitive in detecting implant rupture compared to mammography alone. Given the relatively poor epidemiologic data on breast cancer in transgender women, the Endocrine Society recommends that these patients follow the same screening guidelines as cisgender women.4,6
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Wierckx K et al. J Sex Med. 2014;11(5):1240-7.
2. Mehra G et al. Plast Reconstr Surg Glob Open 2021 Jan 21;9(1):e3362. doi: 10.1097/GOX.0000000000003362.
3. Schecter LS, Schechter RB. Breast and chest surgery for transgender patients. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia, PA: Elsevier, 2020:73-81.
4. Colebunders B et al. Top surgery. In: Salgado CJ et al. ed. Gender Affirmation: Medical and Surgical Perspectives. New York, NY: Thieme, 2017:51-66.
5. De Boer M et al. Aesthet Surg J. 2017;37:NP83-NP87.
6. Coon D et al. Plast Reconstr Surg. 2020 Jun;145(6):1343-53.
7. Kanhai RC et al. Br J Plast Surg. 2000;53:209-11.
Augmentation mammaplasty, otherwise known as a breast augmentation, is one of the most common cosmetic procedures performed in cisgender females. Gynecologists routinely perform annual breast examinations and order screening mammography in cisgender women with breast implants. Similarly, there is an increasing number of transgender women seeking breast augmentation – with approximately 60%-70% of patients having desired or undergone the procedure.1 Consequently, these patients are instructed by their surgeons to follow up with gynecologists for annual examinations and screening. While there are many similarities in technique and procedure, there are nuances in patient demographics, anatomy, and surgical technique that obstetricians/gynecologists should be aware of when examining these patients or prior to referring them to a surgeon for augmentation.2
Many patients who are dissatisfied with breast size from hormone therapy alone will seek out augmentation mammaplasty. In patients taking estrogen for hormone therapy, breast growth will commence around 2-3 months and peak over 1-2 years.3 Unlike chest surgery for transmasculine individuals, it is recommended that transfeminine patients seeking breast augmentation wait a minimum of 12 months before to surgery to allow for maximum breast enlargement. As with breast growth in cisgender females, the extent of breast development is multifactorial and varies from individual to individual. Current literature does not suggest that estrogen type or dose affects the ultimate breast size; however, younger age, tissue sensitivity, and body weight may affect breast volume.3 Referral to a genetic counselor and preoperative imaging may be necessary if a patient has a history concerning for a genetic or familial predisposition to breast cancer.
Implant selection and placement is determined by a variety of factors. While the overall principles of augmentation mammaplasty are essentially the same, there are anatomic differences in transfeminine patients that surgeons must take into consideration at the time of the consultation and during the surgery itself. For example, the pectoralis major muscle is more defined, there is a longer sternal notch-to-nipple distance, the chest wall is broader and more barrel-shaped, and there is a shorter distance between the nipple and the inframammary crease.2-4 As a result of the broader chest wall, it is extremely difficult to achieve central cleavage even with larger implant selection. The surgeon must also ensure that the nipple and areola overlie the implant centrally. Medial placement of the implant will result in lateral displacement of the nipples, which can have an unsatisfactory cosmetic appearance.
Incision location can be axillary, inframammary, or even transareolar, although the latter is less common due to the smaller areolar size and larger implant choice.3 If the inframammary incision is used, it should be placed lower than the natural inframammary fold because the distance between the inferior areolar margin and inframammary fold is shorter and will expand after the implant is placed.4 While both saline and silicone implants are available, many surgeons (myself included), favor more form-stable silicone implants. Given the association between anaplastic large-cell lymphoma and textured implants, many surgeons also use nontextured, or smooth, cohesive gel silicone implants.5
Pocket selection of the implant itself can be subglandular – directly under the breast mound – or subpectoral – behind the pectoralis muscle. For patients with a pinch test of greater than 1.5 cm (outside of the area of the breast bud), good skin softening, and marked pectoralis hypertrophy, subglandular placement is reasonable.6 In thin patients with minimal breast development, subglandular placement can result in a “double-mound” appearance and can lead to visible implant edges on the periphery.6 Use of the subpectoral plane is more common and is associated with less implant visibility due to an increased amount of soft-tissue coverage and has lower rates of capsular contracture.4 However, due to the more robust pectoralis muscle in transfeminine patients, implant displacement can occur more frequently compared to subglandular placement. The surgeon and patient must have a thorough discussion about the location of the incision, implant material, and pocket placement along with the benefits and complications of the surgical plan.
Complications of augmentation mammaplasty are rare. However, when they occur it can include capsular contracture, breast asymmetry, hematoma formation, loss of nipple sensation, implant malposition, implant displacement below the inframammary crease, implant rupture, and need for revisional surgery.7 If an obstetrician/gynecologist observes any of the aforementioned findings in a postoperative patient, consultation and referral to a plastic surgeon is imperative.
Postoperative assessment and screening are mandatory in all patients who undergo breast augmentation. It is important for the gynecologist to note the incision placement, know the type of implant used (saline or silicone), and delineate where the implant was placed. If silicone implants are used, breast MRI is more sensitive in detecting implant rupture compared to mammography alone. Given the relatively poor epidemiologic data on breast cancer in transgender women, the Endocrine Society recommends that these patients follow the same screening guidelines as cisgender women.4,6
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Wierckx K et al. J Sex Med. 2014;11(5):1240-7.
2. Mehra G et al. Plast Reconstr Surg Glob Open 2021 Jan 21;9(1):e3362. doi: 10.1097/GOX.0000000000003362.
3. Schecter LS, Schechter RB. Breast and chest surgery for transgender patients. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia, PA: Elsevier, 2020:73-81.
4. Colebunders B et al. Top surgery. In: Salgado CJ et al. ed. Gender Affirmation: Medical and Surgical Perspectives. New York, NY: Thieme, 2017:51-66.
5. De Boer M et al. Aesthet Surg J. 2017;37:NP83-NP87.
6. Coon D et al. Plast Reconstr Surg. 2020 Jun;145(6):1343-53.
7. Kanhai RC et al. Br J Plast Surg. 2000;53:209-11.
Augmentation mammaplasty, otherwise known as a breast augmentation, is one of the most common cosmetic procedures performed in cisgender females. Gynecologists routinely perform annual breast examinations and order screening mammography in cisgender women with breast implants. Similarly, there is an increasing number of transgender women seeking breast augmentation – with approximately 60%-70% of patients having desired or undergone the procedure.1 Consequently, these patients are instructed by their surgeons to follow up with gynecologists for annual examinations and screening. While there are many similarities in technique and procedure, there are nuances in patient demographics, anatomy, and surgical technique that obstetricians/gynecologists should be aware of when examining these patients or prior to referring them to a surgeon for augmentation.2
Many patients who are dissatisfied with breast size from hormone therapy alone will seek out augmentation mammaplasty. In patients taking estrogen for hormone therapy, breast growth will commence around 2-3 months and peak over 1-2 years.3 Unlike chest surgery for transmasculine individuals, it is recommended that transfeminine patients seeking breast augmentation wait a minimum of 12 months before to surgery to allow for maximum breast enlargement. As with breast growth in cisgender females, the extent of breast development is multifactorial and varies from individual to individual. Current literature does not suggest that estrogen type or dose affects the ultimate breast size; however, younger age, tissue sensitivity, and body weight may affect breast volume.3 Referral to a genetic counselor and preoperative imaging may be necessary if a patient has a history concerning for a genetic or familial predisposition to breast cancer.
Implant selection and placement is determined by a variety of factors. While the overall principles of augmentation mammaplasty are essentially the same, there are anatomic differences in transfeminine patients that surgeons must take into consideration at the time of the consultation and during the surgery itself. For example, the pectoralis major muscle is more defined, there is a longer sternal notch-to-nipple distance, the chest wall is broader and more barrel-shaped, and there is a shorter distance between the nipple and the inframammary crease.2-4 As a result of the broader chest wall, it is extremely difficult to achieve central cleavage even with larger implant selection. The surgeon must also ensure that the nipple and areola overlie the implant centrally. Medial placement of the implant will result in lateral displacement of the nipples, which can have an unsatisfactory cosmetic appearance.
Incision location can be axillary, inframammary, or even transareolar, although the latter is less common due to the smaller areolar size and larger implant choice.3 If the inframammary incision is used, it should be placed lower than the natural inframammary fold because the distance between the inferior areolar margin and inframammary fold is shorter and will expand after the implant is placed.4 While both saline and silicone implants are available, many surgeons (myself included), favor more form-stable silicone implants. Given the association between anaplastic large-cell lymphoma and textured implants, many surgeons also use nontextured, or smooth, cohesive gel silicone implants.5
Pocket selection of the implant itself can be subglandular – directly under the breast mound – or subpectoral – behind the pectoralis muscle. For patients with a pinch test of greater than 1.5 cm (outside of the area of the breast bud), good skin softening, and marked pectoralis hypertrophy, subglandular placement is reasonable.6 In thin patients with minimal breast development, subglandular placement can result in a “double-mound” appearance and can lead to visible implant edges on the periphery.6 Use of the subpectoral plane is more common and is associated with less implant visibility due to an increased amount of soft-tissue coverage and has lower rates of capsular contracture.4 However, due to the more robust pectoralis muscle in transfeminine patients, implant displacement can occur more frequently compared to subglandular placement. The surgeon and patient must have a thorough discussion about the location of the incision, implant material, and pocket placement along with the benefits and complications of the surgical plan.
Complications of augmentation mammaplasty are rare. However, when they occur it can include capsular contracture, breast asymmetry, hematoma formation, loss of nipple sensation, implant malposition, implant displacement below the inframammary crease, implant rupture, and need for revisional surgery.7 If an obstetrician/gynecologist observes any of the aforementioned findings in a postoperative patient, consultation and referral to a plastic surgeon is imperative.
Postoperative assessment and screening are mandatory in all patients who undergo breast augmentation. It is important for the gynecologist to note the incision placement, know the type of implant used (saline or silicone), and delineate where the implant was placed. If silicone implants are used, breast MRI is more sensitive in detecting implant rupture compared to mammography alone. Given the relatively poor epidemiologic data on breast cancer in transgender women, the Endocrine Society recommends that these patients follow the same screening guidelines as cisgender women.4,6
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Wierckx K et al. J Sex Med. 2014;11(5):1240-7.
2. Mehra G et al. Plast Reconstr Surg Glob Open 2021 Jan 21;9(1):e3362. doi: 10.1097/GOX.0000000000003362.
3. Schecter LS, Schechter RB. Breast and chest surgery for transgender patients. In: Ferrando CA, ed. Comprehensive Care of the Transgender Patient. Philadelphia, PA: Elsevier, 2020:73-81.
4. Colebunders B et al. Top surgery. In: Salgado CJ et al. ed. Gender Affirmation: Medical and Surgical Perspectives. New York, NY: Thieme, 2017:51-66.
5. De Boer M et al. Aesthet Surg J. 2017;37:NP83-NP87.
6. Coon D et al. Plast Reconstr Surg. 2020 Jun;145(6):1343-53.
7. Kanhai RC et al. Br J Plast Surg. 2000;53:209-11.
‘Don’t say gay’: The politicization of gender-diverse youth
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
The past several weeks have been rather tumultuous for LGBTQ Americans, particularly transgender youth. The Texas attorney general penned a legal opinion stating that hormone therapy and puberty blockers for transgender youth constitute “child abuse” under Texas law. Following the statement, Texas governor Greg Abbott swiftly issued a directive to protective services to launch investigations into families providing such services to their children. Almost simultaneously, the Florida Senate approved the Parental Rights in Education bill (dubbed the “Don’t Say Gay” bill by opponents), which limits how sexual orientation and gender identity are taught in the classroom.
Despite the benefits of gender-affirming care for gender-diverse youth, 22 states have introduced legislation that bans the provision of gender-affirming medical care under the age of 18, even with the consent of parents or legal guardians.1 Unfortunately, gender-diverse youth are more likely than are their cisgender peers to experience poverty, homelessness, depression, suicide, and violence.1 As a result of ongoing stigma, many gender-diverse patients are hesitant to seek out professional medical care, which includes mental health care, routine health care, and gender-affirming therapies. The positive effects of gender-affirming care for transgender youth are clear, and life saving for many. Gender-affirming medical interventions improve social and mental health outcomes, such as decreased suicidal ideation, depression, and improved peer relations that last until adulthood.1
As with all aspects in medicine, providers and families of gender-diverse youth need to balance the four ethical principles that guide decision-making and informed consent. For practitioners working with the pediatric/adolescent populations, the age at which pediatric or adolescent patients can truly provide consent or assent is still not determined.2 This presents a unique set of challenges in the realm of gender-affirming care particularly when children/adolescents and their parents have differing perspectives on proposed treatment plans. For example, when discussing fertility preservation, a 16-year-old patient is much more likely to understand implications of future fertility than a 9-year-old patient. Furthermore, providers must find the delicate balance between maximizing treatment benefits (beneficence) while minimizing harm (nonmaleficence), while also discussing the uncertainty about the long-term risks of gender-affirming treatments.2 The final obligation for health care providers is ensuring all patients have equitable access to care (justice) – which is why we must all oppose legislation that criminalizes treatment for gender-diverse youth, regardless of our individual opinions on gender-affirming care for patients.
Opponents of gender-affirming care for transgender youth often cite concern about permanent effects or psychological distress if a child begins gender-affirming therapy and then chooses to discontinue. While the medical community should be, and is alarmed about patients who detransition, the solution to limiting the number of patients who experience regret or detransition is most certainly not criminalizing or universally banning gender-affirming care for all patients.3 Experts in transgender medicine and surgery (some of whom are transgender themselves) have expressed apprehension regarding the evaluation of gender-diverse children and youth. The concern is not whether gender-diverse youth should receive gender-affirming treatments, but rather they questioned the assessments made by providers who may be less fully qualified to deliver treatment and who deviate from well-established standards of care.4 The logical solution would be to further improve upon the current standards of care, ensure providers have appropriate training, and to expand multidisciplinary models of gender-affirming centers for youth.
If politicians were truly worried about the welfare of gender-diverse children, there would be a shift in the allocation of funds or resources to improve research endeavors and establish effective multidisciplinary clinics to meet the needs of this marginalized patient population. While the medical community should carefully examine gender-affirming care in transgender youth, criminalizing care is unconscionable. Our community needs more evidence-based research, providers, and centers, not politics.
The LGBTQ community and providers are rightfully fearful of the repercussions of such legislation. And the politicians and supporters of such bills should be equally apprehensive of the negative consequences this legislation will have on the mental health of transgender youth.
While the model for gender-affirming medicine and surgery needs continual assessment to ensure all patients, regardless of age and goals of transition, are receiving evidence-based, quality care, these discussions and subsequent decision-making should occur among medical professionals, not among politicians and the lay press.4
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Hughes LD et al. ‘These laws will be devastating’: Provider perspectives on legislation banning gender-affirming care for transgender adolescents. J Adol Health;2021;69:976-82.
2. Kimberly LL et al. Ethical issues in gender-affirming care for youth. Pediatrics. Pediatrics;018;142(6)e20181537.
3. Ashley F. Psychol Sexual Orient Gender Divers. APA PsycNet. 2021.
4. Ault A. Transgender docs warn about gender-affirmative care for youth. WebMD. 2021 Nov. Accessed March 14, 2022.
Obstetrical care for gender diverse patients: A summary from the SMFM annual meeting
The purpose of this commentary is to provide a brief summary of discussions centering around reproductive health experiences and obstetrical care for gender-diverse patients from the recent Society of Maternal & Fetal Medicine meeting. Two presentations featured patient perspectives combined with physician lectures to provide a comprehensive outlook on unique reproductive care needs for this growing population.
One of the speakers, Trystan Reese, is a transgender activist, educator, and transgender male who chose to carry his own pregnancy and subsequently delivered his son in 2017. During the summit, he described many barriers that he faced during his pregnancy and offered providers suggestions on how to improve the care for members of the gender-diverse community seeking to start a family.
We often think of conception and pregnancy as experiences unique to one gender. This is simply not the case. In discussing preconceptual care and pregnancy, it is paramount for providers to make the distinction between gender identity and natal sex. Gender identity is an internal sense of self in relation to natal sex. Depending on this intrinsic feeling, people may identify as cisgender, transgender, or as a gender outside of the standard binary. Natal sex describes biologic characteristics such as chromosomal makeup, reproductive anatomy, and secondary sexual changes. In keeping these distinctions in mind, pregnancy is therefore exclusive to a person’s natal sex, not gender identity. One of the biggest challenges in caring for transgender patients who desire pregnancy, is the psychological distress related to the gendered notions surrounding this experience.1
There are many ways in which patients encounter unintentional marginalization within the medical system. For example, many electronic medical record systems don’t allow for pronouns or give error messages if the patient’s gender identity is different from their sex assigned at birth. Patients who attend prenatal appointments or birth classes are given documents that center around cisgender women and heterosexual relationships. The labor and delivery wards themselves typically include language such as “maternity,” and birth certificates have distinct “mother” and “father” denotations.1 Insurance coverage for prenatal care and delivery can be problematic if a patient who is assigned female at birth has changed their gender marker to “male” on their insurance card.
Many of these roadblocks can be ameliorated by utilizing more inclusive terminology. Terms such as “maternal” can be replaced with “pregnant patients, parent, or patients giving birth.” Names of maternity wards can be altered to perinatal units, which is more inclusive and more descriptive of the wide variety of patients that may experience childbirth and parenthood.1 Introducing “you-centered” language can also be helpful. Instead of saying “women may find ...” providers can try saying “patients may find ...” or “individuals may find.”1
Most of the medical and obstetrical care of gender-diverse patients is routine. Prenatal labs, aneuploidy screening, ultrasounds, and fetal surveillance do not differ between transgender and cisgender patients. However, the experience of pregnancy itself can significantly heighten feelings of dysphoria as it inherently leads to patients confronting aspects of their biological sex.2 Because of the teratogenic nature of testosterone, patients are required to stop taking testosterone prior to conception and for the duration of pregnancy. This can also heighten dysphoria and lead to increased rates of anxiety and depression.3
Many transgender patients can safely achieve a normal vaginal birth.4 A small survey of 41 people demonstrated that more transgender men who had taken testosterone were delivered by cesarean section (36% vs. 19%).3 Staff training is an important aspect of caring for a transgender patient in labor to ensure that all members of the labor unit are cognizant of appropriate name and pronoun usage. Another interesting, although unsurprising, fact is that many transgender gestational parents chose a community-based (out-of-hospital) birth according to a 2014 study.1 This is predominantly because of the discrimination patients face when delivering within a hospital setting.
Postpartum depression screening should be conducted prior to patients leaving the hospital and individualized during postpartum appointments. Reinitiation of testosterone can occur 4-6 weeks after delivery.1
While pregnancy can pose some unique challenges to gender-diverse individuals, these intricacies are not insurmountable. The result of pregnancy, regardless of one’s gender identity, is the same – parenthood. One patient’s description of his experience was particularly poignant: “Pregnancy and childbirth were very male experiences for me. When I birthed my children, I was born into fatherhood.”1 It is up to all providers to modify clinical settings, as well as our patient interactions and use of language, if we are to provide inclusion in obstetrics.1,5
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Brandt JS et al. “Understanding intersections: Care for transgender and gender diverse patient populations.” SMFM 2022 annual meeting. 2022 Feb 2.
2. Hoffkling A et al. BMC Pregnancy Childbirth. 2017 Nov 8;17(Suppl 2):332.
3. Light AD et al. Obstet Gynecol. 2014;124:1120-7.
4. Moseson H et al. Int J Transgend Health. 2021 Nov 17;22(1-2):30-41.
5. Brandt JS et al. Obstetrical care for trans*person, in “Trans*gynecology: Managing transgender patients in obstetrics and gynecology practice.” (Cambridge, England: Cambridge University Press, 2022).
The purpose of this commentary is to provide a brief summary of discussions centering around reproductive health experiences and obstetrical care for gender-diverse patients from the recent Society of Maternal & Fetal Medicine meeting. Two presentations featured patient perspectives combined with physician lectures to provide a comprehensive outlook on unique reproductive care needs for this growing population.
One of the speakers, Trystan Reese, is a transgender activist, educator, and transgender male who chose to carry his own pregnancy and subsequently delivered his son in 2017. During the summit, he described many barriers that he faced during his pregnancy and offered providers suggestions on how to improve the care for members of the gender-diverse community seeking to start a family.
We often think of conception and pregnancy as experiences unique to one gender. This is simply not the case. In discussing preconceptual care and pregnancy, it is paramount for providers to make the distinction between gender identity and natal sex. Gender identity is an internal sense of self in relation to natal sex. Depending on this intrinsic feeling, people may identify as cisgender, transgender, or as a gender outside of the standard binary. Natal sex describes biologic characteristics such as chromosomal makeup, reproductive anatomy, and secondary sexual changes. In keeping these distinctions in mind, pregnancy is therefore exclusive to a person’s natal sex, not gender identity. One of the biggest challenges in caring for transgender patients who desire pregnancy, is the psychological distress related to the gendered notions surrounding this experience.1
There are many ways in which patients encounter unintentional marginalization within the medical system. For example, many electronic medical record systems don’t allow for pronouns or give error messages if the patient’s gender identity is different from their sex assigned at birth. Patients who attend prenatal appointments or birth classes are given documents that center around cisgender women and heterosexual relationships. The labor and delivery wards themselves typically include language such as “maternity,” and birth certificates have distinct “mother” and “father” denotations.1 Insurance coverage for prenatal care and delivery can be problematic if a patient who is assigned female at birth has changed their gender marker to “male” on their insurance card.
Many of these roadblocks can be ameliorated by utilizing more inclusive terminology. Terms such as “maternal” can be replaced with “pregnant patients, parent, or patients giving birth.” Names of maternity wards can be altered to perinatal units, which is more inclusive and more descriptive of the wide variety of patients that may experience childbirth and parenthood.1 Introducing “you-centered” language can also be helpful. Instead of saying “women may find ...” providers can try saying “patients may find ...” or “individuals may find.”1
Most of the medical and obstetrical care of gender-diverse patients is routine. Prenatal labs, aneuploidy screening, ultrasounds, and fetal surveillance do not differ between transgender and cisgender patients. However, the experience of pregnancy itself can significantly heighten feelings of dysphoria as it inherently leads to patients confronting aspects of their biological sex.2 Because of the teratogenic nature of testosterone, patients are required to stop taking testosterone prior to conception and for the duration of pregnancy. This can also heighten dysphoria and lead to increased rates of anxiety and depression.3
Many transgender patients can safely achieve a normal vaginal birth.4 A small survey of 41 people demonstrated that more transgender men who had taken testosterone were delivered by cesarean section (36% vs. 19%).3 Staff training is an important aspect of caring for a transgender patient in labor to ensure that all members of the labor unit are cognizant of appropriate name and pronoun usage. Another interesting, although unsurprising, fact is that many transgender gestational parents chose a community-based (out-of-hospital) birth according to a 2014 study.1 This is predominantly because of the discrimination patients face when delivering within a hospital setting.
Postpartum depression screening should be conducted prior to patients leaving the hospital and individualized during postpartum appointments. Reinitiation of testosterone can occur 4-6 weeks after delivery.1
While pregnancy can pose some unique challenges to gender-diverse individuals, these intricacies are not insurmountable. The result of pregnancy, regardless of one’s gender identity, is the same – parenthood. One patient’s description of his experience was particularly poignant: “Pregnancy and childbirth were very male experiences for me. When I birthed my children, I was born into fatherhood.”1 It is up to all providers to modify clinical settings, as well as our patient interactions and use of language, if we are to provide inclusion in obstetrics.1,5
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Brandt JS et al. “Understanding intersections: Care for transgender and gender diverse patient populations.” SMFM 2022 annual meeting. 2022 Feb 2.
2. Hoffkling A et al. BMC Pregnancy Childbirth. 2017 Nov 8;17(Suppl 2):332.
3. Light AD et al. Obstet Gynecol. 2014;124:1120-7.
4. Moseson H et al. Int J Transgend Health. 2021 Nov 17;22(1-2):30-41.
5. Brandt JS et al. Obstetrical care for trans*person, in “Trans*gynecology: Managing transgender patients in obstetrics and gynecology practice.” (Cambridge, England: Cambridge University Press, 2022).
The purpose of this commentary is to provide a brief summary of discussions centering around reproductive health experiences and obstetrical care for gender-diverse patients from the recent Society of Maternal & Fetal Medicine meeting. Two presentations featured patient perspectives combined with physician lectures to provide a comprehensive outlook on unique reproductive care needs for this growing population.
One of the speakers, Trystan Reese, is a transgender activist, educator, and transgender male who chose to carry his own pregnancy and subsequently delivered his son in 2017. During the summit, he described many barriers that he faced during his pregnancy and offered providers suggestions on how to improve the care for members of the gender-diverse community seeking to start a family.
We often think of conception and pregnancy as experiences unique to one gender. This is simply not the case. In discussing preconceptual care and pregnancy, it is paramount for providers to make the distinction between gender identity and natal sex. Gender identity is an internal sense of self in relation to natal sex. Depending on this intrinsic feeling, people may identify as cisgender, transgender, or as a gender outside of the standard binary. Natal sex describes biologic characteristics such as chromosomal makeup, reproductive anatomy, and secondary sexual changes. In keeping these distinctions in mind, pregnancy is therefore exclusive to a person’s natal sex, not gender identity. One of the biggest challenges in caring for transgender patients who desire pregnancy, is the psychological distress related to the gendered notions surrounding this experience.1
There are many ways in which patients encounter unintentional marginalization within the medical system. For example, many electronic medical record systems don’t allow for pronouns or give error messages if the patient’s gender identity is different from their sex assigned at birth. Patients who attend prenatal appointments or birth classes are given documents that center around cisgender women and heterosexual relationships. The labor and delivery wards themselves typically include language such as “maternity,” and birth certificates have distinct “mother” and “father” denotations.1 Insurance coverage for prenatal care and delivery can be problematic if a patient who is assigned female at birth has changed their gender marker to “male” on their insurance card.
Many of these roadblocks can be ameliorated by utilizing more inclusive terminology. Terms such as “maternal” can be replaced with “pregnant patients, parent, or patients giving birth.” Names of maternity wards can be altered to perinatal units, which is more inclusive and more descriptive of the wide variety of patients that may experience childbirth and parenthood.1 Introducing “you-centered” language can also be helpful. Instead of saying “women may find ...” providers can try saying “patients may find ...” or “individuals may find.”1
Most of the medical and obstetrical care of gender-diverse patients is routine. Prenatal labs, aneuploidy screening, ultrasounds, and fetal surveillance do not differ between transgender and cisgender patients. However, the experience of pregnancy itself can significantly heighten feelings of dysphoria as it inherently leads to patients confronting aspects of their biological sex.2 Because of the teratogenic nature of testosterone, patients are required to stop taking testosterone prior to conception and for the duration of pregnancy. This can also heighten dysphoria and lead to increased rates of anxiety and depression.3
Many transgender patients can safely achieve a normal vaginal birth.4 A small survey of 41 people demonstrated that more transgender men who had taken testosterone were delivered by cesarean section (36% vs. 19%).3 Staff training is an important aspect of caring for a transgender patient in labor to ensure that all members of the labor unit are cognizant of appropriate name and pronoun usage. Another interesting, although unsurprising, fact is that many transgender gestational parents chose a community-based (out-of-hospital) birth according to a 2014 study.1 This is predominantly because of the discrimination patients face when delivering within a hospital setting.
Postpartum depression screening should be conducted prior to patients leaving the hospital and individualized during postpartum appointments. Reinitiation of testosterone can occur 4-6 weeks after delivery.1
While pregnancy can pose some unique challenges to gender-diverse individuals, these intricacies are not insurmountable. The result of pregnancy, regardless of one’s gender identity, is the same – parenthood. One patient’s description of his experience was particularly poignant: “Pregnancy and childbirth were very male experiences for me. When I birthed my children, I was born into fatherhood.”1 It is up to all providers to modify clinical settings, as well as our patient interactions and use of language, if we are to provide inclusion in obstetrics.1,5
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Brandt JS et al. “Understanding intersections: Care for transgender and gender diverse patient populations.” SMFM 2022 annual meeting. 2022 Feb 2.
2. Hoffkling A et al. BMC Pregnancy Childbirth. 2017 Nov 8;17(Suppl 2):332.
3. Light AD et al. Obstet Gynecol. 2014;124:1120-7.
4. Moseson H et al. Int J Transgend Health. 2021 Nov 17;22(1-2):30-41.
5. Brandt JS et al. Obstetrical care for trans*person, in “Trans*gynecology: Managing transgender patients in obstetrics and gynecology practice.” (Cambridge, England: Cambridge University Press, 2022).
Detransition, baby: Examining factors leading to ‘detransitioning’ and regret in the transgender community
Over the holiday season I had the pleasure of finally reading the national bestseller, Detransition, Baby. On the surface, the story depicts the complex relationships between Reese, a transgender woman who strongly desires a family, her ex-wife, Ames – a transgender woman who detransitioned to live as a cisgender man – and Ames’ cisgender female partner, who is unexpectedly pregnant with his child. The story delves much deeper than the relationships between these characters, as it exceptionally articulates many of the emotional intricacies of the transgender experience and addresses one of the most taboo topics in the transgender community – detransitioning and regret.
The terms “transition” and “detransition” have fallen out of favor in the vernacular of the transgender population as they incorrectly imply that gender identity is contingent upon gender-affirmation processes.1,2 More importantly, the terms “detransition” and regret are not synonymous. Conflating these terms has undermined the intrinsic nature of gender identity, which has resulted in political and legal consequences seeking to limit or outright ban care for transgender patients.
As a gender-affirming surgeon, one of the most common questions I get asked is the rate of regret patients have after their surgeries. While I have no issue answering the question when it is presented, I do not hesitate to point out some of the problematic subtext inherent in such inquiries. Within the line of questioning, many often comment, “It’s so permanent,” “I can’t believe people can do this to their bodies,” or “How sure are patients before undergoing these surgeries?” While these comments and queries can be downright offensive, they seem to stem from the difficulty people have comprehending gender dysphoria and the painstaking steps people take to affirm their identity. The implication of these comments also reveals a more deep-seated issue – general distrust of individual bodily autonomy, personal identity, and choice.
For the obstetrician-gynecologist, understanding the concept of autonomous, patient-centered decision-making should be second nature, as we face a similar line of interrogation when discussing abortion, contraception, and pregnancy. No other field faces this level of scrutiny when it comes to defending a patient’s bodily autonomy. For example, given the history of reproductive injustice with tubal ligation procedures, the American College of Obstetricians and Gynecologists has issued clear guidelines regarding counseling of women while acknowledging the tenuous history of these procedures with minority subgroups. According to their committee opinion, ethical counseling for such a permanent procedure involves understanding the content of information presented to the patient, how that information is conveyed, and self-reflection on the part of the provider.3 The approach to counseling and understanding gender-affirming care is no different.
I want to be clear that regret after gender-affirming surgery is rare, occurring in 0%-3.8% of patients.4-6 In a separate study, 91% of patients expressed significant improvement in quality of life after surgery.7 However, what is disheartening about patients who experience surgical regret is that it originates from continued difficulty from the transition process itself and ongoing discrimination – even though the patient’s physical characteristics match their gender identity.4-6 Similarly, in another survey which examined 17,151 participants who had pursued gender affirmation (broadly defined), approximately 2,242 (13.1%) reported a history of detransition.2 Among these adults, the vast majority (82.5%), cited external factors such as school harassment, sexual violence, family pressure, and social stigma as reasons for detransitioning.2 Other associated factors included male sex assigned at birth, nonbinary gender identity, bisexual orientation, and having an unsupportive family.2
When Ames is explaining his “detransition” to his cisfemale partner, he states: “I got sick of living as trans …[sic]… I am trans, but I don’t need to do trans.”8 While there is still more research needed to further understand detransitioning and surgical regret, these few studies demonstrate a heart-breaking reality – in many aspects of our society it is still extremely difficult to live as a transgender person.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She did not report any disclosures.
References
1. National LGBTQIA+ Health Education Center, A program of the Fenway Institute: LGBTQIA+ glossary of terms for health care teams. 2020. Available at www.lgbtqiahealtheducation.org/wp-content/uploads/2020/10/Glossary-2020.08.30.pdf. Accessed Dec. 30, 2021.
2. Turban JL et al. LGBT Health 2021;8(4):273-80.
3. Sterilization of women: Ethical issues and considerations. Committee Opinion No. 695. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e109-16.
4. Ruppin U, Pfafflin F. Arch Sex Behav. 2015;44:1321-9.
5. Lawrence AA. Arch Sex Behav. 2003;32:299-315.
6. Landen M et al. Acta Psychiatr Scand. 1998;97:284-9.
7. Papdopulos NA et al. J Sex Med. 2017;14(5):721-30.
8. Peters T. Detransition, Baby. New York: Penguin Random House, 2021.
Over the holiday season I had the pleasure of finally reading the national bestseller, Detransition, Baby. On the surface, the story depicts the complex relationships between Reese, a transgender woman who strongly desires a family, her ex-wife, Ames – a transgender woman who detransitioned to live as a cisgender man – and Ames’ cisgender female partner, who is unexpectedly pregnant with his child. The story delves much deeper than the relationships between these characters, as it exceptionally articulates many of the emotional intricacies of the transgender experience and addresses one of the most taboo topics in the transgender community – detransitioning and regret.
The terms “transition” and “detransition” have fallen out of favor in the vernacular of the transgender population as they incorrectly imply that gender identity is contingent upon gender-affirmation processes.1,2 More importantly, the terms “detransition” and regret are not synonymous. Conflating these terms has undermined the intrinsic nature of gender identity, which has resulted in political and legal consequences seeking to limit or outright ban care for transgender patients.
As a gender-affirming surgeon, one of the most common questions I get asked is the rate of regret patients have after their surgeries. While I have no issue answering the question when it is presented, I do not hesitate to point out some of the problematic subtext inherent in such inquiries. Within the line of questioning, many often comment, “It’s so permanent,” “I can’t believe people can do this to their bodies,” or “How sure are patients before undergoing these surgeries?” While these comments and queries can be downright offensive, they seem to stem from the difficulty people have comprehending gender dysphoria and the painstaking steps people take to affirm their identity. The implication of these comments also reveals a more deep-seated issue – general distrust of individual bodily autonomy, personal identity, and choice.
For the obstetrician-gynecologist, understanding the concept of autonomous, patient-centered decision-making should be second nature, as we face a similar line of interrogation when discussing abortion, contraception, and pregnancy. No other field faces this level of scrutiny when it comes to defending a patient’s bodily autonomy. For example, given the history of reproductive injustice with tubal ligation procedures, the American College of Obstetricians and Gynecologists has issued clear guidelines regarding counseling of women while acknowledging the tenuous history of these procedures with minority subgroups. According to their committee opinion, ethical counseling for such a permanent procedure involves understanding the content of information presented to the patient, how that information is conveyed, and self-reflection on the part of the provider.3 The approach to counseling and understanding gender-affirming care is no different.
I want to be clear that regret after gender-affirming surgery is rare, occurring in 0%-3.8% of patients.4-6 In a separate study, 91% of patients expressed significant improvement in quality of life after surgery.7 However, what is disheartening about patients who experience surgical regret is that it originates from continued difficulty from the transition process itself and ongoing discrimination – even though the patient’s physical characteristics match their gender identity.4-6 Similarly, in another survey which examined 17,151 participants who had pursued gender affirmation (broadly defined), approximately 2,242 (13.1%) reported a history of detransition.2 Among these adults, the vast majority (82.5%), cited external factors such as school harassment, sexual violence, family pressure, and social stigma as reasons for detransitioning.2 Other associated factors included male sex assigned at birth, nonbinary gender identity, bisexual orientation, and having an unsupportive family.2
When Ames is explaining his “detransition” to his cisfemale partner, he states: “I got sick of living as trans …[sic]… I am trans, but I don’t need to do trans.”8 While there is still more research needed to further understand detransitioning and surgical regret, these few studies demonstrate a heart-breaking reality – in many aspects of our society it is still extremely difficult to live as a transgender person.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She did not report any disclosures.
References
1. National LGBTQIA+ Health Education Center, A program of the Fenway Institute: LGBTQIA+ glossary of terms for health care teams. 2020. Available at www.lgbtqiahealtheducation.org/wp-content/uploads/2020/10/Glossary-2020.08.30.pdf. Accessed Dec. 30, 2021.
2. Turban JL et al. LGBT Health 2021;8(4):273-80.
3. Sterilization of women: Ethical issues and considerations. Committee Opinion No. 695. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e109-16.
4. Ruppin U, Pfafflin F. Arch Sex Behav. 2015;44:1321-9.
5. Lawrence AA. Arch Sex Behav. 2003;32:299-315.
6. Landen M et al. Acta Psychiatr Scand. 1998;97:284-9.
7. Papdopulos NA et al. J Sex Med. 2017;14(5):721-30.
8. Peters T. Detransition, Baby. New York: Penguin Random House, 2021.
Over the holiday season I had the pleasure of finally reading the national bestseller, Detransition, Baby. On the surface, the story depicts the complex relationships between Reese, a transgender woman who strongly desires a family, her ex-wife, Ames – a transgender woman who detransitioned to live as a cisgender man – and Ames’ cisgender female partner, who is unexpectedly pregnant with his child. The story delves much deeper than the relationships between these characters, as it exceptionally articulates many of the emotional intricacies of the transgender experience and addresses one of the most taboo topics in the transgender community – detransitioning and regret.
The terms “transition” and “detransition” have fallen out of favor in the vernacular of the transgender population as they incorrectly imply that gender identity is contingent upon gender-affirmation processes.1,2 More importantly, the terms “detransition” and regret are not synonymous. Conflating these terms has undermined the intrinsic nature of gender identity, which has resulted in political and legal consequences seeking to limit or outright ban care for transgender patients.
As a gender-affirming surgeon, one of the most common questions I get asked is the rate of regret patients have after their surgeries. While I have no issue answering the question when it is presented, I do not hesitate to point out some of the problematic subtext inherent in such inquiries. Within the line of questioning, many often comment, “It’s so permanent,” “I can’t believe people can do this to their bodies,” or “How sure are patients before undergoing these surgeries?” While these comments and queries can be downright offensive, they seem to stem from the difficulty people have comprehending gender dysphoria and the painstaking steps people take to affirm their identity. The implication of these comments also reveals a more deep-seated issue – general distrust of individual bodily autonomy, personal identity, and choice.
For the obstetrician-gynecologist, understanding the concept of autonomous, patient-centered decision-making should be second nature, as we face a similar line of interrogation when discussing abortion, contraception, and pregnancy. No other field faces this level of scrutiny when it comes to defending a patient’s bodily autonomy. For example, given the history of reproductive injustice with tubal ligation procedures, the American College of Obstetricians and Gynecologists has issued clear guidelines regarding counseling of women while acknowledging the tenuous history of these procedures with minority subgroups. According to their committee opinion, ethical counseling for such a permanent procedure involves understanding the content of information presented to the patient, how that information is conveyed, and self-reflection on the part of the provider.3 The approach to counseling and understanding gender-affirming care is no different.
I want to be clear that regret after gender-affirming surgery is rare, occurring in 0%-3.8% of patients.4-6 In a separate study, 91% of patients expressed significant improvement in quality of life after surgery.7 However, what is disheartening about patients who experience surgical regret is that it originates from continued difficulty from the transition process itself and ongoing discrimination – even though the patient’s physical characteristics match their gender identity.4-6 Similarly, in another survey which examined 17,151 participants who had pursued gender affirmation (broadly defined), approximately 2,242 (13.1%) reported a history of detransition.2 Among these adults, the vast majority (82.5%), cited external factors such as school harassment, sexual violence, family pressure, and social stigma as reasons for detransitioning.2 Other associated factors included male sex assigned at birth, nonbinary gender identity, bisexual orientation, and having an unsupportive family.2
When Ames is explaining his “detransition” to his cisfemale partner, he states: “I got sick of living as trans …[sic]… I am trans, but I don’t need to do trans.”8 While there is still more research needed to further understand detransitioning and surgical regret, these few studies demonstrate a heart-breaking reality – in many aspects of our society it is still extremely difficult to live as a transgender person.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She did not report any disclosures.
References
1. National LGBTQIA+ Health Education Center, A program of the Fenway Institute: LGBTQIA+ glossary of terms for health care teams. 2020. Available at www.lgbtqiahealtheducation.org/wp-content/uploads/2020/10/Glossary-2020.08.30.pdf. Accessed Dec. 30, 2021.
2. Turban JL et al. LGBT Health 2021;8(4):273-80.
3. Sterilization of women: Ethical issues and considerations. Committee Opinion No. 695. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;129:e109-16.
4. Ruppin U, Pfafflin F. Arch Sex Behav. 2015;44:1321-9.
5. Lawrence AA. Arch Sex Behav. 2003;32:299-315.
6. Landen M et al. Acta Psychiatr Scand. 1998;97:284-9.
7. Papdopulos NA et al. J Sex Med. 2017;14(5):721-30.
8. Peters T. Detransition, Baby. New York: Penguin Random House, 2021.
The significance of Transgender Awareness Week
As I sit down to write this article, I cannot help but reflect on the significance of today and the upcoming week – Transgender Awareness Week. While it may seem that the transgender community has made great strides in political, social, and health care forums, this week serves as a cold and grave reality check for members of the community and its allies. We still have a long way to go.
This annual tradition began in 1998 in response to the murder of a transgender woman, Rita Hester. Now Transgender Awareness Week, which occurs from Nov. 13th through the 19th is a week dedicated to help raise awareness and improve visibility of transgender people and the issues they face.1 The week culminates on Nov. 20 with The Transgender Day of Remembrance (TDOR). The day is an annual observance to honor the memory of the transgender people who lost their lives to acts of antitransgender violence during that year.1
Unfortunately, 2021 marks the worst year in recent history for transgender violence and anti-LGBT legislation. Over this past year, 375 transgender people were killed – 96% of whom were black and migrant trans women of color and over half (58%) of whom were sex workers.2 What is even more shocking is that one in four of these victims were murdered in their own homes.2 Compared with 2015, which previously held the title of “worst year,” 250 anti-LGBT bills have been introduced in state legislatures in 2021; 17 of which have been already enacted into law.3 The recently passed laws involve antitrans sports bans, religious refusal, anti-LGBTQ education, antitrans medical care, antitrans birth certificates, and an anti–all comers bill.3 In evaluating the 250 anti-LGBT bills introduced into state legislatures, at least 35 of these would prohibit transgender youth from accessing gender-affirming medical care and an additional 43 bills would allow people to deny or not provide services (including all medical care) by asserting religious freedom.3 The current bills exhibit a flagrant disregard for current best practices, which have demonstrated the benefits of gender-affirming medical care. Furthermore, they can increase the already high death toll for transgender patients by allowing providers and institutions to deny care to patients seeking services unrelated to their gender identity or sexual orientation.
Even if providers are not directly prescribing hormone therapy or performing gender-affirming procedures, all providers have encountered and will treat an LGBTQ patient at some point during their career. It is necessary for all obstetrician-gynecologists to be aware of the systemic damages and threats that LGBTQ patients face, as well as pending legislation that can significantly affect and harm patient care. As a result, we need to screen these patients for depression and history of self-harm, and to assess social support, as well as challenge legislation that can negatively affect LGBTQ care. The American College of Obstetricians and Gynecologists has not only issued formal statements condemning discrimination on the basis of gender identity and sexual orientation, but also advocates for inclusive, thoughtful, and affirming care for transgender individuals.4 In a time when our patients may not feel as though they can advocate for themselves, we as providers must use our voices and medical knowledge to enact these changes to encourage equitable and safe health care for all.
Dr. Brandt is an an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Transgender awareness month 2021. Fenway Health. 2021 Nov 1.
2. Wareham J. 375 transgender people murdered in 2021 – ‘Deadliest year’ since records began. Forbes. 2021 Nov 11..
3. Ronan R. 2021 officially becomes worst year in recent history for LGBTQ state legislative attacks as unprecedented number of states enact record-shattering number of anti-LGBTQ measures into law. Human Rights Campaign Press Release. 2021 May 7..
4. Practice Guideline. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, No. 823. American College of Obstetricians and Gynecologists.
As I sit down to write this article, I cannot help but reflect on the significance of today and the upcoming week – Transgender Awareness Week. While it may seem that the transgender community has made great strides in political, social, and health care forums, this week serves as a cold and grave reality check for members of the community and its allies. We still have a long way to go.
This annual tradition began in 1998 in response to the murder of a transgender woman, Rita Hester. Now Transgender Awareness Week, which occurs from Nov. 13th through the 19th is a week dedicated to help raise awareness and improve visibility of transgender people and the issues they face.1 The week culminates on Nov. 20 with The Transgender Day of Remembrance (TDOR). The day is an annual observance to honor the memory of the transgender people who lost their lives to acts of antitransgender violence during that year.1
Unfortunately, 2021 marks the worst year in recent history for transgender violence and anti-LGBT legislation. Over this past year, 375 transgender people were killed – 96% of whom were black and migrant trans women of color and over half (58%) of whom were sex workers.2 What is even more shocking is that one in four of these victims were murdered in their own homes.2 Compared with 2015, which previously held the title of “worst year,” 250 anti-LGBT bills have been introduced in state legislatures in 2021; 17 of which have been already enacted into law.3 The recently passed laws involve antitrans sports bans, religious refusal, anti-LGBTQ education, antitrans medical care, antitrans birth certificates, and an anti–all comers bill.3 In evaluating the 250 anti-LGBT bills introduced into state legislatures, at least 35 of these would prohibit transgender youth from accessing gender-affirming medical care and an additional 43 bills would allow people to deny or not provide services (including all medical care) by asserting religious freedom.3 The current bills exhibit a flagrant disregard for current best practices, which have demonstrated the benefits of gender-affirming medical care. Furthermore, they can increase the already high death toll for transgender patients by allowing providers and institutions to deny care to patients seeking services unrelated to their gender identity or sexual orientation.
Even if providers are not directly prescribing hormone therapy or performing gender-affirming procedures, all providers have encountered and will treat an LGBTQ patient at some point during their career. It is necessary for all obstetrician-gynecologists to be aware of the systemic damages and threats that LGBTQ patients face, as well as pending legislation that can significantly affect and harm patient care. As a result, we need to screen these patients for depression and history of self-harm, and to assess social support, as well as challenge legislation that can negatively affect LGBTQ care. The American College of Obstetricians and Gynecologists has not only issued formal statements condemning discrimination on the basis of gender identity and sexual orientation, but also advocates for inclusive, thoughtful, and affirming care for transgender individuals.4 In a time when our patients may not feel as though they can advocate for themselves, we as providers must use our voices and medical knowledge to enact these changes to encourage equitable and safe health care for all.
Dr. Brandt is an an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Transgender awareness month 2021. Fenway Health. 2021 Nov 1.
2. Wareham J. 375 transgender people murdered in 2021 – ‘Deadliest year’ since records began. Forbes. 2021 Nov 11..
3. Ronan R. 2021 officially becomes worst year in recent history for LGBTQ state legislative attacks as unprecedented number of states enact record-shattering number of anti-LGBTQ measures into law. Human Rights Campaign Press Release. 2021 May 7..
4. Practice Guideline. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, No. 823. American College of Obstetricians and Gynecologists.
As I sit down to write this article, I cannot help but reflect on the significance of today and the upcoming week – Transgender Awareness Week. While it may seem that the transgender community has made great strides in political, social, and health care forums, this week serves as a cold and grave reality check for members of the community and its allies. We still have a long way to go.
This annual tradition began in 1998 in response to the murder of a transgender woman, Rita Hester. Now Transgender Awareness Week, which occurs from Nov. 13th through the 19th is a week dedicated to help raise awareness and improve visibility of transgender people and the issues they face.1 The week culminates on Nov. 20 with The Transgender Day of Remembrance (TDOR). The day is an annual observance to honor the memory of the transgender people who lost their lives to acts of antitransgender violence during that year.1
Unfortunately, 2021 marks the worst year in recent history for transgender violence and anti-LGBT legislation. Over this past year, 375 transgender people were killed – 96% of whom were black and migrant trans women of color and over half (58%) of whom were sex workers.2 What is even more shocking is that one in four of these victims were murdered in their own homes.2 Compared with 2015, which previously held the title of “worst year,” 250 anti-LGBT bills have been introduced in state legislatures in 2021; 17 of which have been already enacted into law.3 The recently passed laws involve antitrans sports bans, religious refusal, anti-LGBTQ education, antitrans medical care, antitrans birth certificates, and an anti–all comers bill.3 In evaluating the 250 anti-LGBT bills introduced into state legislatures, at least 35 of these would prohibit transgender youth from accessing gender-affirming medical care and an additional 43 bills would allow people to deny or not provide services (including all medical care) by asserting religious freedom.3 The current bills exhibit a flagrant disregard for current best practices, which have demonstrated the benefits of gender-affirming medical care. Furthermore, they can increase the already high death toll for transgender patients by allowing providers and institutions to deny care to patients seeking services unrelated to their gender identity or sexual orientation.
Even if providers are not directly prescribing hormone therapy or performing gender-affirming procedures, all providers have encountered and will treat an LGBTQ patient at some point during their career. It is necessary for all obstetrician-gynecologists to be aware of the systemic damages and threats that LGBTQ patients face, as well as pending legislation that can significantly affect and harm patient care. As a result, we need to screen these patients for depression and history of self-harm, and to assess social support, as well as challenge legislation that can negatively affect LGBTQ care. The American College of Obstetricians and Gynecologists has not only issued formal statements condemning discrimination on the basis of gender identity and sexual orientation, but also advocates for inclusive, thoughtful, and affirming care for transgender individuals.4 In a time when our patients may not feel as though they can advocate for themselves, we as providers must use our voices and medical knowledge to enact these changes to encourage equitable and safe health care for all.
Dr. Brandt is an an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Transgender awareness month 2021. Fenway Health. 2021 Nov 1.
2. Wareham J. 375 transgender people murdered in 2021 – ‘Deadliest year’ since records began. Forbes. 2021 Nov 11..
3. Ronan R. 2021 officially becomes worst year in recent history for LGBTQ state legislative attacks as unprecedented number of states enact record-shattering number of anti-LGBTQ measures into law. Human Rights Campaign Press Release. 2021 May 7..
4. Practice Guideline. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, No. 823. American College of Obstetricians and Gynecologists.
Overview of guidelines for patients seeking gender-affirmation surgery
Gender-affirmation surgery refers to a collection of procedures by which a transgender individual physically alters characteristics to align with their gender identity. While not all patients who identify as transgender will choose to undergo surgery, the surgeries are considered medically necessary and lead to significant improvements in emotional and psychological well-being.1 With increasing insurance coverage and improved access to care, more and more patients are seeking gender-affirming surgery, and it is incumbent for providers to familiarize themselves with preoperative recommendations and requirements.
Ob.gyns. play a key role in patients seeking surgical treatment as patients may inquire about available procedures and what steps are necessary prior to scheduling a visit with the appropriate surgeon. The World Professional Association of Transgender Health has established standards of care that provide multidisciplinary, evidence-based guidance for patients seeking a variety of gender-affirming services ranging from mental health, hormone therapy, and surgery.
Basic preoperative surgical prerequisites set forth by WPATH include being a patient with well-documented gender dysphoria, being the age of majority, and having the ability to provide informed consent.1
As with any surgical candidate, it is also equally important for a patient to have well-controlled medical and psychiatric comorbidities, which should also include smoking cessation. A variety of surgical procedures are available to patients and include breast/chest surgery, genital (bottom) surgery, and nongenital surgery (facial feminization, pectoral implant placement, thyroid chondroplasty, lipofilling/liposuction, body contouring, and voice modification). Patients may choose to undergo chest/breast surgery and/or bottom surgery or forgo surgical procedures altogether.
For transmasculine patients, breast/chest surgery, otherwise known as top surgery, is the most common and desired procedure. According to a recent survey, approximately 97% of transmasculine patients had or wanted masculinizing chest surgery.2 In addition to patients meeting the basic requirements set forth by WPATH, one referral from a mental health provider specializing in gender-affirming care is also needed prior to this procedure. It is also important to note that testosterone use is no longer a needed prior to masculinizing chest surgery.
Transmasculine bottom surgery, which includes hysterectomy, bilateral salpingo-oophorectomy, metoidioplasty, vaginectomy, scrotoplasty, testicular implant placement, and/or phalloplasty have additional nuances. Compared with transmasculine individuals seeking top surgery, the number of patients who have had or desire metoidioplasty and phalloplasty is much lower, which is mainly because of the high complication rates of these procedures. In the same survey, only 4% of patients had undergone a metoidioplasty procedure and 2% of patients had undergone a phalloplasty.2
In evaluating rates of hysterectomy with or without salpingo-oophorectomy, approximately 21% of transgender men underwent hysterectomy, with 58% desiring it in the future.2 Unlike patients pursuing top surgery, patients who desire any form of bottom surgery need to be on 12 months of continuous hormone therapy.1 They also must provide two letters from two different mental health providers, one of whom must have either an MD/DO or PhD. In cases in which a patient requests a hysterectomy for reasons other than gender dysphoria, such as pelvic pain or abnormal uterine bleeding, these criteria do not apply.
For transfeminine individuals, augmentation mammoplasty is performed following 12 months of continuous hormone therapy. This is to allow maximum breast growth, which occurs approximately 2-3 months after hormone initiation and peaks at 1-2 years.3 Rates of transfeminine individuals seeking augmentation mammoplasty is similar to that of their transmasculine counterparts at 74%.2 One referral letter from a mental health provider is also needed prior to augmentation mammoplasty.
Transfeminine patients who desire bottom surgery, which can involve an orchiectomy or vaginoplasty (single-stage penile inversion, peritoneal, or colonic interposition), have the same additional requirements as transmasculine individuals seeking bottom surgery. Furthermore, it is interesting to note that 25% of transfeminine individuals had already undergone orchiectomy and 87% had either undergone or desired a vaginoplasty in the future.2 This is in stark contrast to transmasculine patients and rates of bottom surgery.
Unless there is a specific medical contraindication to hormone therapy, emphasis is placed on 12 months of continuous hormone usage. Additional emphasis is placed on patients seeking bottom surgery to live for a minimum of 12 months in their congruent gender role. This also allows patients to further explore their gender identity and make appropriate preparations for surgery.
As with any surgical procedure, obtaining informed consent and reviewing patient expectations are key. In my clinical practice, I discuss with patients that the general surgical goals are to achieve both function and good aesthetic outcome but that their results are also tailored to their individual bodies. Assessing a patient’s support system and social factors is also equally important in the preoperative planning period. As this field continues to grow, it is essential for providers to understand the evolving distinctions in surgical care to improve access to patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She has no conflicts. Email her at obnews@mdedge.com.
References
1. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. https://www.wpath.org/publications/soc.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality. 2016.
3. Thomas TN. Overview of surgery for transgender patients, in “Comprehensive care for the transgender patient.” Philadelphia: Elsevier, 2020. pp. 48-53.
Gender-affirmation surgery refers to a collection of procedures by which a transgender individual physically alters characteristics to align with their gender identity. While not all patients who identify as transgender will choose to undergo surgery, the surgeries are considered medically necessary and lead to significant improvements in emotional and psychological well-being.1 With increasing insurance coverage and improved access to care, more and more patients are seeking gender-affirming surgery, and it is incumbent for providers to familiarize themselves with preoperative recommendations and requirements.
Ob.gyns. play a key role in patients seeking surgical treatment as patients may inquire about available procedures and what steps are necessary prior to scheduling a visit with the appropriate surgeon. The World Professional Association of Transgender Health has established standards of care that provide multidisciplinary, evidence-based guidance for patients seeking a variety of gender-affirming services ranging from mental health, hormone therapy, and surgery.
Basic preoperative surgical prerequisites set forth by WPATH include being a patient with well-documented gender dysphoria, being the age of majority, and having the ability to provide informed consent.1
As with any surgical candidate, it is also equally important for a patient to have well-controlled medical and psychiatric comorbidities, which should also include smoking cessation. A variety of surgical procedures are available to patients and include breast/chest surgery, genital (bottom) surgery, and nongenital surgery (facial feminization, pectoral implant placement, thyroid chondroplasty, lipofilling/liposuction, body contouring, and voice modification). Patients may choose to undergo chest/breast surgery and/or bottom surgery or forgo surgical procedures altogether.
For transmasculine patients, breast/chest surgery, otherwise known as top surgery, is the most common and desired procedure. According to a recent survey, approximately 97% of transmasculine patients had or wanted masculinizing chest surgery.2 In addition to patients meeting the basic requirements set forth by WPATH, one referral from a mental health provider specializing in gender-affirming care is also needed prior to this procedure. It is also important to note that testosterone use is no longer a needed prior to masculinizing chest surgery.
Transmasculine bottom surgery, which includes hysterectomy, bilateral salpingo-oophorectomy, metoidioplasty, vaginectomy, scrotoplasty, testicular implant placement, and/or phalloplasty have additional nuances. Compared with transmasculine individuals seeking top surgery, the number of patients who have had or desire metoidioplasty and phalloplasty is much lower, which is mainly because of the high complication rates of these procedures. In the same survey, only 4% of patients had undergone a metoidioplasty procedure and 2% of patients had undergone a phalloplasty.2
In evaluating rates of hysterectomy with or without salpingo-oophorectomy, approximately 21% of transgender men underwent hysterectomy, with 58% desiring it in the future.2 Unlike patients pursuing top surgery, patients who desire any form of bottom surgery need to be on 12 months of continuous hormone therapy.1 They also must provide two letters from two different mental health providers, one of whom must have either an MD/DO or PhD. In cases in which a patient requests a hysterectomy for reasons other than gender dysphoria, such as pelvic pain or abnormal uterine bleeding, these criteria do not apply.
For transfeminine individuals, augmentation mammoplasty is performed following 12 months of continuous hormone therapy. This is to allow maximum breast growth, which occurs approximately 2-3 months after hormone initiation and peaks at 1-2 years.3 Rates of transfeminine individuals seeking augmentation mammoplasty is similar to that of their transmasculine counterparts at 74%.2 One referral letter from a mental health provider is also needed prior to augmentation mammoplasty.
Transfeminine patients who desire bottom surgery, which can involve an orchiectomy or vaginoplasty (single-stage penile inversion, peritoneal, or colonic interposition), have the same additional requirements as transmasculine individuals seeking bottom surgery. Furthermore, it is interesting to note that 25% of transfeminine individuals had already undergone orchiectomy and 87% had either undergone or desired a vaginoplasty in the future.2 This is in stark contrast to transmasculine patients and rates of bottom surgery.
Unless there is a specific medical contraindication to hormone therapy, emphasis is placed on 12 months of continuous hormone usage. Additional emphasis is placed on patients seeking bottom surgery to live for a minimum of 12 months in their congruent gender role. This also allows patients to further explore their gender identity and make appropriate preparations for surgery.
As with any surgical procedure, obtaining informed consent and reviewing patient expectations are key. In my clinical practice, I discuss with patients that the general surgical goals are to achieve both function and good aesthetic outcome but that their results are also tailored to their individual bodies. Assessing a patient’s support system and social factors is also equally important in the preoperative planning period. As this field continues to grow, it is essential for providers to understand the evolving distinctions in surgical care to improve access to patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She has no conflicts. Email her at obnews@mdedge.com.
References
1. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. https://www.wpath.org/publications/soc.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality. 2016.
3. Thomas TN. Overview of surgery for transgender patients, in “Comprehensive care for the transgender patient.” Philadelphia: Elsevier, 2020. pp. 48-53.
Gender-affirmation surgery refers to a collection of procedures by which a transgender individual physically alters characteristics to align with their gender identity. While not all patients who identify as transgender will choose to undergo surgery, the surgeries are considered medically necessary and lead to significant improvements in emotional and psychological well-being.1 With increasing insurance coverage and improved access to care, more and more patients are seeking gender-affirming surgery, and it is incumbent for providers to familiarize themselves with preoperative recommendations and requirements.
Ob.gyns. play a key role in patients seeking surgical treatment as patients may inquire about available procedures and what steps are necessary prior to scheduling a visit with the appropriate surgeon. The World Professional Association of Transgender Health has established standards of care that provide multidisciplinary, evidence-based guidance for patients seeking a variety of gender-affirming services ranging from mental health, hormone therapy, and surgery.
Basic preoperative surgical prerequisites set forth by WPATH include being a patient with well-documented gender dysphoria, being the age of majority, and having the ability to provide informed consent.1
As with any surgical candidate, it is also equally important for a patient to have well-controlled medical and psychiatric comorbidities, which should also include smoking cessation. A variety of surgical procedures are available to patients and include breast/chest surgery, genital (bottom) surgery, and nongenital surgery (facial feminization, pectoral implant placement, thyroid chondroplasty, lipofilling/liposuction, body contouring, and voice modification). Patients may choose to undergo chest/breast surgery and/or bottom surgery or forgo surgical procedures altogether.
For transmasculine patients, breast/chest surgery, otherwise known as top surgery, is the most common and desired procedure. According to a recent survey, approximately 97% of transmasculine patients had or wanted masculinizing chest surgery.2 In addition to patients meeting the basic requirements set forth by WPATH, one referral from a mental health provider specializing in gender-affirming care is also needed prior to this procedure. It is also important to note that testosterone use is no longer a needed prior to masculinizing chest surgery.
Transmasculine bottom surgery, which includes hysterectomy, bilateral salpingo-oophorectomy, metoidioplasty, vaginectomy, scrotoplasty, testicular implant placement, and/or phalloplasty have additional nuances. Compared with transmasculine individuals seeking top surgery, the number of patients who have had or desire metoidioplasty and phalloplasty is much lower, which is mainly because of the high complication rates of these procedures. In the same survey, only 4% of patients had undergone a metoidioplasty procedure and 2% of patients had undergone a phalloplasty.2
In evaluating rates of hysterectomy with or without salpingo-oophorectomy, approximately 21% of transgender men underwent hysterectomy, with 58% desiring it in the future.2 Unlike patients pursuing top surgery, patients who desire any form of bottom surgery need to be on 12 months of continuous hormone therapy.1 They also must provide two letters from two different mental health providers, one of whom must have either an MD/DO or PhD. In cases in which a patient requests a hysterectomy for reasons other than gender dysphoria, such as pelvic pain or abnormal uterine bleeding, these criteria do not apply.
For transfeminine individuals, augmentation mammoplasty is performed following 12 months of continuous hormone therapy. This is to allow maximum breast growth, which occurs approximately 2-3 months after hormone initiation and peaks at 1-2 years.3 Rates of transfeminine individuals seeking augmentation mammoplasty is similar to that of their transmasculine counterparts at 74%.2 One referral letter from a mental health provider is also needed prior to augmentation mammoplasty.
Transfeminine patients who desire bottom surgery, which can involve an orchiectomy or vaginoplasty (single-stage penile inversion, peritoneal, or colonic interposition), have the same additional requirements as transmasculine individuals seeking bottom surgery. Furthermore, it is interesting to note that 25% of transfeminine individuals had already undergone orchiectomy and 87% had either undergone or desired a vaginoplasty in the future.2 This is in stark contrast to transmasculine patients and rates of bottom surgery.
Unless there is a specific medical contraindication to hormone therapy, emphasis is placed on 12 months of continuous hormone usage. Additional emphasis is placed on patients seeking bottom surgery to live for a minimum of 12 months in their congruent gender role. This also allows patients to further explore their gender identity and make appropriate preparations for surgery.
As with any surgical procedure, obtaining informed consent and reviewing patient expectations are key. In my clinical practice, I discuss with patients that the general surgical goals are to achieve both function and good aesthetic outcome but that their results are also tailored to their individual bodies. Assessing a patient’s support system and social factors is also equally important in the preoperative planning period. As this field continues to grow, it is essential for providers to understand the evolving distinctions in surgical care to improve access to patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. She has no conflicts. Email her at obnews@mdedge.com.
References
1. The World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. https://www.wpath.org/publications/soc.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality. 2016.
3. Thomas TN. Overview of surgery for transgender patients, in “Comprehensive care for the transgender patient.” Philadelphia: Elsevier, 2020. pp. 48-53.
Why Texas Senate Bill 8 will negatively affect LGBTQ patients
On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.
It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.
A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.1 A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.2 Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.3
Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.
Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.
4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.
5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.
On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.
It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.
A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.1 A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.2 Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.3
Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.
Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.
4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.
5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.
On Sept. 1, Texas enacted astonishing legislation that effectively bans abortion after a fetal heartbeat is detected. In addition, it further empowers private citizens to sue anyone “aiding and abetting” patients who seek abortion services. Many organizations, including Planned Parenthood and the American College of Obstetricians and Gynecologists, have issued formalized statements condemning the bill. While we as obstetrician/gynecologists try to remain as nonpartisan as humanly possible in our patient care, unfortunately our specialty is inarguably one of the few in the medical field that is routinely significantly affected by federal and state politics.
It is no secret that Texas Senate Bill 8, otherwise referred to the “Texas Heartbeat Act,” will have devastating consequences for women, particularly women of color, but it will also have potentially catastrophic repercussions for patients who identify as LGBTQ. Overall, the LGBTQ population faces higher rates of poverty, unemployment, insurance coverage barriers, and provider discrimination because of their gender identity or sexual orientation, which can make access to abortion services challenging. Furthermore, they are more susceptible to hate-motivated violence and sexual assault and as a result, may seek to terminate pregnancies that result from these traumatic experiences.
A survey conducted by the Centers for Disease Control and Prevention examining rates of intimate partner violence and sexual violence found that 44% of lesbians and 61% of bisexual women experience rape and physical violence, compared with 35% of straight women.1 A separate survey revealed that 47% of transgender people are sexually assaulted at some point in their lifetime, with rates reaching as high as 65% among transgender people of color.2 Furthermore, many members of the LGBTQ population are misinformed or have misconceptions regarding their need for contraceptives and experience unintended pregnancies. As discussed in a previous column, one-third of pregnancies in transgender men were unplanned, and 20% of those patients were amenorrheic on testosterone at the time of conception.3
Current studies estimate that approximately 25% of all cisgender women will have an abortion. No corresponding data exist to describe the abortion rates of transgender and gender diverse patients.4,5 Bills such as Texas SB8 make accessing safe abortions for patients virtually impossible and interferes with the ability for physicians to provide patients with much needed health care services. It further delegitimizes rape and incest victims and is almost punitive in requiring such victims to carry the unintended pregnancies resulting from these heinous acts to term.
Regardless of a provider’s feelings toward abortion or even gender-affirming care, it is undeniable that access to these services is necessary and should be readily available to patients seeking them. As we all took an oath in medical school to “do no harm,” we must not only abide by that solemn decree in everyday patient interactions, but also live by those words to advocate for our patients when politics prohibit appropriate care. While discussions surrounding abortion are often limited to cisgender, heterosexual patients, providers must also be aware that abortion access spans across a wider spectrum that includes the LGBTQ community. Our patients, and all patients, deserve equal access to abortion. This harmful law sets a dangerous precedent that could continue to threaten these services with detrimental effects to our patients.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Black MC et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
2. James SE et al. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
3. Abern L, Maguire K. Obstet Gynecol 2018;131:65S.
4. Jones RK et al. Abortion incidence and service availability in the Unites States, 2017. New York, NY: Guttmacher Institute: 2019.
5. Moseson H et al. Am J Obstet Gynecol 2021;224:376.e1-11.
Gender-affirming mastectomy and breast cancer screening in transmasculine patients
Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.1 Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.2 The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.
Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.5 The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.8 Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.
It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.
Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.5 During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.5 The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.
Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.9 For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.9 Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.10
Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.
References
1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.
3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.
4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.
5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.
6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.
7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.
8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.
9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.
10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.
Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.1 Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.2 The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.
Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.5 The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.8 Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.
It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.
Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.5 During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.5 The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.
Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.9 For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.9 Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.10
Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.
References
1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.
3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.
4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.
5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.
6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.
7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.
8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.
9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.
10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.
Since the reversal of the Medicare exclusion in 2014, the rates of gender-affirming surgery have increased markedly in the United States.1 Gender-affirming mastectomy, otherwise known as “top surgery,” is one of the more commonly performed procedures; with 97% of patients having either undergone or expressed desire for the surgery.2 The goals of this procedure are to remove all visible breast tissue and reconstruct the chest wall so it is more masculine in appearance. For transmasculine and nonbinary patients, this procedure is associated with significant improvements in mental health and quality of life.3,4 While the mastectomy procedure is often performed by plastic surgeons, patients will see an ob.gyn. in the preoperative or postoperative period. Ob.gyns. should have a general understanding of the procedure, but most importantly know how to screen for breast cancer in patients who have undergone a gender-affirming mastectomy.
Providers will likely encounter transmasculine or nonbinary patients during annual screening examinations or for a preoperative exam. If a patient is seeking a preoperative risk assessment prior to undergoing a gender-affirming mastectomy, assessing a patient’s risk status for breast cancer is paramount. While testosterone therapy is no longer a prerequisite for gender-affirming mastectomies, documenting hormone use, age at initiation, and dosage is important.5 The overall effects of testosterone on breast tissue are inconsistent. However, studies have demonstrated that patients taking testosterone are not at an increased risk of breast cancer secondary to testosterone use.5-7 Patients should be asked about a personal of family history of breast cancer, breast surgery, history of prior breast biopsies, parity, age at menarche, smoking status, and breastfeeding history if applicable. Patients with high-risk mutations or a strong family history of breast cancer should be referred to genetic counselors, surgical oncologists, and possibly undergo genetic testing.8 Before an examination, providers should counsel patients about the nature of the examination and use gender-neutral language such as “chest” to avoid exacerbating gender dysphoria.
It is important to educate transmasculine patients about their risk for the development of breast cancer after mastectomy. Larger-scale, population-based studies of breast cancer in the transgender population have reported an incidence of 5.9 per 100,000 patients-years and an overall incidence comparable to cisgender men in age-standardized national samples.5-7 Unfortunately, data on the rates of breast cancer in transmasculine patients after gender-affirming mastectomy are limited, which makes defining postoperative guidelines challenging. Additionally, the amount of residual breast tissue remaining varies based on the surgeon and technique.
Several techniques are described for mastectomy procedures with differences that can affect the amount of residual breast tissue. The most common type of gender-affirming mastectomy is the double incision. With this procedure, the nipple-areolar complex is reduced in size, removed, and thinned to improve graft take. Dissection is then carried to the level of the breast capsule and the breast tissue and axillary tail are removed en bloc.5 During the dissection, the subcutaneous fat is left on the skin flap to provide appropriate contour and to avoid creating a concave-appearing chest wall. Prior to closure, the superior and inferior flaps are inspected for any visible residual breast tissue, which is removed if needed. In a circumareolar mastectomy, the nipple-areolar complex is also reduced but is preserved on a 1- to 1.5-cm-thick pedicle to maintain perfusion.5 The mastectomy is performed through an inferior periareolar incision and all visible breast tissue and the axillary tail are removed. Breast tissue specimens are sent for pathologic evaluation at the end of the procedure.
Following gender-affirming mastectomy, there is limited evidence to guide screening. During the patient visit, the provider should obtain a thorough history regarding mastectomy type, and if unknown, attempt to acquire the operative report detailing the procedure. For low-risk patients who undergo a subcutaneous mastectomy such as the double incision or circumareolar technique, screening mammography is not indicated nor is it technically feasible.9 For patients with a high-risk genetic mutation or a strong family history of breast cancer, monitoring with alternative modalities such as breast ultrasound or breast MRI may be beneficial, although there is no evidence to currently support this suggestion. Given the variety of surgical techniques of breast tissue removal, it is difficult to develop strong evidence-based guidelines. Annual chest wall examinations have been suggested as a screening modality; however, the clinical utility of clinical breast and chest exams has been debated and is no longer recommended as a screening method in cisgender patients.9 Clinicians can promote chest self-awareness and discuss the possibility of breast cancer in postmastectomy patients at annual examination visits. As research continues to resolve some of these unknowns, it is important that patients are informed of these areas of ambiguity and updated regarding any changes in screening recommendations.10
Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.
References
1. American Society of Plastic Surgeons. 2018 plastic surgery statistics report. https://www.plasticsurgery.org/documents/News/Statistics/2018/plastic-surgery-statistics-full-report-2018.pdf. Accessed Aug. 20, 2021.
2. James SE et al. The report of the 2015 U.S. Transgender survey. Washington, D.C.: National Center for Transgender Equality, 2016.
3. Agarwal CA et al. J Plast Reconstr Aesthet Surg. 2018;71:651-7.
4. Poudrier G et al. Plast Reconstr Surg. 2018;80:679-83.
5. Salibian AA et al. Plast Reconstr Surg. 2020;147:213e-21e.
6. Gooren LJ et al. J Sex Med. 2013;10:3129-34.
7. Brown GR and Jones KT. Breast Cancer Res Treat. 2015;149:191-8.
8. Deutsch MF et al. Semin Reprod Med. 2017;35:434-41.
9. Phillips J et al. AJR Am J Roentgenol. 2014;202:1149-59.
10. Smith RA et al. CA Cancer J Clin. 2018;68:297-316.
Contraceptive counseling for transmasculine patients
One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.1 Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.2,3
Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).4 While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.2
Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.4 Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.
Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.
In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Unger CA. J Women’s Health. 2015;24(2):114-8.
2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.
3. Light A et al. Contraception. 2018;98:266-9.
4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.
5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.1 Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.2,3
Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).4 While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.2
Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.4 Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.
Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.
In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Unger CA. J Women’s Health. 2015;24(2):114-8.
2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.
3. Light A et al. Contraception. 2018;98:266-9.
4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.
5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
One of the most common reasons patients seek care from an ob.gyn. is for contraceptive counseling and family planning. While prescribing contraceptives for cisgender patients is often part of the daily routine for ob.gyns., many are unfamiliar with counseling and options for patients who identify as transgender. In a survey of practicing ob.gyns. in nine academic centers, 80% did not receive training on caring for transgender patients.1 Other studies have found that 5.5%-9% of transgender men have reported that a clinician informed them that testosterone was a contraceptive.2,3
Testosterone is not a reliable form of contraception and, in fact, testosterone is considered category X, as it can induce labial fusion, produce abnormal vaginal development, cause a persistent urogenital sinus, and cause clitoromegaly in the developing fetus. Given the teratogenic effects of testosterone, it is imperative that patients who do not desire pregnancy receive appropriate contraceptive options. Counseling of patients should be individualized and start by taking a comprehensive sexual history. Such strategies include using gender-inclusive language, avoiding assumptions about sexual orientation, and obtaining an anatomic inventory of both the patient and their partner(s).4 While a majority of patients achieve amenorrhea while taking testosterone, it is important to discuss the need for contraception if patients are engaging in penile-vaginal intercourse. According to a study of 41 transmasculine patients who achieved pregnancy, one-third of pregnancies were unplanned. Another study reported that 20% of transmasculine patients were taking testosterone and amenorrheic at the time of conception.2
Contraindications to certain types of contraception, such as a history of a thromboembolic event precluding a patient from using combined oral contraceptives, still apply. Transmasculine patients have additional concerns that providers should be aware of and sensitive to when prescribing contraceptives. Gender dysphoria may be exacerbated by contraceptive options that require a pelvic exam or procedure, such as an intrauterine device. For patients that desire an IUD but experience heightened distress in anticipation of the procedure, premedication with anxiolytics or topical anesthetics are reasonable options.4 Using an adequate amount of lubricant and a small speculum may also make the exam more comfortable for patients, especially if patients do not engage in receptive frontal intercourse. Of note, certain types of IUDs, such as the Paragard, may cause pelvic cramping or abnormal bleeding, which could be a trigger for dysphoria. Patients may also experience worsening dysphoria by repeatedly taking a medication that is often associated with cisgender women, such as combined oral contraceptives (COCs). Furthermore, patients may want to avoid COCs secondary to concerns about potential feminizing effects of these hormones and their counteraction of masculinizing effects of testosterone. While COCs act to lower androgen levels by increasing sex hormone–binding globulin, which subsequently binds to testosterone, the amount of estrogen in the pill does not contribute significantly to inhibiting masculinization, and patients should be counseled accordingly.4,5 Side effects such as breast tenderness, which is common among COCs and other estrogen-containing contraceptives, can increase dysphoria and make chest binding more painful. In patients who undergo gender-affirming mastectomies, these effects are less pronounced, however, there may be residual breast tissue left behind which can still produce tenderness and pain.
Sterilization is also a reasonable option in transmasculine patients desiring permanent contraception. Similar to sterilization counseling in cisgender women, a discussion about the irreversibility of the procedure and rates of regret should occur. Transmasculine patients may seek hysterectomy for contraception and to avoid further pelvic exams, cervical cancer screening, pelvic cramping, and/or uterine bleeding. Providers should be knowledgeable about the World Professional Association for Transgender Health standards of care for gender-affirming hysterectomies and counsel patients appropriately.
In summary, transmasculine and all gender-diverse patients deserve the same comprehensive care that their cisgender counterparts receive. Even if the ob.gyn. is not the prescribing physician for testosterone, we all must have a basic understanding of the effects of testosterone and provide appropriate contraceptive services and family planning options to patients when indicated.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa.
References
1. Unger CA. J Women’s Health. 2015;24(2):114-8.
2. Abern L and Maguire K. Obstet Gynecol. 2018;131:65S.
3. Light A et al. Contraception. 2018;98:266-9.
4. Krempasky C et al. Am J Obstet Gynecol. 2020;222(2):134-43.
5. Goodman NF et al. Endocrin Pract. 2015:21(11):1291-300.
Vaginoplasty basics – what every gynecologist needs to know
Feminizing gender affirmation surgery is a complex genital surgery that most commonly involves removal of natal male genitalia (testes, penile urethra, a majority of the glans penis, penile shaft) and construction of the vulva and/or neovagina utilizing scrotal and penile shaft tissue. Other surgical procedures can also involve using a peritoneal flap or a portion of the small bowel or sigmoid colon to create the neovaginal canal. As with any major surgical procedure, complications do occur, and these can range from minor to major; intraoperative to postoperative. For the purposes of this article, the focus shall be on postoperative complications. Most postoperative complications occur within the first 4 months of the surgery and include vaginal stenosis, genitourinary fistula formation, urinary stream abnormalities, and sexual dysfunction.1 Minor complications that can be managed in the office include granulation tissue treatment, vaginitis, and hair growth in the neovagina. It is important to note that, if any complication occurs, it is essential to refer to the patient’s original surgeon or to a surgeon with expertise in vaginoplasty techniques and postoperative management.2
For patients who undergo vaginoplasty, or a creation of a neovaginal canal, postoperative dilation is necessary to maintain patency. The frequency and duration of dilation are often determined by each individual surgeon or surgical practice as there is no universal, evidence-based standard to guide recommendations on dilation. Failure to maintain a dilation schedule can result in neovaginal stenosis and inability to engage in penetrative vaginal intercourse (if patients desire). Dilation can be difficult.
Challenges with dilation can occur for a variety of reasons: pain, history of trauma, pelvic floor dysfunction, lack of privacy or a supportive environment, or change in personal goals.3 If the underlying cause is related to pelvic floor dysfunction, postoperative pelvic floor therapy has demonstrated improvement in dilation.4 Additionally, routine douching is required for vaginal hygiene. Unlike natal vaginas, neovaginas do not usually contain mucosa, with the exception of a colonic interposition vaginoplasty, and routine douching with soapy water can help prevent a buildup of lubricant and debris.
If a patient reports abnormal discharge, an exam of the vulva and neovagina is warranted. Many patients are able to tolerate a speculum examination. If a patient has undergone a penile inversion vaginoplasty, the microbiome of the neovagina is quite different than that of a natal vagina and most common causes of abnormal discharge often include retained lubricant, keratin debris, sebum, or semen.5 During a speculum exam, the provider may notice granulation tissue, which is often another cause of persistent vaginal discharge, vaginal bleeding, or pain during dilation. Depending on the patient’s symptoms and quantity of granulation tissue present, it can often resolve spontaneously. Persistent granulation tissue can be treated with silver nitrate. An alternative to silver nitrate is using medical grade honey or a course of a mild-strength topical steroid cream or ointment.5 In some cases, abnormal discharge may be the result of a fistula. If a fistula is noted the patient should be immediately referred back to the original surgeon or to a urogynecologist and/or colorectal surgeon for evaluation and management.
While this surgery often falls outside of the scope of practice of the general obstetrician-gynecologist, most patients will seek the care of a general obstetrician-gynecologist in the postoperative period. It is therefore imperative that obstetrician-gynecologists have a basic understanding of the surgical procedure and the aftercare involved.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. Email her at obnews@mdedge.com.
References
1. Gaither TW et al. J Urol. 2018;199(3):760-5.
2. Ferrando CA and Bowers ML. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 82-92.
3. Chi AC et al. Complications of vaginoplasty. In: Niklavsky D and Blakely SA, eds. “Urological care for the transgender patient: A comprehensive guide” Switzerland: Springer Nature, 2021 p. 83-97.
4. Jiang D et al. Obstet Gynecol. 2019;133(5):1003-11.
5. Obedin-Maliver J and Haan GD. Gynecologic care for transgender patients. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 131-51.
Feminizing gender affirmation surgery is a complex genital surgery that most commonly involves removal of natal male genitalia (testes, penile urethra, a majority of the glans penis, penile shaft) and construction of the vulva and/or neovagina utilizing scrotal and penile shaft tissue. Other surgical procedures can also involve using a peritoneal flap or a portion of the small bowel or sigmoid colon to create the neovaginal canal. As with any major surgical procedure, complications do occur, and these can range from minor to major; intraoperative to postoperative. For the purposes of this article, the focus shall be on postoperative complications. Most postoperative complications occur within the first 4 months of the surgery and include vaginal stenosis, genitourinary fistula formation, urinary stream abnormalities, and sexual dysfunction.1 Minor complications that can be managed in the office include granulation tissue treatment, vaginitis, and hair growth in the neovagina. It is important to note that, if any complication occurs, it is essential to refer to the patient’s original surgeon or to a surgeon with expertise in vaginoplasty techniques and postoperative management.2
For patients who undergo vaginoplasty, or a creation of a neovaginal canal, postoperative dilation is necessary to maintain patency. The frequency and duration of dilation are often determined by each individual surgeon or surgical practice as there is no universal, evidence-based standard to guide recommendations on dilation. Failure to maintain a dilation schedule can result in neovaginal stenosis and inability to engage in penetrative vaginal intercourse (if patients desire). Dilation can be difficult.
Challenges with dilation can occur for a variety of reasons: pain, history of trauma, pelvic floor dysfunction, lack of privacy or a supportive environment, or change in personal goals.3 If the underlying cause is related to pelvic floor dysfunction, postoperative pelvic floor therapy has demonstrated improvement in dilation.4 Additionally, routine douching is required for vaginal hygiene. Unlike natal vaginas, neovaginas do not usually contain mucosa, with the exception of a colonic interposition vaginoplasty, and routine douching with soapy water can help prevent a buildup of lubricant and debris.
If a patient reports abnormal discharge, an exam of the vulva and neovagina is warranted. Many patients are able to tolerate a speculum examination. If a patient has undergone a penile inversion vaginoplasty, the microbiome of the neovagina is quite different than that of a natal vagina and most common causes of abnormal discharge often include retained lubricant, keratin debris, sebum, or semen.5 During a speculum exam, the provider may notice granulation tissue, which is often another cause of persistent vaginal discharge, vaginal bleeding, or pain during dilation. Depending on the patient’s symptoms and quantity of granulation tissue present, it can often resolve spontaneously. Persistent granulation tissue can be treated with silver nitrate. An alternative to silver nitrate is using medical grade honey or a course of a mild-strength topical steroid cream or ointment.5 In some cases, abnormal discharge may be the result of a fistula. If a fistula is noted the patient should be immediately referred back to the original surgeon or to a urogynecologist and/or colorectal surgeon for evaluation and management.
While this surgery often falls outside of the scope of practice of the general obstetrician-gynecologist, most patients will seek the care of a general obstetrician-gynecologist in the postoperative period. It is therefore imperative that obstetrician-gynecologists have a basic understanding of the surgical procedure and the aftercare involved.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. Email her at obnews@mdedge.com.
References
1. Gaither TW et al. J Urol. 2018;199(3):760-5.
2. Ferrando CA and Bowers ML. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 82-92.
3. Chi AC et al. Complications of vaginoplasty. In: Niklavsky D and Blakely SA, eds. “Urological care for the transgender patient: A comprehensive guide” Switzerland: Springer Nature, 2021 p. 83-97.
4. Jiang D et al. Obstet Gynecol. 2019;133(5):1003-11.
5. Obedin-Maliver J and Haan GD. Gynecologic care for transgender patients. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 131-51.
Feminizing gender affirmation surgery is a complex genital surgery that most commonly involves removal of natal male genitalia (testes, penile urethra, a majority of the glans penis, penile shaft) and construction of the vulva and/or neovagina utilizing scrotal and penile shaft tissue. Other surgical procedures can also involve using a peritoneal flap or a portion of the small bowel or sigmoid colon to create the neovaginal canal. As with any major surgical procedure, complications do occur, and these can range from minor to major; intraoperative to postoperative. For the purposes of this article, the focus shall be on postoperative complications. Most postoperative complications occur within the first 4 months of the surgery and include vaginal stenosis, genitourinary fistula formation, urinary stream abnormalities, and sexual dysfunction.1 Minor complications that can be managed in the office include granulation tissue treatment, vaginitis, and hair growth in the neovagina. It is important to note that, if any complication occurs, it is essential to refer to the patient’s original surgeon or to a surgeon with expertise in vaginoplasty techniques and postoperative management.2
For patients who undergo vaginoplasty, or a creation of a neovaginal canal, postoperative dilation is necessary to maintain patency. The frequency and duration of dilation are often determined by each individual surgeon or surgical practice as there is no universal, evidence-based standard to guide recommendations on dilation. Failure to maintain a dilation schedule can result in neovaginal stenosis and inability to engage in penetrative vaginal intercourse (if patients desire). Dilation can be difficult.
Challenges with dilation can occur for a variety of reasons: pain, history of trauma, pelvic floor dysfunction, lack of privacy or a supportive environment, or change in personal goals.3 If the underlying cause is related to pelvic floor dysfunction, postoperative pelvic floor therapy has demonstrated improvement in dilation.4 Additionally, routine douching is required for vaginal hygiene. Unlike natal vaginas, neovaginas do not usually contain mucosa, with the exception of a colonic interposition vaginoplasty, and routine douching with soapy water can help prevent a buildup of lubricant and debris.
If a patient reports abnormal discharge, an exam of the vulva and neovagina is warranted. Many patients are able to tolerate a speculum examination. If a patient has undergone a penile inversion vaginoplasty, the microbiome of the neovagina is quite different than that of a natal vagina and most common causes of abnormal discharge often include retained lubricant, keratin debris, sebum, or semen.5 During a speculum exam, the provider may notice granulation tissue, which is often another cause of persistent vaginal discharge, vaginal bleeding, or pain during dilation. Depending on the patient’s symptoms and quantity of granulation tissue present, it can often resolve spontaneously. Persistent granulation tissue can be treated with silver nitrate. An alternative to silver nitrate is using medical grade honey or a course of a mild-strength topical steroid cream or ointment.5 In some cases, abnormal discharge may be the result of a fistula. If a fistula is noted the patient should be immediately referred back to the original surgeon or to a urogynecologist and/or colorectal surgeon for evaluation and management.
While this surgery often falls outside of the scope of practice of the general obstetrician-gynecologist, most patients will seek the care of a general obstetrician-gynecologist in the postoperative period. It is therefore imperative that obstetrician-gynecologists have a basic understanding of the surgical procedure and the aftercare involved.
Dr. Brandt is an ob.gyn. and fellowship-trained gender-affirming surgeon in West Reading, Pa. Email her at obnews@mdedge.com.
References
1. Gaither TW et al. J Urol. 2018;199(3):760-5.
2. Ferrando CA and Bowers ML. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 82-92.
3. Chi AC et al. Complications of vaginoplasty. In: Niklavsky D and Blakely SA, eds. “Urological care for the transgender patient: A comprehensive guide” Switzerland: Springer Nature, 2021 p. 83-97.
4. Jiang D et al. Obstet Gynecol. 2019;133(5):1003-11.
5. Obedin-Maliver J and Haan GD. Gynecologic care for transgender patients. In: Ferrando CA, ed. “Comprehensive care of the transgender patient” Philadelphia: Elsevier, 2020, p. 131-51.