Terminology in Transgender Patient Care

Sir: We read with great interest the article by Papadopulos and colleagues entitled, “Male-to-Female Sex Reassignment Surgery Using the Combined Technique Leads to Increased Quality of Life in a Prospective Study.”1 The authors should be commended on a prospective study examining patient-reported outcomes in gender affirming surgery. As the authors note, few studies have used patient satisfaction as the standard by which gender affirming surgery is judged. We have previously argued, as do the current authors, that this must be the future standard in transgender care.2 This study represents an important shift in the paradigm of how we assess a positive postoperative result. However, we encourage the authors to exert caution in the future to avoid terminology that may be outdated or even considered inappropriate. Although not directly pejorative, the phrase “sex reassignment surgery” is only once removed from the largely derogatory phrase “sex change surgery.”3 More appropriate terminology has been adopted by many experts in the field to not only confirm but affirm the reality of our transgender patients’ lived experience and sense of self.4 Therefore, there has been a natural progression away from phrases such as sex reassignment surgery to less stigmatizing phrases such as “gender confirming surgery” and most recently to “gender affirming surgery.” The differences between confirming and affirming are subtle, with their meaning still evolving in the context of transgender care. According to the Oxford English Dictionary, “to confirm” is “to make firm or more firm, to add strength to, to settle, establish firmly.”5 In contrast, “to affirm” is “to uphold; to confirm, ratify; to uphold the decision of.”6 Based on these definitions, both verbs appear appropriately used in the context of “gender confirming/affirming surgery.” However, “to confirm” can be performed either positively or negatively on the object of a sentence, whereas “to affirm” is generally only performed in a positive context. Summarized succinctly, the exclamative “affirmative!” leaves no doubt as to the positive context of the declarer. However, the exclamative “confirmative!” does not readily imply a positive or negative context by the declarer. Therefore, we suggest that “gender affirming surgery” represents the best current terminology for antiquated phrases such as “sex reassignment surgery.” Although these differences in terminology may appear to be obsolete, they are laden with significance for our transgender patients. The terminology used by our transgender patients and in their care will only continue to evolve over time. As providers, it is our duty to evolve with it. Remaining conscious of terminology that marginalizes this patient population is imperative. Through semantics and thoughtful prose, we can help shape a positive discourse with our transgender patients and communities. DISCLOSURE The authors have no financial disclosures to declare and there was no funding obtained for the production of this communication. Jonathan P. Massie, M.D.Division of Plastic SurgeryDepartment of SurgeryNorthwestern University Feinberg School of MedicineChicago, Ill. Carl G. Streed, Jr., M.D.Division of General Internal Medicine and Primary CareDepartment of MedicineBrigham and Women’s HospitalBoston, Mass. Paula M. Neira, J.D., R.N.Johns Hopkins Center for Transgender HealthBaltimore, Md. Shane D. Morrison, M.D., M.S.Division of Plastic SurgeryDepartment of SurgeryUniversity of Washington School of MedicineSeattle, Wash.