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urology residents, 54% of respondents received education about or were directly exposed to transgender patients. Urology residents were more likely to have direct patient interaction as opposed to formal lectures.15 Exposure varied geographically in both cohorts. Despite the inconsistencies in training, respondents in both surveys agreed that exposure to transgender education is important.16,17 A secondary survey performed by Morrison et al found that among 154 American plastic surgery and urology Systematic Review programs, as reported by program directors, the median dedicated time to transgender health was 1 didactic hour and 2 clinical hours anually.18 As most surgical training programs range from 5 to 7 years, this amounts to no more than 21 hours of transgender health exposure.19 The reported median allotted time also does not capture that 18% of plastic surgery and 42% of urology programs had no didactic education, and a third of plastic surgery and urology programs had no clinical exposure.18 All three initial surveys indicated that a positive program director attitude toward transgender education correlated with more trainee exposure and formal education.14,15,18 These results built upon the preliminary surveys claims that a surgical trainee’s transgender education was nonuniform and varied, based on factors such as geography and overall program attitude toward transgender care. A 3-year follow-up survey of 43 American plastic surgery program directors asserted that consistent education across residency programs may be improving.20 Magoon et al found that a large majority of programs now devote educational time to transgender health and are planning on increasing these efforts in the coming years.20 Programs now spend 3.5 hours annually on GAS curriculum, an increase of 1 hour per year from prior surveys and an indication that programs are committed to their plans to increase transgender health related education.18,21 Although only 26% of programs report dedicated clinical experience with transgender patients, and the majority of that exposure exclusively dealt with chest/breast surgery, 67% of program directors felt that their residents were prepared to address transgender-related concerns. As opposed to initial surveys, continuing medical education (CME) hours per year dedicated to the topic did not vary by region. Widespread transgender health education among surgical residents may continue to improve as GAS becomes more commonly accepted and practiced. Despite the improvement in recent plastic surgery studies, a survey of multiple specialties from Canada, including urology, found that none of the 14 urology residency respondents felt competent managing trans-related urologic care, and none of them agreed that their current education was adequate.22 Similar to previous studies, 43% of respondents had no curricular exposure to transgender health care.18,22 Half of the urology residents agreed that transgender health care was included as a part of their specialty and only 29% planned on incorporating it into their future practice.20,22 Despite being significantly underpowered, it highlights the need for further transgender health care training in current urological residencies in order to reflect the residentendorsed desire for increased GAS training.15 Other surgical specialties involved in the multidisciplinary approach to GAS and transgender health include otolaryngology, OMS, and dermatology. Otolaryngology and OMS residents are uniquely qualified to perform the facial and pitch alteration surgeries desired by transgender patients, and dermatologists commonly perform minimally invasive gender-affirming procedures (MIGAPs) such as soft-tissue augmentation, laser hair removal, and neuromodulator injections.23,24 However, residency exposure to transgender care is mixed among these surgical specialties. Massenberg et al found that 30% of American ENT residents had exposure to transgender health, most commonly with facial and pitch surgeries such as cricothyroid approximation or endoscopic vocal cord shortening.25 Exposure was similar in American OMS residencies, as identified in a national survey performed by Ludwig et al.26 A survey of 38 program directors, which included not only dermatologists but also otolaryngologists, oculoplastic surgeons, and plastic surgeons, found that 47% of programs offer training in MIGAP procedures.24 These are only preliminary studies in their respective specialties and may not capture the true residency experience and attitudes, as these studies were limited by low-response rates. Further studies will be required to fully understand the experiences and perceptions of surgical trainees in these specialties. Training was even more limited amongst OBGYN providers and fellows. Unger found that among 141 American OBGYN providers, only 20% received any training regarding transgender patient care during residency and only a third felt comfortable providing care to these patients.27 Mehta et al had similar results, identifying only 25% of American providers who received education in lesbian, gay, bisexual, transgender and gender-nonconforming (LGB-TGNC) health during residency and fellowship.28 Those with previous training were more likely to self-identify or have a close contact identifying as LGB-
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