The Role of a Multidisciplinary Approach in Gender Affirmation Surgery: What to Expect and Where Are We Currently?

Round 1

Reviewer 1 Report (New Reviewer)

I commend you on your manuscript.  The trans population will greatly benefit from a combined multidisciplinary effort of the various practitioners outlined.

The content is relevant and informative.  However, the grammatical structure needs revision.  The manuscript does not read smoothly.  I would recommend you further collaborate with your peers to improve the flow of the language. 

Author Response

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Author Response File: Author Response.docx

Reviewer 2 Report (New Reviewer)

The authors provide a detailed, broad overview of gender affirming surgery provision. It is ambitious in scope and covers much relevant territory. There are some language usage that I interpret as errors, which may be due to translation difficulty or differing cultural context (Comment section 1). I have provided my perspectives and at times citations on why I believe this language is not ideal. I have provided further edits to language which are not related to underlying content in the section, “Line Edits,” which is only meant to aid the authors in finalizing the grammar and style of the article.

I believe the article would be stronger if greater specific expert clinical perspective was provided, rather than simply reviewing other reviews and expert opinion articles. Section 4 is among the better portions of the article, providing brief yet rich detail on perioperative medical management. I have provided suggestions where I see opportunity for this specific expert perspective (Comment section 2).

I am deeply concerned with the authors representation of the literature regarding persistence of transgender identity from childhood into adulthood, with access to gender affirming hormones for adolescent minors, and of regret after surgery (Comment section 3). This section should not be published in its current form.  I have provided specific, recent citations which contradict the statements I find most concerning regarding long term outcomes of gender affirming surgery and adolescent minor access to gender affirming care. Additionally, there is a large gap in the authors literature review related to the concept of “Gatekeeping” or overly stringent processes of approval which delays or denies access to gender affirming medical treatments. 

I find much value in well framed review articles, and I would look forward to providing further review of an article from the authors which incorporates the author's specific experience and perspective. The authors present many aspects of the review in sensitive and thorough ways. In the present form, however, I fear that this review in part functions to reify outdated and harmful understandings of transgender medical care.

Comments:
1. Potentially outdated, inaccurate, or vague language. 

1A. Table 1:  What was the source of these definitions? As these are social categories and terms, I make no claim that my own context (USA, urban, english-speaking, white) provides the correct definition for these terms, however the authors use several which appear anachronistic to me. If they are terms that are understood or preferred within Italian transgender community, then please specify that and provide some citation.

-Male-To-Female: this term is outdated and no longer community preferred within my context. Other articles in the academic literature have noted the same (ie, Berli et al 2017  doi:10.1001/jamasurg.2016.5549). The definition the authors provide reads as describing “transfeminine” to me, an umbrella term for those who were assigned male at birth and now identify as feminine nonbinary and/or genderqueer and/or as transgender women. Anyone in this group may or may not access the medical interventions described, as the authors expertly cover. If changing this term to transfeminine, which would be my suggestion, or transgender women, which may also be accurate in context, please also change heading in table 2, 3, and 4.

-Female-To-Male: see above, this reads as describing “transmasculine” to me. I would suggest the authors use “transmasculine.” If changing this term, please also change heading in table 2, 3, and 4. 

-Transvestism is outdated and the description reads as incomplete to me. I would specify that this may include people who do not identify as transgender (table 2 in berli et al 2017)

-Transition may also be social, only, changing name and pronouns legally and socially, changing manner of dress and other social gender signifiers. Please add this to medical interventions “(through hormones and surgery)”. (see Berli et al 2017)

1B. Table 2. In section on breast/chest surgery, “male chest” is used. Males sometimes have normative variations in chest anatomy which may not be the goal of gender affirming mastectomy. In addition there are people assigned female at birth who identify as male, but may not desire mastectomy. If their identity is male their chest is male. I would suggest instead the authors use a more descriptive term such as “creation of a flat chest”

1C. Line 36 and Line 295, “GAS is the last step”. It is this reviewer's opinion that this is an overly linear definition of transition and medical care access. For instance, WPATH’s standards of care explicitly state that gender affirming mastectomy can be performed prior to, or in absence of hormone therapy (as authors cover in table 3). So for a patient who chooses mastectomy as their first treatment, and then later testosterone, this would not be accurate. Patients may also choose surgery as a “last step” and continue to need further gender affirming care. This linear logic is connected to the concept of “gatekeeping” I would like to see the authors address.
1D. Line 383 - Biological sex is not two binary discrete categories, as pointed out by the authors in the section on lab values. I would instead recommend “Assigned sex at birth”

2. Insufficient discussion of expert clinical perspective and application to local context.

2a. The authors review the criterion that twelve months must be spent living in the identified gender prior to genital surgery. Who defines what counts as living in the identified gender? How is it assessed? Have the authors ever encountered a patient who sought treatment despite not meeting this requirement? This is connected to the concept of “gatekeeping” which I would like to see the authors address.
2b. Line 291-293. I appreciate that all patients do, at times, have unrealistic expectations, and that trans patients have specific manifestations of this. I agree that this should be discussed explicitly to promote autonomy. However, that this is the only consideration discussed under the heading of autonomy reads as pathologizing to me (ie, trans people are unrealistic). I would challenge the authors to describe additional factors or considerations which help to promote the autonomy of trans people undergoing GAS, looking to socially imposed barriers to care, perhaps.

2c. Section 6.2. Do the authors believe that regret can be entirely mitigated? How do the authors compare rate regret after say, breast reconstruction following oncologic mastectomy, to gender affirming reconstructive surgery? If regret is a “Type 1 error” (false alarm), then what about the corollary, “Type 2 error” (false negative)? I would like the authors to both review a wider array of the bioethics literature on this topic (ie, https://doi.org/10.1016/j.socscimed.2021.114477 or https://doi.org/10.1037/sgd0000504 ) and to consider the balance between prevention of regret and “gatekeeping” wherin barriers to care prevent or delay access to treatment for those who would benefit. How is this balance managed in their practice?

2d. The authors mention that sterilization is not required in the US. Is it a requirement in Italy? If yes, why? Are the authors aware that transgender people have been granted financial reparations for prior forced sterilization requirements in order to access legal transition in sweden? (https://doi.org/10.1093/hrlr/ngz026)
2e. Gender dysphoria. Throughout the text the authors use gender dysphoria to refer to the clinical diagnosis used to provide access to medical transition. Gender incongruence is the diagnosis that was adopted into ICD 11 after international field testing, which notably does not require symptomatic distress and dysfunction (https://doi.org/10.1016/j.ijchp.2021.100281).  Why continue to use gender dysphoria in this review article? Do the authors use the DSM-V diagnostic criteria in their practice, the ICD-10, or the ICD-11?

3. Inaccurate representation of the current literature

3a. Line 133 a “certifcated surgeon” recommendation from WPATH is mentioned. WPATH has specifically stated they never intend to define any certifying criteria for gender affirming surgeons (https://www.wpath.org/media/cms/Documents/Public%20Policies/2018/5_May/WPATH%20Response%20to%20Open%20Letter.pdf). Please clarify what is meant here, or otherwise be more specific about surgeon preparation and education to provide gender affirming care. 

3b. Lines 316-317, Line 341-343. I may be misunderstanding the authors, but I read this sentence as stating that only 10%-20% of gender dysphoric youth will continue to experience gender dysphoria in adolescence. While this figure is widely cited by those hostile to gender affirming care, it has been thoroughly rebutted (https://doi.org/10.1080/15532739.2018.1456390) as inappropriately including youth who never professed a transgender identity, among other methodological issues. I am also not sure the references provided even state this figure. Please describe the source for this figure. The subsequent lines (317-319) also imply that mismanagement in the form of offering medical treatment is what has been documented to lead to suicidality/self harm. This is the opposite of my interpretation of the literature (ie, https://doi.org/10.1016/j.jadohealth.2021.10.036) where lack of access to medical treatments (hormones, etc) among youth is linked to suicidality/self harm, not active medical management.

3c. Line 320. What law forbids adolescent minors from accessing hormone therapy? Like any other medical care adolescent minors access, they either are assessed for competency for that specific decision (ie Australia https://doi.org/10.5694/mja17.01044) or they provide informed assent, while parents or legal guardians provide informed consent on their behalf. How do hypogonadal children get hormone therapy? Parents provide informed consent for treatment. This is also how gender affirming hormones are managed in the United States for adolescent minors. Is there a law against this model of care in Italy?
3d. Lines 412-413. The authors cite a single study from 2011 which shows transgender people after surgical treatment have worse health outcomes from the general population. The cited study is not of a design which is able to state the causal effect of GAS on outcomes observed, only describes outcomes. Untreated trans people may have even worse outcomes. There are a plethora of recent meta-analysis and systematic reviews which show differing outcomes than described by the authors with this single citation (ie https://doi.org/10.1080/19359705.2021.2016537, https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2038334, https://doi.org/10.1007/s11154-018-9459-y ).

Line Edits
I have provided edits for grammar and style, however further English language editing is needed.

General formatting:
I find the number of paragraph breaks confusing. I would recommend consolidating into fewer paragraphs.
Title:
The last phrase of the title “where we stay” reads as grammatically incorrect. From context, I would expect the authors mean “where we are” or perhaps “where we are currently”
Abstract:
“Bodily change their sexual characteristics and” -> “change their bodily sexual characteristics”
“Who wish to and who the surgical criteria” -> “who wish to, and who meet the surgical criteria”
Main Text:
“Transgenders” this should read “Transgender people”, transgender is an adjective not a noun.
Table 1 - see minor comments 1a.
“Clinical assessment of individuals with gender dysphoria it involves” -> “clinical assessment of gender dysphoria involves"
Line 66-67 “transgender people health” -> “transgender people’s health”
Line 98 is confusingly worded
Line 129-130 is confusingly worded: “of a young” -> “of a young person”
Line 146 is confusingly worded
Table 4 - the headings of the criteria are repeated from table 3, i believe they are supposed to read phalloplasty, metoidioplasty, vaginoplasty, etc
Lines 197-198 are confusingly worded, “impone”?
Line 226 - mandatories -> mandatory
Line 249- I would say “name” or “preferred name” and not noun, but again this term may be more specific to the authors’ cultural context
Line 275- “just not like the only choice” -> “and not a mandated choice”
Line 365- too informal, I suggest “especially as we’re talking about” -> “especially as patients are”

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report (Previous Reviewer 1)

At the outset, I must congratulate the authors on their work. I had reviewed the previous version of the manuscript submitted by the authors. The manuscript at this submission is significantly better and has improved scientific quality. The work has merit. I have a few comments:

-The role of endocrinologists could be elaborated further related to the details of hormonal therapy given 

-Few Grammatical errors are still present, and need correction...

line 98: :Moreover, about genital surgery it is require"

line 113: "significant in counseling of these surgeries"

line 406: "Despite GAS has been"

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 1 Report (New Reviewer)

I have reviewed the manuscript and agree that it is greatly improved and can be submitted for publication.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

At the outset, I would like to congratulate the authors for a well-written review article on this important subject. The subject of the article is extremely important and will be of interest to our readers. However, I have the following comments:

Introduction: The hypothesis behind conducting this review is not clear in this section. Please add 2-3 lines on the hypothesis at the end of the Introduction section.

-The authors have highlighted the role of surgeons, anesthetists, and nurses in particular. But the role of mental health professionals and endocrinologists needs to be elaborated upon.

-Section no 3 (Relationship of surgeons with mental healthcare professionals, hormone- 82 prescribing physicians, and patients) is very detailed. It can be trimmed.

The article also requires extensive spelling and grammatical revisions. A few of the mistakes have
been pointed out as follows:
Line 33- grammar error-Although not all transgenders choose to undergo GASs
Line 61- grammar error- whose purpose is to promote, for
Line66- grammar error- Through the 7 versions
Line 72- spell error- people through safe and effective
Line 75- grammar error- WPATH is aware of that most of the
Line 81- grammar error-and adapt to local realities
Line 93- has many grammar errors
Line 108- spell error- significant in counseling of these
Line 270- Spell error- ‘choice’
Line 275- grammar error- Finally, the nurses take part in the delicate

Author Response

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Author Response File: Author Response.docx

Reviewer 2 Report

Thank you for submitting your article to our journal.  The paper represents a good overall review of Wpath criteria and different medical disciplines that play an important role in the care of the transgender patient.

The study does lack specific data or recommendations for multidisciplinary teams looking to develop a center.

 It would have been helpful for the authors to incorporate their specific protocol when patients are seeking top or bottom surgery.
It would have been helpful to the reader to understand the preoperative education requirements, and the sequence for specific consultations with other specialties involved in the care of the patient.
Including a table with each specialty recommendations when taking care for the transgender patient after surgery would be helpful at one point in your institution to you include different specialties, what is the role of social worker, navigation and case management as many of this patients encounter many challenges before and after surgery.

could you comment on specific strategies to avoid regret and in recommendations to manage patient's who have suffered from regret after surgery.

Author Response

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Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The authors have addressed all my comments in the revised manuscript. The overall scientific quality of the manuscript has improved significantly. Thanks for submitting your work to the journal.

Reviewer 2 Report

The authors reviewed the paper as requested but they did not provide any other novel or informative information besides what is already published.

I don't think this paper should be accepted but it depends on your journal standards.