Background Gender-affirming surgery (GAS) is a component of gender-affirming care. Access to GAS in Canada continues to be inconsistent owing to jurisdictional differences in GAS policies. Given the increasing politicization of transgender, non-binary, and gender-diverse (TGD) individuals and its impacts on policy, we aimed to explore the experiences of individuals involved in GAS policy development across Canada to identify facilitators and barriers to GAS policy advancement. Methods We conducted a qualitative description study with phenomenological overtones. Between May and December 2024, we interviewed 27 individuals who engaged with, were informed, or counseled on GAS-related Medicare policies. Interviews were transcribed verbatim, coded by two independent coders, and developed into themes using NVivo (Version 14.0). Themes were mapped onto Kingdon’s Multiple Streams Framework, encompassing the problem, policy, and political streams, and the policy window. Findings We generated 11 themes from our analysis. Themes were categorized under the problem stream (awareness of or interest in TGD lives and concerns, raising awareness and capturing government attention, and strategies for defining “the problem”), policy stream (feasibility, consensus, and advocate-led policy development), political stream (political will; internal political champions; pressure from TGD activists, advocates, and allies; and transphobia), and policy window (luck, timing, and magic). Participants found that GAS policies were advanced when clearly defined problems, feasible policy solutions, and political converged. Conclusion Advancing GAS Medicare policy requires clearly defined problems, feasible policy solutions, and political will. Successful policy changes hinge on skillful advocates who are prepared with actionable policy solutions that seize brief and unpredictable windows of opportunity when they arise.
Background Symptomatic neuromas following digital nerve injury frequently cause persistent pain and impair hand function. Targeted muscle reinnervation (TMR) is a promising approach that redirects regenerating axons into motor branches; however, its success in the hand relies on precise anatomical knowledge and identification of expendable motor targets. We aimed to identify and characterize motor branches in the hand to guide optimal TMR target selection. Methods Twenty-six arms were dissected to map the motor branches from the median and ulnar nerves to the thenar, hypothenar and lumbrical muscles. The anatomical course, length and diameter of each branch were documented, and anatomical variations were classified. Each branch was evaluated for consistency and expendability to determine its suitability as a TMR target. Results Thenar innervation demonstrated three main distribution patterns. The opponens pollicis (OP) and flexor pollicis brevis (FPB) motor branches were consistently present and deemed expandable, whereas the abductor pollicis brevis branch was preserved owing to its essential role in thumb opposition. Although lumbrical innervation patterns showed variability, branches to the lumbricals of digits 2–3 were reliably identified and suitable for TMR. Hypothenar innervation showed two main patterns, with the flexor digiti minimi (FDM) and abductor digiti minimi (ADM) branches being consistently identified as targets. Conclusion This study provides digit-specific anatomical information on motor branches in the hand that could be used in TMR. For digits 1–3, the OP, FPB and lumbrical branches to digits 2–3 appeared to be promising options; for digits 4–5, the FDM and ADM branches represent useful targets.
The NHS Scotland Exceptional Referral Protocol (ERP), recently renamed the National Referral Protocol (NRP)(SGHD CMO (2025) 17), provides a pathway for patients seeking body-altering procedures where there is an aesthetic element. Routine clinical photography was introduced into the East of Scotland ERP in 2016 to provide additional objective information during primary vetting. This multicentre retrospective cohort study included 2940 referrals submitted between 2012 and 2020. Multivariable logistic regression assessed the association between photography implementation and primary vetting outcome. Following the introduction of routine photography, referrals were significantly less likely to progress at primary vetting (OR 0.78, 95% C.I. 0.67–0.91, p=0.001), with significant reductions observed for body contouring, pinnaplasty, and other procedures. Routine clinical photography was associated with a significant change in primary vetting outcomes and may facilitate more efficient specialist referral pathways; these findings support its continued inclusion within the NRP.
