Surgical and Patient-Reported Outcomes of Gender-Affirming Surgery in Lower- and Middle-Income Countries: A Systematic Review and Meta-Analysis

BACKGROUND: Access to gender-affirming surgery (GAS) is contingent on availability of procedures, affordability, legality, and social norms. Regions with higher accessibility to GAS, typically high-income countries, may report more surgical and patient-reported outcomes (PROs) data related to GAS, while limited research has characterized outcomes in low- or middle-income countries (LMICs). This meta-analysis characterizes and synthesizes the peer-reviewed literature on GAS-related outcomes in LMICs. METHODS: Electronic databases (MEDLINE, Embase, Web of Science, CINAHL, and PsycINFO) were searched from inception to October 2023. Peer-reviewed articles or conference abstracts that were published in any language, reported GAS surgical or patient-reported outcomes (PROs), and were conducted in LMICs were included and reviewed in duplicate. Pooled proportions (pooled%), 95% confidence intervals (95%CI) and heterogeneity (I 2) were calculated using a random intercept logistic regression model. RESULTS: 150 studies were included (65.3% peer-reviewed articles and 32.7% conference abstracts) from 17 LMICs. Most studies were in English (94.7%) and nearly half were produced by authors from Serbia (30.7%) and Brazil (17.3%), both upper middle-income countries with specialized GAS centers. Vaginoplasty (33.3%), phalloplasty (20.0%), and metoidioplasty (13.3%) were the most reported procedures. Common complications included vaginal stricture/stenosis (pooled%=7.4%, 95%CI=4.1%-12.4%, I 2=85.7%), vaginal fistula (pooled%=2.9%, 95%CI=1.8%-4.4%, I 2=29.6%), phalloplasty urethral stricture (pooled%=14.0%, 95%CI=8.2-22.7%, I 2=87.3%), and phalloplasty fistula (pooled%=16.2%, 95%CI=11.5%-22.3%, I 2=87.7%). Overall complication rates ranged from 0%-73.3%. Most studies reported PROs (65.3%) and 35 studies used validated PRO measures. CONCLUSION: GAS outcome data were lacking from the majority of LMICs, and substantial heterogeneity in surgical complication rates and outcomes measured were noted.