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Barriers to care and reproductive considerations for transmasculine gender affirming surgery

Published:October 04, 2019DOI:https://doi.org/10.1016/j.ajog.2019.09.043

      Objective

      The transgender population is marginalized and underserved in medicine. Both clinicians and the transgender community agree that there are many barriers to accessing care, including lack of provider experience, reluctance to disclose, and financial barriers.
      • Roberts T.K.
      • Fantz C.R.
      Barriers to quality health care for the transgender population.
      The American College of Obstetrics and Gynecology provides some guidance, including the importance of discussing future fertility
      Committee on Adolescent Health Care
      Care for transgender adolescents.
      ; however, many clinicians feel inadequately prepared to care for patients seeking gender-affirming surgery.
      • Chang O.H.
      • Haviland M.J.
      • Von Bargen E.
      • Gomez-Carrion Y.
      • Hacker M.R.
      • Li J.
      Female pelvic medicine and reconstructive surgery fellows’ exposure to transgender health care.
      ,
      • Unger C.A.
      Care of the transgender patient: the role of the gynecologist.
      Additionally, some clinicians voice concern the patient will express regret, particularly regarding future fertility.
      Our objective was to identify barriers to care for transmasculine patients who desired gender-affirming surgery and to assess postprocedural regret along with satisfaction regarding future fertility.

      Study Design

      We distributed an institutional review board–approved anonymous survey in 2017 to all trans-masculine patients who were at least 18 years old and underwent a total hysterectomy at our institution from 2006 through 2016. The survey captured perceived barriers to care and clinical experience before and after surgery. We used the validated Decision Regret Scale to assess distress and remorse after surgery.
      User manual, Decision Regret Scale. 1996.
      Scores ranged from 0 to 100; higher scores indicate more regret. Data are presented as median (interquartile range) or frequency (proportion).

      Results

      We distributed 91 surveys; 48 (53%) were completed. Respondents were aware of their gender by a median age of 14 (5–20) years and reported being certain by age 22 (18–27) years. Almost all participants (94%) reported taking testosterone at survey completion, but only 40% of them believed this was a prerequisite to surgery. The majority (75%) traveled less than 25 miles for their surgery, and 96% reported insurance covered the procedure. The median time between desiring the procedure and surgery was 7 (5–12) months.
      Two respondents (4%) regretted having a total hysterectomy, and nearly all (94%) would make the same choice again (Table 1). The median score on the Decision Regret Scale was 0.0 (0.0–5.0). Overall, respondents expressed high levels of satisfaction with the procedure; only 6% reported they were not satisfied with the procedure with respect to future fertility (Table 1). Most (92%) did not have children at the time of surgery. Among all respondents, 67% reported they were counseled about future fertility options, and 21% reported they planned to have children after surgery. The most frequently cited barriers to surgical care were the stigma of being seen as a male patient at an obstetrics and gynecology practice (62.5%), insurance/financial support (49%), and taking time off from work (39%).
      Table 1Respondents’ perspectives regarding their decision to undergo female-to-male gender confirmation surgery
      PerspectivesStrongly agree/ agreeNeutralStrongly disagree/ disagree
      Regarding the decision to undergo hysterectomy and/or bilateral oophorectomies, how strongly do you agree or disagree with these statements?
       It was the right decision
      One missing response.
      47 (98)0 (0)0 (0)
       I regret the choice that I made2 (4)1 (2)45 (94)
       I would go for the same choice if I had to do it again45 (94)2 (4)1 (2)
       The choice did me a lot of harm2 (4)2 (2)45 (94)
       The decision was a wise one47 (98)0 (0)1 (2)
      Very satisfied/ SatisfiedNeutralVery dissatisfied/ dissatisfied
      How satisfied are you with the hysterectomy and/or bilateral salpingectomy in regard to the following?
       Gender identity42 (88)6 (13)0 (0)
       Physical changes34 (71)14 (29)0 (0)
       Hormonal changes
      One missing response.
      30 (63)13 (27)4 (8)
       Surgical recovery43 (90)5 (10)0 (0)
       Future fertility options
      One missing response.
      15 (31)25 (52)3 (6)
       Presurgical counseling
      One missing response.
      39 (81)7 (15)1 (2)
      Data are presented as n (percentage).
      Mendiola. Reproductive considerations for female-to-male gender confirmation surgery. Am J Obstet Gynecol 2020.
      a One missing response.

      Conclusion

      Some clinicians have expressed reluctance to perform gender-affirming surgery because they are concerned patients will regret undergoing a procedure that causes infertility. This study provides additional evidence that most patients do not regret gender-affirming surgery. Interestingly, given that insurance covered the majority of surgeries, the most frequently cited barrier to care was the stigma of being seen as a male patient in an obstetrics and gynecology practice. Thus, optimizing the clinical experience to reduce the perceived stigma may increase transmasculine patients’ access to care.

      References

        • Roberts T.K.
        • Fantz C.R.
        Barriers to quality health care for the transgender population.
        Clin Biochem. 2014; 47: 983-987
        • Committee on Adolescent Health Care
        Care for transgender adolescents.
        (Available at:)
        • Chang O.H.
        • Haviland M.J.
        • Von Bargen E.
        • Gomez-Carrion Y.
        • Hacker M.R.
        • Li J.
        Female pelvic medicine and reconstructive surgery fellows’ exposure to transgender health care.
        Am J Obstet Gynecol. 2018; 219: 625-626
        • Unger C.A.
        Care of the transgender patient: the role of the gynecologist.
        Am J Obstet Gynecol. 2014; 210: 16-26
      1. User manual, Decision Regret Scale. 1996.
        (Available at:)
        www.ohri.ca/decisionaid
        Date accessed: May 31, 2019