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Hart et al. Plast Aesthet Res. 2026;13:3 Page 7 of 10

individuals. For example, a population-based sample of cisgender adults in the UK (N = 182; 58 men, 121
women, 3 unknown) had a significantly higher mean CSES score of 159.62 (SD 41) . Furthermore,
[17]
participants with moderate to severe depressive symptoms (PHQ-2 ≥ 3) demonstrated substantially lower
mean CSES scores (99, SD 40), indicating reduced coping self-efficacy in the context of potential depressive
symptoms and challenging life events.

The minority stress model hypothesizes that members of stigmatized social groups are exposed to unique
and additive stressors - such as social and family rejection, harassment, violence, housing and employment
discrimination, and barriers to accessing healthcare - which can lead to internalized negative beliefs and
contribute to psychological distress [6-8,18] . Our findings align with existing research linking discrimination and
stigma to higher rates of depression, anxiety, and suicidal ideation , highlighting the disproportionate
[5,6]
mental health challenges faced by TGD individuals. Among TGD people, minority stress has been associated
with increased risk of self-injurious behavior and suicidal ideation [8,19,20] . Rates of likely depression (24.3%)
and anxiety (40.6%) in our sample were substantially higher than those reported in the United States
cisgender population, consistent with prior literature on mental health outcomes among TGD
individuals [1,19,21] .

Preparation for GGAS is inherently stressful for TGD individuals, who must navigate the healthcare system
and meet pre-surgical criteria while experiencing minority stress. Social support is a key protective factor
against these adverse outcomes. The minority stress model suggests that strong social connections can buffer
stress, fostering resilience and coping abilities among marginalized communities . Social and peer support,
[7-9]
which creates safe and non-stigmatizing environments, promotes coping and resilience, mitigating the effects
of minority stress [7,18,19,22] . Additionally, social support is associated with higher self-esteem and predicts
quality of life, positive surgical outcomes, and psychological well-being following GGAS [23,24] . In comparing
transgender and cisgender populations, Davey et al. (2014) reported that perceived social support (MSPSS)
was markedly lower for transgender women than for cisgender men and women, as well as transgender men
(assigned female at birth) . Consistent with these findings, our results show that higher coping self-efficacy
[23]
correlates with increased perceived social support among TGD individuals seeking GGAS, suggesting that
interventions aimed at enhancing social support may improve health outcomes in this population.

Coping skills are critical for individuals preparing for and recovering from GGAS, as these processes involve
numerous stressors that may be beyond one’s control. Individuals with higher coping self-efficacy are likely
better equipped to self-regulate and problem-solve when facing insurance challenges, surgical delays, or the
task of assembling and engaging support networks, as well as managing post-operative complications
ranging from minor wound separation to major life-threatening events. Our research examines the interplay
between social support and coping self-efficacy in the context of GGAS for the TGD community. Given the
important role of peer and social support in fostering coping skills, mental health, and positive outcomes
among individuals undergoing life-changing surgeries, access to targeted interventions should be an integral
part of the multidisciplinary care approach for TGD individuals with higher support needs. These findings
underscore the necessity for further research and the development of interventions designed to strengthen
coping capacity, particularly during the GGAS process.

Limitations
There are several limitations to this study. This was a single-center study using convenience sampling via a
survey distributed to TGD patients seeking GGAS (vaginoplasty or vulvoplasty). While our sample included
Medicaid enrollment rates consistent with the U.S. TGD population , generalizability is limited due to
[25]
variability in GGAS coverage across state Medicaid programs and Oregon’s comprehensive Medicaid
expansion following the Affordable Care Act in 2010 . Additionally, our sample does not reflect the broader
[26]