Introduction

Transsexualism is the term to define a person who identifies completely with the gender opposed to the assigned gender at birth. A transsexual person only feels relieved when permanently living in the other gender role, has a strong aversion against the sex characteristics of his/her body, and wants to undergo gender confirming medical interventions such as cross-sex hormones and surgery to alter the body in a way that is closer to one’s gender identity (Zucker et al., 2013).

Transsexual individuals are at increased risk of suffering from minority stress, which is further predictive of psychiatric disorders such as depression and suicidal behavior (Rood, Puckett, Pantalone, & Bradford, 2015). Transsexualism is associated with psychiatric morbidity, including suicidal behavior, known from a recent Swedish community report and epidemiological studies (Dhejne et al., 2011; Zeluf et al., 2016; Zucker, Lawrence, & Kreukels, 2016). Feeling congruent with one’s outward appearance is of importance for many transsexual individuals both for feelings of satisfaction and is related to anxiety and depressive symptoms (Kozee, Tylka, & Bauerband, 2012).

Male-to-female (MtF) transsexual individuals who start their transition late in life may suffer from masculine appearances of their physical stature. MtF are reported to be less satisfied with their overall bodily appearance compared to female-to-males (FtM) (van de Grift et al., 2016). The face is the part of the body that is highly exposed and, as expected, one of the main areas leading to appearance concerns in MtF individuals, focusing on aspects such as jaw line and facial hair (van de Grift et al., 2016).

Facial feminization surgery (FFS) is a technique employed to decrease the degree of physical incongruence and, by so, improving quality of life (Ainsworth & Spiegel, 2010; Altman, 2012). There are different techniques for FFS, but most techniques focus on changing craniofacial features that are coded more masculine (Capitán, Simon, Kaye, & Tenorio, 2014; Ousterhout, 2015). FFS is widely employed within the private sector and included as an optional surgical treatment within the World Professional Association of Transgender Health’s Standards of Care (Coleman et al., 2011).

In April 2015, the Swedish National Board of Health and Welfare published a new national guideline of care for patients suffering from gender dysphoria (God vård av vuxna med könsdysfori Nationellt kunskapsstöd, 2015). As a unique feature, it was concluded that FFS could be deployed as part of the gender confirming health care, within the public health system, something that we previously have reported (Lundgren et al., 2016). In the published report, the conclusion was that the procedure should be limited to individuals whose masculine facial appearance hampers their ability to be perceived as female and with severe distress in relation to this. Lundgren et al. further concluded that clinical experience and evidence base should be built up based upon the individuals undergoing surgery within the public health context.

To meet this, we sought to assess how FFS could be included within the public health system, suitable psychometric ratings, and times of measurement. In this setting, only surgery for feminization purposes could be employed in contrast to any procedures that could be regarded as cosmetic and hence all surgery was limited to work only on parts of the craniofacial skeleton. Surgery was performed largely as described elsewhere (Becking, Tuinzing, Hage, & Gooren, 2007; Capitán et al., 2014; Ousterhout, 2015). Individual surgical recommendations were used based on the surgeons’ experience and also on 3-dimensional radiological preoperative assessments to suggest which parts of the craniofacial skeleton required feminization (forehead, orbital, mid-face, and/or mandibular remodeling) (Lundgren & Farnebo, 2017).

The main aim of this study was to assess how FFS affects self-rated appearance congruence and body satisfaction and to assess psychiatric and psychological outcomes in relation to the surgery. Our primary hypothesis was that appearance congruence would be improved. Our secondary aim was to assess the feasibility of relevant scales in relation to this type of surgery, and relevant timing of assessment in relation to future larger clinical follow-up studies.

Method

Participants

This was designed as a pilot study where a total of 10 participants (MtF) were recruited nationally within Sweden to FFS after referral from gender identity units or through self-referral. Mean age was 44 years (SD = 13; range, 22–57). The patient cohort was a convenience sample. Inclusion criteria were an ICD diagnosis of transsexualism (F64.0) from one of the transgender assessment teams across Sweden and had gone through transition and legal change of gender in accordance with Swedish legislation and medical practice. Patients were all clinically assessed both by a team of gender experienced consultant plastic surgeons and a gender experienced consultant psychiatrist prior to intervention and at a 6-month follow-up after intervention. Patients were recruited at the Department of Reconstructive Plastic Surgery, Stockholm Craniofacial Center, at the Karolinska University Hospital. The time of inclusion and surgery was between June–December 2015, and 6-month follow-up was completed by June 2016. The study protocol (Dnr 2015/2225-31) was approved by the Regional Ethical Review Board in Stockholm, Sweden. All participants gave written informed consent.

Measures

All patients were assessed by a consultant psychiatrist and clinically interviewed in regard to feelings of distress due to perceived appearance concerns and as a consequence avoidance and functional impairment.

For quantitative measures, the primary outcome was appearance congruence, which is the degree of incongruence between the perceived gender identity and the physical appearance. For this outcome, we used:

1. The Transgender Congruence Scale (TCS). The TCS is a newly developed scale that quantitatively rates the degree of perceived incongruence. Appearance congruence was rated by responding to 9 questions. Items in the scale include questions such as how their outward appearance corresponds to their gender identity, how comfortable they are regarding how others perceive their gender identity, or how they perceive their physical body in relation to their gender identity (Appearance Congruence [AC] subscale). Gender Identity Acceptance was rated by responding to 3 questions regarding their pride, happiness, and acceptance about their gender identity (GIA subscale). Response options ranged from 1 to 5, where the score was summed and divided and presented as an average, both for the total score and the subscales (Kozee et al., 2012).

2. The Body Image Scale (BIS) rates the degree of dissatisfaction toward different aspects of the body in 30 questions, ranging from 1 to 5, with 6 questions related to facial appearance (Lindgren & Pauly, 1975). The score for this study was presented both as a total score, and a score related to facial appearance, the BIS head, and neck region.

3. Secondary outcome measures were depressive and anxiety symptoms, using the Hospital Anxiety and Depression Scale (HAD) assessing both depressive symptoms and anxiety symptoms within two domains. There are 14 items in total, 7 questions, respectively, within each domain, where responses range from 0 to 3, with each score stating the current frequency of different depressive or anxiety symptoms. Total score under 6 for each domain is generally regarded as a subclinical symptom level (Zigmond & Snaith, 1983). For functional outcome and quality of life, we used the Sheehan Disability Scale (SDS) assessing functional impairment within three domains: work, social life, and family life, ranging from 0 to 10 within each domain, respectively, with 0 being no impairment and 10 being extreme impairment (Leon, Olfson, Portera, Farber, & Sheehan, 1997), and the EuroQol-5-Dimensions (EQ-5D) visual analogue scale where participants rate their health state from worst imaginable to best imaginable ranging from 0 to 100 (EuroQol Group, 1990).

Assessment points both for clinical interviewing and psychometric ratings were at baseline prior to surgical intervention and at a 6-month follow-up.

Results

Transgender Congruence Scale and Body Image Scale

As can be seen in Table 1, for the total score on the Transgender Congruence Scale, there was a significant improvement at follow-up, as well as for the Appearance Congruence subscale. The Gender Identity Acceptance subscale was high and unchanged, both at baseline and by the time of follow-up.

Table 1 Mean and SD for self-ratings pre- and postsurgical treatment
Full size table

For the total score on the BIS, there was a significant improvement at follow-up, BIS total and a trend for the BIS head and neck region.

Psychiatric Symptoms, Functioning, and Quality of Life

For the secondary outcome measures, none of the variables were significantly altered or improved at the 6-month follow-up (Table 1).

Discussion

To our knowledge, this is the first FFS intervention study that in a structured and prospective manner assessed psychiatric and psychological outcome pre- and post-intervention. The main result was that at a 6-month follow-up post-surgery, self-rated overall appearance congruence and body image satisfaction improved. The self-rating referring to the head and neck region tended to be improved.

Since concerns related to appearance and perceived congruence is related to more severe psychiatric outcome, the fact that appearance congruence was improved could improve psychiatric distress and quality of life in the long run. In relation to our quantitative secondary outcome measures, this was not the case at our 6-month follow-up, indicating that in the short-term FFS surgery was not an end all solution. Self-rated measurements were, however, in the subclinical range on all secondary outcomes at pretreatment limiting the possibility to detect significant effects. The fact that some secondary measures even seemed to point in a negative direction may be due to the brief follow-up at 6 months where healing and time to habituate to an altered feminized appearance may take a longer time to process. Furthermore, a few of the patients were dissatisfied that interventions were limited to be mainly reconstructive even if this was stated beforehand. There may also be a confounding effect depending on the individual resources to cope with appearance concerns, and also the possibility that an overvalued idealization on the potential technical achievements from reconstructive surgery was not caught up in the assessment phase leading to dissatisfaction with the future outcome.

From the process, we learned that for about half of the patients, already by the 6-month follow-up, surgery had made their life a radical turn for the better. The subjective reporting included less avoidance, less day-to-day distress, and partaking in relationship making. As discussed above, a few were not satisfied with the FFS intervention, more in relation to having a desire for further cosmetic interventions, rather than regretting the intervention. To further improve the outcome from this type of surgery, we suggest that careful measurements are deployed when discussing FFS surgery, to assess the individual’s expectations in relation to what can be achieved, and what can be included within a national paid healthcare system. This would optimally be achieved through multidisciplinary team decisions and shared decision making with the patient. Furthermore, psychometric ratings can successfully be used when assessing surgical interventions longitudinally. For the purpose of assessing appearance congruence, the TCS has proven to be a useful tool (Kozee et al., 2012).

Although the patient cohort was small, the fact that we reached statistical significance with regard to improved self-rated appearance congruence and body image highlights the strong impact that FFS surgery can have. This is also the first prospective study conducted with quantitative measures. Limitations are the small sample size and the brief follow-up period. Since this study was a pilot, further studies are planned that aim to identify predictors and patient satisfaction within larger samples that undergo interventions as part of public health at the Stockholm Craniofacial Center at the Karolinska University Hospital.

There is a paucity of data regarding outcome after FFS surgery. One study provided retrospective self-evaluation data on quality of life after gender reassignment surgery, FFS or both, with improvement after such an intervention (Ainsworth & Spiegel, 2010). A recent systematic review concluded that the procedure is generally perceived as safe, but no prospective or quantitative data are provided from previous reports (Morrison et al., 2016).

These data serve as a preliminary evidence base for surgery by skeletal remodeling as a means to provide patients with a facial appearance more congruent with their desired gender. The inclusion of such surgery within the national guidelines in Sweden may help in guiding other policy makers as healthcare reforms are developed for transsexual patients (Lundgren et al., 2016). We believe that more countries will have to decide on whether FFS surgery should be employed within the public health system as patients are increasingly requesting such surgery in addition to, or even in place of genital gender confirming surgery.