Gender-affirming facial surgery: Anatomy and fundamentals of care

Caring for patients who identify as transgender and gender diverse (TGD) requires a ground level understanding of proper patient communication, a framework for decision-making surrounding medical and surgical interventions, and an awareness of obstacles surrounding healthcare. The objective of this chapter is to highlight appropriate terminology and definitions, discuss the current standards of care for transgender health, raise awareness of the barriers to healthcare access facing the TGD population, and discuss basic facial anatomy and sexual dimorphisms. Gender incongruence occurs when birth-assigned sex and gender identity differ for an individual, and gender dysphoria is the distress felt in this state. Persons who experience gender dysphoria may seek gender-affirming hormone therapy or surgery. Access to care is not straightforward, and the current standards of care aim to provide a guideline for administration of hormones and surgery. In order to offer the highest level of care, surgeons should have a fundamental understanding of issues surrounding the TGD community combined with a robust comprehension of facial features characterizing gender. Caring for patients who identify as transgender and gender diverse (TGD) requires a ground level understanding of proper patient communication, a framework for decision-making surrounding medical and surgical interventions, and an awareness of obstacles surrounding healthcare. The objective of this chapter is to highlight appropriate terminology and definitions, discuss the current standards of care for transgender health, raise awareness of the barriers to healthcare access facing the TGD population, and discuss basic facial anatomy and sexual dimorphisms. Gender incongruence occurs when birth-assigned sex and gender identity differ for an individual, and gender dysphoria is the distress felt in this state. Persons who experience gender dysphoria may seek gender-affirming hormone therapy or surgery. Access to care is not straightforward, and the current standards of care aim to provide a guideline for administration of hormones and surgery. In order to offer the highest level of care, surgeons should have a fundamental understanding of issues surrounding the TGD community combined with a robust comprehension of facial features characterizing gender. An estimated 1 to 1.4 million trans and gender diverse (TGD) individuals currently live in the United States.1.Meerwijk EL Sevelius JM. Transgender population size in the United States: A meta-regression of population-based probability samples.Am J Public Health. 2017; 107: e1-e8https://doi.org/10.2105/AJPH.2016.303578Crossref PubMed Scopus (486) Google Scholar,2.Flores AR Herman Jody L. Gates Gary J et al.How many adults identify as transgender in the United States. The Williams Institute, 2016Google Scholar To understand gender identity, it is important to appreciate the difference between sex and gender. Sex is the combination of genetic, biologic, and physical traits that define a person as male or female, and is typically assigned at birth.3.Factor RJ Rothblum ED. A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence.J LGBT Health Res. 2007; 3: 11-30https://doi.org/10.1080/15574090802092879Crossref PubMed Scopus (192) Google Scholar Gender, on the other hand, is viewed as a social construct in the medical community. It is one's definition of identity in the context of how one feels and interprets one's body and emotions in one's environment, irrespective of biology.3.Factor RJ Rothblum ED. A study of transgender adults and their non-transgender siblings on demographic characteristics, social support, and experiences of violence.J LGBT Health Res. 2007; 3: 11-30https://doi.org/10.1080/15574090802092879Crossref PubMed Scopus (192) Google Scholar With sex and gender identity being similar, the individual is considered cisgender. Gender incongruence occurs when biologic sex assigned at birth and gender identity disagree. Gender identity for some individuals is fixed, and others may have fluid gender state or may experience gender as nonbinary. Therefore, the term trans and gender diverse (TGD) is recommended and utilized throughout this issue. TGD individuals may seek different domains of gender affirmation, including social, legal, medical, and surgical affirmation. Gender awareness as either male or female forms evolves during infancy and childhood and can be influenced by environmental and parental interactions. Studies have examined and described this process, but further research is needed to fully understand the process of gender identification. Factors influencing gender identity include a complex interplay between cultural, environmental, and biological factors.4.Steensma TD Kreukels BPC de Vries ALC et al.Gender identity development in adolescence.Horm Behav. 2013; 64: 288-297https://doi.org/10.1016/j.yhbeh.2013.02.020Crossref PubMed Scopus (174) Google Scholar, 5.Rosenthal SM. Approach to the patient: Transgender youth: endocrine considerations.J Clin Endocrinol Metab. 2014; 99: 4379-4389https://doi.org/10.1210/jc.2014-1919Crossref PubMed Scopus (98) Google Scholar, 6.Saraswat A Weinand JD Safer JD. Evidence supporting the biologic nature of gender identity.Endocr Pract. 2015; 21: 199-204https://doi.org/10.4158/EP14351.RAAbstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar It is important to note that gender identity varies from gender expression, which is how one conveys themselves to others in a gendered manner. Gender expression may not always align with gender identity. At birth, there is likely a biological correlation to gender identity. Several studies have examined the role that genetics and hormones play in influencing gender identity. For example, identical twins have greater rates of transgender identity between siblings than fraternal twins.7.Heylens G De Cuypere G Zucker KJ et al.Gender identity disorder in twins: a review of the case report literature.J Sex Med. 2012; 9: 751-757https://doi.org/10.1111/j.1743-6109.2011.02567.xCrossref PubMed Scopus (131) Google Scholar Prenatal androgen exposure has also been examined in gender development. Individuals with congenital adrenal hyperplasia who are exposed to additional androgens in utero have increased rates of male gender identity.8.Dessens AB Slijper FME Drop SLS. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia.Arch Sex Behav. 2005; 34: 389-397https://doi.org/10.1007/s10508-005-4338-5Crossref PubMed Scopus (297) Google Scholar Patients with complete androgen insensitivity have female gender identity.9.Mazur T. Gender dysphoria and gender change in androgen insensitivity or micropenis.Arch Sex Behav. 2005; 34: 411-421https://doi.org/10.1007/s10508-005-4341-xCrossref PubMed Scopus (186) Google Scholar Further research is needed to understand the role of perinatal hormone levels in sexual orientation and gender identity. Studies have not shown differences in sex hormone levels between cis- and transgender individuals, supporting a complexity of influences. It is important to distinguish between the terms used to describe the TGD community versus the terms the TGD community uses to describe themselves and their experiences. Trans is often used to describe individuals who identify with a gender that does not align with the birth-assigned sex. For example, a ‘transgender’ or ‘trans’ man was assigned the female sex at birth but identifies as a man. Likewise, a ‘transgender’ or ‘trans’ woman was assigned the male sex at birth but identifies as a woman. “Genderqueer” and “non-binary” describe individuals with genders that do not exist within the duality of “woman” or “man.” “Non-binary” also includes many identities, such as ‘agender’ or having no gender, ‘bigender’ or having 2 genders, and ‘genderfluid’ or those with genders evolving multiple identities over time.10.Association American Psychological Guidelines for psychological practice with transgender and gender nonconforming people.Am Psychol. 2015; 70: 832-864https://doi.org/10.1037/a0039906Crossref PubMed Scopus (808) Google Scholar, 11.Porter KE Brennan-Ing M Chang SC et al.Providing competent and affirming services for transgender and gender nonconforming older adults.Clin Gerontol. 2016; 39: 366-388Crossref PubMed Scopus (68) Google Scholar, 12.Trans Bodies, Trans Selves: A Resource by and for Transgender Communities.Second Edition. 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