Surgical healthcare needs for transgender patients: surgeons’ perspectives

Dear editor

We read with great interest the article by Dubin et al,¹ who highlighted the specific healthcare needs and barriers the transgender population continues to face. Our department is the largest surgical provider in Europe for those transgender patients requiring male-to-female genital reconstruction surgery and would like to provide our unique perspective.²

We are in total agreement that the exclusion of transgender-specific health needs from the undergraduate curricula is leading to the healthcare inequalities faced by this cohort. As surgeons who provide surgical options for the transgender population, we would also like to highlight the absence of transgender-related surgery in the postgraduate surgical curricula at all levels internationally. Every UK-qualified urologist is required initially to obtain the Member of the Royal College of Surgeons followed by the Fellow of the Royal College of Surgeons (FRCS) qualifications prior to becoming an independent practitioner of this branch of surgery. The syllabus for both these postgraduate exams omits the specific surgical needs, techniques, and issues for this urological reconstructive subspecialty. This is mirrored globally, with evidence of minimal transgender-related educational and clinical content for urological and plastic surgical residency training.³

Training in genital reconstruction operative technique provides transferable skills, such as perineal dissection, which can be applied both in emergency Fournier gangrene debridement and elective incontinence work. However, we recognize the opportunity to train in genital reconstruction is limited to current UK, trainees as very few centers offer this service. Access to specialist training may be improved by establishing recognized and funded cross-specialty Training Interface Group placements for senior urology and plastic-surgery trainees. We would also encourage the inclusion of transgender-related health in future restructuring of the urology curriculum and FRCS syllabus so that all trainees have a basic understanding of its principles.

At an undergraduate level, the largest governing body for urologists in the UK (British Association of Urological Surgeons) has provided a comprehensive undergraduate syllabus available to all medical schools.^4,5 The addition of the surgical transgender health needs in this syllabus could be one such route to increase awareness among medical students.

Given the increasing number of transgender people seeking and undergoing genital reconstruction, the future clinician is likely to encounter such patients in their practice away from specialist centers. It is vital that they have at least a basic understanding of the anatomical and physiological reconstruction these patients have undertaken if they are to care for them appropriately.

Disclosure

The authors report no conflicts of interest in this communication.

References

1.		Dubin SN, Nolan IT, Streed CG Jr, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377–391.
2.		Brittain J, Dunford C, Miah S, Takhar M, Morley R, Rashid T. Enormous mucocele following colonic graft neovagina formation in a transwoman. Urol Case Rep. 2018;21:73–74.
3.		Morrison SD, Dy GW, Chong HJ, et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017;9(2):178–183.
4.		Miah S, Mangera A, Venugopal S, Luk A, McDermid R, Rosario D. The clinical need for undergraduate urology. Clin Teach. 2015;12(5):353–355.
5.		Miah S, Pang KH. Urology – a specialty that will be faced by all future doctors. Adv Med Educ Pract. 2016;7:39–40.

Authors’ reply

Shane D Morrison¹, Samuel N Dubin², Ian T Nolan²

¹Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA; ²New York University School of Medicine, New York, NY, USA

Correspondence: Shane D Morrison, Department of Surgery, Division of Plastic Surgery, University of Washington, School of Medicine, 325 9th Avenue, Mailstop #359796, Seattle, WA 98104, USA
Tel +1 206 744 2868
Email [email protected]

Dear editor

We thank Dr Miah et al for their insightful perspective on gender-minority healthcare education among surgical trainees in response to our article.¹ Their experience with the urological aspects of gender-affirming care in the UK is invaluable. Our previous data point to a similar lack of exposure to gender-minority-related healthcare in surgical residency in the USA.^2–6 Dr Miah et al recommend that integration of further training in gender-affirmation surgery and transgender healthcare be implemented in undergraduate and graduate medical education in the UK. We have similarly felt that inclusion of gender-minority healthcare should be implemented by our medical boards in surgical specialties in the USA.^7–10 Without the inclusion of standardized gender-minority healthcare educational opportunities for all our surgical trainees, our patients may suffer from the lack of adequately prepared surgeons and further discrimination against this population. Integrated surgical education in transgender health will hopefully allow us to continue to innovate in gender-affirming care and strive for improved patient outcomes.^11–15

Disclosure

The authors report no conflicts of interest in this communication.

References

1.		Dubin SN, Nolan IT, Streed CG, Greene RE, Radix AE, Morrison SD. Transgender health care: improving medical students’ and residents’ training and awareness. Adv Med Educ Pract. 2018;9:377–391.
2.		Dy GW, Osbun NC, Morrison SD, Grant DW, Merguerian PA; Transgender Education Study Group. Exposure to and attitudes regarding transgender education among urology residents. J Sex Med. 2016;13(10):1466–1472.
3.		Ludwig DC, Dodson TB, Morrison SD. U.S. Oral and maxillofacial residents’ experience with transgender people and perceptions of gender-affirmation education: a national survey. J Dent Educ. 2019;83(1):103–111.
4.		Massenburg BB, Morrison SD, Rashidi V, et al. Educational exposure to transgender patient care in otolaryngology training. J Craniofac Surg. 2018;29(5):1–1257.
5.		Morrison SD, Chong HJ, Dy GW, et al. Educational exposure to transgender patient care in plastic surgery training. Plast Reconstr Surg. 2016;138(4):944–953.
6.		Morrison SD, Dy GW, Chong HJ, et al. Transgender-related education in plastic surgery and urology residency programs. J Grad Med Educ. 2017;9(2):178–183.
7.		Ludwig DC, Morrison SD. Should dental care make a transition? J Am Dent Assoc. 2018;149(2):79–80.
8.		Morrison SD, Smith JR, Mandell SP. Are surgical residents prepared to care for transgender patients? JAMA Surg. 2018;153(1):92–93.
9.		Morrison SD, Wilson SC, Smith JR. Are we adequately preparing our trainees to care for transgender patients? J Grad Med Educ. 2017;9(2):258.
10.		Smith JR, Morrison SD, Gottlieb LJ. Are surgical residents prepared for fellowship training in gender-confirming surgery? J Sex Med. 2017;14(8):1066–1067.
11.		Berli JU, Capitán L, Simon D, Bluebond-Langner R, Plemons E, Morrison SD. Facial gender confirmation surgery-review of the literature and recommendations for Version 8 of the WPATH Standards of Care. Int J Transgenderism. 2017;18(3):264–270.
12.		Klassen AF, Kaur M, Johnson N, et al. International phase I study protocol to develop a patient-reported outcome measure for adolescents and adults receiving gender-affirming treatments (the GENDER-Q). BMJ Open. 2018;8(10):e025435.
13.		Massenburg BB, Taub PJ, Morrison SD. Do our large surgical databases need a transition? Plast Reconstr Surg. 2018;141(4):618e–620e.
14.		Shen JK, Seebacher NA, Morrison SD. Global interest in gender affirmation surgery: a Google Trends analysis. Plast Reconstr Surg. 2019;143(1):254e–256.
15.		Smith JR, Washington AZ, Morrison SD, Gottlieb LJ. Assessing patient satisfaction among transgender individuals seeking medical services. Ann Plast Surg. 2018;81(6):725–729.
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