25

Page 4 of 5 generate a pool of potential items for a PROM tool. Tis tool will then be rigorously vetted by the transgender and non-binary community members via a modifed Delphi method, an iterative process whereby through data collection, analysis, and interpretation, the item pool is further modifed with repeat in the cycle until there is agreement [32]. Tis enables and prioritizes PROMs that align with actual patient outcomes; this is divergent from the current outcome measurements, which prioritize surgical opinion. Only once agreement and homogeneity are reached amongst experts including TGNB focus group participants, TGNB community partners, qualitative researchers, and genital gender-afrming surgeons will decisions be made on items for the fnal tool, which would encompass domains (e.g., sexual, urinary, quality of life). Tis process will refne and fnalize the tool which will then undergo rigorous validation testing. Te fnal component of Figs. 1 and 2 depict the potential outcomes and areas of improvement from utilization of this PROM tool, including quality improvement, satisfaction, value, and shared decision making. Conclusion PROMs for genital gender-afrming surgery are long overdue. Trough intensive community engagement, we aim to develop PROMs with the transgender and nonbinary community and inform the process of patient-centered care to serve transgender and non-binary patients. If surgeons who provide essential gender-afrming surgical care embrace the opportunity to be early adopters of This Commission came together with the modest goal of assessing whether US military policies that ban transgender service members are based on medically sound rationales.1 In the process of answering this question, we came to have a deeper appreciation for the consequences of these policies, and we were troubled by what we learned. We determined not only that there is no compelling medical reason for the ban, but also that the ban itself is an expensive, damaging and unfair barrier to health care access for the approximately 15,450 transgender personnel who serve currently in the active, Guard and reserve components.