Perspective: Gender-Affirming Care and a Call to Action

Isaac L. Alter, AB, Anaïs Rameau, MD, MS, MPhil, AJ Flaherty, MD, Erynne A. Faucett, MD, Brandon J. Baird, MD, Noriko Yoshikawa, MD, Minka L. Schofield, MD, MPH, and Brian A. Nuyen, MD

Transgender and gender non-conforming (TGNC) individuals encounter rising legislative actions that impede access to gender-affirming healthcare despite its significant impact on improving quality of life. Multiple major medical organizations, including the American Medical Association¹ and the American Academy of Pediatrics,² as well as the American College of Obstetricians and Gynecologists,³ the American College of Physicians,⁴ the American Urological Association,⁵ the Endocrine Society,⁶ the World Health Organization,⁷ and many more,⁸ have affirmed their support via formal position statements in favor of the provision of gender-affirming care to both TGNC youth and adults. However, many surgical societies have yet to do so. Plastic surgery specialties, represented by the American Society of Plastic Surgeons (ASPS), have publicly stated support for gender-affirming care within other released statements, though remaining guarded regarding surgical care for adolescents.^9-11 Notably, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) recently published a Position Statement in support of gender-affirming voice care.¹² 

The AAO-HNS Position Statement rightfully emphasizes the importance of gender-affirming voice treatment. However, future statements recognizing the full spectrum of evidence-based gender-affirming surgical treatment and novel research to advance TGNC facial and vocal care are needed. As policymakers seek medical guidance on head and neck gender-affirming care from experts, the AAO-HNS has the opportunity to expand its stance even further on this crucial issue to firmly support not only vocal gender-affirmation treatment but also gender-affirming facial surgery and the full spectrum of gender-affirming care that can be life-saving for all TGNC individuals. 

While many legislative actions have been focused on the restriction of gender-affirming care for children, increasing efforts by lawmakers have also attempted to extend the reach to adults.¹³ Some states have raised the age cutoff from 18 to 21 or 26, while others have directed Medicaid to no longer cover certain forms of gender-affirming care. In 2023, Missouri sought to effectively ban gender-affirming treatment by enacting such substantial regulatory hurdles—including 18 months of psychological assessment—that access to these services would become a potentially insurmountable obstacle to care. Given that the self-reported number of TGNC individuals in the United States is rising—with more than 5% of adults under 30 identifying as transgender or non-binary—there is an urgent need to secure these individuals’ rights to receive healthcare in the face of these unfavorable legislative actions.¹⁴

TGNC patients face significant discrimination and stigma in American society, which extend into their efforts to engage with the healthcare system, where they face substantial barriers to receiving both general and gender-affirming care.¹⁵ Many of the concerns among TGNC individuals can be grouped into lack of safety and acceptance; otolaryngologists play an integral role in relieving these concerns by providing gender-affirming care that establishes congruence between a patient’s gender identity and how they appear and sound. The amount of gender information in the face and voice, as well as the health impacts of facial and vocal gender dysphoria, are significant,^16,17 solidifying the importance of otolaryngologists, as well as facial plastic surgeons and laryngologist subspecialists. The research behind the effectiveness of gender-affirming healthcare is substantial. 

A recent study demonstrated the sizable impact of facial feminization surgery in improving nearly every measured outcome related to mental health and quality of life.¹⁸ Given that rates of suicide attempts among transgender individuals may be as high as 50% and that these individuals face high rates of assault based on gender presentation,¹⁹ gender-affirming care can be a life-saving intervention. The research and clinical care behind head and neck gender affirmation should validate the need for a broader official position and continued advocacy from the AAO-HNS and its members on these critical issues, as many of its members are already in the trenches providing this essential care for TGNC patients. 

Lastly, diversity, equity, and inclusion have been included as key facets of the mission of the AAO-HNS, which has acknowledged that increasing the diversity of its workforce will lead to improved outcomes for patients of all backgrounds.²⁰ A public position by the Academy supporting all forms of TGNC healthcare would be wholly consistent with this stated goal. Policies and positions inform the cultures of communities, and the cultural impact on LGBTQIA+ medical trainees seeking a specialty that advocates for the needs of the TGNC community cannot be overstated. An important message of support would also be sent to practicing LGBTQIA+ otolaryngologists. 

Medically and ethically, otolaryngologists’ care and advocacy for the marginalized TGNC community are compellingly needed. The evidence and science are clear that without gender-affirming care, TGNC individuals will have poorer quality of life, are likely to face gender-based violence, and may choose to end their lives. We recognize our Academy’s recent statement and call upon our colleagues to continue to publicly affirm the right of TGNC people to life-improving healthcare. 

References

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