The Current State And Future Of Renewable Energy In The Us

Introduction

Gender dysphoria is defined as a difference between one’s experienced or expressed gender and their assigned sex at birth. The significant distress that results from gender dysphoria can lead to severe psychosocial sequelae. It is estimated that 0.5 to 0.9 percent of the U.S. population has some degree of gender dysphoria and there are at least 25 million transgender people worldwide. The number of patients seeking medical or surgical gender-affirmation treatment may rise given the increasing social awareness, decreasing stigma surrounding transgender individuals. This increase will result in a greater need for providers experienced in the management of transgender patients. References go at the end per JOMS style guidelines.

Gender-affirmation (this is a strange word – it is not self-evident what it means) management requires a multi-specialty patient care team comprised of primary care physicians and endocrinologists with experience in transgender care and hormonal therapy, mental health care providers, providers specialized in the delivery of gynecologic, urologic, reproductive care, and speech therapy6, as well as surgical specialists experienced in gender-affirmation surgery. The role of gender-affirmation surgery for gender dysphoria is documented widely in the literature. Providers managing the care of those who are considering gender-affirmation surgery should, however, take into account ones’ eligibility and readiness for such surgery through the World Professional Association for Transgender Health Standards of Care6.

Despite the growing need for multidisciplinary care, the social and institutional stigma against transgender individuals results in discrimination in the health care field. Education on the care of sexual and gender minority patients has been found to be lacking not only in medical education and medical residency programs, but in pre-doctoral dental education. This results in providers who are uncomfortable with the delivery of care to transgender patients.

Gender-affirmation surgery of the head and neck includes pitch alteration surgery and facial feminization and masculinization procedures which are designed to change features of the brow, forehead, eyes, cheeks, nose, lips, mandible, skin and soft tissue. Oral and maxillofacial surgeons are uniquely qualified to perform facial plastic surgery procedures involving the functional and aesthetic aspects of the face, mouth, teeth and jaws. Additionally, oral and maxillofacial surgeons may pursue fellowship training in facial plastic surgery to enhance their surgical expertise with soft tissue manipulation of the face. Despite this, there has been little research in the field of surgical management of transgender patients in the oral and maxillofacial surgery literature. The literature is limited to the review of and experience with facial feminization procedures34-37 and an assessment of the impact on quality of life and delivery of care for patients undergoing facial feminization38. Given the need for surgeons trained in facial plastic surgery to manage transgender patients and perform gender-affirmation surgery, it is prudent to determine the state of transgender patient care and education in oral and maxillofacial surgery (OMS) residency training programs.

The purpose of this study was to evaluate OMS residents' exposure to transgender patient care and their perceived importance of transgender surgical education. The authors hypothesized that OMS residents have limited exposure to transgender patient care but perceive such exposure as an important component of their surgical training. The specific aims were: 1) to determine the current state of transgender-related education in U.S. OMS residency programs and 2) to evaluate trainee perceptions regarding the importance of such training.

Materials and Methods

Study design/Sample:

The investigators designed and implemented an institutional IRB-approved cross-sectional study (University of Washington IRB #50777). The study population was composed of all trainees enrolled in OMS residency training programs based in the United States between July 1, 2017 and June 30, 2018 that were accredited by the Committee on Dental Accreditation (CODA). Subjects were included if they were a non-categorical intern, or a resident pursuing an OMS certificate or a combined MD degree-OMS certificate. Subjects were excluded if they did not wish to participate in the study.

Survey Instrument: Data collection was performed using a modified version of a previously standardized and reliable survey instrument used in the assessment of lesbian, gay, bisexual, and transgender patient education in medical school curricula. Additional iterations of the survey have been used to assess resident exposure to transgender patient care in urology and plastic and reconstructive surgery residency programs. The survey instrument was modified for use with OMS trainees with input from a department chair in oral and maxillofacial surgery. Five OMS residents were selected to pilot the instrument, and their feedback was incorporated into the final survey.

The anonymous 9-question survey (Figure 1) consisted of a cover page followed by four demographics-related questions and five questions related to transgender education and related clinical experience in residency. As terminology in transgender patient care is changing, gender-affirmation was referred to as gender-confirmation in our survey. Demographic information included gender, program name, program type, and postgraduate year. The subject’s institutional affiliation was used to assign a geographic region but was not used in any other analyses. The five questions related to transgender education and related clinical experience in residency addressed the subject’s exposure to transgender patients, aspects of transgender care covered during residency, perceived importance of transgender patient care, and the need for advanced fellowship opportunities in gender-affirming surgery.

The survey was administered between July 1, 2017 and January 30, 2018. The survey was available to subjects in electronic format and all responses were anonymous. The electronic survey instrument was hosted using the University of Washington Catalyst web-based survey tool.

Study variables:

Predictor Variables: The predictor variables included sex (female, male or other), program region, program type and level of training (post-graduate year). Program region was determined by the subject’s reported program affiliation which was assigned to a geographic region as identified in the U.S. Census (West, Midwest, South, Northeast, or Unknown, if not specified). Program type was defined as either “OMS Certificate Program” or “Combined MD-OMS Certificate Program”. Level of training was defined as “non-categorical intern” or, for categorical residents, their respective post-graduate year.

Primary Outcome Variable: The primary outcome variable was the frequency of education or exposure to the care of transgender patients (Question #5) reported as “Yes”, “No” or “Decline to Answer”.

Secondary Outcome Variables: The secondary outcome variables included the subjects’ response to Questions #6-9. The aspects of transgender patient care that subjects were exposed to or received formal education about in residency (Question #6) were divided into three categories: “Psychiatric”, “Medical” or “Surgical”. For each of the three categories, a subject could select “Yes, I receive formal education on this topic in didactics, lectures, etc.”, “Yes, I receive exposure to this topic in the clinic or operating room”, “Yes, I receive exposure to this topic in BOTH didactics/lectures AND clinic/operating room”, “No, I do not receive exposure to this topic in the clinic or operating room” or “Decline to answer”.

Subjects indicated the topics that they were exposed to in their residency regarding gender-affirming surgery (Question #7) by selecting “Facial Surgery”, “Pitch Alteration Surgery”, “Surgical Management of complications of gender confirming surgery or hormonal transition”, “Other” or “None”.

Subjects indicated the importance of OMS residents receiving training in gender-affirming surgery (Question #8) as “Very Important”, “Somewhat important”, “Neutral”, “Not important”, or “Decline to answer”.

Subjects indicated that oral and maxillofacial surgery should offer a fellowship in gender-affirming surgery, specifically related to facial feminization or masculinization surgery (Question #9) as either “Yes”, “No” or “Decline to Answer”

Data collection and analyses:

Data Management: Data obtained from the electronic survey instrument were retrieved from the web-based survey tool and downloaded into an electronic spreadsheet. All data were coded for appropriate analysis.

Data analyses: Basic descriptive statistics were used to describe the subjects (count and percentage for categorical variables). All variables were categorical; therefore, all bivariate analysis consisted of chi-square tests, unless any cell in the contingency tables contained n < 5, in which case Fisher’s exact test was used.

To determine variation in the perceived importance of gender-affirming surgery training by sex, program region, program type or postgraduate year level, Likert scores were averaged (0=not important, 1=neutral, 2=somewhat important, 3=very important) and the groups were compared using chi-square tests. This same methodology was used to analyze subjects’ perceptions regarding the importance of fellowship training in transgender surgery. Data analysis was conducted using “R” (R Core Team, Vienna Austria). A p-value of <0.05 was considered statistically significant.

Results

In total, 89 oral and maxillofacial surgery residents (# of residents for the 2017-2018 academic year n=1174, 7.6% response rate) responded to the survey, of which two declined to participate. The characteristics of the sample are summarized in Table 1. Seventy-one subjects (81.6%) were male. The distribution of subjects by program region included 34 subjects (39.1%) who did not indicate their program name (“Unknown”), 23 subjects (26.4%) in the Northeast, 12 subjects (13.8%) in the South, 11 subjects (12.6%) in the West, and 7 subjects (8.0%) in the Midwest. Fifty-six subjects (64.4%) were in Combined MD-OMS Certificate programs, while 31 subjects (35.6%) were in OMS Certificate programs. There were 9 subjects training at the non-categorical intern level (10.3%).

Primary Analysis: Twenty-seven subjects (31.0%) reported exposure to transgender patient care in their residency program. In the primary analysis, which looked at the association between the predictor variables and frequency of education or exposure to the care of transgender patients, there were no statistical differences in exposure based on the subjects’ sex, program region, or post-graduate year. Those subjects who indicated training in the “West” had the highest exposure (54.5%, n=6), while those training in the “Northeast” had the lowest exposure (17.4%) but these differences were not statistically significant (p=0.25). There was a trend for increased exposure to the care of transgender patients by PGY level with 3 subjects (15.8%) at the PGY-1 level of training indicating exposure and 2 (66.7%) and 1 (100%) subjects respectively, at the PGY-6 and PGY-7 levels of training, but this was not statistically significant (p=0.36). Those training in OMS Certificate programs had higher rates of exposure when compared with those training in Combined MD-OMS Certificate programs and this was statistically significant (54.8% vs 17.9%, respectively. p<0.001).

Secondary Analysis: The secondary analysis aimed to look at the association between the predictor variables and the subject’s response to questions #6-9 and is summarized below.

Exposure to Transgender Patient Care: Overall, 16 subjects (18.4%) reported any exposure to the psychiatric components (e.g. gender identity/gender dysphoria) of transgender patient care, and there were no statistical differences in exposure based on the subject’s sex, program region, program type, or post-graduate year. Of those subject’s reporting exposure, didactic exposure to the psychiatric components of transgender patient care was most frequently reported (68.8%).

Overall, 15 subjects (17.2%) reported any exposure to the medical components (e.g. hormones for transition) of transgender patient care, and there were no significant differences in exposure based on the subject’s sex, program region, program type, or post-graduate year. Of those subject’s reporting exposure, didactic exposure to the medical components of transgender patient care was most frequently reported (60.0%).

Overall, 19 subjects (21.8%) reported exposure to the surgical components (e.g. gender-affirming surgery) of transgender patient care, and there were no significant differences in exposure based on the subject’s sex, program region, or post-graduate year. Of those subject’s reporting exposure, clinical exposure to the surgical components of transgender patient care was most frequent (84.2%). 16 subjects (84.2%) reported being exposed to facial surgery, 0 to pitch alteration surgery, 1 to surgical management of complications of gender confirming surgery or hormonal transition and 2 to other surgical components. Those training in OMS Certificate programs had higher rates of exposure to any component of surgical care when compared to those in Combined MD-OMS Certificate programs (35.5%% vs 14.2%%, p=0.02).

Importance of Training in Gender-Affirming Surgery: Overall, the mean reported importance of OMS residents receiving training in gender-affirming surgery was 1.37±0.94 where 1 equals “Neutral” and 2 equals “Somewhat Important”. Those identifying as female reported greater importance of residents receiving training in gender-affirming surgery when compared to their male colleagues and this difference was statistically significant (1.94±0.77 vs 1.24±0.93, p=0.0063). There were no significant differences in reported importance based on the subject’s program region, program type, or post-graduate year.

Necessity for Fellowship Training in Gender-Affirming Surgery: Overall, 33 subjects (37.9%) reported that a fellowship should be offered in gender-affirming surgery, specifically related to facial feminization or masculinization surgery. Those identifying as female reported a greater necessity for fellowship training opportunities in gender-affirming surgery when compared to their male colleagues and this difference was statistically significant (32.4% vs 62.5%, p=0.02). There were no significant differences in necessity for fellowship training opportunities in gender-affirming surgery based on the subject’s program region, program type, or postgraduate year.

Discussion

Given that the number of individuals seeking gender-affirmation may rise, resulting in an increased need for multi-specialty patient care teams that include oral and maxillofacial surgeons with experience managing the care of transgender patients, it is prudent to determine the state of transgender patient care and education in oral and maxillofacial surgery (OMS) residency training programs. We hypothesized that OMS residents have limited exposure to transgender patient care but perceive such exposure as an important component of their surgical training. We aimed to determine the current state of transgender-related education in U.S. OMS residency programs and evaluate trainee perceptions regarding the importance of such training.

The results of this study support our hypothesis that OMS residents have limited exposure to transgender patient care. Of those residents who participated in the survey, only 31% had any exposure to transgender patient care. In a similar study of 289 urology residents evaluating exposure to transgender education, Dy22 in 2016 found that 54% of urology residents had exposure to transgender patient care. When they broke down exposure by program region, more residents training in programs in the “West” had exposure when compared to other geographic regions (p≤0.01). Similarly, there was a trend in our sample for greater exposure to transgender patient care for OMS residents training in programs in the “West” when compared to other regions combined (54.5% vs 27.6% p=0.25). In another similar study, Morrison21 in 2016, when evaluating exposure amongst plastic and reconstructive surgery (PRS) residents, found that 64% reported exposure to transgender patient care in their training program. While they expected residents at programs in the “West” to have greater exposure to transgender patient care, since two of the counties with the highest populations of transgender individuals are in the “West”, they attributed the distribution in their study (NE > Midwest > West > South) to the number of pioneering programs in the Midwest and Northeast. At present, it is unclear which OMS training programs have become pioneers in delivering care to transgender patients pursuing gender-affirming surgery. Lastly, in a survey of academic deans by Hillenburg28 in 2016, LGBT-specific content is reportedly taught in 59% of U.S. dental schools. We can see then, that when compared to other surgical specialties OMS residents have less exposure to transgender patient care but may receive related training while in dental school.

Interestingly, those training in OMS Certificate programs had a higher rate of exposure to the care of the transgender patient when compared to those training in combined MD-OMS Certificate programs (54.8% vs 17.9%, respectively. p<0.001). The reasons for this are unclear, however, given that most exposure to the care of transgender patients occurs in the clinical setting, it may be that residents training in OMS certificate programs spend a greater amount of their time in residency in clinical oral and maxillofacial surgery, making it more likely that they are exposed to the care of these patients. This may be due, in part, to the required amount of time spent pursuing the MD and any additional general surgery obligations residents are confronted with in combined MD-OMS Certificate programs.

When we look at the category of transgender patient care to which OMS residents are exposed, the highest rate was for the surgical management of transgender patients (21.8%), most often in a clinical setting (84.2%). Exposure to psychiatric and medical care was most commonly obtained through didactic training (68.8% and 60.0%, respectively). This may suggest that the role of the oral and maxillofacial surgery trainee has been primarily limited to surgical management in a clinical setting.

The results also support our second hypothesis by suggesting that exposure to transgender patient care is an important component of surgical training (mean reported importance 1.37±0.94 where 1=Neutral and 2=Somewhat Important). In a similar study by Morrison21 in 2016, the mean reported importance of training residents in gender-affirming surgery amongst PRS residents was 2.13±0.048 (n=322). We can see then, that the OMS residents in our study placed a lower importance of gender-affirming surgery training when compared to PRS residents. Although the reported mean was above “Neutral”, the low overall rate of exposure to transgender patient care (31%), may have played a role in the perceived importance of such training.

When broken down by sex, those identifying as female placed greater importance on training in gender-affirming surgery when compared to their male colleagues, a finding that was also found amongst urology residents22 (91% vs 70%, p<0.001) and PRS residents21 (mean importance, female respondents=2.35±0.07, male respondents=unknown, p<0.05). This may be explained by the higher level of LGBT tolerance by women, a notion discovered in a population of college students42.

When asked if the specialty of Oral and Maxillofacial Surgery should offer a fellowship in gender-affirming surgery, 37.9% of residents responded “yes”. This number is lower than that which is reported by residents in urology residency training programs22 (77%) and plastic and reconstructive surgery programs21 (72%). The interest in fellowship training opportunities by OMS residents may be limited by the amount of exposure to transgender patient care, amount of facial cosmetic surgery experience while in residency training and the existing number of facial cosmetic surgery fellowship opportunities in OMS.

Limitations to this study include the low response rate (7.6%) and the survey participation bias. Of the 1174 residents training in U.S. Oral and Maxillofacial Surgery training programs, only 89 responded to the survey, including two of which who ultimately declined participation. The survey was distributed to program directors of OMS residency training programs in the U.S. three times at an interval of two weeks in order to encourage participation. The low response rate limits the ability of the reader to generalize the results of our study to all OMS residents training in the U.S, however, it provides an initial look into the experience of OMS residents as it relates to the care of the transgender patient. Another limitation of the study is the survey participation bias of those who elected to participate in the study. It is unclear the role of existing bias in those who elected to participate, further limiting this study’s generalizability.

This study adds to the limited research on the care of the transgender patient in the field of Oral and Maxillofacial surgery but highlights the importance of such training given the increasing role of interdisciplinary care, including that which is provided by Oral and Maxillofacial Surgeons. Further research should be undertaken to understand the role of the OMS in the delivery of care to those pursuing gender-affirmation surgery.