Gender Dysphoria in the OMFS Patient and Practitioner: Reflections and Realities
Author: Siddhant Kansal
Gender dysphoria is clinically defined as a ‘marked incongruence between one’s experienced/expressed gender and natal gender of at least 6 months in duration’ (1), with the presence of 2 or more of a list of other specified psychological manifestations.
This can often be confused with gender non-conformity. Gender non-conformity is not a clinical diagnosis, rather a pattern of behaviour exhibited in certain affected individuals where their behaviour and actions are not traditionally conforming to their assigned sex at birth. Gender dysphoria can usually be differentiated by the presence of distress along with the incongruence. (2)
In the field of OMFS it is very important to understand the differences of these diagnoses and how to recognise them. Some of the surgeries (especially those which interface with gender presentation) such as gender-affirming procedures within the field can often be necessary due to these indications, not to mention that some OMFS trainees and staff themselves may be living with these diagnoses themselves.
The Gap:
Despite increasing visibility of patients and staff of the LGBTQ community in healthcare settings, awareness and education of gender dysphoria within OMFS remains quite limited or completely absent, at undergraduate, foundation and specialist level. Massenburg et al. conducted a survey in 2018 of OMFS residents in the US nationally, which showed that only 30% of respondents had any exposure to care for transgender patients and about 40% believe that a fellowship in FGAS should be made available. (3)
Gender Dysphoria in Patients
Aesthetic and Functional Needs
Within the realm of facial gender-affirming surgery (FGAS), there are a multitude of procedures which may be conducted.
Chin Reduction (Genioplasty)
A transfeminine patient may ask for a sliding genioplasty (4) to reduce the prominence of her chin and to soften the facial contours, in keeping with her gender identity. This form of orthognathic surgery is heavily influenced by aesthetic results in mind, and not just the functionality of the result.
Mandibular Contouring
Gonial flare (5) refers to the outward protrusion of the mandibular angle of the jaw. In transfeminine patients, this often needs to be reduced. This may be done alongside a plastic surgeon or ENT surgeon if the muscles of mastication (especially the masseter) needs to be adjusted.
Forehead and Brow Contouring (6)
This is often led by plastics and craniofacial surgeons, as well as ENT surgeons if there is any sinus involvement.
In all these procedures, the main team is composed of OMFS, plastics and ENT surgeons. OMFS is useful for skeletal hard tissue modification, plastics concentrate on the soft tissue and ENT are important for anything involving the trachea (tracheal shaving), sinuses or vocal cords.
Challenges in Access
These procedures can help patients overcome their gender dysphoria, however, challenges such as NHS wait times can prevent patients from realising their gender identity and overcoming these issues (7). The private sector anecdotally dominates this market and financially this is not feasible for every patient.
Clinical Considerations
There are many relevant clinical considerations to take into account when it comes to such procedures. For example, they can require lots of follow up and psychological support from the MDT which can be quite resource intensive and time consuming (8), and could potentially drive up wait times. Anatomical differences can make surgeries more difficult to perform and plan and this can contribute to imperfect results or patient dissatisfaction.
A systematic review of genioplasty in FFS noted that preoperative 3D planning (e.g. CT reconstructions, virtual surgical planning) can enhance outcomes, but is costly, time-consuming, and has a steep learning curve — meaning that in less-resourced settings it may be omitted, raising the risk of suboptimal results. (9)
Looking Forward: The Role of Junior Trainees
Having spoken to some junior trainees in OMFS myself, this is a list of advice given about future considerations on how to improve awareness about this in the field.
Early Career Clinicians MUST lead the charge
The earlier you are in your career, the more time you have to decide on what style of practice you would like to enforce. Therefore you must start to recognise and value gender dysphoria in its clinical significance so you can pass this on to your trainees too.
Encourage reflective practice and allyship
Include trans health cases (or anonymised patient scenarios) in case-based discussions (CBDs), mini-CEX, or reflective portfolios.
You should then prompt trainees to reflect on issues like communication, consent, identity, and bias—not just clinical technique.
Audits, QIPs and curricula reform are key to better integration of psychological understanding of patients behind the clinical indications for surgery and so may be vital in clinicians educating themselves and their local units on gender dysphoria and non conformity.
References
(1) Nokoff NJ. Medical Interventions for Transgender Youth. [Updated 2022 Jan 19]. In: Feingold KR, Ahmed SF, Anawalt B, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Table 2. [DSM-5 Criteria for Gender Dysphoria ()]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK577212/table/pediat_transgender.T.dsm5_criteria_for_g/
(2) Guss C, Shumer D, Katz-Wise SL. Transgender and gender nonconforming adolescent care: psychosocial and medical considerations. Curr Opin Pediatr. 2015 Aug;27(4):421-6. doi: 10.1097/MOP.0000000000000240. PMID: 26087416; PMCID: PMC4522917.
(3) Massenburg, Benjamin B. MD; Morrison, Shane D. MD, MS; Rashidi, Vania; Miller, Craig MD; Grant, David W. MD, MSc; Crowe, Christopher S. MD; Velasquez, Nathalia MD; Shinn, Justin R. MD; Kuperstock, Jacob E. MD; Galaiya, Deepa J. MD; Chaiet, Scott R. MD, MBA; Bhrany, Amit D. MD. Educational Exposure to Transgender Patient Care in Otolaryngology Training. Journal of Craniofacial Surgery 29(5):p 1252-1257, July 2018. | DOI: 10.1097/SCS.0000000000004609
(4) Degala S, Choudhary A. Genioplasty - A Review. Niger J Clin Pract. 2024 Jun 1;27(6):683-695. doi: 10.4103/njcp.njcp_24_24. Epub 2024 Jun 29. PMID: 38943291.
(5) Shree B, Soni S, Sharma SK, Handge K, Kumar A, Das SS, Puri N. Analytical Study of Mandible: Prerequisite for Sex Determination. J Pharm Bioallied Sci. 2023 Jul;15(Suppl 2):S1215-S1217. doi: 10.4103/jpbs.jpbs_155_23. Epub 2023 Jul 11. PMID: 37694097; PMCID: PMC10485538
(6) Khetpal S, Dahoud F, Elias A, Sasson DC, Wolfe EM, Lee JC. Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients. Aesthetic Plast Surg. 2024 Sep;48(18):3577-3588. doi: 10.1007/s00266-024-04143-6. Epub 2024 Jun 10. PMID: 38858245; PMCID: PMC11455672.
(7) Alper DP, Almeida MN, Hu KG, De Baun HM, Hosseini H, Williams MCG, Salib A, Shah J, Persing JA, Alperovich M. Quantifying Facial Feminization Surgery's Impact: Focus on Patient Facial Satisfaction. Plast Reconstr Surg Glob Open. 2023 Nov 3;11(11):e5366. doi: 10.1097/GOX.0000000000005366. PMID: 37928639; PMCID: PMC10624460.
(8) Van Boerum MS, Salibian AA, Bluebond-Langner R, Agarwal C. Chest and facial surgery for the transgender patient. Transl Androl Urol. 2019 Jun;8(3):219-227. doi: 10.21037/tau.2019.06.18. PMID: 31380228; PMCID: PMC6626311.
(9) Gursky AK, Chinta SR, Wyatt HP, Belisario MN, Shah AR, Kantar RS, Rodriguez ED. A Comprehensive Analysis of Genioplasty in Facial Feminization Surgery: A Systematic Review and Institutional Cohort Study. J Clin Med. 2024 Dec 31;14(1):182. doi: 10.3390/jcm14010182. PMID: 39797264; PMCID: PMC11721636.
