Increased access to medical care to treat gender incongruence, the diagnosis adopted in the International Classification of Diseases, Eleventh Revision, to describe enduring persistent incongruence between an individual’s experienced gender and the assigned sex,1 has been accompanied by physician demand for information on this care and increased publications within the clinical literature.2–5 We refer to the heterogeneous group of individuals who experience gender incongruence with the umbrella term transgender, which includes transgender men, transgender women, and nonbinary people. There are transgender individuals who do not desire any gender-affirming surgery and there are individuals who may undergo surgery without identifying as men or women.6Table 1 provides basic terminology applicable to the care of transgender individuals. Retrograde conceptualization of sex, gender, and sexuality in the clinical and scientific communication of gender-affirming surgery contributes to health disparities and mistrust in providers.5
Terms and Definitions Relevant to Care of Transgender and Nonbinary Individuals
|Assigned sex||Label used to define male/female binary sex based on external genitalia at birth.|
|Gender||An innate sense of self relative to widely used social categories, which can vary between cultures.|
|Gender identity||Any label given to describe a gender, such as “man” or “woman”; possessed by every individual, including cisgender people.|
|Gender expression||The means an individual uses to communicate their gender, such as through speech, clothing, or behaviors; may or may not conform to what is expected in a given cultural context for people of that gender identity.|
|Sexual orientation||Describes romantic or sexual attraction toward other people; although it is not determined by gender identity, orientation interacts with gender identity in that one’s own identity is implicated in the description of one’s romantic and sexual partnerships.|
|Sexual behavior||Attraction described by sexual orientation does not always align with sexual behavior. This could include both not participating in sexual contact despite having an attraction and behaviors that seem to contradict stated sexual orientation. These behaviors could result from choosing sexual contact that is available rather than ideally preferred, transactional sex, and discomfort identifying with certain labels. It could also be that in a different cultural context, that behavior is expected for that orientation.|
|Gender binary||A system entrenched in Western society to define all gender as either strictly male or female.|
|Gender incongruence||Experiencing conflict between one’s gender and the sex assigned at birth.|
|Cisgender||An individual whose gender is compatible with the assigned sex.|
|Transgender||Any individual whose gender is incongruent with the assigned sex. This encompasses a variety of identities, including those who feel their gender is the binary opposite of their assigned sex and those who feel their gender is limited or not completely described by their assigned sex.|
|Nonbinary||Any individual whose gender is neither male nor female defined according to the gender binary.|
|Transgender man||A man who was incorrectly assigned female at birth.|
|Transgender woman||A woman who was incorrectly assigned male at birth.|
|Transmasculine||Individuals incorrectly assigned female at birth who feel that their gender is best expressed according to culturally masculine norms while remaining distinct from having only a male gender identity. Can also be used as an umbrella term for nonbinary people and transgender men assigned female at birth.|
|Transfeminine||Individuals incorrectly assigned male at birth who feel that their gender is best expressed according to culturally feminine norms while remaining distinct from having only a female gender identity. Can also be used as an umbrella term for nonbinary people and transgender women assigned male at birth.|
|Two-spirit||A hypernym established to distinguish between Indigenous gender identities aside from male and female and the Western umbrella term/identity “nonbinary.”
|Gender nonconforming||Individuals whose gender expression differs from what would be expected from their gender identity in a cultural context. This can apply to cisgender individuals as well.|
|Intersex||Individuals born with genitalia, chromosomes, or other reproductive organs different from those matching the binary categories of either a “male” or “female” body.|
|Transition||The process transgender individuals may undergo to relieve their feelings of gender incongruence. A transition can include social, medical, and surgical components, but does not necessarily incorporate all three of these.|
*Robinson M. Two-spirit identity in a time of gender fluidity. J Homosex. 2020;67:1675–1690.
Previous attempts to define principles for gender-affirming surgery have delineated the need for cultural competence in support staff, but none has applied this framework to surgeon competencies.4 The decision to undergo reconstructive surgery and satisfaction with communication with plastic surgeons vary for different populations, including by race and ethnicity.7,8 Previous experiences of transgender patients serve to vet surgeons, both regarding surgical outcome and interpersonal communication.2,9 Patient-reported need to educate the provider on cultural competency leads to care avoidance, which can be a detriment to surgical outcomes or other ongoing follow-up care,9 whereas culturally competent care has been shown to increase mental health and quality of life.10,11 Invalidating communication can fracture patient satisfaction, and it is therefore necessary that the well-meaning surgeon is proficient with relevant concepts to provide affirming treatment.4,9,12 We provide case examples specific to gender-affirming surgery in Table 2.
Case Studies on the Effect of Retrograde Communication on Transgender and Nonbinary People
|Case 1||Case 2||Case 3|
|Surgical intervention||Gender-affirming mastectomy||Facial gender-affirming surgery||Gender-affirming vaginoplasty|
|Gender identity||Transgender man||Transfeminine||Transgender woman|
|Sexual orientation||Straight (attracted to women)||Queer (attracted to many genders)||Lesbian (attracted to women)|
|Nonpharmacologic interventions||Social name change and use of “he/him” pronouns, chest-binding garment, and other gender-affirming clothing||Social use of “they/them” pronouns, gender-affirming clothing, and permanent facial hair removal||Legal name change and use of “she/her” pronouns, gender-affirming clothing|
|Clinical communication example||
Case: The patient is told to provide a letter attesting to hormone treatment from primary care in addition to mental health providers for initial consultation.
Clinical outcome: Hormone therapy is not a requirement for chest surgery. Requiring a letter can result in delay in care.
Case: The patient is assumed to be a transgender woman desiring the appearance of a cisgender woman during consultation.
Clinical outcome: When the surgeon does not affirm the patient’s gender, the patient loses confidence in the surgeon’s ability and experiences decreased satisfaction with the surgical outcome.
Case: There is a focus on receptive vaginal intercourse during the consultation, assuming that this is a surgical outcome desired by all patients.
Clinical outcome: The patient and surgeon should discuss the breadth of surgical options in the context of which would be best suited for the patient’s sex life and surgical goals.
Stepwise treatment can perpetuate harm: requiring hormones even without WPATH recommendation to do so.
Gender-affirming surgical procedures do not have only one gender expression: procedures popular for transgender women are not solely sought out by transgender women.
Surgical choice does not dictate gender identity, sexual behavior, or reproductive wish: patients desiring a genital reconstruction do not necessarily seek vaginal canal creation.
WPATH, World Professional Association for Transgender Health.
Our center has evolved in approach to transgender concepts over time. Upon establishment of the multidisciplinary center, the senior surgeons were challenged by novel clinical scenarios and community feedback regarding shortcomings of their practice. As a result of recognizing their limitations as cisgender surgeons, transgender and nonbinary staff were recruited, and a patient and family advisory council was used to steer choices. Such infrastructure changes are not always possible; therefore, our aim is to share lessons learned in the form of recommendations for communication.
Incorporating Nonbinary Perspectives
Sociological understandings of the language of gender identity and affirmation have advanced. This is evidenced by the international adoption of the umbrella term nonbinary, largely replacing gender nonconforming, as the latter term may include those without gender incongruence who identify as cisgender but are perceived as nonconforming to gender expression or roles in certain cultural contexts. Nonbinary identities include those that complicate or add on to binary gender identities, such as transmasculine and transfeminine, and those with gender identities that do not include male or female. It must be emphasized that many genders from other cultures can be classified as nonbinary; however, in that context, the nonbinary label is relative to the imposed Western gender binary. These genders often have their own names ascribed within their language and history, such as the Muxe in Indigenous communities from Mexico, the Hijra in Indian cultures, and two-spirit individuals from the Americas. Categorizing patients as nonbinary can be reductive and can reinforce a patient’s feelings of erasure.13 Furthermore, patients with otherwise-labeled gender identities, such as genderqueer, may perceive the label nonbinary as defining them by what they are not rather than by who they are.8 In situations of uncertainty, it is best to follow how patients refer to their gender identity.
Recent guidance for those undertaking research with transgender communities and institutional review boards has promoted, among other principles, community participation in research, nonstigmatizing language and framing, and culturally sensitive presentation of material.14,15 The best practice in research methodology, including appropriate language, is context-dependent and should be determined by formal, community-driven processes to allow for change with the needs of the specific population being addressed and throughout time. These recommendations cannot substitute such a process specific to local context.
Adopting a community-driven methodology is a lengthy and ongoing process; however, there are steps that can be made toward enhancing more standardized elements of transgender care in the interim. Basic errors have passed peer review and editorial proofing, such as referring to transgender people assigned male at birth receiving vaginoplasty and other surgical procedures to affirm female identity as transgender men.16,17 At our own institution, internal review from transgender and nonbinary staff has resulted in more effective communication and the use of contemporary language of the community served, both in academic articles and in clinical counseling.
The World Professional Association for Transgender Health has outlined 12 guidelines for publishing and research that form a language policy in the Association’s journal,18 providing this guidance to transgender health broadly. We provide greater granular detail applicable to scientific communication in gender-affirming surgery using examples from early drafts of our own writing and fictitious examples anonymized from published literature. Language is always evolving. For instance, terms that may have once been community-preferred, such as male-to-female, female-to-male, and transsexual, are considered outdated and offensive when applied to populations broadly. To guide practices in a moderately more durable way, we delineate six principles that encompass important aspects of gender-affirming surgery. Specific examples are provided to elucidate underlying conceptual competencies, rather than absolute designations of correct and incorrect language. These examples should not be treated as comprehensive or beyond reproach; as language continues to evolve, the terminology used here is likely to be lacking or outdated in the future.
1. Specific Anatomical Structures or the Identity of the Patient Should Be Used in Place of Sex
Example: Male gonadal cancers in transgender persons do not seem to be more common than in cisgender men.
Correction: Testicular cancers in transgender women and nonbinary people do not seem to be more common than in cisgender men.
Rationale: Given the heterogeneity in medicolegal determination of the binary sex category, people who are identified within health records as female have a range of anatomical organs, including testicles. Furthermore, the term “male gonadal” identifies the anatomy as fundamentally male when the patient may identify with her anatomy as female regardless of surgical intervention.
Example: Depending on the specific operation, the accessibility of surgeons capable of performing sex reassignment surgery is highly variable across different areas.
Correction: Depending on the specific operation, the accessibility of surgeons capable of performing gender affirmation surgery is highly variable across different areas.
Rationale: Medicolegal sex assigned at birth is an insufficient term to account for the diversity in genitalia at birth, such as with intersex individuals, and there are patients who do not desire a surgical outcome constrained by the male or female genital sex binary. The use of “reassignment” implies that the patient depends on the surgical procedure for the validation of the experienced sex and/or gender. The terminology of gender affirmation surgery accounts for gender incongruence outside the binary and correctly depicts the dynamic among surgical intervention, patient, and gender.
2. The Anatomy Does Not Have a Gender Identity
Example: Like tissue should be replaced with like to reconstruct subunits of the vulva, mirroring homologous structures in cisgender vulva.
Correction: Like tissue should be replaced with like to reconstruct subunits of the vulva, mirroring homologous structures of the natal vulva.
Rationale: People who are not cisgender, such as transgender men, may have natal vulvas. The anatomical features, when discussed decontextualized from an individual or population, should not be assigned a gender identity, such as cisgender. Use of the term “natal” in reference to gender identity or an entire person (i.e., natal male) is inappropriate and counter to professional guidelines.18 Designating specific anatomical structures as natal, however, differentiates from neostructures (i.e., neovagina), much as cisgender differentiates gender identities that are not transgender.
Example: The elongation of the native female urethra is in part responsible for the high complication rate associated with phalloplasty and metoidioplasty procedures.
Correction: The elongation of the natal perineal urethra is in part responsible for the high complication rate associated with phalloplasty and metoidioplasty procedures.
Rationale: Referring to the anatomy of transgender men with terms such as “female urethra” implies there is an aspect of them that is still fundamentally female. Proposed here is the use of “perineal urethra” as an alternative, consistent with the verbiage used for cisgender men after they undergo a perineal urethrostomy.
3. Stepwise Treatment Can Perpetuate Harm
Example: The pectoralis muscle will hypertrophy on hormone replacement therapy, and the postoperative result is more successful after a year or more of ongoing treatment with testosterone.
Correction: For patients who undergo hormone therapy, maximal pectoralis hypertrophy from testosterone alone will occur after approximately 1 year, which may aid surgical planning.
Rationale: Hormone therapy is not a prerequisite for gender-affirming mastectomy. Not all patients desiring surgical intervention will desire hormone therapy, and some who do desire this therapy may have medical contraindications or other barriers to receiving it. A rigid stepwise model that places surgical treatment at the end of transition elides the role of multidisciplinary care throughout the lifespan.
Example: The specific requirements outlined in the World Professional Association for Transgender Health Standards of Care must be fulfilled for transgender women seeking to complete their transition through vaginoplasty.
Correction: The specific requirements outlined in the World Professional Association for Transgender Health Standards of Care must be fulfilled for transgender women and nonbinary individuals seeking to undergo vaginoplasty.
Rationale: Assigning finality to a patient’s transition based on a surgical intervention ignores the subjectivity of a “complete transition” and outlays a singular path for transition that may not be applicable to nonbinary individuals. It is also predicated on purely internal motivations for undergoing a procedure. Many transgender individuals desire surgery to be perceived as cisgender to others, and whether they find the surgical outcome successful toward this endeavor can vary over time.9 Transitioning is a fluid process; interventions that once constituted a complete transition for an individual may later become insufficient gender affirmation, requiring additional treatment. In addition, surgical procedures that may seem incomplete to the medical team, such as double-incision mastectomy without nipple grafts or vaginal canal creation without penectomy, should be considered regardless of whether these low-frequency requests match expectations for a complete procedure.4
4. Pathologizing Gender Incongruence Creates Stigma
Example: Only after they have undergone extensive psychological treatment are patients referred for gender-affirming surgery.
Correction: Patients seeking gender-affirming surgery experience marginalization and can benefit from multidisciplinary psychosocial support, including mental health care. Standards of care support an assessment from a mental health provider before gender-affirming surgery.
Rationale: World Professional Association for Transgender Health Standards of Care version 719 state that minimal psychotherapy requirements to access medical interventions can be a barrier to authentic mental health engagement. To this end, treating clinicians are advised against requiring psychotherapy before surgery, instead advocating for psychosocial assessments. The foundational texts of transgender studies specifically explore the effect of imposed psychological engagement before surgery, including assessments, on transgender subjectivity and the relationship to medicine.20,21 The limited availability of competent mental health providers further complicates this requirement.2 Given psychosocial barriers to care, supportive management outside of the scope of surgical practice may be beneficial, including mental health support.22
Example: The exact incidence of gender identity disorder and associated surgical procedures is unknown because of the historical erasure of transgender individuals and limited access to health care.
Correction: The exact incidence of gender incongruence and associated surgical procedures is unknown because of the historical erasure of transgender individuals and limited access to health care.
Rationale: The term gender identity disorder is an anachronistic remnant from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and implicates the patient’s gender identity as aberrant or disordered, thereby bringing its legitimacy into question.23 Previous classifications of gender incongruence as a disorder have resulted in physicians conflating it with paraphilias and considering transgender patients as innately mentally ill or as being at higher risk for mental illness.2,19 Gender incongruence can exist without the patient qualifying as mentally ill; thus, the term gender identity disorder was removed in favor of the more accurate term gender incongruence in the most recent International Classification of Diseases.23–25
5. Gender-Affirming Surgical Procedures Do Not Have Only One Gender Expression
Example: Facial feminization surgery is most commonly performed for transgender women and less commonly for cisgender women seeking an enhanced womanly appearance.
Correction: Facial gender-affirming surgery is most commonly performed for transgender women and less commonly for nonbinary people or cisgender women who seek to enhance feminine gender expression.
Rationale: What is feminine or masculine in appearance and behavior (gender expression) is culturally determined. Whereas these are deeply interrelated with bodily form, femininity is not a singular, stable concept. When a surgeon or patient describes a “more feminine jaw” as an outcome, they could be including or excluding any combination of mandibular angle, chin height, chin projection, or masseter muscle prominence in their conception. Using “feminine” to describe the specific desired visual outcome before this has been clarified leaves room for misinterpretation. In addition, transgender men and nonbinary people may undergo facial gender-affirming surgery, which could be described as masculinizing or with a more neutral term, depending on the stated goals of the patient.26
Example: Breast feminizing surgery is an operation commonly performed in transgender women.
Correction: Gender-affirming breast augmentation is an operation commonly performed in transgender women.
Rationale: Nonbinary patients who do not identify as female may undergo procedures traditionally used for transgender women undergoing gender-affirming surgery but find “feminizing” to be an inappropriate description of their surgical goals. Patients may interpret the use of feminizing as the surgeon assuming their preferred outcome and ergo their identity as female, and such a misunderstanding has been noted to foster mistrust between physician and patient. However, some patients may prefer the use of “feminizing” or “masculinizing” when discussing surgery. Adopting the patient’s perspective on the procedure is always most appropriate. To be inclusive of the diverse patient population, we recommend describing surgical interventions to treat gender incongruence broadly as gender-affirming; clear communication between the surgeon and individual patient can elucidate specific preferences.
6. Surgical Choice Does Not Dictate Gender Identity, Sexual Behavior, or Reproductive Wish
Example: In transgender women, vaginoplasty is able to provide a vagina of sufficient depth for intercourse with most partners.
Correction: In those who wish to have receptive vaginal intercourse after vaginoplasty, a vagina of 10 cm or more in depth is usually possible.
Rationale: Intercourse is a vague concept that includes multiple specific activities. Vaginal receptive intercourse may not be the preferred activity of many who would elect vaginoplasty or vulvoplasty only,27 in which case vaginal depth may or may not be relevant. Vaginal depth may be desired for reasons other than intercourse and is a discussion to be had with patients on an individual basis.
Example: There exists no required or universal pathway for transitioning, and many transgender men do not remove their female reproductive organs.
Correction: There exists no required or universal pathway for transitioning, and many transgender men do not remove their uterus or ovaries.
Rationale: There are transgender men whose transitions are complete without removal of their uterus or their ovaries, and this decision does not change their gender. There are some transgender men who desire pregnancy after transitioning; thus, the uterus is not an exclusively female reproductive organ.28 A transgender woman who does not have a uterus may regard herself as having female reproductive organs.
Standardized reconstructive procedures aside from gender-affirming surgical procedures have always been protean, accommodating for biological and psychosocial factors such as age, variability in skin and fat volumes, and general health status. Bodily norms are culture-bound and unstable, both over time and among communities, which have different experiences related to race and ethnicity, disability, education level, and socioeconomic class. These demographic characteristics compound and intersect with a patient’s experience of gender identity. Notably, the history of medical gender affirmation has been intertwined with racialized experiences of medicolegal gender.29
Concepts that destabilize the foundations of gendered bodies and sex categories taught in medical education are difficult to incorporate into scientific schema. Surgeons desire clear algorithms and pathways to provide appropriate and reproducible treatment outcomes, and standardizing communications within surgical literature will aid in these goals. The specific principles outlined in this article allow for proficient clinical implementation of a previously established, broad framework when planning gender-affirming procedures: (1) establishing and conveying an accurate understanding of patients’ gender, their culturally specific perception of masculine, feminine, and androgynous features, and how congruent those attributes are with their gender; (2) presenting all available operations conducive to affirming the patient’s gender; (3) setting realistic expectations of surgical outcome within the demonstrated shared understanding of the patient’s gender; and (4) explaining the importance of multidisciplinary care in the patient’s satisfaction with the surgical outcome.12,22 Incorporating recent advancements into surgical treatment can serve to clarify for the surgeon–scientist the differing patient experiences of the same physiologic outcome and strengthen the application of shared decision-making within surgical planning.
We aim to provide scientific communication and clinical care that does not perpetuate incorrect assumptions about identity, behavior, and surgical goals. For some transgender and nonbinary people, however, normative representations of identity and behavior are accurate to their experience and clinical needs. Gender-affirming surgery requires a delicate balance of concepts in tension with each other. Holding complex and multidimensional forces together in a manner unique to the individual patient such that the outcome is seamless is the daily work of the plastic surgeon navigating complex reconstructive surgery. The training and principles of plastic surgery are the baseline expertise needed to tailor any gender-affirming operation to the unique gender identity, cultural values, and treatment goals of the individual patient.
These recommendations are the opinion of the authors, a group that includes gender-affirming surgeons at an academic medical center and transgender-identified experts in gender-affirming surgery in an urban, North American, English-speaking context. In the future, formal guidelines with input from multiple stakeholders could better delineate communication within gender-affirming surgical care. Furthermore, race and ethnicity, language, and cultural context, among other factors specific to a community being addressed, may require use of differing languages and concepts.
The language used to describe the science of gender-affirming surgery must adapt to an evolving understanding of gender. Surgeons must balance classical conceptions of surgical gender affirmation that continue to apply to many patients with efforts toward fluency in evolving conceptions of gender. Formal guidelines with input from multiple international stakeholders should be sought to better delineate communication of gender-affirming surgical care.