Barriers to care and reproductive considerations for transmasculine gender affirming surgery


The transgender population is marginalized and underserved in medicine. Both clinicians and the transgender community agree that there are many barriers to accessing care, including lack of provider experience, reluctance to disclose, and financial barriers. The American College of Obstetrics and Gynecology provides some guidance, including the importance of discussing future fertility ; however, many clinicians feel inadequately prepared to care for patients seeking gender-affirming surgery. , Additionally, some clinicians voice concern the patient will express regret, particularly regarding future fertility.

Our objective was to identify barriers to care for transmasculine patients who desired gender-affirming surgery and to assess postprocedural regret along with satisfaction regarding future fertility.

Study Design

We distributed an institutional review board–approved anonymous survey in 2017 to all trans-masculine patients who were at least 18 years old and underwent a total hysterectomy at our institution from 2006 through 2016. The survey captured perceived barriers to care and clinical experience before and after surgery. We used the validated Decision Regret Scale to assess distress and remorse after surgery. Scores ranged from 0 to 100; higher scores indicate more regret. Data are presented as median (interquartile range) or frequency (proportion).


We distributed 91 surveys; 48 (53%) were completed. Respondents were aware of their gender by a median age of 14 (5–20) years and reported being certain by age 22 (18–27) years. Almost all participants (94%) reported taking testosterone at survey completion, but only 40% of them believed this was a prerequisite to surgery. The majority (75%) traveled less than 25 miles for their surgery, and 96% reported insurance covered the procedure. The median time between desiring the procedure and surgery was 7 (5–12) months.

Two respondents (4%) regretted having a total hysterectomy, and nearly all (94%) would make the same choice again ( Table 1 ). The median score on the Decision Regret Scale was 0.0 (0.0–5.0). Overall, respondents expressed high levels of satisfaction with the procedure; only 6% reported they were not satisfied with the procedure with respect to future fertility ( Table 1 ). Most (92%) did not have children at the time of surgery. Among all respondents, 67% reported they were counseled about future fertility options, and 21% reported they planned to have children after surgery. The most frequently cited barriers to surgical care were the stigma of being seen as a male patient at an obstetrics and gynecology practice (62.5%), insurance/financial support (49%), and taking time off from work (39%).

Table 1

Respondents’ perspectives regarding their decision to undergo female-to-male gender confirmation surgery

Perspectives Strongly agree/ agree Neutral Strongly disagree/ disagree
Regarding the decision to undergo hysterectomy and/or bilateral oophorectomies, how strongly do you agree or disagree with these statements?
It was the right decision a 47 (98) 0 (0) 0 (0)
I regret the choice that I made 2 (4) 1 (2) 45 (94)
I would go for the same choice if I had to do it again 45 (94) 2 (4) 1 (2)
The choice did me a lot of harm 2 (4) 2 (2) 45 (94)
The decision was a wise one 47 (98) 0 (0) 1 (2)

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Aug 21, 2020 | Posted by in GYNECOLOGY | Comments Off on Barriers to care and reproductive considerations for transmasculine gender affirming surgery

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