Challenging the Binary Bias in Gender-Affirming Surgery

This is the authors' abstract. We don't add key points for this paper.

Gender-affirming surgery (GAS) is evolving rapidly to include the care needs of all transgender and gender diverse (TGD) people. The volume of GAS, continued integration of gender-affirming care into medical training, and a strong movement to look at patients from a holistic, intersectional lens are continually increasing.1 Although these changes represent significant progress, to continue this momentum we must also reflect on how we came to practice in an exclusionary system that often reinforces the marginalization of certain groups of TGD people. Given that systems are built by individuals, we can start by looking at our own biases. The breadth and scope of differing gender identities beyond the binary male and female is well-documented. However, GAS as a treatment for gender dysphoria has long been practiced under the influence of a binary bias. This binary bias historically, and currently, informs the procedures traditionally offered, reinforcing the idea that gender affirmation requires a direction from one binary status to another. As it stands, this model goes against the reality of gender expansiveness that has existed for as long as humans have recorded history. It also reinforces White Western ideals about gender identity and expression, further affecting care sought by gender-diverse Black, indigenous, and people of color who may come from a lineage of more expansive understandings of gender. Although many TGD people seek surgery to align with the binary paradigm, this is not true for all. People with nonbinary identities make up a large portion of the TGD community. Care needs for nonbinary people may deviate from what is conventional.2–4 Our literature scarcely mentions nonbinary identities and even more rarely presents variations in surgical procedures that fall outside of a fully binary option (eg, shaft-only phalloplasty, vulvoplasty, and other procedure subtypes).5 Instead, we continue to reinforce White ideals of what it means to be masculine or feminine, which continues the othering of those affected by colonialism and white supremacy. Plastic surgeons must avoid creating unintentional harm by perpetuating a rigid binary treatment algorithm for all TGD people that enforces a clinical narrative valuing assimilation over authenticity. The goal of GAS is to alleviate dysphoria or incongruence at the individual level. Matching external anatomy to internal identity does not always mean reinforcing a binary appearance. By withholding medical treatment that can better address a patient’s concerns, we are prioritizing the reinforcement of a social norm over the health of individuals and communities. GAS practices are creating an opportunity to move beyond traditional procedures; they are inviting us to use surgical techniques in a flexible manner to assist a person in the process of physically actualizing their internal sense of self while prioritizing safety, recognizing limitations of anatomy, and providing truly informed consent. Significant progress has been made toward providing accessible and personalized care for all TGD people. However, GAS is still dominated by a binary care model. We encourage those in this field to challenge their own binary bias and ensure the care we provide moving forward is as patient-centered and expansive as the myriad of experiences of gender that exist. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.