Tag Archives: sex reassignment surgery

Orgasm after Vaginoplasty

Orgasm and sexual pleasure are important goals of gender reassignment surgery (GRS). Most trans women report being able to orgasm after penile-inversion vaginoplasty with clitoroplasty using the glans penis.* However, some are not able to orgasm and some report difficulty orgasming.

Two large studies found that 18% of trans women were not able to orgasm by masturbation after surgery. In one of the studies an additional 30% of the women had difficulty orgasming from masturbation.

The number of women who couldn’t orgasm went down to 14% or 15% when they included all sexual activities.

Other recent studies** have found numbers of anorgasmic women ranging from 0% to 52%, although most results were close to 18%.

It is clear that a significant percentage of trans women are not able to orgasm after this type of vaginoplasty, but it is not clear exactly how many.

SOME RECENT STUDIES OF ORGASM AFTER GRS

There were five studies where the women had clearly been sexually active:

Lawrence, 2005 – anonymous questionnaires from 232 trans women, 227 answered the question on orgasm by masturbation:

18% were never able to achieve orgasm by masturbation.

15% were rarely able to orgasm with masturbation.

15% were able to orgasm less than half the time by masturbation.

However, it seems that only 15% were completely unable to orgasm. “About 85% of participants who responded to questions about orgasm were orgasmic in some manner after SRS [GRS].” 

Imbimbo et al., 2009 – 139 trans women (93 questionnaires at clinic, 46 phone interviews):

14% of the trans women complained of anorgasmia

18% of the trans women were never able to orgasm by masturbation (out of 33 women who masturbated)

33% of the trans women were never able to orgasm by vaginal intercourse and 25% seldom orgasmed this way (out of 60 women having vaginal intercourse)

22% of the trans women were never able to orgasm by anal sex and 13% seldom did (out of 75 women having anal sex)

56 women had oral sex, but the study gives no numbers for orgasm.

Buncamper et al., 2015 – 49 trans women completed questionnaires:

10% had not had orgasm after surgery, although they had tried.

Selvaggi et al., 2007 – 30 trans women were personally interviewed by a team of experts:***

15% had not experienced orgasm after surgery during any sexual practice.

Giraldo et al., 2004  – 16 trans women were given structured interviews at follow-up visits:

0% had problems – all the women reported the ability to achieve orgasm

Note: This study is about a modification to the technique for creating a clitoris.

There is one study where 18% of the women never orgasmed after surgery, but it is not clear if they were sexually active or not:

Hess et al., 2014 – 119 trans women completed anonymous questionnaires, 91 answered the question “How easy it is for you to achieve orgasm?”:

18% said they never achieve orgasm

19% said it was rarely easy for them to achieve orgasm

The other studies above asked about sexual activity or gave the women an option to say the question did not apply or they had not tried. This one did not.

On the other hand, some people did not answer the question, so perhaps women who were not sexually active skipped the question on orgasm.

There are three studies that only give brief information on how many women could orgasm; it is not clear what is going on with the rest of the women.

Perovic et al., 2000 – 89 trans women were interviewed:

It looks like 18% had not experienced orgasm during vaginal sex, but it is possible that some of the women were not sexually active.

“Information on sensitivity and orgasm was obtained by interviewing the patients; the sensitivity was reportedly good in 83, while 73 patients had experienced orgasm.”

and

“If the penile skin is insufficient, the creation of the vagina depends on the urethral flap, which also provides moisture and sensitivity to the neovagina. The results of the interviews showed that orgasm was mainly dependent on the urethral flap.”

Goddard et al., 2007 – 70 trans women were interviewed by a telephone questionnaire; 64 of them had had a clitoroplasty:

It looks like 52% of the women with clitorises were not able to achieve clitoral orgasm, but again it is not clear if they were sexually active.

“Clitoral sensation was reported by 64 patients who had a neoclitoris formed and 31 (48%) were able to achieve clitoral orgasm.”

14% of the women complained of “uncomfortable clitoral sensation.”****

Wagner et al. (2010), – 50 trans women completed a questionnaire:

It looks like between 17% and 30% were not able to achieve clitoral orgasm.

“Of the 50 patients, 35 (70%) reported achieving clitoral orgasm” but

“90% of the patients were satisfied with the esthetic results and 84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm.” 

If we look only at the group having regular intercourse, 17% of them are not having clitoral orgasms. But were the women not having intercourse masturbating and unable to orgasm? If so, they were also sexually active and the 30% number is the relevant one.

The study gives very little information on the questionnaire and results, but it seems surprising that 83% of the women were having clitoral orgasms from sexual intercourse; that is not typical in cis women.

A final study asked about pleasurable sexual intercourse, not orgasm:

Salvador et al., 2012 – 52 trans women participated in the study. It is unclear how they were surveyed, but based on this earlier study, it could have been a combination of a questionnaire and interview.

8% did not consider vaginal sex pleasurable.

However, only one woman said sexual intercourse was unsatisfactory (2%) while 10% of the women said it was average; presumably some of the women who said it was average also said it was pleasurable and some did not.

About Orgasms

Freud believed that women had vaginal and clitoral orgasms; unfortunately he also believed that vaginal orgasms were superior and mature women should give up clitoral orgasms. In the 1960s Masters and Johnson showed the physiological basis for clitoral orgasms in the lab; they argued that orgasms during intercourse were also clitoral orgasms, just harder to achieve. More recently, some sexologists have shown that some women have G-spot orgasms during intercourse, although not all experts believe in them.

For most women it is easiest to have an orgasm from masturbation or clitoral stimulation. Most women are not able to have clitoral orgasms during vaginal intercourse without additional clitoral stimulation. Some women experience other types of orgasms during vaginal intercourse.

Although trans women’s biology is somewhat different from cis women’s, their clitorises are formed from the most sensitive area of the penis. Therefore, we might expect trans women to have orgasms most easily from masturbation of the clitoris; the study by Imbimbo et al. that compares different sexual activities supports this hypothesis.

It also makes sense that when we look at orgasms from all sexual activities, we find more trans women are able to orgasm than when we look at just clitoral orgasms; some trans women may be having G-spot orgasms involving their prostate gland.

Interestingly, Imbimbo et al. found that it was easier for trans women to have orgasms from anal sex than vaginal sex (65% of the women often had orgasm from anal sex, 35% seldom or never did; 42% of the women always or often had orgasm from vaginal sex and 58% seldom or never did). Furthermore, more of the trans women were having anal sex than vaginal sex (54% versus 43%). Perhaps they had more experience with anal sex before surgery or perhaps anal sex worked better for some women.

Studies that simply ask about orgasm without talking about what type of orgasm or sexual activity is involved do not give enough information about what is happening. Future studies that include this information would make it easier to compare the results and to improve outcomes.

Comparing the Studies

It is difficult to compare the results of the studies. The studies are of surgery at different clinics around the world; the work is being done by different surgeons and may involve variations in technique. Some of the surgeries are more recent than others as well.

In addition, the studies use different methodologies to collect data and they do not ask the same questions. Some are focused on clitoral orgasms, others talk about orgasm during intercourse, some studies talk about masturbation, and some are vague about what they mean by orgasm.

As is common in follow-up studies, almost all of the studies had a significant drop-out rate; not everyone who had the surgery participated in the study. This could create a bias in either direction – people who regret the surgery might be too depressed to respond to the clinic or people who were dissatisfied might be more motivated to participate in the study.

The method of the study could also introduce biases; people may be more likely to tell the truth in an anonymous survey than in an interview. On the other hand, interviews may allow for follow-up questions and clarifications.

With only 10 studies that are so different it is impossible to come to any definitive conclusions about orgasm after GRS. I like to believe that Goddard et al.’s numbers of anorgasmic women are so high because some of them were sexually inactive or because their study included women 9-96 months after surgery. It could also be something to do with their surgical technique. After all Perovic’s et al.’s study also included women 0.25-6 years after surgery and some of them may have been sexually inactive, but their numbers were much better.

I suspect that the reason all of Giraldo et al.’s patients were orgasmic is that their sample size is so small, but again, it could be that they have a superior technique.

It might be that Buncamper et al. had better numbers than most of the studies because their patients had surgery more recently with improved techniques, but it might also be because their study was smaller.

With so few studies, I could find no clear pattern based on when people had surgery, how data was collected, or follow-up time after surgery. For further information on the studies, see this appendix.

What is clear is that we need more research on patients who are not able to orgasm after surgery. Are some people more at risk than others? Does the surgical technique make a difference? What role does aftercare play?

Is being non-orgasmic just a possible complication of the surgery? If so, how common is it?

And most important, what can be done to enable all trans women to be able to orgasm after surgery?

 

 

 

*I did not find data on orgasm after intestinal vaginoplasty. According to this 2014 review of studies, most studies of intestinal vaginoplasty did not look at sexual function; for those that did the review reports a score for sexuality rather than information on orgasms.

** I have excluded studies published before 1994 and studies where all of the surgeries were performed before 1994. The studies by Imbimbo et al. and Selvaggi et al. may include some participants who had surgery before 1994.

*** The exact number of the participants is unclear because this study is one of a pair using the same participants. The other study by de Cuypere et al. did in-depth interviews with 32 trans women while this one focused on testing the sensitivity of the genitals for 30 trans women. Unfortunately, the de Cuypere study reports data in terms of how many women “Never-sometimes” had orgasm so their data is not comparable to other studies. (They found that 34% of the women never-sometimes had orgasm during masturbation and 50% never-sometimes had orgasm during sexual intercourse.)

**** Goddard also reports that despite problems, “no patient elected to have their clitoris removed.” Is the man mad?

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Sensate Vagina Pedicled-Spot for Male-to-Female Transsexuals: The Experience in the First 50 Patients – Review

A Dutch surgeon has developed a new technique to create erotic sensations in trans women’s vaginas.

The author operated on 50 trans women (born male) between August 2009 and May 2014. He created a a sensate vagina pedicled-spot and a neo-clitoris during primary penile skin inversion vaginoplasty. Part of the corona glandis of the penis is “pedicled on the dorsal penile neurovascular bundles” and put into the neo-vagina.

The goal of the operation is to increase sexual sensitivity for trans women.

“One of the goals of sex reassignment surgery is to create tactile and erogenous sensitivity in the reconstructed genitals. A neo-clitoroplasty performed during primary gender-confirming surgery for male-to-female transsexuals, is a procedure which has been considered state of the art for over 40 years, gives sexual functionality to the neo-female genitalia. This goal falls short due to the inner neo-vagina’s lack of erogenous sensitivity, having instead only tactile sensitivity of the skin and prostate. This shortcoming persists despite the refinements to the vaginoplasty throughout the years.

To improve the sexual functionality, I have innovated a technique that creates a sexual sensate vagina pedicled-spot in the male-to-female transsexuals, which could be compared with the G-spot, in combination with neo-clitoroplasty.”

At 15 weeks, 82% of the patients had sexual feelings in the clitoris and 62% had sexual feelings in the sensate pedicled spot within the vagina. However, the study also says that erogeneous sensibility recurred in all the patients; so perhaps some patients developed sensitivity after 15 weeks.

The study does not discuss orgasms or patient satisfaction. There is no information on whether or not the trans women were having active sex lives. Future studies should look at these issues.

Future research should also look at whether there are any differences between neo-clitorises created with this procedure and other neo-clitorises. Does it affect the clitoris if part of the corona glandis is used to create the sensate pedicled spot within the vagina?

This is an exciting first study, however. Creating sexual arousal and pleasure is an important part of gender reassignment surgery.

What about safety?

The technique added 15 minutes to the time of the operation. This might increase the risk of blood clots, although they did not report any.

Complications included:

6% per-operative rectal lesions which were directly closed

2% post-operative bleeding

34% one or more aesthetic corrections involving the introitus, labia majora, or clitoral region,

4% infections treated with antibiotics

10% post-operative bladder retention which resolved spontaneously after 1 week

20% had meatoplasty to enlarge the opening for peeing

It is difficult to evaluate the relative rate of complications. The rate of bleeding in this series compares well to rates reported in this 2010 German study (6%) and this 2011 overview from the United Kingdom (10%). On the other hand, their rate for problems with narrowing of the urethra is much higher than in the other two studies (none and 3-4% respectively). In this review of studies, a 2001 German study had higher rates of complications. None of the other studies discuss aesthetic corrections.

We need studies that compare the relative safety and rates of complications of different surgical procedures, including this one.

More Details on the Study:

40% of the patients felt sensations in the clitoris an average of 11 weeks before the sensate pedicled spot, 40% felt sensations in both at the same time, 4% felt sensations in the sensate pedicled spot first, and 12% were unclear on the timing.

Erogenous feelings in the clitoris recurred after 7.6 weeks on average in 46 patients, with a range of 5 days to 48 weeks. Erogenous feelings in the sensate pedicled spot recurred after 12.6 weeks on average in 44 patients, again with a range of 5 days to 48 weeks.

For one patient, “the sensate pedicled-spot was lost due to pressure but remarkably the sensate potency was not lost in this case.”

“Hypersensibility occurred in two patients of the sensate pedicled-spot along with hypersensibility of the clitoris.”

The average age of the patients was 38.4 years (range 19–65 years).

Follow-up ranged from 17 to 73 months (mean 46.7 months) and is still ongoing.

You can read details of the surgical technique used below.

Original source (contains graphic photos of surgery):

Sensate Vagina Pedicled-Spot for Male-to-Female Transsexuals: The Experience in the First 50 Patients by Kanhai RC in Aesthetic Plast Surg. 2016 Apr;40(2):284-7.

Technique described in this study:

“For the vaginoplasty, I employ a modification of the abdominally pedicled penile skin inversion technique enhanced by a dorsal rectangular scrotal skin flap. For this, the penile skin tube with the fascia penis superficialis (dartos fascia) and superficial dorsal cutaneous veins adherent to it are dissected from the erectile corpora, leaving the dorsal neurovascular bundles unharmed and covered by Buck’s deep penile fascia. Subsequently, two longitudinal incisions through Buck’s fascia, but not through the tunica albuginea, are made bilateral to the dorsal neurovascular bundles. By blunt and sharp dissection, the intermediate fascia, including both dorsal neurovascular bundles, is raised from the tunica albuginea all the way from the base of the glans to the urogenital diaphragm. After undermining part of the glans, two small parts of its corona and a part of the preputium is left attached to this pedicle which will be divided. One part will serve as a vascularized sensate neoclitoris with its preputial hood and the other part will be the sensate pedicled-spot. The sensate pedicled-spot will be attached to the anterior wall of the vagina in the ostium region and invisible in frontal view.”

Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality – Review of Abstract

The authors of the study suggest that gender reassignment surgery may increase psychiatric problems for some people and decrease them for other people.

The study looked at the medical records of 104 people who had sex reassignment surgery in Denmark between 1978 and 2000.

They found that there was no statistically significant difference between the number of psychiatric diagnoses before surgery and after surgery.

In addition, the people who had diagnoses before surgery were different from the people who had diagnoses after surgery. Only 6.7% of the group had a psychiatric diagnosis both before and after surgery while 27.9% of the group had a psychiatric diagnosis before surgery and 22.1% had one afterwards.

According to the authors “this suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.”

The study also found that:

Psychiatric diagnoses were over-represented both before and after surgery (i.e. the group had more psychiatric issues than the general population).

Trans men (born female) had a significantly higher number of psychiatric diagnoses overall; there were no other statistically significant differences between trans men and trans women.

At the same time “significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth.”

10 people had died at an average age of 53.5 years.

Questions for the Future

The most important question is, of course, how can we make sure that SRS does not increase psychiatric problems in the future?

Is it a question of better screening to identify gender dysphoria?

Do people need more support and counseling after surgery?

Should some people transition without getting surgery?

Were poor surgical outcomes linked to psychiatric problems?

Could low hormone levels after surgery cause problems for some people?

Were people’s problems caused by the surgery or some other aspect of transition that happened after surgery?

Or to put it another way, how do we identify which people might benefit from surgery and which might be hurt by it? or do we need to make other changes to prevent new psychiatric diagnoses after surgery?

It would also be helpful to know more about the specific psychiatric diagnoses before and after surgery. Are we seeing increases in depression, anxiety, eating disorders, or what?

How did the patients whose mental health improved compare to those whose mental health got worse? Were they older or younger? What were their life circumstances?

What does it mean that trans men had more psychiatric diagnoses before surgery? Was surgery more beneficial for them than for trans women or did trans men just have more psychiatric problems overall?

How long after surgery did people get the new psychiatric diagnoses?

More about the study:

Only the abstract of the study is available online, so it is hard to interpret some of their results.

The abstract gives few further details on their methodology, but a similar study of physical illnesses and death looked at the records of 56 trans women (born male) and 48 trans men (born female). The follow-up period began when people received permission for surgery. The group used in the other study represented 98% of all people who officially had SRS in Denmark from 1978 to 2000.

Original source:

Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality by Simonsen RK, Giraldi A, Kristensen E, Hald GM in Nord J Psychiatry. 2016;70(4):241-7.

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients – Study Review

This is a 2010 study of the functional and cosmetic outcomes of the surgical techniques used at a German clinic. They followed 50 trans women who had surgery between May 2001 and April 2008. The surgeries were all performed by the same surgeon who had extensive surgical experience.

Before surgery, all the patients had completed a two year “real life” test and had been recommended for surgery by two independent psychiatrists. They had been on hormones for at least one year, although they stopped taking hormones a month before the surgery.

The patients were sent a questionnaire to follow-up on sexual function and patient satisfaction with the surgery. All 50 patients completed the questionnaire; the mean follow-up time was 3 years.

Outcomes of Surgery

Regrets:

One person regretted the surgery and became clinically depressed. They attempted suicide twice and had not fully recovered two years later.

The patient was 24 years old and the authors suggest that the ideal age for surgery is 30 years old. They also recommend thorough evaluation and good counseling before surgery.

This is consistent with other studies that found a regret rate after surgery of 3-4%. In a group of 50 people getting the surgery, you would expect one or two people to wish that they had not had the surgery.

The patient regretted the surgery 3 days after the operation.

Complications:

6% had bleeding after surgery

4% required operative revision due to the bleeding (two of the three who had bleeding)

10% had shrinkage of the vagina which could be corrected by a second surgical intervention

4% had a minor bulge in the anterior vaginal wall which could be easily fixed with simple excision

There were no post-operative rectocele (bulge of the rectum into the vagina) or urethrovesical fistulae.

The authors of the study say that the incidence of surgical complications was comparable to the data in the literature.

The 6% of patients with bleeding that they report is better than the 10% reported by a United Kingdom clinic in this review.

Their rate of complications is considerably better than this 2001 study at a different German hospital which reported that “Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.”

They do not report any problems with narrowing of the urethra, which is also an improvement over the 3-4% reported by the clinic in the Untied Kingdom.

They do not report any problems with pulmonary embolisms or fistualae between the rectum and vagina. These are problems that are relatively rare and you might not expect to see them in a group of only 50 people; the review from the United Kingdom reported a rate of 2 in 1000 pulmonary embolisms with 1 death. They also reported a rate of 6 in 800 rectal fistulae.

Minor complications:

6% subcuntaneous hematoma that did not require any further therapy (i.e. they had a ruptured blood vessel causing a lump or bruise under the skin)

General:

Mean operative time – 190 (160–220) minutes or 3.16 (2,66- 3.66) hours

Mean depth of the vagina – 10 (6–14) cm or 3.93 (2.36-5.51) inches

Median hospital stay – 10 (6–14) days

In comparison, the United Kingdom clinic reported an operative time of 120-150 minutes, while the 2001 German study reported a mean time of 6.3 hours with a range of 4-9 hours.

Satisfaction with results at follow-up

Appearance:

10% of the patients were dissatisfied with the appearance of their labia

90% were satisfied with the appearance of their genitals

We need more research on how to construct labia that are satisfactory for all trans women.

Depth of Vagina:

20% were dissatisfied with the depth of their vagina

80% were satisfied with the depth of their vagina

4% were still dissatisfied with their vagina after a second operation

Of the ten women who were dissatisfied with the depth of their vagina, eight had a new operation to augment the vagina. Of the women who had the second operation, two were still dissatisfied (25%). Perhaps the secondary operation could be improved.

We need to know more – why were 20% dissatisfied with the depth of their vagina? What can be done to ensure that all trans women have vaginas that are deep enough?

How deep were the vaginas at follow-up? Were there some women whose vaginas were not deep who were satisfied anyway?

Sexual Pleasure:

5% of the trans women having regular sexual intercourse experienced pain during intercourse; 84% of the trans women were having regular sexual intercourse

70% of the trans women reported achieving clitoral orgasm

The authors are not clear here, but it looks like 30% of the trans women who had this surgery are unable to achieve orgasm. This is a serious problem; they should have addressed it more fully.

Were some of the women not attempting orgasm? Did everyone answer the question?

At one point the authors say, “84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm” – that would change the numbers to 35 out of 42 women which would be better (although it would still leave 17% of the sexually active women not having orgasms). On the other hand, they also say, “Of the 50 patients, 35 (70%) reported achieving clitoral orgasm.”

As it stands, it looks like a large percentage of trans women are not having orgasms after surgery. That would be a problem and worthy of more discussion in the results. The ability to orgasm is an important, vital aspect of the outcome of these surgeries.

In addition, doctors and surgeons need to address the problem of pain during intercourse. Is there something trans women can do themselves to reduce the pain? Can the surgeries be improved in this area?

From their Discussion and Conclusions:

“The incidence of surgical complications was comparable to the literature data. The most common complication (10%) in the follow-up was shrinkage of the neovagina. In all cases a second surgical correction was necessary to definitively solve the problem. In all patients vaginopexy to the sacrospinous ligament was carried out, reducing the rate of neovaginal prolapse as described in the literature.

After 3 years, 49 patients were satisfied and did not regret or had doubts about having undergone sexual reassignment surgery. The only exception was a 24-year old patient who, 3 days after the operation, regretted his decision. After that, he developed a strong depression which needed psychological therapy. Two years after surgery, the patient had still not recovered completely and had attempted suicide twice.

We agree with Rehman and Melman that the best age to undergo sexual reassignment surgery is 30 years, an age that enables patients to adjust socially and sexually, increasing the possibility to develop attractiveness and allowing the patients to mature in dealing with new life stresses. Moreover, before undergoing such surgery, it is our opinion that all patients at all ages need deep and intensive psychological examination and must be informed about all the functional and cosmetic risks associated with this operation and, above all, about the impossibility of regretting the decision and returning to their natural gender.

With improvements in surgical technique over the years, male-to-female gender-transforming surgery can assure satisfying cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains a central important aspect for obtaining optimal results.”

The full article includes graphic pictures of surgery as well as details of their technique; you can get it at the link below.

Original Source:

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients by Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, Fornara P in Urol Int. 2010;84(3):330-3.

Review of Evaluation of surgical procedures for sex reassignment: a systematic review

This is a 2007 review of research on gender reassignment surgery. It shows clearly that we need more research in this area.

The research is not strong enough to evaluate the efficacy of gender reassignment surgery in general. In addition, we do not have a way to evaluate particular surgeries.

From the abstract:

“The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.”

The authors reviewed all the articles they could find on gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The great strength of this review is that they looked at individual surgical procedures. Too often studies lump together all gender reassignment surgeries and then evaluate whether or not they were effective. It is possible that some surgeries are more helpful for people’s mental well-being than others. In addition, some surgeries may have better physical outcomes or fewer risks than others. The physical outcomes could certainly affect people’s mental well being as well.

They did not find enough good studies looking at individual surgeries; there is a great need for more such studies. We need to know what are the complications and problems with various surgeries. Are some techniques better than others? Do some medical centers have better physical outcomes than others?

Only a few of the studies reported on patients’ well-being, mental health, or satisfaction; these studies had the same methodological weaknesses as the others.

This is the main finding of the review – we don’t have great data and we need further research. You can read more about some of the specific surgical procedures here.

The authors discuss the quality of research and directions for future research; I have included their discussion below.

Discussion

In the first section concerning MTF surgical procedures, 38 published papers met the inclusion criteria (23 case series and 15 case studies) with an additional 13 papers excluded (four case series, three case studies, four reviews, one prospective non-randomized controlled study, one expert opinion). The level of included evidence was of poor quality. There was a clear lack of randomized controlled evidence and only one excluded study included a control group comparison. No studies met the inclusion criteria for labiaplasty, orchidectomy or penectomy procedures. A large amount of evidence is available reporting vaginoplasty and clitoroplasty procedures. Some complications have been reported. All the studies report, to various degrees, satisfactory outcomes in terms of being able to have penetrative sexual intercourse and achieving sexual fulfilment.

In the second section concerning FTM surgical procedures, 44 published papers met the inclusion criteria (26 case series, 17 case studies, one cohort study) with an additional 19 papers being excluded (seven reviews, five expert opinions, four case series, three case studies). The majority of included evidence was of poor quality. Many of the studies reported good satisfactory outcomes with few complications for each of the individual procedures. The main outcomes reported were the ability to perform penetrative sexual intercourse and achieve orgasm. Another key factor requested by many FTM patients was the ability to void whilst standing. Whilst successful results were reported by many studies for phalloplasty procedures, an inability to perform sexual penetration due to the construction of a small phallus was a common problem reported following the metoidioplasty procedure. Some of the FTM core surgical procedures are frequently completed along with other surgery, making it difficult to assess the effectiveness of each procedure alone. Furthermore, the assessment of effectiveness is also confounded by the lack of controlled evidence, unclear outcome measures, and a reliance on case series and case studies.

Six previous reviews have reported the clinical effectiveness of GRS. Six reviewed evidence in MTF patients and three of these also reviewed evidence in FTM patients. Of these, three were systematic reviews. These earlier reviews provide a summary of approximately 172 individual studies. Two recent unpublished reports provided a brief summary of some of the reviews. Several key points were raised in these previous reviews. The first related to the quality of the evidence and study design. Concerns were raised about the lack of randomized controlled evidence, the majority of evidence involved case studies and case series, with few studies using group comparisons, standardized measures or the follow up of participants. A second concern related to the validity of findings. Many studies involved a combination of different surgical procedures. Thirdly, there was concern about the validity of outcome measures. Despite many reports of positive outcomes of patients, there was little consensus of how to measure effectiveness. The large range of outcomes reported across studies makes it difficult to accurately evaluate the overall outcomes of individual surgical procedures.

Several previous reviews reported a controlled study which compared 20 patients having immediate surgery with 20 patients awaiting surgery for penectomy, orchidectomy and the construction of a neovagina. The remaining studies reflect lower grades of evidence, and had further problems in their design such as selected patient groups, retrospective analysis and losses to follow up. Conclusions from the reviews are understandably tentative, but highlight improvements in patients across most studies, although 10–15% of patients with transsexism who undergo GRS have poor outcomes.

The quality of evidence included in this review has been poor due to the lack of concealment of allocation, completeness of follow up and blinding. As well as the fundamental limitation in study design, several other issues regarding the interpretation of the evidence are worth consideration. Firstly, all the reviews, and many of the individual studies within them, examine different types of GRS. The Mate-Kole study, for example, is essentially an evaluation of three surgical techniques. Clearly, trying to reach a robust conclusion about GRS as a whole is not possible when the combination of techniques varies across studies. Secondly, the patient populations within, and across studies, are heterogeneous and we have little idea about the referral, diagnosis, assessment and selection processes that precede inclusion within the studies. Consequently, Brown concludes that a lengthy differential diagnosis and a specialized approach to interviewing gender dysphoric patients are needed. Thirdly, the choice of outcome measures varies across studies, with very little use of validated health-related quality of life (QOL) measures. This complicates further our ability to draw conclusions, and also limits the commissioners’ ability to identify studies that use outcomes that are relevant to their role. Finally this review has focused on a subset of surgical procedures that are used within this field. Whilst these are considered to be the most routine, it is recognized that other procedures are currently used and these too need to be critically appraised in future reviews.

No published evidence on cost-effectiveness was found. Best and Stein speculate that some cost offsets are possible following surgery due to the reduced need for psychiatric and hormonal treatment, but no evidence is available for this. The lack of generic QOL measures means that measures of cost-effectiveness that can be used to assess value for money relative to other healthcare interventions are not possible.

When trying to consider all of the evidence together, there is a dilemma regarding its interpretation. Reviews of heterogeneous patient groups and interventions clearly give the greatest depth of evidence, but give little in the way of specific information that is of use to purchasers. In contrast, studies of individual techniques have a more limited evidence base but allow us to focus on specific clinical questions with more consistent reporting. But these provide information on purchasing decisions that are less realistic, as some procedures are unlikely to be purchased in isolation. In between these extremes, are sets of studies that investigate various combinations of multiple procedures, but matching these studies to the activity of different providers and patients, is extremely complex.

Taking this reasoning further, some would argue that assessment of GRS in isolation is difficult to interpret, as it is the final step in a longer treatment process. This is more contentious, as many patients do not reach the point of referral for surgery and many do not wish to undergo any surgery. Also, taking this argument to its extreme would require studies of the effectiveness of treatment from initial diagnosis to the end of post-surgical follow up; such studies do not exist.

Despite these difficulties in interpretation of review evidence the conclusion about the strength of evidence regarding GRS appears clear: little robust evidence exists.

Future research

There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.

An important consideration for future studies is how best to evaluate the effectiveness of a surgical procedure. One possibility is assessment of patient satisfaction and regret following surgery. More importantly is the need for standardised measures to assess the outcome of surgery. One suitable method, which has received limited research, is the use of QOL measures in samples before and after GRS. Rakic et al. investigated several aspects of QOL after GRS in 32 patients with transsexism (22 MTF, 10 FTM). Four aspects of QOL were examined: sexual activity; attitude towards the patients’ own body; relationships with other people; and occupational functioning. For the majority of persons with transsexism, QOL improved after surgery in terms of these aspects. All patients (100%) were satisfied with their GRS. However, only 20 patients (62%) were satisfied with how their bodies looked. In a study by Barrett, they used the General Health Questionnaire and assessments of depression inpatient groups. More controlled studies using this type of experimental design are needed to provide a better measure of surgical effectiveness.

For many patients undergoing GRS, their desire is to look ‘normal’ and be capable of having a normal sexual relationship. The results presented in this review have provided little evidence on how successful individual surgical procedures are in achieving these goals. Further research is needed to investigate these specific outcome measures of satisfaction and function.

In conclusion, we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.

Original Source:

Evaluation of surgical procedures for sex reassignment: a systematic review by Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy CM in J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):294-306.

Evaluation of surgical procedures for sex reassignment: a systematic review – information on specific surgeries

This is a 2007 review of research on gender reassignment surgery. The authors found that there was not enough strong research to evaluate gender reassignment surgery; you can read more about the study as a whole here. This article looks more at specific surgical procedures.

The authors of the review evaluated individual surgical procedures rather than just looking at the outcome of all gender reassignment surgeries together. This allows a better understanding of which procedures are the most effective. It also means excluding some studies that looked at more than one procedure.

The authors reviewed all the articles they could find on specific gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The following are some of the results they found for specific surgeries. There is not enough data to definitively evaluate particular procedures and techniques, but there is useful information on possible complications. Clearly, however, we need more research.

Surgeries for Trans Women (born male)

Clitoroplasty/neoclitoris construction – The authors reviewed three studies that used a range of surgical techniques. The results were generally good but in one study 2 out of 10 patients had necrosis of the neoclitoris; in another study three out of nine patients did not report sexual satisfaction.

“All three included papers reported successful results in terms of function and cosmetic appearance with few or no complications (e.g. urine leakage). Rehman and Melman reported that the neoclitoris had remained intact postoperatively in eight out of 10 patients and the functional and cosmetic appearance was comparable to a normal clitoris. In two patients, however, the results were not satisfactory because of necrosis of the neoclitoris.

Using the dorsal portion of the glans penis with the dorsal neurovascular pedicle for clitoroplasty, the neoclitorides in nine patients survived well, and six patients reported sexual satisfaction. However, the transpositioning of glans on the long dorsal neurovascular pedicle appears to be a procedure with high risks. Overall, several studies have reported that the neoclitoris construction can result in good preservation of light touch and sexual sensation.

Vaginoplasty/neovagina construction – The authors reviewed 32 studies. Satisfactory cosmetic and functional results were reported in many of the studies, although one found that “vaginoplasty combining inversion of the penile and scrotal skin flaps produced poor functional outcomes.” 

One study reported some severe complications.

A 2001 study from Germany reported that “major complications during, immediately and after surgery occurred in nine of the 66 patients (14%), including necrosis of the distal urethra (n = 1), necrosis of the glans (n = 3), a rectal lesion (n = 3), and severe wound infections (n = 6).”  

In addition, according to the abstract of the 2001 study, “Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft.”

At the same time, 47% of the patients in the 2001 study completed a follow-up questionnaire and almost all of them reported that they were “satisfied with the cosmetic result and capacity for orgasm.” Over half of the people who answered the follow-up questionnaire had had sexual intercourse. It is not clear if the satisfied group included the people who had had complications.

It would be good to have more information to compare to the German results. Are these rates of complications normal?

The reviewers did not find studies that met their criteria for labiaplasty, orchidectomy, or penectomy.

Surgeries for Trans Men (born female)

Hysterectomy – The authors only reviewed one study that met their criteria; it reported successful operations for two trans men. The study also reported that “a laparoscopic hysterectomy using the McCartney tube for FTM GRS was a useful procedure in overcoming difficulties encountered due to restricted vaginal access.”

Mastectomy – The authors reviewed three studies: “Colic and Colic found the use of a circumareolar approach for subcutaneous mastectomy produced flatter masculine breasts, leaving sufficient dermal vascularization for the nipple-areola complex. Of the 12 FTM patients all were very satisfied with the outcomes of surgery mainly because of the periareolar scar. It was reported, however, that two areolar necroses occurred due to perforation of the thin vascular dermal pedicle.”

Metoidioplasty – The authors reviewed two studies.

In the first, the procedure was successful for 32 patients with an average hospital stay of 11 days. One patient had a severe haematoma (solid swelling of clotted blood), but there were no other complications.

In the second study, 17 patients were satisfied with the size and appearance of their penis, but 5 people required additional augmentation phalloplasty. In two cases, the trans men developed urethral stenosis (narrowing of the urethra) and in three cases they developed fistula. The complications were related to the urethroplasty.

The reviewers add: “The metoidioplasty procedure produces a very small phallus (e.g. mean = 5.7 cm, range = 4–10 cm), hardly capable of sexual penetration, if at all. Only 10 of the 32 patients were able to void whilst standing. It should be noted that in the study by Hage et al, 18 patients combined the metoidioplasty procedure with the construction of a bifid scrotum in which testicular prostheses were implanted. Overall these two studies found metoidioplasty was an appropriate method where the clitoris seems large enough to provide a phallus and satisfies the patient.”

Phalloplasty – There is only limited data on the outcomes of phalloplasty, although two studies reported good outcomes in terms of size and stiffness and one reported good psychological outcomes.

However, there are a range of procedures and they have mixed results.

Serious complications have been reported and phalloplasty leaves a scar somewhere on the body.

One study found that creating the neourethra in two stages could reduce complications.

Another study using a suprapubic abdominal wall flap produced a good cosmetic appearance for 68% of the people; presumably 32% of the trans men had phalluses that did not look as good. A small study of using a lateral arm free flap reported good results.

“There appear to be limited data on outcome measures, including social integration, patient satisfaction and physiological function. Good operative results have been reported in terms of appropriate size and stiffness without vascular compromise and in terms of psychological outcomes. In addition to an aesthetically appealing look either while being nude (81%) or wearing a tight swim suit (91%), to void whilst standing appears to be an important goal for many FTM patients. It is important to recognize that there are a range of phalloplasty procedures available with mixed findings being reported in terms of effectiveness. Hage et al. reported several serious complications such as vesicovaginal, urethrovaginal fistulas and urinary incontinence. Furthermore, unlike the metoidioplasty procedure, free flap phalloplasty techniques produce extensive scarring to the donor site, unless techniques such as tissue expansion are used. Of the 85 FTM patients who had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, Bettocchi et al. reported the cosmetic appearance of the phallus was considered good in 68% of the patients. Major complications (n = 60) were associated with the neourethra (75%), stricture formation (64%) and/or fistulae (55%). It should be noted that the complication rates found by Bettocchi et al. were significantly less (P < 0.001) when the neourethra was created in two stages. In contrast, Khouri et al. concluded by using a prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction.”

Scrotoplasty/scrotum construction/testicular prosthesis – The authors reviewed two studies that met their criteria. “This procedure is generally accomplished by hollowing out the labia majora, inserting silicone implants, and attaching the labia to develop a single scrotal sac. Implant expulsion, rupture or dislocation is encountered in a small number of patients.”

Urethroplasty – The authors did not find any studies that met their criteria, but they reported that “A one-stage total phalloplasty and urethroplasty was associated with a significant rate of fistulas and strictures.”

The authors did not find studies that met their criteria for Salpingo-oophorectomy or vaginectomy/vaginal closure.

The authors conclude that “There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.”

And, “we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.”

I have included more of their discussion in my review  here.

Original Source:

Evaluation of surgical procedures for sex reassignment: a systematic review by Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy CM in J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):294-306.

Review of Gender reassignment surgery: an overview

This article is a good summary of surgeries used in medical transition. It is not a study or review of studies, but it is written by two experienced surgeons from the United Kingdom. They provide some numbers related to complications and some valuable information on specific techniques.

It is important to remember that this is not a scientific study or survey; it is a report by surgeons based on their experience. The results in other clinics may be different. If you are seeking surgery, ask your doctor about their work.

The authors’ discussion of sexual pleasure and orgasm is very limited. They do not discuss patient satisfaction. They do not look at the mental health effects of surgery, either, just the physical outcomes.

As always, there are many areas where we do not yet have any studies and we don’t know the answer. We could use more studies and articles about the various techniques, their outcomes, and their complications. Any evaluation of these techniques should include patient satisfaction and sexual function.

So what are the physical outcomes and complications of various surgeries that the authors discuss?

SURGERIES FOR TRANS WOMEN

Some Complications and Risks, Vaginoplasty

Death from pulmonary embolism – 1 in 1000 among recent patients at their clinic.

Pulmonary embolism (blood clot that travels to the lungs) – 2 in 1000 among recent patients at their clinic. The length of the surgery makes blood clots a problem; this clinic works to reduce them.

“MtF surgery can be complicated by all the normal nonspecific complications of major surgery. For instance, venous thromboembolic disease is a particular problem, partly owing to the nature of the operation (pelvic surgery), the prolonged duration of the operation (5 h in some units) and the practice, which is still common, of keeping patients on bed rest for several days after the operation. In our unit, the operative time is reliably in the region of 120–150 min and patients are mobilized immediately after surgery to reduce the risk of thromboembolism. Combined with routine use of low-­molecularweight heparins and compression stockings, we have seen only two pulmonary emboli in the last 1,000 MtF surgical procedures (one of which was fatal).”

Clinically significant bleeding – At least 10%. Most of the bleeding is from the “corpus spongiosum surrounding the urethra.”

“Specific to the operation itself, the most common complication of MtF surgery is bleeding. In units with large numbers, labial hematomas are seldom seen, but do occasionally occur. Most may be managed conservatively, but they do result in an increased incidence of wound dehiscence [opening up along the incision], as observed in our institution. The principle source of postoperative hemorrhage is from the corpus spongiosum surrounding the urethra. Even with meticulous suturing, some 10% of patients will experience clinically significant bleeds. This bleeding may be reduced by leaving the postoperative pressure dressing in place for longer, but that in turn can inhibit patient mobilization and may result in increased risk of thromboembolism.”

Fistula (hole) between the rectum and vagina – 6 in 800 at their clinic in 2008 – the numbers are unknown in general and possibly “seriously under-reported.” The cause is unknown.

Fistuals frequently require further surgery and sometimes lead to the removal of the neovagina.

“When a fistula occurs, a defunctioning colostomy is usually needed. About 50% of fistulas will then close spontaneously, but in the remainder further surgery is needed. In difficult cases, removal of the neovagina may be required.”

Narrowing of the urethra – 3-4% minimum rate. This problem causes “dribbling incontinence.” The narrowing develops a few months after the operation and requires surgery. The surgery is usually effective – “although a few do go on to long-term intermittent catheterization.”

Loss of vaginal depth and width – The authors give no numbers, but believe that these complications are under-reported. The loss of depth could be due to loss of skin; in this case a new vaginoplasty is required using using tissue from the bowel. Loss of depth and width could also be caused by not following a proper dilation routine.

“Again, these complications are probably markedly under-reported, as some patients are effectively celibate or do not need much vaginal depth and width for their chosen sexual activities.”

Growth of hair in the vagina – This is caused by not removing hair either before surgery or perioperatively. There is no cure; if your surgeon is using skin from the scrotum, be sure to have the hair removed.

“Once hair growth is seen in the vault of the neovagina, little can be done to prevent its continued growth, and a number of patients will have to return at intervals for removal of hairballs.”

Overall complicate rate – Under 25%. It is not clear exactly what complications they are including in this number.

Clitoroplasty

The authors don’t give numbers on orgasms or sexual satisfaction. In their experience, the vast majority of innervated neoclitorides have sensations.

Some surgeons create additional erogenous sensation by putting the part of the glans penis left after making the clitoris between the urethra and neoclitoris.

Past techniques led to problems with urethtral fistualas and leaking pee, but the techniques have changed.

“The rate of urinary leakage from urethral fistulas was substantial with this technique and it has now been largely superseded by techniques in which the neurovascular bundle to the glans, which lies between Buck’s fascia and the corpora cavernosa, is preserved. This technique has been widely described and seems to provide good rates of sensitivity and sexual satisfaction.”

Labioplasty

Creating labia minora is challenging. The best technique to use will depend on how much skin is left from the penis; this may vary depending on the individual and the surgery. There aren’t any guidelines on how to do this.

“Overall, a balance needs to be achieved between construction of a satisfactory neovagina, and a good, realistic, cosmetic external appearance. To date, no guidelines exist that give an indication of when and how penile or scrotal skin should be used for clitoral hood or labia minora reconstruction, or the ideal penile skin length, depth of the vagina or tissue that should be used. The choice of technique for labioplasty is, therefore, largely that of the individual surgeon.”

Urethrostomy

The authors describe one technique which has a low rate of immediate complications like bleeding, but can lead to peeing upwards or narrowing of the urethra. In addition, this technique leaves in place some erectile tissue that swells during sexual arousal.

The authors prefer a different technique which creates a satisfactory direction of pee and which they believe looks better cosmetically. However it has a raised risk of bleeding.

Specifically, with the first technique they “divide the urethra in the proximal bulb and suture the urothelium direct to the skin (bringing the urethra through the anterior skin flap)” and with the second they “spatulate the urethra, and excise some or all of the corpus spongiosum posterior to the urethral meatus.”

Other Surgeries for Trans Women

The authors briefly mention breast augmentation, vocal cord and throat surgery, and facial feminization surgery.

Breast augmentation in trans women is similar to breast augmentation in cis women, but will be affected by the shape and size of the starting breast tissue and muscles.

Speech therapy is required after vocal cord surgery.

“In facial feminization, good results are achieved by shaving of the frontal bossae, the brow ridges, the mandible angles and the chin, accompanied sometimes by rhinoplasty.”

SURGERIES FOR TRANS MEN

Some Complications and Risks, Metoidioplasty

One of the advantages of a metoidioplasty is that there are few complications and recovery time is “quick.”

“The complication rate is relatively low (overall complication rate <20%)—especially when compared with more elaborate microsurgical techniques, in which complications are reported in 40% of patients.”

The disadvantages of this type of surgery are that it produces a short phallus that may not be capable of sexual penetration. Not everyone can pee standing up.

On the other hand, sexual sensations are well preserved which is a pretty important factor. The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

“…micturition in a standing position is somewhat, but not always, achievable. Despite the small size, some patients report satisfactory intercourse with female partners, and sensation is usually well preserved. Nevertheless, this approach is not well suited to individuals in whom clitoral hypertrophy is less marked, and the small size of the resultant phallus is unsatisfactory for most patients, not least because it is inadequate to show in clothing and for satisfactory sexual penetration.”

Are they trying to cause dysphoria here? I don’t think there are any numbers on what percentages of trans men prefer which form of surgery.

Some Complications and Risks, Phalloplasty

Overall complication rate – Over 40%. it is not clear exactly what complications they are including.

Microsurgical flap failure – Less than 2%.

Fistulas involving the neourethra – 25-30% in most series.

“Most fistulas will eventually close after a period of catheterization, but many require revision surgery.”

Urethral stricture formation (narrowing of the tube that carries pee out of the body) – 18%.

Postmicturition dribble (dribbling after peeing) – In one study, 79% of patients reported this problem.

Erectile function – Most phalloplasty techniques require the insertion of an inflatable prosthesis to become erect for sexual activity. “…the failure rate for penile prostheses is considerable, usually owing to infection of the device…”

We don’t know much about this yet. “Long-term results on the use of these erectile implants in FtM transsexuals is still lacking.”

There are some techniques that do not require a prosthesis, but they may have other issues.

“When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis without requiring a prosthesis. Flaps harvested with bone (for example, fibula or osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection.”

Sexual sensation – For free-flap phalloplasties, “Sexual sensation with retention of ability to orgasm is usually preserved.” The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

Different techniques – There are a few different techniques for phalloplasty, but we don’t have any studies comparing them to see which ones are best.

“To date, the gender team at Ghent University Hospital, Belgium, has published the largest series on phalloplasty (with radial forearm flap technique). The investigators demonstrated that the radial forearm flap is a reliable technique, although evidence that other techniques are similarly reliable, or even better than the radial forearm flap, is lacking.”

Mastectomy

An earlier review found few studies of mastectomies specifically for trans men. However, as the authors note here, it is important to have a surgeon experienced in mastectomies for trans men. The surgery is not the same as it is for women.

The authors give no numbers on complications but note that people often need minor revisions for cosmetic reasons.

The authors provide a few notes on techniques:

“The exact technique will depend on the volume of breast tissue, and the skin excess and elasticity. In small breasts, a satisfactory result may be achieved by subcutaneous mastectomy via a circumareolar incision, but in most patients more extensive surgery, with additional noticeable scars, is required. For very ptotic breasts, a breast amputation with free nipple– areola complex graft is indicated. Finally, the nipple itself and the diameter of the areola are often reduced. When done properly, the results may be very satisfactory, but poor technique can lead to unacceptable cosmetic results. Minor revisions to ameliorate the final cosmetic outcome are often required.”

Other Surgeries for Trans Men

For scrotal reconstruction, “As long as this advancement of the neoscrotum to the natural position in front of the legs is carried out, very satisfactory results can be obtained with no major complications.”

The authors say patients should get their uteruses and ovaries removed. They don’t provide any additional information on the procedures.

“Patients will also require hysterectomy and ovariectomy, because of the potential risk of endometrial carcinoma with protracted testosterone use, and are usually accomplished laparoscopically at the time of one of the stages of subsequent phalloplasty. The short blind-ended vagina can be left in place or removed.”

We could use more studies and articles on all of the above surgeries.

AUTHORS’ CONCLUSIONS

“Gender reassignment surgery—in which elective surgery is performed to alter an individual’s body to resemble the other sex and in doing so adapt the body to the patient’s perception and lifestyle—is one of the most challenging surgical disciplines.

In MtF surgery, the technique is largely standardized, but refinements are needed to satisfy specific patient requests, such as vaginal depth and ‘perfect’ cosmetic outcome.

In FtM surgery, the variety of techniques available demonstrates that the ideal technique has not yet been identified and, depending on a patient’s request, a different surgical approach should be used. Furthermore, very few centers have the experience of, and subsequently can offer, different techniques for FtM gender reassignment. Moreover, complications are frequent and limitations to the ideal reconstruction are present with every technique used.

The complex psychological background of the patients and their expectations further challenge gender reassignment surgeons. The cooperation of the gender team in making a diagnosis, selecting appropriate patients for surgery, and deciding timing and type of surgical procedures to be performed, is crucial in reducing patients’ regrets or minor dissatisfactions (at both physical and psychosocial functioning levels) as a result of possible complications or for not having achieved the result expected.”

Original Source:

Gender reassignment surgery: an overview by Selvaggi G, Bellringer J. in Nat Rev Urol. 2011 May;8(5):274-8.