An Early Experience with Gender-affirming Facial Feminization Surgery at a Public, Safety-net Hospital
Year: 2021
Type: article
Study design: Observational Study
Abstract: PURPOSE: Facial feminization surgery (FFS) improves quality of life and reduces the risk of mental health disorders in trans women.1 However, the prohibitive cost and poor insurance coverage make FFS inaccessible for many patients. Zuckerberg San Francisco General Hospital (ZSFG) was among the first public, safety net hospitals nationwide to provide gender-affirming care, including FFS. We sought to examine the postoperative course of patients who underwent FFS at ZSFG and describe barriers to providing FFS in a public hospital setting. METHODS: A retrospective review identified patients who underwent facial feminization surgery at ZSFG. All patients had at least 1 year of follow up. Demographic data, comorbidity profiles, and postoperative complications were collected from the medical record. FACE-Q modules (scored 0–100) were used to survey patients at least 1 year postoperatively to assess their quality of life and satisfaction with surgery. Hospital capacity data were generated from an internal review of gender-affirming care services. RESULTS: Between 2017 and 2019, 17 patients underwent comprehensive FFS surgery at ZSFG. The median age was 41 years (IQR 38–55), and 9 patients (53%) racially identified as nonWhite. All patients were uninsured. FFS consisted of a median of 9 procedures, the most common of which were frontal cranioplasty (n = 13, 77%), open brow lift (n = 13, 77%), rhinoplasty (n = 12, 71%), and mandible contouring (n = 12, 71%). There were no complications, readmissions, or reoperations within 30 days. Five patients (29%) underwent revision procedures, the most common of which was revision rhinoplasty (n = 3). The postoperative survey, with 47% of patients responding, found high satisfaction with the surgical outcome (median 90, IQR 50–100), excellent postoperative psychological functioning (median 88, IQR 77–100), and low levels of appearance-related distress (median 19, IQR 0–46). The primary challenge to scheduling and performing FFS at ZSFG during the study period was operating room and hospital capacity, as an estimated 243 operating room hours and 45 inpatient bed days were required to cover all FFS procedures. Several patients had their surgery rescheduled because emergent trauma cases took precedence, which posed a hardship for patients who had previously made arrangements for their postoperative recovery. CONCLUSIONS: Performing FFS for trans women in a public hospital setting was associated with low rates of postoperative complications and excellent patient satisfaction. The hospital resources required to provide comprehensive gender-affirming care, and scheduling conflicts with emergent procedures, negatively affected efficient care delivery. Ultimately, a financial assessment led the ZSFG administration to outsource comprehensive FFS to a nearby academic hospital. Future efforts should continue to expand access to gender-affirming surgery for underserved populations, with an eye toward sustainability from a cost and healthcare utilization perspective. REFERENCE: 1. Padula WV, Heru S, Campbell JD. Societal implications of health insurance coverage for medically necessary services in the US transgender population: a cost-effectiveness analysis. J Gen Intern Med. 2016;31(4):394–401. doi:10.1007/s11606-015-3529-6
Authors: Andre Alcon, Ryan K. Badiee, Laura L. Barnes, Seth T. Pardo, Barry Zevin, Jason H. Pomerantz
Institution: University of California, San Francisco
Language: English
Subfield: Social Psychology
Field: Psychology
Domain: Social Sciences
Open Access status: gold
Estimated APC paid: $2,195
OpenAlex ID: W4310486338