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Establishing the First Gender Surgery Center in an American Children's Hospital
David A. Diamond, MD, Elizabeth R. Boskey, Ph.D., M.P.H., L.I.C.S.W., Amir H. Taghinia, MD, Oren Ganor, MD.
Boston Children's Hospital, Boston, MA, USA.

Establishing the First Gender Surgery Center in an American Children's Hospital
Introduction: in 2007 our Children's Hospital established the Gender Management Service (GeMS) program. Originally intended for the multidisciplinary management of children with DSD's, it also attracted a growing number of transgender youth, whose management was purely medical and psychological. Over the past decade the transgender patient population has exploded, and concerns about unmet need for gender affirmation surgeries led to the development of a gender surgery center (GSC) for adolescents and young adults in 2018.
Patients and methods: The program provides multidisciplinary evaluation (Urology, Plastics, Psychology, Nursing, Social Work) and referral services, chest surgeries for transition age adolescents (>15) and genital surgery for young adults (18-33). Within the first 18 months, the center completed 268 patient evaluations and performed six radial forearm flap phalloplasties (F to M), one vaginoplasty (M to F), one testicular prosthesis implantation and 72 chest surgeries. In addition, complications from other programs were referred to the GSC, including urethral fistulae and strictures, retained vaginal segments and malpositioned testicular prostheses all of which resulted in surgical correction.
Results: The 7 patients operated on primarily at our facility ultimately had favorable outcomes although, to date, four phalloplasty patients (57%) required correction of complications: one urethrocutaneous fistula closure, two urethral stricture repairs and one urethral meatoplasty with skin grafting. The inherited complications have been successfully corrected with one retained vaginal segment awaiting repair.
Conclusions: There are unique challenges in performing gender affirmation surgery in the pediatric setting. In addition to the expected surgical complications, in particular associated with radial forearm flap phalloplasty, the concerns include determination of age guidelines for specific procedures, the need for parental consent and sterilization of minors with fertility preservation options. However, it can be appropriate and a source of patient satisfaction for pediatric institutions to provide surgical gender affirmation to older adolescent and young adult patients as part of a continuum of transgender care, if the necessary infrastructure is provided.


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