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On June 15 in a 6-3 decision, the U.S. Supreme Court held that the protections enshrined under Title VII of the 1964 Civil Rights Act apply to discrimination based on sexual identity and gender orientation. Continuing in the recent tradition of upholding and protecting the rights of gay and transgender people, the Court signaled a move that may transform the legal condition of people whose sexual orientation or gender identity don’t conform to traditionally held beliefs. Justice Neil Gorsuch, writing for the majority, stated, “An employer who fires an individual merely for being gay or transgender defies the law.”
Much is at stake in the current climate of consternation and fear surrounding the COVID-19 pandemic, the social justice movement related to police violence and the death of George Floyd, and the potential economic reverberations of these two events. This legal action put in place workplace protections that may affect millions of employees across the country.
The Supreme Court often moves in accordance with public opinion; however, the medical fate of LGBTQ individuals remains murky. On June 12, three days before the aforementioned Supreme Court decision, the Department of Health and Human Services (HHS) released a rule change that reversed healthcare and health insurance nondiscrimination protections for LGBTQ people. Stating that the previous interpretation (2016 Rule) of section 1557 of the Affordable Care Act “exceeded its authority in promulgating parts of the legislation,” the HHS vacated and terminated some of those protections. The rule change is expected to save insurance companies and hospitals $2.9 billion over five years, but it restricts essential care for transgender individuals.
Changing Public Opinions
Estimated to include over 1.9 million individuals in the U.S., the transgender population is one of the most marginalized in our society. The 2015 U.S. Transgender Survey for the National Center for Transgender Equality found disturbing trends within the transgender community: Of the 28,000 transgender people completing the survey, 54% reported verbal harassment, 29% lived in poverty, 33% reported negative experiences with healthcare providers, and 40% had attempted suicide (approximately nine times the 4.6% national rate). While the majority of respondents expressed a desire for access to gender-affirming care, only 49% had transitioned medically and 25% had undergone surgical transition. This underlines the concept of unmet needs for transpeople, as supported by temporal trends in increasing interest in and search for transgender services (J Craniofac Surg. 2020;31:606-607).
Otolaryngologists are among the healthcare providers most available to provide medical and surgical services for transgender patients interested in making their bodies more closely match their internal sense of gender identity.
Public opinion regarding transgender rights has been evolving quickly. Though the political squabbles regarding bathroom access for transgender people seem to have occurred only yesterday, recent surveys reveal a striking change in opinion. An Ipsos poll of 16 countries, including the U.S. and Canada, showed that 70% of respondents believe that governments should do more to protect transgender people, and 69% of respondents believed that transgender people should be allowed to undergo surgery so that their bodies match their identities.
Polls limited to the United States show similar trends. A recent Public Religion Research Institute survey revealed that 62% of Americans state that they have become more supportive of transgender rights compared with five years ago. Majorities of every age and major religious group also report becoming more supportive of transgender rights (“America’s Growing Support for Transgender Rights,” June 11, 2019).
A Revolution of Understanding
While transgender people were once stigmatized with a diagnosis of gender identity disorder, U.S. society has undergone a revolution of understanding regarding the psychological travails and psychosocial challenges they face. The American Psychiatric Association provided an update to its diagnostic manual in 2012, replacing “gender identity disorder” with “gender dysphoria.” This change in wording attempts to incorporate the potential negative feelings and psychosocial challenges of being born into a body that doesn’t match one’s strong internal sense of gender identity. Individuals with gender dysphoria frequently face a reality filled with lack of acceptance, harassment, professional and social roadblocks, and intimate partner violence.
The underlying logic for the treatment of gender dysphoria rests on several presuppositions: 1) The person’s body is wrongly gendered in relation to a self-identified gender identity; 2) The wrong gender is a series of bodily properties that can be identified and changed to what’s considered normal for the chosen gender; and 3) The conflict between “self” and “body” cannot be resolved through psychotherapy alone (Sex Relatsh Ther. 2014;29:154–214). The challenge for insurance coverage arises through the conflict between what procedures are perceived as cosmetic surgery versus those deemed medically necessary. The ethics and financial impact of these policy and treatment decisions are both complex and beyond the scope of this article.
Through careful study and analysis, researchers have come to recognize many facial features as important components of overall facial attractiveness. Lisa Welling, PhD, associate professor of psychology at Oakland University in Rochester, Mich., has studied and published extensively on factors that affect a person’s perception, evolutionary approaches to mate choice, individual differences in preferences, and other aspects of human sexual behavior. Self-resemblance, apparent health, youthfulness, averageness, symmetry, and sexual dimorphism are all critical components of facial gender affirmation. Each of these facets can undergo modulation in carefully selected and assessed individuals to enhance facial masculinization or feminization.
Unfortunately, relatively few otolaryngologists get training or instruction in caring for this underserved population.
Transgender Care and Otolaryngology
Otolaryngologists are among the physicians most available to provide medical and surgical services for transgender patients interested in making their bodies more closely match their internal gender identity, including voice therapy, chondrolaryngoplasty (aka tracheal shave), facial implants, mandible shaving, rhinoplasty, and frontal sinus manipulations. Scott Chaiet, MD, MBA, an assistant professor at the University of Wisconsin in Madison, has thoroughly documented the role of otolaryngologists in providing care for transgender people, particularly if insurance coverage is provided (Otolaryngol–Head Neck Surg. 2018;158:974–976).
Although we work at the University of California at San Francisco (UCSF), we believe the university has been at the forefront in providing access to care for patients seeking voice care through its Voice and Swallowing Center, headed by Clark Rosen, MD, and facial gender-affirming surgery through its division of facial plastic and reconstructive surgery. Providing multidisciplinary care alongside the division of plastic surgery and the departments of dermatology, endocrinology, gynecology, and psychiatry, UCSF aims to provide complete medical and surgical care for transpeople.
The World Professional Association for Transgender Health acts as a global advocate for the representation and care of transgender people. Its website offers a wealth of information, including standards of care for health professionals, public policy statements, and a transgender health-friendly physician locator. It’s an invaluable resource for any medical center or physician group interested in offering care to transgender individuals.
Facial gender-affirming surgery employs many techniques that are typically associated with cash-pay aesthetic surgery. In order to overcome the visual stereotyping that frequently elicits scorn and misunderstanding in public, transgender female faces may need to undergo extensive surgical manipulation. This usually takes the form of hairline advancements, brow lifts, eyelid surgery (blepharoplasty), rhinoplasty, cheek fat grafting and/or facial implant placement, chondrolaryngoplasty, and jaw reductive surgery. Although typically considered aesthetic plastic surgery, when artfully performed in a thoughtful and effective manner, facial feminization surgery is able to authentically change a patient’s outward appearance from masculine to feminine in a majority of cases. Given the importance of youthfulness in perceived femininity, face and/or neck lifting performed with fat grafting or cheek implantation in transgender females older than 50 is an invaluable tool in achieving overall facial femininization.
Facial masculinization treatment as a field of endeavor shouldn’t be ignored. Transgender men are, of course, equally deserving of care and consideration, but their mechanism of physical transformation most often doesn’t require surgery. The provision of hormone therapy usually suffices to bring about the physical changes associated with social acceptance of masculinity. When facial surgery is indicated, it usually takes the form of craniomaxillofacial enlarging procedures, such as facial implantation and volumization, as well as potential laryngeal altering procedures (rib graft augmentation).
Quality-of-life outcomes associated with gender reassignment surgery (aka “bottom surgery”) and facial feminization surgery have been investigated. In 2016, Jeffrey Spiegel, MD, one of the pioneers in facial gender affirming surgery, published a paper demonstrating a statistically significant improvement in quality of life among 247 transgender females who had undergone facial gender-affirming surgery (Qual Life Res. 2010;19:1019-1024). Many ongoing studies are looking at the same issues and searching for answers about the true benefits of surgical and medical care for this population. A new patient-reported outcome instrument, the GENDER-Q, is currently in development as part of the validated quality-of-life, patient-reported outcomes measures available through www.qportfolio.org.
Gender-Affirming Surgical Training
Unfortunately, relatively few otolaryngologists get training or instruction in caring for this underserved population. A recent survey of 527 Accreditation Council for Graduate Medical Education programs in dermatology, facial plastic surgery, plastic surgery, and oculoplastic surgery found a very low rate of trainee exposure to minimally invasive gender-affirming surgical procedures—only 10 programs reported trainee exposure. Although the low response rate to the surveys—only 7%—limits the generalizability of the results, it likely reveals the paucity of training and exposure available to the fields most likely to perform these services.
Unquestionably, the field of gender-affirming surgical care of transgender individuals is growing as access to and interest in it increase. While controversy regarding insurance coverage, government support, and societal acceptance will continue, understanding of the transgender community will improve. Although frustrating at times in its pace, acceptance of and protection for marginalized groups is progressing. Dr. Martin Luther King, Jr., once stated, “If you can’t fly, then run, if you can’t run, then walk, if you can’t walk, then crawl, but whatever you do, you have to keep moving forward.”
Dr. P. Daniel Knott is director of facial cosmetic and reconstructive surgery within otolaryngology–head and neck surgery at UCSF. Dr. Rahul Seth is an associate professor in the facial plastic and aesthetic surgery subdivision of the otolaryngology-head and neck surgery department at UCSF.