Unreasonable Expectations: A Call for Training and Educational Transparency in Gender-affirming Surgery

Summary:

Although in most areas of practice, there is a reasonable expectation that doctors are sufficiently trained to offer care, this is not true in the case of gender-affirming procedures, which are not required learning in any surgical residency. At the current time, the field of gender surgery is too rapidly evolving, with available resources too scarce for fellowship or residency training to be a realistic requirement for offering these procedures, as the demand already outstrips the available workforce. However, patients are currently given too little information about surgeons’ history with these procedures to provide truly informed consent. There is, as such, an ethical mandate to mold the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care.

Takeaways

Question: Are providers of gender-affirming surgery giving patients sufficient information for them to make informed decisions about care?

Findings: Patients may have inaccurate beliefs about the amount of training and experience surgeons have with the gender-affirming procedures they offer.

Meaning: There is an ethical mandate to change the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care.

INTRODUCTION

Although relatively unknown until recently, gender-affirming surgical procedures have been around for approximately a century.^1–4 As the stigma associated with such procedures has started to recede, the field began a rapid growth with the current workforce insufficient to meet demand.^5–7

With this growth, a paradigm shift will be critical to preserving the quality of care. This is in part brought on by the rising popularity of procedures far more rarely attempted in previous decades. Although transgender chest procedures have relatively low rates of complication and are similar to breast procedures included in plastic surgery training, this is not true for masculinizing genital procedures involving urethral lengthening, some of which have complication rates as high as 50% and entail a substantial burden of recovery.⁸ There have been calls from both patients and surgeons to improve the quality of training in gender-affirming surgery and reduce the risk of long-term complications, but no such practices have been implemented at scale.^9,10

TRAINING AS AN OBSTACLE TO INCREASING AVAILABILITY OF GENDER-AFFIRMING PROCEDURES

Despite the need to increase the number of surgeons performing gender-affirming procedures, there is currently neither a standard training pathway nor an effective way to regulate who can and should be offering this care. Graduate and postgraduate medical training is structured to require that doctors are trained in the procedures they are expected to encounter in the course of their practice through a process of observation (see), practice (do), and education (teach).^11,12 These requirements are set and regulated by the Accreditation Council for Graduate Medical Education (ACGME) and monitored through the use of a system of case logs.¹³ Providers in specialty fields are generally required to have completed a set number of each procedure to begin independent practice.^14,15

The expectation that surgeons have been trained to provide the care¹⁶ they offer does not hold for gender-affirming surgery. Gender-affirming procedures may be performed by general surgeons, plastic surgeons, urologists, gynecologists, and others who may or may not have any specific formal or informal training.^17–19 As such, surgeons are variably prepared to the extent to which gender-affirming procedures are similar to other areas of their practice and/or they have sought out specialty training—often on their own time and at their own expense. Until quite recently, there have not been formal training programs in gender-affirming surgery, and some of the formal training programs that have been developed are structured as observerships with no hands-on operative experience.

There is likely an insufficient number of surgeons trained in gender-affirming procedures and working in academic environments to mandate their inclusion in ACGME case log requirements for residency and fellowship programs at the current time. However, as occurred at the start of laparoscopic surgery training, we would advocate for the development of teaching materials and curricula designed to facilitate the growth of this expertise.²⁰ In addition, programs that do house surgeons with such expertise should consider not only the creation of specialized gender-affirming surgery fellowships but also piloting minimum gender-affirming surgery case requirements in any other attached residency or fellowship programs—with the goal of ACGME eventually requiring gender-affirming surgery cases during residency training in relevant surgical fields. When that happens, residency programs should not be permitted to opt out of offering this training.²¹

ISSUES WITH TRANSPARENCY AND DISCLOSURE AROUND SURGICAL TRAINING

The fact that this field has only recently emerged into the medical mainstream means that many of the surgeons currently practicing gender-affirming surgery have not undergone any process of formal training and examination. This makes it difficult for transgender patients to determine the procedural competence of any particular surgeon. That problem is further compounded by the relatively low number of surgeons offering gender-affirming procedures, which may leave patients feeling like they have few or no choices for receiving the care they need.

Transgender medicine has a complex history with respect to transparency.² In an ideal world, surgeons seeking to provide gender-affirming care would seek and implement feedback from the communities they wish to support^22–24 and involve transgender providers at all levels of care. Doing so has the potential to reduce inherent power imbalances implicit in working with a marginalized population^25–27 and improve quality of care. At minimum, however, there is a need for providers to be open and honest with potential patients about their skills and limitations.

Right now, the most useful sources of information about gender surgeons’ skills and surgical outcomes are neither surgeons nor certifying medical associations. They are, instead, resources within the community, including websites devoted to transgender surgical experiences and Facebook groups created for patients seeking a particular surgery or care with a specific surgeon.^28–30 These groups often disclose systemic problems with care by a given surgeon or institution that are not available to individuals unaware of these unofficial resources.

Because of the lack of formal training requirements in the field, there is a need to change the culture of gender-affirming surgery such that surgeons are expected to disclose their history with these procedures to patients seeking care.³¹ At minimum, this requires surgeons to be transparent about their training, experience, and outcomes in any offered procedures (Table 1). Ideally, this would be done either as part of the initial consultation process or included in educational material about the practice. Better still would be community-centered modes of practice that involve ongoing consultation and collaboration, including facilitating connections of community members who have gone through these procedures with those who wish to undergo them in the future. Given the level of overhead investment required for such initiatives, it is incumbent upon institutions with more resources to begin this process of community engagement.

Table 1.

Proposed Disclosure Areas for Surgeons Offering Gender-affirming Procedures

Area	Disclosure Requirement
Training	Formal training—name of program, type of program (certificate, CME, and fellowship), and program hours
	Informal training—whether training was observational or participatory, training surgeon/site
	No. procedures observed—by procedure
	No. procedures assisted in—by procedure
	Relevant fellowship/residency training—eg, craniofacial fellowship for facial feminization surgeons
Experience	No. procedures performed as attending/primary surgeon—by procedure*
	No. procedures performed as co-surgeon*—by procedure
Outcomes	No. patients requiring reoperation*—by procedure
	No. patients requestion/requiring* revision—by procedure
	Major complications*—number and type, by procedure
	Minor complications*—number and type, by procedure

^*Surgeons offering procedure variants (ie, flap type in phalloplasty) should quantify these for each specific procedure rather than the overarching procedure.

CONCLUSIONS

Both patients and institutions should expect surgeons to disclose their histories with any procedures they are planning to perform, to make informed decisions about their competence to offer that care. The incorporation of new surgical techniques into fields of practice is an issue not restricted to the field of gender-affirming surgery.³² However, vulnerable populations need enhanced protections. Surgical specialties that perform substantial quantities of gender-affirming procedures should consider the implementation of guidelines around training, and the American College of Surgery has proposed a framework for the acquisition of new skills more generally.³³ In the interim, surgeons should consider their ethical responsibility to be competent in a procedure before incorporating it into practice and make certain that their institution has both the resources and willingness to provide any necessary postoperative follow-up.