Gender-Affirming Care in Plastic Surgery Training: Moving beyond Metrics of Exposure

Abstract

Volume 149, Number 3 • Viewpoints 601e published in Plastic and Reconstructive Surgery have examined plastic surgery residents' training in transgender and gender-diverse care. In a survey of program directors, 67 percent described their trainees as prepared to address plastic surgery-related care for transgender and gender-diverse patients but reported only 28 percent of their residents had exposure to genital surgery and 56 percent had exposure to facial surgery. 2 In a national survey of plastic surgery residents, 64.6 percent of residents stated they had "[received] education or exposure to the care of transgender patients," but there were significant differences in exposure by region. 3 The metrics used in these studies to assess the current state of gender-affirming surgery training were largely limited to measurements of exposure, rather than competency and actual experience in clinical and operative care. The World Professional Association for Transgender Health's recommendations for clinical training encompass a far greater breadth of experience beyond surface-level exposure. 4 Although residents train in many areas involved in gender affirmation, these surgical techniques are often highly complex and take significant training and experience to master, especially given the profound psychosocial implications for patients. Surgical providers must have a robust understanding of the perioperative experience of patients to achieve safe, successful outcomes.Gender-affirming surgery is an evolving area of subspecialization that should be given the same priority as any other subspecialty in plastic surgery. As more individuals seek gender-affirming procedures, plastic surgery trainees will benefit from additional training tailored to transgender and gender-diverse patients, with 71.9 percent of residents endorsing the necessity for fellowship training in gender-affirming surgery. 3 Moving beyond metrics of exposure to national training guidelines for plastic surgery residents on the clinical skills and competencies needed to care for transgender and gender-diverse patients is both a necessary step and our responsibility to help alleviate and address the inequities facing transgender and genderdiverse patients.

How Should Surgeons Approach Gender-Affirming Surgery Revisions When Patients Were Not, Perhaps, Well Informed in Prior Counseling?

“…T's prior residence and health plan may also have contributed to his seeking a revision procedure, as a lack of trained surgeons and barriers to insurance coverage have led some patients to access care that may be less comprehensive. 18,19 Dr D has potentially encountered these downstream effects of social marginalization as experienced by T and other transgender patients. Although Dr D cannot single-handedly reverse the unjust distribution of research attention and medical resources, he can acknowledge their maldistribution to build an alliance with his patient.…”

“…Alternatively, the first surgeon may have counseled T that future urethroplasty would be ill-advised but T did not retain this information 19 or may have misunderstood his goals. For patients like T who initially lacked a realistic understanding of outcomes, surgeons like Dr D who are considering revision must carefully reset patient expectations.…”

Nondiscrimination Protections in Gender-affirming Surgery: US Government’s Proposed Update to Section 1557 of the Affordable Care Act

“…This move would significantly expand the workforce capable of performing such procedures. 5 Health-care access is crucial for everyone, and this proposed update would further guarantee that TGD people can obtain the care and coverage they need. The update's other components, such as expanding provisions for people with low English-proficiency or disabilities, and prohibiting discrimination on the basis of sexual orientation and diverse family unit structures, would all enhance healthcare access and delivery for TGD people.…”

Challenging the Binary Bias in Gender-Affirming Surgery

“…The volume of GAS, continued integration of gender-affirming care into medical training, and a strong movement to look at patients from a holistic, intersectional lens are continually increasing. 1 Although these changes represent significant progress, to continue this momentum we must also reflect on how we came to practice in an exclusionary system that often reinforces the marginalization of certain groups of TGD people. Given that systems are built by individuals, we can start by looking at our own biases.…”