Surgical healthcare needs for transgender patients: surgeons' perspectives.

Dear editor

We read with great interest the article by Dubin et al,1 who highlighted the specific healthcare needs and barriers the transgender population continues to face. Our department is the largest surgical provider in Europe for those transgender patients requiring male-to-female genital reconstruction surgery and would like to provide our unique perspective.2

We are in total agreement that the exclusion of transgender-specific health needs from the undergraduate curricula is leading to the healthcare inequalities faced by this cohort. As surgeons who provide surgical options for the transgender population, we would also like to highlight the absence of transgender-related surgery in the postgraduate surgical curricula at all levels internationally. Every UK-qualified urologist is required initially to obtain the Member of the Royal College of Surgeons followed by the Fellow of the Royal College of Surgeons (FRCS) qualifications prior to becoming an independent practitioner of this branch of surgery. The syllabus for both these postgraduate exams omits the specific surgical needs, techniques, and issues for this urological reconstructive subspecialty. This is mirrored globally, with evidence of minimal transgender-related educational and clinical content for urological and plastic surgical residency training.3

Training in genital reconstruction operative technique provides transferable skills, such as perineal dissection, which can be applied both in emergency Fournier gangrene debridement and elective incontinence work. However, we recognize the opportunity to train in genital reconstruction is limited to current UK, trainees as very few centers offer this service. Access to specialist training may be improved by establishing recognized and funded cross-specialty Training Interface Group placements for senior urology and plastic-surgery trainees. We would also encourage the inclusion of transgender-related health in future restructuring of the urology curriculum and FRCS syllabus so that all trainees have a basic understanding of its principles.

At an undergraduate level, the largest governing body for urologists in the UK (Brit-ish Association of Urological Surgeons) has provided a comprehensive undergraduate syllabus available to all medical schools.4,5 The addition of the surgical transgender health needs in this syllabus could be one such route to increase awareness among medical students.

Given the increasing number of transgender people seeking and undergoing genital reconstruction, the future clinician is likely to encounter such patients in their practice away from specialist centers. It is vital that they have at least a basic understanding of the anatomical and physiological reconstruction these patients have undertaken if they are to care for them appropriately.

Dear editor

We thank Dr Miah et al for their insightful perspective on gender-minority healthcare education among surgical trainees in response to our article.1 Their experience with the urological aspects of gender-affirming care in the UK is invaluable. Our previous data point to a similar lack of exposure to gender-minority-related healthcare in surgical residency in the USA.2–6 Dr Miah et al recommend that integration of further training in gender-affirmation surgery and transgender healthcare be implemented in undergraduate and graduate medical education in the UK. We have similarly felt that inclusion of gender-minority healthcare should be implemented by our medical boards in surgical specialties in the USA.7–10 Without the inclusion of standardized gender-minority healthcare educational opportunities for all our surgical trainees, our patients may suffer from the lack of adequately prepared surgeons and further discrimination against this population. Integrated surgical education in transgender health will hopefully allow us to continue to innovate in gender-affirming care and strive for improved patient outcomes.11–15