Condensation
This study suggests the majority of patients undergoing gender affirming surgery do not regret their decisions based on their limited future fertility options.
Keywords: Access to care, barriers to care, future fertility, regret, stigma, transgender patients
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 1. The American College of Obstetrics and Gynecology provides some guidance, including the importance of discussing future fertility 2; however, many clinicians feel inadequately prepared to care for patients seeking gender affirming surgery 3,4. 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 post-procedural regret along with satisfaction regarding future fertility.
STUDY DESIGN
We distributed an IRB-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 2006-2016. 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 5. Scores ranged from 0-100; 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). Almost all participants (94%) reported taking testosterone at survey completion, but only 40% of them felt 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 (4%) respondents 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 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 1.
Respondents’ perspectives regarding their decision to undergo female-to-male gender confirmation surgery
| Regarding the decision to undergo hysterectomy and/or bilateral oophorectomies, how strongly do you agree or disagree with these statements? |
Strongly agree/ Agree |
Neutral | Strongly Disagree/ Disagree |
|---|---|---|---|
| It was the right decision* | 47 (98) | 0 (0) | 0 (0) |
| I regret the choice that I made | 2 (4) | 1 (2) | 45 (94) |
| I would go for the same choice if I had to do it again | 45 (94) | 2 (4) | 1 (2) |
| The choice did me a lot of harm | 2 (4) | 2 (2) | 45 (94) |
| The decision was a wise one | 47 (98) | 0 (0) | 1 (2) |
| How satisfied are you with the hysterectomy and/or bilateral salpingectomy in regards to the following? |
Very satisfied/ Satisfied |
Neutral | Very dissatisfied / Dissatisfied |
| Gender identity | 42 (88) | 6 (13) | 0 (0) |
| Physical changes | 34 (71) | 14 (29) | 0 (0) |
| Hormonal changes* | 30 (63) | 13 (27) | 4 (8) |
| Surgical recovery | 43 (90) | 5 (10) | 0 (0) |
| Future fertility options* | 15 (31) | 25 (52) | 3 (6) |
| Pre-surgical counseling* | 39 (81) | 7 (15) | 1 (2) |
Data presented as n (%)
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 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.
AJOG at a Glance.
To identify if patients who underwent gender affirming surgery regretted their decision regarding their future fertility
The majority of patients undergoing gender affirming surgery do not regret their decisions based on their limited future fertility options.
The majority of patients undergoing gender affirming surgery have considered their reproductive options prior to the operation.
Financial Support
This work was conducted with support from Harvard Catalyst ∣ The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award UL1 TR001102) and financial contributions from Harvard University and its affiliated academic health care centers.
Footnotes
Disclosure Statement
The authors report no conflict of interest.
Presentations
Chu J, Haviland MJ, Hacker MR, Meservey M, Mahoney B, Gomez-Carrion Y. Barriers to care and reproductive considerations for female-to-male transgender confirmation surgery. 2018. Poster presentation at the annual meeting of the Society of Gynecologic Surgeons, Orlando, FL.
References
- 1.Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clin Biochem. 2014;47(10-11):983–987. doi: 10.1016/j.clinbiochem.2014.02.009 [DOI] [PubMed] [Google Scholar]
- 2.Care for Transgender Adolescents. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co685.pdf. Accessed May 31, 2019. [Google Scholar]
- 3.Chang OH, Haviland MJ, Von Bargen E, Gomez-Carrion Y, Hacker MR, Li J. Female pelvic medicine and reconstructive surgery fellows’ exposure to transgender health care. Am J Obstet Gynecol. 2018;219(6):625–626. doi: 10.1016/J.AJOG.2018.09.012 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Unger CA. Care of the transgender patient: the role of the gynecologist. Am J Obstet Gynecol. 2014;210(1):16–26. doi: 10.1016/J.AJOG.2013.05.035 [DOI] [PubMed] [Google Scholar]
- 5.User Manual-Decision Regret Scale.; 1996. www.ohri.ca/decisionaid. Accessed May 31, 2019. [Google Scholar]