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addition to the requisite technical knowledge and skill regarding specific surgical procedures, surgical education and training should include exposure to the entire multidisciplinary process, including the mental health evaluation and assessment, hormonal management, and details of pre- and postoperative care. From a programmatic standpoint, continuing medical education should include participation in multidisciplinary conferences that are didactic and oriented toward patient care and reflect the evolving practice patterns of transgender care. This might include opportunities for cadaver dissections, live transmission of surgical procedures, and focused educational seminars. In addition, research opportunities should be offered, and findings should be presented at regional, national, and international conferences and published in peer-reviewed journals. EDUCATION MODEL Based on our experience in developing and implementing a comprehensive gender surgery program, we recommend the following structure for surgical education: 1. Core lecture series: Lectures consisting of terminology, history, etiology, mental health assessment, hormonal management, surgical therapies, adolescent therapy, general medical care, and ongoing challenges and barriers to care should be offered. These lectures should be consistent with the WPATH SOC. 2. Office-based experience: Exposure to the pre- and postoperative care of the transgender individual should be offered. 3. Technical experience: Training in surgical therapies for transmen and transwomen should be offered. This can be in conjunction with related surgical disciplines including urology, colorectal surgery, gynecology, and OHNS. In addition, hands-on experience can be supplemented with cadaver courses. A minimum case requirement with tracking of postoperative outcomes should be provided. 4. Continuing medical education: Participation in multidisciplinary educational and case conferences should be required. This includes exposure to mental health and medical professionals. 5. Focused seminars: Seminars on care of transgender and gender nonconforming individuals should be developed and participation in national and international meetings should be encouraged. 6. Research: Participation in outcome studies and other academic efforts should be pursued. This includes quality measurements, long-term patient-reported outcome measurements, and strategies to address unfavorable results and complications. Presentations at recognized conferences and publications in peer-reviewed journals should be expected. 7. Institutional requirements: Hospital staff (ie, nursing, administration, support staff, etc) should be educated on proper terminology and cultural sensitivity. Formal hospital record-keeping mechanisms (ie, electronic medical records) should be updated to allow for non-binary selection options and gender diversity. Ongoing educational programs should be developed to maintain optimal gender-sensitive care. Ideally, most training programs should begin under the guidance of an experienced surgeon who has a demonstrated commitment to multidisciplinary care and education. Furthermore, training programs will likely develop at institutions that have demonstrated the commitment to caring for transgender and gender nonconforming individuals. As the number of trained surgeons increases, it is likely that the number of training institutions will increase. However, training requires financial and personnel resources. Although some institutions have chosen to “self-fund” training programs, a long-term strategy to ensure financial stability for these programs is desirable. QUALITY PARAMETERS Integral to the success of any program is a mechanism to assess and track results. It is incumbent on institutions and providers to (i) develop a system to track outcome measurements, (ii) work collaboratively with other providers and institutions to develop evidence-based guidelines for care, (iii) implement a mechanism to coordinate follow-up and transitional care, and (iv) develop a mechanism for performance improvement. Central to this challenge is the development of patientreported outcome measurements specific for the transgender and gender nonconforming population. These measurements must be reliable, valid, and reproducible. At this time, no such assessment exists. Current studies often rely on data extrapolated from existing questionnaires designed for a gender binary population. Research is needed to determine whether these traditional tools are satisfactory for assessing surgical results in the transgender and gender nonconforming population. This will require collaboration between providers and institutions worldwide. These measurements will likely include patient satisfaction and quality-of-life measurements specific to a gender nonconforming population. Because of the wide range of surgical procedures, multiple surgical specialties are involved in caring for transgender individuals. Certain specialties will likely have a natural affinity for specific procedures. For example, facial feminization is probably best performed by plastic surgeons, OHNS, and/or maxillofacial surgeons, whereas breast surgery is likely to be performed by plastic surgeons and, in some cases, gynecologists. In regard to

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