Scientific Abstract Presentations: Gender Surgery Session 1 Thursday, October 15 Thu, Oct 15 5:00-6:00 p.m. CDT

INTRODUCTION: Top surgery procedures, formally referred to as breast reduction down to zero skin flaps (BR) and gender-affirming breast augmentations (BA), have been shown to improve the mental health, and overall livelihood of transgender individuals(1). Despite the increasing surgical volume of these gender affirming procedures and the increases in quality of life, these surgeries still pose their own series of complications, which may be influenced by demographical factors. Here, we assess the discrepancies in BR and BA patients' demographics and elucidate any patterns that may be present with post-operative complications.

METHODS: Patients who underwent gender-affirming BR or BA with the ICD code F64.9 (Gender Dysphoria) and F64.8 (Other gender identity disorders) between January 2020 and January 2025 at a single academic institution were queried. A retrospective chart review was conducted to collect demographical information, length of diagnosis and any complications following the procedure. The Agency for Healthcare and Research Quality's Social Determinants of Health Database was used to further compare economic trends within the patient population using patients' zip codes.

RESULTS: A total of 47 patients underwent gender-affirming breast reduction (BR), with 8.5% of patients identifying as non-binary. 26 patients underwent gender-affirming breast augmentation (BA) with all patients identifying as assigned male at birth (AMAB) females. The BR group was significantly younger at the time of surgery than the BA group (27.8 vs. 39.1, p <0.002), with the BA group pursuing top surgery later upon gender dysphoria diagnosis (4.9 years vs. 2.4 years, p<0.001). There was no difference between race disparities across each group, with 34% of the BR and 23% of the BA group identifying as a person of color (POC) (p<0.43). No differences were found between the distribution of insurance-type across groups, with 47% of the BR group and 58% of the BA group utilizing commercial insurance. Similarly, median income was similar between groups (68351 vs. 70821, p<0.38). Despite similar economic trends, only the BR group included self-pay patients. While rates of post-operative concerns did not vary between procedural groups, POC patients were found to have significantly higher rates of post-operative related issues (42.3% vs. 84.5%, p <0.002). While minor concerns of hypopigmentation, scarring, tissue excess and neuropathy were observed, only one patient (2%) had a major complication requiring return to the OR. No income differences were noted between patients with and without complications in either group. (69721 vs. 70201, p<0.94).

CONCLUSION: Despite the highly contested nature of these procedures, gender-affirming top surgery outcomes demonstrative a relative high safety profile all demographics. While these procedures can mitigate the burdens of emotional and societal stigma this patient population faces, those in racially marginalized communities remain at higher risk for minor aesthetic-related post-operative concerns. Furthermore, economic factors may play a greater role in gender-affirming breast augmentations more than breast reductions due to baseline costs differences (2). Understanding the intersectionality of these variables allows surgeons to manage patient expectations accurately and ultimately improve the patient-centered consultation process.

References: (1) Poudrier G, Nolan IT, Cook TE, Saia W, Motosko CC, Stranix JT, Thomson JE, Gothard MD, Hazen A. Assessing Quality of Life and Patient-Reported Satisfaction with Masculinizing Top Surgery: A Mixed-Methods Descriptive Survey Study. Plast Reconstr Surg. 2019 Jan;143(1):272-279. doi: 10.1097/PRS.0000000000005113. PMID: 30286047. (2) Ngaage LM, Knighton B, McGlone K, Benzel C, Rada EM, Bluebond-Langner R, Rasko YM. Health Insurance Coverage of Gender-affirming Top Surgery in the United States. Plast Reconstr Surg Glob Open. 2019 Sep 10;7(8 Suppl ):83-84. doi: 10.1097/01.GOX.0000584692.69743.3e. PMCID: PMC6750526.

Purpose:

Neovaginal stricture remains one of the most common complications following gender-affirming vaginoplasty, with reported rates of 12-15% and frequent need for revision.[1] While topical corticosteroids demonstrate anti-fibrotic effects in other stricture-prone surgical contexts [2,3], their role in neovaginal stricture prevention has not been evaluated. Therefore, the objective of this study was to examine whether use of prophylactic topical corticosteroids is associated with reduced stricture following primary vaginoplasty.

Methods:

A retrospective review was performed of all patients who had undergone primary vaginoplasty at a single academic center between 2016 and 2022. Postoperative topical corticosteroid use (via application to vaginal dilators) and documented indication for steroid usage were recorded. The primary outcome was neovaginal stricture. To mitigate confounding by indication, all patients who were prescribed steroids specifically for the treatment of existing postoperative stricture were excluded in sensitivity analysis. Multivariable logistic regression adjusted for age, body mass index (BMI), smoking history, diabetes mellitus, race, vaginoplasty technique, and history of keloid/hypertrophic scarring. Statistical significance was set at p<0.05.

Results: Among 235 patients (mean age 33.0 +/- 11.3 years, mean BMI 25.3 +/- 4.4 kg/m2), 71 (30.2%) received postoperative topical corticosteroids. Overall stricture rate was 19.6%. Stricture occurred in 8.5% of steroid users versus 24.4% of non-users (p=0.003). In multivariable analysis, topical corticosteroid use was independently associated with reduced odds of stricture (adjusted OR 0.38, 95% CI 0.14-1.00, p=0.049). In sensitivity analysis excluding 13 patients who had been previously prescribed steroids for existing stricture, the protective association strengthened (adjusted OR 0.21, 95% CI 0.07-0.60, p=0.003).

Conclusion:

Prophylactic postoperative topical corticosteroid application to vaginal dilators is independently associated with significantly reduced neovaginal stricture risk following primary vaginoplasty, and the protective association strengthened after exclusion of patients treated for established stricture. These findings suggest topical corticosteroids may represent a simple, low-cost adjunct in postoperative vaginoplasty care, and prospective studies are warranted to confirm causality and define optimal protocols.

References:

[1] Vaginoplasty Complications - ClinicalKey. Accessed February 24, 2026. https://www-clinicalkey-com.offcampus.lib.washington.edu/#!/content/playContent/1-s2.0-S0094129818300208?returnurl=https:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0094129818300208%3Fshowall%3Dtrue&referrer=https:%2F%2Fpubmed.ncbi.nlm.nih.gov%2F [2] Kobayashi S, Kanai N, Ohki T, et al. Prevention of esophageal strictures after endoscopic submucosal dissection. World J Gastroenterol WJG. 2014;20(41):15098-15109. doi:10.3748/wjg.v20.i41.15098 [3] Soliman C, Pan HYC, Mulholland CJ, et al. Effect of local steroids on urethral strictures: A systematic review and meta-analysis. Investig Clin Urol. 2022;63(3):273-284. doi:10.4111/icu.20210391

Background:
Gender-affirming bottom surgery (GABS) is well-established to alleviate symptoms of gender dysphoria in the transgender community. At present, two main procedures utilized in transfeminine GABS: orchiectomy and vaginoplasty. While orchiectomies are simple, vaginoplasties vary in technique, depth, and complexity. At present there is a paucity of data on post-operative complications following the 30-day mark for these procedures despite some developing beyond the timeframe (1).

Purpose: To track complications over 1-to-30-day and 30-to-90-day intervals to ascertain trends and characterize their severity as they relate to GABS (orchiectomy and vaginoplasty) by collating outcome measures from previous literature (2, 3, 4).

Methods:
In this multicenter retrospective cohort study, a query was generated on the TriNetX US Collaborative Network, comprising 68 healthcare organizations. Adult patients were identified using CPT and ICD-10 codes and stratified into either the Orchiectomy Group (OG) or Vaginoplasty Group (VG) and assessed pre- and post-1:1 propensity score matching (PSM), with observed complications classified as either minor or major.

Results:
Pre-PSM, 5,771 patients were identified. Post-PSM, 4,902 patients (2,451 orchiectomy, 2,451 vaginoplasty), were included. For 1-to-30-days, the OG posed significantly reduced risk when compared to VG for minor complications (pre-PSM: 6.462% vs. 15.619%; post-PSM: 7.287% vs. 15.789%; p<0.0001). Similarly, 30-to-90-day outcomes significantly reduced risk when compared to VG for minor complications (pre-PSM: 3.244% vs. 6.156%; post-PSM: 4.03% vs. 6.108%; p<0.0050).

For 1-to-30-day outcomes, OG posed significantly reduced risk when compared to VG for major complications (pre-PSM: 6.084% vs. 13.555%; post-PSM: 6.706% vs. 13.892%; p<0.0001). For 30-to-90-day outcomes, OG posed no significant risk difference post-PSM when compared to VG for major complications (pre-PSM: 2.654% vs. 4.26%, p=0.0057; post-PSM: 2.909% vs. 4.161%; p=0.0502), despite higher observed absolute complications recorded in the vaginoplasty group.

In both 1-to-30- and 30-to-90-day analyses, minor complications included UTI, urination difficulties, hematoma, and wound dehiscence. Major complications included unexpected ED visits, DVT, pneumonia, and sepsis. Certain complications, like cerebrovascular disease and cardiac arrest, were observed more frequently in the VG, while acute MI was unique to the OG.

Conclusion:
Complication rates were predominant in the VG, supporting previous literature proposing the complexity involved. However, the preponderance of OG and VG major complications between 30-to-90-days posed no significant risk difference. Similarly, the skewing of certain major complications to each group warrants further analysis to explain these observations.

1. Ho P, Torres C, Andrade F, Palese M, Djordjevic M, Purohit RS. Overactive Bladder after Gender Affirming Vaginoplasty. Urology. Feb 6 2026;doi:10.1016/j.urology.2026.02.002
2. Goldman J, Hu A, Hammer A, et al. Thirty-Day Complication Rates After Gender-Affirming Bottom Surgery: An Analysis of the NSQIP Database From 2010 to 2020. Ann Plast Surg. Jan 1 2025;94(1):94-99. doi:10.1097/SAP.0000000000004069
3. Mishra K, Ferrando CA. Postoperative adverse events following gender-affirming vaginoplasty: an American College of Surgeons National Surgical Quality Improvement Program study. Am J Obstet Gynecol. May 2023;228(5):564 e1-564 e8. doi:10.1016/j.ajog.2023.01.011
4. Russell CB, Hong CX, Fairchild P, Bretschneider CE. Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database. Urogynecology (Phila). Feb 1 2023;29(2):202-208. doi:10.1097/SPV.0000000000001312

Background:
While socioeconomic disadvantage and racial inequities are known to influence gender-affirming care, no prior work has systematically assessed how social vulnerability affects the progression from social to medical transition to first surgical intervention in FFS populations. This study seeks to investigate the impact of the Social Vulnerability Index (SVI) on timing of social transition, medical transition, first access to gender-affirmation surgery, and psychosocial outcomes.

Methods:
A retrospective cohort study was conducted at a single institution including all patients who underwent FFS between 2019 and 2025. We collected information about demographics, SVI, psychosocial diagnoses, age at social and medical transition, and age at first FFS. SVI is a composite measure of a community's socioeconomic disadvantage, where higher scores indicate greater vulnerability. Standard statistical analyses were performed using independent-samples t-tests for continuous variables and chi-square tests for categorical variables.

Results:
A total of 126 patients with complete medical records were included. Of these, 95 (75.4%) were White and 18 (14.3%) were Hispanic. The mean age at first FFS was 33.6 ± 9.4 years. Patients transitioned socially at a mean age of 27.7 ± 9.9 years and medically at 29.4 ± 9.7 years, with an average interval of 5.8 ± 4.8 years between social transition and first FFS. Social vulnerability distribution included 16.7% of patients in the lowest SVI quartile, 16.7% in low-medium, 47.6% in medium-high, and 19.0% in the highest quartile.

SVI demonstrated the strongest association with transition timing. Compared to the lowest SVI quartile, patients in the highest quartile (i.e., most socially vulnerable) have later social transition (29.2 vs 22.5 years, p = 0.022), later medical transition (32.7 vs 24.1 years, p < 0.001), and underwent surgery at an older age (36.2 vs 29.0 years, p < 0.001).

Race and ethnicity were not associated with age at social transition, age at medical transition, age at surgery, or number of staged FFS (p > 0.05). However, non-Caucasian patients experienced substantially longer delays from social transition to first FFS than Caucasian patients (8.17 vs 5.03 years, p = 0.010). This delay occurred despite similar ages at social transition (28.2 vs 26.3, p >0.05) and medical transition (29.7 vs 28.5, p >0.05) between Caucasian and non-Caucasian patients, respectively. Low-SVI patients had higher but statistically non-significant rates of anxiety diagnoses (71.4 vs 45.0%, p = 0.162), major depressive disorder (71.4 vs 45.0%, p = 0.162), and psychiatric medication use (52.4 vs 30.0%, p = 0.256) compared to high-SVI patients.

Conclusion:
Higher SVI delayed all stages of transition from social to medical transition to FFS, but it did not correlate with a higher psychosocial burden. Race produced a separate access pattern in which non-Caucasian patients transitioned socially and medically at similar ages to Caucasian patients but faced an additional three-year delay from social transition to surgery. Achieving equitable access to FFS requires dual strategies: expanding insurance coverage and financial supports to reduce socioeconomic vulnerability-based delays and addressing racial barriers embedded in referral pathways, insurance authorization processes, and possibly provider bias.

Background: The U.S. transgender population is approximately 1-1.6 million adults. This community experiences significant health disparities exacerbated by inadequate provider competency in transgender-specific health needs. This extends to cancer care, where transgender individuals face increased risks for certain malignancies from behavioral factors (higher rates of smoking, alcohol, and HIV), hormone therapy, and lower screening rates. A key driver of this stems from the knowledge and attitudes of healthcare providers. Previous studies have identified gaps amongst providers in knowledge of cancer screening guidelines, however to what extent and in which medical specialties is less understood. This systematic review consolidates existing literature on healthcare providers' knowledge, attitudes, and practices regarding cancer screening guidelines for transgender patients to identify existing knowledge gaps and inform future targeted educational efforts.

Methods: We used Covidence to screen the following: PubMed, Google Scholar, Embase, Scopus. Inclusion criteria included addressing cancer screening/guidelines for transgender patients and sufficient assessment of provider knowledge level. All types of cancer screenings were eligible. There was no limitation on publication year or country, as long as the text was published in English.

Results: Our search resulted in 136 papers, with 23 undergoing full text review. 13 papers met final inclusion criteria. Publication year ranged from 2016 - 2023. Each study had a unique group of providers, with 77% (n = 10) including medical doctors (MDs), 46% (n = 6) including nursing practitioners (NPs) or registered nurses (RNs), 31% (n= 4) including physician assistants (PAs), and 15% (n = 2) including genetic counselors. Amongst MD professionals, medical specialties included radiology (40%; n = 4), oncology (40%; n = 4), surgical oncology (40%; n = 4), internal medicine (30%; n = 3), and family medicine (20%; n = 2). 85% (n = 11) of papers used surveys, with 18% (n = 2) also including multiple choice and open-ended questions. Common items assessed included breast and cervical cancer screening, HPV risk, anal cancer risk, impact of hormone therapy, and prostate cancer screening. In surveys directly assessing knowledge, providers averaged 50% correct responses. Some found specialties such as internal medicine were more likely to be uncomfortable with treating transgender patients, whereas OB/GYN providers had high rates of comfortability. Additionally, younger practitioners were more likely to be knowledgeable on screening standards and agree that knowing patient gender is crucial to their care. Notably, a common incongruity observed amongst surveys showed cohorts endorsing high comfort levels in caring for trangender patients, but also lower percentages of agreement that knowing patient gender was important to providing quality care. Overall, there was a high consensus amongst providers in all studies that they would benefit from more education and training.

Discussion: This review identifies the variability in knowledge gaps and attitudes of healthcare providers on cancer screening guidelines for transgender patients based on factors like provider speciality and age. While provider attitudes and knowledge were incongruent with their comfort level treating transgender patients, this discrepancy highlights opportunities for targeted, specialty-focused educational interventions. Encouragingly, most providers expressed interest in additional transgender-specific training.

Purpose: Gender-affirming bottom surgery (GABS) is associated with improved mental health and reduced suicidality for transgender and gender-diverse individuals [1]. Although utilization has increased in recent years, it remains unclear whether this expansion has been equitably distributed. National-level analyses examining disparities by race, income, insurance, and geography, and how these patterns evolve over time, remain limited. This study examines demographic, socioeconomic, and hospital-level factors associated with receipt of GABS and assesses temporal shifts in equity from 2016–2022. Methods: Patients with gender dysphoria (GD) were selected from the 2016-2022 National Inpatient Sample, and GABS procedures were identified using relevant ICD-10 codes for genital reconstruction (including vaginoplasty, phalloplasty, metoidioplasty, orchiectomy, hysterectomy, vaginectomy, and related procedures). Multivariable logistic regression adjusting for demographic, socioeconomic, and hospital characteristics identified independent predictors of GABS receipt. Log-transformed multivariable linear regression evaluated adjusted total hospital charges (inflation-adjusted) and length of stay (LOS). Temporal trends among GABS recipients were analyzed using logistic regression with year modeled continuously. All analyses used weighted national estimates. Results: Of 146,895 GD-related admissions, 10,115 (6.9%) involved GABS. Annual procedure volume increased from 685 in 2016 to 2,160 in 2022. The median age of GABS patients was 32 years (IQR 26–44). On multivariable analysis (AUC 0.792), likelihood of undergoing GABS was lower among Black (OR 0.69; 95%CI 0.63–0.75), Hispanic (OR 0.88; 95% CI 0.82–0.95), and Asian (OR 0.82; 95% CI 0.72–0.93) patients compared with White patients. Patients in the highest ZIP-code income quartile were more likely to receive GABS (OR 1.25, 95% CI 1.16–1.34), while Medicaid recipients had nearly four-fold lower odds compared with privately insured patients (OR 0.27, 95% CI 0.25–0.28). Procedures were concentrated in urban teaching hospitals and the Pacific division. Odds of undergoing GABS were markedly lower in the East South Central (OR 0.13) and New England (OR 0.15) divisions relative to Pacific. After adjustment, Black (+12.3%), Hispanic (+11.3%), and Asian/Pacific Islander (+17.3%) patients incurred significantly higher total hospital charges than White patients. Minority patients also experienced modest but statistically significant longer LOS (4–8% longer). Over time, disparities widened. The odds that GABS recipients were Black, in the lowest income quartile, or insured by Medicaid decreased by 4.50%, 8.24%, and 5.72% per year, respectively (p = 0.015, p < 0.001, and p < 0.001). Conversely, the odds that GABS recipients were White, in the highest income quartile, or privately insured increased by 3.52%, 4.86%, and 11.50% per year, respectively (p = 0.003, p < 0.001, and p < 0.001) Conclusions: Racial and ethnic minorities and those of lower socioeconomic status experience reduced access to GABS, and these disparities have grown in magnitude over time. Minority patients also face higher hospital charges and longer length of stay. These findings underscore the need for reimbursement reform, geographic expansion, and equity-focused policy implementation to promote equitable access to gender-affirming care.

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

Purpose At the Mount Sinai Center for Transgender Medicine and Surgery (CTMS), gender dysphoria in patients seeking gender-affirming plastic surgery procedures has been measured using Gender Dysphoria Index (GDI), a patient-reported measure. This retrospective study aims to validate the GDI against the Transgender Congruence Scale (TCS) and Body Image Disturbance Questionnaire (BIDQ). These scales possess strong psychometric validity for measuring gender dysphoria and body image impact on physical and psychological wellbeing, respectively. A validated GDI is a concise point-in-time assessment, making it practical for routine use by gender affirmation surgeons in clinic to measure patient-reported gender dysphoria at multiple timepoints and assess outcomes of gender-affirming surgeries (GAS). This may improve postoperative survey compliance and strengthen the quality and applicability of outcomes research.

Methods The Gender Dysphoria Index (GDI) is a patient-reported measure of gender dysphoria on a 0-10 Likert scale, where zero is no dysphoria and 10 is maximal dysphoria. We collected preoperative and postoperative GDI, BIDQ and TCS scores from 141 patients who have undergone primary vaginoplasty procedures at CTMS between April 2023 and August 2025. Responses were collected via phone call within the two month to one year postoperative period. Validation was completed using patient response data through Reliability Analysis, assessed with Cronbach's alpha, and convergent and discriminant validity, assessed with Pearson's correlation coefficient measurements.

Results Reliability Analysis demonstrated excellent internal consistency for both the preoperative and postoperative values for BIDQ (a= 0.779, a=0.809) and TCS (a=0.900, a=0.768). Convergent and discriminant validity as measured with Pearson's correlation coefficient reflected strong linear correlation between the BIDQ and GDI for preoperative (r = 0.504, p < 0.001) and postoperative (r = 0.346, p < 0.001) values. Good linear correlation was shown between TCS and GDI for preoperative (r = 0.417, p < 0.001) and postoperative values, especially for the surgical subset (r = 0.245, p = 0.005). These results demonstrate good validity of the GDI in measuring preoperative and postoperative patient gender dysphoria in the patient population. Preoperative scores for participants in all three measures were significantly reduced postoperatively, with average preoperative GDI score of 8.10 (± 1.79), significantly reduced to 1.22 (± 1.30).

Conclusions The BIDQ and TCS demonstrated excellent internal consistency in our patient population, serving as coherent measures of gender dysphoria and body image impact on physical and psychological wellbeing. Good linear correlation is shown between the GDI and BIDQ, as well as GDI and TCS, for both preoperative and postoperative settings scores as demonstrated by significant Pearson's correlation coefficients. These results validate the GDI in measuring patient-reported gender dysphoria. Patients reported significant reduction in all three scales of measurement, demonstrating the efficacy of GAS in addressing patient gender dysphoria and promoting gender congruence, psychological well-being, and quality of life. The validated GDI can be an effective standardized tool in clinical and research settings, designed to measure patient-reported gender dysphoria at multiple timepoints throughout the patient's clinical course, and aiding surgeons in diagnosis, treatment planning, and assessment of surgical efficacy of GAS in addressing gender dysphoria.

Background: Psychiatric comorbidities are highly prevalent among individuals seeking gender-affirming top surgery, with depression and anxiety occurring at substantially higher rates than in cisgender populations. The broader literature demonstrates that top surgery is associated with meaningful postoperative improvements in mental health measures, gender dysphoria, and quality of life. However, the extent to which preexisting psychiatric diagnoses influence short-term surgical complications and unplanned healthcare utilization remains incompletely defined. In this study, we evaluated whether psychiatric comorbidity is associated with postoperative complications or unplanned healthcare utilization following gender-affirming mastectomy.

Methods: A retrospective, single-institution review of adults (age ≥18) undergoing gender-affirming mastectomies was conducted from 2017 to 2025. Patients were included if follow-up duration was ≥30 days. Psychiatric comorbidity was defined as any self-reported and documented psychiatric illness, and patients were grouped initially by the presence or absence of these diagnoses. Outcomes included 30-day complications (cellulitis, surgical site infection [SSI], hematoma, wound dehiscence, delayed healing, nipple-areolar complex [NAC] necrosis) and unplanned healthcare utilization (ED visits, readmission, reoperation). Unadjusted comparisons were done using Fisher's exact or Chi-square tests. To mitigate confounding, propensity scores for psychiatric comorbidity were estimated using variables such as age at the time of surgery, body mass index (BMI), smoking status, surgeon, and insurance coverage status. Stabilized inverse probability of treatment weighting (IPTW) was applied, with weighted logistic regression generating adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Within the group of patients with a history of psychiatric illness, diagnoses were mapped into broader diagnostic spectra, including anxiety disorders, depressive disorders, bipolar disorders/mood dysregulation, trauma/stress-related disorders, and psychotic. Firth logistic regression was conducted with multiplicity control via Benjamini-Hochberg false discovery rate (FDR).

Results: Of 443 masculinizing cases, 370 met the inclusion criteria (Psychiatric history n=296; No psychiatric history n=74). IPTW weights demonstrated good stability (mean 0.977, SD 0.116; range 0.424-1.209). In IPTW-adjusted analyses, psychiatric comorbidity was not associated with increased odds of cellulitis, SSI, hematoma, wound dehiscence, NAC necrosis, readmission, reoperation, or ED presentation (all p>0.05). Delayed healing was less frequent among patients with psychiatric diagnoses (IPTW OR 0.19, 0.04-0.89; p=0.035), though events were sparse. Within the psychiatric subgroups, psychotic disorders (including schizophrenia and schizoaffective disorders) remained associated with SSI (OR 55.23; p=0.00013), even after global FDR correction across diagnosis-spectrum tests (FDR p=0.01048). Other exploratory associations did not remain significant after correction.

Conclusions: In our institution's adult masculinizing top surgery cohort, psychiatric comorbidity was common but was not associated with higher odds of short-term surgical complications or unplanned utilization after propensity weighting. These findings suggest that coexisting psychiatric diagnoses, in most cases, should not be assumed to confer increased short-term surgical risk. This aligns with existing literature showing improved postoperative mental health and quality-of-life outcomes following top surgery. A signal linking disorders involving psychotic-spectrum diagnoses with SSI warrants cautious interpretation due to small subgroup size and should be validated in larger cohorts with careful adjustment for psychosocial and clinical confounding.

Introduction In 2025, the One, Big, Beautiful Bill Act was signed into law, executing changes to Medicaid policies, with specific sections prohibiting federal Medicaid funding for gender affirming surgeries (GAS). Given that transgender and gender diverse (TGD) adults are at greater odds of being publicly insured than privately insured [1], we sought to determine 1) whether each state's Medicaid program covers GAS for adults with or without restrictions or prior authorization (PA), and 2) whether an association exists between each state's LGBTQ+ legislative favorability (LF) [2] and its Medicaid coverage of GAS.

Methods To obtain information, we placed telephone calls to the 51 Medicaid provider support services, all within the same 2.5-week timeframe. Each call consisted of the same set of questions inquiring about Medicaid coverage of breast reduction (BR), mastectomy, breast augmentation (BA), vaginoplasty, phalloplasty, cricotracheal resection (CR), intersex procedures, and whether there are restrictions or PA requirements. If unable to reach a representative after calling back twice, we consulted official online fee schedules for information. We performed a state-level cross-sectional analysis of all states, which were categorized by LGBTQ+ LF (favorable, unfavorable, neutral) (categorized based on overall LGBTQ+-related policy tallies). Medicaid coverage was coded as present or absent. A chi-square test of independence assessed the association between LF and coverage, with statistical significance defined as p<0.05.

Results We spoke with 25/51 programs. Information on remaining states was obtained online. All cover mastectomy +/- PA, except Kentucky (does not cover mastectomy for gender affirming reasons). Maryland, WestVirginia, Tennessee, Louisiana, Oregon, Washington require PA for mastectomy only in patients with gender dysphoria. All except SouthCarolina and Wyoming cover BA +/- PA. Kentucky, Texas, Montana, Utah, Wyoming, Hawaii do not cover vaginoplasty. Of the covering programs, Maryland, Louisiana, Tennessee, Oregon specify that PA is required if a patient pursues gender affirming vaginoplasty. Pennsylvania, Alabama, Texas, Utah do not cover phalloplasty. WestVirginia requires PA if the phalloplasty is pursued for gender affirmation. Washington, Utah, Texas, WestVirginia do not cover CR while the remaining states do (+/- PA). 21 states do not recognize or cover intersex surgeries, though we could not determine whether lack of recognition is due to recognition of non-bundled procedures constituting intersex surgery (i.e., RhodeIsland covers unbundled procedures, but does not recognize intersex surgeries while Connecticut covers intersex surgeries if the patient is pursuing GAS, but not the unbundled procedures). Medicaid coverage of each surgery did not differ significantly by LGBTQ+ LF category (all p>0.05).

Conclusions Variability in Medicaid policies exist in terms of GAS coverage, with LGBTQ+ legislative favorability not being associated with the chance that a state covers any GAS type. Further research should explore how these policies specifically impact Medicaid-enrolled TGD individuals and how these policies will change over time.

References [1] Downing, et al. Prevalence of private and public health insurance among transgender and gender diverse adults. Med Care 2020;60(4):311-315. [2] Movement Advancement Project. Equality Maps. Movement Advancement Project. Accessed February 25, 2026. https://www.lgbtmap.org/equality-maps/

Background: Gender-affirming mastectomy (GAM) is the most commonly performed gender-affirming surgery in the United States (1) and has been shown to reduce gender dysphoria and improve quality of life (2). The UCSF GenderQoL instrument was developed to evaluate multidimensional postoperative outcomes across domains of Gender Identity, Social Health, Satisfaction with Physical Appearance, and Recovery from Surgery. While the initial validation study demonstrated favorable outcomes across these domains, age-stratified patient-reported outcomes have not yet been evaluated. In addition to GenderQoL domains, decisional regret was assessed as a complementary patient-reported outcome. This study evaluated domain-level quality-of-life outcomes and decisional regret across age groups to determine whether age at surgery influences postoperative experiences following GAM.

Methods: A cross-sectional survey was administered to a single-surgeon cohort of patients aged 15-59 who underwent GAM ≥1 year prior. The survey comprised the UCSF GenderQoL instrument, Decision Regret Scale, and Satisfaction with Decision measures. Domain-level composite scores and decisional regret scores were compared across age groups using Kruskal-Wallis with Dunn's post hoc testing. Higher scores reflected greater quality of life and satisfaction, and lower decisional regret.

Results: A total of 196 participants completed the survey. At the time of surgery, 7% were <19-years-old, 23% were 19-21, 24% were 22-25, 19% were 26-30, and 27% were >30 years-old. Participants completed the survey a mean of 5.17 years postoperatively (range 1–10 years). Most participants identified as transgender men (70%) or nonbinary (28%). The cohort was predominantly White (66%) and non-Hispanic (82%). The most common surgical technique was double incision mastectomy (DIM) with free nipple grafts (FNG) (80%), followed by DIM without FNG (11%) and periareolar incision (9%). Social Health, Satisfaction with Physical Appearance, and Decisional Regret scores were higher in transgender men compared with nonbinary participants (all p<0.05). Recovery from Surgery scores were higher among patients undergoing DIM without FNG compared with DIM with FNG and periareolar techniques (p<0.05). Across age groups, mean domain-level composite scores were high, ranging from 81%-89% across Gender Identity, Social Health, Satisfaction with Physical Appearance, and Recovery from Surgery domains. Domain-level composite scores did not differ significantly between age groups (all p>0.05). Overall decisional regret was low, with no significant differences across age groups (p>0.05).

Conclusions: Quality-of-life outcomes following GAM were consistently high across age groups, with no meaningful differences at the domain level based on age at surgery. Decisional regret was similarly low across all age groups. These findings provide age-stratified evidence supporting equitable access to gender-affirming surgery, inform surgical counseling, and strengthen shared decision-making for patients considering GAM.

References 1. Wright JD, Chen L, Suzuki Y, Matsuo K, Hershman DL. National estimates of gender-affirming surgery in the US. JAMA Netw Open. 2023;6(8):e2330348. doi:10.1001/jamanetworkopen.2023.30348 2. Kilmer LH, Chou J, Campbell CA, DeGeorge BR, Stranix JT. Gender-affirming surgery improves mental health outcomes and decreases antidepressant use in patients with gender dysphoria. Plast Reconstr Surg. 2024;154(5):1142-1149. doi:10.1097/PRS.0000000000011325