Nnenaya Agochukwu-Mmonu, Asa Radix, A Mark Fendrick
Extract The development of validated patient-centered outcome measures with direct input from the TGNB community is a necessary and critical component of the CED model. Without standardization, findings are frequently not generalizable, and the policy discourse is guided less by rigorous, often inconsistent measures. For example, the studies examining the mental health benefit for patients undergoing gender-affirming surgeries include measures that lack standardization, evaluate different interventions (ie, surgeries are rarely done with concurrent hormone administration), include dissimilar patient populations, and use different study designs. Given this heterogenity, wide variation in reported outcomes is not unexpected; although many studies demonstrate benefit, others report that patients have unrealistic expectations or experience decision regret, including rare reports of reversal surgery.
Joseph K. Canner, Omar Harfouch, Lisa M Kodadek, Danielle Pelaez, Devin Coon, Anaeze C Offodile II, Adil H. Haider, Brandyn D Lau
Abstract Importance:Little is known about the incidence of gender-affirming surgical procedures for transgender patients in the United States.
Objectives:To investigate the incidence and trends over time of gender-affirming surgical procedures and to analyze characteristics and payer status of transgender patients seeking these operations.
Design, Setting, and Participants: In this descriptive observational study from 2000 to 2014, data were analyzed from the National Inpatient Sample, a representative pool of inpatient visits across the United States. The initial analyses were done from June to August 2015. Patients of interest were identified by International Classification of Diseases, Ninth Revision, diagnosis codes for transsexualism or gender identity disorder. Subanalysis focused on patients with procedure codes for surgery related to gender affirmation.
Main Outcomes and Measures: Demographics, health insurance plan, and type of surgery for patients who sought gender-affirming surgery were compared between 2000-2005 and 2006-2011, as well as annually from 2012 to 2014.
Results; This study included 37 827 encounters (median [interquartile range] patient age, 38 [26-49] years) identified by a diagnosis code of transsexualism or gender identity disorder. Of all encounters, 4118 (10.9%) involved gender-affirming surgery. The incidence of genital surgery increased over time: in 2000-2005, 72.0% of patients who underwent gender-affirming procedures had genital surgery; in 2006-2011, 83.9% of patients who underwent gender-affirming procedures had genital surgery. Most patients (2319 of 4118 [56.3%]) undergoing these procedures were not covered by any health insurance plan. The number of patients seeking these procedures who were covered by Medicare or Medicaid increased by 3-fold in 2014 (to 70) compared with 2012-2013 (from 25). No patients who underwent inpatient gender-affirming surgery died in the hospital.
Conclusions and Relevance: Most transgender patients in this national sample undergoing inpatient gender-affirming surgery were classified as self-pay; however, an increasing number of transgender patients are being covered by private insurance, Medicare, or Medicaid. As coverage for these procedures increases, likely so will demand for qualified surgeons to perform them.
Abstract In her paper Cosmetic surgery and conscientious objection’, Minerva rightly identifies cosmetic surgery as an interesting test case for the question of conscientious objection in medicine. Her treatment of this important subject, however, seems problematic. It is argued that Minerva’s suggestion that a doctor has a prima facie duty to satisfy patient preferences even against his better clinical judgment, which we call Patient Preference Absolutism, must be regarded with scepticism. This is because (1) it overlooks an important distinction regarding autonomy’s meaning and place in clinical practice, and (2) it makes obsolete the important concepts of expert clinical judgment and beneficence. Finally, we discuss two ideas which emerge from consideration of cosmetic surgery in relation to conscientious objection. These are the possible analogy between clinical judgment and conscientious objection, and the possible role the goals of medicine can play in defining the scope of conscientious objection.
Abstract In this paper, I analyse the issue of conscientious objection in relation to cosmetic surgery. I consider cases of doctors who might refuse to perform a cosmetic treatment because: (1) the treatment aims at achieving a goal which is not in the traditional scope of cosmetic surgery; (2) the motivation of the patient to undergo the surgery is considered trivial; (3) the patient wants to use the surgery to promote moral or political values that conflict with the doctor’s ones; (4) the patient requires an intervention that would benefit himself/herself, but could damage society at large.
Abstract Many countries, Sweden among them, lack professional guidelines and established procedures for responding to young females requesting virginity certificates or hymen restoration due to honour-related threats. The purpose of the present survey study was to further examine the attitudes of the Swedish healthcare professionals concerned towards young females requesting virginity certificates or hymen restorations. The study indicates that a small majority of Swedish general practitioners and gynaecologists would accommodate these patients, at least given certain circumstances. But a large minority of physicians would under no circumstances help the young females, regardless of speciality, years of practice within medicine, gender, or experience of the phenomenon. Their responses are similar to other areas where it has been claimed that society should adopt a zero tolerance policy against certain phenomena, for instance drug policy, where it has also been argued that society should never act in ways that express support for the practice in question. However, this argument is questionable. A more pragmatic approach would also allow for follow-ups and evaluation of virginity certificates and hymen restorations, as is demonstrated by the Dutch policy. Hence, there are some obvious advantages to this pragmatic approach compared to the restrictive one espoused by a large minority of Swedish physicians and Swedish policy-makers in this area.
Abstract Court-ordered caesarian sections against the explicit wishes of the pregnant woman have been criticised as violations of the woman’s fundamental right to autonomy and to the inviolability of the person-particularly, so it is argued, because the fetus in utero is not yet a person. This paper examines the logic of this position and argues that once the fetus has passed a certain stage of neurological development it is a person, and that then the whole issue becomes one of balancing of rights: the right-to-life of the fetal person against the right to autonomy and inviolability of the woman; and that the fetal right usually wins.