Reply: Terminology in Transgender Patient Care

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We read with much interest the commentary1 by Massie and colleagues as a response to our original article. Our study prospectively evaluated the quality of life of transgender patients undergoing sex reassignment surgery or, rather, gender affirming surgery. Massie et al. discuss the current transgender terminology and recommend the latter as the most appropriate umbrella term for the multitude of operative procedures.
We agree with the authors that the terminology regarding gender dysphoria and transgenderism remains a matter of ongoing debate and includes a variety of different diagnostic and operative terms. They bring up a very important point that certain nomenclature might be regarded as pathologizing or stigmatizing. This is a sensitive issue we regard as highly important in the care of our patients. There is indeed a trend in medical literature from the potentially outdated “sex/gender reassignment surgery” to “gender affirming/confirming surgery.” Unfortunately, we as surgeon-scientists may not always be on par with the latest and most appropriate terminology because the art of publishing is, by nature, a time-consuming process. Had we written this article today, in August of 2017, we would have likely used the newer operative descriptions.
However, these reforms must be applied cautiously to avoid prohibiting patient access to health care providers. A minor change of diagnostic or operative codes may lead to health insurers rejecting financial compensation for transgender procedures because they will not be regarded as medically indicated any longer.2,3 Thus, numerous health professionals recommend retention of these established terms. In our practice, but also in many other institutions around the world, we have come a long way to achieve coverage by commercial and governmental health insurances for psychological, psychiatric, endocrinologic, and surgical treatment of transgender patients. In these cases, older terminology, such as the International Classification of Diseases, Tenth Revision diagnostic classification “transsexualism,”4 may still be the foundation for surgical compensation even if the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) “gender dysphoria”5 is considered more in line with the times. We are hopeful that the updated International Classification of Diseases, Eleventh Revision, which is expected for release in 2018,6 will shed some light into this darkness by improving current terminology without disrupting insurance coverage.
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