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Quantifying the psychosocial benefits of gender-affirming surgery with patient reported outcomes: The San Francisco Transgender Survey (SFTS).
Andre Alcon, M.D.1, Eric Wang, M.D.1, Rachel Lentz, M.D.1, Natnaelle Admassu, B.S.1, Kelsey B. Loeliger, MPhil2, Merisa Piper, M.D.1, Esther Kim, M.D.1.
1University of California, San Francisco, San Francisco, CA, USA, 2Yale University School of Medicine, New Haven, CT, USA.

PURPOSE: While there are a growing number of public health studies addressing the burden of mental health disease and HIV in transgender populations, there are disproportionately fewer investigations into the benefits of gender affirming surgery (GAS). The psychometric instruments that have been validated for measuring patient reported quality of life are unable to adequately address the unique psychosocial , legal, and medical stressors confronting transgender patients. Thus, we developed a patient-reported outcome instrument to evaluate the surgical outcomes and the post-operative experience of female-to-male (FTM) transgender men undergoing chest reconstruction.
METHODS: Transgender male patients at two university-affiliated transgender centers underwent structured interviews individually and in focus groups. Based on this qualitative feedback, a multidisciplinary panel of mental health providers, plastic surgeons, and primary care providers from transgender health clinics generated a 29-item survey module addressing three general domains of quality of life related to chest reconstruction in transgender male patients. The surveys were initially administered to 15 transgender male patients who underwent gender affirming surgery and were revised following cognitive debriefing interviews. The WHO Quality of Life (WHOQOL-BREF) survey, a previously validated quality of life instrument, was administered simultaneously for comparison. Wilcoxon signed-rank tests were used to test for significant differences in the median pre- and post-operative scores. Cronbach’s α and Pearson Correlation Coefficients were calculated to measure internal validity.
RESULTS: 11 transgender men to date have completed the revised SFTS pre-and post-operatively. Seventy percent were Caucasian and the median age was 32.5 (range 22-50) years. All patients underwent bilateral mastectomy with free nipple grafting. Only one patient (9%) experienced a major surgical complication requiring reoperation. Ultimately, the patient was pleased with his results and reported a significant improvement in his quality of life after surgery. The survey detected statistically significant median quality of life post-operative improvements in all three sections of our survey (p<0.005). While similar statistically significant improvements were found using the WHO Quality of Life survey (p<0.05), qualitative feedback revealed that patients perceived the WHO survey as an inappropriate tool for evaluating issues important to them. The median time to complete the pre and post-operative surveys was 10 minutes. Calculation of Cronbach’s α (0.67-0.81) and the Pearson Correlation Coefficient for each section revealed excellent internal validity.
CONCLUSION: The SFTS is a valid and simple instrument for measuring changes in quality of life in transgender men undergoing chest reconstruction. Although this ongoing evaluation is based on a small sample size thus far, pertinent quality of life measures can be expected to help better establish the many benefits of GAS and influence public policy to broaden access to GAS. The external validity of the SFTS needs to be established with future multicenter studies. Further modules applicable to facial, chest, and urogenital surgery for both transgender men and women are undergoing revision and validation


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