Gender Identity Alters Gaze: The Use Of Eye Tracking To Assess Outcomes In Gender-Affirming Chest Surgery
Shanique A. Martin, BS1, Shane D. Morrison, MD, MS2, Thomas Satterwhite, MD3, Rahim Nazerali, MD, MHS4
1Stanford University School of Medicine, Palo Alto, CA, USA, 2Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine, Seattle, WA, USA, 3Align Surgical Associates, San Francisco, CA, USA, 4Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Palo Alto, CA, USA.
PURPOSE: Outcomes of gender-affirming chest surgery can be variable. Placement of nipple areolar complexes, orientation of scars and amount of tissue removed can drastically affect the aesthetic outcomes of these procedures. Currently, there is limited data on the perception of favorable aesthetic post-operative outcomes . Here, we compared attention and perception of aesthetic outcomes following masculinizing and feminizing gender-affirming chest surgery between people, based on their gender identity. METHODS: Thirty-two participants (14 transgender and 18 cisgender) were enrolled and shown sets of post-operative masculinized and feminized chests, along with unlabeled surgery na´ve control chest photos for each gender. Each participant was presented with a photo for 12 seconds and attention and gaze were captured using the Tobii X2 60 eye-tracking device. Participants also scored the perceived gender appearance of each photo on a 1-to-5 Likert-type scale ranging from feminine appearing to masculine appearing. RESULTS: Both cohorts consisted of majority female gender identifying participants. On average participants spent 7.03▒2.59 seconds fixated on the masculine chest photos and 6.91▒2.61 seconds fixated on feminine chest photos. Transgender participants spent more time evaluating the nipples in the masculinized photos (p = 0.004) yet there was no significant difference in fixation duration on the nipples for the feminized photos (p = 0.205). Cisgender participants were more likely to notice scars in both the masculinized (0.607 vs 0.462 sec, p = 0.026) and feminized (0.113 vs 0.056 sec, p = 0.012) photos, spending more time fixated on this feature (Figure 1). Notably, transgender participants on average perceived post-operative chests as more similar in appearance to the control chests for both masculinized (p=0.002) and feminized (p = 0.014) photos. CONCLUSION: Our results illustrate how gender identity can affect assessment and perception of the gender appearance of chests following gender-affirming top surgery. These demonstrated differences in areas of attention and ratings of chest gender appearance by gender identity indicate that observer characteristics should be considered in the assessment of gender-affirming chest surgery aesthetic outcome.
Figure 1. Comparison of total fixation duration (milliseconds) on nipples and scars for cisgender and transgender participants, for female/feminized (A) and male/masculinized (B) chests, demonstrating increased attention on the scars in both feminized and masculinized photos by cisgender participants. *Statistically significant (p<0.05).
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