Behavioral Health Concerns and Eligibility Factors Among Adolescents and Young Adults Seeking Gender-Affirming Masculinizing Top Surgery

Purpose: We evaluated behavioral health histories and eligibility factors for patients seeking chest reconstruction. Methods: One hundred and fifty-eight consecutive transgender patients were seen for initial masculinizing top surgery consults between May 2017 and July 2019. Chart review was used to assess behavioral health and demographic factors, and eligibility factors related to the World Professional Association for Transgender Health (WPATH) Standards of Care. Univariate and age-adjusted regression models were used to examine the relationship between demographic and behavioral health factors and WPATH criteria. Results: The average age of patients at the time of their first consult was 18 (standard deviation = 3.3, range = 14-33). Eighty-five percent had at least one behavioral health diagnosis; 27% had three or more. Sixty-four percent endorsed a history of self-harm or suicidal ideation, 13% within the last 6 months. Thirty-two percent reported a history of marijuana use and 19% a history of nicotine use. For those prescribed testosterone, additional months on testosterone were significantly associated with male (vs. nonbinary) gender (beta = 4.64, 95% confidence interval [CI] 0.37-8.90, p = 0.033), age (beta = 0.87, 95% CI 0.41-1.34, p < 0.001), living as one's affirmed gender for over 1 year (beta = 6.37, 95% CI 1.37-11.37, p = 0.013), history of marijuana use (beta = 4.54, 95% CI 1.10-7.98, p = 0.010), and history of nicotine use (beta = 6.23, 95% CI 2.22-10.26, p = 0.003). Conclusion: Patients seeking gender-affirming masculinizing top surgery are behaviorally complex, in ways not necessarily associated with surgical eligibility. Involving a behavioral health provider in perioperative assessment can help identify and address potential risks to recovery and outcomes.