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establishing gender confirmation surgery programs. As the demand for gender confirmation surgery services continues to increase, surgeons need to respond. A proactive approach incorporating and integrating theoretical knowledge with practical hands-on experience will allow us to care for individuals in an ethical, thoughtful, and responsible manner. Surgeons and surgery residents should be trained in the surgical care and the overall management of patients with gender dysphoria. Although it is our responsibility as surgeons to take the initiative in coordinating and developing short- and long-term action plans with the ultimate goal of establishing training programs for clinical care, the curriculum should be built on existing principles consistent with the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) guidelines established by the World Professional Association for Transgender Health (WPATH).1 The WPATH is an international organization with a diverse membership composed of surgeons, primary care providers, mental health professionals, and advocacy groups already engaged in international education through its Gender Education Initiative. The Gender Education Initiative began its educational programing in 2015, and its purpose is “to increase access to competent and compassionate care for transsexual, transgender, and gender nonconforming people worldwide.” The mission and vision statements of WPATH indicate that its goals are “to promote evidence based care, education, research, advocacy, public policy, and respect in transgender health [and] to bring together diverse professionals dedicated to developing best practices and supportive policies worldwide that promote health, research, education, respect, dignity, and equality for transgender, transsexual, and gender-variant people in all cultural settings.” 2 This document represents a template by which to establish a standardized method for surgical training in transgender care. Although it does not address every detail, we hope that through expert review and debate, surgical guidelines will continue to evolve. Importantly, the WPATH Board of Directors unanimously approved this article as the framework for surgical training for gender confirmation procedures. MULTIDISCIPLINARY TREATMENT MODEL No single discipline can satisfy all treatment needs for the transgender individual. Care is delivered in a collaborative fashion using a multidisciplinary approach. The surgeon is part of a health care team that includes mental health professionals, primary care providers, endocrinologists, plastic surgeons, urologists, gynecologists, colorectal (or general) surgeons, otolaryngology/head and neck (voice) surgeons (OHNS), and midlevel practitioners. Additional providers including speech and physical therapists also are desirable. Furthermore, administrative and support staff, such as social workers, familiar with and sensitive to the needs of the transgender patient also are important. In addition, the use of case managers, provided by third-party payers and/or institutions, can assist with the coordination of procedures and the transition of care to the individual’s primary care provider. Although the composition of the multidisciplinary team can vary, consideration must be given to the possibility of participation of members by electronic means. Because of geographic and time constraints, electronic communication may represent a viable and meaningful method of participation for some members of the gender team. EDUCATIONAL PHILOSOPHY The surgeon plays a key role in the success of a comprehensive gender program. Therefore, it is essential that the surgeon be knowledgeable in the complexity of care of transgender individuals. An educational model should include didactic and theoretical knowledge as well as hands-on experience. Although surgeons agree that a learning curve exists, few studies have looked at the methods, timing, and required number of cases.3e5 For example, Leclère et al3,4 described four steps in the learning process for vaginoplasty: (i) each surgical step should be thoroughly reviewed with an expert, (ii) hands-on training should be performed on fresh cadavers, (iii) vaginoplasty should be performed under supervision from an expert, and (iv) vaginoplasty should be performed with an expert immediately available. Our model expands on the technical aspects, recognizing that surgical training also should incorporate a multidisciplinary model. Here we describe a model that is currently being implemented at some institutions. From an educational and practice perspective, the surgeon should assume an active and integral role in the care of transgender individuals. Although typically introduced to a transgender individual after mental health and medical evaluations, the surgeon should have an understanding of the patient’s previous treatments, including mental health and medical therapies. It is the responsibility of the operating surgeon to understand the diagnosis that has led to the recommendation for surgery, medical comorbidities that can affect the surgical outcome, the effects of hormonal therapy on the patient’s health, and the patient’s ultimate satisfaction with the surgical result.6 J Sex Med 2017;14:852e856 Surgical Training in Gender Surgery 853 Therefore, in
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