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current understanding of surgical training related to transgender care is primarily derived from survey-based studies. These are often limited by generalizability and incomplete participation and are frequently susceptible to selection and response bias. These studies are also restricted to North America and do not provide insight into training elsewhere in the world. GAS are commonly performed in Africa, Asia, Europe, and South America. Further studies will be required to better understand the robustness of surgical Fig. 2 Resident exposure to transgender health across surgical specialties. Average percent of resident exposure to transgender health and gender-affirming surgery (GAS), based on specialty. This figure included results from six obstetrics and gynecology (OBGYN) studies, one oral and maxillofacial surgery (OMS) study, one otolaryngology study, three plastic and reconstructive surgery studies, and three urology studies. Indian Journal of Plastic Surgery © 2022. Association of Plastic Surgeons of India. All rights reserved. Gender-Affirming Surgery Training Khouri et al. training in transgender health globally. However, the surveys included in this study together identify an overall understanding of the current surgical trainee experience in North America. Ultimately, existing research will lay foundation for interventional studies such as the development of training modules to be implemented in surgical curriculums. One such training experience has been demonstrated by Pfaff et al, who executed a structured facial feminization course that included a 1-hour lecture and cadaveric dissection for 11 plastic surgery residents and five medical students (►Table 2).40 Pre- and postcourse self-assessments confirmed an improved understanding of facial feminization in transgender females. Several barriers to establishing similar training modules have been cited, such as lack of faculty expertise, formal curriculum, and resources.33 There is no consensus regarding which formats of educational interventions are best suited to teach transgender health.41 However, initial curriculums may be best achieved through easily accessed online training modules. Online material may offer programs an affordable, high-quality, standardized educational resource in transgender health.42 Live surgery training courses for gender-affirming procedures have been produced annually via WPATH. A set of guiding principles to drive the development of new curricula has been previously explored by Schechter et al. This includes recommendations for surgical trainees to perform at least 25 top and bottom surgeries over a 2-year period.36 However, technical skills alone will not sufficiently prepare residents. An effective surgical training in transgender health will require a multidisciplinary, holistic approach that includes core lectures, clinical and technical training, CME, and research.35,36,43 This well-rounded experience will prepare residents for competency-based interactions with transgender patients which will translate to a multitude of care settings.44 Eventually, this comprehensive education may be adapted by the ACGME or other global medical education councils. Formal training will also standardize trainee exposure and education, limiting program and geographical variation and better preparing trainees for the recent increase in new GAS fellowships.19 Summary Current postgraduate surgical training in GAS is nonuniform across surgical specialty, geographical region, and individual program and does not sufficiently prepare all surgical residents to care for this marginalized population. Incorporating training modules and hands-on experiences into surgical trainee education as well as working toward the development of a formal GAS curriculum will better prepare residents for the numerous clinical and surgical interactions with transgender patients and standardize exposure. Development of fellowships in GAS will allow those seeking further education to explore these opportunities. Further research is required to better understand how to best incorporate these experiences into existing surgical curriculums. Financial Disclosures The authors have no financial interest to declare. Conflict of Interest None. References 1 Meerwijk EL, Sevelius JM. Transgender population size in the united states: a meta-regression of population-based probability samples. Am J Public Health 2017;107(02):e1–e8 2 Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet 2016;388(10042):390–400 3 Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism 2011;13(04):165–232 4 James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016 5 Reisner SL, Hughto JM, Dunham EE, et al. Legal protections in public accommodations settings: a critical public health issue for transgender and gender-nonconforming people. Milbank Q 2015; 93(03):484–515 6 Poteat T, German D, Kerrigan D. Managing uncertainty: a grounded theory of stigma in transgender health care encounters. Soc Sci Med 2013;84:22–29 7 Lane M, Ives GC, Sluiter EC, et al. Trends in gender-affirming surgery in
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