Scientific Abstract Presentations: Gender Affirmation Session 4 Saturday, October 11 Sat, Oct 11 2:00-3:30 p.m. CDT

Background: Full depth vaginoplasty is a common procedure performed for individuals with gender dysphoria seeking feminizing genital reconstruction. Various surgical approaches have been described with the most common being standard penile inversion vaginoplasty (PIV) and robotic-assisted peritoneal flap vaginoplasty (RAPFV). The RAPFV is also commonly used in revision cases of primary PIV complicated by vaginal stenosis and has shown excellent clinical outcomes. Recently, tissue substitutes, such as acellular dermal matrix (ADM), have been used to bridge the introitus to the peritoneal flap when RAPFV is used for revision of primary PIV. To date, no study has evaluated utilizing tissue substitutes in primary RAPFV. We present our experience with primary RAPFV utilizing ADM for patients with inadequate genital tissue.

Methods/Technique: This is a retrospective case series of three patients with inadequate genital tissue underwent RAPFV with ADM. RAPFV started with standard PIV techniques. Following vaginal canal dissection, all patients required additional tissue to bridge the gap between the penile skin and peritoneal flap and the scrotal skin was inadequate. A piece of ADM was tubularized using the orange 25 mm dilator and sewn to the penile skin flap. For the 3 patients, the ADM dimensions were 7 cm x 12 cm, 8 cm x 12 cm, and 6 x 12 cm respectively. This structure was then inverted into the neovaginal canal. The penile skin flap – ADM construct was scored with cautery and trimmed by the external surgeon. The ADM was then sewn to the peritoneal flaps using the DaVinci Xi robotic system. The rest of the RAPFV was completed in a standard fashion.

Results/Outcomes: For the 3 patients included, the age at the time of surgery was 20, 33, and 39, and the age at the start of hormone therapy was 13, 30, and 35, respectively. The preoperative penile length was 4, 6.5 and 8.5 cm, respectively. The scrotal skin was small in all cases. Total operative time was 300, 313, and 48 minutes, respectively. There were no intraoperative complications. There were no immediate postoperative complications. One patient required sharp dissection of granulation tissue and collagenase ointment. Otherwise, there have been no major vaginal canal complications, and all patients are using the 35 mm dilator to the last dot. To date follow-up was at postoperative day 213, 103, and 66, respectively.

Conclusion: Inadequate genital tissue may be present in transgender and gender-diverse adults requesting feminizing genital reconstruction for gender affirmation. In addition, pre-pubertal gender affirming hormonal blockade is becoming increasingly common and is associated with genital hypoplasia. ADM is an option that does not require a secondary donor site for the creation of the neovagina in cases of inadequate native genital tissue. We report the successful use of ADM in patients with inadequate genital tissue undergoing primary RAPFV.

Purpose Facial feminization surgery (FFS) improves mental health in transgender and gender non-binary (TGNB) individuals, but the influence of social risk factors on outcomes is unclear. The Area Deprivation Index (ADI) and Social Vulnerability Index (SVI) measure socioeconomic deprivation through U.S. Census Bureau data. This study examines whether ADI or SVI score severity may be associated with substandard improvement of psychosocial functioning after gender-affirming FFS.

Methods 185 TGNB adults undergoing FFS at a single institution between 2020-2025 were prospectively enrolled to complete preoperative and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) instruments for anxiety, anger, depression, global mental health, global physical health, and global total health, positive affect, emotional support, social isolation, companionship, and meaning and purpose. The impact of ADI/SVI on PROMIS scores was analyzed via multivariable regression. Insurance type, preexisting mental health diagnoses, and preoperative depression PROMIS scores were also included in the model.

ADI quantifies socioeconomic disadvantage based on factors including poverty level, income, education, housing, and access to utilities, transportation, and healthcare. Scores (0-100) represent percentiles ranking neighborhoods at census block group level relative to others nationwide. Higher ADI score indicates greater disadvantage.

SVI measures vulnerability to external stressors on health and well-being such as disasters and disease outbreaks. Scores (0-1) represent percentiles ranking neighborhoods at the census tract level relative to others nationwide. Neighborhoods are classified into four quartiles: lowest (0-0.25), moderate (0.26-0.50), high (0.51-0.75), and highest vulnerability (0.76-1.00). SVI captures scores for separate domains, with higher scores indicating greater vulnerability: Socioeconomic Status (higher poverty and unemployment rates, lower income, and fewer residents with higher education), Household Composition (higher proportions of older adults, children, individuals with disabilities, and single-parent households), Racial & Ethnic Minority Status (higher percentages of racial/ethnic minority populations and households with limited English proficiency), and Housing Type & Transportation (higher rates of overcrowding, mobile or multi-unit housing, and lack of vehicle access).

Results 185 TGNB patients (mean age: 33.1 ± 10 years) were included. Mean ADI score was 12.6 ± 11.3. Mean scores for each SVI domain are reported: Socioeconomic Status 0.5575 ± 0.2838, Household Characteristics 0.3576 ± 0.2725, Racial & Ethnic Minority Status 0.6725 ± 0.1992, Household Type and Transportation 0.6388 ± 0.2667. No significant correlations were found between ADI/SVI scores and preoperative or postoperative PROMIS scores. Changes in PROMIS scores (postoperative minus preoperative) showed significant associations with SVI scores across multiple domains. Differential PROMIS scores were used as outcome variables in the multivariable regression analysis. Household Type and Transportation SVI domain significantly predicted postoperative change in depression (B=-6.2, 95%CI -11.5,-0.91, P= 0.02), social isolation (B=-6.3, 95%CI -11.8,-0.74, P=0.03), and companionship (B=6.6, 95%CI 1.3,11.9, P=0.02), with trends towards significance for global total health (B=7.6, 95%CI -0.58,15.8, P=0.07).

Conclusion Housing type and transportation vulnerability may enable prediction of associated outcome variance, significantly influencing psychosocial outcomes after FFS. Other SVI domains were not significant, suggesting that structural factors like housing stability and transportation access uniquely impact psychosocial recovery, emphasizing the need for targeted interventions to support TGNB individuals postoperatively.

Introduction: Gender-affirming surgeries (GAS) play a critical role in the well-being of transgender and gender-diverse (TGD) individuals by alleviating gender dysphoria and improving mental health outcomes (Almazan 2021) Despite increased demand, access remains hindered by inconsistent insurance coverage and policy limitations (Dozier 2023). This study examines the landscape of insurance policies for GAS, barriers to coverage, and the impact of policy changes on patient access and surgical outcomes at a major transgender care center.

Methods: An IRB-approved Qualtrics survey was distributed to patients treated at a transgender care center from 2020-2024. Survey questions were adapted from the 2015 National Transgender Survey and supplemented with original items assessing insurance status, surgical access, and experiences with coverage denials. Descriptive statistics and chi-squared analyses (p<0.05) were performed using Stata SE.

Results: A total of 214 respondents (64.07% response rate) participated. Of these, 77.36% were assigned female at birth, and 68.69% identified as transgender. Most (70.95%) had private insurance, while 24.76% were publicly insured. Insurance denials for GAS were reported by 10% of participants, with nonbinary individuals experiencing disproportionately high denial rates for hormone therapy (8.11%, p<0.001). Partial insurance coverage for GAS was reported by 29.47% of patients (p=0.034), and 7.35% noted the absence of in-network providers for gender-affirming surgery (p<0.001).

Transgender women were more likely to experience partial insurance coverage for their procedures (44.12%) compared to transgender men and nonbinary individuals (p=0.034). Additionally, 32.35% of transgender women reported a lack of in-network providers despite insurance coverage for surgery, significantly more than other groups (p<0.001). The 2021 expansion of GAS coverage by our institutional health plan significantly influenced the insurance choices of 45.45% of transgender women (p=0.023), yet 63.64% of transgender men were unaware of this policy change. Among those insured by our institution, 57.6% expressed increased interest in additional GAS following coverage expansion. Patients cited long wait times, aesthetic dissatisfaction, and financial burdens as primary barriers to satisfaction with care.

Conclusion: While expanded insurance coverage has improved access to GAS, disparities persist, particularly among transgender women and nonbinary individuals, who face higher rates of denials due to restrictive eligibility criteria and cosmetic classifications. The findings underscore the need for standardized policies ensuring equitable access to all gender-affirming procedures. Additionally, increased provider networks, clearer policy communication, and patient navigators could help mitigate existing barriers. Financial burdens and lack of in-network specialists continue to hinder access, emphasizing the need for ongoing policy reform. Further advocacy, healthcare provider training, and research are necessary to ensure that gender-affirming care is comprehensive, inclusive, and accessible to all who need it.

References: 1. Almazan AN, Keuroghlian AS. Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surg. 2021;156(7):611-618. doi:10.1001/jamasurg.2021.0952 2. Dozier R. How Navigators Influence Insurance Coverage for Gender-Affirming Surgeries: A Qualitative Study. Perm J. 2023 Mar 15;27(1):72-76. doi: 10.7812/TPP/22.115. Epub 2023 Mar 14. PMID: 36916175; PMCID: PMC10013711.

Background: Preoperative mental health is being increasingly recognized for its impact on surgical outcomes, namely length of stay, complications, postoperative pain, and opioid use. Among vulnerable surgical populations, transgender and gender-diverse (TGD) patients experience a high prevalence of mental health comorbidities, with 58-77% of individuals known to carry a mental health diagnosis per our institutional cohort of patients and national estimates. Facial gender affirming surgery (FGAS) is an important procedure for TGD individuals who experience dysphoria from their facial features and has been shown to independently improve mental health quality of life outcomes. However, baseline psychosocial functioning plays a significant role in postoperative recovery, with preoperative depression independently predicting worse postoperative outcomes. Therefore, given the importance of mental health prior to surgery, the aim of the current work is to investigate the impact of psychotherapy prior to FGAS on both surgical and mental health quality of life outcomes.

Method: Adults registered male at birth undergoing deo novo FFS from 2020-2024 were retrospectively reviewed. Patient-reported outcomes utilizing the Patient-Reported Outcomes Measurement Information System (PROMIS) were evaluated preoperatively and postoperatively at three to six months and/or 12 to 18 months. Patients were excluded from the study if they did not complete a preoperative assessment and at least one postoperative assessment. A retrospective chart review was performed to collect demographic information, past medical history, psychiatric history, surgical history, and hospital course, including operative time, hospital length of stay, average self-reported pain score, and opioid use. Generalized linear models, binary logistic regression, and maximum likelihood estimation were used to calculate outcomes.

Results: 191 TGD patients were included. Using generalized linear models, mental health diagnoses increased the length of stay by 2545.9% (B=3.237; 95% CI: 2.456, 4.018; p<0.001). Length of stay was reduced by 94.8% when assessing the interaction of therapy and mental health diagnoses (B=-2.906; 95% CI: -4.100, -1.713; p<0.001). Similarly, the presence of mental health diagnoses increased the total opioid use by 2518.4% (B=3.265; 95% CI: 1.839, 4.691; p<0.001). Lastly, therapy was found to mitigate the impact of mental health diagnoses on patient-reported outcomes, particularly in the anxiety and social isolation of generalized linear mixed models.

Conclusion: This study demonstrates that preoperative mental health diagnoses influence hospital length of stay and postoperative opioid use, while a history of psychotherapy before FGAS serves as an important mitigator of these outcomes. These findings demonstrate the importance of optimizing preoperative mental health among TGD patients undergoing FGAS to improve both surgical and mental health quality of life outcomes. Psychological prehabilitation and other preoperative interventions may offer additional benefits, however, further research is needed to determine the most effective type, modality, timing, and duration of psychotherapy interventions, specifically in the setting of gender-affirming surgery.

Background: Despite a large body of evidence and techniques described in the cisgender brow lift literature, there remains a paucity of objective outcome data pertaining to transgender patients undergoing upper-third FFS for gender dysphoria. The current study therefore presents our surgical approach to brow lift in FFS and a series of objective outcomes.

Methods: A retrospective review was conducted for patients who underwent facial feminization brow lift between December 2020 and December 2024. Inclusion criteria required pre- and postoperative photographic documentation. Data collection included demographics, surgical details, and postoperative outcomes. Three brow lift techniques were utilized: (1) endoscopic brow lift with Endotine fixation, (2) suture suspension, and (3) direct brow-to-bone suspension. Objective outcomes were assessed using pixel-based photometric analysis in ImageJ, standardizing measurements based on interpupillary axis and iris diameter.

Results: Sixty-four patients met inclusion criteria, with a median age of 35.1 years [IQR: 16.3] and BMI of 27.5 kg/m² [IQR: 4.9]. All patients had received hormone therapy for over 12 months. The most common concurrent procedures were forehead contouring (96.9%), genioplasty (76.6%), and hairline advancement (70.3%). The primary brow lift technique was Endotine fixation (91.9%). Mean operative duration was 292.6 ± 82.7 minutes. At a mean of 3.8 ± 4.4 months postoperatively, photographic analysis demonstrated significant reductions in hairline position at the right (-3.3 ± 8.1 mm, p=0.002), center (-4.5 ± 8.4 mm, p<0.001), and left (-3.8 ± 8.5 mm, p<0.001) landmarks. Forehead height similarly decreased at the right (-3.5 ± 7.2 mm, p<0.001), center (-4.0 ± 7.6 mm, p<0.001), and left (-3.4 ± 7.1 mm, p<0.001) regions. Statistically significant increases in measurements were observed at the left midbrow (+0.6 ± 1.9 mm, p=0.020) and left lateral brow (+0.6 ± 2.2 mm, p=0.043). Changes at other brow landmarks were not significant. One patient (1.6%) developed a postoperative hematoma, and five patients (7.8%) underwent revision for aesthetic purposes.

Conclusion: Our results demonstrate that the three brow lift techniques outlined (endoscopic with Endotine fixation, suture suspension, and direct brow-to-bone suspension) offer safe and consistent approaches to upper-third facial feminization in transgender patients, with objectively measured improvements in brow height and hairline position. These findings provide valuable outcome data for clinicians and patients seeking evidence-based strategies to optimize facial feminization.

Background: Despite a large body of evidence and techniques described in the cisgender brow lift literature, there remains a paucity of objective outcome data pertaining to transgender patients undergoing upper-third FFS for gender dysphoria. The current study therefore presents our surgical approach to brow lift in FFS and a series of objective outcomes.

Methods: A retrospective review was conducted for patients who underwent facial feminization brow lift between December 2020 and December 2024. Inclusion criteria required pre- and postoperative photographic documentation. Data collection included demographics, surgical details, and postoperative outcomes. Three brow lift techniques were utilized: (1) endoscopic brow lift with Endotine fixation, (2) suture suspension, and (3) direct brow-to-bone suspension. Objective outcomes were assessed using pixel-based photometric analysis in ImageJ, standardizing measurements based on interpupillary axis and iris diameter.

Results: Sixty-four patients met inclusion criteria, with a median age of 35.1 years [IQR: 16.3] and BMI of 27.5 kg/m² [IQR: 4.9]. All patients had received hormone therapy for over 12 months. The most common concurrent procedures were forehead contouring (96.9%), genioplasty (76.6%), and hairline advancement (70.3%). The primary brow lift technique was Endotine fixation (91.9%). Mean operative duration was 292.6 ± 82.7 minutes. At a mean of 3.8 ± 4.4 months postoperatively, photographic analysis demonstrated significant reductions in hairline position at the right (-3.3 ± 8.1 mm, p=0.002), center (-4.5 ± 8.4 mm, p<0.001), and left (-3.8 ± 8.5 mm, p<0.001) landmarks. Forehead height similarly decreased at the right (-3.5 ± 7.2 mm, p<0.001), center (-4.0 ± 7.6 mm, p<0.001), and left (-3.4 ± 7.1 mm, p<0.001) regions. Statistically significant increases in measurements were observed at the left midbrow (+0.6 ± 1.9 mm, p=0.020) and left lateral brow (+0.6 ± 2.2 mm, p=0.043). Changes at other brow landmarks were not significant. One patient (1.6%) developed a postoperative hematoma, and five patients (7.8%) underwent revision for aesthetic purposes.

Conclusion: Our results demonstrate that the three brow lift techniques outlined (endoscopic with Endotine fixation, suture suspension, and direct brow-to-bone suspension) offer safe and consistent approaches to upper-third facial feminization in transgender patients, with objectively measured improvements in brow height and hairline position. These findings provide valuable outcome data for clinicians and patients seeking evidence-based strategies to optimize facial feminization.

Purpose: In the United States, approximately 1 in 200 individuals identifies with a gender different from their sex assigned at birth.1 Current research on gender-affirming care (GAC) primarily addresses binary identities, often overlooking non-binary individuals.1,2 Although qualitative studies provide insights into non-binary perspectives, there is a lack of research utilizing validated clinical tools to assess outcomes in non- binary populations.1 This study aims to address this gap using a validated psychometric tool to objectively measure outcomes in non-binary individuals seeking gender-affirming surgery (GAS).

Methods: The Vanderbilt Mini Patient-Reported Outcomes Measures-Gender (VMP-G), a validated tool with scores ranging from 20 to100, in which higher scores indicate better outcomes.3 The tool assesses patient-reported outcomes measures (PROMs) across five scales (quality of life, self-concept, satisfaction, gender dysphoria, and regret). Data were collected from non-binary patients undergoing GAS between September 2022 and October 2024 via EPIC survey prompts during preoperative visits and post-surgical timepoints.

Results: 108 patients (median age 28.4 [19.0, 53.0]) were included, of whom 39% had undergone GAS. Post-operative VMP-G scores increased significantly across multiple measures, reflecting positive outcomes. GLM analysis revealed that overall VMP-G (p<0.0001), quality of life (p<0.0001), satisfaction (p<0.0447), and self-concept (p<0.0001), and gender dysphoria (p<0.0001) scores improved significantly. Notably, linear regression indicated significant differences in overall VMP-G scores at various postoperative periods compared to baseline, with adjusted p-values remaining significant for early (1-3 months) and later (7-9, 10-12 months) postoperative periods.

Conclusion: These findings highlight significant improvements in well-being and reduced dysphoria following gender-affirming surgery in non-binary individuals, underscoring the intervention's effectiveness in this gender-diverse population.

1. Agochukwu-Mmonu N, Radix A, Zhao L, et al. Patient reported outcomes in genital gender-affirming surgery: the time is now. J Patient Rep Outcomes. 2022;6(1). doi:10.1186/s41687-022-00446-x
2. Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. Journal of Sexual Medicine. 2018;15(1):102-113. doi:10.1016/j.jsxm.2017.11.007
3. Hung YC, Park BC, Assi PE, Perdikis G, Drolet BC, Kassis SA. Multidimensional Assessment of Patient-Reported Outcomes After Gender-Affirming Surgeries Using a Validated Instrument. Ann Plast Surg. 2023;91(5):604-608. doi:10.1097/SAP.0000000000003652

Background: Transgender and non-binary (TGNB) individuals face disproportionately limited access to gender-affirming surgery (GAS) due to systemic inequities. This study examines how these inequities, such as race and ethnicity, impact the utilization of GAS and associated surgical complications across different GAS subtypes.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we retrospectively reviewed TGNB individuals who underwent GAS from 2012 to 2021. The primary outcome was the incidence of major complications (e.g., unplanned reoperation and readmission) and minor complications (e.g., wound complications) within 30 days postoperatively. Bivariate and multivariable tests were used to compare the frequency of GAS and complications across racial and ethnic groups.

Results: Among n=6013 TGNB individuals, most were White (n=3994, [66.4%]), followed by Black (n=880 [14.6%]) and Hispanic (n=788, [13.1%]). Chest masculinization surgery was the most common procedure (n=2395 [39.8%]), followed by genital masculinization surgery (n=1298 [21.6%]), genital feminization surgery (n=958 [15.9%]), chest feminization surgery (n=843 [14%]), and facial feminization surgery (n=396 [6.6%]). White individuals were significantly more likely to undergo chest and genital masculinization surgery than Hispanic and Black individuals. Black individuals undergoing chest masculinization surgery had a higher frequency of unplanned reoperation (n=14 [4.5%], n=28 [1.7%]; P = 0.042) and readmission (n=7 [2.3%], n=8 [0.5%]; P = 0.048) compared with White individuals. For genital feminization surgery, Hispanic and Black individuals experienced significantly higher frequencies of wound disruption than White individuals (n=12 [9.8%], n=12 [8.7%], n=21 [3.3%]; P = 0.006). No significant disparities were observed for chest feminization, genital masculinization, or facial feminization surgeries.

Conclusion: Racial and ethnic disparities exist in surgical utilization and complications among TGNB individuals, highlighting the need for additional research and possibly targeted interventions to address these inequities.

Background:

Surgical approaches to breast augmentation have been well-described in the cisgender population but are limited for transgender patients. This study aims to characterize the outcomes and complications following implant-based gender-affirming breast augmentation using the subfascial plane while comparing follow-up periods between those with private and public insurance.

Methods:

A retrospective chart review was conducted on transgender women that underwent subfascial breast augmentation from June 2017 to August 2024 at a single institution under the care of the senior author. Patient demographics, comorbidities, postoperative outcomes, and follow-up time were collected. Data was analyzed to determine predictors of short and long-term complications as well as revision rates using IBM SPSS 24. A p-value of < 0.05 was considered significant.

Results:

A total of 65 patients with a mean age of 40.2 years, mean implant volume of 505 cc, and mean follow-up of 212 days were assessed. Within 30 days (n = 60), seven patients (11.7%) had at least one incident/complication with one (1.7%) of these patients requiring revision surgery. Two patients developed infection (one managed surgically, one managed non-surgically). The remaining five (8.3%) patients developed malposition. Outside of 30 days (n = 51), 10 patients (16.7% of the total population, 19.6% of the > 30-day follow-up population) had at least one incident/complication that required further management. These incidents/complications included 5 instances of malposition, 5 asymmetries, and 3 capsular contractures all requiring further management. Overall, five patients (7.6% of all patients, 9.8% of the > 30-day follow-up population) underwent revision operations for incidents/complications. Diabetes, increased implant profile and greater duration of hormone therapy were each found to be significantly associated with complications(p < 0.05). A statistically significant difference in follow-up between patients with public and private health insurance was also observed(p < 0.05). Those with public health insurance (n = 38) were found to have a mean follow-up period of 294 days compared to 58.4 days for those with private health insurance (n = 32).

Conclusion:

The subfascial plane offers a chest contour free from the lateralizing and flattening influence of the pectoralis major muscles, potentially allowing for a more feminine result for those seeking gender-affirming breast surgery. Poor patient follow-up has been shown to be correlated with use of private health insurance, while public health insurance are more likely to follow up with their physicians as reflected in our study1. In cisgender patients, fluctuations in endogenous hormones have been shown to affect capsular contracture risk and a similar effect may be observed in those receiving gender-affirming breast augmentation. Overall, subfascial plane outcomes appear to be comparable to other techniques reported in the literature. However, further prospective investigation with larger, matched cohorts and longer follow-up may better delineate differences in outcomes between breast augmentation techniques, as well as the role of hormone therapy in capsular contracture and other complications.

1. Wray CM, Khare M, Keyhani S. Access to Care, Cost of Care, and Satisfaction With Care Among Adults With Private and Public Health Insurance in the US. JAMA Netw Open. 2021;4(6):e2110275. doi:10.1001/jamanetworkopen.2021.10275

Purpose: Access to gender-affirming care has dramatically shifted over the past few decades as a result of policy changes in the United States (US). A shortage of providers represents one of the main barriers to care, with profound but poorly defined geographic differences. This study explores the current geographic availability of surgeons offering gender-affirming surgeries in the US, with a study of variations based on state legislation.

Methods: Five databases were queried to identify gender-affirming surgeons and the procedures offered in the US. An isochrone API software mapped all counties within a 2-hour drive of each surgeon. US Census Bureau and transgender population data were used to calculate the surgeon: transgender ratio per state. Access to gender-affirming care based on related state legislation was assessed.

Results: The number of surgeons per 10,000 transgender individuals varies from 0 to 13.6, with 12 states having none for the five procedures studied. While 31.6% of counties, covering 64.8% of the U.S. population, have access to at least one FFS surgeon, only 5.5% of counties, representing 22.7% of the population, offer voice feminization or masculinization. States with restrictive laws average 1.76 surgeons per 10,000 transgender individuals, compared to 2.18 in neutral states, 3.81 in protective states, and 4.01 in states with shield laws.

Conclusion: The majority of the US population has inadequate access to GAS, especially in rural areas. States with legislation that restrict access to gender-affirming care have a lower surgeon density, while states that protect access have a higher surgeon density.

Intro Transgender and gender-diverse (TGD) patients often use estrogen as part of their gender affirming hormone therapy (GAHT). Estrogen is known to increase the risk of venous thromboembolism (VTE) and pulmonary embolism (PE). As part of their gender-affirming care, these patients can also undergo facial feminization surgery (FFS), which can last upwards of 8-11 hours. Historically, surgeons have advised stopping hormones preoperatively to mitigate this risk. However, this can pose a psychological burden for patients. Recent guidelines suggest that GAHT in therapeutic dosages may not increase risk of VTE. This study retrospectively evaluates incidence of VTE/PE in TGD patients undergoing FFS, comparing outcomes between those who discontinued or continued GAHT before surgery.

Methods A retrospective chart review of all TGD patients who underwent FFS at our institution between 2018-2024 were included. Patients were divided into those that stopped GAHT preoperatively (2018-4/2021) and those instructed to continue GAHT until the day of surgery (4/2021-onwards). Patient demographics, operative details, postoperative complications were reviewed. DVT/PE within 3 months of surgery were included. T tests were performed to evaluate for differences between groups. Statistical significance was set at p<0.05.

Results A total of 420 patients were included, of which 174 paused GAHT and 246 continued GAHT. There was no difference in the mean age (38.3 years old vs 36.9, respectively, p=0.24) or body mass index (26.8 kg/m2 vs 26.6 kg/m2, p=0.76) between the two cohorts. The two groups did differ significantly in mean length of stay (0.6 days vs 0.1 days, p<0.001) and surgical duration (5.3 hours vs 6.5 hours, p<0.001). There were no incidences of DVT or PE recorded in either cohort.

Conclusion Continuing GAHT perioperatively does not seem to increase the risk of DVT or PE in TGD individuals undergoing FFS. Given the potential negative psychological effects of discontinuing hormones, these findings support a shift in clinical practice. Further studies looking at other gender-affirming surgeries should be performed.

Background Medical malpractice lawsuits in gender-affirming care have garnered significant media attention, already leading to increases in insurance premiums in the space.1 This study sought to analyze medical malpractice complaints in the United States dealing with the specific phenomenon of gender detransition, of which nearly all lawsuits have been filed since 2022. While past review articles have sought to analyze malpractice cases related to gender affirming care, they have yielded smaller sample sizes (n = 5).2

In this study, 16 cases with sufficient information were analyzed (n = 16). Collected data included defendant specialty, location, year, stated medications prescribed and procedures performed in lawsuit, and status/outcome of litigation where applicable.

Methods The Bloomberg Law Database was queried for all time using the keywords gender, de-transition or detransition, and malpractice. Out of the 60 cases, cases relating to employment, prisoner rights, health care coverage, or civil rights were excluded yielding 3 relevant cases. The list was combined with two published detransition lawsuit trackers with duplicates and two wrongful death lawsuits excluded to yield 20 lawsuits.3,4 Of these 20, 16 had sufficient complaint information on the legal websites Trellis, Justia, Bloomberg Law, or downloadable County Clerk Documents to analyze. Plaintiff Name was cross referenced with specialty through Physician's Hospital Webpages. The complaints were analyzed for medications and medical procedures listed in the lawsuits. For each case, the corresponding legal history was sought on Trellis, Justia, Bloomberg Law, or County Clerk offices to determine if the case was decided in favour of the plaintiff or defendant and if compensatory damages were awarded.

Results

Of the 46 individually named defendants in the queried cases, 63% were MD or DO physicians and 37% were non-MD nurses, nurse practitioners, therapists, and social workers. The MD Physician Breakdown was as follows: 37.9% plastic surgery, 13.8% obstetrics and gynecology, 10.3% endocrinology, 6.9% pediatrics, 6.9% internal medicine, 6.9% psychiatry, 6.9% urology, 3.4% Pediatrics and Psychiatry, 3.4% Otolaryngology, 3.4% General Surgery. All lawsuits were filed after 2022.

100% of cases cited improper mental health evaluation in their complaints. 56.25% of the cases cited double mastectomy had been performed in their complaint. 87.5% stated transgender hormone therapy (either testosterone or estrogen) was prescribed in their complaint, while only 18.75% of cases stated puberty blockers were prescribed in their complaint. 1 complaint stated a facial feminization, vaginoplasty, clitoroplasty, perineal urethroplasty, and bilateral orchiectomy had been performed. 1 complaint stated a hysterectomy and oophorectomy had been performed.

Of the 16 cases, none have been exclusively decided in favor of the plaintiffs in the courts. 12.5% of cases have been dismissed by plaintiffs, with possible binding arbitration in one. One more case has been requested to be dismissed by the plaintiffs. 81.25% of cases are either pending or do not have updated court dockets indicating pending dismissal. Notably, a number of the cases are being dismissed against specific defendants, a common practice in medical malpractice law. As of date in February 2025, no court compensatory damages have been required of the plaintiffs, although plaintiffs may choose to settle outside of court.

Discussion The number of detransition cases is in fact small, and no fault to date has been found with the defendants. The plurality of the individually named defendants are plastic surgeons (37.9%), demonstrating an increased risk exposure to lawsuits for this specialty in this space.

Citations

1. Nowell, C. (2023, December 21). Malpractice premiums are blocking gender-affirming care for minors. Time. https://time.com/6549690/rising-malpractice-premiums-price-small-clinics-out-of-gender-affirming-care-for-minors/
2. Brozynski M, Oleru O, Seyidova N, Rew C, Nathaniel S, Taub PJ. Litigation in gender affirming surgery: Reviewing five decades of the medical malpractice landscape. J Plast Reconstr Aesthet Surg. 2024 Jun;93:190-192. doi: 10.1016/j.bjps.2024.04.036. Epub 2024 Apr 16. PMID: 38703709; PMCID: PMC11147691.
3. U.S. detransitioner cases. Themis Resource Fund. (2025a, February 19). https://themisresourcefund.org/detransitioner-cases/ Home.
4. Transition Justice Lawsuit Tracker. (n.d.). https://www.transitionjustice.org/

Purpose: GENDER-Q is a comprehensive patient-reported outcome measure (PROM) that includes 56 scales and checklists that measure outcomes of gender-affirming care, including facial surgery and procedures. Aim: To assess the construct validity of 12 GENDER-Q face, neck and hairline appearance scales and 5 health-related quality of life (HRQL) scales for use in facial feminization surgery. Methods: Between 2022 and 2024 an international field-test was undertaken to collect psychometric data to validate the GENDER-Q, a modular patient-reported outcome measure. Scales for facial feminization measure appearance of Face Overall, Facial Features, Upper Face, Eyebrows, Cheeks, Nose, Nostrils, Lips, Chin, Jawline, and Adam's Apple and Hairline. The HRQL scales measure Body Image, Gender Dysphoria, Social Acceptance, Psychological Distress and Psychological Well-being. Scales are scored from 0 (worst) to 100 (best). Participants in the GENDER-Q survey were asked to report if they had or wanted surgery to change the appearance of their face (brow, eyes, nose, lips, cheeks, chin or jawline), hairline and/or Adam's apple. Construct validation was tested using pre-defined hypotheses of known or expected group differences. Acceptance of at least 75% of hypotheses was considered sufficient evidence of validity. Results: From the international GENDER-Q field-test, 2040 participants wanted a more feminine facial appearance. Participants identified as women (86%), non-binary (10%) or other (4%). Most participants were white (80%), lived in USA (41%) or Canada (33%), and ranged in age from 18 to 83 years of age (mean=38 yrs; sd=14). Of the 2040 participants, 12% did not want any form of facial surgery, 43% wanted but had not yet had any facial surgery, 29% had undergone from 1 to 9 different facial surgeries, and 17% were unsure or had minimally invasive treatment only. Of those who had undergone at least one surgery, the most commonly reported procedures were browlift (76%) and/or rhinoplasty (62%). Mean scores on the Face Overall and Facial Feature scales decreased as participants reported they wanted more surgeries (p<0.001). The mean scores for those who did not want facial surgery or had completed surgery were significantly higher than scores for participants who wanted surgery or needed more surgery (p<0.001). For the scales that measure specific facial areas, those that wanted surgery scored significantly lower than those who have had at least one facial surgery: Adam's Apple (50±22 vs 86±21), Hairline (42±15 vs 60±19), Upper Face (33±19 vs 65±20), Eyebrow (52±20 vs 68±20), Jawline (31±18 vs 64±21), Chin (29±17 vs 67±23), Cheeks (38±18 vs 70±24), Nose (34±17 vs 66±22), Nostrils (45±23 vs 66±23), Lips (37±17 vs 63±21). In terms of HRQL, mean scores were significantly lower for those who wanted surgery versus those who had at least one facial surgery for Body Image (50±23 vs 60±23), Gender Dysphoria (57±20 vs 65±21), Social Acceptance (71±18 vs 76±18), Psychological Distress (59±20 vs 67±20), and Psychological Well-being (59±20 vs 64±20). Conclusion: GENDER-Q's face, neck and hairline appearance scales and HRQL scales evidenced construct validity for use in people undergoing gender-affirming facial feminization surgery.

Introduction: The Traditional wound coverage following penile inversion vaginoplasty consists of bolsters. Incisional Negative Pressure Wound Therapy has been implemented at our institution for wound dressing following PIV. While the benefits of NPWT are well known, utilizing it at perineal wounds can be cumbersome due to anatomical location. This can result in NPWT failures. This study aims to assess the experiences of nurses with NPWT and standard dressings in PIV patients, focusing on the challenges encountered and problem-solving strategies employed. Methods: This is a single-institution, IRB-approved study. The survey was set up, designed, and distributed via REDCap to the 27 nurses at our institution who work in plastic surgery and care for PIV patients. Two reminder emails were sent at 10-day intervals to encourage participation. The questionnaire collected data on provider experience, perceived challenges, problem resolution strategies, satisfaction, and workload comparison between NPWT and standard dressings. Descriptive statistics were used to summarize the responses using BlueSky Statistics © 2025. Open-ended responses were analyzed for qualitative themes. Results: The response rate was 59.25%, with 86.7% of respondents being female, and the median age was 29 years (range 22–51). Experience in transgender care varied, with most having ≥3 years (62.5%). Similarly, NPWT experience was diverse, with 43.8% having ≥3 years. 81.3 % reported that the most common challenges associated with NPWT included device malfunction or failure, 50 % responders mentioned skin irritation or damage, and 43.8% reported patient discomfort. Problem resolution strategies primarily included improved seal techniques (58.3%), increased patient monitoring (50.0%), and enhanced staff training (31.2%). Open-ended responses highlighted both the benefits and challenges of NPWT. Providers noted reduced dressing changes, improved hygiene, and better patient comfort with NPWT compared to bolster dressing changes. However, some patients experienced anxiety due to the inability to visualize the wound, while staff reported frequent air leaks, difficulty maintaining dressing integrity in high-friction areas, and occasional exudate management issues. Certain providers also cited staff training gaps and the need for improved device reliability. Satisfaction with NPWT was high, with 81.0% of respondents being satisfied or very satisfied and none reporting dissatisfaction. Workload was perceived as low (50.0%) or moderate (50.0%), with 46.7% indicating NPWT reduced workload compared to standard dressings. Open-ended feedback suggested that NPWT required more initial troubleshooting but ultimately reduced dressing maintenance and the overall burden on staff. Conclusion: Providers reported high satisfaction with NPWT, citing advantages in hygiene, reduced dressing changes, and increased patient comfort. However, technical challenges, patient anxiety, and skin irritation remain concerns. Qualitative responses emphasized the need for better training, enhanced sealing techniques, and improved patient education to mitigate anxiety and optimize NPWT use. Future efforts should focus on refining device reliability, addressing troubleshooting concerns, and ensuring comprehensive staff training to enhance NPWT efficacy in transgender surgical care.

Purpose: Transgender and nonbinary (TGNB) adults face complex healthcare decisions for gender-affirming care (GAC) yet decision support resources are limited. Despite the benefits of GAC, factors (e.g. resource access, social network, and state policies) can influence outcomes. While decisional regret after gender-affirming mastectomy (GAM) is rare, it is associated with increased risk of depression and suicidality. This study explored the decision-making process, social support needs, and decisional regret post-GAM. Methods: Participants who were post-GAM within the last 12 months were recruited via email from the University of Virginia Plastic Surgery Clinic. Data collection included semi-structured interviews, baseline demographic form, clinical history form, the Decision Making Quality Scale (DMQS) and the Decision Regret Scale (DRS). Results: A total of 32 patients were included in this study. 5 patients reported no social support yet had a DRS score of 0 (mean DRS 4.2 (0-40)). Those who had no support were significantly older (p < 0.001) with a mean age of 38.6 compared to a mean age of 28.1 years old in the group who reported having at least one person for social support. One participant had a DRS score of 40 responding "agree" for both "I regret this decision" and "I would go for the same choice if I had to do it over again," noting permanent tradeoffs. Mean DMQS score was 17.5 (12-21) indicating quality decision making. Participants reported utilization of social media, TGNB peer networks, and websites for GAM decision support. All participants expressed strong social support is needed throughout the process and critical during the post-operative phase. All participants cited financial concerns and health insurance status as the largest barrier to access to care in addition to geographical location (distance to clinic ranged from 1.4 miles to 140 miles). Conclusion: Post-GAM satisfaction was high and participants did not report decisional regret. Participants endorsed that health insurance status, geographical location, and social network are factors that influence the timing and decision to undergo GAM. Findings warrant further research to develop decision and social support interventions to assist TGNB individuals considering GAM.