Satisfaction with male-to-female gender reassignment surgery

"Escaping the Gender Prison"-Transgender Men's Experience Before and After Hysterectomy: A Qualitative Study

This study aimed to examine the experiences of female-to-male transgendered individuals (FtMs) who underwent gender-affirming hysterectomy (GAH) and to investigate patients' perceptions of GAH and their expectations and support needs from healthcare professionals before and after the surgery. The study used a phenomenological approach and a qualitative research method. Data were collected through in-depth interviews. The sample was selected using diversity sampling, which is one of the deliberate sampling methods. The study included 20 FtMs with a GAH in Turkey between February 2022 and 2023. As a result of the study, participants identified three main themes: experiences with body and gender identity, experiences with health professionals and systems, and mental and physical recovery from surgery. FtMs individuals reported less distress and more happiness after undergoing a hysterectomy. The participants expected health professionals and society to raise awareness, normalize the process, and improve legal procedures. They advocated for legal regulations that address reproductive deprivation and identity issues without surgery and the ability to freeze oocytes before hysterectomy. This study sheds light on the experiences of transgender FtMs before and after GAH. These findings can potentially improve gender-affirming healthcare, particularly in our country.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

[New S2k guideline "Surgical techniques for gender incongruence"]

BACKGROUND

Various techniques for the surgical treatment of gender incongruence (GI) have been available for years. The spectrum is broad and covers various specialties. In recent years, there has been an increase in the number of clinics offering body-modifying procedures. This has led to a considerable variation in methods in some cases. Although the topic has recently found its way more and more into teaching and the relevant specialist literature, there are still no evidence-based recommendations on the various techniques.

AIM

A compendium of established surgical techniques was to be compiled, containing recommendations on indication, performance and aftercare as well as complication management and subjecting them to a consensus-based evaluation.

MATERIALS AND METHODS

In accordance with "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften" (AWMF) regulations, the guideline was developed at level S2k, i.e., it is consensus based. The guideline group was founded in February 2019 in a formal constituent meeting. A total of 14 medical societies and 2 interest groups were recruited for the guideline work. In the end, two consensus meetings were held, which was due to the large number of recommendations and background texts to be adopted.

RESULTS

The guideline focuses on the choice and applicability of surgical techniques as well as the wishes of those seeking treatment and protection of fertility. There is a wide variety of methods and treatment goals for each individual. Taking into account medical standards, recommendations, and contraindications, an optimal result that minimizes individual suffering can be achieved together with the person seeking treatment.

CONCLUSION

The content of the guideline represents a unique compendium of surgical methods, recommendations for the selection of procedures, and common indications in the field of body-modifying surgery for gender incongruence.

[Psychiatric, socio-legal and perioperative aspects of vaginoplasty]

The number of scientific papers on gender-confirming surgeries as well as the surgeries themselves have increased by leaps and bounds in recent years. This leads to sometimes considerable waiting times for people seeking treatment. Social media and the internet do not always provide reliable and high-quality information. Therefore, it is necessary that both surgically and conservatively active urologists are familiar with topics regarding transgender persons. The establishment of structured training, the guarantee of minimum quality standards in the treatment of transgender persons and the further education and training of medical staff pose particular challenges. The German Society for Urology (DGU) and the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) have already founded their own working groups on the surgical side, which coordinate their work. Under the auspices of the professional societies DGU and DGPRÄC, a guideline on surgical procedures for gender incongruence was developed under the umbrella of the AWMF ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften") which is currently being finalised. For a long time, the health care of transgender people has been moving in a field of tension between the right of self-determination of those seeking treatment, on the one hand, and the fear of making the wrong medical decisions, on the other. In contrast to most other conditions in urology, the goal of treatment is largely determined by the person seeking treatment and does not necessarily follow predetermined schedules or content. The treatment should primarily aim at reducing the individual's suffering and promoting quality of life.

Creation of a decellularized vaginal matrix from healthy human vaginal tissue for potential vagina reconstruction: experimental studies

BACKGROUND

When a disorder causes the absence of a healthy, full-size vagina, various neovaginal creation methods are available. Sometimes dilation or stretching of the vaginal cavity is sufficient, but intestinal or dermal flap tissue is generally required. However, different inherent tissue properties cause complications. Therefore, a lost body part should be replaced with a similar material. The use of organ-specific acellular vaginal tissue carries great potential, as its similar architecture and matrix composition make it suitable for vaginal regeneration.

METHODS

The authors developed an optimized protocol for decellularization of healthy human vaginal tissue. Resected colpectomy tissue from 12 healthy transgender patients was used. Successful decellularization was confirmed by applying acellular criteria from in-vivo remodeling reports. Suitability as a tissue-mimicking scaffold for vaginal reconstruction was determined by visible structural features, biocompatibility during stretching, and the presence of visible collagen, elastin, laminin, and fibronectin.

RESULTS

Histological examination confirmed the preservation of structural features, and minimal cellular residue was seen during fluorescence microscopy, DNA and RNA quantification, and fragment length examination. Biomechanical testing showed decreased peak load (55%, P <0.05), strain at rupture (23%, P <0.01), and ultimate tensile stress (55%, P <0.05) after decellularization, while the elastic modulus (68%) did not decrease significantly. Fluorescence microscopy revealed preserved Fibronectin-I/II/III and Laminin-I/II, while Collagen-I and Ficolin-2B were decreased but mostly retained.

CONCLUSIONS

The absence of cellular residue, moderately altered biomechanical extracellular matrix properties, and mostly preserved structural proteins appear to make our decellularized human vaginal matrix a suitable tissue-mimicking scaffold for vagina transplantation when tissue survival through vascularization and innervation are accomplished in the future.

Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review

Background

Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS.

Results

After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general.

Discussion

The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.

Effects of Gender Affirming Surgery on the Quality of Life of Transgender Women in Chiang Mai Province, Thailand

Gender affirming surgery (GAS) helps individuals to achieve a physical presence consistent with their gender identity. In this study, we explored the decision, expectation, experience, satisfaction, and quality of life (QOL) of transgender women (TGWs) who have undergone GAS and compared their QOL with transfeminine individuals (TFs) who have not and are seeking to do so in Thailand. The median overall QOL score of the TGWs who have undergone GAS was slightly higher than that of the TFs who have not (95 (92-103) vs. 92 (86-98); p = 0.003), which was also reflected in the specific domains of psychological health, social relationships, and environmental health, the exception being physical health. Not being financially prepared was the most relevant reason for delaying undergoing GAS among the TFs who have not undergone it and want to do so. In addition, more than half of the TGWs who have undergone GAS regretted not being socially accepted after surgery. Although the difference between the QOLs of the two groups is statistically significant, the clinical significance should be further investigated to provide more insight. In addition, the higher QOL of TGWs might not solely be due to having undergone GAS.

Sexual Satisfaction After Gender Affirmation Surgery in Transgender Individuals

Gender affirmation surgery (GAS) is a collection of surgical procedures that involve the reconstruction of patients’ genitalia with the aim of achieving the physical appearance and functional abilities of the gender they desire. They are classified into male-to-female (MtF) and female-to-male (FtM). This study is aimed at assessing sexual satisfaction after MtF GAS. A total of 150 patients who underwent MtF GAS at the Urology Group of Southern California and Sinclair Plastic Surgery in Los Angeles, California, were retrospectively surveyed. In total, we received 29 responses, with an average of five years after their surgery. There was a significant correlation between the sensitivity of the neoclitoris and sexual satisfaction but not with vaginal sensitivity or depth. Furthermore, this study revealed an important correlation between gender dysphoria relief after GAS.

Gender Dysphoria and Sexual Well-Being Among Trans Masculine and Nonbinary Individuals

Prior qualitative research has noted that gender dysphoria impacts sexual engagement and satisfaction for many trans masculine and nonbinary individuals. As such, the current cross-sectional study aimed to investigate the exact relations between distinct aspects of gender dysphoria (i.e., genital, chest, other secondary sex characteristics, and social) and engagement in, and enjoyment of, specific sexual acts. To achieve this aim, a sample of 141 trans masculine and nonbinary participants who were assigned female at birth and whom had not undertaken a medical transition were recruited. Participants were identified as trans masculine (n = 52), nonbinary (n = 72), and agender (n = 17). Participants completed a survey rating both body and social gender dysphoria and their engagement and enjoyment of receptive and performative roles across six partnered sex act domains (i.e., insertion, oral sex, sex toys, manual stimulation, nipple stimulation, and anal stimulation), as well as masturbation and noncoital activities. The overall results demonstrated that gender dysphoria is more salient to sexual acts that involve receiving versus providing sexual pleasure. In addition, genital and chest dysphoria were often significantly related to lower ratings of engagement and enjoyment. These results support the understanding that trans masculine and nonbinary individuals are likely negotiating sexual encounters to avoid sexual acts that involve areas of their body they find most distressing and marks an important area for future interventions and research.

Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review

As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.

Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty. Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18-61 years); the average of operative time was 3.3 h (range 2-5 h); the average duration of hormone therapy before surgery was 12 years (range 1-39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS. Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis

Supplemental Digital Content is available in the text.

Background:

Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes.

Methods:

A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed.

Results:

After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%–2%] of fistula, 11% (95% CI 8%–14%) of stenosis and/or strictures, 4% (95% CI 1%–9%) of tissue necrosis, and 3% (95% CI 1%–4%) of prolapse. Overall satisfaction was 91% (81%–98%). Regret rate was 2% (95% CI <1%–3%). Average neovaginal depth was 9.4 cm (7.9–10.9 cm) for the penile skin inversion and 15.3 cm (13.8–16.7 cm) for the intestinal vaginoplasty.

Conclusions:

Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening

Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors' preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.

Quality of Life Following Male-To-Female Sex Reassignment Surgery

BACKGROUND

The prevalence of persons who are born with primary and secondary male sexual characteristics but feel that they are female (trans women) is ca. 5.48 per 100 000 males in Germany. In this article, we provide a detailed overview of the currently available data on quality of life after male-to-female sex reassignment surgery.

METHODS

This review is based on publications retrieved by a systematic literature search that was carried out in the PubMed, EMBASE, Web of Science, and PsycINFO databases in March 2017.

RESULTS

The 13 articles (11 quantitative and 2 mixed quantitative/qualitative studies) that were found to be suitable for inclusion in this review contained information on 1101 study participants. The number of trans women in each study ranged from 3 to 247. Their mean age was 39.9 years (range: 18-76). Seven different questionnaires were used to assess postoperative quality of life. The findings of the studies permit the conclusion that sex reassignment surgery beneficially affects emotional well- being, sexuality, and quality of life in general. In other categories (e.g., "freedom from pain", "fitness", and "energy"), some of the studies revealed worsening after the operation. All of the studies were judged to be at moderate to high risk of bias. The drop-out rates, insofar as they were given, ranged from 12% to 77% (median: 56%).

CONCLUSION

Current studies indicate that quality of life improves after sex reassign- ment surgery. The available studies are heterogeneous in design. In the future, prospective studies with standardized methods of assessing quality of life and with longer follow-up times would be desirable.

How Gender Identity and Treatment Progress Impact Decision-Making, Psychotherapy and Aftercare Desires of Trans Persons

The gender identity of trans individuals influences their treatment preferences, and this in turn seems to affect their individual treatment progress. However, there has been no research which—next to the impact of gender identity on treatment desires—has also investigated the influence of treatment progress using a measure which assumes various possible transition pathways of trans persons.Therefore, an online community survey of trans people was conducted in Germany in 2015. Data were collected via an online survey from a non-clinical sample of n = 415 trans individuals (over half assigned female at birth), aged 16–76 (Mean (M) = 38.12). Almost one fifth of participants embraced non-binary or genderqueer (NBGQ) identities. Participants progressed 60.77% (standard deviation (SD) = 35.21) through treatment at point of data collection, as measured by the individual treatment progress score (ITPS). All participants, especially participants assigned male at birth, differed significantly in desire to participate in decision-making processes based on transition progress; individuals without treatment experience had less desire to decide treatment plans. NBGQ participants assigned male at birth in early stages of transition had significantly more desire for psychotherapy during transition than participants of the same identity in later transition stages. All participants, especially binary participants, significantly differed in desire for aftercare based on transition progress; individuals without treatment experience indicated more desire for aftercare. Results indicate health professionals should expect changing treatment desires in trans individuals at various stages of transition, particularly at treatment start, and based on gender identity.

Sexuality after Male-to-Female Gender Affirmation Surgery

Male-to-Female (MtF) gender affirmation surgery (GAS) comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all 254 MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between 2004 and 2010. In total, we received 119 completed questionnaires after a median of 5.05 years since surgery. Of the study participants, 33.7% reported a heterosexual, 37.6% a lesbian, and 22.8% a bisexual orientation related to the self-perceived gender. Of those who had sexual intercourse, 55.8% rated their orgasms to be more intensive than before, with 20.8% who felt no difference. Most patients were satisfied with the sensitivity of the neoclitoris (73.9%) and with the depth of the neovaginal canal (67.1%). The self-estimated pleasure of sexual activity correlated significantly with neoclitoral sensitivity but not with neovaginal depth. There was a significant correlation between the ease with which patients were able to become sexually aroused and their ability to achieve orgasms. In conclusion, orgasms after surgery were experienced more intensely than before in the majority of women in our cohort and neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than neovaginal depth.

[Gender confirming surgery : Female-to-male and male-to-female]

BACKGROUND

Gender confirming surgery (GCS) represents a new and interdisciplinary urological field of activity.

OBJECTIVES

Based on more than 20 years of experience, the development of interdisciplinary strategies in the surgical management of male-to-female (MtF) and female-to-male (FtM) transgenders is summarized.

MATERIALS AND METHODS

The current national and international literature, as well as the surgical experience of the authors in the field of GCS, were evaluated, and aspects relevant for urologists are presented in a comprehensive review.

RESULTS

Since 1990 more than 1200 primary GCS in MtF transgenders and more than 230 primary GCS in FtM transgenders have been performed in the authors' institutions. Presuming an incidence of at least 1:20,000 for patients with gender dysphoria (GD) in the general population, the overall number of patients is limited. The complex surgical procedures should be realized in an interdisciplinary team, trained and specialized in this field of surgery, given the high rate of complications and secondary procedures with MtF GCS.

CONCLUSION

Postoperative satisfaction rates of FtM and MtF transgenders at over 80% are satisfactory. During the last few decades, surgical procedures have been widely standardized. In the field of penile reconstruction, the free forearm lap represents the preferred method, while several surgical alternatives arise from the current literature in this field.

[Social support in gender reassignment surgery]

BACKGROUND

Gender reassignment surgery (GRS) can lead to discrimination. This transition makes great demands on the individual and also affects the social environment.

OBJECTIVES

To evaluate the social support of male-to-female (MtF) transgender people.

MATERIALS AND METHODS

Group A comprised 254 consecutive MtF transsexuals, who received a penile inversion vaginoplasty between 2004 and 2010. These women were surveyed retrospectively. Group B comprised 144 consecutive MtF transsexuals who presented for preoperative counselling. These patients were asked to answer the survey in advance of the planned GRS.

RESULTS

The return rate was 46.9 % (A) and 95.1 % (B). In both groups, approximately two-thirds lived with their parents or children at ease. About 13.4 % (A) and 16.9 % (B) estimated the relationship towards their parents and one- seventh (A) or one-sixth (B) woman rated their relationship towards their children as poor. The acceptance of the parents regarding GRS was 65.6 % (A) and 77.1 % (B). In total 20 % (A) and 9.2 % (B) did not, however, accept GRS in their children. The acceptance of children regarding GRS was 64.9 % (A) and 71.1 % (B) with 10.8 % (A) and 6.7 % (B) who did not approve the decision.

DISCUSSION

Social support is an important resource in the context of gender reassignment surgery. Understanding can help to improve the situation for transsexuals and to reduce consecutive healthcare utilisation.