Meeting the Demand

BACKGROUND: Gender-affirming (GA) surgeries have increased over 400% in the past decade, yet plastic surgery (PRS) residents receive limited training in GA genital reconstruction. Although plastic and reconstructive surgery is central to GA care, urology also plays a key role. This cross-sectional study compares genital surgery training in urology and PRS residency programs, availability of GA fellowships, and geographic distribution, and outlines the history and growth of GA fellowships in PRS. METHODS: United States-based, accredited integrated PRS and urology residency programs were identified via the Accreditation Council for Graduate Medical Education (ACGME) and American Urology Association (AUA) databases. Residency and institutional websites were then reviewed for rotation schedules, GA fellowships, and presence of GA surgical services. Unaccredited genital reconstruction fellowships were included if they trained plastic or urologic surgeons. Programs were grouped by US region. Analyses were performed using SPSS v28.0.1. RESULTS: Of 232 programs, 88 were PRS and 144 were urology. Gender-affirming fellowships existed at 8 PRS institutions (9.1%) and 9 urology institutions (6.3%) ( P = 0.42). However, 59 urology programs (41%) offered fellowships that included genital reconstruction ( P < 0.001). There was no significant geographic difference in fellowship distribution. Interestingly, 41.2% of programs with a GA fellowship did not advertise GA procedures, whereas 46.7% of those without fellowships did. Programs with fellowships more often referenced a "gender" clinic or rotation ( P = 0.009). Since 2017, PRS GA fellowships have steadily expanded, with several major institutions launching programs through 2026. CONCLUSION: Despite increasing demand for GA care, PRS residents have limited exposure to genital reconstruction, with urology offering more training opportunities. Specialized GA surgical education remains limited and insufficient given the growing needs of the transgender population.