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Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for t...

Experts in each aspect of transgender health have summarized the content of the global education initiative in this article. It provides valuable information to surgeons of all disciplines and other health care professionals to help guide the treatment and management of transgender individuals.

In July of 2011, the American Society of Plastic Surgeons Executive Committee approved the Venous Thromboembolism Task Force Report. The report includes a summary of the scientific literature relevant to venous thromboembolism and plastic surgery along with five evidence-based recommendations. The recommendations are divided into two sections: risk stratification and prevention. The risk stratification recommendations are based on the 2005 Caprini Risk Assessment Module, which has been validated in the scientific literature as an effective tool for risk-stratifying plastic and reconstructive surgery patients based on individual risk factors for 60-day venous thromboembolism. The three prophylaxis recommendations are dependent on an individual patient's 2005 Caprini Risk Assessment Module score.

Background: A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret.This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients.Methods: This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference.Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results:The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either:(I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature.Conclusions: In this study, regret following GAS was rare and was consistent with the existing literature.Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.

Objective: To perform the first systematic review of all available genderaffirming surgery (GAS) publications across all procedures to assess both outcomes reported in the literature and the methods used for outcome assessment. Summary of Background Data: Rapidly increasing clinical volumes of gender-affirming surgeries have stimulated a growing need for high-quality clinical research. Although some procedures have been performed for decades, each individual procedure has limited data, necessitating synthesis of the entire literature to understand current knowledge and guide future research. Methods: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify all outcomes measures in GAS cohorts, including PCOs, complications, and functional outcomes. Outcome data were pooled to assess currently reported complication, satisfaction, and other outcome rates. Results: Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications. Of non-genitoplasty titles, 35 were mastectomy, 6 mammoplasty, 21 facial feminization, and 31 voice/cartilage. Although 59.1% of non-genitoplasty papers addressed PCOs in some form, only 4.3% used instruments partially-validated in transgender patients. Overall, data were reported heterogeneously and were biased towards high-volume centers. Conclusions: This study represents the most comprehensive review of GAS literature. By aggregating all previously utilized measurement instruments, this study offers a foundation for discussions about current methodologic limitations and what dimensions must be included in assessing surgical success. We have assembled a comprehensive list of outcome instruments; this offers an ideal starting basis for emerging discussions between patients and providers about deficiencies which new, better instruments and metrics must address. The lack of consistent use of the same outcome measures and validated GAS-specific instruments represent the 2 primary barriers to highquality research where improvement efforts should be focused.

Background At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. Aim To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. Methods We use expert opinion to provide a “first of its kind” framework for training surgeons to care for transgender and gender nonconforming individuals. Outcomes We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. Results This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. Clinical Implications The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. Strengths and Limitations This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. Conclusion We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures.

stablished in 1966 under the Social Security Administration, Medicare is the primary health insurance for many Americans older than 65 years. 1 In 2018, Medicare represented more than 61.5 million individuals, and its budget was approximately $750 billion. 2 Medicare reimburses physicians based on a national fee schedule. 1 To establish this fee schedule, each medical procedure or service is represented by a CPT code and linked to an International Classification of Diseases, Tenth Revision, diagnosis. This represents the relative resources required to provide a particular service and forms the basis for physician and hospital reimbursement. 3 These relative value units are updated annually by the Centers for Medicare and Medicaid Services and effectively set the standard by which hospitals and/or physicians are reimbursed. Relative value units consider expenses related to physician work, practice expenses, and malpractice insurance. The final fee schedule for each procedure/service is then determined by applying the conversion factor to the relative value units. The conversion factor is a number selected by Centers for Medicare and Medicaid Services every year based on complex formulas that take into consideration the Medicare charges the year prior, the number of Medicare enrollees, the overall status of the U.S. economy, and any expected regulations that may affect Medicare services. The goal of the conversion factor is to limit potential increases in the Medicare budget higher than 20 percent from the last year's budget. 4 Growth in the aging population, steadily rising health care costs, and increased demand for health care services combined with fluctuations in the national political and financial landscape lead to financial unpredictability in the health