Background

Transgender and gender-diverse individuals account for 0.4% to 1.3% of the worldwide population, a figure that may even be underreported.¹ Within the US alone, an estimated 1.3 million adults and 300,000 youth identify as transgender or gender diverse.² Gender dysphoria refers to the psychological distress caused by an incongruence between a person’s gender identity and sex assigned at birth. This diagnosis is used to facilitate medical, surgical, and mental health care in transgender and gender-diverse individuals. The process of transitioning is not linear, and certainly not “one size fits all.” The elements often included in a person’s individualized transition include social, medical, and surgical facets. Within these 3 broad categories exist the need for care bestowed by providers specific to each realm. In order to optimize the care and emotional experience, collaboration among these various services is paramount.

Our Model

The extent of education required by all participating in the care process is beyond the scope of this discussion, but making efforts to understand the experience of this patient population, along with training to improve cultural sensitivity, must be employed before a program can exist. The foundation of the program must be set by implementing the pieces or personnel necessary for its success. The organization can be considered in terms of surgical and nonsurgical care.³ Within surgical care, providers may be plastic surgeons, urologists, general surgeons, or gynecologists, though gynecologists may also provide nonsurgical services such as hormone therapy. In the nonsurgical arm of care delivery, these practitioners include primary care physicians, endocrinologists, behavioral health specialists, physical therapists, procedural specialists like hair removal technicians, and social workers. Moreover, the impact of resident physicians, advanced practice providers, nurses, medical assistants, and all other participants, like front desk and call center staff, cannot be undervalued.

At our institution, a 3-fold practice has been set in motion by the early pioneers of the program. First, the goal was to establish and create the program from a rudimentary idea. This process required developing a strategic plan and accounting for administrative buy-in and support. Next came building, in which additional providers responsible for creating the core team were assembled and partnerships with community were established. The last phase, in constant evolution, is to expand. With needs demonstrated, the impetus to further support the program with additional funding, personnel, and educational resources, among others, is more easily accepted and embraced. For example, in an independent review of departmental and hospital revenue margins for gender-affirming surgical services, one institution found 720% growth in a 2-year period, translating to 23.8% of total annual departmental work relative value units for plastic surgery and 17.8% for urology.⁴ This degree of revenue generated balances the cost of investment in additional resources. Ultimately, good care begets better care for the patients we serve. With the expansion process, multidisciplinary efforts are better aligned in space and time. A multidisciplinary clinic occurs weekly in which nearly all providers are housed in 1 location, often providing multidisciplinary consults in an effort to streamline experiences and improve patient knowledge and understanding. This process is particularly important in the partnership between the plastic surgeon and urologist in discussions surrounding genitourinary reconstruction. Additionally, a monthly conference allows for exchange of ideas among all providers and those with a vested interest in the program’s success. Visiting speakers highlight community concerns or initiatives to continue to provoke the spirit of collaboration.

Conclusion

Developing a multidisciplinary gender-affirming care service is an undertaking that requires consistent efforts be made to improve care as we eliminate and overcome barriers. Identifying providers with a willingness to charge ahead on the mission of delivering first-rate gender-affirming and general medical care for transgender and gender-diverse individuals sets the stage for further development. As providers, continual introspection and commitment to personal growth and evolution facilitates a space for growth among colleagues and collaborators that, with time, may have more societal impact. Education and innovation also allow for the invention and adaptation of surgical operations as evidenced by improvements in targeted nerve reinnervation in chest surgery, improved functional depth of vaginoplasty through the addition of peritoneal flaps in the setting of penile and scrotal hypoplasia, and creative adjuncts for reconstruction in face masculinization, all components not previously identified as typical gender-affirming surgical operations. Without a set blueprint in place, and recognizing that institutions vary in process and progress, the aforementioned facets of our gender-affirming care model provide the favorable framework for developing a creative program that suits your organization.

Conflict of Interest Disclosures: The Authors have no conflicts of interest to disclose.