Gender-affirming Surgeries/ Procedures
Gender Affirming Surgeries/ Procedures– particularly genital surgery – is often the last and the most considered step in the treatment process for gender dysphoria. While many trans, intersex and gender diverse individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim,2006).
Criteria for Gender-affirming Procedures
1. Breast/Chest Surgery (One Referral)
Criteria for mastectomy in transmasculine patients and breast augmentation in transfeminine patients
persistent, well-documented gender dysphoria;
capacity to make a fully informed decision and to consent for treatment; Age of consent in a given country
If significant medical or mental health concerns are present, they must be reasonably well controlled.
It is recommended that transfeminine patients undergo feminizing hormone therapy (for a minimum of 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.
2. Genital Surgery (Two Referrals)
Criteria for hysterectomy/ salpingo-oophorectomy in transmasculine patients and for orchiectomy in transfeminine patients
persistent, well-documented gender dysphoria;
capacity to make a fully informed decision and to consent for treatment; age of majority in a given country;
If significant medical or mental health concerns are present, they must be well controlled.
continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).
The aim of gender-affirming hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression before the patient undergoes irreversible surgical intervention. These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria.
Criteria for metoidioplasty or phalloplasty in transmasculine patients and for vaginoplasty in transfeminine patients
persistent and well-documented gender dysphoria
capacity to make a fully informed decision and to consent for treatment; age of majority in a given country;
If significant medical or mental health concerns are present, they must be well controlled.
continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).
continuous months of living in a gender role that is congruent with their gender identity.
It is recommended that these patients also have regular visits with a mental health or other medical professional.
REFERRAL FOR SURGERY
Surgical treatments for gender dysphoria can be initiated by a referral (one or two, depending on the type of surgery) from a qualified mental health professional.
The mental health professional provides documentation—in the chart and/or referral letter—of the patient’s personal and treatment history, progress, and eligibility.
One referral from a qualified mental health professional is needed for breast/chest surgery (e.g., mastectomy, chest reconstruction, or augmentation mammoplasty).
Two referrals—from qualified mental health professionals who have independently assessed the patient—are needed for genital surgery (i.e., hysterectomy/salpingo-oophorectomy,orchiectomy, genital reconstructive surgeries).
REFERRAL LETTERS
The recommended content of the referral letters for surgery is as follows:
The client’s general identifying characteristics;
Results of the client’s psychosocial assessment, including any diagnoses;
The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;
An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;
A statement about the fact that informed consent has been obtained from the patient;
A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.
For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.
Gender Affirming Surgical Procedures for the Treatment of Patients with Gender Dysphoria
Transmasculine people
Gender-affirming procedures may include the Following:
Breast/chest surgery: subcutaneous mastectomy, creation of a male chest;
Genital surgery: hysterectomy/salpingo-oophorectomy, reconstruction of the fixed part of the urethra, which can be combined with a metoidioplasty or with a phalloplasty (employing a pedicled or free vascularized flap), vaginectomy, scrotoplasty, and implantation of erection and/or testicular prostheses;
Nongenital, nonbreast surgical interventions: voice surgery (rare), liposuction, lipofilling, pectoral implants, and various aesthetic procedures.
Transfeminine people
Gender Affirming Procedures may Include the Following:
Breast/chest surgery: augmentation mammoplasty (implants/lipofilling);
Genital surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty;
Nongenital, nonbreast surgical interventions: facial feminization surgery, liposuction, lipofilling,voice surgery, thyroid cartilage reduction, gluteal augmentation (implants/lipofilling), hair reconstruction, and various aesthetic procedures.
GENITAL SURGERY TECHNIQUES
Transfeminine people
Genital surgical procedures for the transfeminine patient may include orchiectomy, penectomy, vaginoplasty, clitoroplasty, and labiaplasty. Techniques include penile skin inversion, pedicled colon sigmoid transplant, and free skin grafts to line the neovagina. Sexual sensation is an important objective in vaginoplasty, along with creation of a functional vagina and acceptable cosmesis Klein & Gorzalka, 2009; Lawrence, 2006).
Transmasculine people
Genital surgical procedures for transmasculine patients may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, and phalloplasty. For patients without previous abdominal surgery, the laparoscopic technique for hysterectomy and salpingo-oophorectomy is recommended to avoid a lower-abdominal scar.
Vaginal access may be difficult as most patients have often not experienced penetrative intercourse. The current operative techniques for phalloplasty are varied.
The choice of techniques may be restricted by anatomical or surgical considerations and by a client’s financial considerations.
If the objectives of phalloplasty are a neophallus of good appearance, standing micturition, sexual sensation, and/or coital ability, patients should be clearly informed that there are several separate stages of surgery and frequent technical difficulties, which may require additional operations.
Even metoidioplasty, which in theory is a one-stage procedure for the construction of a microphallus, often requires more than one operation. The objective of standing micturition with this technique cannot always be ensured (Monstrey et al., 2009).
GENITAL SURGERY COMPLICATIONS
Surgical complications of transfeminine genital surgery
They may include :
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complete or partial necrosis of the vagina and labia,
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fistulas from the bladder or bowel into the vagina,
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stenosis of the urethra, and
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vaginas that are either too short or too small for coitus
Surgical complications of transmasculine genital surgery
They may include :
frequent urinary tract stenoses and fistulas,
and occasionally necrosis of the neophallus.
Metoidioplasty results in a micropenis without the capacity for standing urination.
Phalloplasty, using a pedicled or a free vascularized flap, is a lengthy, multi-stage procedure with significant morbidity that includes frequent urinary complications and unavoidable donor site scarring. For this reason, many transmasculine patients never undergo genital surgery other than hysterectomy and salpingo-oophorectomy (Hage & De Graaf, 1993).
Even patients who develop severe surgical complications seldom regret having undergone surgery.
The importance of surgery can be appreciated by the repeated finding that the quality of surgical results is one of the best predictors of the overall outcome of sex reassignment (Lawrence, 2006).
POSTOPERATIVE CARE AND FOLLOW-UP
Long-term postoperative care and follow-up after surgical treatments for gender dysphoria are associated with good surgical and psychosocial outcomes (Monstrey, 2009).
Follow-up is important to a patient’s subsequent physical and mental health and to a surgeon’s knowledge about the benefits and limitations of surgery. Surgeons who operate on patients coming from long distances should include personal follow-up in their care plan and attempt to ensure affordable local long-term aftercare in their patients’ geographic region.
RESOURCES
Gender-Affirming Surgeries
TRANS CARE BC
Surgery Considerations
TRANS CARE BC
Upper Body Surgeries
TRANS CARE BC
Lower Body Surgeries
TRANS CARE BC
Surgery Assessment
TRANS CARE BC
Surgery Referral
TRANS CARE BC
Preparing for Surgery
TRANS CARE BC
Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People
THE WORLD PROFESSIONAL ASSOCIATION FOR TRANSGENDER HEALTH (WPATH)
Gender Affirmation (Confirmation) or Sex Reassignment Surgery
CLEVELAND CLINIC
Please Remember:
Gender Affirming Surgeries/ Procedures– particularly genital surgery – is often the last and the most considered step in the treatment process for gender dysphoria. While many transsexual, transgender, and gender-nonconforming individuals find comfort with their gender identity, role, and expression without surgery, for many others surgery is essential and medically necessary to alleviate their gender dysphoria (Hage & Karim,2006).