American Society of Plastic Surgeons
For Medical Professionals
 

Boosted by positive cultural changes, gender affirmation procedures are soaring

The world of plastic surgery represents and reflects much more than just a medical field. Popularity of specific procedures, along with the plastic surgery specialty itself, can be viewed as something of a referendum on society at large. As ASPS data over the years illustrates, strong economic climes equal strong plastic surgery practices – while a downturn, such as the recession of 2008 recession, can mean a dip for some practices.

New ASPS data outlining the range and rising frequency of gender affirmation surgery reflects a different kind of societal change. ASPS members Loren Schechter, MD, of Chicago, and Justine Lee, MD, from UCLA, both specialize in gender affirmation procedures, and have helped to advance this important – but often neglected – medical category.

Wider cultural acceptance and shifting perceptions

Drs. Schechter and Lee both credit the expanding cultural acceptance and visibility of the trans community as a major factor of the growing gender affirmation interest.

Along with the COVID-19 pandemic, 2020 saw a fraught election year and a bitter political climate – creating a buzz of uncertainty, especially for the trans community.

"No one knew what the future would hold in terms of third-party coverage, who was going to win the election or what was going to happen within the context of COVID," Dr. Schechter explains, estimating that about half of states still have some form of anti-trans legislation, with the ability to affect state-sponsored coverage.

Nevertheless, the evolving perception of the trans community also made positive gains over the past year, particularly with the reinstitution of trans people serving in the military and President Biden's Assistant Secretary of Health, Rachel Levine, MD, being the first openly transgender cabinet member ever to be appointed by the U.S. Senate.

"I've been doing this for over 20 years, and I think the increase in the volume of surgery reflects several things," Dr. Schechter notes, listing increases in access to care, societal acceptance, awareness that these surgeries are medically necessary care and acceptance from within the medical community itself.

"Historically, there's been quite a bit of marginalization of the transgender and gender-diverse communities," he says, adding that although there isn't total acceptance yet, substantial strides have been made in the past five years to ensure healthcare is more inclusive – for example, electronic medical records now allow appropriate use of pronouns. "I think all of those structural changes are really responding to the needs of the community."

Democratization of medical care

These leaps in progressive medical care reflect society's expanding perception of gender, as evidenced by an increased emphasis on inclusivity and diversity from corporations, universities and institutions.

"Patients within the trans community are starting to, for the first time, have access to procedures, as well as organized medical care," Dr. Lee explains. "I think this is really a backlog of patients, mainly because they haven't had care their entire lives and now are getting it for the first time."

Since first taking part in gender affirmation surgery in the 1990s, Dr. Schechter has seen firsthand the drastic differences behind the medical curtain as procedures evolved over the past quarter-century.

"The environment changed 180 degrees," he says. "Our biggest barrier 20 years ago was that hospitals wouldn't allow us to perform the procedures, and very few surgeons would perform them."

As for insurance companies covering the expense? Forget it. This, of course, made the procedures cruelly out of reach for many.

"Not only was it very expensive, but people had to leave the U.S. to access this medically necessary care," he says, ensuring that only the wealthy and usually older, established demographics had access.

Now, however, many large public corporations and universities are taking stronger stances on diversity, equity and inclusion.

"We're seeing expansions in coverage, where they provide insurance coverage through work or school, and as insurance expands, people at a younger age have access to care," Dr. Schechter says.

Looking ahead

The confluence of social media, the Affordable Care Act, and Medicare reimbursement enabled people to speak to one another across borders and demographics.

"They realize they're not alone, that there are other people with similar questions, concerns, feelings, attitudes," Dr. Schechter says. "This results in a natural increase in the number of individuals seeking surgery. The age of surgery has also lowered; we operate on more younger trans men, mostly for mastectomies, and even the age for vaginoplasty, for our transgender women, has become lower."

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