The Landscape of Transgender Surgery in the United States

0.3% - 0.5% of the general population identifies as transgender.^1,2 Many individuals require both hormone therapy and surgery to alleviate gender dysphoria, though others need only one, or neither.³ Transgender operations are a burgeoning area of Plastic Surgery. This large multi-center retrospective study provides a broader view of surgical transgender care in the US.

Purpose: Aims were to evaluate demographic and clinical differences between MTF and FTM, summarize transgender surgery across surgical disciplines, and identify predictors of life-threatening surgical complications in transgender patients. We also examined whether data from this cohort reflect known adverse effects of hormone therapy.⁴

Methods: Records from the ACS-NSQIP database from years 2005-2016 with postoperative diagnosis codes corresponding to transgender patients were reviewed. Operations were classified by direction of transition and anatomic region (FTM top surgery, FTM hysterectomy/oophorectomy, FTM bottom surgery, MTF top surgery, etc). Demographics, medical comorbidities (including, diabetes, COPD, hypertension and history of cardiovascular disease), preoperative labs, primary surgical subspecialty, and life-threatening complications (including superficial, deep and organ-space infections, PE/DVT, bleeding, and unplanned reoperation) were compared.

Results: 953 patients met inclusion criteria (319 MTF, 633 FTM). MTFs were older (38.323 vs. 30.661, p=0.000), and likelier to have at least one medical comorbidity (31.88% vs. 23.54%, p=0.006). More MTF were African American (18.85% vs. 9.40%, p<0.001), while more FTM were White (81.06% vs. 74.62%, p=0.001). MTF had higher hypertension rates (11.29% vs. 5.85%) but this effect was not significant after controlling for age. Otherwise comorbidities were similar between the groups and low overall.

Preoperative bilirubin and alkaline phosphatase were higher in FTM but few patients had values in abnormal ranges. Total operative time and MTF bottom surgery were independent predictors of higher complication rates. 

MTF underwent operations by Plastic Surgery (78.06%), Urology (18.50%), General Surgery (1.88%) and Otolaryngology (1.57%). FTM underwent operations by Plastic Surgery (53.64%), Gynecology (32.91%), General Surgery (13.13%) and Urology (0.32%). There were many areas of overlap between subspecialties.

Conclusions: Whereas transgender patients are often considered a single patient population, MTF and FTM differ significantly in demographics, operations and surgical complications. Several surgical subspecialties operate on transgender surgical patients with significant overlap, and Plastic Surgery is centrally involved. All operation had an acceptably low complication rate (0-5%). The approach and considerations toward the transgender patient should vary depending on patient goals of transition.

1. Zucker KJ, Lawrence AA. Epidemiology of Gender Identity Disorder: Recommendations for theStandards of Careof the World Professional Association for Transgender Health. International Journal of Transgenderism. 2009;11(1):8-18.

2. Bakker A, van Kesteren PJ, Gooren LJ, Bezemer PD. The prevalence of transsexualism in The Netherlands. Acta Psychiatr Scand. 1993;87(4):237-238.

3. Bockting W, Coleman E, Deutsch MB, et al. Adult development and quality of life of transgender and gender nonconforming people. Current Opinion in Endocrinology Diabetes and Obesity. 2016;23(2):188-197.

4. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism. 2012;13(4):165-232.