Best Practice HPI for Top Surgery in Transgender Patients
For a patient seeking top surgery who has met all WPATH requirements, the HPI should document gender identity using a two-step method (current gender identity first, then sex assigned at birth), preferred name and pronouns, duration and type of gender-affirming hormone therapy, mental health history including treatment of gender dysphoria, surgical goals and expectations, and a complete organ inventory relevant to perioperative care. 1
Essential Demographic and Identity Documentation
Document gender identity using the two-step question technique: First query the patient's current gender identity (male, female, transmale/transman/FTM, transfemale/transwoman/MTF, genderqueer/gender-non-conforming, or other), then separately document sex assigned at birth (male, female, or other). 1
- This method emphasizes the importance of gender identity over assigned birth sex from the patient's perspective and increases accurate identification of transgender patients compared to older one-step methods. 1
Record the patient's preferred name and pronouns as separate demographic variables distinct from legal name, ensuring this information is visible to all care team members to prevent use of "dead names" that could cause distress or safety concerns. 1
Document current legal sex as listed on insurance and state-issued identification, as this may differ from gender identity and affects billing processes. 1
Gender-Affirming Treatment History
Specify the type, duration, and current regimen of gender-affirming hormone therapy (testosterone for transmasculine individuals, estrogen/anti-androgens for transfeminine individuals), including start date, current dosages, route of administration, and prescribing provider. 1, 2
- Note that body composition changes significantly after 3-6 months of established hormone therapy, which affects perioperative pharmacokinetic considerations. 1
Document any previous gender-affirming surgeries with specific details about procedures performed, dates, surgical approach, and complications, as this information is critical for understanding current anatomy and future cancer screening needs. 1
Surgical Goals and Expectations
Record the patient's specific goals for top surgery, including desired chest contour, nipple placement preferences, and how this procedure aligns with their gender identity and expression. 3
- Gender-affirming surgery significantly improves body-gender congruence, body image satisfaction, and reduces depression and anxiety compared to no treatment. 3
Document the patient's understanding of surgical options: For transmasculine patients, this typically involves subcutaneous mastectomy with chest wall contouring; for transfeminine patients, breast augmentation may be pursued. 1
Mental Health and Psychosocial Assessment
Document the history of gender dysphoria, including onset, duration, severity, and how it has affected the patient's quality of life and daily functioning. 2, 4
Record current mental health status, including any history of depression, anxiety, or suicidality, and current treatment (therapy, medications). 3
- Note that withholding surgery until mental health conditions are fully resolved may not be optimal, as gender-affirming surgery itself reduces psychological distress. 3
Confirm WPATH eligibility criteria have been met: persistent, well-documented gender dysphoria; capacity to make informed decisions and consent; age of majority (or appropriate adolescent criteria); and any significant medical or mental health concerns are reasonably well-controlled. 2, 4
- Patient-centered readiness criteria focusing on factors that could impair surgical recovery may be more appropriate than strict adherence to all WPATH SOC-7 requirements, as they result in fewer barriers to care while optimizing outcomes. 5
Medical History and Organ Inventory
Conduct a complete organ inventory documenting current anatomy, as this is essential for appropriate perioperative care, cancer screening recommendations, and avoiding inappropriate clinical decision support alerts. 1
Document relevant medical comorbidities including cardiovascular disease, diabetes, bleeding disorders, and any conditions that may affect surgical candidacy or anesthetic management. 1
Record current medications beyond hormone therapy, including anticoagulants, psychiatric medications, and any supplements. 1
Social History and Support Systems
Document social transition status, including how long the patient has been living in their affirmed gender role, legal name change status, and identity document updates. 1, 4
Assess support systems including family acceptance, housing stability, employment status, and access to postoperative care assistance. 4
Screen for experiences of discrimination or trauma in healthcare settings, as 33% of transgender individuals report negative healthcare experiences and 23% avoid care due to fear of mistreatment. 1
Cancer Screening Considerations
For transmasculine patients planning top surgery: Discuss that residual breast tissue may remain after subcutaneous mastectomy, though the specific cancer risk is not well-studied. 1
Document plans for future cancer surveillance: After top surgery, most guidelines recommend yearly chest examinations rather than imaging, though some suggest ultrasound or MRI may be appropriate after thorough discussion. 1
Documentation Approach
Use trauma-informed, affirming language throughout the HPI, avoiding stigmatizing terms like "biologically male/female," "natal sex," or "transgenderism." 1
Use "assigned [male/female] at birth" or "recorded [male/female] at birth" rather than outdated terminology. 1
Ensure the patient's affirmed name and correct pronouns are used consistently throughout all documentation to prevent inadvertent "outing" or distress. 1