Gender Confirmation Surgery: Principles and Techniques for an Emerging Field 3030290921, 9783030290924

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Gender Confirmation Surgery Principles and Techniques for an Emerging Field Loren S. Schechter Editor

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Gender Confirmation Surgery

Loren S. Schechter Editor

Gender Confirmation Surgery Principles and Techniques for an Emerging Field

Editor Loren S. Schechter Department of Plastic Surgery The Center for Gender Confirmation Surgery Weiss Memorial Hospital Chicago, IL USA

ISBN 978-3-030-29092-4    ISBN 978-3-030-29093-1 (eBook) https://doi.org/10.1007/978-3-030-29093-1 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

It has been a privilege dedicating my career to caring for transgender and gender diverse individuals. I have seen time and time again how safe and effective medical care can assist individuals in expressing their gender identity, help to alleviate gender dysphoria, improve quality of life, and reduce negative health outcomes. But I have also seen the adverse effects of barriers to medically necessary care—such as the distress associated with a lack of insurance coverage and the frustration of long wait times and distant travel due to shortages of qualified healthcare providers. The positive progress in recent years inspires and encourages me. We have improved access to medical care and advanced social equality related to gender diversity. The landmark decision to remove Medicare’s ban on gender confirmation surgery in 2014 changed the landscape for healthcare coverage. Numerous private insurance plans and many state programs followed Medicare’s lead and now cover medically necessary gender confirming surgery. Still, there are great hurdles ahead. Each day, transgender and gender diverse individuals experience marginalization, discrimination, and bias. Battles over military service, bathroom access, and legal recognition of one’s gender identity continue. Person by person and law by law, we must continue to educate those around us and fight for equality and justice. This book is written for healthcare professionals—physicians, mental health professionals, nurses, allied health professionals, and students with an interest in gender confirmation surgery. Its purpose is to address a range of issues related to the care of transgender and gender diverse individuals so as to allow caregivers to provide thoughtful, ethical, and compassionate care. Beyond this, this book serves as a tool to educate the next generation of healthcare providers on the complex medical and social issues facing our patients. We assembled a group of internationally distinguished professionals to author chapters in their areas of expertise. In this book, we explore medical care—mental health, endocrinology, surgery, and physical therapy. But we delve much deeper than this—chapters examine historical context, social science, legal rights, and religious views. I believe that this is the most up-to-­ date and comprehensive text regarding surgical care for transgender and gender diverse individuals.

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Thank you to our authors who spent countless hours writing these outstanding chapters. Thank you to our readers for recognizing the importance of comprehensive care for transgender and gender diverse individuals. Thank you to transgender and gender diverse individuals and advocates for the tireless work to make our world a better place. Let’s keep forging ahead. Chicago, IL, USA 

Loren S. Schechter

Contents

1 History, Societal Attitudes, and Contexts��������������������������������������   1 Jamison Green 2 Etiology of Gender Dysphoria��������������������������������������������������������  21 Randi Ettner 3 History of Gender Identity and Surgical Alteration of the Genitalia ��������������������������������������������������������������������������������  29 David M. Whitehead and Loren S. Schechter 4 Language and Terminology in Transgender Health ��������������������  41 Gail Knudson 5 The Mental Health Assessment for Surgery����������������������������������  47 Dan H. Karasic 6 Primary Care for the Transgender and Gender Nonconforming Patient��������������������������������������������������������������������  53 Frederic M. Ettner 7 Hormone Therapy for Transgender Women ��������������������������������  59 Vin Tangpricha and Joshua D. Safer 8 Hormone Therapy for Transgender Men��������������������������������������  65 Joshua D. Safer and Vin Tangpricha 9 Medical Management of the Adolescent Individual with Gender Dysphoria ������������������������������������������������������������������  69 Jennifer L. Miller and Courtney Finlayson 10 Male-to-Female Breast Augmentation and Body Contouring ����  75 Thomas Satterwhite and Stelios C. Wilson 11 The Importance of Facial Gender Confirmation Surgery ����������  91 Jens Urs Berli and Eric Plemons 12 Facial Gender Affirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery��������  99 Jordan Deschamps-Braly 13 Fertility Preservation Options for Transgender and Trans Masculine Patients Planning Hysterectomy���������������� 115 Katherine T. Hsiao vii

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14 Penile Inversion Vaginoplasty �������������������������������������������������������� 123 Jess Ting and Marci Bowers 15 Intestinal Vaginoplasty�������������������������������������������������������������������� 137 Jiri George Melich and Slawomir Marecik 16 Chest Masculinization Surgery������������������������������������������������������ 147 Cori A. Agarwal and Daniel P. Donato 17 Urethral Anatomy and Urethral Reconstruction in Phalloplasty and Metoidioplasty������������������������������������������������ 161 Ervin Kocjancic and Valerio Iacovelli 18 MLD (Musculocutaneous Latissimus Dorsi) Phalloplasty���������� 171 Rados Djinovic 19 Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction������������������������������������ 181 Walter Lin and Bauback Safa 20 Management of Urethral Complications Following Metoidioplasty and Phalloplasty���������������������������������������������������� 201 Jessica Schardein, Aaron C. Weinberg, Lee C. Zhao, and Dmitriy Nikolavsky 21 Strategies to Optimize Sexual Function with Feminizing and Masculinizing Genital Gender-­Affirming Surgery���������������� 215 Maurice Marcel Garcia 22 Postoperative Care from the Primary Care Perspective�������������� 229 Asa Radix 23 Religious Attitudes Toward Gender-Confirming Surgery ���������� 237 Leonard A. Sharzer, David A. Jones, Mehrdad Alipour, and Kelsey Jacob Pacha 24 Establishment of a Gender Confirmation Program �������������������� 259 Loren S. Schechter and Rebecca Schechter Index���������������������������������������������������������������������������������������������������������� 265

Contents

Contributors

Cori A. Agarwal, MD  Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA Mehrdad Alipour, PhD  Institute of Arab and Islamic Studies, Exeter, UK Jens  Urs  Berli, MD Department of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR, USA Marci Bowers, MD  Mills-Peninsula Hospital, Burlingame, CA, USA San Mateo Surgery Center, San Mateo, CA, USA Jordan Deschamps-Braly, MD, FACS  Deschamps-Braly Clinic of Plastic & Craniofacial Surgery, San Francisco, CA, USA Rados  Djinovic, MD  Department of Urology, Sava Perovic Foundation – Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia Daniel P. Donato, MD  Division of Plastic Surgery, The University of Texas Medical Branch, Galveston, TX, USA Frederic  M.  Ettner, MD Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA Randi Ettner, PhD  Clinical and Forensic Psychologist, Evanston, IL, USA Courtney  Finlayson, MD Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Maurice  Marcel  Garcia, MD, MAS Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA Department of Urology & Department of Anatomy, University of California San Francisco (UCSF), Los Angeles, CA, USA Cedars-Sinai Medical Center Transgender Surgery and Health Program, Los Angeles, CA, USA Jamison Green, PhD, MFA  Independent Scholar, Vancouver, WA, USA Katherine T. Hsiao, MD  Department of Obstetrics and Gynecology, Sutter Health, San Francisco, CA, USA Valerio  Iacovelli, MD Department of Surgical Sciences, Tor Vergata University of Rome – San Carlo di Nancy Hospital, Rome, Italy

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David A. Jones, MA(Cantab), MA, MSt, DPhil(Oxon), FHEA  St. Mary’s University, Twickenham, UK Dan  H.  Karasic, MD  Department of Psychiatry, University of California San Francisco, Health Sciences Clinical Professor of Psychiatry, San Francisco, CA, USA Gail  Knudson, MD, MEd, FRCPC Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada Ervin Kocjancic, MD  Department of Urology, University of Illinois Health and Science, Chicago, IL, USA Walter Lin, MD  The Buncke Clinic, San Francisco, CA, USA Slawomir  Marecik, MD, FACS, FASCRS Department of Colorectal Surgery, Advocate Lutheran General Hospital & University of Illinois at Chicago, Park Ridge, IL, USA Jiri George Melich, MD, FRCS  Department of Surgery, Royal Columbian Hospital, University of British Columbia, Vancouver, BC, Canada Jennifer L. Miller, MD  Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA Dmitriy Nikolavsky, MD  Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA Kelsey Jacob Pacha, MA, M.Div.  Master of Divinity and Master of Arts in Religion and Psychology, Pacific School of Religion, Berkeley, CA, USA Eric Plemons, PhD  School of Anthropology, University of Arizona, Tucson, AZ, USA Asa  Radix, MD, MPH, FACP Department of Medicine, Callen-Lorde Community Health Center, New York, NY, USA Bauback Safa, MD MBA  The Buncke Clinic, San Francisco, CA, USA Joshua D. Safer, MD, FACP, FACE  Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York, NY, USA Thomas  Satterwhite, MD Align Surgical Associates, Inc, San Francisco, CA, USA Jessica  Schardein, MD, MS Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA Loren  S.  Schechter, MD Department of Plastic Surgery, The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA Rebecca Schechter, MD  Highland Park, IL, USA Leonard  A.  Sharzer, MD, MS(Surg.), MA(Div), Rabbi Finkelstein Institute for Religious and Social Studies, The Jewish Theological Seminary, New York, NY, USA

Contributors

Contributors

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Vin Tangpricha, MD, PhD  Department of Medicine, Emory University of Medicine, Atlanta Medical Center, Atlanta, GA, USA Jess  Ting, MD  Department of Plastic and Reconstructive Surgery, Center for Transgender Medicine and Surgery, Mount Sinai Hospital, New York, NY, USA Aaron  C.  Weinberg, MD Department of Urology, New York University School of Medicine, New York, NY, USA David M. Whitehead, MD  Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North New Hyde Park, NY, USA Stelios C. Wilson, MD  Hansjorg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, NY, USA Lee C. Zhao, MD, MS  Department of Urology, NYU Langone Health, New York, NY, USA

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History, Societal Attitudes, and Contexts Jamison Green

The Concept of Transsexualism

and stimulated by prurient lust and moral indignation – that has continued into the twenty-first The modern concept of transsexualism is rooted century. firmly in the nineteenth century when the applied Transsexualism per se was not mentioned in science of sexology was emerging and the fields Krafft-Ebing’s text (the term had not yet been of science and medicine were “intoxicated with coined), but several of the case studies he docutheir relatively new systems of classification and ments under his categories of “antipathic sexuexamination” [1]. ality”  – homosexuality, “viraginity”, “psychic In 1886, Richard von Krafft-Ebing (1840– hermaphroditism”, “gynandry”, “androgyny”, 1902) published Psychopathia Sexualis, a collec- “effemination”, “eviration”, “defemination”, tion of recountings by patients, as documented by etc. – describe people whose appearance, mannerKrafft-Ebing, of their sexual fantasies, desires, or isms, feelings, experience, or self-­understanding feelings and acts [1]. His text was reissued 11 might today be understood as typical of what, times before he died; each new edition expanded since the 1950s, has become the “classic transto include an ever-increasing number of cases sexual narrative”.1 Psychopathia Sexualis set divided into detailed categories of perversions, the stage for subsequent discussions of the topic dementia, and degeneration. The project was of gender variance (or deviance, or diversity), intended to guide the legal profession in the from Krafft-Ebing’s contemporary sexologists application of jurisprudence and to present to such as Magnus Hirschfeld (1868–1935), Albert physicians and jurists facts from an important Moll (1862–1939), Havelock Ellis (1859–1939), sphere of life: sexuality (emphasis added) (Krafft-­ and Max Marcuse (1877–1963) to later profesEbing 1886). It became a surprise bestseller, even sionals who took an interest in sexology, most though Krafft-Ebing had obscured what he felt notably David O. Cauldwell (1897–1959) whose were its most obscene passages by rendering article “Psychopathia Transexualis” [4] invoked them in Latin rather than German. At that time, of an extremely pathological view of female gencourse, the sections in Latin could be read by any der variance, unsurprising for post-­World War educated person, including members of the II society, and introduced the concept of transclergy. As one might expect, the text sparked a sexualism (with a single “s”) in North America controversial debate in the public sphere over [4] and John Money (1921–2006), who, with colsexuality – tinged with fascination and revulsion For a detailed discussion of the transsexual narrative and its conflation with sexual deviance, erotic pleasure, and especially homosexuality, see Sharpe [3].

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J. Green (*) Independent Scholar, Vancouver, WA, USA

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_1

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leagues Hamsun and Hamsun, first promoted the concept of gender [5]. Karl Ulrichs (1825–1895), a German writer who studied law, theology, and history, first worked to create a taxonomy to enable discussion of sex and gender variance from the simple binary concepts that most people believed in and thought they understood. He described homosexual men as having a “female psyche in a male body”, giving us language that was adopted in the early twentieth century to describe transsexual people. Magnus Hirschfeld believed science and scientific understanding of sexuality would lead to justice and social acceptance for sexual minorities. He contended that each human being is neither a man nor a woman but is both, at the same time, in “unique and unrepeatable proportions”, thus theorising his doctrine of sexual intermediaries, a refinement of a concept which can be traced back to Charles Darwin (see [6]: 22–23) and even to the ancient Greek physician Galen (see [7]: 4–7). Hirschfeld first invoked the term transsexual by way of the phrase seelischen Transsexualismus (spiritual transsexualism) in a 1923 essay “Die Intersexuelle Konstitution”. Surgical sex reassignment began experimentally, using animals, in Vienna in 1912, and attempts were made to surgically transform people from one sex to the other throughout Europe in the 1920s. Hirschfeld’s Institute for Sexual Science in Berlin was a site of some of the earliest “sex change” or “sex reversal” surgical procedures, later referred to by English speakers as sex reassignment surgery (SRS), transsexual surgery, gender (or sex) confirmation surgery, and (most recently) gender affirmation (or affirming) surgery. The term phalloplasty was first used by Jos. Sprengler in 1858 to mean a repair to external tissues of the penis ([7]: 311), and the first reconstruction of an entire penis was reported by Nikolaj A. Bogoras [8, 9], while the first application of the procedure in a transsexual patient was reported by Harold Gillies and R.J.  Harrison in 1948 [10]. The first reported vaginoplasty performed on a trans woman was done by Felix Abraham in 1931 [11] (for greater detail, see [12] and [13]). Surgical normalising of intersex chil-

J. Green

dren enabled a practice forum for the fashioning of both male and female genitalia. Gillies and others created new techniques to create normalappearing genitals in adults. Because of the drive toward normalising, transsexual people could only access services if they subscribed to (or at least could convincingly claim acceptance of) the medical definition of who they were and they shared the medical objective of conformance to the binary view, then the only moral justification for such procedures. By the late 1950s, the medical community had firmly assumed captaincy of the ship of sex and gender, which were thought to be essentially the same thing. An uncomfortable debate on the fringes of the medical and psychological communities persisted, with some asserting trans people were helped by finding congruence between their body and mind (see [14, 15]), and others arguing that people who requested sex reassignment were exhibiting neurosis, which does not respond to surgical intervention (see [16]). For transsexual people, to look for information about themselves in the psycho/medical scientific literature of the second half of the twentieth century (almost the only literature available) was, in most cases, to see themselves objectified and ridiculed – often an intimidating experience. But it didn’t stop them from seeking relief. The taxonomy of binary sex and gender which posits only male and female as essential and valid physical categories, with specific social roles, has been reinforced by social inequality between women and men and by an assumption of heterosexuality as a behavioural norm. Hirschfeld’s idea of “sexual intermediaries” found desexualised (idealised) psychological expression in Carl Jung’s concept of animus and anima, the internal male or female that lives within each woman or man, respectively, and sexualised physical expression in human beings born with ambiguous genitals or other problems of sexual differentiation, often called “hermaphrodites” or “intersex people” (see [17]). Another German sexologist, Max Marcuse (1877–1963), published about the “drive for sex transformation” (geschlechsumwandlungstrieb) in 1916, distinguishing the desire for “sex-change sur­

1  History, Societal Attitudes, and Contexts

gery” from the more generalised “sexual inversion” (conceived of as homosexuality, exemplified by extremely feminine males or masculine females who were attracted to samesex intimate partners) or “cross-gender identification”, which was frequently associated with cross-dressing behaviour ([6]: 19), though over a century later, its legitimacy is still being questioned. German endocrinologist and American émigré Dr. Harry Benjamin (1885–1986), who later was to popularise the term “transsexual” [14], encouraged effective medical treatment and legal recognition in the “new sex”. He would become a champion of transsexual people in medical and legal arenas through the latter half of the twentieth century, until a new, less-medicalised self-­ advocacy emerged in the 1990s [18, 19], heralded by the term transgender. Transgender quickly became an “umbrella” term, intended to be inclusive of a wide variety of behaviours and identities that did not conform to the stereotypes reinforced by “the binary”. To complicate matters further, many people objected to the term transgender because they felt their gender never changed, but it was their sex characteristics that wrongly circumscribed their identity. Others felt the stigma of having their label associated with “sex”, and they were more comfortable with the euphemism “gender”. Eventually, and partly to avoid the sex/gender debate, many people simply shortened the label to “trans”. More recent terms coming into wider acceptance are “nonbinary”, “GNC” which means “gender-nonconforming”, “TGNC” for “trans and gender-nonconforming”, and “TGNB” for transgender and non-binary”. This article will continue to use the terms “transsexual”, “transsexualism”, and “trans” because these are the most commonly understood terms intra-­ culturally at present. Readers should not take this to mean that all transgender or nonbinary or TGNC-­identified people will desire or eschew surgical intervention. The boundaries between these categories are highly permeable, and new vocabulary arises continuously, so medical professionals must be flexible and listen to and respect the terms their patients employ.

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For many trans people, though, “transsexualism” is a term fraught with social disapprobation, fear, shame, and negative judgement. One important resource publication targeted toward the transsexual reader seeking legal information in the 1990s stated that ...gender dysphoria syndrome is described thoroughly in the literature. The literature suggests that: (1) the causes remain unknown; (2) presurgical transsexuals as a group are among the most miserable of people, often exhibiting extreme unhappiness which frequently brings them to the verge of suicide or self-mutilation... [and] [t]he literature indicates a consistent trend towards [sic] rejection by both family and friends, harassment and/or discrimination in varying degrees by most of society, and more often than not a refusal by many in the legal and medical professions to render services, either by reason of questioning the validity of such a diagnosis, or perhaps fear of potential peer and/or community sanctions. [20]

Incidence and Prevalence of Transsexualism At the turn of the twenty-first century, thousands of transsexual people are living ordinary and extraordinary lives around the world. However, there are no reliable numbers that specify either the incidence2 or the prevalence3 of transsexualism. What little is known has been derived from studies in a few clinics in several European countries, notably Sweden [21, 22], the UK [23], the Netherlands [24–26], Germany [27], and Belgium [28], and one study in Singapore [29]. The numbers yielded by these studies cannot be crosscompared because they rely on different data collection methods and different criteria for eligibility of subjects to be counted as a transsexual person (e.g. whether or not a person has undergone genital reconstruction, versus whether a person has initiated hormone treatment, versus Incidence = the number of new cases arising in a given period, e.g. a year 3  Prevalence = the number of individuals having a condition, divided by the number of people in the general population 2 

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whether a person has come to the clinic for assistance in accessing medically supervised transition services). They also do not consider the fact that the available treatments offered in the clinic setting might not be perceived as affordable, useful, or acceptable by all self-identified transsexual people in a given area; therefore, by counting only those people who enter the clinic, some number of transsexual people will be overlooked. That these and other culturally specific factors have been unaccounted for in studies indicates that results are likely to underestimate significantly the actual occurrence of transsexualism in nearly every cultural setting. In 2007, two professors of electrical engineering, Femke Olyslager of Ghent University in Belgium and Lynn Conway of the University of Michigan, presented a paper at the World Professional Association for Transgender Health (WPATH) Symposium in Chicago, describing their efforts to arrive at a reasonable prevalence rate [30]. Analysing the data from the studies cited above in new ways and extracting further results from them, they arrived at a prevalence rate between 1:1000 and 1:2000. This figure is more than an order of magnitude greater prevalence than the accepted figure of 1:17100, which is derived from the clinical records in the Netherlands (1996), where it has been reported that roughly 1:11,900 adult malebodied people medically changes their sex to female and 1:30,400 adult female-bodied people medically changes their sex to male [26]. Applying the Dutch ratio to the US population yields ~13,500 adult transsexual people who have had genital reconstruction in the US (US Census Bureau estimated the adult population = ~230,000,000 in 2008: 115 million natal males and 115 million natal) females. Credible researchers looking at the same data can arrive at widely varying estimates of the adult transsexual population of the USA. It is reasonable to conclude that there are probably between 13,500 (Dutch ratio) and 230,000 [30] transsexual adults in the USA and that this range, though broad, is relatively consistent across populations worldwide.

Cultural Extent of Transsexualism Evidence of transsexualism exists in virtually every known culture, race, and class, and while the frequency and sex ratio might vary among different cultures,4 it is most likely, as shown above, that there are far more transsexual people than have been estimated. For the most part, transsexual people are invisible to mainstream society, and many function successfully as unremarkable men or women; if this were not the case, society would already be more aware of transsexual people. Many others live on the social fringe, unable to find legitimate employment, struggling with drug addiction, mental health issues, or other disabilities that may or may not be related to their transsexualism or the reaction of people around them to their transsexualism. This type of existence has long been common in India; in Brazil, Peru, and Mexico; and in Malaysia (migrations through Europe and the Americas are common), although some transsexual people in these countries are rapidly becoming politicised and undertaking efforts toward social change.5 Also, the global effort to prevent the transmission of HIV and other sexually transmitted diseases has created a literature and a sociology that includes transsexual people, mostly trans women, even if only marginally.6 For the most part, although their bodies and medical histories are unusual, after a few years of treatment and living permanently in the preferred gender role, only a transsexual person’s physicians, those with whom they are intimate, and/or those to whom they choose to reveal their history are likely to know that they have changed their For example, significant differences from the Dutch figures are noted in Singapore [29], Thailand [31], Serbia [32], and New Zealand [33]. 5  A simple Google Scholar search on “transsexual sex workers” yields over 26,000 articles on the subject, revealing studies conducted in Europe, Asia, Africa, North and South America, Australia, and numerous Pacific Island cultures. 6  Over 43,000 articles are available via Google Scholar on the subject of “transgender HIV prevention”. 4 

1  History, Societal Attitudes, and Contexts

sex, especially in the case of trans people living as men [34]. Generally, trans lives are made easier or more complicated in correlation with the agreements operating within their culture: if their existence is culturally acknowledged, especially with validation of their expressed gender identity, and if they have access to jobs and basic health care, transsexual people are much more likely to lead healthy and successful lives [35]. The willingness, or not, of governmental bodies to acknowledge a trans person’s affirmed identity can influence their ability to find and retain employment, a key factor in normalising life experience in the USA [36]. In some cases, where there is no other social place for them, trans people are forced into sex work [37]. Some seek sex work as a way of self-validation in their new gender role [12]. When trans people are engaged in criminal behaviour, whether for survival or self-gratification, they are more likely to come to harm and to the attention of the public; this form of visibility lies at the root of many stereotypes about trans people.7 The fact that more trans women (aka transfeminine people, those born with male bodies who transition to female) than trans men are active in the entertainment industry, too, increases their visibility. The public is often ignorant of transsexual men (those born with female bodies who transition to male, also called transmasculine people or trans men); being much less visible, they are assumed not to exist. The image of a man in a dress, made up to look ultrafeminine, seeking attention, or especially soliciting sex on the street in a run-down neighbourhood or urban park, is, thanks to the media, a prototypical notion of transsexualism in the USA.8 Such images contribute to the sense of guilt, shame, and low self-­ esteem that many trans people experience, feelings that warn against engaging in any activity that brings public attention [39]. Trans men generally are not glamorous or flamNote the story of the murder of Chanelle Pickett, for which her killer was acquitted, as described in Thomas [38]. 8  For example, the American television series “Law & Order” has featured several such characters. 7 

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boyant, so they largely escape notice. They, and the majority of trans women, too, are generally law-abiding and prefer to avoid courts and jails, knowing that trans people do not always fare well in prison [40]. The human body historically has been conferred certain rights in law. For centuries, rights, privilege, and status could accrue only to male bodies (in some cases in British, European, and American societies, only to Caucasian, light-­ skinned, male bodies9), while women and other non-white men were chattel, servants, or little more than beasts of burden and were frequently regarded as lacking the capacity to reason, even lacking souls [7]. Particular qualities: autonomy, authenticity, authority, dignity – and rights: privacy, freedom, and equality – attach to, or conversely are denied, a corporeal presence. Yet the ways in which “difference”, particularly gender variance, has been both objectified and exploited have presented trans people with immense barriers against achieving equality under the law as the men, women, and human beings they know themselves to be. Opinions about transsexualism found a wide audience in popular literature of the 1940s and 1950s. Transsexualism was apparently attractive to mass-market publishers who were willing to exploit “freakish” subjects, and there were successful business models in Krafft-Ebing’s publishing history and Barnum and Bailey’s sensational displays. Legitimate scientists and medical practitioners concerned with the health and well-being of transsexual people had difficulty finding acceptance in peer-reviewed journals for topics that many physicians considered “bizarre” or “deviant”.10 American sexologist David O.  Cauldwell, M.D., Sc.D., found an expressive niche as an author with the general distribution publication Sexology: Sex Science Magazine from 1946 until his death in 1959 [43]. This publication sought “to provide for the layman ‘true sex information of a scientific nature’ (Editorial, 1958: 751)” [43]. Cauldwell wrote The eugenics movement in Britain and in the USA, as well as American miscegenation laws, attests to this. 10  See, for example, Collyer [41]; see also, Green [42]. 9 

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over 3000 articles for the magazine, which ­carried essays about such topics as “Homosexual Chickens”, “Extra Breasts in Women”, “Can Humans and Animals Crossbreed?”, “Sex and Satan”, and “Types of French Prostitutes” [44]. These are titles from the contents of Yoe’s anthology; Cauldwell was the author of “Can Humans and Animals Crossbreed?” and many others. He used his medical credentials to establish an authoritative tone that captured his readers’ attention and respect. Yet, according to Ekins and King, “there is no trace of Cauldwell publishing in the academic literature”. Cauldwell’s 1949 [4] article “Psychopathia Transexualis” established several myths about transsexual people in the popular consciousness, even though almost nothing was known at the time about transsexualism as a scientific or medical construct. Cauldwell wrote that there are people who live as members of the opposite sex because of some misfortune, accident, or physical malformation which causes them to become “transsexuals by affectation”, enabling them to live useful lives; these individuals are, he declared, “evidently…all purely autosexual”. This claim implies transsexual people are so inverted; they are not a social or sexual threat to others. They do not impose themselves on others, lie, cheat, or seduce, like the specific female-to-­ male case he describes in his article. He inferred that an obsessive desire for hormones and surgery is indicative of the underlying psychopathology in transsexual people. He blatantly stated it would be a criminal act for a surgeon to “mutilate a pair of healthy breasts” or to “castrate a woman with no disease…and without any condition wherein castration might be beneficial” ([4]: 276), never imagining that such treatment might have intrinsic benefit for the patient. Psychopathic transsexual individuals, Cauldwell asserted, have “a poor hereditary background and a highly unfavourable childhood environment”. This claim recalls eugenic theories about homosexual men. He also claimed that “[p]roportionately there are more individuals in this [psychopathic transsexual] category among the well-to-do than among the poor. Poverty and its attendant necessities serve, to an extent, as deterrents” ([3]: 274). This

implies that children of the rich are spoiled, wilful, selfish, and delusional, while the poor are respectful of others and able to subdue their desires and are, therefore, virtuous and realistic; or it might imply that poor people are simply too busy trying to meet their basic survival needs to indulge in such fantasies. He never considered that there might be any number of reasons that it might not occur to an uneducated, economically disadvantaged gender-variant person to seek professional help, not the least of which would be the expense. Cauldwell provided few references to any scientific literature to substantiate his opinions. Yet, many of Cauldwell’s assertions were frequently repeated in popular commentary about transsexual people even into the 1990s,11 indicating that his opinions, or inferences made from them, had become foundational to many damaging beliefs about gender-variant people (and possibly about “poor” people as well). Practitioners of both law and medicine live in society, too, and they are just as easily informed by popular beliefs, especially if they have no reason or opportunity to become otherwise educated; this is particularly true concerning marginalised subjects. Lending historical perspective to the misplaced confidence we have seen in judicial rulings that chromosomes are the definitive element of sex, it was only in 1956 that the world learned humans have 23 pairs of chromosomes instead of the 24 pairs previously believed ([45]: 41). Science never stops seeking, and finding, new facts; society, however, may not be ready to hear them.

The Benjamin View Endocrinologist Harry Benjamin, M.D., whose 1966 book on transsexualism [14] reached a wide popular audience, had his first contact with a For example, the extremely popular novel and film, Silence of the Lambs, in which an FBI agent declares, “There’s no correlation between transsexualism and violence”, and her brilliant antagonist says, “Transsexuals are very passive  – clever girl”. It is not an inherently bad statement, just one that is overgeneralising and rooted in assumptions.

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transsexual person in the early 1920s, though he acknowledged he did not think of the patient as transsexual [46]. A male-bodied individual who lived as a woman at home, presented as male outside the home, and wondered whether a newly available estrogenic hormone would “enlarge his breasts, which would give him a great emotional satisfaction”. The hormone was effective in producing mild gynecomastia (enlargement of breast tissue in the male) “to the infinite delight of the patient and with emotional improvement”. Benjamin wrote: This desire for physical changes, I realized later, characterized the transvestite as having a transsexual trend. The true transvestite would not be interested in it, at least not seriously enough to do something about it. He is content with cross-­ dressing alone. (Benjamin [14]: 2)

Benjamin later encountered two young adult males who exhibited enough feminine characteristics and behaviours that they were repeatedly harassed by their college classmates. One young man sought masculinisation, and his father told Dr. Benjamin that his son had “never been a real boy”. The other, Benjamin notes, “was afraid he was on his way to becoming a homosexual”. Benjamin reported: I was unable to follow either one’s career but, in retrospect, I am reasonably certain that at least the second boy was more likely to develop into a transsexual than a homosexual, because in him there was a disturbance of gender consciousness, which is not the case in homosexuality.

It is difficult to know what Dr. Benjamin meant by “a disturbance of gender consciousness”. He may have meant a particular awareness on the part of the patient that he was not or could not be male in some way that felt expected of him. Alternatively, Benjamin (and possibly his patient as well) may have conflated homophobia with transsexualism, such that the patient’s expressed fear of being homosexual somehow signalled a desire to align his body with his feminine qualities so that if he were attracted to men, he then would not be homosexual. Nevertheless, it is clear that Dr. Benjamin was cognizant of the different taxonomies between transsexual people, people who cross-dress, and people who are

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homosexual in their attraction, but secure in their gender identity (as it is aligned with their body). Benjamin represents, and certainly championed, the harmony principle in medicine with respect to the trans body. He recognised the ability of hormones and surgery to relieve the distress and suffering of those individuals who understood themselves as belonging to the “opposite sex”. He was later joined, directly and indirectly, by many other skilled physicians, surgeons, psychiatrists, psychologists, and theorists of various disciplines,12 who have agreed with Benjamin that “[p]sychotherapy in all its presently available forms had failed utterly to induce these patients to accept themselves in their anatomical and genetic sex” (Benjamin [14]: 4). Confusion between sex, sexuality, and gender, as meaningful terms, has infused debates about transsexualism since Hirschfeld. Even Dr. Benjamin found these terms problematic, and in his 1966 book, he tried to make sense of them for his readers: “There is hardly a word in the English language comparable to the word ‘sex’ in its vagueness and in its emotional content. It seems definite (male or female) and yet is indefinite. The more sex is studied in its nature and implications, the more it loses an exact scientific meaning. The anatomical structures, so sacred to so many, come nearer and nearer to being dethroned. Only the social and legal significances of sex emerge and remain” (Benjamin [14]: 15), and determinists continue to rely upon the concept of “true sex” to deny legal recognition to trans people, despite Benjamin’s efforts to inspire professional compassion. A paper published in 1968 by a surgeon and two psychiatrists, members of the Gender Identity Committee of the Johns Hopkins Hospital [48], discussed the problems of evaluation and selection criteria that were applied to transsexual people at that time. The paper reveals the authors’

Pauly [47: 465]; see also Carroll [12: 134]; also, the interdisciplinary professional society, the World Professional Association for Transgender Health has nearly 2500 members as of May 2019, the majority of whom concur with Benjamin’s perspective in this regard because of their own clinical experience.

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belief that the desire for “a change of sex operation” is an: “illness [involving] a conflict antedating genital sexuality […–] an attempt by the patient to become asexual, and then appear female to fulfil infantile needs, the origins of which derive from this pregenital period” ([48]: 520).

This focus on “pregenital”, “infantile needs” suspends transsexual people in a state of helplessness and incapacity. No matter how they described themselves, transsexual people’s issues and concerns risked being misinterpreted or negatively judged. Benjamin noted that “[o]pposition came mainly from psychoanalytically oriented physicians” (Benjamin [46]: 5). The University of California, Los Angeles, psychiatry professor Robert J. Stoller, M.D., wrote: “transsexualism, a term with a scientific, diagnostic ring, bears no such weight” (Stoller [49]: 161). Relying on a 1968 article by Kubie and Mackie, Stoller wrote: Though there can be sex reassignment, there cannot yet be – I believe – sex change or sex transformation. Sex reassignment is a social phenomenon to be accomplished by legal means and by convincing others to accept one’s changed role (new name, clothes, job, voice, and so on). In brief, the term does not imply that one has changed sex, for that would require chromosomal and anatomic reversal, but only that an assignment – and therefore a role – has changed. Guppies can change sex; humans cannot. Cosmetic surgery and manipulating secondary sex characteristics with hormones or electrolysis create biologic facsimiles only. (Stoller [49]: 162–163)

Lawrence S. Kubie (an M.D. psychoanalyst) and James B. Mackie (a Ph.D. editor of The Journal of Nervous and Mental Disease) recommended the term “gender transmutation” as an alternative to transsexualism “to refer to changes of those bodily characteristics associated with gender differences” [50]. They also questioned how much was known (in the late 1960s) about the differences between homosexuality, transvestism, and the desire for “gender transmutation” (transition from one gender role to the other, presuming there are only two gender roles, male and female). They compared “gender disturbances” (expression of or identification with a gender role that is

not the one prescribed by one’s genitals) in humans with gender role behaviour in subhuman primates, and, after citing many of the limitations on such comparative studies, they nevertheless offered the conclusion that “artificial environments and atypical patterns of development increased both the amount and variety of sexual behaviour shown by adult chimpanzees”. Specifically, they noted: Under these conditions they also observed peculiarities in gender-role behaviour: adult males appeared to be more interested in the care of infants and juveniles; females became more aggressive; social dominance for both males and females ceased to be related to sexual behaviour; and sex perversions appeared more often among both males and females, though the range and frequency of these perversions were greater among males than females, just as they are greater among human males [50].

No conclusion was offered, and no scientifically logical connection was drawn between the study of primates and human subjects. This information was simply inserted into a superficial discussion of the acquisition of gender identity, and the reader was left to infer whatever implications might be drawn regarding human gender identity and expression and how transsexualism or “gender transmutation” develops in human beings. Readers were apparently intended to infer that human beings in “artificial environments and [encouraged to adopt] atypical patterns of development” will exhibit increased, varied sexual behaviour. The underlying message was that to prevent these developments, parents must provide appropriate environments and limitations on behaviour to ensure comportment with assigned/ expected gender roles.

 he Gender Clinics of the 1960s T and 1970s: John Money’s Paradigm Throughout the twentieth century, discussion of transsexualism has been marginalised by mainstream medicine, while debates about sex, gender, and sexual behaviour have consumed politics, religion, and education; social sciences such as psychology, sociology, and anthropology; and

1  History, Societal Attitudes, and Contexts

such scientific fields as biology, genetics, and neurophysiology. Some of the debates have roots in feminism and reaction to the changing roles of women in society; and some have had to do with changing sexual mores; the political visibility of gay men and lesbians; the study of sexology, sexually transmitted diseases, and human sexual response; and better medical understanding of sexual development and differentiation. But antipathy from some practitioners and administrators toward transsexualism did not prevent some medical researchers from using it as a point of comparison in attempts to understand gender identity development and behaviour. New Zealand native John Money, Ph.D., professor of medical psychology and paediatrics, enjoyed a long career as a teacher and researcher at Johns Hopkins University in Maryland. In 1955, Money published an influential paper with department colleagues Joan G. Hampson and her husband John L. Hampson (Money et al. [51], in which they introduced the concept of “gender role”: to signify all those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It includes, but is not restricted to, sexuality in the sense of eroticism. (Money [52]: 119)

Money was trying to describe the psychology and sexology of “hermaphroditism,” looking for a term that would allow him to discuss the situation of a person, for example, without male genitalia, but living and functioning as a man in every way except “genital, copulatory sex”. For Money, this meant that the man could not fulfil the male sex role; hence, without the creation of the term “gender role”, Money and his colleagues had no way to discuss the subject’s behaviour. Money reflected that, by the mid-1960s, the concept of gender role merged with the concept of “gender identity”, which had developed at UCLA with Stoller, the originator of the concept of “core gender identity”, and psychologist Evelyn Hooker, who became known for depathologising homosexuality ([52]: 120). In what was thought of as a logical outgrowth of his work in gender-role development and sex differentiation, Money directed the first North

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American university-based gender clinic, established at Johns Hopkins in 1963, first publicised in 1966 ([52]: 121). John Randell established the first clinic in Britain at Charing Cross Hospital in 1967. The Johns Hopkins clinic was made possible following a Maryland court decision ruling “that a transsexual could be operated, and thereby protect[ing] the physicians and hospitals involved against legal consequences” ([47]: 468). Money’s work in this area received financial support from the National Institutes of Health, the US Public Health Service, and grants from the Stiles E.  Tuttle Trust and the Erickson Educational Foundation13 [54]. Money and his colleague and co-author, Anke A. Ehrhardt, were, for decades, two of the most influential writers in the USA on gender, sexuality, and sexual dimorphism. They collaborated on one book and numerous articles concerning human sexuality and gender variance. Their theories about ‘tomboyish’ girls, some of whom had an intersex condition called adrenogenital syndrome, were criticised heavily by feminist scholars Barbara Fried [55] and Lesley Rogers and Joan Walsh, for attempting to reinforce outdated gender stereotypes about women and for supporting biological determinism as an explanation “for groups in society who behave differently, the so-­ called sexually deviant groups  – homosexuals, transvestites, and transsexuals” [56]. The conflation of biological sex, physical intersex characteristics, and “deviant” sexual behaviour categories was common because so little was known, and so much presumed about what was “normal” and what was not. John Money and Clay Primrose published a paper in 1968 entitled “Sexual Dimorphism and Dissociation in the Psychology of Male

The Erickson Educational Foundation was established by an independently wealthy transsexual man, Reed Erickson, who also supported the work of Harry Benjamin, and the early interdisciplinary scientific symposia on gender identity, held in London (1969), Copenhagen (1971), Dubrovnik (1973), and again in London (1974), plus several other meetings, clinics, and educational groups in the USA and Europe, which he hoped would establish, rationalise, validate, and institutionalise medical treatment for transsexual people like himself. See Devor [53].

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Transsexuals” in which they discussed theories of gender variance driven by hormonal ­imbalances in the womb (and corroborating animal experiments) and compared 14 transsexual women’s self-described sexual histories and behaviours against generalised sexual histories (mostly stereotypes) of homosexual men and heterosexual trans women (then called male transsexuals). This article postulated that a psychosexual ambiguity of differentiation analogous to hermaphroditism “might result in sexual deviations such as homosexuality, transvestism or, more rarely, transsexualism”. It also declared that “[t]he male transsexual [is] the extreme form of homosexual” […] “completely dissociated from male identity” ([53]: 483–484). Psychological aberrations such as multiple personality disorder in one patient and “reports in the literature to indicate that, occasionally, a change of personality toward transvestism may occur in conjunction with the development of temporal lobe seizures” are offered as evidence that “[i]t is […] in neurophysiology as well as neuropsychology that the answer will one day be found to lie” ([53]: 483). John Money’s research of this period helped reinforce the idea of the primacy of the body, and the belief that sexual expression (even when expressed by gender signals rather than erotic intention) that did not conform to heterosexual norms was, at best, the manifestation of deformity. While physical intersex conditions compelled both curiosity and compassion in the late 1960s, homosexuality remained a strong focus of social concern, even among many of the people who came forward to request medical assistance for transsexualism at the university-based interdisciplinary clinics in North America. These clinics were extremely selective about the patients they chose to treat. Screening out homosexual men intent on avoiding the stigma of same-sex erotic attraction was a time-consuming activity for clinicians. According to Vern and Bonnie Bullough, a husband-and-wife team of educators/researchers who were both registered nurses, sociologists, and historians, who wrote many books and articles on sexuality and sexual history, this “is a

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commentary on our society that some people feel less of a stigma about being transsexual than they do about being homosexual” [57]. It may be argued that this was supported by the “intersex” connection to transsexualism and the idea that those afflicted did not choose to feel the way they did about their gender, while homosexual behaviour was cast as a choice and a perversion. In part because it was the first “sex change clinic” in the USA but also because of John Money’s confidently expressed and frequently published theories, Money’s Johns Hopkins gender clinic became the training ground for most American psychiatric gender practitioners through the 1980s. However, the clinic experience was less rewarding for patients. Most applicants to the university-based clinics were rejected as “transvestites” or homosexual men and were offered therapy to help them adjust to life as a member of their natal sex [58]. Patients with physical abnormalities or “hermaphroditism” were not classified as transsexual and therefore were not treated in these clinics, even though they might have had surgical sex reassignment in another wing of the same hospital. The mental illness model of transsexualism gained precedence in this clinical environment, where stringent requirements were imposed on those who met acceptance criteria that included “adoption of a sex-stereotyped manner of dress and appearance (literally along John Wayne/Marilyn Monroe lines)” [59]. Candidates became like performing animals, following prescriptive behavioural instructions in order to achieve the withheld prize of hormones, surgery, and legal status in their “new sex”, and were then criticised by their “trainers” for their efforts. This professional attitude enabled the sociological critique of what were presumed to be delusional fabrications that transsexual people employed to achieve their aims. It can be argued that objectification from both the hard sciences and the social sciences, combined with prescriptive, rigid, and gender-­ stereotypical (if not sexist) requirements for treatment, and a general inability to imagine that a person could actually feel that they had the “wrong body” led to the easily accepted conclusion that trans people are liars.

1  History, Societal Attitudes, and Contexts

Psychiatrist Ira B.  Pauly, M.D. summarised the clinical experience accumulated by the late 1960s as follows: Psychotherapy has not proved helpful in allowing the transsexual to accept that gender identity which is consistent with his genital anatomy. [emphasis in original] […] Transsexual patients have been pushed into psychosis, at the point where their well-meaning therapists felt that they were beginning to ‘cure’ the patient of his gender misidentification. There is considerable evidence from studies on hermaphrodites and intersexed patients that gender identity is established early, and once established firmly, is difficult, if not impossible to change. […] It would appear that a satisfactory outcome to sex reassignment surgery, in terms of improved social and emotional adjustment, is at least 10 times more likely than an unsatisfactory outcome. […] This is particularly true of those operated transsexuals who are successful in obtaining a legal change of status and thus are free to subsequently marry […]. (Pauly [47]: 465–466)

Dr. Pauly wrote that “[e]nough experience has now been accumulated so that certain criteria for sex reassignment surgery can be suggested” ([47]: 469). This was over 10  years before the development of the first version of Standards of Care for hormonal and surgical sex reassignment of gender dysphoric persons.14 Pauly’s comment that legal status is particularly important to a successful outcome for transsexual patients is notable, since even now, two decades into the new millennium, recognition in the law remains a significant goal for trans people and a barrier to their full participation in society in most countries.15 Ultimately, much of Money’s work was discredited by his support of behaviourist theories and his refusal to admit to the failure of the “John/ Joan” experiment ([61]; see also [62]) in which 14  Standards of Care were created in 1979 by the founding committee of the Harry Benjamin International Gender Dysphoria Association, Inc., or HBIGDA. The members of HBIGDA voted in 2008 to change the Association’s name to the World Professional Association for Transgender Health, or WPATH.  See http://www.wpath. org (retrieved 30 April 2019). 15  Currently Great Britain and Spain permit legal status change without evidence of genital reconstruction and/or sterilisation. Many countries (and three US states) refuse to consider any change to birth records and/or identity documents. See, for example, Whittle et al. [60].

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one identical twin boy’s penis was damaged in a hospital accident in Canada, offering the renowned Dr. Money an opportunity to prove his theory that children were blank slates with respect to gender and that making the genitals resemble female physiology and raising the child as a girl would result in a socially well-adjusted female adult. Sexologist Professor Milton Diamond, who had long been challenging Money’s theories of sexual identity formation [63], and the psychiatrist who had treated “John/Joan”, Keith Sigmundson, M.D., collaborated on an exposé of the case that Money had claimed was “lost to follow-up, and therefore a success” when it clearly was no such thing. “Joan” had experienced a very difficult childhood as a girl whom other children perceived as excessively masculine and was relieved when, at age 14, she was told she had been born a boy: she renamed herself David and began living as a male [62]. It seems illogical that Money’s experience with transsexual people would not have already informed him that no matter what their genitals look like and how their parents try to raise them, some people’s gender role/identity is different from that which their body might attempt to dictate. However, in the 1970s and 1980s, John Money remained very much at the epicentre of gender role developmental theory.

 egemony of the Mental Health H Model and Demise of the Clinics Within the structured environment of the Johns Hopkins Gender Identity Clinic, one psychiatrist, Jon K. Meyer, M.D. (then the clinic director), and a department secretary, Donna J. Reter, published an article that attempted “to step back from ‘normalization’ of sex reassignment procedures [that seemed to them to have occurred rather quickly after the establishment of the clinic in 1963] in order to look objectively at the long-range effects of surgery”. They arrived at the conclusion that: sex reassignment surgery confers no objective advantage in terms of social rehabilitation, although it remains subjectively satisfying to those who have rigorously pursued a trial period and who have undergone it. (Meyer and Reter [64]: 1015)

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This article was “widely cited by professionals” [5] in conjunction with other critical writings by women’s studies scholar Janice G.  Raymond ([65], 1994 edition) and journalist Roger Starr [66] and used to build consensus for defunding research-based gender programmes and attempting to curtail the practice of sex reassignment surgery. The Johns Hopkins GIC was abruptly closed later in 1979. The Meyer and Reter study also was widely criticised among counselling professionals and transsexual people themselves for its faulty methodology (see [5, 58]). Dallas Denny postulates that publication of the article was: orchestrated by Johns Hopkins Chair of Psychiatry Paul McHugh, who, in a 1992 article in American Scholar, stated that one of his reasons for accepting the Johns Hopkins position was to shut down the gender identity program. […] Within a year or two [of the Meyer and Reter article], most of the other gender identity programs in the United States had closed or had become private providers. [59]

Work by Ohio psychology professor and clinical researcher Dr. Leslie Lothstein, including the first fully developed monograph concerning female-to-male transsexual people [67], continued to promote a clinical picture of transsexual people as slightly to severely dysfunctional in many aspects of social and psychological adaptation, with conditions such as schizophrenia, borderline personality disorder, narcissism, profound ego defects, and impaired reality testing as distinguishing features ([68]: 248–254). To his credit, however, Lothstein did exhort his professional colleagues to put improvements in place in clinical applications, calling for standardised clinical assessment tools, and acknowledgement of regional, racial, sexual, and educational patient differences, as well as for the “training and qualifications of the clinical investigators and the time frame for obtaining postsurgical results” ([67]: 562), all of which he believed would lead to better outcome analysis and improved long-term treatment protocols. In 1979, the same year that Janice Raymond published The Transsexual Empire and Meyer and Reter published their study, the Harry Benjamin International Gender Dysphoria Association (HBIGDA) published the first edi-

tion of their Standards of Care for the Treatment of Gender Dysphoric Persons. In 1980 the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-III) contained diagnostic criteria for “transsexualism”, with input from some members of HBIGDA, while “homosexuality” was delisted as a mental disorder. In 1983, at HBIGDA’s biennial meeting, incoming President, surgeon Milton T. Edgerton, M.D., gave an address entitled “The Role of Surgery in the Treatment of Transsexualism”, which was reproduced as an article published in the Annals of Plastic Surgery in 1984. It contained an historical summary of transsexual surgery and the conflicting attitudes toward transsexual patients evident throughout the medical profession. Although the numbers of professionals interested in treating trans people with compassion and dignity appeared to be increasing (HBIGDA’s membership counted approximately 100 clinicians and scientists in 1984; see [69]), many doctors would still “roll their eyes or tell off-colour jokes when the subject of transsexual surgery is raised” [70]. Edgerton noted, however, that progress was being made: …it is evident that excellent surgical results are generally correlated with excellent psychosocial results. Significant complications will always reduce the level of patient satisfaction and make postoperative adjustments more difficult. […] … integrated clinics should continue to offer sex reassignment surgery. The work of such teams should be oriented toward clinical research. The studies must continue despite the fluctuations in political climate, cultural tolerance, and medicoeconomic decisions. In a very deep sense, in fact, these operations on transsexual patients should be viewed as ‘sex-confirmation’ operations  – and not as ‘sex-­ reassignment’ procedures. The difference is important. (Edgerton [70]; emphasis in original)

Edgerton’s long experience with transsexual people led him to understand that it was social gender that confirmed social, and therefore legal, sex. Prior to medical treatment, transsexual people often express (or, at the very least, feel) the conflict between the message of their body’s sex and the message of their gender. This conflict is frequently perceived by others and interpreted as sexual deviance or perversion. As Dr. Benjamin and others began to help through hormones and

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surgery rather than attempt to dissuade or cure through psychological means, which have proven ineffective, transsexual people were able to bring their gender expression into conformity with their sex. Hence, in Edgerton’s language, those who are assisted in making their sex concretely reflective of their gender have had their sex confirmed, because gender “speaks for” sex. Perhaps all factors of one’s sex cannot be changed, in the sense that chromosomes remain unchanged in sex reassignment procedures, but when all the factors that compose one’s sex combine in concert by being aligned with their psychological sex (the gender through which one is most comfortable expressing themselves), trans people are able to lead more authentic lives. This view acknowledges the integration of the psyche and the body that trans people seek through medical treatment; and mental illness, which might be concurrent and might be a result of the stress or stigma of gender variance, may be mitigated or resolved once physical treatment begins. The mental illness model, however, frames gender variance as a personal defect, an inability to accept the “reality” of one’s birth-assigned sex and the “natural body”. By 1994, the diagnosis of “transsexualism” was superseded in the DSM-IV by “Gender Identity Disorder”, framing the experience squarely in the mind and dissociating it from the sex of the body through the rhetoric of the label. One of the loudest voices advocating the mental illness model for the treatment of transsexualism was Paul McHugh, M.D., the former director of the Department of Psychiatry and Behavioral Sciences at the Johns Hopkins University School of Medicine, who has characterised providing “sex-change surgery” as “collaborating with madness” [71]. Dr. McHugh has claimed credit for closing down Johns Hopkins’s gender reassignment programme in 1979 and justified his rationale in his 2004 article.16 16  First Things magazine published by the Institute on Religion and Public Life defines itself as “an interreligious, nonpartisan research and education institute whose purpose is to advance a religiously informed public philosophy for the ordering of society” http://www.firstthings.com/masthead (retrieved 30 April 2019).

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McHugh characterised gender-variant males as “strange”, preoccupied with “sexual hungers and adventures”, “indifferent to children”, and “attracted to women”. According to McHugh, these patients could never be women because they did not faithfully or convincingly conform to a feminine demeanour and appearance. McHugh rejected the “opinion” that sex and gender “were distinct matters” and did not consider the social conditions in which clinic patients were raised or living or other factors that might have influenced their gender expression or understanding of their sexuality or gender identity: he simply labelled them mentally ill. McHugh supported his contentions by recounting the results of a long-term study by William G.  Reiner, originally “reported in the January 22, 2004, issue of the New England Journal of Medicine”. Reiner “followed up sixteen genetic males with cloacal exstrophy”, a condition which “produces a gross abnormality of pelvic anatomy”; however, “they develop within a male-typical prenatal hormonal milieu provided by their Y chromosome and by their normal testicular function”. Fourteen of the subjects underwent neonatal assignment to femaleness, socially, legally, and surgically. The other two parents refused the advice of paediatricians and raised their sons as boys. Eight of the 14 subjects assigned to be females had since declared themselves to be male. Five were living as females, and one lived with unclear sexual identity. The two raised as males had remained male. All 16 of these people had interests that were typical of males, such as hunting, ice hockey, karate, and bobsledding. Reiner concluded from this work that sexual identity followed genetic constitution [71]. Cloacal exstrophy is a rare birth defect of the bladder which can occur in both male and female infants. In males, it results in undescended testes, a “turning out” or exposure of a portion of the intestine, and epispadias – with the urethral opening on top of the phallus. In some cases, deformity of the penis is severe.17 Genital reconstruction to 17  h t t p : / / w w w. m e d t e r m s . c o m / s c r i p t / m a i n / a r t . asp?articlekey=13211 (retrieved 30 April 2019).

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preserve male anatomy is thought virtually impossible in some cases, so physicians used to recommend sex reassignment: removal of the testes and penile tissue and construction of female genitalia. There is no logical reason to associate cloacal exstrophy with hormonal or chromosomal intersex conditions that affect the genitalia, nor with sexual orientation, nor with gender variance. Yet McHugh’s invocation of Reiner’s conclusion about sexual identity is a semantic sleight of hand intended to create the impression of causal linkages between chromosomes and social behaviours, as well as the primacy of the body. Readers are supposed to conclude that the five boys who were living as girls are really boys because of their chromosomes and their interest in sports: no matter what the doctors had to do to correct this unfortunate condition (including having parents raise some of them as girls), these boys remained boys; therefore, McHugh implied, transsexual people remain members of their birth sex, too. McHugh went on to say: […] Sexual dysphoria – a sense of disquiet in one’s sexual role – naturally occurs amongst those rare males who are raised as females to correct an infantile genital structural problem. A seemingly similar disquiet can be socially induced in apparently constitutionally normal males, in association with (and presumably prompted by) serious behavioural aberrations, amongst which are conflicted homosexual orientations…”. [71]

The evidence Dr. McHugh offered is insufficient to provide any insight into the experience of transsexualism, but the authority with which he presented Reiner’s conclusions and his deliberate linkage of these findings with his opinions about the damage caused by “sex-change operations”, whether they are performed on infants or adults, is calculated to reinforce in the reader’s mind agreement with McHugh’s belief that any attempt to resist the sexual role dictated by one’s natal chromosomes and genital configuration, whether perfect or deformed, is dangerous and unethical. McHugh’s conviction that sexual identity is fundamental to the human constitution (as McHugh has observed that constitution) appeals to those who see gender-variant behaviour  – and homosexuality – as lifestyle choices. But this is not a

two-way street: transsexual people are never given the benefit of the doubt that their own sexual (or gender) identity could be natural to them. McHugh’s ability to spread confusion and cast doubt on transsexual experience can be attributed to his position of professional authority, as well as his sense of moral superiority in the conviction that it is “madness” to feel that a “normal” body (one without diagnosable birth defects, which are “natural” in that God creates them) is “the wrong sex”. McHugh’s argument makes perfect sense to people with “normal” bodies and gender identities that correspond “properly” or who have relegated issues of sexuality and gender to a position of minor, or negligible, importance in their personal hierarchy of human concerns.

 eassignment, Change, or R Affirmation? Does the truth lie in biology? Is gender dysphoria and/or transsexualism a physical, mental, or social problem? With hormones and/or surgery, is it sex or gender that is changed? And for whom does “the problem” pose the most difficulty? The medical literature of transsexualism and gender dysphoria through the 1980s and 1990s consists largely of descriptions of surgical technique and surgical, psychological, and endocrinological case studies. Consensus concerning the aetiology or treatment of gender-variant people was still lacking. Even the outcome studies that appeared during this period were inconclusive, though they cumulatively indicated increasing success rates, while measurement criteria varied according to the factors each researcher deemed important (see [72]). As professor of biology and medicine, Dr. Anne Fausto-Sterling wrote: …social belief systems weave themselves into the daily practice of science in ways that are often invisible to the working scientist. To the extent that scientists proceed without seeing the social components of their work, they labor with partial sight. In the case of sex hormones, I suggest that widening our scientific vision would change our understanding of gender. But of course, such changes can occur only as our social systems of gender change. (Fausto-Sterling [73]: 194)

1  History, Societal Attitudes, and Contexts

In his 1992 book, Sexual Science and the Law, Richard Green’s chapter on transsexualism raised areas of the law as problematic for transsexual people: employment discrimination, marriage, child custody, name change procedures, sports competition, access to restroom facilities, and treatment in prison. Although the problem areas remain, Green offered his own expert witness testimony in several legal proceedings, and his clinical experience, as evidence that transsexual people are best served medically and psychologically when able to experience employment in the new gender role. This is part of the “real-life experience”,18 mandated for at least 1 year prior to genital reconstruction surgery.19 Green also noted the 1945 Swiss court that ruled “psychological sex or gender identity was the criterion for determining the sex of the postoperative transsexual” ([75]: 111), establishing legal marriage in the postoperative sex for transsexual people in Switzerland, a ruling ignored in other courts. Green’s writings, though, also indicate the slow advent of availability of medical and psychological services for transsexual people and of more humane approaches to the full participation of gender-variant people in social institutions. In Europe, the 1990s brought significant progress in medical treatment of transsexualism. Some of the most important work was done at the Academic Hospital of the Free University in Amsterdam, where endocrinologist professor L.J.G. Gooren and Dr. Joris J. Hage, a plastic surgeon, published numerous papers in medical journals. Dr. Gooren also gave influential testimony before governmental bodies. In his closing 18  Green [45: 104]. Green uses the old language, “real-life test”, which was removed from the HBIGDA Standards of Care (SOC) in 1980. Continued use of the obsolete term has contributed widespread misunderstanding of the SOC among trans people that creates antagonism between the community and medical providers. 19  This requirement refers to the Standards of Care: Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons that emerged in 1979, with Richard Green a contributor: Walker [74]. Revisions were published in 1980, 1981, 1990, 1997, 2001, and 2011. Version 8 is anticipated to be released in 2020. Current and past versions of the SOC may be found on the website www. wpath.org

15

address before the Council of Europe, at the 23rd Colloquy on European Law, 14–16 April 1993, Dr. Gooren gave new evidence concerning the sexual differentiation of the brain: this developmental process is incomplete at birth and continues over a protracted period, culminating when between ages 3 and 4. Gooren wrote: Assignment to sex on the criterion of external genitalia is an act of faith, but well-founded and time-­ honoured. Only 1 in 10,000–30,000 will be a false prognostication [as seen earlier in this chapter, this number is likely grossly underestimated]. […t] ranssexualism is not an isolated phenomenon in the area of sex errors of the body. It is one on a sliding scale. […] It would be absolute medical ignorance, medical incompetence, even abuse NOT to rehabilitate a person with a sex error of the body. […] We must create the conditions for successful rehabilitation to the male or female sex as much in the cases of transsexualism as in other cases of intersex subject. [76]20

Dr. Gooren also wrote of the effects of cross-­sex hormones based upon 10,152 patient years of experience in the Dutch system, finding that hormonally induced skeletal changes prior to cross-­ sex hormone treatment, while they can be modified, are rarely eliminated; nevertheless, cross-sex sexual hair growth patterns, body-fat distribution changes, vocal changes in femaleto-­males, increased libido, and clitoral enlargement, in a small number of subjects sufficient for vaginal intercourse with a partner, are all possible where genetics allows the effects to occur. Continuous use of cross-sex hormones following gonadectomy is necessary to prevent symptoms of hormone deprivation and osteoporosis. There was no increase in mortality among the transsexual population studied as compared to the entire Dutch population. Gooren also recommended treating prepubertal gender-variant children with hormone blockers to delay pubertal development “until an age that a balanced and responsible decision can be made” regarding whether cross-­sex hormone and irreversible surgical treatments may be productively or beneficially administered [78].

Gooren [77].

20 

J. Green

16

In 1995, Dutch plastic surgeon Dr. Joris J. Hage noted that: [i]t takes a rather long period of experience with gender dysphoric subjects before one may come to believe that the patient with genuine gender dysphoria carries a discrepancy that is valid as an indication for surgical sex reassignment. (Hage [79]: 17)

By the late 1990s, a new trend emerged that reflected the burgeoning self-confidence of the gender-variant population. Transsexual people came to resist the stereotypes and victim status implied by the diagnostic system of medical practitioners. The term “transgender”, introduced in the early 1970s, came to be used in the early 1990s as a term of self-definition, defying the medically imposed life scripts transsexual people were supposed to follow. Denny, et al. wrote: The pathology-based medical model followed by the clinics was surgically-based. […] The new transgender model broke with the pathology-based medical model [and emphasized gender variance as] a natural form of human variability, one that is present in all societies throughout history. […] Without the clinics as a place for intake [in the US], transsexual [people] in search of sex reassignment services began to communicate with one another and to build networks of service providers who were interested not only in providing professional care to gender-variant people, but in learning from their lived experiences. (Denny et  al. [59]: 163)

By the end of the twentieth century, trans people began to exercise greater decision-making power over their own lives, over which surgical techniques they preferred, and whether to have genital reconstruction surgery at all. Instead of hiding themselves away, as doctors had advised for the previous 50 years, they began building social networks, sharing information, holding conferences, and publishing books and articles. They were refusing to leave their jobs when they transitioned and sometimes lived openly in their preferred gender without full, or even any, medical intervention. Trans people were obtaining professional credentials and advocating for themselves in all aspects of life. By the dawn of the twenty-­ first century, trans physicians, surgeons, psychologists and psychiatrists, attorneys, university

professors, small business owners, engineers, artists, filmmakers, and more were practising their professions in large cities and small towns around the world. And young trans people continue to come forward to join their ranks.21 This evolution was expressed in the medical literature in a 1999 article by psychologist and professor Dr. Richard A.  Carroll. Dr. Carroll emphasised: An appreciation of the diversity of the transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her. (Carroll [80]: 128)

The realisation that not all transgender and transsexual people were alike and that not everyone would fit a mould with respect to presenting characteristics or adaptability to solutions offered made some providers uncomfortable. Medical practitioners who refused to accept patients who did not obediently follow “the script”, or who made insulting or degrading comments about patients in their journal articles, developed reputations among trans people who shared information, often thanks to the Internet, but also to widening circles of people attending community-­ based conventions or academic conferences devoted to explorations of transgender identity and gender-variant experience.22 By 2000, Dr. Milton Diamond, professor in the Department of Anatomy and Reproductive Biology at the University of Hawaii, had stated clearly that he believed transsexual people are

See, for example, Professor Lynn Conway’s “Transsexual Women’s Successes” website at http://ai. eecs.umich.edu/people/conway/TSsuccesses/ TSsuccesses.html and “Successful TransMen” at http:// ai.eecs.umich.edu/people/conway/TSsuccesses/ TransMen.html 22  One example of a surgeon who fell out of favour in the USA is Dr. David Gilbert, who was reported to have remarked in a presentation (at the International Foundation for Gender Education annual conference, Houston, TX, April 1992) concerning radial forearm flap transfer phalloplasty procedure that women who partner with transsexual men “love to suck on forearms” (anonymous personal communication, April 1992). 21 

1  History, Societal Attitudes, and Contexts

intersexed.23 He disagreed with Money and with Hampson and Hampson that “learning is […] the sole or dominant determiner of the gender role” ([63]: 165–166). He disagreed with the [76] framing of transsexualism as a “sex error” and viewed the phenomenon as one of intersex variation, not a disorder.24 The social factors involved in each and every transsexual person’s early life, upbringing, and young adulthood are unique and varied. Diamond wrote: Benjamin […] could find no evidence that childhood conditioning is involved in the etiology of […] transsexualism in 47 out of 87 patients. In the remaining 40 patients conditioning was of “doubtful” influence in 24 individuals, and definitely influential in only 16 cases. […] The learning of a gender role is a culturally fostered ontogenetic phenomenon of development superimposed on a prenatally determined pattern and mechanism of sexual behavior. (Denny et al.[59]: 166)

In other words, the manifestation of a gender identity in contrast to one’s body arises from a biological predisposition that may be culturally influenced in some cases. Transsexualism is not always apparent in childhood or is often ignored when observed, or, worse, it may be vigorously suppressed, leading to significant psychological damage ([47]: 465–466). Theories about transsexualism as an intersex condition are not new: Benjamin subscribed to this theory ([84]: 13), as did the renowned British plastic surgeon Sir Harold Gillies [85]. It was the intuitive theory that Magnus Hirschfeld tentatively advanced, even before modern hormonal and surgical treatment was imagined. Over 100  years later, there are still no definitive answers to questions concerning what makes someone trans, but certainly more is known about how to effectively treat those who experience disabling gender variance. Outcome studies are the closest thing to ultimate See Diamond [81: 50]. His theory that transsexual people are intersexed mentally was articulated in Diamond [82], Pediatric Management of Ambiguous and Traumatized Genitalia. [National Kidney Foundation Lecture] in The Journal of Urology, 162, 1021–1028, but it was not elaborated upon until the 2000 article, and developed further in Diamond [82]. 24  Personal communication with Prof. Milton Diamond, 15 May 2010. 23 

17

proof that we have, and while these do show that life is not always easy for trans people, the cumulative rate of postoperative regret is quite small: less than 1% in female-to-male transsexual people and less than 2% in male-to-female transsexual people. [… Further,] “In over 80 qualitatively different case studies and reviews from 12 countries, it has been demonstrated during the last 30  years that the treatment that includes the whole process of gender reassignment is effective” [72]. It seems appropriate here to mention just two of the more recent research discoveries that will soon become part of the discourse about transsexualism and gender variance: “new evidence that the brain begins to develop differently in males and females much earlier than was thought – before sex hormones come into play” [86] and the demonstration “that a single factor, the forkhead transcriptional regulator FOXL2, is required to prevent transdifferentiation of an adult ovary to a testis” [87], which means that an active process must take place within the female body throughout the life course to prevent the female gonads from becoming male gonads. In other words, neither the brain nor the gonads are as concretely or discretely dimorphic and correspondent with other physical characteristics as has been thought previously. These discoveries mean that the old scientific paradigm of human sexual differentiation, so successfully manipulated by trans antagonists like Raymond or McHugh, is shifting to a broader, more variable, less reductively certain paradigm which may soon offer validation for trans people’s sense of their own authenticity.

References 1. King B.  Introduction (B.  King, trans.) Psychopathia Sexualis. Burbank: Bloat Books. (reprinted from: 12). 1999. 2. Krafft-Ebing, R. v. Psychopathia Sexualis. (B. King, Trans.). Burbank: Bloat Books; 1906, tr. 1999. 3. Sharpe AN.  Transgender jurisprudence: dysphoric bodies of law. London: Cavendish Publishing; 2002. 4. Cauldwell DO. Psychopathia Transexualis. Sexology Magazine. 1949;16(December):274–80.

18 5. Fleming M, Steinman C, Bocknek G. Methodological problems in assessing sex-reassignment surgery: a reply to Meyer and Reter. Arch Sex Behav. 1980;9(5):451–6. https://doi.org/10.1007/ BF02115944. 6. Meyerowitz J.  How sex changed: a history of transsexuality in the United States. Cambridge: Harvard University Press; 2002. 7. Laqueur T.  Making sex: body and gender from the Greeks to Freud. Cambridge: Harvard University Press; 1990. 8. Bogoras NA. Plastic restoration of the penis. Sov Khir (Soviet Surgery). 1936a;303 9. Bogoras NA.  Production of a coitus-capable penis. Zentralblatt Chirurgie (Central Journal for Surgery). 1936b;63:1271–6. 10. Gillies H, Harrison RJ.  Congenital absence of the penis with embryological considerations. Br J Plast Surg. 1948;1(8):8. 11. Abraham F.  Genitalumwandlung an zwei männlichen Tranvestiten (Genital reassignment on two male transvestites). Zeitschrift für Sexualwissenschaft (Journal of Sexology). 1931;18:223–26. Reprinted in International Journal of Transgenderism. 1998;1(3). 12. Colebunders B, Verhaeghe W, Bonte K, D’Arpa S, Monstrey S.  Male-to-female gender reassignment surgery. In: Ettner R, Monstrey S, Coleman E, editors. Principles of transgender medicine and surgery. 2nd ed. New York: Routledge; 2016. p. 250–78. 13. Colebunders B, D’Arpa S, Weijers S, Lumen N, Hoebeke P, Monstrey S. Female-to-male gender reassignment surgery. In: Ettner R, Monstrey S, Coleman E, editors. Principles of transgender medicine and surgery. 2nd ed. New York: Routledge; 2016. p. 279–317. 14. Benjamin H. The transsexual phenomenon. Paperback ed. New York: Warner Books, Inc.; 1966. https://doi. org/10.1016/0002-9378(66)90231-6. 15. Green R, Money J, editors. Transsexualism and sex reassignment. Baltimore: The Johns Hopkins University Press; 1969. 16. Ostow M. “Transvestism.” Correspondence. JAMA. 1953;152(16):1553. https://doi.org/10.1001/ jama.1953.03690160053020. 17. Dreger AD.  Hermaphrodites and the medical invention of sex. Cambridge: Harvard University Press; 1998. 18. Green J.  Becoming a visible man. Nashville: Vanderbilt University Press; 2004. 19. Lev AI.  Transgender emergence: therapeutic guidelines for working with gender-variant people and their families. Binghamton: The Haworth Clinical Practice Press; 2004. https://doi.org/10.1007/ s10630-005-0007-z. 20. Elizabeth SM.  Legal aspects of transsexualism. Wayland: International Foundation for Gender Education; 1990. 21. Walinder J.  Transsexualism: definition, prevalence and sex distribution. Acta Psychiatrica Scandinavia. 1968;203:255–7.

J. Green 22. Walinder J. Incidence and sex ratio of transsexualism in Sweden. Br J Psychiatry. 1971;119:195–6. https:// doi.org/10.1192/bjp.119.549.195. 23. Hoenig J, Kenna JC.  The prevalence of trans sexualism in England and Wales. Br J Psychiatry. 1974;124:181–90. 24. Bakker A, Van Kesteren PJM, Gooren LJG, Bezemer PD.  The prevalence of transsexualism in the Netherlands. Acta Psychiatrica Scandinavia. 1993;87(4):237–8. https://doi. org/10.1111/j.1600-0447.1993.tb03364.x. 25. Eklund PLE, Gooren LJG, Bezemer PD.  Prevalence of transsexualism in the Netherlands. Br J Psychiatry. 1988;152:638–40. https://doi.org/10.1192/ bjp.152.5.638. 26. Van Kesteren PJ, Gooren LJ, Megens JA. An epidemiological and demographic study of transsexuals in the Netherlands. Arch Sex Behav. 1996;25(6):589–600. https://doi.org/10.1007/BF02437841. 27. Weitze C, Osburg S.  Transsexualism in Germany: empirical data on epidemiology and application of the German Transsexuals’ act during its first ten years. Arch Sex Behav. 1996;25(4):409–25. https://doi. org/10.1007/BF02437583. 28. De Cuypere G, Van Hemelrijck M, Michel A, Carael B, Heylens G, Rubens R, Monstrey S.  Prevalence and demography of transsexualism in Belgium. Eur Psychiatry. 2007;22(3):137–41. https://doi. org/10.1016/j.eurpsy.2006.10.002. 29. TsoiWF. The prevalence of transsexualism in Singapore. Acta Psychiatrica Scandinavia. 1988;78:501–4. https://doi.org/10.1111/j.1600-0447.1988.tb06373.x. 30. Olyslager F, Conway L.  On the calculation of the prevalence of transsexualism. In: Paper presented at the world professional Association for Transgender Health 20th international symposium. Chicago; 2007. 31. Chokrungvaranont P, Tiewtranon P.  Sex reassign ment surgery in Thailand. J Med Assoc Thail. 2004;87(11):1402–7. 32. Vujovic S, Popovic S, Sbutega-Milosevic G, Djordjevic M, Gooren L.  Transsexualism in Serbia: a twenty-year follow-up study. Journal of Sexual Medicine. 2009;6(4):1018–23. 33. Veale J.  Prevalence of transsexualism among New Zealand passport holders. Aust N Z J Psychiatry. 2008;42(10):887–9. https://doi. org/10.1080/00048670802345490. 34. Eyler AE.  Primary medical Care of the Gender Variant Person. In: Ettner R, Monstrey S, Eyler AE, editors. Principles of transgender medicine and surgery. New York: The Haworth Press; 2007. p. 15–32. 35. Devor AH.  Witnessing and mirroring: a fourteen stage model of transsexual identity formation. J Gay Lesbian Psychother. 2004;8(1):41–67. https://doi. org/10.1300/J236v08n01_05. 36. Ventura A, Manaois A. Good jobs NOW!: a snapshot of the economic health of San Francisco’s transgender communities. San Francisco: Transgender Law Center; 2006. p. 12. Available at https://transgenderlawcenter.org/resources/employment/good-jobs-now

1  History, Societal Attitudes, and Contexts 37. Denny D. Changing models of transsexualism. J Gay Lesbian Psychother. 2004;8(1):25–40. https://doi. org/10.1300/J236v08n01_04. 38. Thomas K.  Afterword: are transgender rights inhuman rights? In: Currah P, Juang RM, Minter SP, editors. Transgender rights. Minneapolis: University of Minnesota Press; 2006. p. 310–26. 39. Brown ML, Rounsley CA. True selves: understanding transsexualism for families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass; 1996. 40. Cota I, McIntyre K. Tough love for state’s transgender inmates. 2010. Retrieved from ktvu.com website: http://www.ktvu.com/news/24206972/detail.html. 41. Collyer F.  Sex-change surgery: an ‘Unacceptable innovation?’. J Sociol. 1994;30(3):3–19. https://doi. org/10.1177/144078339403000101. 42. Green R. Attitudes toward sex reassignment. In: Green R, Money J, editors. Transsexualism and sex reassignment. Baltimore: The Johns Hopkins University Press; 1969. p. 235–42. 43. Ekins R, King D.  Pioneers of Transgendering: the popular sexology of David O. Cauldwell. International Journal of Transsexualism. 2001;5(2) 44. Yoe C, editor. The best of sexology, the illustrated magazine of sex Science: kinky and kooky excerpts from America’s first sex magazine. Philadelphia: Running Press; 2008. 45. Money J.  The Adam principle: genes, genitals, hormones, and gender: selected readings in sexology. Buffalo: Prometheus Books; 1993. https://doi. org/10.1159/000276415. 46. Benjamin H.  Introduction. In: Green R, Money J, editors. Transsexualism and sex reassignment. Baltimore: The Johns Hopkins University Press; 1969. p. 1–10. 47. Pauly IB. The current status of the change of sex operation. J Nerv Ment Dis. 1968;147(5):460–71. https:// doi.org/10.1097/00005053-196811000-00003. 48. Knorr NJ, Wolf SR, Meyer E.  The Transsexual’s request for surgery. J Nerv Ment Dis. 1968;147(5):517–31. https://doi. org/10.1097/00005053-196811000-00008. 49. Stoller RJ. Presentations of gender. New Haven: Yale University Press; 1985. 50. Kubie LS, Mackie JB.  Critical issues raised by operations for gender transmutation. J Nerv Ment Dis. 1968;147(5):431–43. https://doi. org/10.1097/00005053-196811000-00001. 51. Money J, Hampson JG, Hampson JL.  An examination of some basic sexual concepts: the evidence of human hermaphroditism. Bull Johns Hopkins Hosp. 1955;97:301–19. 52. Money J.  Sin, science, and the sex police: essays on sexology and Sexosophy. Amherst: Prometheus Books; 1998. https://doi.org/10.1006/fgbi.1998.1052. 53. Devor AH.  Reed Erickson and The Erickson educational foundation. http://web.uvic.ca/~erick123/. 2005. Retrieved 30 Apr 2019.

19 54. Money J, Primrose C.  Sexual dimorphism and dissociation in the psychology of male transsexuals. J Nerv Ment Dis. 1968;147(5):472–86. https://doi. org/10.1097/00005053-196811000-00004. 55. Fried B. Boys will be boys will be boys: the language of sex and gender. In: Hubbard R, Henifin MS, Fried B, editors. Biological woman – the convenient myth. Cambridge, MA: Schenkman Publishing Co, Inc.; 1982. 56. Rogers L, Walsh J. Shortcomings of the psychomedical research of John Money and co-workers into sex differences in behavior: social and political implications. Sex Roles. 1982;8(3):269–81. https://doi. org/10.1007/BF00287311. 57. Bullough B, Bullough VL.  Transsexualism: historical perspectives, 1952 to present. In: Denny D, editor. Current concepts in transgender identity. New York: Garland Publishing, Inc.; 1998. p. 15–34. 58. Denny D.  The politics of diagnosis and a diagnosis of politics: the university-affiliated gender clinics, and how they failed to meet the needs of transsexual people. Transgender Tapestry. 1991;1(98  – Summer 2002), 2–8 (17–22). 59. Denny D, Green J, Cole S.  Gender Variability. In: Owens AF, Tepper MS, editors. Sexual health, vol. 4. Westport: Praeger; 2007. p. 153–87. 60. Whittle S, Turner L, Combs R Rhodes S. Transgender EuroStudy: legal survey and focus on the transgender experience of healthcare. ILGA Europe and Transgender Europe. Available at http://www.ilgaeurope.org/europe/publications/reports_and_other_ materials. 2008. Retrieved 9 Apr 2010. 61. Diamond M, Sigmundson HK.  Sex reassignment at birth: long-term review and clinical implications. Archives of Pediatric Adolescent Medicine. 1997;151(3):298–304. https://doi.org/10.1001/ archpedi.1997.02170400084015. 62. Colapinto J.  As nature made him: the boy who was raised as a girl. New York: HarperCollins; 2000. 63. Diamond M. A critical evaluation of the ontogeny of human sexual behavior. Q Rev Biol. 1965;40(2):147– 75. https://doi.org/10.1086/404539. 64. Meyer JK, Reter DJ.  Sex reassignment: follow-up. Arch Gen Psychiatry. 1979;36:1010–5. https://doi. org/10.1001/archpsyc.1979.01780090096010. 65. Raymond JG. 1994 edition. In: The transsexual empire: the making of the she-male. New  York: Teachers College Press; 1979. 66. Starr R. Cutting the ties that bind: the matter of sex reassignment. Harper’s. 1978;1:48–56. 67. Lothstein LM.  The postsurgical transsexual: empirical and theoretical considerations. Arch Sex Behav. 1980;9(6):547–64. https://doi.org/10.1007/ BF01542158. 68. Lothstein LM.  Female-to-male transsexualism: historical, clinical, and theoretical issues. Boston: Routledge & Kegan Paul; 1983. 69. Laub DR, M.D.  Invited comment. Ann Plast Surg. 1984;13(6):476.

20 70. Edgerton MT, M.D. The role of surgery in the treatment of transsexualism. Ann Plast Surg. 1984;13(6):473–6. https://doi.org/10.1097/00000637-198412000-00003. 71. McHugh, P.  Surgical sex. First things, (November). 2004. Retrieved from http://www.firstthings.com/ article/2009/02/surgical-sex%2D%2D35 72. Pfafflin F, Junge A. Sex reassignment: thirty years of international follow-up studies after sex reassignment surgery: a comprehensive review, 1961–1991. 1998. Retrieved from http://www.symposion.com/ijt/pfaefflin/1000.htm 73. Fausto-Sterling A. Sexing the body: gender politics and the construction of sexuality. New  York: Basic Books; 2000. https://doi.org/10.1002/​j.23261951.2000.tb03504.x. 74. Walker PA.  Standards of care: hormonal and surgical sex reassignment of gender dysphoric persons. Palo Alto: Harry Benjamin International Gender Dysphoria Association; 1979. https://doi.org/10.1136/ bmj.2.6205.1641. 75. Green R.  Sexual science and the law. Cambridge: Harvard University Press; 1992. 76. Gooren, LJG. Closing speech. Paper presented at the transsexualism, medicine and law: XXIII colloquy on European law, Amsterdam (Netherlands); 1993, 14–16 April. 77. Gooren LJG. Closing Speech. Paper presented at the Transsexualism, medicine and law: XXIII Colloquy on European Law, Amsterdam (Netherlands); 1993, 14–16 April. p. 237–238.

J. Green 78. Gooren LJG.  Hormonal sex reassignment. Int J Transsexualism. 1999;3(3). Retrieved from http:// www.symposion.com/ijt/ijt990301.htm 79. Hage JJ.  Medical requirements and consequences of sex reassignment surgery. Med Sci Law. 1995;35(1):17–24. 80. Carroll RA.  Outcomes of treatment for gender dysphoria. Journal of Sex Education and Therapy. 1999;24(3):128–36. 81. Diamond M.  Sex and Gender: Same or Different? Fem Psychol. 2000;10(1):46–54. 82. Diamond M.  Pediatric Management of Ambiguous and Traumatized Genitalia. [National Kidney Foundation lecture]. J Urol. 1999;162:1021–8. https:// doi.org/10.1016/S0022-5347(01)68054-6. 83. Diamond M.  Sex and gender are different: sexual identity and gender identity are different. Clin Child Psychol Psychiatry. 2002;7(3):320–34. 84. Benjamin H.  Transvestism and transsexualism. Int J Sexol. 1953;7:12–4. 85. Gillies H, Millard DR. The principles and art of plastic surgery, vol. 1. London: Butterworth; 1957. 86. Dennis C. The most important sexual organ. Nature. 2004;427(29 January):390–2. 87. Uhlenhaut NH, et  al. Somatic sex reprogram ming of adult ovaries to testes by FOXL2 ablation. Cell. 2009;139:1130–42. https://doi.org/10.1016/j. cell.2009.11.021.

2

Etiology of Gender Dysphoria Randi Ettner

Introduction

Historical Background

Humans have sought, since the beginning of time, to understand the physical world and one another. Ancient people passed myths down orally, to account for the unknown mysteries of life. These stories explained how supernatural deities created the world and other natural phenomena. Mythmakers of all religions and cultures recognized that it was the autocracy of the gods to inflict sickness or bestow health [1]. The Scientific Revolution of the sixteenth and seventeenth centuries heralded the dawn of a revolution in physics and modern-day science. Theory replaced myth, and the printing press disseminated knowledge. The medical profession made great strides in understanding the human body and the origins of disease. But human beings do not easily capitulate to taxonomy, and in the absence of observable disease or organ damage, one relies on theory – the modern equivalent of myth – to explain enigmatic phenomena and “unseen forces.” Such is the case with gender incongruity  – the most misunderstood area of human behavior.

Cross-gender behavior dates back to Biblical times, and the Old Testament railed against such displays [Deuteronomy 22:5]. Ovid, a first-­ century B.C. poet, referred to the “stuff from a mare in heat,” a reference to conjugated estrogen, which is derived from pregnant mares [2]. But prior to the mid-twentieth century, gender transition was unknown in the Western world. In 1877, Krafft-Ebbing referenced case histories of cross-gender behavior in the medical literature, but it was the German sexologist Magnus Hirschfeld’s 1910 monograph, Die Transvestism, that fully described the phenomenon [3]. In 1921, Harry Benjamin, a German gerontologist living in New York, and Eugen Steinach noted that ligation of the vans deferens appeared to be therapeutic for aging men, in what presaged the use of hormone replacement for the aged. Steinach experimented with “changing the sex” of animals, by castration and implantation of sex glands. Benjamin was very interested in Steinach’s experiments and spent the next decade of his life treating geriatric patients with endocrine therapy. In 1948, an incident occurred that changed Dr. Benjamin’s life and the lives of countless people [4]. Alfred Kinsey, the famous sex researcher, referred a 23-year-old man named Van to Benjamin, with a most unusual request: Van wanted to be a woman. Van and his mother

R. Ettner (*) Clinical and Forensic Psychologist, Evanston, IL, USA

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_2

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pleaded with Benjamin for help. Van had been dressing in girl’s clothing since age 3, and special toilet arrangements had been made for him throughout his grade school years. The family consulted with psychiatrists who assured them the child would outgrow this behavior. Van, who was highly intelligent, left high school when the school refused to accommodate him and spent his days performing housework. Van’s insistence that there must be a means by which he could change sex led to his institutionalization by the courts, a year prior to his meeting with Benjamin. Benjamin encouraged Van to go to Germany, where accounts of surgeries appeared in the literature. Van made three trips to Europe and ultimately had a neovagina constructed from a thigh graft [5]. But it wasn’t until 1952, when the US citizen Christine Jorgenson underwent a highly publicized surgery in Denmark, that “sex-change surgery” captured the public’s attention.

Early Theories As Ms. Jorgenson’s fame rose, so did opposition to surgical intervention. The “Christine operation” gave rise to legal, medical, and moral controversy. Most damaging was the rhetoric of the psychiatric community that challenged the legitimacy of the surgery and decried those who performed it. A 1978 article in the Journal of the American Medical Association stated: “…most gender clinics report that many applicants for surgery are actually sociopaths seeking notoriety, masochistic homosexuals, or borderline psychotics…” [6]. According to prominent psychiatrists of the time, gender dysphoric individuals seeking surgery had a serious psychiatric disorder and were either psychotic or otherwise severely disturbed. Unfortunately, this view and the conflation of homosexuality, gender dysphoria, and psychopathology too often resulted in institutionalization. If psychoanalysis failed to effect a “cure,” individuals were often subjected to electroshock or other aversion therapies [7]. Some researchers rejected psychoanalytic theories and searched for a biological basis for the

condition. Several early attempts included roentgenological examination of skulls [8], screening for anomalous hormonal milieus [9, 10], cytotoxicity assay inspection of h-y antigen status [11, 12, 13, 14], and quantitative EEG analysis. Despite the failure of these early attempts, some researchers remained convinced that a yet unknown change in hormonal-dependent brain structure was implicated [15]. Psychologists, too, played a role in debunking the psychoanalytic theory. Using psychometric testing, they dispelled the notion that transgender individuals had serious psychopathology. Indeed, several studies concluded that surgical applicants demonstrated a “notable absence of psychopathology” [16–19]. These research findings became increasingly robust as Internet databases became available. For the first time, meta-­ analyses were possible. Large-scale studies found no evidence that child-rearing practices accounted for the development of the phenomenon [20], and with that, psychoanalytic theories were put to rest. In addition to the Internet, advances in technology led to increasingly sophisticated hypotheses. By the 1990s, the theory of “gender transposition” emerged. The evidence of a link between steroid hormones, brain structure, and animal sexual behavior [21] was extrapolated to suggest a switch of hormone-induced cephalic differentiation at a critical gestational stage in animal development might likewise occur in humans [22, 23]. This theory, too, was ultimately abandoned [24] as human behavior was far too complex to correspond to animal models.

Environmental Theories As psychoanalysis waned, a movement of radical behaviorism arose in the United States. Psychologist B.F.  Skinner asserted that humans mistakenly believe they have “free will” but behavior  – even complex behaviors  – were the consequence of environmental reinforcement histories. Skinner maintained that the infant was a tabula rasa – a blank slate. The French philosopher Michel Foucault espoused a similar view, in

2  Etiology of Gender Dysphoria

what became known as the theory of social constructionism. Foucault, like Skinner, argued that there is no such thing as fixed human nature. Rather, gender is a social construct assigned onto bodies. Heavily influenced by Foucault, the movement gathered steam and aimed to surmount the restriction of society’s rigid gender roles. The social construction of gender  – the belief that people learn to become men or women – viewed gender as performance, i.e., people do gender: “In social interaction, throughout their lives individuals learn what is expected, act and react in expected ways, and they simultaneously construct and maintain gender order” [25]. By the 1970s, many scientists, most notably John Money, regarded socialization to be the essential condition of the formation of gender identity. Individuals born with disorders of sexual development and surgically assigned a sex at birth displayed a gender identity at maturity that did not align with the sex assignment, invalidating the primacy of socialization.

Anatomical Postmortem Studies In 1995, researchers in the Netherlands reported the groundbreaking results of a study comparing autopsied brains of transsexual individuals to heterosexual and homosexual non-transgender men. Those transsexual individuals who were assigned male at birth had an area of the hypothalamus, the bed nucleus of the stria terminalis (BSTc), wherein the volume of the central sulci was comparable to that of control females and dissimilar to the larger volume of control males. The findings were widely reported, and the New York Times proclaimed that this study “cast new light on perplexing issues of sexual identity” [26]. This finding offered a new line of research and tantalizing clues into consciousness and identity. But the study also raised questions. What if the differences found in the BSTc were the result of hormone usage? To settle this question, a subsequent study was designed [27] that quantified the number of somatostatin neurons (SOM) in the BSTc rather than using volume as a metric. The neuron numbers of heterosexual and homosexual

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men, lesbian and transsexual women, males and female with sex steroid disorders, a transsexual man, and a transsexual individual who had not received hormones were compared. The findings were consistent with the original study. Moreover, the one transsexual man displayed a pattern consistent with control males, providing further confirmation that gender identity evolves as a result of the interaction of the developing brain and sex hormones. In 2002, Chung et al. [28] reported that BSTc volume was not apparent until adulthood. This surprising discovery questioned how could the late occurrence of sexual dimorphism be explained? The researchers hypothesized that neuronal activity or differentiation or changes in fetal hormone levels pre-paved the structural change that would only become apparent at a later stage of life. In 2008, another nucleus of the brain was identified that was implicated in the formation of gender identity, namely, the interstitial nucleus of the anterior hypothalamus number 3 (INAH3) [29]. Postmortem brain tissue revealed that the gene encoding neurokinin B (NKB) in the infundibular nucleus (INF) is sexually dimorphic. In children, both sexes have equivalent levels of NKB immunoreactivity, but adulthood ushers in dimorphism. As with the BSTc, there was a reversal in the brain tissue on autopsy of transsexual women, indicating that GnRH secretion is regulated via estrogen feedback and a mutation in NKB creates gonadotropin deficiencies. This finding implicated hormones, genes, and cephalic structure in a neurodevelopmental theory of gender identity formation [30].

Prenatal Hormonal Influences The burgeoning theory that early hormonal influences on the fetus were the precursors to later structural brain change gained traction. Dessens et al. reported an elevated incidence of gender incongruity in the offspring of women exposed to phenobarbital and diphenylhydantoin [31]. Phenobarbital was used extensively in many countries as a prophylactic treatment for neonatal hyperbilirubinemia, owing to its ability

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to enhance liver function. But its use raised postnatal testosterone levels, demonstrating that certain substances could alter steroid hormone levels [32]. Corroborating evidence for the effect of prenatal influences came from a source far from the laboratory. Environmental scientists noted an alarming escalation of birth defects, sexual abnormalities, and reproductive failures in wildlife. They traced these endocrine disruptions to environmental assaults – synthetic chemicals that mimic natural hormones  – that derail normal reproduction and development. Animal biologists demonstrated the extreme sensitivity of developing mammals to the slightest shift in hormone levels in the womb: “...hormones permanently organize or program cells, organs, the brain, and behavior before birth, in many ways setting the individual’s course for an entire lifetime” [33]. They posited that humans were similarly vulnerable to endocrine disruption, which could explain the escalating incidence of disorders of sexual development, infertility, hypospadias, cryptorchidism, double uteruses, and blind vaginas in the human population. Diethylstilbestrol (DES), the most widely studied endocrine disruptor, has been implicated in numerous health problems in female offspring of exposed women [34]. Few studies, however, have examined its impact on male offspring. DES Sons International, an online forum, surveyed 500 member respondents, 90 of whom identified as “transsexual,” 48 described themselves as “transgender,” 17 identified as “gender dysphoric,” and 3 as “intersex” [35]. It is a well-documented phenomenon that the ratio of the second to fourth finger (2D:4D) is smaller in human males than in females. This sexually dimorphic trait is established prenatally, due to hormones [ [36] [37] [38],,,]. Galis et al. [39] analyzed the digit ratio in deceased fetuses and determined that, at 14  weeks of gestation, there was a small but significant difference in the 2D:4D ratio among male and female fetuses and that the ratio increases during childhood. This led to the inevitable conclusion that prenatal sex hormones have a lasting impact, affecting sexual dimorphism both pre- and postnatally. Schneider

et al. [40] compared the digit ratio between transgender individuals and non-transgender controls. The transgender women had a digit ratio comparable to control females. No such difference was found in transgender men or control females. The researchers established that decreased prenatal androgen exposure is implicated in the development of gender incongruity in transgender women.

Genetic Influences In 2000, Green reported on familial concordance of gender dysphoria in ten sibling or parent-child dyads [41]. He predicted that advances in technology would make the exploration of genetic variants a viable area of exploration in the quest to discover the origins of atypical gender identity. Other researchers also found a co-occurrence of gender dysphoria in families. Gomez-Gil et al. examined a sample of 995 transgender people and identified 12 pairs of non-twin siblings. They concluded that the probability of a sibling of a transgender individual also being transgender was 4.48 times greater for siblings of transgender women than transgender men probands and 3.88 times greater for the brothers than for the sisters of transgender probands. The study indicates that a sibling of a transgender person was more likely to be transgender than someone in the general population [42]. Diamond reported on a study of gender incongruity among 112 sets of twins, illuminating the relative contribution of genetics and social factors. He found a 33.3% concordance among monozygotic male twins and a 22.8% concordance among monozygotic female twins. Interestingly, among the twin probands, there were three sets of twins who were reared apart but concordant for gender transition [43]. Several landmark studies undertook to directly assess the role of specific genes of the androgen and estrogen receptors. First, Henningsson et al. [44] found that transwomen differed from controls with respect to the mean length of the ERb repeat polymorphism, suggesting lesser effective

2  Etiology of Gender Dysphoria

function of the ER receptor. Bentz et  al. [45] found transgender men to differ from non-­ transgender controls in a specific allele distribution pattern and to display an allele distribution akin to male controls. The identified gene, CYP17, is associated with gender incongruity, as is the loss of the female-specific genotype distribution [45]. Hare et al. [46] looked at polymorphisms in genes involved in steroidogenesis. Specifically, they examined repeat length variants in the androgen receptor (AR), the estrogen receptor beta (ERb), and aromatase (CYP19) genes. They found a significant association between gender incongruity in birth-assigned males and the AR gene. Fernandez et  al. [47] looked at a Spanish sample of 442 transgender women and found no significant association with AR, ER, or CYP 19. However, in a subsequent study, the same group found an association of the ERb gene and transmasculinity [48]. To date, these are the two largest genetic studies conducted.

Neurodevelopmental Cortical Hypothesis The advent of sophisticated brain imagery techniques enabled researchers to study large numbers of brains in vivo, overcoming the limitation of small sample size in postmortem studies. Studies pre- and post-hormone treatment reveal that transgender women, transgender men, nontransgender women, and non-transgender men present clear and distinct phenotypes, with respect to the gray and white matter of the brain. The images of gray matter focus on the thickness of the cortex and volume of the subcortical structures, while the white matter has been approached by analyzing the microstructure of the main bundles of the brain. The cortex, central to behavior and connected to subcortical structures, is the seat of the most consistently documented differences between transgender and non-transgender people. Additionally, the cortex contains both androgen and estrogen receptors, making it the principal focus of study. The human cortex is

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sexually dimorphic. Females have a thicker cortex than males [49], and the cortex thins throughout the first three decades of life [50]. Transgender men and transgender women with early-onset gender incongruity likewise have a thicker cortex than males, but there are regions of the cortex in which they do not differ from non-transgender males [51]. No cortical feminization was found in transgender women with late-onset gender incongruity [52]. Transgender people differ from non-­ transgender people in the microstructure of the brain bundles that connect the regions of the brain. Transwomen show demasculinization of these bundles [53], while transmen show a masculinization in some bundles [54]. Considering both white and gray matter, it appears that transwomen, transmen, and non-­ transgender women and men each display a unique phenotype. It’s likely that androgen receptors are implicated, perinatally, in the architecture of these unique developmental trajectories. The timing of the thinning of the cortex in the parietal, visuoperceptive regions and the insula follows a different pattern eventuating in the establishment of these visible distinctions. Additionally, the morphological differences in transgender individuals primarily involve the right hemisphere of the brain (see Table 2.1). The significance of the right hemisphere is of the most importance, in that one’s perceptual experience of the body and body phenomenology emanate from parietal and insular networks, located within the right hemisphere. Longo et al. [55] anchor the right hemisphere to higher somatosensory cognitive processes. One such perceptual process is “somatorepresentation.” This refers to the abstract cognitive construction of “semantic knowledge and attitudes about the body, including lexical-semantic knowledge about bodies generally, and one’s own body specifically, configural knowledge about the structure of bodies, emotions and attitudes directed toward one’s own body, and the link between the physical body and the psychological self.” Perhaps this is the seedbed of gender identity and consciousness of anatomical alignment or misalignment.

26 Table 2.1 Morphological differences in transgender individuals in the hemispheres of the brain

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transwomen, post-treatment. Hulshoff Pol et  al. [56] first reported a decrease in the total volume of Phenotype Hemisphere the brain and the hypothalamus in transwomen Transmena after short-term cross-sex hormone treatment. Cerebral More recently, Zubiaurre-Elorza et al. [57] meacompartments sured cortical thickness after a minimum of Feminine Gray matter 6 months of treatment. They found a decrease in Feminine White matter Feminine Intracraneal volume volume of the brain and cortical and subcortical Feminine Cerebrospinal fluid structures. In addition to this generalized decrease Cortical thickness in cortical thickness, there is an increase in the Right Feminine Global ventricular system. Right and Feminine Parietotemporal left Feminine Parietal After testosterone treatment, transmen show Right an increase in total brain [56] and cortical thickSubcortical structures ness and subcortical structures [57], but there is Putamen Masculine Right no effect on the ventricular system. It appears White matter that hormone treatment affects both the gross microstructure structure and the microstructure of the brain [58], Right and Longitudinal superior Masculine left Masculine Forceps minor presumably via AR and ER receptors and glucoRight Masculine Corticospinal tract corticoid receptors [57]. Right Defeminized Do these brain changes that hormones eventuTranswomen b ate have clinical significance? In a comprehenCerebral sive review of the extant literature, Guillamon compartments Masculine Gray matter et al. [59] conclude that to date, this has not been Masculine White matter systematically studied. Neuropsychological studMasculine Intracraneal volume ies have focused solely on sexually dimorphic Masculine Cerebrospinal fluid cognitive behaviors, e.g., mental rotation, after Cortical thickness initiation of hormonal therapy. Sensitive neuroRight Feminine Global Right Feminine Orbitofrontal psychological instruments designed to detect Right Feminine Insular subtle brain changes or to assess function in the Right Feminine Cuneus domain of areas known to be impacted have yet White matter to be employed. microstructure Longitudinal superior Demasculinized Right As greater numbers of individuals access care, Fronto-occipital Masculine Right there is a heightened need to understand the effects inferior of hormones on the brain, particularly long term. Forceps minor Demasculinized Right Guillamon et al. [59] have demonstrated that indiCingulum Demasculinized Right viduals with a history of early-­onset gender inconCorticospinal tract Demasculinized gruity evidence a specific brain phenotype that a Data transformed from Rametti et  al. [54]; Zubiarre-­ differs from those with later onset. Additional Elorza et al. [51] b Data transformed from Rametti et  al. [53]; Zubiarre-­ research and longitudinal studies can advance our Elorza et al. [51] understanding of unique identities and hopefully inform treatment across the lifespan. Hormones diminish gender dysphoria and alter secondary sex characteristics. But few studies have thoroughly examined the effects of hormonal References treatment on the brain. When systematically investigating pre-and post-treatment in a given individ- 1. Eliot A. Myths. London: McGraw Hill; 1976. ual, via neuroimaging techniques, researchers 2. Taylor T. The prehistory of sex: four million years of human sexual culture. New York: Bantam; 1996. consistently report a decrease in brain volume in

2  Etiology of Gender Dysphoria 3. Pauly IB.  Terminology and classification of gender identity disorders. In: Bockting WO, Coleman E, editors. Gender dysphoria: interdisciplinary approaches in clinical management. New  York: Haworth; 1992. p. 1–11. 4. Ettner R.  Gender loving care. New  York: WWW Norton; 1999. 5. Schaefer L, Wheeler CC. Tribute to Harry Benjamin, 1885–1986. Paper presented at the tenth international symposium on gender dysphoria. Amsterdam: Harry Benjamin International Gender Dysphoria Association; 1987. 6. Belli M. Transsexual surgery: a new tort? J Am Med As. 1978;239(20):2143–8. 7. Shtasel TF. Behavioral treatment of transsexualism: a case report. J Sex Marital Ther. 1979;5(4):362–7. 8. Lundberg PO, Sjovall A, Walinder J.  Sella turcica in male-to-female transsexuals. Arch Sex Beh. 1975;4(6):657–62. 9. Gooren L.  The neuroendocrine response of luteinizing hormone to estrogen administration in heterosexual, homosexual, and transsexual subjects. J Clin Endocr Metab. 1986;63(3):583–8. 10. Kula K, Dulko S, Pawlikowski M, et al. A nonspecific disturbance of the gonadostat in women with transsexualism and isolated hypergonadotropism in the male-to-female disturbance of gender identity. Exp Clin Endocrinol. 1986;87(1):8–14. 11. Eicher W, Spoljar M, Murken JD, Richter K, Cleve H, Stengel-Rutkowski S, Steindel E.  Transsexuality and X-Y antigen. Geburtshilfe Frauenheilkd. 1980;40(6):529–40. 12. Spoljar M, Eicher W, Eiermann W, Cleve H. H-Y antigen expression in different tissues from transsexuals. Hum Genet. 1981;57(1):52–7. 13. Eicher W, Spoljar M, Murken JD, Richter K, Cleve H, Stengel-Rutkowski S. Transsexualism and the X-Y antigen. Fortschr Med. 1981;99(1–2):9–12. 14. Engel W, Pfafflin F, Wiedeking C.  H-Y antigen in transsexuality, and how to explain testis differentiation in H-Y antigen positive males and ovary differentiation in H-Y antigen positive females. Hum Genet. 1980;55(30):315–9. 15. Gooren L.  The endocrinology of transsexualism: a review and commentary. Psychoneuroendocrino. 1990;15(1):3–14. 16. Greenberg RP, Laurence L.  A comparison of the MMPI results for psychiatric patients and male applicants for transsexual surgery. J Nerv Ment Dis. 1981;169(5):320–3. 17. Tsushima WT, Wedding D.  MMPI results of male candidates for transsexual surgery. J Pers Assess. 1979;43(4):385–7. 18. Leavitt F, Berger JC, Hoeppner JA, Northrop G.  Presurgical adjustment in male transsexuals with and without hormonal treatment. J Nerv Ment Dis. 1980;168(11):693–7. 19. Cole CM, O’Boyle M, Emory LE, Meyer WJ.  Comorbidity of gender dysphoria and other

27 major psychiatric diagnoses. Arch Sex Beh. 1997;26(1):13–26. 20. Buhrich N, McConaghy N.  Parental relationships during childhood in homosexuality, transvestism, and transsexualism. Aust N Z J Psychiatry. 1978;12(2):103–8. 21. Dorner G, Poppe I, Stahl F, et  al. Gene and environment-­ dependent neuroendocrine etiogenesis of homosexuality and transsexualism. Exp Clin Endocrinol. 1991;98(2):141–50. 22. Elias AN, Valenta LJ. Are all males equal? Anatomic and functional basis for sexual orientation in males. Med Hypotheses. 1992;39(1):39–45. 23. Giordano G, Giusti M.  Hormones and psychosocial differentiation. Minerva Endocrinol. 1995;20(3):165–93. 24. Coleman E, Gooren L, Ross M.  Theories of gender transpositions: a critique and suggestions for further research. J Sex Res. 1989;26(4):525–38. 25. Butler J. Gender trouble: feminism and the subversion of identity. New York: Routledge; 1990. 26. Angier, N.  Size of region of brain may hold crucial clue to transsexuality, a study finds The New  York Times November 2; 1995 27. Krujiver FPM, Zhou J, Pool CW, et al. Male-to-female transsexuals have female neuron numbers in a limbic nucleus. J Clin Endocr Met. 2000;85:2034–41. 28. Chung W, De Vries G, Swaab D.  Sexual differentiation of the bed nucleus of the stria terminalis in humans may extend into adulthood. J Neurosci. 2002;22(3):1027–33. 29. Garcia-Falgueras A, Swaab DF, et al. Brain. 2008;131: 3132–46. 30. Taziaux M, Swaab DF, Bakker J. Sex differences in the neurokin B system in the human infundibular nucleus. J Clin Endocrin Metab. 2012;97(12):E2010–20. 31. Dessens AB, Cohen-Kettenis PT, Mellenbergh GJ, et al. Prenatal exposure to anticonvulsants and psychosexual development. Arch Sex Beh. 1999;28:31–44. 32. Swaab DF. Sexual differentiation of the human brain: relevance for gender identity, transsexualism and sexual orientation. Gynecol Endocrinol. 2004;19:301–12. 33. Colborn T, Dumanoski D, Myers JP. Our stolen future. New York: Penguin Books; 1996. 34. Langston N.  Toxic bodies: hormone disruptors and the legacy of DES.  London: Yale Unviersity Press; 2010. 35. Kerlin, SP. The presence of gender dysphoria, transsexualism, and disorders of sex differentiation in males prenatally exposed to diethylstilbestrol: initial evidence from a 5-year study: DES Sons International network; 2004. TransAdvocate.org 36. Phelps VR.  Relative index finger length as a sex-­ influenced train in man. Am J Hum Gen. 1952;4:72–89. 37. Garn SM, Burdi AR, Babler WJ, et  al. Early prenatal attainment of adult metacarpal-phalangeal rankings and proportions. Am J Phys Anthro. 1975;43: 327–32.

28 38. Manning JT, Fink B, Neave N, et al. The ratio of 2nd to 4th digit length, a predictor of sperm numbers and concentrations of testosterone, luteinizing hormone and oestrogen. Hum Reprod. 1998;13:3000–4. 39. Galis F, Ten Broek C, Van Dongen S, et  al. Sexual dimorphism in the prenatal digit ratio (2D:4D). Arch Sex Beh. 2010;39(1):57–62. 40. Schneider HJ, Pickel J, Stalla GK.  Typical female 2nd–4th finger length (2D:4D) ratios in male-to-­ female transsexuals-possible implications for prenatal androgen exposure. Psychoneuroendocrinol. 2006;31(2):265–9. 41. Green R.  Family co-occurrence of “gender dysphoria”: ten siblings or parent-child pairs. Arch Sex Beh. 2000;29(5):499–507. 42. Gomez-Gil E, Esteva I, Almaraz MC, et al. Familiality of gender identity disorder in non-twin siblings. Arch Sex Beh. 2010;39(2):265–9. 43. Diamond M.  Transsexuality among twins: identity concordance, transition, rearing, and orientation. Int J Trans. 2013;14:24–8. 44. Henningsson S, Westberg L, Nilsson S, et  al. Sex steroid-related genes and male-to-female transsexualism. Psychoneuroendocrino. 2005;30(7):657–64. 45. Bentz EK, Hefler LA, Kaufman U, et  al. A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism. Fertil Steril. 2008;90(1):56–9. 46. Hare L, Bernard P, Sanchez FJ, et  al. Androgen receptor length polymorphism associated with male-to-female transsexualism. Biol Psychiatry. 2009;65:93–6. 47. Fernandez R, Esteva I, Gomez-Gil E, Rumbo T, Almaraz MC, Roda E, Haro-Mora JJ, Guillamon A, Pasaro E.  Association study of ERb, AR, and CYP19A1 genes and MtF transsexualism. J Sex Med. 2014a;11:2986–94. 48. Fernandez R, Esteva I, Gomez-Gil E, Rumbo T, Almaraz MC, Roda E, Haro-Mora JJ, Guillamon A, Pasaro E.  The (CA) in polymorphism of ERb gene is associated with FtM transsexualism. J Sex Med. 2014b;11:720–8. 49. Luders E, Narr KL, Thompson PM, Rex DE, Woods RP, Deluca H, Toga AW.  Gender effects on cortical

R. Ettner thickness and the influence of scaling. Human Beh Mapping. 2006;27:314–32. 50. Shaw P, Kabani NJ, Lerch JP, Eckstrand K, Lenroot R, Gogtay N, Greenstein D, Clasen L, Evans A, Rapoport JL, Giedd JN, Wise SP.  Neurodevelopmental trajectories of the human cerebral cortex. J Neurosci. 2008;28:3586–94. 51. Zubiaurre-Elorza L, Junque C, Gomez-Gil E, Segovia S, Carrillo B, Rametti G, Guillamon A.  Cortical thickness in untreated transsexuals. Cereb Cortex. 2013;23:2855–62. 52. Savic I, Arver S.  Sex dimorphism of the brain in male-to-female transsexuals. Cereb Cortex. 2011;23:2855–62. 53. Rametti G, Carrillo B, Gomez-Gil E, Junque C, Segovia S, Gomez A, Guillamon A.  White matter microstructure in female to male transsexuals before cross-sex hormonal treatment: a diffusion tensor imaging study. J Psychiatr Res. 2011a;45:199–204. 54. Rametti G, Carrillo B, Gomez-Gil E, Junque C, Zubiarre-Elorza L, Segovia S, Guillamon A.  The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment: a DTI study. J Psychiatr Res. 2011b;45:949–54. 55. Longo MR, Azanon E, Haggard P.  More than skin deep: body representation beyond primary somatosensory cortex. Neuropsyhologia. 2010;48:655–68. 56. Hulshoff Pol HE, Cohen-Kettenis P, Van Haren N, et  al. Changing your sex changes your brain: influences of testosterone and estrogen on adult human brain structure. Eur J Endocrinol. 2006;155:S107–11. 57. Zubiaurre-Elorza L, Junque C, Gomez-Gil E, Guillamon A. Effects of cross-sex hormone treatment on cortical thickness in transsexual individuals. J Sex Med. 2014;11:1248–61. 58. Rametti G, Carrillo B, Gomez-Gil E, Junque C, Zubiarre-Elorza L, Segovia S, Guillamon A.  Effects of androgenization on the white matter microstructure of female-to-male transsexuals: a diffusion tensor imaging study. Psychoneuroendocrinology. 2012;37:1261–9. 59. Guillamon, A., Junque, C. & Gomez-Gil, E., (2015). A review on the status of brain structure research in transsexualism, submitted.

3

History of Gender Identity and Surgical Alteration of the Genitalia David M. Whitehead and Loren S. Schechter

Introduction As we continue to refine surgical procedures, medical professionals should be familiar with not only current literature and research, but also understand the history of gender-related surgery. Like any historical survey, the history of gender surgery is limited by the documentation of historic examples and practices, the reliability of this documentation, and the ways that current thinking views the past. Nonetheless, the purpose is to present surgical interventions for gender identity as part of a longer continuum. The goal is to allow historical cases to assist today’s practitioners in serving their patients.

Ancient History There are records of surgical alteration of the genitalia dating back to ancient times. Although not necessarily related to gender identity or expression, it is thought that the practice of cirD. M. Whitehead (*) Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North New Hyde Park, NY, USA e-mail: [email protected] L. S. Schechter Department of Plastic Surgery, The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA e-mail: [email protected]

cumcision of the penis dates back 15,000 years to ancient Egypt. However, wall carvings and mummified remains more definitively demonstrate the use of that procedure in the region at least 6000  years ago. It is also thought that, in some cases, in contrast to common application for cultural reasons, circumcision was used as an attenuation of castration. This practice allowed the acquisition of trophies while avoiding killing one; in the Hebrew Scriptures, David brings King Saul 200 foreskins of his enemies to demonstrate worthiness [1]. Male castration, in some form, has existed in many cultures for political, ritual, or punitive purposes. Historically, the extent of tissue removed during “castration” is not always clear. Castration is often referred to as either “partial,” typically entailing removal of the testes and, at times, a portion of the penis, or “complete,” entailing removal of both the testes and penis. The earliest record of systematic human castration occurred in the twenty-first century BCE in Sumeria. The sons of female slaves were castrated and then put to work hauling barges along the Tigris and Euphrates rivers. The practice of human castration was present through most of Old World Eurasia, spreading much later to sub-­ Saharan Africa and the post-Columbia New World. Historically, castrated males have been referred to as eunuchs [25]. The term “eunuch” is an Old English word derived from the Greek eunoukhos, meaning “bedroom guard,” as

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eunuchs were often employed for harems in polygamous cultures. However, eunuchs have served a variety of critical roles through many societies, at times occupying positions of trust and honor. Aucoin and Wassersug [5] present an excellent review of the role of castrated men through history, identifying how they helped some of the great civilizations function. In Asia, over the last 4000  years (including through 23 Chinese dynasties), most prominent societies had eunuchs serving in positions of power and trust. In China, eunuchs were permitted to marry and adopt children. This permitted significant social mobility for their families and allowed an adopted heir of a court eunuch to rule in the third century. In the twelfth century, during the Jin dynasty, Tong Guan, a eunuch, was a great military commander of 800,000 soldiers. In the mid-1600s, during the Ming dynasty, it is estimated that there were 100,000 eunuchs in China, and that eunuchs owned up to 60% of property in the capital city. In medieval Islam, eunuchs served in a variety of roles. They were, at times, viewed as highly desirable sexual partners for both men and women, occupying something of another gender category. Eunuchs who underwent orchiectomies but maintained intact or partially intact penises served as sexual partners for women who desired intercourse without the risk of pregnancy. As harem guardians, even if they engaged in sexual intercourse with the women they guarded, eunuchs were incapable of impregnating them, thus assuring the perpetuation of the ruler’s lineage. Eunuchs were often viewed as spiritually awakened intellectuals and served as tutors for young nobles. They were also entrusted with guarding the tomb of the prophet Mohammed since the twelfth century. This role continued until at least 1990, when 17 eunuchs remained as guards. In the Byzantine Empire (330–1453  CE), eunuchs adopted a mode of dress and manner that distinguished themselves from others. They also helped define the sacred space around the emperor, who served as a messenger to the divine. It has been argued that the modern image of

D. M. Whitehead and L. S. Schechter

angels was constructed from Byzantine art that depicted individuals who strongly resembled eunuchs. Perhaps the most well-known eunuchs of recent history were the Italian Castrati. In the seventeenth and eighteenth century, boys identified for their singing ability underwent castration to preserve and supplement the quality of their voices. This combined a prepubescent larynx with the lung capacity and chest resonance of a grown man. Castrati were employed extensively in the opera, playing the roles of women during a time that it was considered unacceptable for women to perform the roles themselves. Celebrity Castrati who retained an intact libido and erectile function were also viewed as desirable sexual partners for aristocratic women at a time that was otherwise without reliable means of birth control [5]. Over time, the utility of Castrati diminished as women began to play their own operatic roles. While never officially permitted by canon law, the practice was formally banned by the Catholic Church in 1870, and no new Castrati were hired as of 1878. Alessandro Moreschi, a solo singer for the Sistine Chapel, was the last Castrato, sent into retirement by Pope Pius X in 1912 [23]. The use of genital surgery for the purpose of expressing an alternate gender identity has persisted from antiquity to today. The Hijra of South Asia (including Nepal, Pakistan, India, and Bangladesh) have existed for hundreds of years. They originated in pre-Muslim times, but rose to greater prominence during times of Muslim influence, especially following the founding of the city of Hyderabad in 1591 [34]. The Hijra are considered a “third sex,” viewed as neither male nor female. Some Hijra undergo ritual removal of the penis and testes and are believed to endow newborns or newly married couples with fertility. There are a few ancient examples of individuals seeking genital alteration specifically to obtain the experiences of an identified gender. One such individual, Elagabalus, the Roman Emperor from 218 to 222  CE, was known for their interest in exploring all aspects of human sexuality. Records indicate that they offered vast sums of money to any surgeon who would be able to give them a vagina [8].

3  History of Gender Identity and Surgical Alteration of the Genitalia

While there are some historical accounts which describe individuals assigned female at birth living as men, there are no known historical accounts which include the request for, or performance of, surgical procedures to modify anatomy. The lack of anesthesia and modern surgical techniques likely acted as a disincentive. Joan d’Arc, who was burned at the stake for the heresy of wearing men’s clothing, may have done this more for military purpose than gender expression [17]. Other individuals were often able to live “invisibly” as men; at times their biology only discovered at the time of postmortem examination [24] (Box 3.1).

Box 3.1 A Guide for Terminology

Many terms have been used to describe transgender and gender diverse individuals. Language evolves as our understanding of gender and identity evolve. Eonist – A term coined by the late nineteenth century physician Havelock Ellis and named after the Chevalier d’Éon, a French diplomat and spy in the 1700s CE. D’Éon’s work as a spy was facilitated by presenting as a young woman in the court of Empress Elizabeth of Russia. D’Éon was so comfortable in the role of a woman that, once she had returned to France and retired as a diplomat, she continued to live as a woman. There was much debate regarding d’Éon’s “biological” sex. In fact, when she died at age 83, an attestation was published, with multiple witnesses, as to the fact that she had normal male genitalia [24]. Ellis [19], and others [21, 24], used “eonist” to describe individuals who, in the absence of an intersex state, used a mode of dress and attempted to take on the social role inconsistent with their sex assigned at birth, without any fetishist or erotic purpose. The term described individuals who simply felt that they were born in the wrong body, and who were most comfortable expressing themselves as members of the “opposite” sex.

Transvestite  – Original descriptions of individuals who donned clothing inconsistent with the cultural expectations associated with their sex designated at birth, regardless of reason. Thus, transgender individuals were mixed in with drag queens/kings, as well as those for whom the clothing itself represented an erotic stimulus. In the United States in the mid-­ twentieth century, the term “transvestite” became synonymous with cross-dressing. However, in Europe, the term remained a preferred, and less judgmental term, and referred to transgender individuals [42]. Transsexual – David O. Cauldwell, and American physician and sexologist, is credited with the first use of the term “transsexual.” This term was used to refer to individuals who wished to change their “biological” sex [13]. The term continued to be popular through the end of the twentieth century, promoted also by Dr. Harry Benjamin and through the association founded in his name, the Harry Benjamin International Gender Dysphoria Association (HBIGDA). Transgender  – Through the nineteenth century, medicine and society began to differentiate between sex and gender. “Sex” referred to the “biological” sex  – male or female, determined by specific genes and designated at birth based upon the appearance of genital anatomy. “Gender”  – woman/man or girl/boy – refers to the set of behaviors that are culturally expected of individuals of a certain “sex.” It has been preferable to refer to identity and behavior as gender-related and anatomy as sexrelated. Thus, “transgender” became the preferred term for describing individuals who identify as other than their sex designated at birth. Intersex  – Individuals whose genes or gene expression grants them either ambiguous genitalia or other biologic features related to gonadal development that devi-

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ate from the “male/female” dichotomy (i.e., individuals with differences of sexual development, also called disorders of sexual development, the preferred terminology is variability or variation in sexual development). Nonbinary/gender-diverse – Individuals whose gender expression is either outside a dichotomy of masculine and feminine or is different from societal expectations for behavior expected for an individual of their sex designated at birth. Mx. – A non-gendered honorific used in place of Mr., Ms., Mrs., more commonly used in Britain. Other terms  – there are many other terms for identities (e.g., genderqueer, gender fluid, two-spirit) that are beyond the scope of this text. A reference for further reading regarding gender and identity can be found in the Glossary of LGBT Terms for Health Care Teams [30]. Singular “they”  – In 2015, the style guide for the Washington Post added the singular use of the word “they,” along with “them” and “their,” for use in situations when the gender of the individual is either not known or deliberately omitted in a rejection of the binary concept of gender. Singular “they” was voted as 2015 Word of the Year by the American Dialect Society and came to appear in the Associated Press stylebook in 2017 [4]. Consistent with this concept, this chapter also uses the singular version of they.

 odern Era (Nineteenth Century M to Today) The late nineteenth century saw many new medical advances, especially in the realm of endocrinology. In 1912, Eugen Steinach performed experiments on guinea pigs involving the transplantation of testes into a castrated female guinea pig, leading to the latter developing stereotyped

male sexual behavior, including mounting behavior. Similarly, he found that transplantation of an ovary into a castrated male guinea pig lead to stereotyped female sexual behavior [28]. Early operative procedures for transgender individuals were strongly driven by patient request and typically involved the removal of anatomy representative of their sex designated at birth (i.e., breasts, testes, and uterus). In 1902, Earl Lind, who went by the street name of Jennie June and the autobiographical pen-name of Ralph Werther, underwent bilateral orchiectomy at age 28 due to profound dysphoria (although the official diagnosis was spermatorrhea) and with the hope that orchiectomy would decrease facial hair growth [29]. Similarly, in 1917, Dr. Alan L. Hart (b. 1890) was able to convince his psychiatrist to recommend hysterectomy in order to eliminate menstruation and allow him to more fully live as a man  – this was thought to be the first time a psychiatrist recommended removal of a healthy organ based on gender identity [28]. However, access to this kind of care was not commonplace; with limited medical and surgical options, gender expression was performed primarily through mode of dress which, in the early twentieth century, was highly gendered. In fact, the wearing of clothing not associated with one’s sex designated at birth was considered deviant and immoral, and multiple municipalities had laws against such behavior. In 1848 and 1851, Columbus, Ohio, and Chicago, Illinois, were two of the earliest municipalities to create laws against cross-dressing. Cincinnati, Ohio was one of the latest, which created the law in 1971 [42]. Similar laws were not uncommon in Europe and violation of those laws could lead to either punishment or referral for psychological treatment. Such was the case in Germany for Dörchen (Dora) Ritcher. Dora, legally named Rudolph Ritcher and designated male at birth, was arrested multiple times for wearing feminine clothing. Eventually, she was referred by a judge to Dr. Magnus Hirschfeld of the Institut für Sexualwissenschaft (Institute for Sexual Science). Dr. Hirschfeld was an early advocate for sexual minorities. Many of Dr. Hirschfeld’s patients

3  History of Gender Identity and Surgical Alteration of the Genitalia

merely required a letter stating that the patient had no intention of committing a crime and that there would be a mental health benefit in being permitted to dress as they desired [6]. Dora, however, had such profound dysphoria associated with her genitalia that she requested additional treatment. She was chemically castrated in 1922 and underwent vaginoplasty in 1931. She stayed close with the Institute, and, given the great difficulty of finding employment because of social stigmatization, she worked as janitorial staff at the Institute. Another prominent patient of the Institute was Lili Elbe. Lili was born in 1882 and given the name Einar Magnus Andreas Wegener. Lili socially transitioned, presented as a woman in the 1920s and 30s, and, in 1930, underwent an orchiectomy. Subsequent to this, Lili endured a series of experimental procedures, including transplantation of an ovary. She died in 1931 from heart failure after what was thought to be an attempted vaginoplasty [28]. Hirschfeld’s Institute for Sexual Science remained active in providing letters of support and, in some cases, medical and/or surgical treatment until 1933. The destruction of the Institute, and the burning of its library and records was one of the early actions of the Nazi party. Dr. Hirschfeld, who had been denounced by Adolf Hitler as “the most dangerous Jew in Germany,” extended a planned trip out of the country in 1930. He eventually settled in Nice, France, where he passed away in 1935 [42]. It is unknown how long Dora Richter, who had still been working at the Institute, survived. Surgical treatments for the construction of male genitalia were developed some years later. In 1936, the Russian surgeon, Bogoraz, described the technique of phalloplasty for a cisgender 23-year-old male whose penis was allegedly amputated by his wife [38]. Bogoraz’s procedure involved the creation of a tubed abdominal flap, with rib cartilage for stiffness, but did not include reconstruction of the pendulous portion of the urethra. Sir Harrold Gillies further refined the procedure and described a tube-within-a-tube technique, using a groin flap for the urethra and an abdominal flap for the phallus.

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Dr. Gilles was also the first to use this procedure for gender confirmation. In 1939, Dr. Laurence Michael Dillon, a physician himself, was thought to be the first transgender man treated with oral testosterone. In 1946, Dillon wrote, “Where the mind cannot be made to fit the body, the body should be made to fit, approximately at any rate, the mind” [28] (Meyerowitz, 2002). Later that year, Dr. Dillon began a series of 13 operations with Dr. Gilles for the creation of external male genitalia [33].

Gender Surgery in Popular Culture For most of the twentieth century, transgender individuals were not well-known in the mainstream public. Similarly, little was known about how best to help those individuals. In the 1950s, a transgender woman, known by the pseudonym Val Barry, was seen by Dr. Alfred Kinsey. At Dr. Kinsey’s recommendation, the patient corresponded with Dr. Harry Benjamin, seeking referral for surgery to help the distress associated with her genitalia. Dr. Benjamin was born in Berlin in 1885 and, in the 1920s, spent time with Dr. Hirschfeld at the Institute for Sexual Science. Dr. Benjamin later moved to the United States and developed an interest in endocrinology, corresponding frequently with Dr. Eugen Steinbach (well-known for his experiment involving the effect of hormones on sexual behavior in animal models [22]). Dr. Benjamin was sympathetic toward Ms. Barry’s request, and, while at his summer office in San Francisco, he sought a legal opinion from California state attorney general Edmond (Pat) Brown. After some deliberation, Brown expressed concern that modification of healthy genitalia might constitute criminal mayhem and leave the operating surgeon open to potential prosecution. While Dr. Benjamin strongly objected to this opinion, both Dr. Kinsey and Dr. Karl Bowman, an expert in human sexuality from the University of California at Los Angeles, agreed that similar patients should not undergo operative intervention and should, instead, be treated by other means [42]. Dr. Benjamin, who had started Ms. Barry on

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feminizing hormones, recommended that she travel to Germany for surgical treatment [35]. It was not until the story of former United States World War II veteran Christine Jorgensen, splashed across the front page news that gender identity – and genital surgery for gender confirmation – entered the modern parlance. Christine, designated male at birth and given the name George William Jorgensen Jr., had always felt she was different from other boys. She was attracted to men, but did not identify as homosexual, feeling as though, emotionally, she was a woman. Upon reading, in late 1948, The Male Hormone by Paul de Kruif, who suggested that glandular secretions were responsible for masculine and feminine appearance, feelings, and behavior, she was inspired to start taking estrogen [28]. She requested ethynyl estradiol from a local pharmacy. The pharmacist was initially hesitant, but agreed to give the prescription after Christine told him the she was a student at the Manhattan Medical and Dental Assistants School [35]. Christine initially started taking the pills without medical supervision, but did eventually establish care with  – and continued treatment under the supervision of  – the husband of classmate Genevieve Angelo, Dr. Joseph Angelo. With hormone therapy, she began to feel more rested and refreshed, and she developed some sensitivity in her breasts [28]. Christine then traveled to Denmark to visit friends and family with the intent of eventually pursuing surgery in Sweden. Instead, Christine met with Dr. Christian Hamburger, a prominent endocrinologist who had performed a number of prior hormone studies. Dr. Hamburger then began to manage Christine’s hormone treatments while she remained in Denmark. Eventually, Christine was referred for surgery, and, after petitioning the Medico-Legal Council of the Ministry of Justice, underwent orchiectomy, and later, penectomy. Christine corresponded regularly with her family in the United States to inform them of her progress. Her transition became public only after a family friend in the United States sold the story to the press in 1952 [35]. Initially shy of publicity, Christine eventually embraced her new celebrity. After her return to

D. M. Whitehead and L. S. Schechter

the USA, her interviews provoked much public discussion, both derisive and some inquisitive. As Christine stated, she needed “as much good publicity as possible for the sake of all those to whom I am a representation of themselves” [42] (Stryker, 2008). She received letters from many individuals, including Harry Benjamin, who, although he was close to a planned retirement, had begun to treat transgender individuals. In the letter, Dr. Benjamin requested to meet her in consultation. She agreed, and he began managing her hormone therapy as well as later providing a referral to Dr. Elmer Belt, a urologist in Los Angeles, for vaginoplasty. Christine, who had been inundated by mail from other transgender individuals, referred those individuals to Dr. Benjamin. After having previously treated only about a dozen transgender individuals, including Val and Christine, Dr. Benjamin delayed his retirement 25  years, eventually treating over 1500 transgender individuals [35]. Dr. Belt performed several other vaginoplasties, typically displacing the testes into the inguinal canal to avoid accusations of mayhem. He stopped for some time in 1954 after a committee of physicians at UCLA decided that the procedure should not be offered at the institution. He quietly offered the procedures again a few years later, having some difficulty finding other hospitals that would permit him to perform the operation. He eventually stopped in 1962 at the behest of his family and office manager and upon hearing of the excellent work of Dr. Georges Borou in Casablanca, Morocco. Other surgeons providing gender affirmation surgery in the mid-60s included Dr. Orion Stuteville in Chicago, Drs. Jaime Caloca Acosta and Jose Jesus Barbosa in Tijuana, as well as Professor Francesco Sorrentino in Naples [28] (Box 3.2).

Box 3.2 World’s Worst Sex Change Surgeon

Although many individuals have contributed to improving techniques and access to gender confirmation surgery, one particular individual stands out in infamy. John Ronald Brown, born in 1922, was academi-

3  History of Gender Identity and Surgical Alteration of the Genitalia

cally gifted. He finished high school by age 16 and, when he was drafted into the Army for the Second World War, he scored so high on the General Classification Test that that he was sent to the University of Utah for medical school, from which he graduated in 1947. After 20 unsuccessful years as a general practitioner, during which he almost lost a patient during a thyroidectomy, he pursued formal surgical training at a program in New Jersey. After he finished 2 years as chief resident, he attended a plastic surgery program in New  York. Although he easily passed the written boards, he was never able to pass the oral exam necessary to achieve board certification from the American Board of Plastic Surgery. He blamed his failure to perform in the face of authority on his experiences with an overbearing father. Dr. Brown then practiced in California through the 1970s, offering genital surgery for gender confirmation. He performed surgeries on an outpatient basis as he had difficulty obtaining privileges at an acute care facility. He offered surgery at significant discount, and for those who could not pay, he allowed them to work in his clinic as compensation. However, in 1977, the Medical Board of California revoked his medical license for “gross negligence, incompetence, and practicing unprofessional medicine in a manner which involved moral turpitude.” This was, in part, due to the inappropriate settings in which he operated, his association with James Spence (an unlicensed provider and assistant), his use of unlicensed persons (including patients) to write prescriptions, inappropriate diagnoses, failure to admit a patient with a severe soft tissue infection, and failure to take medical histories or perform exams prior to operating. He then attempted to practice outside of the contiguous United States, but subsequently lost his medical license in Alaska

and Hawaii, as well as losing permission to practice in St. Lucia (where, at 59 years of age, he married a 17-year-old local). He then moved back to southern California, but operated in Tijuana. In the late 1980s, after attracting attention by being the subject of an Inside Edition documentary entitled “The Worst Doctor in America,” he was arrested for practicing medicine without a license. In 1990, he was sentenced to 19 months in prison [11]. He and his wife divorced, and, after serving his time, he worked as a cab driver for a year. He then reopened his practice in Tijuana and started operating again. He was arrested again in 1998 after the death of Philip Bondy, a 79-year-old engineer with a significant cardiac history from the Upper East Side of Manhattan. Mr. Bondy traveled from New York with Gregg Furth, PhD, a published Jungian psychologist. Both men felt as though one of their legs did not belong to them, and that they would be made whole if the leg was removed. Dr. Furth found that Brown was willing to perform the amputation in order to respect Furth’s autonomy as a patient. The procedure had to be rescheduled after Brown’s first assistant refused to participate. By the time another assistant was found, Furth had changed his mind, and so arrangements were made for Bondy to undergo the procedure 2 weeks later. After the amputation, Bondy was initially pleased, but rapidly deteriorated on account of C. perfringens infection at the surgical site. He was found dead by Furth in a room at the Holiday Inn near San Diego in the morning of the second postoperative day. Brown was convicted on one count of second-degree murder and one count of unlawful practice of medicine, having plead guilty to seven additional counts of the unlawful practice of medicine. His appeal was formally denied in 2001, and he was sentenced to a prison term of 15 years

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to life. His former patients both came to his defense and testified against him. His reputation for poor outcomes and poor followup, as well as Brown’s own videos demonstrating poor technique in deplorable conditions, were used by the prosecution. Later, in an interview, when asked if he had been worried about Bondy’s recent pneumonia, heart disease, and bypass surgery, and if people might question if the patient died, Brown replied “I didn’t spend much time thinking about it” [15, 32]. In 2007, he was the subject of a UK Channel 4 documentary “World’s Worst Sex Change Surgeon” [44]. He died in prison on May 16, 2010.

As medical and social scientists of the 1950s attempted to understand the inner workings of sexual differentiation and human gender expression, popular media kept the conversation in the mainstream. A month after Jorgenson’s return to the United States, the book Half, by Cyril Kornbluth (under the pseudonym Jordan Park), told the story of an intersexed individual, designated male at birth, who develops feminine characteristics through adolescence and undergoes surgery to become a woman at age eighteen. In the book, as in some of the news coverage at the time, transsexuality was conflated with an intersex condition [41]. Later in 1953, the Lili Elbe biography Man into Woman by Niels Hoyer, translated into English by H. J. Stenning and initially published in 1933, was reissued. (A fictionalized account of Lili’s story, The Danish Girl, by David Ebershoff, written in 2000, later hit number nine on the LA Times Bestseller’s paperback fiction list after the release of the Oscar-winning film adaptation of the same name in 2015 [7].) The 1950s and 1960s were a tumultuous time for social change in the United States. As soldiers returned home from World War II, women, who had been significantly more involved in manufacturing were encouraged to resume domestic roles. Reinforcing traditional gender roles made the awareness of transgender individuals even more

shocking. The civil rights movement was getting underway, and many social conservatives saw the changing social climate as the downfall of society. In response, homosexual and transgender individuals (among many others) faced significant legal challenges. Obscenity laws were enforced to prohibit distribution of materials related to transgender experiences and homosexuality. ONE Magazine, a pro-gay publication which began distribution in 1952 and sold openly at newsstands in Los Angeles, was banned from the mail until 1958, when the US Supreme Court intervened. Similarly, Transvestia, a publication by Virginia Price and others, faced a ban in 1960, when Ms. Price was charged with violating postal law for sexually explicit correspondence with another individual. She plead guilty to a lesser charge, but, in 1962, her sentence was deemed fulfilled after Transvestia was determined not obscene. Distribution of the publication was then allowed by the postal service [42]. Laws against cross-dressing, created in the 1800s, were enforced, and 34 US cities in 21 states banned cross-dressing between 1900 and 1948. In Detroit and Miami, anti-cross-dressing statutes were created in the 1950s. As transgender individuals fought for acceptance, many of these laws were struck down. For example, in San Francisco, California’s law against cross-­ dressing, created in 1863, was in place until 1974 [39]. During the 1950s, 60s, and 70s, these laws were frequently used to target and harass transgender individuals. Confrontations between sexual minorities (including transgender individuals) and police were not infrequent in the 1960s and 70s. There are a few events that stand out prominently. A dining establishment in Los Angeles, Cooper’s Donuts, known for its late hours, had been a popular hangout spot for homosexual persons, drag queens, and other minorities of ethnicity, orientation, and gender identity, some of whom were also sex workers. Police often requested individuals to present identification – this was problematic for those whose appearance did not match their legal identification, as it often led to their arrest. One night, in May of 1959, the patrons

3  History of Gender Identity and Surgical Alteration of the Genitalia

resisted, and a minor riot broke out culminating in many arrests. A similar, albeit nonviolent, incident occurred at Dewey’s, a late-night coffee house in Philadelphia. In April of 1965, the management began refusing young patrons in “nonconformist clothing,” suggesting that “gay kids” were driving away business. A sit-in was held on April 25, and three individuals were arrested after refusing to leave after being denied service. Local activists were outraged and staged another sit-in on May 2, which resulted in the management agreeing to serve all patrons [42]. In 1966, the first gay and transgender youth organization, Vanguard, was founded in San Francisco. Vanguard frequently met at Compton’s Cafeteria, a restaurant in the Tenderloin neighborhood. After the restaurant instituted a “service charge” to reduce the number of non-paying customers, hired private security, and called the police to facilitate removal of street kids, Vanguard coordinated with other LGBT organizations to stage a picket. In August, the situation exploded into a riot, with a broken window, a vandalized police care, and a burnt newsstand [42]. This event was a precursor to the Stonewall riots that occurred in Greenwich Village in Manhattan in 1969, and Compton was the beginning of an organized transgender rights movement in San Francisco. During this time of social upheaval, significant steps were made to better understand sex and gender. In 1966, 1  month prior to the Compton Cafeteria incident, Harry Benjamin published The Transsexual Phenomenon. This book discussed his clinical experience and insights regarding gender dysphoria. In it, he wrote “Since it is evident… that the mind of the transsexual cannot be adjusted to the body, it is logical and justifiable to… adjust the body to the mind. If such a thought is rejected, we would be faced with a therapeutic nihilism to which I could never subscribe in view of the experiences I have had with patients who have undoubtedly been salvaged or at least distinctly helped by their conversion” [6]. By the late 1960s, several academic institutions opened gender programs providing surgery for transwomen, including Stanford, the University of Minnesota, and Johns Hopkins [28].

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The Hopkins program was established by a team consisting of John Money, a psychologist who posited that gender was determined primarily by socialization, Claude Migeon, a pediatric endocrinologist with experience in the treatment of intersex children, and Milton Edgerton, then chief of plastic surgery. A total of 24 patients had been treated between 1966 and 1979. The program was closed after Jon Meyer, a psychiatrist associated with Hopkins, published a study suggesting that patients who underwent surgery were not better adjusted to society than those who did not. This prompted Paul McHugh, then Psychiatrist-in-Chief, to shut down the program [43] (Box 3.3).

Box 3.3 David and Brian Reimer

John Money, in the late 1970s, came under fire with the case of David and Brian Reimer, identical twin brothers. One of the brothers, David, experienced a near-­ complete thermoablation of his penis during a circumcision performed for phimosis at 8 months of age [18]. Working under the hypothesis that gender was purely determined through socialization (a conclusion which was reached after examining a limited case series of intersex patients with limited follow-up), Money and colleagues recommended raising David as a girl. As it was felt that David would suffer irreparable psychological harm by not having a normal penis, David subsequently underwent bilateral orchiectomy and vulvoplasty at age 22 months. Through his childhood, the patient frequently rejected clothing and activities associated with being a girl. The patient and his twin brother continued to follow-up for about 12 years, and reported multiple distressing occasions where the twins were told to inspect each other’s genitals [18]. When the patient was 14, after expressing immense frustration with developing breasts resulting from feminizing hormones, his local doctors recommended that the patient be told about his medical history.

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Once his history was revealed, John was quoted as saying “I was relieved. Suddenly it all made sense why I felt the way I did. I wasn’t some sort of weirdo.” He was then placed on testosterone and underwent phalloplasty. At 23, he married a woman with young children and raised them as his own. The follow-up was written in 1997 by Diamond and Sigmundson and derived from interviews with the patient and his family, but without input from Money. His case was then reported in a Rolling Stone article later that year by John Colapinto. At age 33, in 2004, the patient committed suicide, 2  years after his brother, who had been diagnosed with schizophrenia, died of an overdose of antidepressants and 2 days after his wife told him she wanted to separate [16]. This case helped support the biological basis of gender and refuted the idea that gender expression could be altered through therapy.

The mutability of gender and sex was explored in science fiction through the 1960s and 1970s. Two examples include Gore Vidal’s Myra Breckinridge (1968) and Angela Carter’s The Passion of New Eve (1977). Both explore gender as alterable, based upon changes in anatomy (perhaps based on John Money’s sexological writings of the time). Specific transgender individuals continued to have an impact on popular culture [40]. Christine Jorgensen: A Personal Autobiography was published in 1967, providing a personal account of the transgender experience. In 1976, Renee Richards, a transwoman, tennis player, and ophthalmologist, made headlines after being denied entry into the United States Open Tennis Championship. She refused to undergo chromosomal testing and sued the United States Tennis Association (USTA). In 1977, an injunction was issued by the New  York State Supreme Court against the USTA, barring the USTA from excluding Dr. Richards [2]. Dr. Richards’ autobiography, Second Serve, written with John Ames, was published in 1983 and provided an evocative view of her life and experiences [36].

The Harry Benjamin International Gender Dysphoria Association (later renamed the World Professional Association for Transgender Health, WPATH) produced its first standards of care for the management of transgender individuals in 1979. In 1980, the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, fourth edition, added gender identity disorder (GID), 7 years after homosexuality was removed as a diagnosis. GID was changed to gender dysphoria in the fifth edition, published in 2013 [3]. Gender diverse individuals featured prominently in film through the 1990s and 2000s, touching on drama, comedy, and tragedy. The Crying Game (1992), which won multiple awards including the Oscar for Best Writing, featured Dil, a transgender woman, played by Jaye Davidson, a cisgender man [10]. Davidson was nominated for the Academy Award for Best Supporting Actor in 1993. Hedwig and the Angry Inch, a 1998 queer punk musical which was adapted into a 2001 film, and, in 2014, presented again on stage starring Neil Patrick Harris (a cisgender man). Hedwig tells the fictional story of a young gender diverse person, designated male at birth, who undergoes genital surgery, in order to marry a United Stated soldier to escape East Germany [27]. Boys Don’t Cry (1999) was based on a true story from 1993 in Falls City, Nebraska, where a young transman, Brandon Teena, was raped and later murdered by two acquaintances upon discovery of the fact that he had female genitalia [42]. Hillary Swank (a cisgender woman) won the Academy Award for Best Actress for her work in the role of Brandon. Transamerica (2005) featured a transgender woman, played by another cisgender woman, Felicity Huffman, who reunites with a previously unknown son. The son does not know she was his father, and the two go on a road trip together. In the last few years, transgender individuals have featured prominently in the media, helping improve transgender representation. In June of 2014, Laverne Cox, a transgender actress, was featured as the cover story in Time magazine, because of her work on the show Orange is the New Black. In July 2015, Caitlyn Jenner was featured in Vanity Fair Magazine [9]. Ms. Jenner

3  History of Gender Identity and Surgical Alteration of the Genitalia

was well-known for her gold-medal decathlon performance in the 1976 Olympics as Bruce Jenner, as well as being a member of the reality television Kardashian family. Also, in 2015, Aydian Dowling, a transgender model, was featured on the cover of Men’s Health magazine. Access to surgery for individuals with gender dysphoria has steadily increased. Historically, transgender individuals had to pay out-of-pocket for medical and surgical treatments. However, in 2014, Denee Mallon, a 72-year-old Vietnam veteran, successfully sued the United States Center for Medicare and Medicaid Services (CMS) for denying her gender confirmation surgery. This lifted a 33-year-old ban on the procedures, as they were, at the time, considered experimental [14]. Her story was reported by NBC news, and she went on to have her surgery later that year by Dr. Loren Schechter. The current political environment, at least in the United States, has been somewhat tumultuous. Since CMS lifted its ban on gender affirmation procedures, more insurers cover the procedures [12]. However, at the same time, civil rights protections have waxed and waned. In 2014, the administration of President Barack Obama added “gender identity” to the categories protected from discrimination in federal hiring. This followed a 2012 ruling that Title VII of the Civil Rights Act of 1964, which prohibited workplace discrimination on the basis of sex, should be interpreted to include gender identity [37]. In 2016, the United States military lifted a ban on transgender troops serving openly. Additionally, in 2016, the Obama administration recommended that Title IX of the Education Amendments Act of 1972, which covered sex discrimination in federally funded education, should be interpreted to allow transgender and genderdiverse students to use the restroom or locker room which most closely matches their gender identity. This was controversial and prompted multiple states to adopt “bathroom bills” to restrict facility use based upon sex assigned at birth [20]. In late 2016, a preliminary injunction was filed against the United States Department of Health and Human Services (HHS) regarding Sect. 1557 of the Affordable Care Act. This prevented HHS from enforcing nondiscrimination in health insurance programs on the basis of gender

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identity. However, in September 2018, federal courts in Minnesota and Wisconsin argued that the language contained within the statute independently prevents discrimination, striking down exclusions in each state [26]. In October 2017, the administration of President Donald Trump attempted to reverse the policy that provided protection from workplace discrimination on the basis of gender identity. This, too, is being challenged in court [20, 31]. Legal protections for transgender and gender diverse individuals are continuously evolving. As health care professionals committed to providing medically necessary care, we continue to advocate on behalf of our patients.

References 1. Alanis MC, Lucidi RS.  Neonatal circumcision: a review of the world’s oldest and most controversial operation. Obstet Gynecol Surv. 2004;59(5):379–95. 2. Amdur N. Renee Richards ruled eligible for U.S. Open. The New  York Times, 17 August 1977. Retrieved from https://www.nytimes.com/1977/08/17/archives/ renee-richards-ruled-eligible-for-us-open-rulingmakes-renee.html. 3. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013. 4. Andrews TM.  The singular, gender-neutral ‘they’ added to the Associated Press Stylebook. Washington Post, 28 March 2017. Retrieved from https:// www.washingtonpost.com/news/morning-mix/ wp/2017/03/28/the-singular-gender-neutral-theyadded-to-the-associated-press-stylebook/. 5. Aucoin MW, Wassersug RJ. The sexuality and social performance of androgen-deprived (castrated) men throughout history: implications for modern day cancer patients. Soc Sci Med. 2006;63(12):3162–73. https://doi.org/10.1016/j.socscimed.2006.08.007. 6. Benjamin H. The transsexual phenomenon. New York: Julian Press; 1966. 7. Bestsellers. 10 January 2016. Retrieved November 18, 2018, from http://projects.latimes.com/bestsellers/ lists/2016/01/10/#danish-girl. 8. Betzig L. Suffodit inguinal: genital attacks on Roman emperors and other primates. Politics Life Sci. 2014;33(1):54–68. https://doi.org/10.2990/33_1_54. 9. Bissinger B.  Caitlyn Jenner: the full story, July 2015. Retrieved February 19, 2018, from https://www.vanityfair.com/hollywood/2015/06/ caitlyn-jenner-bruce-cover-annie-leibovitz. 10. Brady T. ‘The crying game’: ‘they wanted me to cast a woman that was pretending to be a man.’ The Irish

40 Times, 1 August 2017. Retrieved from https://www. irishtimes.com/culture/film/the-crying-game-theywanted-me-to-cast-a-woman-that-was-pretending-tobe-a-man-1.3167472. 11. Callahan B. Ex-doctor who served time faces murder charge. San Diego Union Tribune, The, p. B-1, 23 May 1998. 12. Canner JK, Harfouch O, Kodadek LM, Pelaez D, Coon D, Offodile AC, et al. Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surg. 2018;153(7):609–16. https://doi.org/10.1001/jamasurg.2017.6231. 13. Cauldwell DO.  Psychopathia transexualis. Int J Transgenderism. 2001;5(2). Retrieved from https:// www.atria.nl/ezines/web/IJT/97-03/numbers/symposion/cauldwell_02.htm. 14. Cha AE.  Ban lifted on medicare coverage for sex change surgery. Washington Post, 30 May 2014. Retrieved from https://www.washingtonpost.com/ national/health-science/ban-lifted-on-medicare-coverage-for-sex-change-surgery/2014/05/30/28bcd122e818-11e3-a86b-362fd5443d19_story.html. 15. Ciotti P.  Why did he cut off that man’s leg? LA Weekly, 15 December 1999. Retrieved from https://www.laweekly.com/news/why-did-he-cutoff-that-mans-leg-2131451. 16. Colapinto J, Teng B. Gender gap. Slate, 3 June 2004. Retrieved from http://www.slate.com/articles/health_ and_science/medical_examiner/2004/06/gender_gap. html. 17. Crane S. Clothing and gender definition: Joan of arc. J Mediev Early Mod Stud. 1996;26:297–320. 18. Diamond M, Sigmundson HK.  Sex reassignment at birth. Long-term review and clinical implications. Arch Pediatr Adolesc Med. 1997;151(3):298–304. 19. Ellis H. Eonism and other supplementary studies. In: Studies in the psychology of sex, vol. 2. New York: Random House; 1936. 20. Green EL, Benner K, Pear R. Trump may limit how government defines one’s sex. New  York Times, p. A1, 21 October 2018. 21. Hamburger C, Sturup GK, Dahl-Iversen E. Transvestism: hormonal, psychiatric, and surgical treatment. JAMA. 1953;152(5):391–6. 22. Harms E. Forty-four years of correspondence between Eugen Steinach and Harry Benjamin. A valuable addition to the Manuscript Collection of The Library of The New York Academy of Medicine. Bull N Y Acad Med. 1969;45(8):761–6. 23. Hatzinger M, Vöge D, Stastny M, Moll F, Sohn M.  Castrati singers—all for fame. J Sex Med. 2012;9(9):2233–7. https://doi. org/10.1111/j.1743-6109.2012.02844.x. 24. Hirschfeld M. Transvestites: the erotic drive to crossdress (MA Lombardi-Nash, Trans.). Buffalo/New York: Prometheus Books; 1991. 25. Johnson TW.  Castrati singersDOUBLEHYPHENall for fame: a commentary. J Sex Med. 2013;10(2):618– 9. https://doi.org/10.1111/j.1743-6109.2012.02940.x. 26. Keith K.  More courts rule on section 1557 As HHS reconsiders regulation, 2 October 2018. Retrieved

D. M. Whitehead and L. S. Schechter January 4, 2019, from https://www.healthaffairs.org/ do/10.1377/hblog20181002.142178/full/. 27. Krulwich S. This is no doctor. And no lothario, either. New York Times, p. C1, 23 April 2014. 28. Meyerowitz J. How sex changed: a history of transexuality in the United States. Cambridge, Massachusetts/ London: Harvard University Press; 2002. 29. Meyerowitz J. Thinking sex with an androgyne. GLQ J Lesbian Gay Stud. 2011;17:97–105. https://doi. org/10.1215/10642684-2010-020. 30. National LGBT Health Education Center. Glossary of LGBT Terms for Health Care Teams. The Fenway Institute, March 2018. Retrieved from https://www.lgbthealtheducation.org/wp-content/ uploads/2018/03/Glossary-2018-English-update-1. pdf. 31. Pear R. Transgender workers gain new protection in U.S. court ruling. New York Times, p. A25, 25 March 2018. 32. People v. Brown, No. D035066 (Court of Appeal, Fourth District, Division 1, California August 2, 2001). Retrieved from https://caselaw.findlaw.com/ ca-court-of-appeal/1300186.html. 33. Rashid M, Tamimy MS. Phalloplasty: the dream and the reality. Indian J Plast Surg. 2013;46(2):283–93. https://doi.org/10.4103/0970-0358.118606. 34. Reddy G. With respect to sex: negotiating hijra identity in South India. Chicago/London: The Universty of Chicago Press; 2005. 35. Rudacille D. The riddle of gender: science, activism, and transgender rights. 1st ed. New York: Pantheon; 2005. 36. Sadock VA.  Second serve: the renee richards story. JAMA. 1984;251(15):2022. https://doi.org/10.1001/ jama.1984.03340390068034. 37. Savage C.  Reversal by justice Dept. in transgender protections. New  York Times, p. A19, 6 October 2017. 38. Schultheiss D, Gabouev AI, Jonas U.  Nikolaj A. Bogoraz (1874–1952): pioneer of phalloplasty and penile implant surgery. J Sex Med. 2005;2(1):139–46. https://doi.org/10.1111/j.1743-6109.2005.20114.x. 39. Sears C.  Arresting dress: cross-dressing, law, and fascination in nineteenth-century San Francisco. Durham/London: Duke University Press; 2015. 40. Sellberg K.  The subjective cut: sex reassignment surgery in 1960s and 1970s science fiction. Med Humanit. 2016;42(4):e20–5. https://doi.org/10.1136/ medhum-2016-010968. 41. Stryker S.  Queer pulp: perverted passions from the golden age of the paperback. San Francisco: Chronicle Books; 2001. 42. Stryker S. Transgender history. Berkeley: Seal Press; 2008. 43. Witkin R. Hopkins Hospital: a history of sex reassignment, 1 May 2014. Retrieved February 19, 2018, from http://www.jhunewsletter.com/article/2014/05/hopkins-hospital-a-history-of-sex-reassignment-76004. 44. World’s Worst Sex Change Surgeon. Channel 4 (UK) documentaries: season 2007, 9 April 2007. United Kingdom: Channel 4 (UK).

4

Language and Terminology in Transgender Health Gail Knudson

 iagnostic Codes in the American D Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) The closest diagnosis related to gender role expression, not gender identity, first appeared in the DSM-II [1].  The diagnosis, transvestism, was included under the parent sexual deviations. The first diagnosis related to gender identity was Transsexualism, which was included in the third revision (DSM-III) [2] and DSM-III-R (1987) under the parent psychosexual disorders. The term was replaced by Gender Identity Disorder in DSM-IV [3] and DSM-IV-TR [4]. Following the trend of depathologizing of gender identity, DSM-5 (2013) uses the term Gender Dysphoria under the parent of the same name. This diagnosis was a significant move forward as the diagnosis was attributed to people with dysphoria between their sex assigned at birth and their gender identity, rather than pathologizing people with different gender identity to their sex assigned at birth. The DSM-5 criteria (2013) include “A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration,” as demonstrated G. Knudson (*) Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada e-mail: [email protected]

by two of six indicators. Four of these six allow for “some alternative gender different from one’s assigned gender, ” recognizing of the need to include gender spectrum identity and expression. However, the desire for physical or social transition is still listed as symptoms of a disorder. A “post-­transition” specifier further clouds the trans person’s exit from having a mental disorder [14].

 iagnostic Codes in the World D Health Organization’s International Classification of Diseases (ICD) The first diagnosis related to gender identity was introduced in ICD-9 [11], the condition known as Transsexualism and was classified under Sexual Deviation and Disorders. This diagnosis (Transsexualism) persisted in ICD 10 [12] under the parent Gender Identity Disorders and was based on the belief that the individual was disordered if their gender identity was different from the sex assigned at birth. ICD 11 [13] heralded a significant move forward in the field of transgender health. Two significant revisions took place: Transsexualism and eleven other diagnoses related to gender identity and sexual orientation were removed from the Mental Health Disorders section of the ICD. A new chapter, “Conditions Related to Sexual Health” Chapter 6 (separate from Mental

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Disorders), was created and a new term, gender incongruence, appears intending to maintain or increase access to healthcare. Language in the most recent versions of DSM, ICD, and the SOC are thus meant to be non-­ pathologizing of identities while at the same time providing access to needed care. This gradual depathologization has resulted in reduced barriers to care and more flexibility in the SOC.

WPATH and the Standards of Care

meet a formal diagnosis of a disorder rather than the person’s gender identity itself being a disorder [7].

Terminology from a Western Perspective Cisgender Person A person whose gender identity matches their sex assigned at birth, and who, therefore, unlike transgender people, experiences no gender incongruence [14].

The World Professional Association for Transgender Health (WPATH), formerly known Gender as the Harry Benjamin International Gender The attitudes, feelings, and behaviors linked to Dysphoria Association (HBIGDA) is an interdis- the experience and expression of one’s biological ciplinary professional and educational organiza- sex [14]. tion of over 2500 members devoted to transgender health. The mission of WPATH is to promote Gender Affirming evidence-based care, education, research, advo- Refers to medical procedures that enable a trans cacy, public policy, and respect in transgender person to live more authentically in their gender identity [10]. health (www.wpath.org). WPATH publishes the Standards of Care and Ethical Guidelines, which articulate an Gender Identity evidenced-­ based approach to gender affirm- The personal experience of oneself as a boy or ing care. WPATH has published seven versions man, girl or woman, as a mix of the two, as nei(1979, 1980, 1981, 1990, 1998, 2001 and 2012) ther, or as a gender beyond man or woman. Some of Standards of Care (SOC) and version 8 with an individuals (particularly in cultures which expected release date of 2020. The goal of gender accept the idea of genders beyond man and affirming care is lasting personal comfort with woman) identify as members of “third genders” the gendered self in order to maximize overall or use indigenous gender labels [14]. psychological well-being and self-fulfillment [6]. When the first SOC and diagnoses were writ- Gender Expression ten, the assumption was that trans people seeking The expression of one’s gender identity, often treatment would move from one sex to another, through appearance and mode of dress, and also requiring cross-sex hormones and sex-­sometimes through behavior and interests. reassignment surgery to alleviate the gender dys- Gender expression is often influenced by gender phoria. The paradigm was based on a gender stereotypes [14]. binary and an opposite-sex model [7]. Gender identity is now understood as a spec- Genderqueer trum, and thus the S0C 7 [6] includes its own Identity label that may be used by individuals definition of gender dysphoria, which purports a whose gender identity and/or expression does not nonbinary approach to gender identity and notes conform to a binary understanding of gender as that it is the distress of the dysphoria that can limited to the mutually exclusive categories of

4  Language and Terminology in Transgender Health

man or woman, male or female [5]. This includes individuals who identify as both man and woman (bigender, pangender), as a third or another gender, or as without gender (agender/genderless) [6].

Gender Stereotypes Ideas, current in the culture and times in which a person lives, about the different characteristics that men and women have and should have. Many transgender people can encounter rejection and hostility because of departure from a gender stereotype [14]. Gender Incongruence Gender incongruence is characterized by marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behavior and preferences alone are not the basis for assigning the diagnoses in this group [13]. Gender Dysphoria Refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). Only some gender-­ nonconforming people experience gender dysphoria at some point in their lives [14]. Gender Transition A person’s adoption of characteristics that they feel match their gender identity. Gender transition can involve social aspects such as changing appearance (including styles of dress and hair) and name, arranging new identity documents, or merely the use of a more suitable gendered pronoun. It can also involve a change in physical characteristics. A physical transition can facilitate social transition, enabling styles of dress, social activities, and (in many countries) changes in the documentation that would not otherwise be possible. Those who engage in a physical transi-

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tion are often popularly described as transsexual people [14].

Intersex Intersex individuals develop atypically concerning some or all aspects of their biological sex (chromosomes, hormones, gonads and/or genitals). They are described as having a “disorder of sexual development”). Even when a newborn’s sex characteristics are evidently anomalous, it is common for that baby to be assigned to one of the two sexes. Sometimes that sex assignment does not match the individual’s later gender identity development. In such cases, the intersex person in effect also becomes transgender [14].  ex S A person’s biological status (chromosomal, hormonal, gonadal, and genital) as male or female. An individual’s sex at birth (birth-assigned sex) is usually determined based on genital appearance, with those present usually assuming that other components of sex are consistent with the newborn’s genital sex [14].  ex Assigned at Birth S The sex to which a person is assigned at, or soon after, birth. This assignment may or may not accord with the individual’s sense of gender identity as they grow up. In medical and sociological literature, this often is referred to as a person’s “natal sex” or “biological sex.” For most people, gender identity and expression are consistent with their sex assigned at birth. For trans people, gender identity or expression differ from their sex assigned at birth [6]. Sexual Orientation Sexual orientation is about whom one is sexually attracted to and is not the same as gender identity [14]. Transcultural Competence Transcultural competence refers to the ability to understand, communicate with, and effectively

G. Knudson

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interact with trans people. It can be measured by awareness, attitude, knowledge, skills, behaviors, policies, procedures, and organizational systems [8].

Transgender Person Transgender people experience a degree of gender incongruence. Some intersex people, as well as some people considered by others to be cross dressers, experience gender incongruence and accompanying dysphoria [14]. Transgender Man A person assigned female who identifies as a man or in similar terms (e.g., as a “trans man” or “man of transgender experience”) [14]. Transgender Woman A person assigned male at birth who identifies as a woman or in similar terms (e.g., as a “trans woman” or “woman of transgender experience”) [14].

Terminology from a Non-Western Perspective

Regional Terms Used for People Assigned Male at Birth Who Identify as Female or as a Third Gender Include the Following [8]: • • • • • • • • • • • • • • • •

hijra and thirunangai (India) khwaja sira (Pakistan) meti (Nepal) kathoey (Thailand) waria (Indonesia) mak nyah (Malaysia) transpinay (the Philippines) bin-sing-jan and kwaa-sing-bit (Hong Kong) in Asia fakafifine (Niue) fa’afafine (Samoa and Tokelau) leiti (Tonga) palopa (Papua New Guinea) akava’ine (Cook Islands) whakawahine (New Zealand) Sistergirl (Australia) in the Pacific ([8], p. xii) “transgéneras” (Latin America) [9]

Regional Terms Used for People Assigned Female at Birth Who Identify as Male Include the Following:

• bandhu (Bangladesh) • transpinoy (the Philippines) • thirutambi and kua xing nan (Malaysia) in Asia Third Gender  Among some aboriginal/first • fa’afatama (Samoa) nations or native peoples of the Americas gen- • tangata ira tane (New Zealand) der systems may not be binary (i.e. masculine-­ • brotherboy (Australia) in the Pacific ([8], p. xii) feminine) but include additional categories such as “two-spirit persons” among Ojibwa, Navajo, and Mohave peoples in Canada and the Gender Affirming Medical United States or “muxes” among Zapotecs in Interventions Mexico [9]. Internationally, trans people often identify using more culturally specific labels.

Travesti  Term used in Latin America to describe persons assigned male at birth who go to great length feminizing their body and appearance and prefer female pronouns without typically considering themselves women or desiring to alter their natal primary sexual characteristics through genital surgery (Kulick 1998) [9].

Breast augmentation  The enlargement of the breasts using breast implants. Chest masculinization/chest surgery  Removal of breast tissue usually in the form of bilateral mastectomy and then providing contouring into a male chest. Refinement of the nipple areolar complex (NAC) may also be involved.

4  Language and Terminology in Transgender Health

Facial feminization surgery (FFS)  Surgery to provide more feminine appearing hard and soft structures of the face. These include reshaping the nose (rhinoplasty), and forehead lift (also known as a brow lift or temporal lift); reshaping of the chin, cheek and jaw; tracheal shave (chondrolaryngoplasty); lip augmentation and hairline restoration. Facial masculinization surgery (FMS)  Surgery to provide more masculine appearing hard and soft structures of the face. These may include forehead lengthening and augmentation, cheek augmentation, reshaping the nose and chin (rhinoplasty), and jaw augmentation. Hormone replacement therapy (HRT)/hormone therapy (HT)/hormone treatment (HT)  A form of medical transition in which the individual takes medication that has either a feminizing (usually estrogen and androgen blockers) or masculinizing (usually testosterone) effect. Metoidioplasty  A masculinizing type of surgical procedure which produces a phallus without using a skin graft. Existing androgenized clitoral tissue is released from the pelvic bone and sculpted into a phallus/penis. Many variations on this technique are available, including urethral lengthening, so the individual can urinate while standing. Addition of testicles and scrotum (made from labial skin) is also an option. Penile construction/phalloplasty  A type of surgical procedure which produces a phallus/ penis using a free flap. Before the formation of the penis, an individual usually undergoes a hysterectomy, bilateral salpingo-oophorectomy (removal of the ovaries and fallopian tubes), and a vaginectomy (removal of the vagina). The penis (phalloplasty) is created by a free flap from the forearm (radial forearm), thigh (anterolateral), or back (latissimus dorsi). The urethra is lengthened using skin from the flap, making a tube-withina-­tube and connected to the existing urethra. A glans (glansplasty) can be created either during

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the initial phalloplasty or subsequently to sculpt the appearance of a circumcised penis tip. The scrotum (scrotectomy) is created using skin from the labia majora, and prosthetic testicles are put in place. An erectile device may be placed within the penis one year after the initial phalloplasty. Vaginal construction/vaginoplasty  A feminizing type if surgical procedure whereby the penis and testes are removed and the skin from the penis and scrotum (penile inversion technique) are used for the construction of clitoris, labia, and, if desired, vagina. This surgery is usually performed in one stage.

References 1. American Psychiatric Association. Diagnostic statistical manual of mental disorders, 2nd ed. (DSM-II); 1968. 2. American Psychiatric Association. Diagnostic statistical manual of mental disorders, 3rd ed. (DSM-III); 1980. 3. American Psychiatric Association. Diagnostic statistical manual of mental disorders, 4th ed. (DSM-IV); 1994. 4. American Psychiatric Association. Diagnostic Statistical Manual of Mental Disorders, 4th Edition, Text Rev (DSM IV-TR). 2000. 5. Bockting WO. Psychotherapy and the real-life experience: from gender dichotomy to gender diversity. Sexologies. 2008;17(4):211–24. https://doi. org/10.1016/j.sexol.2008.08.001. 6. Coleman E, Bockting W Botzer M, et  al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgender. 2012;13:165–232. 7. Fraser L, Knudson G.  Education needs of providers of transgender population. Endocrinol Metab Clin. 2019;48(2):465–77. 8. Health Policy Project, Asia Pacific Transgender Network, United Nations Development Programme. Blueprint for the Provision of Comprehensive Care for Trans People and Trans Communities. Washington: Futures Group, Health Policy Project; 2015. 9. Pan American Health Organization [PAHO], John Snow, Inc., World Professional Association for Transgender Health, et al. Blueprint for the Provision of Comprehensive Care for Trans Persons and Their Communities in the Caribbean and Other Anglophone Countries. Arlington: John Snow, Inc; 2014.

46 10. United Nations Development Programme, IRGT: A Global Network of Transgender Women and HIV, United Nations Population Fund, UCSF Center of Excellence for Transgender Health, Johns Hopkins Bloomberg School of Public Health, World Health Organization, Joint United Nations Programme on HIV/AIDS, United States Agency for International Development. Implementing comprehensive HIV and STI programmes with transgender people: practical guidance for collaborative interventions. New  York: United Nations Development Programme; 2016. 11. WHO.  International statistical classification of diseases and related health problems, 9th revision. Geneva: World Health Organization; 1978.

G. Knudson 12. WHO.  International statistical classification of diseases and related health problems, 10th revision. Geneva: World Health Organization; 1992. 13. WHO.  International statistical classification of diseases and related health problems, 11th revision. Geneva: World Health Organization; 2018. 14. Winter S, Diamond M Green J, et  al. Transgender people: health at the margins of soicety. Lancet. 2016;388(10042):390–400. https://doi.org/10.1016/ S0140-6736(16)00683-8.

5

The Mental Health Assessment for Surgery Dan H. Karasic

 PATH Standards of Care W and the Mental Health Assessments for Surgery The WPATH Standards of Care Version 7 (WPATH SOC 7) describes a process for mental health assessments before genital and chest/ breast transgender surgeries [1]. SOC 8, which is in development at time of printing, may change the requirements listed below. The latest version of the SOC is available for download at wpath.org. The assessment for surgery, per SOC 7, may be done by the patient’s therapist or psychiatrist or a mental health professional who sees the patient just for the assessment. There is no requirement for psychotherapy in SOC 7. There is no set number of visits for this assessment, but it can be completed expeditiously in those who do not have co-occurring mental illness or substance abuse that must be addressed prior to surgery. One assessment is required for chest/breast surgery and two for genital surgery. SOC 7 requires the mental health assessors to be licensed practitioners who are knowledgeable on trans care. Ideally, the mental health assessor has a thorough understanding of the surgeries

D. H. Karasic (*) Department of Psychiatry, University of California San Francisco, Health Sciences Clinical Professor of Psychiatry, San Francisco, CA, USA

and, in the process of assessing the patient’s understanding of the risks and benefits of surgery, can help inform the patient on the process of surgery, potential risks, presurgical preparation (e.g., hair removal), and preparation for the perioperative period and help the patient with a plan for practical supports, e.g., from friends and family, during this period. The mental health professional can help the patient with questions they may have of the surgeon. Discussing risks and benefits of surgery with multiple providers can aid in the process of informed consent and in addressing patient questions and concerns. For each surgery, SOC 7 requires that the patient has capacity for informed consent. Of course, consent is required for surgeries generally, but per SOC 7, the assessment of the patient’s understanding the risks and benefits is not only the responsibility of the surgeon but also of those doing mental health assessments. Capacity to give informed consent is rarely grossly impaired, as with dementia or delirium. Hallucinations and delusions, as with schizophrenia, can impair capacity to give informed consent, and stabilization with medication is advisable when possible. Some patients, whether due to education, language differences, or neurodevelopmental differences, have capacity to give informed consent but may require extra time and effort to make sure that they understand the procedure under consideration. Asking that they explain back to the interviewer their u­ nderstanding

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of the risks, after these are discussed with them, is important to assessing their understanding of risks. A Standards of Care 7 requirement for surgery is “persistent, well-documented” gender dysphoria. If an assessment is being done for a patient who is not well-known to the assessor, it may be helpful to be able to share information with the other mental health assessor, if two letters are required, or with the patient’s medical provider, to get a better understanding of the patient over time. The Standards of Care 7 criteria for adults list “age of majority” as a requirement. However, SOC 7 also states that chest surgery may be appropriate for adolescents under the age of majority, and in those with long-standing gender dysphoria and a stable gender identity, chest surgery for transmasculine youth may be helpful in relieving distress and facilitating social transition [2]. Genital surgery for those under the age of majority, while not supported by SOC 7, is done by some surgeons. Surgeons list the maturity of individual patients and desirability of completing surgery while the patient is still living with family, before the youth goes away to university, as reasons why genital surgery is sometimes done on minors [3]. SOC 7 criteria for chest/breast surgery state that mental illness if present should be “reasonably well-controlled” and for genital surgery should be “well-controlled” [1]. Mental illness and substance abuse can affect ability to give informed consent. They can affect ability to make it to appointments with medical and surgical providers, complete appointments for hair removal when needed, and otherwise prepare for surgery. Substance withdrawal can complicate the perioperative period [4]. Substance use when smoked can affect respiratory function for anesthesia. Nicotine can affect vascularization and healing [5]. Mental illness and substance abuse can impair necessary postoperative care, such as dilation after vaginoplasty, and follow up appointments for all surgeries. The patient with a substance use disorder may have difficulty coping with the stressors of the perioperative period without relapse or increased use.

However, the risks of delaying or denying surgery must be considered as well. In particular, because chest surgery for trans men can happen at the start of transition, before hormones or social transition, per SOC 7, delaying surgery may delay other transition interventions to reduce distress. In each case, one must weigh the risks and benefits of proceeding with surgery versus delaying surgery due to mental illness, when the mental illness may be exacerbated by gender dysphoria [6]. Mental health assessments may be required for insurance coverage for procedures for which there are not SOC 7 criteria. Facial feminization surgery (FFS), for example, for some is covered by their insurance. Insurance policies typically cover medically necessary procedures but not cosmetic procedures. For the various procedures of FFS, there may be overlap of the medically necessary and the cosmetic. In the mental health assessment, it is important to describe why the procedures are medically necessary treatments for gender dysphoria, if they are to be covered by insurance. Describing the distressing symptoms that may be alleviated by the surgeries, as well as specifically how the surgeries may improve the patient’s occupational and social functioning, may be helpful in demonstrating medical necessity.

The Initial Interview When a patient comes for an assessment for surgery, the mental health assessor gives space to hear what the person is seeking and why, without imposing the provider’s own narrative on the patient [7]. The patient’s conceptualizations of gender and priorities for care may differ from those assumed by healthcare providers. The mental health professional should be aware that trans people may have previously encountered discrimination in healthcare settings [8] and may be wary of the assessment as “gatekeeping.” Some people present knowing exactly what surgery they want, which surgeon they are planning to use, and having thoroughly researched the procedure they are seeking.

5  The Mental Health Assessment for Surgery

Others are less certain and seek more guidance from the mental health professional. The mental health assessor can assess the patient’s needs and provide information on alternatives, when appropriate. The assessor should ask what surgery or surgeries are sought and why the person is seeking them at this time and then explore their information-gathering and decision-making process. Gender identity and gender dysphoria are explored in relation to the surgeries desired. One may seek surgery so that one’s body is more congruent with one’s identity, whether that is a binary identity opposite to the sex assigned at birth or a nonbinary identity [1, 7]. The assessor should ask about how the patient identifies in terms of gender, about gender dysphoria related to the body and body parts, the person’s recollection of the development of gender identity and dysphoria, and what surgeries are desired to increase congruence with identity and decrease dysphoria about aspects of the body, again in an open-ended way. One can also ask about functional impairment, e.g., socially or occupationally, related to gender dysphoria, and how the desired surgery might help. The mental health assessor should ask about how the transition process has gone prior to seeking surgery, e.g., social transition and hormones, assessing for persistent gender dysphoria that is benefitting from transition care, and when required by SOC 7, whether the person has been on hormones and living in accordance with their gender identity continuously over the past year. When appropriate, mental health interviews for people, cis or trans, include a sexual and relationship history. For trans people, how surgery might affect sex and relationships should be discussed. When appropriate, there should be a discussion about fertility, how it may be affected by surgery, and whether the patient has an interest in maintaining reproductive capacity. A mental health and substance use history should be obtained, including current psychiatric symptoms and medications if the patient is taking them. Whether the person is a tobacco smoker (or otherwise uses nicotine) is important, as abstinence from nicotine is often required before

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surgery. Medical conditions that could impact surgery, such as diabetes, should be discussed. A discussion about the patient’s social circumstances, particularly as they relate to the perioperative period is important. Does the patient have a stable place to live? Are there family and friends who can help out when needed? Does the patient have transportation to appointments? If the patient has to travel for surgery, what is the patient’s ability to make plans for having surgery away from home? Suggested format for mental health assessment letters: 1. Dated and addressed to surgeon. It is usually best to address and send the letter to one particular surgeon, with consent of the patient to communicate further as necessary. 2. Name and date of birth of patient. If the legal name is different than the one the patient uses, include “Legal Name: (Xxx Xxxx)” at the start of the letter, for insurance identification and medical records purposes, and then use the name and pronouns the patient uses throughout the rest of the letter. 3. Who the mental health assessor is and the assessor’s relationship with the patient. For example: “I am a psychiatrist experienced in surgical assessments for trans surgeries, and I saw the patient for three sessions in November 2018, which included an assessment for vaginoplasty.” 4. The history of the patient’s gender dysphoria, what treatment (e.g., psychotherapy, hormones, other surgeries) the patient has already undergone, and their response to prior treatment. 5. The patient’s social transition, with pertinent details. (e.g., when the patient started living in full time their current gender role, relationships and functioning in current gender role, legal name/gender change.) 6. For genital surgery, specify length of time on hormones and in current gender role, meeting WPATH SOC 7 1-year requirements. 7. History of mental illness and substance abuse, with pertinent details.

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8. Current medical or mental health conditions, current medications, and level of stability of these conditions. 9. Capacity for informed consent and patient’s understanding of the risks and benefits of the planned surgery. 10. Fertility discussion, when appropriate. 11. Psychosocial stability: Housing, support, and plan for postoperative period. 12. Diagnosis: Gender dysphoria (or gender incongruence once ICD 11 is used for billing). A diagnosis typically is necessary for insurance reimbursement of the procedure. Note SOC 7 refers to the symptom of gender dysphoria, which may be relieved by transition. Capitalized “Gender Dysphoria” refers to the DSM 5 diagnosis [9], which insurance companies may require for coverage. The current ICD 10CM billing code is F64.0, which may be listed in electronic health records as the ICD 10 term transsexualism or DSM 5 label Gender Dysphoria. For ICD 11, the name of the diagnosis has been changed to Gender Incongruence, which has been moved out of the mental disorders chapter and is now listed under Conditions related to Sexual Health [10]. 13. A statement that the patient meets SOC 7 criteria for the surgery. The fulfillment of each of the SOC 7 criteria already has been described in the letter, but this explicit statement may be helpful for the surgeon and for insurance coverage. 14. A statement that the requested surgery is a medically necessary treatment for F64.0 Gender Dysphoria. This may be helpful for insurance coverage, as insurance typically covers treatments determined to be medically necessary, but not cosmetic treatments. 15. A request that the surgeon contact you (at XXX-XXX-XXXX) if further information is needed. This is to facilitate further communication, as necessary. Some surgeons’ offices will

call the mental health assessor to confirm receipt of the assessment and that it came from the assessor.

The Second Assessment SOC 7 requires two mental health assessments for genital surgery. The second assessment is an independent assessment that is like the first assessment and includes the 15 points above. Communication between the assessors is useful, especially if the first assessor has a longer history working with the patient [11]. After the assessment is completed, the mental health assessor should remain available for consultation to the surgeon for further questions about the patient or, possible, for assistance if new mental health issues arise. A mental health professional doing ongoing work with the patient can help with the process of the patient getting support in the perioperative period and can be available in case there are mental health issues postoperatively. Ideally for communication, the patient’s mental health provider, the medical provider, and the surgeons are part of an interdisciplinary team [12]. As it is common that each provider practices separately, communication across disciplines should be maintained as necessary for the care of the patient.

References 1. Coleman et  al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13: 165–232. 2. Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018 May 1;172(5):431–6. https://doi.org/10.1001/ jamapediatrics.2017.5440. 3. Milrod C, Karasic DH. age is just a number: WPATH-­ affiliated surgeons’ experiences and attitudes toward vaginoplasty in transgender females under 18 years of age in the united states. J Sex Med. 2017;14:624–34.

5  The Mental Health Assessment for Surgery 4. Cone JD, Harrington MA, Kelley SS, et  al. Drug abuse in plastic surgery patients: optimizing detection and minimizing complications. Plast Reconstr Surg. 2011;127(1):445–55. 5. Coon D, Tuffaha S, Christensen J, et al. Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications. Plast Reconstr Surg. 2013;131(2):385–91. 6. Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HFL, Pleak RR, Pula J. Gender dysphoria in adults: an overview and primer for psychiatrists. Transgen Health. 2018;3(1):57–73. 7. Karasic DH.  Transgender and gender nonconforming patients. In: Lim RF, editor. Clinical manual of cultural psychiatry. 2nd ed. Arlington: American Psychiatric Publishing; 2015. p.  397–410. (Karasic 2015–1). 8. Grant JM, Mottet LA, Tanis J, Harrison J, Herman JL, Keisling M.  Injustice at every turn: a report

51 of the national transgender discrimination survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. 9. American Psychiatric Association. Diagnostic and statistical manual of mental disorders 5. Washington, DC: American Psychiatric Publishing; 2013. 10. ICD 11. World health organization. https://icd.who. int/ Accessed 15 July 2018. 11. Karasic D. Mental health assessments of transgender adults. Webinar, February17, 2015. LGBT Education Center. https://www.lgbthealtheducation.org/webinar/ mental-health-assessment-trans-adults/ . Accessed from web 29 June 2018. (Karasic 2015–2) 12. Karasic DH, Fraser L. Multidisciplinary care and the standards of care for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45:295–9. https://doi.org/10.1016/j.cps.2018.03.016.

6

Primary Care for the Transgender and Gender Nonconforming Patient Frederic M. Ettner

Introduction As physicians, primum non nocere (first, do no harm) is more than a motto. It defines our responsibility to all patients who seek our services. Primary care physicians (family medicine, pediatricians, internists, and obstetrician/gynecologists), physician’s assistants, and nurse practitioners are the vanguard of medical practice. Gender is an integral part of humanity and one of the more misunderstood foundations of human behavior. This is especially true for the transgender individual. The healthcare system has been largely indifferent to the needs of people with unique gender identities and presentations, causing health disparities, stigmatization, and minority stress [1]. This chapter will introduce the surgeon, the “captain of the ship,” to primary care for the transgender/gender diverse patient (TGGD). The protocols offered here have been developed through years of patient encounters, extensive review of the medical literature, and the guidance provided by the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC). The generalist is usually the first physician to see the patient. Indeed, it may be the first time the patient has visited any physician. The current

F. M. Ettner (*) Department of Family Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA

accepted prevalence of TGGD people is 200–700 per 100,000 [2]. Therefore, a primary care physician working 40  hours a week may have seen, knowingly or unknowingly, 10–35 gender diverse patients in a year. The encounter begins when the patient makes an appointment. Gathering appropriate demographics, i.e., sex assigned at birth, self-described gender identity (nonbinary, fluid, queer), and preferred pronouns, can be a demonstration of respect, if office staff have been appropriately trained. Creating an environment conducive to lessening the stress for these persons is crucial to establishing a trusting relationship. Within this context, medical and social history taking, physical examination, and treatment can proceed. Many TGGD individuals lack access to healthcare or fear discrimination and thus are at increased risk for common medical conditions. Promoting well-being is the goal of the primary care provider, regardless of the patient’s gender identity or presentation. The recognition that gender nonconformity is not synonymous with gender dysphoria is important in consulting with all TGGD patients. “Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex. Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth and the associated gender role

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and/or primary and secondary sexual characteristics). Only some TGGD people experience gender dysphoria [3]. Familiarity and knowledge of primary medical care, hormonal treatment, and regular follow­up is essential in providing care to this population. Collaboration with other professionals, such as mental health providers, contributes to ensure optimal care. TGGD patients encompass all age groups – pediatric, adolescent, adult, and geriatric. Each age group brings challenges medically, surgically, psychologically, and socially. There are no algorithms, and each patient needs to be treated as an individual. With the initial consultation, or face-to-face encounter between medical provider and patient, the expectations of patient and provider are discussed, and the process of obtaining informational consent begins. There are no diagnostic physical findings, laboratory tests, imaging studies, psychological profiles, or questionnaires to assess TGGD patients. The TGGD person is self-­ diagnosed, and the initial encounter confirms the patient’s self-disclosure. Following this initial consultation, a subsequent visit will include a complete history and physical examination. Baseline laboratory tests are scheduled after the initial consultation. The purpose of this evaluation is to discuss the patient’s gender identity and assess gender dysphoria and the presence of morbid conditions that may contraindicate or impact hormonal therapy. The initial complete medical history should include: • History of patient’s realization of gender identity and gender dysphoria, desire for cross-sex hormone therapy and expectations, and/or gender-affirming surgical goals (facial, breast, genital). • A detailed past medical history with emphasis concerning cardiovascular disease (hypertension, coronary artery disease, cerebrovascular disease, thromboembolic phenomena), hepatic disease (hepatitis, cirrhosis, alcohol/drug use, metabolic diseases (diabetes, thyroid, kidney), myeloproliferative disease (erythrocytosis, leukemia, lymphoma, bone marrow dyscra-

•

•

• •

•

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sias), cancer (breast, uterine, genital), hormonal abnormalities (hypothyroid, pituitary adenomas, congenital adrenal hyperplasia, genital/urinary abnormalities (gravida/para, menarche, menstrual cycle, days of flow, last menstrual period, PAP with HPV screening, HIV, sexually transmitted infection testing), sexual health history (fertility, preferred partners, asexual, sensuality, experienced expected sexual response, abuse), substance abuse (tobacco, alcohol, illicit drugs), nutrition (note weight-positive problems of hormonal treatment), and activity (maintain ideal body mass index – BMI). Family history of chronic disease (cardiovascular, hypertension, diabetes, blood clotting disorders, liver disease, kidney disease, unusual anesthetic problems) and familial diseases. Medication history  – documentation of all medications especially previous hormonal therapy either prescribed or acquired (non-prescribed). Surgical history including silicone injections or other body modifications. Social history – family dynamic, support, discussion of transitioning and/or pre/intra/postoperative care, alcohol/tobacco use (CAGE questionnaire  – alcohol dependence surveillance tool), illicit drugs, and harms (suicidal ideation, plan, or attempt). Mental health history – major disorders (psychosis, bipolar, depression, impulse control disorder, substance abuse), administer depression questionnaire (i.e., PHQ-9). Education/occupation – explore potential difficulties transitioning in these settings. Review of systems  – skin, musculoskeletal, cardiovascular, respiratory, digestive, genital (review sexual history emphasizing change in sexual response and possible infertility with hormonal treatment and permanence of gonadal surgeries with resultant infertility), and neurological.

Physical examination  – the examiner should be cognizant of the disdain, fear, and anxiety that a physical examination may provoke in the TGGD

6  Primary Care for the Transgender and Gender Nonconforming Patient

patient. Creating a safe environment by discussing the rationale for examination and the information it yields is essential. This is especially evident in the transmale without any previous vaginal penetration (tampon, penis, or sexual “toy”). In the transmale with a narrow introitus, vaginal examination is not possible (in the office setting); rectal examination can suffice to assess pelvic structures and a “blinded” PAP smear, if necessary. The physical examination should include: • Vital signs. • Appearance – male, female, androgynous. • The skin, head, ears, eyes, nose, tongue, fundi, tympanic membranes, throat, neck, lymphadenopathy (neck, supra/infraclavicular, axilla, inguinal), chest (deformity pectus excavatum/ carinatum), breasts, cardiovascular, lungs, abdomen, rectal (tone, prostate size, consistency, masses), genital-urinary (penis, testicles, external genitals, vagina, cervix, uterus, ovaries), extremities, pulses, neurological exam.

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diagnostic code F64.9 and the endocrine disorder code E34.9. Discussion and Plan • Hormonal therapy and laboratory surveillance (detailed in next section). • Strategies re: maintenance of good nutrition, ideal BMI, activity and fitness, fertility discussion (preservation of gametes). • Follow-up return visits every 3 months during the first year of treatment and then 6 months to 1  year depending on the treatment plan and individual requirements.

Hormonal Therapy

The medical necessity of hormone therapy for gender dysphoria has been well-established. The protocol is comprised of exogenous endocrine agents to induce feminizing or masculinizing changes [4]. The administration of hormone therapy must be individualized, based on the patient’s Laboratory tests should include: goals, the risk/benefit ratio, medical contraindicaComprehensive metabolic profile, complete tions, and adverse effects [5]. Some people seek blood count, lipid profile, thyroid-stimulating maximum feminization/masculinization, while hormone, estradiol, testosterone, hemoglobin others experience relief with an androgynous preA1c, urinalysis, sexually transmitted infection sentation, resulting from hormonal minimization of existing secondary sex characteristics [6]. screening, hepatitis screening B and C. The initiation of hormonal therapy should be Specialized tests (depending on patient’s pre- preceded by a psychosocial assessment either by sentation) electrocardiogram, chest X-ray, a qualified mental health practitioner or primary pelvic ultrasound, mammography (if indi- care physician/nurse practitioner/physician’s cated), prostatic serum antigen (family or per- assistant, with abundant experience with assesssonal history of prostatic pathology), prolactin ment and treatment. The criteria for hormone (suspected prolactinoma), sex hormone-­ therapy are as follows: binding globulin (history of insensitivity to 1. Persistent, well-documented gender dysphoria. hormonal therapy). 2. Capacity to make a fully informed decision and to consent for treatment. Diagnoses should include: 3. Age of majority in a given country (if younger, follow the SOC outlined in Sect. VI TGGD and/or gender dysphoria. Assessment and Treatment of Children and New diagnoses (elevated BMI, discussion of Adolescents With Gender Dysphoria). past history and treatment). Discussion of ICD 10 codes  – depending on 4. If significant medical or mental health concerns are present, they must be reasonably insurance coverage. Currently, many insurwell controlled [4]. ance providers accept the gender dysphoria

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Informed consent is a critical component of treatment. The informed consent document is an educational piece that should include (1) the nature of the decision/procedure; (2) reasonable alternatives to the proposed intervention; (3) relevant risks, benefits, and uncertainties related to each alternative; (4) assessment of the patient understanding the issues; and (5) acceptance of the intervention by the patient [7]. A medical history, physical examination, and risk assessment utilizing relevant laboratory tests and patient’s goals should be performed and discussed (see History Physical examination). Prior to prescribing, a discussion of the adverse effects of feminizing/masculinizing medications and the effects on a reduction in fertility [8, 9] is necessary. Establishing a supportive and trusting relationship with the patient is essential for ongoing regular monitoring and maintaining best medical practices. This will include assessing the effectiveness of hormonal treatment utilizing laboratory tests, face-to-face interaction, and examination approximately every 3 months for the first year of treatment. If goals are met clinically, then follow-up can be scheduled biannually. The following comprises a reasonable treatment regimen for transgender and gender nonconforming patients. Transfemale – Androgen suppression and the stimulation of female physical characteristics are the goals of feminization. Spironolactone (100– 200 mg daily), an antihypertensive agent, directly inhibits testosterone secretion and androgen binding to the androgen receptor. Cyproterone acetate is a progestational compound with anti-­ androgenic properties. This medication is not approved in the United States because of concerns over potential hepatotoxicity, but it is widely used elsewhere. 5-alpha reductase inhibitors (finasteride 2.5  mg daily and dutasteride 0.5 mg every other day) block the conversion of testosterone to the more active agent, 5-alpha-­ dihydrotestosterone. These medications have beneficial effects on scalp hair loss, decreased body hair growth, sebaceous glands, and skin consistency. The use of oral estrogen, and specifically ethinyl estradiol 2–6  mg daily, appears to increase the risk of venous thromboembolism.

Gonadotropin-releasing hormones (GnRH) are utilized after boys and girls first exhibit physical changes of puberty to “pause” secondary sexual characteristic development and in the adult to arrest hormonal secretion and initiate cross-­ hormone therapy. GnRH (3.75 mg monthly) are neurohormones that block the gonadotropin-­ releasing hormone receptor, thus blocking the release of follicle-stimulating hormone and luteinizing hormone. Transdermal estrogen is recommended for those patients with risks factors for venous thromboembolic events. These include ethinyl estradiol patch 50–100 mcg every 3.5  days or estradiol gel 2–3 pumps daily or estradiol valerate 5–10  mg weekly intramuscularly. The beneficial effects of estrogen therapy include redistribution of body fat, decreased muscle mass, softening of the skin, and decreased libido. Breast change and development appears within 1 month after estrogen induction and will continue for up to 2 years. Dosages are adjusted by need, goals, and risk. The risk of adverse events increases with higher doses, particular doses resulting in supraphysiologic levels [9]. Transmale – Transdermal testosterone is recommended in a variety of vehicles gel, patch, pellets, and intramuscular. Common dosages include testosterone gels or patches and intramuscular testosterone 100  mg per week. The beneficial effects of testosterone include increased muscle mass, decreased fat on the hips and buttocks, increased facial and body hair, elimination of menses, and deepened voice. Adverse effects include acne, decreased fertility, and atrophic vaginitis. Dosages vary according to patient need, goals, and risks. In the adolescent transmale with the initiation of pubertal change, GnRH is utilized to “pause” secondary sexual characteristic development.

Care of the Adolescent The adolescent patient offers unique challenges to mental healthcare professionals, physicians, and surgeons. Therefore, an expert multidisciplinary team is strongly recommended (medical and mental health professional) [10].

6  Primary Care for the Transgender and Gender Nonconforming Patient

Psychosocial acceptance, family issues, fertility, and harm reduction are among the issues faced by patients, parents, and healthcare professionals. Collaboration within a multidisciplinary approach is optimal in promoting healthy outcomes. Treatment of the adolescent has evolved to embrace the recognition that gender identity is unique and not necessarily binary. The primary care physician and allied professionals seek to create a supportive environment that allows for the safe exploration of identity and the promotion of resilience. Establishing a diagnosis of gender dysphoria that requires treatment is essential prior to providing medical interventions. The current guidelines for treatment, proffered by the Endocrine Society and WPATH, are valuable protocols. However, each adolescent and family has unique needs, dynamics, and concerns. The evaluation of youth and adolescents may be initiated by mental health professionals. Before any physical interventions, consultation by trained mental health professionals who have competence and experience with gender dysphoria/gender incongruence is necessary. Criteria and recommendations are documented in the SOC and the Endocrine Society guidelines. Adolescents who meet diagnostic criteria for gender dysphoria/gender incongruence and exhibit physical changes of puberty may be prescribed GnRH analogues to suppress secondary sexual characteristic development. Prior to the initiation of hormonal treatment, clinicians need to confirm the diagnosis of gender dysphoria/gender incongruence. Collaboration with mental health professionals, primary care clinicians, and surgeons is essential for thorough assessment and healthy outcomes [10].

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transwomen include prostate, breast, and mammography with 10 plus years of estrogen exposure. Annual postsurgical breast, pelvic, periurethral (observe exposed urethra forming “labia minor” and covering neo-clitoris), prostate, vaginal (depth, stenosis, fistula), and rectal exams should be completed yearly. Lifelong follow-up is necessary for patients receiving hormones. Screening for osteoporosis in the transmale is also essential [11].

Surgery

Discussion of surgical options, i.e., genital confirmation surgeries, facial feminization, breast augmentation, body contouring, phalloplasty, metoidioplasty, mastectomy, voice therapy/surgery, and patient goals, is a component of care. Frank discussion of expectations, both from the surgeon’s and patient’s viewpoint, will optimize outcomes. The permanence of surgical change and infertility needs to be reiterated. Scheduled follow-up postoperatively with allied therapies in place including medical, physical therapy, and continuity of care with mental health professionals should be available and encouraged. Transparency of the surgeon’s experience permits informational consent, and patients should be encouraged to do their own due diligence. The understanding and planning for patients’ who lack housing and financial resources need special consideration. Discussion of the realities of home healthcare upon discharge and the responsibilities of those who provide postoperative care must occur prior to surgery. The patient’s ability to recover in an appropriate environment, the provision of surgical wound care, and the ability to dilate in a secluded place must likewise Prevention and Care be topics of discussion, as well as consideration Preventative and follow-up care are essential of when to return to work. These face-to-face discomponents of TGGD patient healthcare. Post-­ cussions are essential to optimize outcomes. The TGGD patient may have “unusual” hormonal and surgical follow-up care for these patients includes physical exam, weight, blood requests regarding secondary sexual characterispressure, and laboratory studies (metabolic pro- tic changes. Variations include flat front  – no file, liver function tests, complete blood count, genitals and reconstruction voiding meatus, lipids, testosterone, estradiol, prolactin if neces- maintaining vagina and neo-phallus, and mainsary). Additionally, annual screening tests for taining unilateral testicular function and vagino-

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plasty with or without phallus. These requests to the surgeon may raise ethical questions and practical questions (“never did this kind of surgery”) and questions regarding the patient’s ability to give consent. A collaborative approach with primary care, mental health professionals, surgeon, and patient will inform decisions in these unique cases.

Conclusion With knowledge of gender-affirming models of care, the surgeon will be equipped to safely treat the TGGD patient with respect and purpose. Due to a variety of factors, many TGGD lack access to healthcare and therefore are at increased risk for common medical conditions. Collaboration with mental healthcare and primary care professionals is fundamental to healthy outcomes. Therefore knowledge of basic medical care, hormonal treatment, and regular follow-up is necessary. By providing complete and compassionate healthcare, positive surgical outcomes will follow.

References 1. Eyler EA.  Primary medical care of transgender and gender non-conforming persons. In: Ettner R, Monstrey S, Coleman E, editors. Principles of transgender medicine and surgery. New York: Routledge; 2016. p. 44. 2. Collin L, Goodman M, Tangpricha V. Worldwide prevalence of transgender and gender non-­conformity. In:

F. M. Ettner Ettner R, Monstrey S, Coleman E, editors. Principles of transgender medicine and surgery. New  York: Routledge; 2016. p. 32. 3. Coleman E, Bockting W, Botzer M, et  al. Hormone therapy in standards of care for the health of transsexual, transgender, and gender nonconforming people, version 7. Int J Transgend WPATH. 2011: 33–50. 4. Coleman E, Bockting W, Botzer M, et  al. The difference between gender nonconformity and gender dysphoria in standards of care for the health of transsexual, transgender, and gender nonconforming people, version 7. Int J Transgend. 2011;13(4):165–232. 5. Meyer W III.  World professional association for transgender health’s standard of care requirements of hormonal therapy for adults with gender identity disorder. Int J Transgend. 2009;11(2):127–32. 6. Factor RJ, Rothblum E.  Exploring gender identity and community among three groups of transgender individuals in the United States: MtFs, FtMs, and genderqueers. Health Sociol Rev. 2008;17(3): 235–53. 7. Graham J. Global education initiative WPATH lecture. Presentation to physicians, nurses, physicians assistants, and mental health professionals: Informed Consent; 2016. 8. Feldman J, Safer J. Hormone therapy in adults: suggested revisions to the sixth version of the standards of care. Int J Transgend. 2009;11(3):146–82. 9. Hembree WC, Cohen-Kettenis P, van de Wal D, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–54. 10. Hembree W, Chen-Kettenis P, Gooren L, et  al. Endocrine treatment of the gender-dysphoric/ gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):2–3. 11. Feldman J. Preventive care of the transgender patient an evidence based approach. In: Ettner R, Monstrey S, Coleman E, editors. Principles of transgender medicine and surgery. New York: Routledge; 2016. p. 69–80.

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Hormone Therapy for Transgender Women Vin Tangpricha and Joshua D. Safer

Introduction

Principles of Hormone Therapy

Sex steroid hormones play an important role in gender-confirming therapies of transgender women to modify the external physical appearance to align with gender identity. Most transgender women seeking gender-confirming surgeries will be taking gender-confirming sex steroid hormone therapy. Under medical supervision, hormone therapy appears to be safe with very low risk of complications [3]. However, some patients may be receiving hormone therapy without a prescription or routine medical monitoring which may lead to increased risk of complications [2]. Surgeons and physicians and other healthcare providers should understand and recognize the goals of gender-affirming hormone therapy and potential pitfalls during the pre-, peri-, and postoperative period of gender-confirming surgery which will be covered in this chapter.

The overall goal of gender-affirming hormone therapy for a transfeminine person is to lower the circulating blood testosterone concentrations to a female range (  27) [12]. current evidence to screen at earlier ages in the Physicians should counsel transfeminine patients transgender population. to quit smoking, maintain a healthy weight, avoid Transgender persons have a higher rate of supraphysiologic levels of estradiol, and consider depression and anxiety compared to the general a switch to transdermal estrogen with advancing population [20]. Transgender persons seeking age [13]. Patients should be made aware of the care at the Veterans Affairs healthcare system risks of thromboembolism, counseled on how to have increased mortality related to suicide 1. Clinical assessment and laboratory monitoring for estradiol and testosterone levels every 3 months for the first year then twice yearly 2. Monitoring of potassium concentrations upon initiation of spironolactone and with dose changes (every 3 months for the first year), then once or twice yearly 3. Baseline assessment of prolactin concentration and periodic measurement of prolactin 4. Measurement of bone mineral density in patients with risk factors for osteoporosis including gonadectomy, personal history fracture, family history of osteoporosis, low BMI, tobacco, or alcohol misuse 5. Screening for hormone-sensitive cancers such as prostate and breast cancer should follow age-specific recommendations by national societies

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compared to non-transgender veterans and the ­general population [21]. Studies have indicated that hormone therapy in transgender persons improves quality of life and mood disorders, but the rate of depression and anxiety still remained elevated [22, 23]. Physicians should continue to screen for depression and mood disorders at each visit and refer patients to qualified mental health specialists for evaluation if mood disorders are present.

Surgical Considerations Most transgender women who seek gender confirmation surgery will be on hormone therapy with estrogen and a testosterone-lowering agent. It is the responsibility of the surgeon to obtain letters of referral according to the World Professional Association for Transgender Health (WPATH) guidelines [24]. For breast reconstruction surgery, the current WPATH guidelines recommend a referral letter without a minimum amount of time on hormone therapy. For gonadectomy surgery (oophorectomy or orchiectomy), the WPATH guidelines recommend 2 referral letters and that the transgender woman be on hormones for at least 12  months prior to surgery. Finally, for gender-confirming genital surgery, the WPATH guidelines recommend 2 referral letters, 12 months of continuous hormone therapy, and 12 months living in the desired gender role. The surgeon should review the patient’s past medical history and obtain the appropriate consultations for any chronic medical illnesses that may impact the surgery and/or postoperative recovery. The surgeon should verify that the hormone regimen is appropriate and may need to communicate with the hormone-prescribing physician. Hormone regimens that appear to be supraphysiologic or non-standard may require a perioperative assessment by an endocrinologist with experience in transgender medicine. Since estrogen has been associated with increased risk of thromboembolism, most centers will hold estrogen therapy 2–4 weeks prior to surgery although there are no data for such a need. It may also be appropriate to check estradiol levels

prior to surgery to ensure that levels are not supraphysiologic. It is most important to ensure that all patients have adequate postoperative DVT prophylaxis and that patients do not reinitiate on estrogen therapy until they are fully ambulatory after surgery. After gonadectomy surgery, testosterone-lowering agents can be stopped. Following gonadectomy and/or gender-­ confirming genital surgery, transgender women should have a reassessment of their hormone levels with serum estradiol and testosterone values. The testosterone levels should be nearly undetectable and no longer need to be measured following gonadectomy. Following gonadectomy surgery, estrogen doses may be lowered as long as serum estradiol levels are maintained in the female range.

Conclusions Most transgender women will take gender-­ confirming hormone therapy prior to undergoing gender-confirming surgery. The most common regimens include an estrogen taken together with a testosterone-lowering agent. The risks of gender-­ confirming hormone therapy are low, especially when prescribed under medical supervision. Transgender women should stop taking gender-confirming hormone therapy for a period of time prior to gender-confirming surgery and then resume hormone therapy once ambulatory after the surgery. Long-term risks of gender-­confirming hormone therapy appear to be low; however, large prospective cohort studies are needed to measure the long-term risks of therapy [25].

References 1. Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; a review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015 Jun;2(2):55–60. 2. Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.  Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens. J Clin Endocrinol Metab. 2012 Dec;97(12):4422–8.

7  Hormone Therapy for Transgender Women 3. Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; a review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015 Jun;2(2):55–60. 4. Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, Gooren LJ, Meyer WJ 3rd, Spack NP, Tangpricha V, Montori VM.  Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009 Sep;94(9):3132–54. 5. Tangpricha V, den den Heijer M, Oestrogen and anti-­ androgen therapy for transgender. Lancet Diabetes Endocrinol, 5, 4, 291–300. 6. Berli JU, Knudson G, Fraser L, Tangpricha V, Ettner R, Ettner FM, Safer JD, Graham J, Monstrey S, Schechter L.  What surgeons need to know about gender confirmation surgery when providing Care for Transgender Individuals a Review. JAMA Surg. 2017;152(4):394–400. https://doi.org/10.1001/ jamasurg.2016.5549. 7. Irwig MS.  Persistent sexual and nonsexual adverse effects of finasteride in younger men. Sex Med Rev. January 2014;2(1):24–35. 8. Tangpricha V, den Heijer M.  Oestrogen and anti-­ androgen therapy for transgender women. Lancet Diabetes Endocrinol. 2017 Apr;5(4):291–300. 9. Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.  Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens. J Clin Endocrinol Metab. 2012;97:4422–8. 10. Ott J, Kaufmann U, Bentz EK, Huber JC, Tempfer CB. Incidence of thrombophilia and venous thrombosis in transsexuals under cross-sex hormone therapy. Fertil Steril. 2010;93:1267–72. 11. Asscheman H, T’Sjoen G, Lemaire A, et  al. Venous thrombo-embolism as a complication of cross-sex hormone treatment of male-to-female transsexual subjects: a review. Andrologia. 2014;46:791–5. 12. Ribeiro DD, Lijfering WM, Rosendaal FR, Cannegieter SC.  Risk of venous thrombosis in persons with increased body mass index and interactions with other genetic and acquired risk factors. J Thromb Haemost. 2016;14:1572–8. 13. Gooren LJ, T’Sjoen G. Endocrine treatment of aging transgender people. Rev Endocr Metab Disord. 2018 Sep;19(3):253–62. 14. Van Caenegem E, Taes Y, Wierckx K, et al. Low bone mass is prevalent in male-to-female transsexual per-

63 sons before the start of cross-sex hormonal therapy and gonadectomy. Bone. 2013;54:92–7. 15. van Kesteren P, Lips P, Gooren LJ, Asscheman H, Megens J. Long-term follow-up of bone mineral density and bone metabolism in transsexuals treated with cross-sex hormones. Clin Endocrinol. 1998;48:347–54. 16. Fischer EM, Patsch J, Muschitz C, Becker S, Resch H.  Severe osteoporosis with multiple vertebral fractures after gender reassignment therapy  – is it male or female osteoporosis? Gynecol Endocrinol. 2011;27:341–4. 17. Wierckx K, Van Caenegem E, Schreiner T, et  al. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. Sex Med. 2014;11:1999–011. 18. Braun H, Nash R, Tangpricha V, Brockman J, Ward K, Goodman M. Cancer in transgender people: evidence and methodological considerations. Epidemiol Rev. 2017 May 9;39:1–15. https://doi.org/10.1093/epirev/ mxw003 [Epub ahead of print]. 19. GR B, Jones KT.  Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Res Treat. 2015 Jan;149(1):191–8. 20. Dhejne C, Van Vlerken R, Heylens G, Arcelus J. Mental health and gender dysphoria: a review of the literature. Int Rev Psychiatry. 2016;28(1):44–57. 21. Blosnich JR, Brown GR, Wojcio S, Jones KT, Bossarte RM. Mortality among veterans with transgender-related diagnoses in the veterans health administration, FY2000–2009. LGBT Health. 2014 Dec;1(4):269–76. 22. Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology. 2012;37:662–70. 23. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol. 2010;72:214–31. 24. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13:165–232. 25. Feldman J, Brown GR, Deutsch MB, Hembree W, Meyer W, Meyer-Bahlburg HFL, Tangpricha V, T’Sjoen G, Safer JD. Priorities for transgender medical and healthcare research. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):180–7.

8

Hormone Therapy for Transgender Men Joshua D. Safer and Vin Tangpricha

Introduction

The physician should consider the age, hormonal status, and medical conditions of the transLike transgender women (Chap. 7), sex steroid gender man at the initiation of transgender hormones play an important role in gender-­ hormone therapy. The physician and transgender confirming therapies of transgender men to mod- person should discuss all of the potential risks, ify the external physical appearance to align with benefits, the anticipated time course for emogender identity. Most transgender men seeking tional and physical changes to occur, and suggender-confirming surgeries will already have gested monitoring and screening for adverse started gender-confirming sex steroid hormone events during hormone therapy. therapy. Under medical supervision, hormone therapy appears to be safe [1]. The surgeon should be aware that some patients may receive Treatment Regimens hormone therapy without a prescription or routine medical monitoring, which may lead to Typically, hormone treatment for transgender increased risk [2]. Surgeons and other health-care men consists of testosterone to bring the serum providers should understand the goals of gender-­ testosterone level from the female range to the affirming hormone therapy along with its poten- male range. The doses required are similar to tial pitfalls. those used for treatment of hypogonadal males in general (Table 8.1). Testosterone is administered parenterally (either intramuscularly or subcutaneously) or transdermally (via gel or patch). Principles of Hormone Therapy Parenterally administered testosterone prepaThe overall goal of gender-affirming hormone rations include testosterone enanthate and testostherapy for a transmasculine person is to raise the terone cypionate. Both formulations can be circulating blood testosterone concentrations to a administered intramuscularly or subcutaneously [6]. Dosing intervals range from 1 to 3  weeks male range (300–1000 ng/dL) [3–5]. with less periodicity in serum levels with shorter intervals. Where available, longer-acting testosJ. D. Safer (*) Center for Transgender Medicine and Surgery, terone undecanoate permits administration only Mount Sinai Health System, New York, NY, USA every 8–12 weeks. V. Tangpricha Transdermal testosterone products include Department of Medicine, Emory University both gels and patches. Both can be considered of Medicine, Atlanta Medical Center, attractive because they can provide stable serum Atlanta, GA, USA © Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_8

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66 Table 8.1 Testosterone regimens for transmasculine persons Parenteral regimens Drug name Testosterone enanthate Testosterone cypionate Testosterone undecanoate

Route IM or SQ IM or SQ IM

Dose range 50–200 mg every 1–3 weeks 50–200 mg every 1–3 weeks 1000 mg every 8–12 weeks

Long-Term Monitoring and Potential Adverse Events

The typical monitoring regimen includes indicated examination and laboratory testing every 3  months when making changes to the regimen and then every 6–12  months thereafter. Usual monitoring includes serum testosterone (to determine success of therapy), hematocrit, and lipid Transdermal regimens profile. Drug name Route Dose range The biggest concerns for testosterone therapy Testosterone gel Cutaneously 1–4 pump actuations are an increase in hematocrit (with a potential 1.6% (50–100 mg) daily increased thrombosis risk) and a decrease in Testosterone Cutaneously 2.5–7.5 mg daily HDL cholesterol (which may be an increased patch coronary artery disease risk). Patients may also be advised to be aware of more aggressive behavlevels with less periodicity than parenterally ior. While laryngeal tissue growth under androadministered products. However, the transdermal gen stimulation may result in the voice deepening products suffer from relatively inefficient trans- that most trans men consider a benefit, the androdermal transfer. Some individuals may be unable gen stimulation to those tissues may also increase to achieve therapeutic serum levels with transder- the risk of sleep apnea. mal products. As well, individuals using transOsteoporosis is not typically considered a dermal gels may accidentally deliver doses to concern for trans men. Similarly, past concern others if they come into skin-to-skin contact with about liver toxicity related to oral androgen prodthe area where the dose was applied too soon ucts are no longer in use. after application. Patches are often not well-­ Breast cancer has been reported in transgentolerated due to cutaneous irritation. der men who have had chest reconstruction surTestosterone is aromatized to estradiol in gery [1]. Therefore, all tissue present must be peripheral tissues, specifically in fat. Some monitored, including cervical tissue, if present, patients express concern that exogenous testos- and breast tissue. After chest reconstruction surterone will be aromatized to supraphysiological gery, screening mammogram will no longer be levels of estradiol. However, there are no data for productive and chest self-exam is most practical. such an event when physiologic doses of testos- The Endocrine Society currently recommends terone are used. Therefore, there is no known pur- cancer screening based on the age-appropriate pose for adjunctive aromatase-inhibiting therapy. screening guidelines for any existing tissues [3]. Clinical expectations from treatment include However, there is no current evidence to screen at absence of menses after several months at thera- earlier ages in the transgender population. peutic levels, increased facial hair developing slowly over months and years, and increased acne especially early in treatment. Over the years, Surgical Considerations muscle and fat may redistribute into more masculine patterns including larger muscles and more Most transgender men who seek gender confiromental fat. Testosterone also stimulates growth mation surgery will be on hormone therapy with of midline structures over multiyear periods. testosterone alone. It is the responsibility of the Treated individuals can anticipate slow growth in surgeon to obtain letters of referral according to the area of the nose, the larynx, and the phallus/ the World Professional Association for clitoris with substantial virilization of the latter Transgender Health (WPATH) guidelines. For given enough time. breast reconstruction surgery, the current WPATH

8  Hormone Therapy for Transgender Men Table 8.2  Suggested monitoring for transgender men 1. Clinical assessment and laboratory monitoring every 3 months for the first year then twice yearly 2. Periodic assessment of hematocrit (or hemoglobin) and lipids 3. Measurement of bone mineral density in patients with risk factors for osteoporosis including gonadectomy, personal history of fracture, family history of osteoporosis, low BMI, tobacco or alcohol misuse 4. Screening for cancers in tissue present including cervix and breast should follow recommendations by national societies Source: Adapted from the Endocrine Society guidelines

guidelines recommend a referral letter without a minimum amount of time on hormone therapy. For gonadectomy surgery (hysterectomy/oophorectomy), the WPATH guidelines recommend 2 referral letters and that the transgender man be on hormones for at least 12 months prior to surgery. Finally, for gender-confirming genital surgery, the WPATH guidelines recommend 2 referral letters, 12 months of continuous hormone therapy, and 12 months living in the desired gender role (Table 8.2). Like transgender women, the surgeon should review the patient’s past medical history and obtain the appropriate consultations for any chronic medical illnesses that may impact the surgery and/or postoperative recovery. Hormone regimens that appear to be supraphysiologic or nonstandard may require a perioperative assessment by an endocrinologist with experience in transgender medicine. There are no specific testosterone-associated surgical complications known. Therefore, in the author’s opinion, there may be no need for trans men to alter their hormone regimens to accommodate surgery. Postoperative hormone regimens are usually unchanged from preoperative regimens except for trans men taking larger testosterone doses than they might have preferred in order to stop menses. In that relatively narrow instance, hysterectomy may facilitate a slight decrease in the testosterone dose.

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Conclusions Most transgender men will take gender-­ confirming hormone therapy prior to undergoing gender-confirming surgery. The most common routine is exogenous testosterone to achieve typical male testosterone serum levels. The risks of gender-confirming hormone therapy are low, especially when prescribed under medical supervision. Although risks of gender-confirming hormone therapy appear to be low, large prospective cohort studies are needed to measure the long-­ term risks of therapy [7].

References 1. Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; a review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015 Jun;2(2):55–60. 2. Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.  Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens. J Clin Endocrinol Metab. 2012 Dec;97(12):4422–8. 3. Hembree WC, Cohen-Kettenis P, Gooren L, Hannema SE, Meyer WJ, Murad M, Rosenthal S, Safer JD, Tangpricha V, T’Sjoen G. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):1–35. PMID 28945902. 4. Tangpricha V, den Heijer M.  Oestrogen and anti-­ androgen therapy for transgender. Lancet Diabetes Endocrinol. 5(4):291–300. 5. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgend. 2012;13:165–232. 6. Spratt DI, Stewart II, Savage C, Craig W, Spack NP, Chandler DW, Spratt LV, Eimicke T, Olshan JS.  Subcutaneous injection of testosterone is an effective and preferred alternative to intramuscular injection: demonstration in female-to-male transgender patients. J Clin Endocrinol Metab. 2017 Jul;102(7):2349–55. 7. Feldman J, Brown GR, Deutsch MB, Hembree W, Meyer W, Meyer-Bahlburg HFL, Tangpricha V, T’Sjoen G, Safer JD.  Priorities for transgender ­ medical and healthcare research. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):180–7.

9

Medical Management of the Adolescent Individual with Gender Dysphoria Jennifer L. Miller and Courtney Finlayson

Introduction Medical care for gender non-conforming and transgender youth has evolved rapidly since the World Professional Association for Transgender Health (WPATH) first published guidelines in 1979, including that for use of gender affirming hormones and surgery in post-pubertal patients. In 2006, the Dutch protocol was published, recommending pubertal suppression at the onset of secondary sexual characteristics for adolescents with gender dysphoria followed by gender-­ affirming hormones at 16 years or older if gender dysphoria persists [1]. The Endocrine Society published their first Guidelines in 2009 which were very similar to the Dutch protocol [2] and subsequently published a revision in 2017 [3]. For youth who fulfill eligibility and readiness criteria, pubertal suppression is recommended when they first exhibit physical changes of puberty, confirmed by sex steroid (estradiol or testosterone) levels, but not earlier than Tanner 2–3. Initiation of pubertal development of the desired opposite sex with gender affirming hormones may be considered prior to the age of 16 years, which allows more flexibility than the original Dutch Protocol. In practice, timing of initiation J. L. Miller · C. Finlayson (*) Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA e-mail: [email protected]; [email protected]

of hormone treatment varies widely by practitioner, and care continues to evolve as our experience grows in caring for these youths.

Puberty Puberty is the process by which an individual matures from a sexually immature to sexually mature individual. The process of gonadarche, or waking of the gonads, initiates the endocrine process. Pulsatile production of gonadotropin-­ releasing hormone (GnRH) from the hypothalamus regulates production of gonadotropins, luteinizing hormone (LH), and follicle-­ stimulating hormone (FSH) from the pituitary gland. While LH and FSH are produced in very small pulsatile amounts prior to puberty, when puberty begins production rises substantially, with increased amplitude of gonadotropin production. Initially, this increase is primarily nocturnal, but as puberty progresses there is no difference between day and night gonadotropin release [4, 5]. In the ovary, LH and FSH stimulate steroidogenesis (estradiol and progesterone production), cause development ovarian follicles, and induce ovulation. In the testis, LH induces androgen production and FSH stimulates spermatogenesis. While puberty typically refers to the process that occurs in adolescence, GnRH, gonadotropins, and sex steroids are also produced earlier,

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during a mini-puberty of infancy. In natal males, this occurs during the first 6 months of life, and in natal females this occurs during the first year of life [6–8]. Subsequently, gonadotropin production is largely suppressed until puberty begins in adolescence. Thus, normal puberty is more accurately considered a reactivation of the hypothalamic-­pituitary-gonadal axis. The mechanism for pubertal onset is one of the important unanswered questions in endocrinology. It appears to involve an interplay of both stimulatory and inhibitory mechanisms including specific genes, neuropeptides, and physiologic factors including energy balance [9]. Adrenarche, or waking of the adrenal gland, is temporally related to gonadarche but is an independent process from sexual maturation. Adrenocorticotropic hormone (ACTH) stimulates increased production of dehydroepiandrosterone (DHEA) and androstenedione. The usual age of adrenarche onset is about 6 years old [10] although appearance of androgen-dependent hair growth (pubic hair and axillary hair) is typically seen during puberty. The progression of pubertal development is typically described via the system of Marshall and Tanner [11]. In natal females, the first sign of puberty and estradiol production is thelarche, the onset of breast development. On average this occurs at 10 years old, but traditionally the onset of puberty in girls is considered normal anytime from 8–13  years (7–13  years in some ethnic groups) [12, 13]. Breast development and a growth spurt occur during puberty and menarche, the onset of menses, occurs at approximately Tanner 3–4 of breast development. Axillary hair and pubic hair develop, primarily mediated by adrenal androgens. The average duration of puberty is 3–4  years, and menarche most often occurs 2–2.5  years after onset of thelarche. In natal males, the onset of puberty is heralded by increase in testicular size and thinning of the penile and scrotal tissue. On average, this occurs around age 12 years but can be normal beginning anytime from 9 to 14 years [13]. Testicular size increases from 1–3 mL pre-pubertally to 4 mL at the onset of puberty [14] (Tanner 2), 10–15 mL in Tanner 3, 16–20 mL in Tanner 4, and 25 mL in

J. L. Miller and C. Finlayson

Tanner 5, or at maturity. Increasing gonadal production of testosterone leads to an increased size of the larynx, deepening of the voice, increased bone mass, increased muscle strength, increased red blood cell mass, and increased pubic and axillary hair growth as well as truncal and facial hair growth [15]. Occasionally pubarche, the appearance of pubic hair or axillary hair, can precede the onset of true puberty [16]. Thus, it is important to realize that the presence of pubic hair or axillary hair does not indicate pubertal onset in either sex. The distinction between pubarche (typically resulting from adrenarche) and gonadarche can be made through physical examination of breast or testicular tissue and first morning, third-generation assay serum levels of gonadotropins, sex steroids, and adrenal steroid intermediates. Other important aspects maturation, separate from secondary sexual characteristics, also occur during puberty. Individuals undergo a growth spurt with peak growth velocity in natal females around Tanner 2–3 and in natal males around Tanner 3–4 [17]. Bone mineral density increases in parallel with pubertal development and is primarily mediated by estrogen (direct secretion in natal females and from aromatization of testosterone in natal males) [17]. Cognitive and behavioral abilities also change during adolescence including development of mature executive functioning (reasoning, problem-solving, forward planning) with continued development until age 20–25 years [18]. Finally, sleep pattern changes during puberty including increased daytime sleepiness and later onset of sleep [19]. Evaluation of pubertal onset is initially by physical examination. If there are signs of testicular enlargement or thelarche, biochemical confirmation can be done via serum analysis of gonadotropin and sex steroid levels. Because early in puberty gonadotropin production is nocturnal, it is optimal to check basal levels with a first morning sample, using a third-generation assay, which is sensitive enough to detect the lower ranges of LH, FSH, estradiol, or testosterone seen at the onset of puberty [20]. If these levels, particularly LH, are below the detectable limit of the assay, puberty is not yet present, and if the levels are above the detectable level of the

9  Medical Management of the Adolescent Individual with Gender Dysphoria

assay, this indicates puberty has begun [20]. However, in early puberty even early morning measurement of LH may not confirm the biochemical rise. In these cases, a leuprolide stimulation test can be used to confirm pubertal onset [peter lee reference pediatrics 2009]. Evaluation of bone age to assess skeletal maturation, and as a proxy of exposure to sex steroids, can also be helpful.

GnRH Agonists In the 1980s, long-term GnRH agonists (GnRHa) were developed. Chronic administration of the GnRHa, rather than the typical physiologic pulsatile secretion of GnRH, resulted in suppression of gonadotropin secretion [21]. This revolutionized care of central precocious puberty as GnRHa was shown to be a safe and effective treatment to suppress central precocious puberty in girls and boys [22]. Use of GnRHa for central precocious puberty has been shown to suppress the pituitary-gonadal axis, decrease sex steroid production to prepubertal levels, halt pubertal development, and decrease growth velocity and rate of bone maturation [23]. In precocious puberty, many GnRHa are available for treatment, depending on the country [24]. In the United States, leuprolide and histrelin are most commonly used. Leuprolide is available as an intramuscular depot formulation administered every 1–3 months [24]. Histrelin is a subcutaneous implant which delivers a therapeutic dose for at least 1  year but likely 2  years [25]. Adverse effects of GnRHa have been relatively mild. Girls may experience withdrawal vaginal bleeding after the initial dose of the GnRHa. It can be helpful to them and their families to warn them of this possibility before use. In addition, symptoms likened to menopause, including nausea, hot flashes, headache, and emotional lability have been reported [24]. Cutaneous effects including erythema, induration, and sterile abscess are reported in 3–13% [24]. Finally, spontaneous implant extrusion has been reported with histrelin [25]. Decreased linear growth velocity and increase in weight have also been reported [26].

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Gonadotropin-Releasing Hormone Agonist Treatment Youth with gender dysphoria can be treated with a GnRHa for pubertal suppression at the onset of development of secondary sexual characteristics [2]. This fully reversible treatment allows them time to reflect on their gender dysphoria without the distress caused by further development of undesired physical characteristics associated with their endogenous hormone production [27]. Otherwise, the physical changes of puberty can be difficult or impossible to reverse. The only treatment for voice deepening, for example, is voice training which can modulate, but not reverse the change [28]. Other changes, like breast development, require surgery to reverse. As the individual ages, this will likely make it easier for the person to “pass” as their affirmed gender. Studies on the long-term outcome of pubertal suppression are limited, although psychological functioning does seem to be improved. In one evaluation, 55 transgender adolescents were treated with pubertal suppression (average age 14.8  years), followed by gender-affirming hormones (average age 16.7  years) and underwent sex reassignment surgery (average age 19.2 years). Gender dysphoria and psychological functioning were assessed before each treatment and at least 1 year after surgery [29]. Overall, in young adulthood, gender dysphoria was alleviated and psychological functioning improved. None of the participants reported regret for having chosen any of the treatments. It is important to note, however, that gender dysphoria did not remit with pubertal suppression treatment. It is postulated that this is because the body remains appearing more as the natal sex rather than the affirmed gender [29]. Another study of 201 adolescents treated with psychosocial support and/or pubertal suppression showed improvement in gender dysphoria and psychosocial functioning in both groups, but significantly greater improvement in those treated with psychosocial support and pubertal suppression [30]. While use of pubertal suppression is a relatively new treatment modality in this population, 22-year follow-up is available in one individual who began treatment

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with a GnRHa at 13 years, began androgen treatment at age 17 years, and underwent gender reassignment surgery at 20 years. He was reported to have no regret, to be functioning well psychologically, and to be in good health [31]. Potential adverse effects of treatment with pubertal suppression include detrimental effects on bone mineral density, unknown effects on brain development, and infertility. While children treated with GnRHa for precocious puberty have normal bone mass at adult height attainment, there is concern for gender dysphoric youth for whom treatment begins and continues at older ages [32]. Again, data on the effects of treatment is limited. Thirty-four adolescents with gender dysphoria treated with GnRHa therapy were followed in a longitudinal observational study, evaluating bone density. On average, they began GnRHa monotherapy at age 15  years (duration about 1.5  years), began gender affirming hormones at age 16.5 years, and underwent sex reassignment surgery after age 18  years. Bone mineral density was assessed using dual-energy X-ray absorptiometry (DXA) before initiating GnRHa, before initiating gender affirming hormones, and at age 22 years old. Between the start of GnRHa therapy and 22 years old, the lumbar bone mineral density z-score decreased significantly for transwomen and there was a trend toward a decrease in transmen, suggesting that attainment of peak bone mass was attenuated or at least delayed [32]. It is not known, however, whether this decrease will result in clinically significant in future fracture risk, and further study is needed. As mentioned earlier, significant neurodevelopment occurs during puberty. It has been questioned whether the use of GnRHa impacts development of executive functioning, therefore affecting an individual’s ability to make complex life decisions. Again, data is limited, but in a functional MRI study of 41 adolescents with gender dysphoria, no differences were found in executive functioning between those who were treated with GnRHa and those who were not [33]. Not only dose GnRHa pause the external development of secondary sexual characteristics, it simultaneously pauses the maturation of gam-

J. L. Miller and C. Finlayson

etes in the gonads. During puberty, primary oocytes undergo meiosis and spermatogonia undergo mitosis and meiosis to become secondary oocytes and sperm. By pausing puberty, this development is also paused and thus may affect an individual’s future biological fertility potential. If GnRHa treatment is discontinued, puberty will resume and gametes will mature. If, however, an individual continues GnRHa treatment and begins gender-affirming hormones, they may be infertile with existing fertility preservation technology [34]. As reviewed above, Tanner 2 pubertal development may normally occur at a broad range of ages, from as early as 8 years old in natal females to as late as 14 years in natal males. It is not recommended to prevent pubertal onset as the peripubertal period is considered a critical diagnostic stage [29]. Thus, it is recommended to confirm pubertal development by physical examination and serum analysis. In addition, prior to initiation of GnRHa, baseline DXA, and bone age are recommended. Programs caring for gender non-­ conforming youth vary in their models of care and approach to initiation of treatment. Some require letters of readiness from mental health providers and a formal consent process, whereas others may not [35]. Discussion of the potential side effects of GnRHa, including infertility, is important. Recommendations for monitoring while taking GnRHa are limited. Clinically, it is important to evaluate for adequate pubertal suppression by history and physical examination (including linear growth velocity and development of secondary sexual characteristics). In practice, many practitioners monitor serum gonadotropins, sex steroids, creatinine, and liver function tests, but in a recent study of safety and efficacy, this did not seem to be necessary [36]. Monitoring of bone age and bone density, via DXA, is recommended [36]. The ideal duration of GnRHa treatment is unknown. GnRHa treatment is generally continued at least until the individual begins ­ gender-­affirming hormone treatment. Continuing the GnRHa while beginning hormone treatment may help to decrease the dose of gender-affirming hormone needed for desired transition, poten-

9  Medical Management of the Adolescent Individual with Gender Dysphoria

tially decreasing risk of side effects, but data is lacking. Furthermore, whether continuing GnRHa throughout treatment with gender affirming hormone is helpful is unknown. Anecdotally, many providers note that continuing GnRHa is clinically helpful, particularly for transwomen. There is evidence that orchiectomy may be protective for metabolic health in transwomen [37]. By extension, if GnRHa treatment has a similar effect to orchiectomy, the continued use may be recommended. In patients who present after their endogenous puberty has been completed, GnRHa may not be the best option and is certainly not the only option, particularly to suppress menses in transmen. GnRHa is more expensive than other options, such as continuous combination oral contraceptive pills (OCPs) or every 3-month medroxyprogesterone acetate (MPA) injection. However, many transmen are uncomfortable taking a medication containing estrogens, as in OCPs, and both OCPs and MPA can have the undesirable side effect of possible breakthrough bleeding.

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situation, sex steroid treatment aims to mimic typical pubertal development with gradual development of secondary sex characteristics. Estrogen or testosterone is initiated a very low dose and increased progressively. Potential risk factors of these medications are similar to those in adults and reviewed in the chapter pertaining to use of gender affirming hormone.

Conclusion The medical care of gender non-conforming and transgender youth is a field in evolution, as we learn more about the physical, mental, and psychosocial needs of this population. At this time, GnRHa treatment is recommended at the onset of pubertal development to prevent undesired secondary sex characteristics and allow time to explore gender nonconformity. Initiation of cross-sex hormone treatment is individualized and can be started at or before age 16  years to mimic the normal puberty of one’s peers. Further study of the long-term effects of these treatments is needed.

Gender-Affirming Hormone Treatment

References

The next phase of medical transition for adolescents is to begin gender-affirming hormone treatment. The original Endocrine Society Guidelines recommend these be “initiated at about the age of 16 years” [2], but the revision in 2017 stated that there may be compelling reasons to start treatment prior to the age of 16 years although there was little data available about treatment in individuals before 13.5–14 years old [3]. In practice, treatment may be started at earlier ages, depending on the clinician. Some argue that earlier treatment is preferred to allow adolescents to mature at a similar rate to peers and to decrease potential side effects such as lower bone density. For those who have progressed through puberty in their natal sex, not having been treated with GnRHa to suppress puberty, treatment mirrors that in adults. For those who have used GnRHa treatment to suppress puberty, the protocol differs. In this

1. Shumer DE, Spack NP. Current management of gender identity disorder in childhood and adolescence: guidelines, barriers and areas of controversy. Curr Opin Endocrinol Diabetes Obes. 2013;20(1):69–73. 2. Hembree WC, et  al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132–54. 3. Hembree WC, et  al. Endocrine treatment of gender-­ dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. Endocr Pract. 2017;23(12):1437. 4. Dunkel L, et  al. Developmental changes in 24-hour profiles of luteinizing hormone and follicle-stimulating hormone from prepuberty to midstages of puberty in boys. J Clin Endocrinol Metab. 1992;74(4): 890–7. 5. Albertsson-Wikland K, et  al. Twenty-four-hour profiles of luteinizing hormone, follicle-stimulating hormone, testosterone, and estradiol levels: a semilongitudinal study throughout puberty in healthy boys. J Clin Endocrinol Metab. 1997;82(2):541–9. 6. Bergada I, et  al. Time course of the serum gonadotropin surge, inhibins, and anti-Mullerian hormone in

74 normal newborn males during the first month of life. J Clin Endocrinol Metab. 2006;91(10):4092–8. 7. Forest MG, et  al. Hypophyso-gonadal function in humans during the first year of life. 1. Evidence for testicular activity in early infancy. J Clin Invest. 1974;53(3):819–28. 8. Bidlingmaier F, et  al. Testosterone and androstenedione concentrations in human testis and epididymis during the first two years of life. J Clin Endocrinol Metab. 1983;57(2):311–5. 9. Abreu AP, et al. Central precocious puberty caused by mutations in the imprinted gene MKRN3. N Engl J Med. 2013;368(26):2467–75. 10. Havelock JC, Auchus RJ, Rainey WE.  The rise in adrenal androgen biosynthesis: adrenarche. Semin Reprod Med. 2004;22(4):337–47. 11. Marshall WA, Tanner JM.  Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44(235):291–303. 12. Himes JH.  Examining the evidence for recent secular changes in the timing of puberty in US children in light of increases in the prevalence of obesity. Mol Cell Endocrinol. 2006;254–255:13–21. 13. Lifshitz F. Pediatric endocrinology. 5th ed. New York: Informa Healthcare; 2007. 14. Largo RH, Prader A. Pubertal development in Swiss boys. Helv Paediatr Acta. 1983;38(3):211–28. 15. DeGroot LJ, Jameson JL.  Endocrinology: adult and pediatric. 6th ed. Philadelphia: Saunders/Elsevier; 2010. 2 volumes 16. Siegel SF, et  al. Premature pubarche: etiologi cal heterogeneity. J Clin Endocrinol Metab. 1992;74(2):239–47. 17. Jameson JL. Endocrinology: adult & pediatric. 7th ed. Philadelphia: Elsevier Saunders; 2016. 2 volumes (xvii, 2687, 77 pages) 18. Blakemore SJ, Choudhury S.  Brain development during puberty: state of the science. Dev Sci. 2006;9(1):11–4. 19. Taylor DJ, et  al. Sleep tendency during extended wakefulness: insights into adolescent sleep regulation and behavior. J Sleep Res. 2005;14(3):239–44. 20. Houk CP, Kunselman AR, Lee PA.  Adequacy of a single unstimulated luteinizing hormone level to diagnose central precocious puberty in girls. Pediatrics. 2009;123(6):e1059–63. 21. Boepple PA, et al. Use of a potent, long acting agonist of gonadotropin-releasing hormone in the treatment of precocious puberty. Endocr Rev. 1986;7(1):24–33. 22. Styne DM, et al. Treatment of true precocious puberty with a potent luteinizing hormone-releasing factor agonist: effect on growth, sexual maturation, pelvic sonography, and the hypothalamic-pituitary-gonadal axis. J Clin Endocrinol Metab. 1985;61(1):142–51. 23. Roger M, et  al. Long term treatment of male and female precocious puberty by periodic administration

J. L. Miller and C. Finlayson of a long-acting preparation of D-Trp6-luteinizing hormone-releasing hormone microcapsules. J Clin Endocrinol Metab. 1986;62(4):670–7. 24. Antoniazzi F, Zamboni G.  Central precocious puberty: current treatment options. Paediatr Drugs. 2004;6(4):211–31. 25. Silverman LA, et al. Long-term continuous suppression with once-yearly Histrelin subcutaneous implants for the treatment of central precocious puberty: a final report of a phase 3 multicenter trial. J Clin Endocrinol Metab. 2015;100(6):2354–63. 26. Mouat F, et  al. Initial growth deceleration during GnRH analogue therapy for precocious puberty. Clin Endocrinol. 2009;70(5):751–6. 27. de Vries AL, et al. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276–83. 28. Rosenthal SM. Transgender youth: current concepts. Ann Pediatr Endocrinol Metab. 2016;21(4):185–92. 29. de Vries AL, et  al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696–704. 30. Costa R, et al. Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. J Sex Med. 2015;12(11):2206–14. 31. Cohen-Kettenis PT, et  al. Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up. Arch Sex Behav. 2011;40(4):843–7. 32. Klink D, et  al. Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J Clin Endocrinol Metab. 2015;100(2):E270–5. 33. Staphorsius AS, et  al. Puberty suppression and executive functioning: an fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology. 2015;56:190–9. 34. Finlayson C, et  al. Proceedings of the working group session on fertility preservation for individuals with gender and sex diversity. Transgend Health. 2016;1(1):99–107. 35. Chen DH, Hidalgo MA, Leibowitz S, Leininger J, Simons L, Finlayson C, Garofalo R. Multidisciplinary care for gender-diverse youth: a narrative review and unique model of care. Transgender Health. 2016;1(1):117–23. 36. Schagen SE, et al. Efficacy and safety of gonadotropin-­ releasing hormone agonist treatment to suppress puberty in gender dysphoric adolescents. J Sex Med. 2016;13(7):1125–32. 37. Nelson MD, Szczepaniak LS, Wei J, Szczepaniak E, Sanchez FJ, Vilain E, Stern JH, Bergman RN, Bairey Merz CN, Clegg DJ. Transwomen and the metabolic syndrome: is orchiectomy protective? Transgender Health. 2016;1(1):165–71.

Male-to-Female Breast Augmentation and Body Contouring

10

Thomas Satterwhite and Stelios C. Wilson

Introduction Gender dysphoria is characterized by marked emotional and social distress caused by a discrepancy between an individual’s gender identity and their assigned sex [1]. The care for this patient population requires a multidisciplinary approach [2]. Although not all patients with gender dysphoria require surgical intervention, gender confirmation surgery continues to be recognized as one of the optimal treatments for this patient population [3]. With progressive societal acceptance, public discourse, and improvement in insurance coverage, an increasing number of individuals will seek appropriate care. Thus, practitioners who care for transgender individuals should be aware of the surgical procedures commonly performed. The World Professional Association for Transgender Heath (WPATH) is an international, multidisciplinary society that establishes the standards of care (SOC) and criteria for medical professional who care for transgender patients [4]. Prior to surgical intervention of

T. Satterwhite (*) Align Surgical Associates, Inc, San Francisco, CA, USA S. C. Wilson Hansjorg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, NY, USA e-mail: [email protected]

transwomen (transgender women), the diagnosis of persistent gender dysphoria is required. Specifically, a referral letter from a mental health professional is required for breast augmentation (compared to two referral letters for genital surgery) documenting legal age, capacity to consent, and appropriately controlled concomitant mental health diagnoses. While not specifically addressed by WPATH SOC, some providers will also require a mental health referral for body contouring procedures. Hormone therapy is often recommended for 1 year prior to gender confirmation surgery. This is especially helpful for breast augmentation to allow for tissue growth and fat redistribution but is not required, especially given that not all patients choose to undergo hormone therapy. Hormone therapy for transgender woman generally involves both estrogen and anti-androgen medications, like spironolactone [5]. The goal of hormone therapy is to achieve feminization and reduce virilizing effects of endogenous testosterone [5]. Specifically, these medications are used to induce breast development, reduce male pattern hair growth, and alter fat distribution patterns [2]. Unfortunately, these medications have been implicated with increased risk of venous thrombosis, cerebrovascular disease, and myocardial infarctions. However, they have never been shown to elevate cancer prevalence or overall mortality rates [6]. Taken together, hormone therapy with proper physician supervision and

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_10

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76 Table 10.1  Surgical options for transgender women Chest/breast  Breast augmentation Body (abdomen, flanks, buttocks)  Contouring procedures

Head and neck  Facial feminization  Thyroid cartilage reduction  Vocal cord surgery Genital  Penectomy/ orchiectomy  Vaginoplasty

when not medically contraindicated has become the standard of care for transgender women [6]. Surgical options for transgender women include, but are not limited to, breast augmentation, vaginoplasty, facial feminization, thyroid cartilage reduction, vocal cord surgery, and body contouring procedures (Table  10.1) [7–10]. For the context of this chapter, we will discuss breast augmentation and body contouring procedures.

Preoperative Care and Medications A complete history and physical should be obtained. Careful attention should be paid to assess for a history of diabetes, heart or lung disease, immunosuppression or immunosuppressive conditions. For patients seeking breast augmentation, a specific history of prior chest surgery or chest radiation therapy should be elicited. Although there are no clear standards, it is our practice to obtain preoperative mammograms in patients age 40 or older or those with a strong family history of breast cancer. Given the lack of data to support this algorithm and the potentially traumatic experience of going to a mammography center that does not routinely care for this patient population, we only refer our patients to trans-friendly providers and environments. For patients seeking body contouring procedures, any history of abdominal surgery or pelvic radiation should be documented. In addition, it is important to elicit any possible history of coagulopathy or bleeding disorders. Smoking status should be ascertained, as individuals should be instructed to abstain from

all nicotine products for 4 weeks prior to surgery and 4 weeks after surgery. In the author’s practice, if there is a concern that a patient continues to smoke, a formal nicotine panel is ordered with standard preoperative labs. There is evidence to suggest an increased risk of deep venous thrombosis in transgender women taking hormone therapy [2]. In our practice, we educate our patients on these risks, but we do not routinely ask our patients to stop taking these medications in the preoperative or perioperative period. Anecdotally, we have seen a negative emotional and physiologic changes experienced by the patient. However, for extensive body contouring procedures, we may hold estrogen at the time of surgery. We prefer our patients to avoid aspirin and other antiplatelet medications if not contraindicated although this discussion occurs on a case-by-case basis.

Breast Augmentation Breast Augmentation Background For transgender women, the acquisition of a female appearance is essential to help ameliorate the incongruity between an individual’s gender identity and their assigned sex. A feminine-­ appearing chest is one of the most obvious characteristics necessary for the transfeminine transition [11]. Thus, it is not surprising that this is one of the first, and sometimes only, surgical procedures that transgender women undergo. Although individuals typically first initiate hormone therapy which induces mammary hypertrophy, exogenous hormone therapy has been shown to have a wide range of responses in male mammary tissue [12]. Thus, the majority of individuals will ultimately need additional volume and contouring. In fact, one group quantified that nearly 70% of the transgender women in their series ultimately underwent breast augmentation [13]. Given that breast augmentation is an operative procedure and caries both short-term and long-term risks, it is important to understand the benefits of the procedure. Studies have confirmed

10  Male-to-Female Breast Augmentation and Body Contouring

that breast augmentation in transgender women improves breast satisfaction, and psychosocial and sexual well-being, and is thus a clinically meaningful and medically necessary operation [13, 14].

 ifferences in Male and Female D Chests There are notable anatomic differences between male and female chests, many of which cannot be overcome with current breast reconstructive procedures. Males tend to have wider chests with great distances between nipple-areolar complexes (NACs). This will lead to a tradeoff between medial fullness and NAC placement during augmentation. In most cases, the implant is centered behind the NACs. Patients should be counseled that this could cause more laterally displaced nipples than the average female patient. In addition, the wider sternum will also allow for limited cleavage in most transgender females. The implant can be positioned slightly more medial to attempt to correct this finding as long as the patient understands that her NACs will be even more laterally displaced. Although fat grafting to the medial breasts after augmentation can help smooth and fill the medial breast, transgender women may not be able to obtain sufficient feminine cleavage. This must be discussed if their goal is to be able to wear low-cut clothing. To help camouflage, the use of certain “push up” bras can elevate the breasts medially to help narrow the cleavage while wearing clothing. Taken together, the patient must be aware of these limitations prior to proceeding with augmentation. In addition, there are also differences between male and female NACs with men having smaller, more ovoid areolas compared to round, feminine areolas [15, 16]. In our experience, male nipples tend to become rounder once the overlying tissue is placed on stretch from the underlying prosthesis. If a patient is still unhappy with their NACs following augmentation, tattooing can be performed to help create larger, rounder areolas.

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 reast Augmentation Preoperative B Assessment As previously mentioned, the WPATH SOC recommends at least one referral letter from a mental health professional prior to chest/breast surgery (Table 10.2) [4]. While some argue that this requirement places undue strain on individuals during an already stressful process, it is important to adhere to current WPATH SOC guidelines and request appropriate medical-legal documentation [17, 18]. After an appropriate referral letter has been obtained and patients are compliant with the surgeon suggested feminizing hormone treatment, the patient is ready for surgical planning. All aspects of the procedure should be explained and the patient should be properly educated. Specifically, the patient should be walked through the preoperative, perioperative, and postoperative courses. In addition to medical preoperative assessment, standard breast measurements should be performed including breast base width, nipple to inframammary fold (IMF) distance, and both upper and lower pole pinch test. Asymmetries should be pointed out to the patient with the explanation that any underlying asymmetries of the chest, breast, or nipples will likely be accentuated by a breast augmentation procedure. The patient should understand the risks of this proceTable 10.2  The WPATH SOC recommends a referral letter containing the following 1. The client’s general identifying characteristics. 2. Results of the client’s psychosocial assessment, including diagnoses. 3. The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date. 4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery. 5. A statement that informed consent has been obtained from the patient. 6. A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

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dure that include, but are not limited to, postoperative pain, loss of nipple sensation, ­ hypersensitivity, hematoma, seroma, infection, asymmetries, implant malposition or rupture, capsular contracture and need for revisionary procedures both in the short term and the long term. Ultimately, the patient will need to understand that this procedure will not necessarily resolve gender dysphoria, but can improve it. Most of the preoperative decisions regarding implant pocket location, implant type and size, optimal location of the IMF, and incision location are based around well-cited articles from the esthetic surgery literature [19–21]. In general, our patients will most often have minimal glandular tissue, even after 1  year or more of hormone therapy. We have found that we rarely have greater than 2.0  cm of tissue thickness in the upper pole. In addition, we often do not have greater than 0.5 cm of tissue at the IMF. Based on the these measurements, we find it necessary to do a true subpectoral reconstruction in the majority of our patients [19]. While the pectoralis major is thicker than that generally found in women, we have found this pocket location to yield both safe and reproducible results. While many types of implants have been described, our team prefers to use silicone gel form-stable implants. We use these implants in a similar fashion as they have been described in the literature [22]. Given the lack of overlying breast tissue in transgender women and our patient’s preference for natural appearing breasts, we have found continued success using these prosthetics. Overall, the surgeon must still assess each patient’s preferences, expectations, and goals when deciding on specific implants. Based on our patient population, it would not be unusual to have a base width greater than 15 cm with a relatively short, constricted IMF that can be reconstructed in a natural way using low- or moderate-profile anatomic silicone gel devices. Based on the authors’ experience, the relatively tight pocket in the majority of patients makes high-profile implants suboptimal. Ultimately, the size of the implant will be based primarily on the patient’s breast diameter. With the short nipple to IMF distance and a very tight lower pole, the

T. Satterwhite and S. C. Wilson

IMF will typically need to be lowered based on the aforementioned characteristics for optimal results [19]. Prior to surgery, the patient is a marked in the following fashion (Fig.  10.1). First, the chest midline is marked. Next, each of the native IMFs is marked. The breast diameters are confirmed to ensure proper implants are available prior to starting the operation. A 3  cm zone is clearly marked between the base markings over the sternum that is not violated as a way to preserve the medial breast architecture and prevent medial implant migration and symmastia. As previously mentioned, the IMF will likely need to be lowered given the larger base diameters found in transgender females and their short nipple to IMF distance. Using a combination of the base diameter, pocket stretch, and native IMF, a new IMF can be calculated and marked accordingly [19].

 reast Augmentation Surgical B Approach There are many techniques described for both primary breast augmentation and implant-based breast reconstruction. Unfortunately, there is much less available describing breast augmentation in transgender women. In this section, we will describe the technique commonly used by the senior author that is a combination of the aforementioned research and years of clinical experience. Once in the operating room, cefazolin is dosed in a weight-based manner and readministered per previously described guidelines [23]. The patient is brought into the operating room and a time out is performed confirming the correct patient, site, operation, preoperative markings, and equipment necessary. The patient is then placed supine on the operating table with arms abducted to 90 degrees. Kerlex is used to circumferentially wrap the arms to the arm boards once it is confirmed the patient’s hips are situated over the flex in the bed; both measures taken to allow the patient to sit up for intraoperative assessment. The patient is then secured and grounded, and proper deep venous thrombosis

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1 cm

1 cm

Original IMF

12 cm

12 cm

Marking for Pocket Dissection

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Lowered IMF 5 cm

5 cm

Fig. 10.1  Standard breast augmentation preoperative markings

prophylaxis is initiated [24]. If not medically contraindicated, we typically prefer to perform this procedure under general anesthesia. After induction of anesthesia, the patient is prepped with chlorhexidine from the umbilicus to the base of the neck. Local anesthesia is infiltrated as a field block in the location of the inframammary incision. The patient is then draped in the standard, sterile fashion. Semiocclusive dressings are used as nipple shields over the entire areola to prevent possible bacterial contamination [25]. The 5 cm access incision is made at the level of the new IMF which, in most circumstances, will need to be below the native IMF (Fig. 10.1). In general, this incision and subsequent dissection should not occur below the new IMF as this will weaken the lower support of the implant and may predispose a patient to implant migration and/or double bubble deformity [22]. In the authors’ experience, patients will tolerate an incision that rides up slightly onto the breast mound much better than one below the chest that will be visible in a bathing suit or brassiere. Once through the skin, dissection is performed with electrocautery through the subcutaneous tissue to the pectoralis fascia. Dissection is continued below the pectoralis major with the help of a

lighted retractor. Care is taken to dissect a pocket to the exact dimensions of the previously chosen implant as to avoid possible implant migration or rotation. Once the pocket is properly defined, hemostasis is attained and the pocket is irrigated with triple antibiotic solution as previously described [26]. While the preferred implant is generally chosen during the preoperative consultation, occasionally there is some degree of uncertainty leading to intraoperative surgeon discretion. For these instances, saline or gel sizers can be used. If sizers are utilized, care must be taken to insert and remove these sizers carefully to prevent over dissection of the pocket. In addition, the surgeon should be critical of the skin envelope and tension on the medial breast borders that may predispose a patient to medial migration and symmastia. In rare instances, mildly relaxing the lateral pocket will help accommodate a larger implant without placing unwanted forces medially, but overall, the size of the implant will more likely be limited by the skin envelope. A Keller funnel is typically used for insertion, since implants can be relatively large. Although not typically performed in our practice, a 3 point fixation stitch with 3.0 PDS may be used to tack Scarpa’s at the level of the new IMF to the chest

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wall to prevent downward migration of the implant. The wound is then closed in layered fashion using 3–0 monocryl for the Scarpa’s layer and the deep dermal layer and 4–0 monocryl for the subcuticular closure. Steristrips are placed over the incision and then a semiocclusive dressing is placed.

 reast Augmentation Postoperative B Care At the conclusion of the procedure, a circumferentially placed ace-wrap is used for compression. When not medically contraindicated, this procedure is performed in the outpatient setting with the patient being sent home several hours after the procedure. The patients are instructed to keep the ace-wrap and incisions dry until follow-up in 5–7  days. At follow-up, the patients are instructed to wear a sports bra for the next 4–6 weeks. During this time, strenuous activity should be avoided to prevent implant migration. Patients are instructed to abstain from reaching, pulling, or lifting anything heavier than a gallon of milk during this time. At 3 weeks, the steristrips have generally fallen off and the patients are instructed to massage the scars with silicone-based cream to attempt to minimize hypertrophic scarring. Typical long-term results are seen in Fig. 10.2.

Breast Augmentation Complications It is difficult to quantify complications in breast augmentation in this specific patient population. Instead, we defer to the cosmetic surgery literature to give our patients a sense of the likely risk profile. Specifically, we mention the risk of capsular contracture, hematoma, seroma, rupture, infection, scarring, and NAC sensation changes [27]. We also mention the reported but very low risk of breast implant-associated anaplastic large-­ cell lymphoma (ALCL) [28]. Needless to say, research is needed to more accurately quantify risk for transgender women undergoing breast augmentation.

 reast Augmentation Postoperative B Considerations As previously mentioned, there have been no associations between hormone therapy and cancer risk or mortality [6]. Still, we recommend our patients to follow national guidelines for breast cancer screenings following breast augmentation in addition to gender-specific medical maintenance [29]. Given that our patients may undergo reconstruction with textured silicone devices, we educate such patients on the signs and symptoms of ALCL and stress the importance of regular MRI surveillance for rupture starting 3  years after reconstruction and every 2 years thereafter.

 reast Augmentation Additional B Approaches While our results have been promising based on one-stage implant-based augmentations, there may be a utility for a two-staged approach with tissue expansion. In our practice, we have yet to encounter the need, but, in theory, this strategy could be beneficial for patients with thin skin and subcutaneous tissue, little breast parenchyma, and a hypertrophied pectoralis major. Fat grafting can be considered for patients who are averse to implants and are content with having only modest gains. Also, fat grafting may prove to be a powerful adjunct for this patient population, especially when attempting to create more cleavage in wide-chested individuals.

Body Contouring Body Contouring Background For many transgender women, gender confirmation surgery involves not only breast augmentation, but also feminization of other aspects of their body. One of the other areas of recent interest in this population’s transition is body contouring with specific attention being paid to the abdomen, flanks, hips and buttock

10  Male-to-Female Breast Augmentation and Body Contouring

regions. As previously mentioned, estrogen and anti-­ ­ androgen therapies stimulate growth of mammary tissue. In addition, these therapies have an effect on other tissues throughout the body. Specifically, estrogen is thought to deposit adipose tissue preferentially in the gluteofemoral region while testosterone is thought to stimulate adipose deposition in the abdomi-

Fig. 10.2  Breast augmentation before and after

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nal region [30]. MRI evidence of transgender men and women has confirmed these changes in early as 12 months after initiating hormone therapy [31]. Still, even with hormonal therapy, there are marked differences between transgender women and cisgender women, some of which can be ameliorated with body contouring procedures.

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Fig. 10. 2 (continued)

 ifferences in Male and Female Body D Habitus Fat distribution in humans is a multifactorial process with general trends for both age and genetic sex. The iconic representation of the ideal female body as having an “hourglass” figure has withstood the test of time (Figs. 10.3 and 10.4) [32]. Some argue that the evolutionary psychology that an hourglass figure offers important favorable biologic information to potential mates regarding a woman’s reproductive potential [33]. A widely used anthropometric measurement technique to discuss the narrowest point between the iliac crests and the base of the ribs (waist) and the widest portion at the level of the buttocks (hip) to calculate a waist-to-hip ratio (WHR). The basis of this measurement is based on combination of adipose quantity, adipose deposition patterns, and underlying bony architecture. During infancy and early childhood, fat distribution patterns are very similar for both men and

women. After puberty, men tend to undergo an android fat distribution pattern with increased volume of both intraabdominal and subcutaneous fat of the abdomen and flanks [34]. In contrast, women tend to undergo a gynoid fat distribution with lower levels of fat deposited in the abdomen and a greater amount in the gluteal region and hips [34]. The typical range of WHR for healthy young adult women has been shown to be 0.67– 0.80 compared to healthy young men with a range of 0.85–0.95 [35]. Interestingly, following menopause, the WHR of women becomes closer to that of age-adjusted male counterparts [36]. Although somewhat subjective, many studies looking at both contemporary cross-cultural and historic artistic representations mention an ideal WHR to be approximately 0.7 [32]. One review looked at studies that analyzed everything from recent playboy centerfolds to ancient Greek and Egyptian sculptures as evidence to support this claim [32]. Taken together, body contouring in transgender females should aim to better establish this ratio.

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Fig. 10.3  Difference in female and male boney structure. In general, women have more obtuse subpubic c angles, wider pelvic brims, and flared iliac crests

Ilium Sacrum Pubic outlet Ischial spine Coccyx Pubic arch

Male

There are also differences in male and female gluteal forms. Gynoid bodies tend to have more adipose deposition in the gluteal region with a distinct transition from the lower back. Also, the mid-lateral portion of gynoid buttocks tend to have a fuller, rounder, shape while a defining characteristic of the android buttock shape, not to be diminished with regard to goals of this procedure, is that the mid-lateral portion of the android buttocks can be flat or even have a distinct concavity (Fig. 10.4).

Female

Finally, there are differences in male and female pelvises. Overall, there are few characteristics of the bony architecture that helps strengthen the aforementioned differences in WHR between men and women. Women have more obtuse subpubic angles, wider pelvic brims, and flared iliac crests (Fig.  10.3) [37]. Unfortunately, it is unlikely that the bony architecture will remodel in any meaningful way with hormone therapy and surgical reconstruction would be excessively morbid. Thus, any

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Fig. 10.4  Difference in female and male gluteal forms. In general, gynoid bodies tend to have more adipose deposition in the gluteal region with a distinct transition from the lower back. In addition, the mid-lateral portion of the android buttocks tends to be flat or even has a distinct concavity

a­ lteration to camouflage these differences will have to occur with soft tissue reduction and augmentation.

history and physical as previously described should be performed. It is important for the patient to be aware of the differences in male and female body types (Figs.  10.3 and 10.4). This understanding will Body Contouring Preoperative allow the patient to appreciate the individualized Assessment starting point, the goals, and the limitations of body contouring. Body contouring in transgender Unlike traditional body contouring procedures females will be a balance between skin elasticity following massive weight loss or pregnancy-­ and contour discrepancy. Ultimately, we will not associated changes, body contouring for trans- be able to change the underlying bony architecgender women requires special consideration. ture. Instead, the surgeon must try to feminize the Our authors recommend waiting to perform these body form by attempting to establish as much of procedures until at least 1  year after initiating a waistline as possible and to improve the shape hormone therapy and after obtaining preoperative and proportions of the buttocks and hips. evaluation and documentation from a mental Commonly, lipodystrophy occurs in all individuhealth professional as per WPATH guidelines [4]. als but certainly in transgender women, which All aspects of the procedure should be explained, results in a waistline that is usually considerably and the patient should be properly educated. higher than desired. Simply lowering this waistSpecifically, the patient should be walked through line makes significant improvements in contour the preoperative, perioperative, and postoperative and overall shape. This will be especially imporcourses. In addition, a careful preoperative tant for transgender women who seek to fit into

10  Male-to-Female Breast Augmentation and Body Contouring

female clothing that often accentuates this type of waistline. In general, the amount of lipoaspirate obtained is the limiting factor for body contouring procedures in this population. Thus, preoperative and intraoperative decisions on how to best utilize the injectable fat are critical. With a sometimes-­ limited volume of fat to graft, it is important to have esthetic priorities for the use of available volume. In the authors’ opinion, the most important possible improvements in descending order would be: 1. To establish as uniform and properly low waistline as much as possible, and along with this goal, to accentuate the curvature and improve the transition zone better the lower back and the upper buttock area. 2. To improve the shape and roundness of the mid-lateral buttocks which in androgenic bodies is commonly flattened or even concave. 3. To improve the transition between the buttocks and the hips to create width and fullness that is more characteristic of a gynoid silhouette. 4. To improve the overall size, projection, and upper fullness of the buttocks. Prior to surgery, the patient is marked in a way to have an organized plan addressing these improvements. The surgeon sits in front of the patient with the umbilicus at eye level. A line is then made at this level in a horizontal fashion out toward the flanks bilaterally. The patient is then asked to turn 180 and the lines are continued to the center of the back. Ultimately, this is the area where the surgeon will be most aggressive in attempting to establish and new, generally lower, waistline using liposuction. The aggressiveness of lipoaspirate yield will be tapered into the surrounding areas. The next marking is a shadow in the mid-­lateral buttock area, which is often concave in transgender women. Our system utilizes crosshatch pattern markings in the areas of concern as a way to clearly define where volume is needed. In our experience, deficiencies in this area are most easily identified on posterolateral oblique view.

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The final marking is performed on the superior portion of the buttocks to establish the inverted upper heart shape curvature to the superior and mid buttocks. Unfortunately, there are limited landmarks in this region. In patients with visible dimpling in the parasacral area, a line can be drawn from each dimple to the superior most portion of the gluteal cleft creating a V.  These lines can then be smoothed out and continued in a parabolic way to define a round and symmetric superior pole. In addition to adding volume to the area below the markings, liposuction can be performed above the sacrum (above the marked V) and above the lateral markings to better define this transition.

Body Contouring Surgical Approach There are many techniques described for body contouring with liposuction and for gluteal augmentation with fat grafting. Similarly to breast augmentation, there is much less available describing these techniques in transgender women. In this section, we will describe the techniques commonly used by the senior author. In the holding area prior to surgery, the patient is marked as previously described. The patient is then brought into the operating room and started in the supine position. After the skin prep, draping and time out, access incisions are planned and tumescent fluid is infiltrated using a tumescent cannula followed by a waiting period of 20 minutes for the local anesthesia to take effect. Power-assisted liposuction (PAL) is performed under low pressure of 10–20 mmHg and a combination of liposuction cannulas. For trunk liposuction, we will frequently use 3, 4, and 5 mm cannulas with both Mercedes and a basket tips (also known as the birdcage) with larger cannulas being used in deeper planes and basket tips being particularly effective in the more fibrous areas of the lower back and posterior flanks. Fat is collected in a 500  mL assay bottle prior to processing. Once the anterior surface is sufficiently contoured, all stab incisions are closed using 5–0 fast absorbing gut sutures and sterile dressings

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are placed. The patient is then carefully flipped to the prone position. The process of tumescent and liposuction are then repeated on the posterior surface. Once the posterior surface is sufficiently contoured, the lipoaspirate is then poured in a sterile fashion into a stainless steel sieve. A wooden tongue depressor is used to gently mix the lipoaspirate to allow faster straining. Once strained of all excess tumescent fluid and blood, the fat cells are washed by pouring sterile saline into the sieve and again allowing for the fluid to strain. This process is repeated two times, or until all gross blood has been removed. The residual filtered fat is then loaded into 20 mL syringe. Fat grafting is then performed to address, in the aforementioned priority, the previously described deficiencies. Specifically, a combination of 3 mm by 20 cm blunt-tipped cannulas (for superficial injections) and a 3  mm by 15  cm blunt-tipped cannula (for intramuscular injections) is used. Depending on the access incisions used during liposuction, we can often use the same access for fat grafting. In general, we need at least one incision in the sacral region, one in the upper outer buttocks adjacent to the hips and one in each infragluteal crease, which our team tends to place several centimeters lateral to the midline of each buttock as this is where we have found to have the most control grafting both the mid-lateral gluteal region and the hips. Fat grafting is performed slowly and cautiously using only 0.5  mL amount across the entire length of the retreating cannula as it is moved outward through all layers of the tissue to be grafted. We only inject when the cannula is being actively moved, and only on the withdrawal portion of cannula movement, to reduce the degree of intravascular fat injected should the cannula enter a blood vessel lumen during a portion of its trajectory. Grafting is performed in the deep plane first if possible, but if there is a very limited supply of fat, we sometimes will start in the superficial plane where it is most efficient at creating contour. In general, all injections should be performed with a blunt-tipped cannula with the cannula parallel to the operating table or

T. Satterwhite and S. C. Wilson

aimed superficially to avoid potentially dangerous complications. Once satisfied with the patient’s contour or, more likely, when all fat has been used, all stab incisions are closed using 5–0 fast absorbing gut sutures and sterile dressings are placed.

Body Contouring Postoperative Care At the conclusion of the procedure, the patient is placed in a compression garment. At this time, there are no garment manufacturers that produce female body shape garments with the additional genital opening for transgender women who have yet to undergo penectomy/vaginoplasty. For the sake of patient comfort and compliance, we typically use a male compression garment. As with any body contouring procedure, it is imperative for patients to ambulate as quickly as possible. Patients are also told that we want them to move their ankles back and forth “like stepping on a gas pedal” constantly when they are not sleeping or walking during the first 7 days after the surgery. Though anecdotal, we believe this coaching may have played a role in our not having seen a DVT or PE in a body contouring procedure to date. One of the challenges for patients with fat grafting to the buttocks is the restriction in placing their body weight on the grafted areas. This can be especially challenging in transgender women because fat grafting is performed not only in the buttocks but also on the bilateral hips. In these instances, the patients must not sit directly on their buttocks and they must sleep on their abdomen to avoid pressure to the buttocks or hips. This management can be further complicated when patients wish to have a breast augmentation at the same time as the fat grafting procedure. In these instances, we prefer patients to sleep on their sides and to try to turn from side to side as frequently as logistically possible throughout the night. After 2 weeks, patients can sit directly on their buttocks and can sleep without pressure restrictions. Typical long-term results are shown in Fig. 10.5.

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Fig. 10.5  Body contouring before and after

Body Contouring Complications At this point, it is difficult to quantify complications for body contouring performed specifically for gender confirmation purposes. Instead, we defer to the cosmetic surgery literature to educate outpatients on potential risks. For the liposuction portion of the procedure, we explain the risks of skin surface irregularities and possible pigments changes, especially given the aggressiveness in liposuction to obtain optimal results. For the fat grafting portion of the procedure, we explain that a portion of the fat will survive and that this value changes based on both patient characteristics and on the avoidance of postoperative pressure to the grafted areas. With proper postoperative compliance and use of the micro fat grafting technique of 0.5 cc per passage of the cannula length, we experience an 85% maintenance of the injected fat volume long term. In addition to variable graft survival, the patient must understand the risk of gluteal asymmetry, fat necrosis, hematoma, oil cyst formation, infection, seroma, postoperative bruising, DVT, and the rare but possible need for blood transfusion. Further, the patient should be aware of possible injury to the sciatic nerve and also should be

educated on the reported complication of fat embolism. Our technical approach attempts to minimize the risk of these rare, but serious complications. Needless to say, research is needed to more accurately quantify risk for transgender women undergoing body contouring procedures.

 ody Contouring Special B Considerations As previously mentioned, the total amount of fat grafted varies widely between individuals, and especially in our demographic, it is not uncommon for healthy, fairly athletic individuals to have no more than 200 mL per side for us to use as concentrated fat graft. This is why it must be used so judiciously. These challenges underscore the importance of going into the operation with clear goals and objectives. While liposuction will ultimately help with the waistline and the transition between the lower back and the upper buttock, we may only have enough fat to treat one or possibly two areas of concern. For a slender individual with only flank lipodystrophy, we often only have enough fat to address the concavity in the mid-lateral buttock region. In the minority of

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cases, we are also able to address the hips. In larger patients with circumferential subcutaneous trunk excess, we commonly have enough fat to improve upon size, projection, and upper fullness of the buttocks. These potential volume limitations should be conveyed to patients at the preoperative consultation as to set realistic goals and expectations.

Conclusions Breast augmentation and body contouring are powerful tools for transgender women seeking gender confirmation surgery. While most of our current techniques are based from studies reported in the esthetic surgery literature, these patients require special considerations. In addition to highlighting our surgical management, we hope that this chapter brings to light the challenges and limitations of these procedures.

References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). Arlington: American Psychiatric Pub; 2013. 2. Gooren LJ.  Care of transsexual persons. N Engl J Med. 2011;364:1251–7. 3. Selvaggi G, Bellringer J.  Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8:274–82. 4. Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13:165–232. 5. Spack NP.  Management of transgenderism. JAMA. 2013;309:478–84. 6. Weinand JD, Safer JD. Hormone therapy in transgender adults is safe with provider supervision; a review of hormone therapy sequelae for transgender individuals. J Clin Transl Endocrinol. 2015;2:55–60. 7. Colebunders B, Brondeel S, D’Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5:103–9. 8. Berli JU, Capitan L, Simon D, Bluebond-Langner R, Plemons E, Morrison SD. Facial gender confirmation surgery  – review of the literature and recommendations for version 8 of the WPATH standards of care. Int J Transgenderism. 2017;18(3):264–70. 9. Morrison SD, Satterwhite T, Grant DW, Kirby J, Laub DR Sr, VanMaasdam J.  Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female

T. Satterwhite and S. C. Wilson gender reassignment surgery. Plast Reconstr Surg. 2015;136:386–94. 10. Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: systematic review of the literature. Plast Reconstr Surg. 2016;137:1759–70. 11. Seal LJ, Franklin S, Richards C, Shishkareva A, Sinclaire C, Barrett J.  Predictive markers for mammoplasty and a comparison of side effect profiles in transwomen taking various hormonal regimens. J Clin Endocrinol Metab. 2012;97:4422–8. 12. Orentrei N, Durr NP. Mammogenesis in transsexuals. J Investig Dermatol. 1974;63:142–6. 13. Kanhai RCJ, Hage JJ, Asscheman H, Mulder JW.  Augmentation mammaplasty in male-to-female transsexuals. Plast Reconstr Surg. 1999;104:542–9. 14. Weigert R, Frison E, Sessiecq Q, Al Mutairi K, Casoli V. Patient satisfaction with breasts and psychosocial, sexual, and physical well-being after breast augmentation in male-to-female transsexuals. Plast Reconstr Surg. 2013;132:1421–9. 15. Beckenstein MS, Windle BH, Stroup RT. Anatomical position for the nipple position and areolar diameter in males. Ann Plast Surg. 1996;36:33–6. 16. Shulman O, Badani E, Wolf Y, Hauben DJ. Appropriate location of the nipple-areola complex in males. Plast Reconstr Surg. 2001;108:348–51. 17. Salgado CJ, Fein LA.  Breast augmentation in transgender women and the lack of adherence amongst plastic surgeons to professional standards of care. J Plast Reconstr Aesthet Surg. 2015;68:1471–2. 18. Latham J.  Ethical issues in considering transsexual surgeries as aesthetic plastic surgery. Aesthet Plast Surg. 2013;37:648–9. 19. Tebbetts JB, Adams WP.  Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116:2005–16. 20. Adams WP. The process of breast augmentation: four sequential steps for optimizing outcomes for patients. Plast Reconstr Surg. 2008;122:1892–900. 21. Hidalgo DA.  Breast augmentation: choosing the optimal incision, implant, and pocket plane. Plast Reconstr Surg. 2000;105:2202–16. 22. Schwartz MR.  Algorithm and techniques for using Sientra’s silicone gel shaped implants in primary and revision breast augmentation. Plast Reconstr Surg. 2014;134:18S–27S. 23. Platt R, Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med. 1990;322:153–60. 24. Caprini JA. Risk assessment as a guide for the prevention of the many faces of venous thromboembolism. Am J Surg. 2010;199:S3–S10. 25. Hidalgo DA, Sinno S.  Current trends and contro versies in breast augmentation. Plast Reconstr Surg. 2016;137:1142–50. 26. Adams WP, Rios JL, Smith SJ.  Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study (Reprinted from Plast

10  Male-to-Female Breast Augmentation and Body Contouring Reconstr Surg. 117(1):30, 2006). Plast Reconstr Surg. 2006;118:46S–52S. 27. Handel N, Cordray T, Gutierrez J, Jensen JA. A long-­ term study of outcomes, complications, and patient satisfaction with breast implants. Plast Reconstr Surg. 2006;117:757–67. 28. Jewell M, Spear SL, Largent J, Oefelein MG, Adams WP.  Anaplastic large T-cell lymphoma and breast implants: a review of the literature. Plast Reconstr Surg. 2011;128:651–61. 29. Smith RA, Cokkinides V, Brooks D, Saslow D, Brawley OW. Cancer screening in the United States, 2010 a review of current American Cancer Society guidelines and issues in Cancer screening. CA Cancer J Clin. 2010;60:99–119. 30. Rebuffe-Scrive M.  Neuroregulation of adipose tis sue: molecular and hormonal mechanisms. Int J Obes. 1991;15(Suppl 2):83–6. 31. Elbers J, Asscheman H, Seidell J, Gooren L. Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals. Am J Physiol. 1999;276:E317–25.

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32. Singh D. Universal allure of the hourglass figure: an evolutionary theory of female physical attractiveness. Clin Plast Surg. 2006;33:359. 33. Thornhill R, Gangestad SW. The evolution of human sexuality. Trends Ecol Evol. 1996;11:98–102. 34. Singh D.  Adaptive significance of female physical attractiveness: role of waist-to-hip ratio. J Pers Soc Psychol. 1993;65:293. 35. Marti B, Tuomilehto J, Salomaa V, Kartovaara L, Korhonen HJ, Pietinen P. Body fat distribution in the Finnish population: environmental determinants and predictive power for cardiovascular risk factor levels. J Epidemiol Community Health. 1991;45:131–7. 36. Kirschner M, Samojlik E.  Sex hormone metabo lism in upper and lower body obesity. Int J Obes. 1991;15:101–8. 37. Meindl RS, Lovejoy CO, Mensforth RP, Carlos LD. Accuracy and direction of error in the sexing of the skeleton: implications for paleodemography. Am J Phys Anthropol. 1985;68:79–85.

The Importance of Facial Gender Confirmation Surgery

11

Jens Urs Berli and Eric Plemons

 econdary Sex Characteristics S and Their Role in Gender Dysphoria To distinguish the phenotypic sex of a newborn, observers typically inspect the primary external genitalia and pronounce the child female, male, or intersex. As a result of exposure to increased gonadal hormones during puberty, a number of secondary sex characteristics develop (Table  11.1). These include the development of patterned body hair, the presence or absence of breasts, change in muscle mass, and differentiation of the skeleton, including the face and skull. Taken together, secondary sex characteristics are the visible signs of bodily sex; they influence how each of us understands our own sexed embodiment and how others see us in sexed and gendered categories, as well. A person whose gender identity is incongruent with his/her sex characteristics can experience gender dysphoria. Since the earliest formulation of gender dysphoria as a medical disorder in the 1950s, a person’s bodily sex was determined by the primary genitalia. Transsexualism, as the diagnostic entity J. U. Berli (*) Department of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR, USA e-mail: [email protected] E. Plemons School of Anthropology, University of Arizona, Tucson, AZ, USA

was known at the time, was conceived as a mental health dysfunction best treated through endocrine supplementation and surgical reconstruction of the genitalia. This was the “sex” that “sex reassignment surgery” was intended to alter [1, 2]. It was a definition of sex that focused narrowly genital aspects of the patient’s body. Contemporary transgender care emphasizes a consideration of the individual patient’s experience of dysphoria rather than asserting a course of treatment or definition of sex or gender from a clinician’s point of view. The patient-centered approach takes seriously patients’ understandings of their gender dysphoria and their goals for medical transition. First emerging in the USA in the 1990s, two decades of patient-centric care has demonstrated that rather than a narrowly defined genital or endocrine issue, gender dysphoria can be associated with any or all of the sex or gender markers of the body in varying degrees of severity throughout the life course [3]. A shift from clinician- to patient-centered approach has also demonstrated that rather than individual psychological distress associated with discrete body parts  – as early formulations of transsexualism once had it  – the majority of transgender-­ identified individuals identify social stigma, social exclusion, and mistreatment as their main cause of suffering [3]. The US 2016 National Transgender Discrimination Survey revealed that 50% of respondents were harassed on the job, 20% lost

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_11

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92 Table 11.1  Secondary sex characteristics Face  Hairline  Osseous structures  Soft tissues/Skin  Facial hair Musculoskeletal system Fat Vocal cords/Thyroid cartilage Height Eccrine/Apocrine glands Breast gland Body hair

Male Square M shaped; alopecia More pronounced Coarse Abundant/coarse More bulk, larger, more pronounced skeletal system. Larger hands/feet Truncal distribution; higher body fat Larger

Female Oval O Shaped Smoother, more childlike Fine Rare/fine Less muscle mass; less bone mass; smaller hands/feet Pelvic distribution; lower body fat Smaller

Higher Higher secretion

Shorter Lower secretion

Minimal enlargement Proportionally higher in any given ethnicity

Breast growth Proportionally lower in any given ethnicity

or were denied housing due to their gender identity, and 78% of trans students were harassed or assaulted [4]. Other studies confirm similar findings [5, 6]. These negative effects are disproportionately experienced by people whose bodies display sexed characteristics seen to be at odds with their gender presentation. It is not being a transgender person that results in harassment on the street, for example. Negative and sometimes violent attention comes from having a gender-­ nonconforming appearance [5, 7]. This fact makes the value of facial gender confirmation surgery (FGCS) clear.

I mpact of Facial Gender Confirmation Surgery Facial features are among the most recognizable of the secondary sex listed in Table  11.1. They are visible to others in social life and to patients when they look in the mirror. Facial features are also among the hardest secondary sex characteristics to alter or camouflage. While the importance of facial appearance is frequently regarded as common sense, its value for social sex determination is not reflected in current standards of care for transgender patients. The WPATH Standards of Care (Version 7) defines facial surgery as an auxiliary procedure to medical transition, a process whose surgical components focus

on chest and genital reconstruction [8]. This categorization affirms that for the WPATH and the many medical, professional, and advocacy groups who depend on its Standards of Care for guidance, chests and genitals are the most important sites of sexual difference and all other aspects of the sexed and gendered body are auxiliary to them. This is not how any of us experiences sexed and gendered bodies however – our own or anyone else’s. While the surgical prioritization of chests and genitals certainly reflects the preferences and experiences of many transgender surgical patients, it is also the case that the focus on these body parts bears the legacy of the transsexual diagnosis and its associated clinician-­ centric treatment philosophies. These represented a very narrow understanding of what prospective patients wanted from surgical intervention [9–11]. In its current form, the SOC leaves open the therapeutic status of FGCS by acknowledging that in some circumstances, facial procedures may be considered “medically necessary” rather than cosmetic. This vague definition does not reflect the daily experience of individuals whose facial appearance makes them subject to discrimination and harassment, nor those who locate the source of their dysphoria in the distinct and visibly sexed features of their face [5, 6, 12, 13]. As a procedure that alters the sex signifiers of the face, facial gender confirmation surgery

11  The Importance of Facial Gender Confirmation Surgery

(FGCS) aims to transform the social recognizability of the patient. It affirms sex as a social identity by intervening in the social body. We adopt the term FGCS here as a way to acknowledge that the set of procedures aims to confirm a patient’s gender identity. Combining bone and soft tissue procedures, FGCS is a powerful means to alleviate internal and external gender dysphoria, and its efficacy has been confirmed in a variety of studies [14–16]. Except for select case reports and experience by individual providers, the vast majority of FGCS practice and literature focuses on feminizing the face and skull rather than masculinizing it. This is not a surprise since the range of facial structures that are recognized as acceptably masculine or plausibly male is far wider than those recognized as acceptably feminine or plausibly female. As a result, though not exposed to the masculinizing effects of testosterone during puberty, trans men’s faces are more frequently recognized by the man himself and by others to be sufficiently masculine such that surgery is unnecessary. This is especially the case if facial hair is present. As techniques improve and healthcare coverage expands, demand for masculinizing procedures may increase in the future [17]. Trans women whose faces were changed significantly during puberty – widened jaw, larger nose, more prominent chin and forehead, pronounced thyroid cartilage, and male-pattern hairline  – often find that these features render their faces implausibly female to those around them; others see their facial features as a reflection of their male bodily history. Frequently, these women also feel personal dissatisfaction and dysphoria due to their facial features. FGCS intervenes in sex not solely as a property of the patient’s body but also as an identity produced through social interaction and recognition. When others in social life recognize a trans woman as female and treat her as such, her identity as a woman is confirmed. This confirmation constitutes the therapeutic value of FGCS as a treatment for gender dysphoria. To understand FGCS as medically necessary, we must take the effects of social recognition as seriously for

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transgender patients as we do for other non-life-­ saving reconstructive surgery such as that for cleft lip and burn reconstruction, for example. Put simply, it matters how we look to others. While certainly not all negative social interaction associated with gender nonconformity can be prevented by FGCS, early research has shown that it can make a significant improvement in the daily lives of some trans women [15, 16, 18–20]. Validated patient-reported outcome surveys are needed to further bolster the evidence [21].

 istorical Aspects of Facial Gender H Confirmation Surgery FGCS was first developed in the 1980s, when San Francisco-based surgeon Dr. Douglas Ousterhout was presented with a patient who had undergone genital reconstruction surgery but was still recognized by others as male. She wondered if a procedure existed that could feminize her masculine face. At the time, as a surgical category, “the female face” did not yet exist. Finding no guidance from the surgical literature, Ousterhout created his models of sexed facial structure from anthropological research and the metrics of a longitudinal craniofacial growth study from the early twentieth century. Based on these models, Ousterhout developed a set of procedures to transition the patient’s masculine face into a feminine form [22]. His initial focus was on bone reconstruction of the chin, nose, and forehead, and soft tissue modifications of the thyroid cartilage and hairline. He termed the set of feminizing procedures “facial feminization surgery” (FFS), and it remains commonly known as FFS in most medical literature. Administrators of European gender clinics began incorporating FFS into their holistic healthcare programs for trans women in the late 1990s [23–25], and a growing number of clinicians from around the world now name avoiding facial reconstruction as one reason to start young trans girls on testosterone blockers before pubertal bone structure changes begin [26–30].

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Patient Perspective The following section expands on the accounts of trans women the authors have witnessed either in direct patient interaction (JB) or during ethnographic research (EP). FGCS patients frequently reported that they choose to undergo facial surgery either before or in lieu of genital or chest reconstruction. This prioritization reflects the value of the impact FGCS will have on their lives  – despite the fact that it is often far more expensive than other procedures and only rarely covered by insurance. One patient explained simply that she wanted FGCS so that when she “went into a grocery store, the person would say,” “Can I help you, Miss?” “That’s really what I want,” she said. “I want to be read as, accepted as, and reacted to as a woman.” Another patient explained that no matter what chest or genital anatomy she had going into the operating room, when she came out with a new face, she would finally be a woman. Others asserted that they wanted to look at themselves in the mirror and see a woman looking back at them. Without being accepted by others as a woman, one patient argued, she would never have taken on the requirement to “live as her preferred gender” (formerly known in the SOC as the Real Life Test). “How could I live as a woman,” she asked exasperatedly, “when everyone saw me as a man?! When I found out about FFS it was like a Christmas present in my world,” she said. “You can do a lot of things but if your face doesn’t reflect – not only to society but probably even more to myself – the gender that I want to present in, really I personally thought that transitioning in any other way would be kind of useless. If I’m going to transition, I need to have FFS. It’s that simple” [13]. Ethnographic research also supports the findings commonly reported in surgical literature that FGCS patients are generally pleased with the results of their procedures. The other author’s (JB) experience working with trans female patients confirms the above statements. Patients with low incomes who in the current healthcare landscape have access to other affirming procedures are often stranded in their transition process. In individual circumstances, this may leave

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the patient more vulnerable than they were pre-­ transition. A patient reported that until her facial features could be altered, she would not be willing to socially transition out of fear for her personal safety and discrimination. In her example, the lack of access to FGCS prevented her from living her authentic self and receiving the medical and surgical care she needed. Even more disconcerting is the example of a patient wanting to detransition due to the obvious effects of unwanted societal recognition and all its sequelae making it safer for her to return to her pre-transition anatomy.

Current Evidence and Controversies There is strong evidence confirming that gender-­ affirming care can decrease psychosocial sequelae of gender dysphoria [7, 8]. In their study of cost per quality-adjusted life year (QALY) in the US population [31], Padula et al. found that despite the small added expense, it is cost-­ effective to provide transgender-related medical insurance coverage because the presence of gender-­affirming care reduces negative and costly outcomes including incidence of HIV, depression, suicidality, and drug abuse. In addition to avoiding these negative outcomes, proposed benefits include improved access to the workforce and a resulting decrease of reliance on government subsidies [31]. Controversies surrounding gender-affirming surgical procedures are as old as the procedures themselves. Despite good evidence supporting the efficacy of affirming care and recent increases in visibility and acceptance of transgender individuals, debates rage on about whether and how insurance should cover transition-related care [14, 15, 18–20]. Against the backdrop of rising healthcare costs worldwide and expanding access to care, it will be necessary to define and justify which procedures should and should not be covered by insurance and why. US third-party insurers as well as select countries such as Sweden and Holland have integrated FGCS in their treatment algorithm for transgender patients [32].

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Determining which procedures should be considered medically necessary for transgender individuals seeking treatment requires an articulation of what treatment aims to do. The WPATH asserts that the purpose of the SOC is to “provide clinical guidance for health professionals to assist transsexual, transgender, and gender-­nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves.” It identifies genital and chest surgeries as medically necessary for this purpose, while other gender-altering procedures including FGCS, liposuction and lipofilling, implants, and voice surgery are defined as “other surgeries.” As such, the increasingly flexible diagnosis of gender dysphoria and the broadly stated goals of the SOC are employing interventions developed in response to a narrow and genital-centric diagnosis of transsexualism, one focused on sex as a primarily genital property. Although the SOC still identifies chest and genital reconstruction as the means of surgical transition, this is not a claim supported by a growing number of trans-surgical patients. Defining the medical necessity and therapeutic legitimacy of FGCS is particularly tricky since it is not one set of procedures but rather a conglomerate of craniofacial procedures, several of which have traditionally been thought of as cosmetic. Of course, procedures themselves are neither cosmetic nor reconstructive; it is the patient outcome to which the procedure is applied that determines its intent and effect. Current evidence supports our position that FGCS should be considered a medical necessity for transgender women with recognizably masculine features. It may also be considered so for those transgender men who are not recognized as male following the masculinizing effects of testosterone supplementation. The question of how to frame the medical necessity of FGCS is complicated by the fact that FGCS names an aim of surgical intervention rather than a strictly defined and universally applied set of bone and soft tissue procedures. Clinicians and policy makers must work to build consensus first about the therapeutic benefits of FGCS and next how to communicate those benefits as a part of medically

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Table 11.2  Proposed female facial gender confirmation procedures Forehead reconstruction (including eyebrow repositioning) Lower jaw and chin contouring Rhinoplasty Laryngeal chondroplasty Hairline treatment or redefinition Laser hair removal/electrolysis

necessary treatment for some patients experiencing gender dysphoria. A proposal of procedures that should be included under the umbrella of medical has been reported in the literature [14] (Table 11.2). Although there is considerable evidence from patient perspectives on the desirability and efficacy of FGCS, further research is needed to help demonstrate clinical efficacy and produce guidelines for FGCS best practice. These include the need for validated instruments to assess outcomes and patient satisfaction [21, 33] and the need to develop patient action protocols [19]. Those who oppose designating FGCS as medically necessary often do so not by contesting its therapeutic value or benefit to patients – a point which is frankly uncontested  – but by asserting the problems that such a designation poses for health insurers. How can they justify covering a rhinoplasty for a trans woman with a marked dorsal hump, for example, when the same procedure would not be covered for a cisgender person with the same unaesthetic feature? Of course, health insurance providers make such distinctions all the time. The medical necessity of a procedure is determined by its relation to a qualifying diagnosis, not decided in advance by the technique employed. Patients with ptosis undergo reconstructive blepharoplasty (blepharoptosis) while patients with aging faces undergo cosmetic blepharoplasty, for example. Similar techniques are used to different therapeutic ends. The artificial line between reconstructive and aesthetic surgery is constantly in negotiation. There were days when a simple cleft lip was considered a purely aesthetic defect; few would argue today that this is indeed a solely aesthetic concern. Over time, we have become aware that

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normal facial structure has vital physiological as well as social function. The stigma associated with unusual or abnormal facial appearance can have wide-ranging effects, including negative self-esteem and social exclusion. The insight from FGCS patients and providers is that sexually distinct facial features can result in these same negative consequences for transgender individuals whose faces render them unrecognizable to themselves or others as the gender with which they identify. The role of the medical and scientific community is to demonstrate that a procedure indeed has the effect it set out to have. Although more studies are welcome and needed, current evidence is conclusive on the therapeutic efficacy of FGCS [14]. Through educational efforts and advocacy work, this evidence has led to a recent increase in coverage through third-party insurers and select state Medicaid programs. This development may serve as a stepping-stone to confirm the need and benefit in the treatment of gender dysphoria by means of FGCS and assist in further expansion of care. The broadening of the diagnosis of transsexualism into gender identity disorder, gender dysphoria, and now gender incongruence has occurred because of our evolving understanding of gender and the associated treatment approaches that allow individuals an authentic, productive, and safe life. Medical and surgical responses evolve alongside, and must consider patients’ experiences of their sexed and gendered faces with as much gravity as we’ve long given to their chests and genitals. FGCS may for many be the most important affirming surgical procedure to allow patients to live life to its fullest and be productive members of society without fear of harassment, discrimination, and internal dysphoria.

Conclusion Facial features are the most defining and recognizable gender marker and make individuals whose gender expression is incongruent with their physical appearance prone to numerous negative psychosocial sequelae. Research has

confirmed the efficacy of FGCS, and it is therefore time that this set of medically necessary procedures be more clearly defined as such and therefore more widely available through healthcare advocacy and surgical training.

References 1. Benjamin H.  Transsexualism and transvestism as psycho-somatic and somato-psychic syndromes. Am J Psychother. 1954;8:219–30. 2. Benjamin H. The Transsexual Phenomenon. Trans N Y Acad Sci. 1966;29(4 Series II):428–30. https://doi. org/10.1111/j.2164-0947.1967.tb02273.x. 3. Cavanaugh T, Hopwood R, Lambert C.  Informed consent in the medical care of transgender and gender-nonconforming patients. AMA J Ethics. 2016;18(11):1147–55. https://doi.org/10.1001/ journalofethics.2016.18.11.sect1-1611. 4. National Center for Transgender Equality. Medicare and transgender people; 2014. 5. Clements-Nolle K, Marx R, Katz M.  Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51(3):53–69. https://doi.org/10.1300/ J082v51n03_04. 6. Nuttbrock L, Hwahng S, Bockting W, Rosenblum A, Mason M, Macri M, Becker J. Psychiatric impact of gender-related abuse across the life course of male-to-­ female transgender persons. J Sex Res. 2010;47(1):12– 23. https://doi.org/10.1080/00224490903062258. 7. Winter S, Diamond M, Green J, Karasic D, Reed T, Whittle S, Wylie K. Transgender people: health at the margins of society. Lancet. 2016;388(10042):390–400. https://doi.org/10.1016/S0140-6736(16)00683-8. 8. WPATH.  WPATH.  Standards of care of transsexual, transgender, and gender nonconforming people; 2012. 9. Irvine, J. 1990. Disorders of desire. 10. Rudacille D.  The riddle of gender. New  York: First Anchor Books; 2005. 11. Meyerowitz J.  How sex changed: a history of transsexuality in the United States. Cambridge: Harvard University Press; 2002. 12. Clements-Nolle K, Marx R, Guzman R, Katz M. HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: implications for public health intervention. Am J Public Health. 2001;91(6):915–21. 13. Plemons E.  The look of a woman: facial feminization surgery and the aims of trans- medicine. Durham: Duke University Press; 2017. 14. Berli JU, Capitán L, Simon D, Bluebond-Langner R, Plemons E, Morrison SD. Facial gender confirmation surgery—review of the literature and recommendations for version 8 of the WPATH standards of care. Int J Transgen. 2017;18:1–7. https://doi.org/10.1080/ 15532739.2017.1302862.

11  The Importance of Facial Gender Confirmation Surgery 15. Morrison SD, Vyas KS, Motakef S, Gast KM, Chung MT, Rashidi V, et  al. Facial feminization: systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759–70. https://doi.org/10.1097/ PRS.0000000000002171. 16. Isung J, Möllermark C, Farnebo F, Lundgren K.  Craniofacial reconstructive surgery improves appearance congruence in male-to-female transsexual patients. Arch Sex Behav. 2017;46:1–4. https://doi. org/10.1007/s10508-017-1012-7. 17. Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK. First female-to-male facial confirmation surgery with description of a new procedure for masculinization of the thyroid cartilage (Adam’s apple). Plast Reconstr Surg. 2017;139(4):883e–7e. https://doi. org/10.1097/PRS.0000000000003185. 18. Ainsworth TA, Spiegel JH.  Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery. Qual Life Res. 2010;19(7):1019–24. https://doi.org/10.1007/ s11136-010-9668-7. 19. Capitan L, Simon D, Kaye K, Tenorio T.  Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg. 2014;134(4):609–19. https://doi.org/10.1097/ PRS.0000000000000545. 20. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438–48. https://doi. org/10.1097/01.prs.0000475754.71333.f6. 21. Morrison SD, Crowe CS, Wilson SC. Consistent quality of life outcome measures are needed for facial feminization surgery. J Craniofac Surg. 2017;28(3):851–2. https://doi.org/10.1097/SCS.0000000000003450. 22. Plemons E. Description of sex difference as prescription for sex change: on the origins of facial feminization surgery. Soc Stud Sci. 2014;44(5):657–79. 23. Becking AG, Tuinzing DB, Hage JJ, Gooren LJG.  Facial corrections in male to female transsexuals: a preliminary report on 16 patients. J Oral Maxillofac Surg. 1996;54:413–8. 24. Gooren LJG, Doorn CD. What is medically necessary and what is needed in some other sense? the case of the

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transsexual operation. In: De Beaufort I, Hilhorst M, Holm S, editors. The eye of the beholder: ethics and medical change of appearance. Oslo: Scandinavian University Press; 1997. p. 15–25. 25. Hage JJ, Vossen MK, Becking AG.  Rhinoplasty as part of gender confirming surgery in male transsexuals: basic considerations and clinical experience. Ann Plast Surg. 1997;39:266–71. 26. Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJ. The treatment of adolescent transsexuals: changing insights. J Sex Med. 2008;5(8):1892–7. 27. Cohen-Kettenis PT, Schagen SE, Steensma TD, de Vries AL, Delemarre-van de Waal HA. Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up. Arch Sex Behav. 2011;40(4):843–7. 28. Sadjadi S.  The endocrinologist’s office—puberty suppression: saving children from a natural disaster? Journal of Medical Humanities. 2013;34(2):255–60. 29. Shumer DE, Spack NP. Current management of gender identity disorder in childhood and adolescence: guidelines, barriers and areas of controversy. Curr Opin Endocrinol Diabetes Obes. 2013;20(1):69–73. 30. Rosenthal SM.  Approach to the patient: transgender youth: endocrine considerations. J Clin Endocrinol Metabol. 2014;99(12):4379–89. 31. Padula WV, Heru S, Campbell JD.  Societal implications of health insurance coverage for medically necessary services in the U.S. transgender population: a cost-effectiveness analysis. J Gen Intern Med. 2016;31(4):394–401. https://doi.org/10.1007/ s11606-015-3529-6. 32. Lundgren TK, Isung J, Rinder J, Dhejne C, Arver S, Holm LE, Farnebo F.  Moving transgender care forward within public health organizations: inclusion of facial feminizing surgery in the Swedish National Treatment Recommendations. Arch Sex Behav. 2016;45(8):1879–80. https://doi.org/10.1007/ s10508-016-0830-3. 33. Barone M, Cogliandro A, Persichetti P.  Role of rhinoplasty in transsexual patients. Plast Reconstr Surg. 2017;140:624e. https://doi.org/10.1097/ PRS.0000000000003706.

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Jordan Deschamps-Braly

Background

the “Einstein of Sex” by Hearst newspaper in 1931, served as the cornerstone of modern-day The history of transgender surgery has an inter- transgender care. Dr. Hirschfeld served as a esting place in time. Before describing the tech- source of empathy and care for a population that niques used to feminize or masculinize the face, a was scorned by society. Magnus Hirschfeld was brief tour of these procedures is warranted. born in 1868 in Kolberg, Poland to an Ashkenazi Issues relating to gender nonconformity span Jewish family. Dr. Hirschfeld migrated to the history of human civilization. There are Germany in 1880 studying philosophy and medidescriptions of individuals who fit the modern-­ cine, even visiting the United States during this day description of a transgender person, who time. He identified as homosexual and advocated were revered in various ancient societies. This that there was nothing intrinsically wrong about includes ancient Egypt, the Indian subcontinent, his sexual orientation. In 1897, Hirschfeld Europe, sub-Saharan Africa, and even the North founded the Scientific Humanitarian Committee American Native American population. These with an aim to overturn and reform laws which descriptions also include modern-day religions criminalized homosexuality in Germany. In order such as Islam, Hinduism, and, to a lesser extent, to achieve this goal, two tactics were employed: Buddhism. Overall, it is unclear to what extent (1) to study homosexuality as an anthropological these descriptions depict cultural attitudes toward and medical science and, more controversially, transgender individuals or are isolated events that (2) to “out” prominent closeted homosexuals. were noteworthy and therefore preserved. The purpose of the “outing” tactic was to demonIn more recent times, the lack of recordkeep- strate that “normal” and even prominent people ing highlights the biases of human prejudice. In identified as homosexual. This was intended to addition, the intentional destruction of literature raise awareness, change the perception of homoby less enlightened parties is quite shocking. The sexuality, and influence lawmaking. Early petibirth of modern transgender healthcare originates tions were signed by notable people, including in Germany, between the two great wars of the the physicist Albert Einstein and the author twentieth century. The activities of a German Herman Hesse. In addition to Hirschfeld’s work Jewish physician Magnus Hirschfeld, also called regarding homosexuality, in 1904, he joined the Bund für Mutterschutz (League for the Protection of Mothers), a feminist organization that camJ. Deschamps-Braly (*) Deschamps-Braly Clinic of Plastic & Craniofacial paigned for decriminalization of abortion and Surgery, San Francisco, CA, USA other pro-female causes. e-mail: [email protected]

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_12

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In 1919, during the Weimar Republic, Hirschfeld formed the Institut für Sexualwissenschaft. The laws against homosexuality were still in place; however, they were not enforced by the government. The institute became a mecca for the study of sexology and also housed a public museum. The “Institute” hosted individuals from around the world who hoped to gain greater understanding regarding the study of sexology. In addition, medical procedures were performed in the “Institute,” and many of the staff were marginalized people who identified as homosexual or transgender. It is Hirschfeld who is credited with coining the term “transsexual.” The first patients to undergo surgical treatment for gender dysphoria were likely intersex individuals. In 1907, a patient by the name of Karl Baer [1] underwent what seems to be some type of metoidioplasty. Following the discovery of an affair, Karl attempted suicide by stepping in front of a streetcar in Berlin. Karl’s identification paperwork stated his name as Martha, which did not correlate with his appearance. Karl ultimately married the woman with whom he was having an affair and moved to Tel-Aviv. The records of his medical care were destroyed by the Nazis; however, he published his memoirs under a pen name of N.O.  Body. The epilogue was written by Magnus Hirschfeld. As such, much about his history is well known [2]. Lile Elbe, “The Danish Girl,” is referenced in popular culture as the first transgender person to undergo surgery. Ms. Elbe’s surgery was performed in Dresden in 1933 by Dr. Kurt Warnekos. However, one decade earlier, in 1922, the first known “male-to-female” transgender person to undergo medical procedures related to gender dysphoria was Rudolph Richter. Rudolph was a “house-maid” in the Hirschfeld’s “Institute.” While there, she underwent an orchiectomy. Subsequently, she underwent a penectomy by Dr. Levy-Lenz and a “vaginal reconstruction” by Dr. Gorhbrandt [3]. Dr. Levy-Lenz initially practiced as a gynecologist at the Institute. Following the destruction of the Institute by the Nazis, Dr. Levy-Lenz relocated to Egypt and developed a reputation as a highly regarded “cosmetic” surgeon.

J. Deschamps-Braly

The first facial procedures occurred long after genital surgeries and were pioneered and described by Douglas Ousterhout MD, DDS, FACS, in the late 1980s (Fig.  12.1). Douglas Ousterhout was the first American fellow of the world-renowned French craniofacial surgery pioneer Dr. Paul Tessier. Following his training as a maxillofacial and plastic surgeon, Dr. Ousterhout spent one year in Paris with Dr. Tessier. Ousterhout recalled to me that Dr. Tessier had said that someday “this amazing craniofacial surgery will become very useful for cosmetic surgery.” [4] Ousterhout began his practice in San Francisco in 1974. He maintained a private practice and also joined the cleft surgery clinic at The University of California San Francisco, which had been founded by Dr. John Owsley. In 1982, Lucy, a transgender woman, came to the office of Dr. Ousterhout. She said that her forehead was a source of dissatisfaction for her; she felt that she was gendered incorrectly because of it. At the time, craniofacial surgery focused on congenital anomalies, and little thought was given to the differences that gender and sex gave to the facial skeleton. Ousterhout researched this question at the “Atkinson Skull Library” at the University of the Pacific Dental School. By studying both skulls and anthropology texts, Ousterhout determined the craniofacial skeletal differences between male and female skulls. He then devised a number of operations to feminize the forehead and the mandible, and he published his techniques in 1987 [5]. Subsequent academic work by Spiegel et  al. demonstrated a positive correlation between transgender patients receiving facial feminizing procedures and an improvement in their psychosocial health [6]. In 2011, Ousterhout described facial masculinizing procedures. These procedures were initially based on cisgender men seeking to masculinize their face by modifying the craniofacial skeleton. In 2017, Deschamps-Braly et al. published a report of the first transgender male to undergo facial masculinization, including a new technique for augmenting the thyroid cartilage to enlarge the “Adam’s apple” [7]. These feminizing and masculinizing procedures have been adopted worldwide and are becoming more prevalent.

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a

b

Fig. 12.1 (a, b) Facial feminization procedures for transgender patients, such as the surgeries performed on this patient, were pioneered by Douglas Ousterhout, MD, DDS, FACS

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Feminization of the Hairline

J. Deschamps-Braly

corrected using hair transplants, as no surgical procedure can adequately relocate tissue into this The hairline is important in the evaluation of a area. Conversely, temporal recession may be patient for either facial feminization or facial treated using a combination of scalp advancemasculinization surgery. Female hairlines differ ment and temporal lifting. These maneuvers from male hairlines. In cisgender females, the reduce the area to be treated by hair transplants. center point of the hairline is lower than in cisIn order to lower the hairline, the incision is gender males. In cisgender females, the center placed at the junction of hair-bearing and non-­ point is about 5.5–5.8 cm above the center point hair-­bearing skin. A tricophytic incision is used of the eyebrows, whereas in cisgender males, the so as to allow regrowth of hair. The incision concenter point typically exists 7–10  cm above the tinues into the visible temporal hollow before center point of the eyebrows [8, 9]. In cisgender turning inferiorly toward the ear (as with a tradimen, 80% of the time the hairline has a small “V” tional coronal incision). in the middle, known as the “widow’s peak.” The After making the “hairline” coronal incision, term “widow’s peak” is derived from the super- the scalp is elevated in a subgaleal plane to the stitious belief that having one was an early pre- level of the occiput. This allows for forward mobidictor of widowhood. The term is commonly lization of the scalp. If additional advancement is misused, particularly since male pattern hair loss required, galeotomies may be performed. has characteristic recession on either side of the However, care must be taken to avoid damage to middle tuft (the temporal peaks), mimicking an the vascular pedicles of the scalp. Following actual widow’s peak. Considering that the size of advancement, the scalp is fixed to the bone. The the face is often measured from the level of the author’s preferred fixation technique is unicortical hairline, lowering a patient’s hairline can give the tunnels and resorbable suture. Following posterior impression of a smaller face. flap fixation, excess skin is removed from the anteHowever, when considering facial height, the rior flap. If there are significant forehead rhytids or surgeon must also consider facial proportions. glabellar furrows, frontalis myotomies and/or corThe often referenced “rule of thirds” is not an rugator or procerus resection may be performed. accurate measurement and attempts to package a Hair transplants are a useful adjunct and may formula for surgical success that does not apply compliment a scalp advancement. Traditionally, to the vast majority of humans. Most notably, the the author prefers to wait six months prior to persurgeon should consider the height of the patient. forming hair transplantation. More recently, we For instance, a tall patient with a large face will used the follicular unit method to transplant hair tolerate a longer hairline, whereas a short patient taken from the temples during closure of the hairwill require a lower hairline position. In addition, line coronal incision. However, the survival rate the height of the upper face should balance the of transplanted hair follicles performed in this patient’s midface height. If the patient has a long manner is not as high as when transplants are midface, and the patient does not desire correc- delayed. The author estimates that only 60% of tion (i.e., midface impaction), then a higher hair- the grafts survive when performed concomitant line may be acceptable. with surgical scalp advancement. Capitan et  al. Additional important landmarks regarding the have written about immediate hair transplantahairline are the temporal points and the temporal tion as a primary technique for lowering and mounds. The temporal points refer to the arrow-­ reshaping hairlines [11]. They describe harvestshaped points of hair, and the temporal mounds ing a strip of hair during closure of a traditional refer to the wispy hair composed of single follicle coronal incision. The disadvantage of this techhair units through which the scalp is often visi- nique is that a coronal incision raises the hairline, ble. According to one detailed study of female thereby requiring even more hair than would be hairlines, the temporal points were present in needed if a scalp advancement was performed. 98% of the subjects [10]. This area can only be An additional disadvantage is that grafted hair,

12  Facial Gender Affirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery

although convincing in the temples, is less convincing in the central hairline. Alternatively, when forehead lengthening is required, a coronal incision is placed behind the hairline. Forehead lengthening is performed to address a low hairline or when facial masculinization is requested. Galeotomies through the frontalis muscle may be performed (less than 5% of transfeminine patients). Incidentally, galeotomies should stop medial to the terminal branches of the facial nerve. Approximately 1–1.5  cm of forehead lengthening may be achieved (Fig. 12.2).

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Forehead Type I The type I forehead either lacks a frontal sinus or has a frontal sinus which is sufficiently thick such that contouring may be performed without an osteotomy. The author estimates this configuration occurs in 3–6% of his patient population.

Forehead Type II

The type II forehead implies that the glabellar ridge is situated in an appropriate anterior-­ posterior position and that surgical modification should focus above this level. This typically The Forehead involves augmentation of the recess above the Cis-female and cis-male foreheads are shaped frontal bossing; adjustments to the orbital aperdifferently. Cis-male foreheads are more pro- ture and the lateral orbital rims may still be truded in front of the eyes, giving the sense of required. Options for forehead augmentation deeper set eyes. Additionally, the cis-male fore- include hydroxyapatite, calcium phosphate puthead tends to have prominent glabellar bossing ties, and methyl methacrylate (MM). Methyl above the orbits and also has an alternating con- methacrylate has a long history of use in craniovexity and concavity (as opposed to the cis-­ facial applications and is relatively inexpensive female foreheads which tends to be convex in all [13]. In terms of facial feminization, methyl directions). The lateral orbital rims are also more methacrylate was best studied by Ousterhout prominent in the cis-male skull and may also who described shaping approximately 400 methyl methacrylate implants [14, 15]. Among require modification. Forehead modification would be simple if it that group, there were only two infections. One weren’t for the existence of the frontal sinus. The patient required removal due to infection from a sinus results in an overall lighter weight to the frontal sinus fracture after secondary trauma, skull and speculation suggests this may provide and another patient seeded the implant due to a an evolutionary advantage. In Ousterhout’s retro- sternal wound infection after open-heart bypass. spective analysis of his patients, 5% of patients Both instances of infection occurred years after either did not have a frontal sinus or had a suffi- placement of the implant. It is important to recciently thick frontal sinus that contouring could ognize that if exposure of the sinus occurs, augbe achieved without an osteotomy [12]. The mentation of the forehead should be avoided as author’s experience indicates that only 3% of this exposes the implant to airway bacteria. patients lack a sinus, and another 3% of patients Methyl methacrylate does have some drawhave a hypoplastic unilateral sinus. In 89% of the backs. The primary drawbacks are heat generaauthor’s cases, forehead modification requires tion and potential toxicity during the curing osteotomy and reconstruction of the anterior wall phase. In order to avoid bone necrosis, no more than 5  mm of methyl methacrylate should be of the frontal sinus. Four forehead configurations were described placed before allowing it to cure [16]. Additional by Ousterhout in his landmark 1987 paper layers of material may be added secondarily (Fig. 12.3). describing forehead feminization [5].

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J. Deschamps-Braly

a

b

Fig. 12.2 (a, b) Compared to male foreheads, female foreheads are less protruded in front of the eyes, do not have prominent glabellar bossing above the orbits, and are

more likely to be convex. This patient has undergone forehead contouring, among other procedures

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Fig. 12.3  The type III forehead demands the most technical skill when feminizing a forehead. Pictured above is a typical bone incision made in a type III forehead, the

removal and reshaping of the bone plate, and replacement of the reshaped bone plate. (Illustrations ©2018 Christine Gralapp)

Forehead Type III

to that of fine artisanal woodworking. The result is permanent, irregularities of 1 mm may be felt through the skin, and bone grafts must be secured well to avoid resorption. Gentle technique and pericranial preservation must be meticulous, as the entire bone flap is vascularized through close adherence of the pericranium. Also, prevention of temporalis muscle retraction is important, as this creates an unsightly bulge in the temporal fossa which is difficult, if not impossible, to correct. The type III procedure (required in approximately 93% of patients) involves treatment of the

The forehead type III is the most common situation we encounter. Incidentally, it is also the most technically demanding and difficult procedure to master as it requires mastery of both craniofacial surgery and plastic surgery. While pediatric craniofacial surgery often requires large overcorrections and intentional lack of precision because of the variables that growth, relapse, and resorption entail, the opposite is true when performing a type III forehead procedure. The fit and finish of the result must be similar in quality and character

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central forehead as well as reduction of the lateral orbital rims and shaping of the orbital aperture. Treatment of the central forehead requires osteotomy and reshaping as burring alone is rarely sufficient to feminize this type of forehead. In fact, burring alone is often barely visible through the thick skin of the forehead. Furthermore, if only the lateral orbital rims are addressed, patients will have a common characteristic central prominence, for which they often seek revision. The central forehead is treated with tangential osteotomy. Preoperative x-rays and CT scans help to ascertain the extent of the sinus; however, no particular technique is used to mark or outline the sinus prior to surgery. After performing the osteotomy, septa that may restrict drainage are removed, and if the naso-frontal duct is too small or an ethmoid air cell interferes with the drainage pathway, those passages may be opened. A high-­ speed rotating burr is used to “fine-tune” the shape of the forehead. Care is taken to reduce the risk of injury to the supraorbital nerve. However, in approximately 1–2% of patients, the supraorbital nerves cannot be preserved due to an aberrant exit from the forehead, sometimes as high as 2 cm above the level of the orbit. Once the desired shape is obtained, the bone graft is replaced and secured using stainless steel wire. The thinnest available plates and screws are 350 microns in thickness, while twisted 30 gauge stainless wire has only a 200 micron diameter. This difference may reduce the likelihood of palpability, especially with skin thinning as a result of aging and hormone therapy. Pericranial flap placement, scalp advancement, and skin closure complete the procedure.

Rhinoplasty

Discussion of rhinoplasty techniques is sufficiently complex to encompass an entire book, and this is not intended to be an exhaustive analysis of rhinoplasty techniques. The intent is to frame the issues of feminizing rhinoplasty. The majority of rhinoplasties performed in transgender women are reduction in nature, while rhinoplasties in transgender men are most frequently augmenting. There are exceptions to these general paradigms, most typically in African American or certain Asian noses. The most important modern-day advance was made in Hungary in the 1920s when Rethi described the use of the columellar incision. This allowed visualization, which, prior to that, was not possible [17]. In the context of feminization surgery, when the forehead is recessed, the nose will appear larger. In addition, a step is created at the junction of the forehead and nose just above the radix. This step may be visible if the nose is left unattended. The creation of a smooth dorsal line from the new forehead to the caudal tip of the septum is critical, and the proper naso-frontal angle, nasolabial angle, and angle of the nose relative to the facial plane should also be considered. Achieving these goals often entails large dorsal reductions, sometimes as large as 6–7 mm. This creates large open roof deformities and necessitates medialization of the nasal bones. In nasal feminization, spreader grafts made from septal cartilage are often too wide and must be modified. The nasal tip is almost always too large, and modification of the lower lateral cartilages is required. Lastly, the need to perform alar wedge resections is more apparent in feminizing rhinoplasties. The author consents all patients for alar wedge excisions but Forehead Type IV only makes the decision to perform this maneuType IV forehead feminization is the least com- ver at the conclusion of the case. It is often diffimon situation encountered. This category cult to predict the necessity of alar wedge describes a forehead that is too small with under- resections given the dramatic changes that are projection of the brow ridge. In these cases, pan-­ otherwise performed. One concern regarding reduction rhinoplasties forehead augmentation is required. While quite rare, treatment is similar to that described for is the potential for secondary deformities. With type II feminization with the addition of material the exception of one instance, we do not find this to be the case. Reduction of the radix, which is to the area above the eyes and the forehead.

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a

b

Fig. 12.4 (a, b) The procedures performed in this patient, including forehead contouring, scalp advancement, brow lift, rhinoplasty, and upper lip lift, have dramatically reshaped the face

often necessary in order to blend the forehead and the nose, may lead to excess skin of the medial canthal region. Should this fail to resolve,

secondary treatment is performed using a medial upper lid blepharoplasty with a W type extension (Fig. 12.4).

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Upper Lip The upper lip length varies in men and women and with age. The typical male vertical upper lip length ranges between 20 and 22  mm in older patients and 18 and 20 mm in younger patients. A typical youthful female vertical upper lip measures between 14 and 16 mm with approximately 4–5  mm of upper tooth show. Upper lip height reduction is often performed in conjunction with lip augmentation in order to produce more tooth show, increase the visibility of the upper lip vermillion, and add volume to reduce wrinkling. It is also possible to perform concomitant resurfacing procedures as long as the area of the incision is avoided. If the corners of the mouth are downturned, direct excision along the vermillion border may be performed. However, this procedure may improve visualization of the vermillion rather than correct the downturn (Figs. 12.5 and 12.6).

The Jaw The cis-male jaw is larger and broader than the cis-female jaw. The gonial angles are sharper, the mandibular plane is flatter, and the oblique

Fig. 12.6  The chin is much taller in males than females. Vertical reduction of the mandible (as in the photo here) is often needed when providing facial feminization surgeries

J. Deschamps-Braly

line on the midbody portion of the mandible is heavier and thicker. While different structures, the jaw and chin should be considered together so as to allow simultaneous contouring. The

Fig. 12.5  Genioplasty Advance Illustration) A T-osteotomy of the chin is used to achieve vertical height and width reduction in facial feminization. This method can also allow for advancement when necessary. (Illustrations ©2018 Christine Gralapp)

for transgender patients. (Illustrations ©2018 Christine Gralapp)

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usual maneuvers include burring or removal of portions of the outer table of the mandible and, in some circumstances, removal of spongy bone so as to narrow the jaw. Masseter muscle reduction may be performed via an intraoral approach; however, some reduction of the masseter may be achieved with removal of the gonial angle. Oftentimes, wide degloving of the mandible is required. This mandates protection of the soft tissues, including both the mental and marginal mandibular nerves. The cis-male chin is vertically taller, even when adjusting for height. Therefore, vertical reduction is almost always warranted. Approximately 85% of patients are suitable candidates for chin surgery as part of their facial feminization procedure. This typically involves osseous genioplasty, as a chin implant does not result in feminization. Chin implants make the chin larger, usually in the anterior vector. While this may correct retrogenia, it does not improve the chin shape or vertical height. SA Wolfe described methods to alter the vertical height of the chin in 1987 [18]. His technique has been modified into a T-osteotomy of the chin. This osteotomy allows for both vertical height removal and width reduction, and also allows for either advancement or setback when necessary. Knowledge of dento-facial planning techniques helps to determine chin position (in both the vertical and anterior-posterior dimensions). Also, appreciation of changes in the facial plane as a result of concomitant forehead surgery should be considered when planning chin surgery. Titanium hardware fixation allows for stable fixation. Lateral fixation may be required if segmentation of the chin was performed. Knowledge of mental nerve anatomy is required to prevent injury; the position of the nerve is lower than the mental foramen, as the nerve runs cranially so as to exit the foramen [19]. Numerous studies demonstrate the safety of osseous genioplasty. When appropriate precautions are taken, lip sensation should remain largely intact. However, transient lip numbness is common, and often resolves over the course of two years. These sensory alterations may also affect the lower incisors. On occasion, a small, midline vertical strip of hypesthesia may persist (Figs. 12.7 and 12.8).

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The Thyroid Cartilage The thyroid cartilage sits atop the cricoid and trachea. From a functional perspective, it provides a framework for swallowing, closure of the airway during swallowing, and helps to maintain vocal cord tension. Cis-male thyroid cartilage is larger and more projected than cis-female thyroid cartilage and results in the characteristic masculine Adam’s apple. The Adam’s apple is often a concern for individuals who are transitioning in a binary fashion. However, the author has also treated cisgender individuals (both male and female) who are bothered by the appearance of their Adam’s apple. Chondrolaryngoplasty was first described by Wolfort et al. in 1975 [20], and in 1990, he published a series with 30 patients [21]. The thyroid cartilage may be approached directly or, in the author’s preferred technique, indirectly. The direct approach entails an incision directly over the top of the thyroid cartilage. Alternatively, the indirect approach utilizes a submental incision similar to that used in a facelift. This incision requires skin undermining with separation of the strap muscles from above. The benefits of this approach include a concealed scar and a scar that does not adhere to the underlying cartilage. Scar adherence is often seen in the direct approach. This results in unsightly movement when the patient speaks. In young patients, the cartilage is soft and can be reduced with a blade. During cartilage removal, avoidance of the site of vocal cord insertion is important. This area is usually significantly below the level of the most prominent portion of the cartilage. Visualization of the vocal cord insertion is facilitated with the use of a fiber-­optic scope and laryngeal mask airway. The location of vocal cord insertion can be marked so as to allow precise cartilage reduction. Historically, there were a number of patients who complained of long-term hoarseness following this procedure (Fig.  12.9). Milton Edgerton drew attention to this in his discussion to Wolfort’s original article [22]. Masculinization of the thyroid cartilage may also be performed. This was described by Deschamps-Braly et  al. in 2017. [7] This procedure is performed through a submental limited access approach. Rib cartilage is harvested and

J. Deschamps-Braly

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a

b

Fig. 12.7 (a, b) In this patient, a genioplasty was performed to taper the jaw

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a

b

Fig. 12.8 (a, b) Genioplasty has tapered the jaw and feminized the chin in this patient. To create a more feminine appearance, other procedures were also used, including forehead contouring, scalp advancement, brow lift, and rhinoplasty

J. Deschamps-Braly

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a

b

Fig. 12.9 (a, b) The thyroid cartilage was reduced in this patient to make the Adam’s apple less prominent. The patient also underwent forehead contouring, fat grafting, rhinoplasty, upper lip lift, and tapering of the jaw

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shaped in a fashion analogous to that of ear reconstruction. The cartilage construct is fixed to the overlying native thyroid cartilage, usually in a slightly lower position. The strap muscles are approximated over the cartilage in order to present a more masculine appearance.

Other Procedures There are various additional procedures that may be considered in the context of facial surgery. Some of these procedures may be performed concurrently, while others are best performed in stages. These procedures are not necessarily specific to feminization and often have an element of beautification or rejuvenation. For instance, while many patients may benefit from upper lid blepharoplasty or facelift, in the author’s opinion, these are best performed secondarily. It is difficult to determine the exact and ultimate brow position following forehead surgery, and under−/overresection of upper lid skin is possible. Similarly, estimating skin resection at the time of underlying skeletal work is difficult. As such, a facelift is best performed following resolution of skin swelling. Other procedures, such as cheek implants, are not necessarily feminizing. While there are ethnic differences in cheek shape, there are not necessarily reproducible differences in cheek shape between cis-men and cis-women. Cheek implants (or lipofilling) may be used to enhance aesthetic results, but are not necessarily gender related (Fig. 12.9).

Conclusion Under the combined term of facial gender affirmation surgery, facial feminization surgery and facial masculinization surgery provide power tools to improve the lives of transgender and gender-­nonconforming individuals. These procedures are technically demanding. However, if one is willing to undertake the prerequisite training, it is a fulfilling surgery that can be rewarding to the provider. The author recommends that surgeons begin with procedures they can safely accomplish and that are within their scope of practice.

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References 1. Baer-Berlin KM. Über den Mädchenhandel. Zeitschrift für Sexualwissenschaft. 1908;9:513–28. 2. N.O.  Body (Karl Baer); translation by Deborah Simon; University of Pennsylvania Press; 2005. 3. Web Reference: (Hirschfeld Institute, Germany). http://www.hirschfeld.in-berlin.de/institut/en/personen/pers_34.html 4. Personal communication, Douglas Ousterhout, San Francisco; 2015. 5. Ousterhout DK.  Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg. 1987;79:701–13. 6. Spiegel JH.  Challenges in care of the transgender patient seeking facial feminization surgery. Facial Plast Surg Clin North Am. 2008;16:233–8. viii 7. Deschamps-Braly JC, Sacher CL, Fick J, Ousterhout DK. Plast Reconstr Surg. 2017;139(4):883e–7e. 8. Nusbaum B, Fuentefria S. Naturally occurring female hairline patterns. Dermatol Surg. 2009;35:907–13. 9. Unger WP, Shapiro RS, editors. Hair transplantation. New York: Marcel Dekker, Inc.; 2004. p. 151–63. 10. Nusbaum BP, Sandra F.  Naturally occurring female hairline patterns. Dermatol Surg. 2009;35(6):907–13. 11. CapitanL SD, et al. Facial feminization surgery: simultaneous hair transplant during forehead reconstruction. Plast Reconstr Surg. 2017 Mar;139(3):573–84. 12. Ousterhout DK. Facial feminization surgery: a guide for the transgendered woman. Chicago: Addicus Books; 2010. 13. Gonzales-Ulloa M, Stevens E.  Implants in the face. Plast Reconstr Surg. 1964;33:532. 14. Ousterhout DK.  Feminization surgery: a guide for the transgendered woman. Chicago: Addicus Books; 2010, January. 15. Ousterhout DK, Zlotolow IM.  Aesthetic improve ment of the forehead utilizing methyl methacrylate onlay implants. Aesthetic Plast Surg. 1990;14(4, Fall):281–5. 16. Stelnicki EJ, Ousterhout DK.  Prevention of thermal tissue injury induced by the application of polymethyl methacrylate to the calvarium. J Craniofac Surg. 1996 May;7(3):192–5. 17. Rethi A.  Operation to shorten an excessively long nose. Rev Chir Plastic. 1934;2:85. 18. Wolfe SA.  Shortening and lengthening the chin. J Craniomaxillofac Surg. 1987 Aug;15(4):223–30. 19. Ousterhout DK. Sliding Genioplasty, avoiding mental nerve injuries. J Craniofacial Surg. 1996;7(4):297–8. 20. Wolfort FG, Parry RG.  Laryngeal chondroplasty for appearance. Plast Reconstr Surg. 1975;56:371. 21. Wolfort FG, Dejerine ES, Ramos DJ, More. Plast Reconstr Surg. 1990;86(3):464–9. 22. Discussion by Edgerton, Milton T: Chondrolaryngoplasty for appearance, Wolfort, Francis G.; Dejerine, Erik Sorrel; Ramos, Douglas J; More. Plast Reconstr Surg. September 1990;86(3):464–9.

Fertility Preservation Options for Transgender and Trans Masculine Patients Planning Hysterectomy

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Katherine T. Hsiao

Family building is a life goal for many individuals, whether it be genetic (biological) or non-­ genetic (adoption, fostering, blended families, egg or sperm donation). Many transgender and gender-diverse people share this desire to raise children [1–3]. Some transgender persons become parents prior to transitioning and this is associated with a positive effect on quality of life. Studies demonstrate that children are not adversely impacted by having transgender or gender-diverse parents. These children are not any more likely to be transgender themselves nor does having a transgender parent affect a child’s gender identity, sexual orientation or other pediatric developmental milestones [4, 5]. Since transgender and gender-diverse persons face unique challenges in achieving parenthood, it is imperative that surgeons provide them with clear, evidence-based, counseling regarding fertility preservation options prior to gender-­ confirming surgery. The Committee Opinion of the American Society of Reproductive Medicine (ASRM) states that “transgender identity/status by itself should not automatically bar a person from accessing fertility preservation and assisted reproductive services” [6].

K. T. Hsiao (*) Department of Obstetrics and Gynecology, Sutter Health, San Francisco, CA, USA

This opinion is supported by the World Professional Association for Transgender Health Standards of Care Version 7 (WPATH SOC 7), the Endocrine Society, and the American College of Obstetricians and Gynecology (ACOG). These internationally recognized health organizations affirm that informed consent should include counseling regarding genetic fertility preservation options prior to gender-confirming surgery [7–9]. Gender-confirming surgery for transgender patients often includes surgical procedures which involve the removal of the gonads and modification of the genitalia. This may permanently and irreversibly affect one’s future ability to genetically contribute to family building. Forced sterilization is still required by law in many countries before one’s gender can be legally changed. Institutionalized sterilization of transgender persons has been vigorously challenged as an international human rights violation. There have been recent successful efforts to champion transgender person’s inalienable rights to choose whether to reproduce or not reproduce [10, 11]. Recently, the European Court of Human Rights struck down laws requiring transgender individuals to be sterilized prior to changing their legal gender [12]. Transgender individuals in Sweden have been monetarily compensated for having been forced to undergo sterilization in order to change their legal gender [13].

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_13

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Mainstream medical organizations have statements recommending counseling patients regarding fertility options, but these have been historically limited to a discussion for non-trans-­ identified patients undergoing gonadotoxic treatments such as surgery, radiation, or chemotherapy for cancer (oncofertility) [14–17]. Trans masculine individuals who desire to have a genetic contribution to future family building can participate in various ways. They may consider gamete (egg) or gonad (ovary) cryopreservation or gonadal conservation (retaining an ovary) when planning gender-confirming surgery. Many patients are unaware of these options, and unfortunately, are not provided adequate counseling on fertility preservation options prior to surgery. Clinicians should ensure that adult as well as adolescent transgender patients and their families are aware of their fertility preservation options. Recent studies demonstrate that transgender youth underutilize fertility preservation. Some of the reasons for underutilization by transgender youth include unwillingness to delay surgery, cost, and lack of understanding of long-term consequences [18]. Clinical providers may under-­counsel because they lack knowledge of options and/or have limited access to transfriendly fertility resources. Patients and their families often do not realize fertility preservation options exist [19]. Many transgender youths and their parents are faced with having to make gender-confirming treatment choices such as initiation of puberty blockers and cross-hormone therapy which may permanently and adversely affect future fertility. A particularly challenging issue is that transgender youth may be asked to make choices regarding future parenting before they are biologically able to reproduce and often before they are psychologically mature enough to understand these choices. Age-appropriate counseling by mental health professionals is essential to informed consent and assent [20]. Many transgender men use exogenous testosterone to help them transition. It alleviates some of the dysphoria producing symptoms, such as menses, which are associated with having a body

K. T. Hsiao

which is incongruent with their affirmed gender and also leads to increased levels of psychological function [21]. Testosterone-induced amenorrhea and ovulation suppression are dose-dependent [22]. The use of testosterone after estrogen-induced puberty does not preclude future pregnancy for trans masculine patients. Some trans masculine patients have become pregnant themselves and have given birth. In a study of 41 trans masculine patients who became pregnant and gave birth, a majority had used testosterone prior to pregnancy and then used their own eggs to achieve pregnancy with healthy outcomes [23]. Pregnancy, however, may be very dysphoric for many trans masculine patients. It is important to counsel trans masculine individuals that they have options other than pregnancy for future family building via fertility preservation strategies prior to gender-­confirming surgery, including hysterectomy. For many trans masculine patients, hysterectomy is important to their personal hormonal and surgical journey to a gender-congruent body. A recent national survey of transgender individuals found that 57% of trans masculine individuals desire to have a hysterectomy as part of their gender-confirming surgery plan. In contrast only 14% have had a hysterectomy [24]. Hysterectomy involves the surgical removal of the uterus. The whole uterus, which includes the cervix, may be removed (total hysterectomy), or the cervix may be retained (supracervical hysterectomy). The ovaries and Fallopian tubes may also be removed or retained. Trans masculine patients are still frequently advised to remove their ovaries because they are thought to be at a higher risk for ovarian cancer due to multiple risk factors. Transgender and gender-diverse patients are less likely to access regular health screening, less likely to have used birth control pills or have given birth, and more likely to have a higher BMI and smoke. All of these are risk factors known to be associated with an increased risk of ovarian cancer [25].

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Bilateral salpingo-oophorectomy (removal of both Fallopian tubes and ovaries) does decrease one’s lifetime risk of ovarian cancer [26]. Historically, some physicians have advised trans masculine patients to remove their ovaries for health reasons based on a few case reports of ovarian cancer in transgender patients taking testosterone. Their assumption was that natal gonads exposed to cross-hormones were at increased risk for neoplasia or malignancy as is true for gonadal dysgenesis or cryptorchidism (undescended testes). Their ovaries were assumed to be cancer prone. However, trans masculine patients who have undergone an estrogen-induced puberty do not have the same gonadal histology nor genetics as patients with gonadal dysgenesis or cryptorchidism (Y-gene) [27, 28]. An observational, prospective research study on a cohort of trans masculine patients in Ghent, Belgium, demonstrates that after prolonged testosterone use, the ovarian tissue histology necessary for future fertility, primordial cortical follicles, is normal and preserved [29]. Additionally, a long-term prospective cohort trial of 365 Dutch trans masculine patients demonstrated that the long-term use of testosterone (median use of over 18 yr) is not associated with an increased risk for any cancer or death. Total mortality and cause-specific mortality were not significantly different from that of the general Dutch population. There was no increased incidence of any cancer for trans masculine patients using testosterone long-term. Notably, since gender-­confirming surgery is a covered benefit in the Netherlands, 94% of this cohort had hysterectomies and bilateral oophorectomies. Although trans masculine patients often develop hyperlipidemia on testosterone, surprisingly, they do not have an increased risk of cardiovascular death or disease [30]. It is unclear whether there is a cardio-­ protective effect of a history of endogenous estrogen exposure (pre-transition) for trans masculine patients as there is in cis feminine premenopausal women [31]. Most current adult trans masculine patients have undergone estrogen-based puberty and not had puberty blockers.

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The effects of cross-hormones on the immature gonads of persons whom have had puberty-­ blocking hormones and then cross-hormones are yet to be determined. Many clinicians continue to counsel trans masculine individuals that leaving their ovaries in situ is dangerous. Clinicians and community websites continue to state that trans masculine patients may be at increased risk for ovarian cancer due to testosterone use [32]. Ovarian cancer was historically believed to originate from the ovaries. Recent ovarian cancer research has determined that a majority of the most fatal type of ovarian cancer, epithelial ovarian cancer (EOC), originates in the Fallopian tubes, not in the ovaries [33]. Removal of the Fallopian tubes, without removal of the ovaries, in average-risk individuals may substantially decrease lifetime ovarian cancer risk. This is called “risk-reducing salpingectomy” or “opportunistic salpingectomy.” Exceptions to this recommendation are persons with strong familial medical history with risk factors for BRCA1 and BRCA2 germline mutations. These persons should be offered carrier testing and their tubes and both ovaries should be removed if positive for BRCA gene carrier status [34]. Gynecologists are now encouraged by the American College of Obstetricians and Gynecologists (ACOG) to counsel low- or average-­risk premenopausal (cisgender) women planning hysterectomy regarding the potential ovarian cancer risk-reducing strategy of prophylactic removal of the Fallopian tubes [35]. Since testosterone has not been found to cause ovarian cancer in trans masculine patients, it is prudent to counsel transgender patients similarly and share with them the potential fertility and non-fertility health benefits of retaining one or both gonads. A Cochrane review of ovarian conservation demonstrated that cisgender women under 45 who retained their ovaries at the time of hysterectomy had lower rates of cardiovascular disease, death from cardiovascular disease, dementia and Parkinson’s disease [36]. Historically, many clinicians have shared the belief that polycystic ovarian syndrome (PCOS) is more common among transmen. This belief

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has been quoted as another reason why trans masculine patients should undergo bilateral oophorectomy. Studies suggesting a correlation between PCOS and trans masculine gender identity have used Rotterdam 2003 PCOS diagnosis criteria such as oligomenorrhea or amenorrhea, signs of hyperandrogenism, and polycystic ovarian morphology on ultrasound [37]. These changes may not be intrinsic to these trans masculine patients but secondary to exogenous testosterone cross-hormone use. Testosterone has been demonstrated to induce hypertrophic changes in the ovaries of trans masculine patients which can be misinterpreted as PCOS.  Classic PCOS is associated with elevated anti-Mullerian hormone (AMH) levels [38]. In contrast, exogenous testosterone use by trans masculine patients is associated with decreased levels of AMH. While PCOS causes endogenous hyperandrogenism, exogenous hyperandrogenism via testosterone use does not cause PCOS [39]. Exogenous testosterone exposure can cause ovarian hyperthecosis with cortical and stromal hyperplasia which can grossly mimic classic PCOS [40]. More importantly, PCOS is not an indication for oophorectomy [41]. Until more research is published on specific health issues for trans masculine patients, clinicians may share current evidence-based best practice from research on non-trans-identified populations to counsel patients on the potential benefits, risks, consequences, and alternatives to bilateral salpingo-oophorectomy. Research on the long-term consequences of oophorectomy for cisgender women under 50 reveals lower rates of ovarian and breast cancer but no increased rates of survival and increased rates of all-cause mortality [42]. There may be non-fertility health benefits for trans masculine patients who choose to retain, or conserve, one gonad/ovary or both. Trans masculine patients who decline to freeze eggs or ovaries prior to pelvic surgery have the option of temporarily retaining one or both ovaries. Gonadal conservation has no recommended time limit and gonadectomy may be deferred (staged gonadectomy) for years or not done at all.

K. T. Hsiao

This gives patients the option to have eggs or the ovary to be retrieved from the pelvis after hysterectomy. Some trans masculine patients discontinue exogenous testosterone use after they feel that they are sufficiently masculinized. Oophorectomy is associated with an increased risk for osteoporosis. Testosterone use appears to increase bone density. Discontinuation of testosterone secondary to bilateral oophorectomy may lead to increased osteoporosis risk [43]. In the past, it was assumed that gonads which had not undergone biological puberty could not produce viable gametes. However, recent case reports document successful pregnancies and healthy infants born to individuals who had prepubertal gonadal cryopreservation [44]. Additionally, there is more data supporting the viability of cryopreserved gametes or gonadal tissue for transmen [45]. For individuals who have undergone natal puberty, pre-hysterectomy egg retrieval requires discontinuation of testosterone and induction of superovulation with female hormones. The process requires multiple transvaginal ultrasound examinations and transvaginal aspiration of eggs. This may cause an intolerable level of gender dysphoria and is therefore not a viable option for many trans masculine patients. Recently some fertility centers are offering ovarian tissue biopsy with cryopreservation prior to or concurrently with gender-confirming surgery. Unfortunately, this is not covered by most insurance plans and is very costly. Some centers have initiated research trials, however, in which patients may participate free of cost. In our institution, we offer unilateral gonad preservation and perform total hysterectomy with unilateral gonadectomy, as well as concurrent bilateral risk-­ reducing salpingectomies for ovarian cancer risk reduction. This gives an individual the opportunity to retrieve eggs at a later date followed by removal of the ovary (staged gonadectomy) if desired. Testicular biopsy with cryopreservation is also available at some fertility centers for trans ­feminine women. In the future, stem cell retrieval may be a viable option for producing haploid

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gametes for individuals to produce genetic offspring [46]. Hysterectomy options include total hysterectomy which involves the removal of the uterus and cervix or subtotal (supracervical or partial) hysterectomy which involves removal of the uterus but retention of the cervix. Hysterectomy is often performed with concurrent removal of the Fallopian tubes and ovaries (salpingo-oophorectomy). There are three surgical approaches for hysterectomy. The traditional approach is the abdominal hysterectomy, which is performed through a Pfannenstiel incision, a relatively large abdominal incision. This is no longer supported as a first choice due to significant postoperative pain, the necessity for inpatient hospitalization, and long recovery times. The preferred options are now vaginal hysterectomy or laparoscopic hysterectomy, which compared to abdominal hysterectomy offers the benefits of smaller incisions, less operative blood loss, lower infection rates, less intraabdominal adhesion formation, quicker return of bowel function, lower rates of ileus, less postoperative narcotic use, faster recovery, and greater patient satisfaction [47]. Hysterectomy is medically necessary and indicated for the treatment of gender dysphoria in transgender men [48]. It allows trans masculine patients to permanently stop having periods, which may reduce gender dysphoria as well as decrease lifetime risk for gynecologic cancers. It also helps patients who want to progress to gender confirmation surgeries such as metoidioplasty and phalloplasty. Many trans masculine patients report chronic pelvic pain, and this is an accepted indication for hysterectomy. However, the diagnosis of gender dysphoria or gender incongruence alone is sufficient to perform hysterectomy and does not require any additional diagnosis [49]. Hysterectomy must be performed prior to vaginectomy as failure to do so can result in delayed diagnosis of uterine or cervical cancer. Cervical cancer screening (Pap smear) cannot be obtained if a vaginectomy is performed. Therefore, patients wishing to retain their uterus or cervix must have vaginal access for testing. One of the

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most common symptoms of uterine or cervical cancer is vaginal bleeding, which would not be detected in patients who have undergone vaginectomy. Most trans masculine patients want complete removal of the uterus, cervix, tubes, and ovaries and keeping any part of the female reproductive system may lead to persistent gender dysphoria. Informed surgical consent should include counseling regarding risks, benefits, and alternatives to ovarian removal, as well as the fertility-­ related consequences associated with these choices. Studies show cisgender women who undergo hysterectomy but retain their ovaries have lower incidences of cardiovascular disease, osteoporosis, colon cancer, and all-cause mortality. The Nurses’ Health Study concluded that “For women younger than 50 at the time of hysterectomy, bilateral oophorectomy was associated with significantly increased mortality in women who had never-used estrogen therapy. At no age was oophorectomy associated with increased overall survival” [50]. Therefore, there may also be other non-­ fertility-­ related long-term health benefits for trans masculine patients who retain their ovaries. Our program has provided trans masculine patients the option of staged (deferred) gonadectomy with hysterectomy. It is reasonable to offer to keep one gonad or both if a patient might want to be a genetic parent in the future and they do not want to are unable to undergo or afford egg freezing or ovarian tissue biopsy with cryopreservation. For patients retaining one or both ovaries, it is prudent to remove both Fallopian tubes to decrease lifetime risk for ovarian cancer in trans masculine patients. Genetic history should be obtained for screening familial hereditary breast ovarian cancer syndrome with BRCA gene mutation. If they are at risk and test positive for BRCA gene carrier status, both tubes and ovaries should be removed because they would be at increased risk for ovarian cancer. Testosterone induces a dose-dependent amenorrhea and subsequent hypoestrogenic vaginal atrophy in individuals who have undergone an estrogen-induced puberty. Testosterone leads to

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anovulation, which in turn leads to hypoestrogenism, and then endometrial and vaginal atrophy. Testosterone typically induces reversible atrophic changes on the uterine endometrium [51]. Obese trans masculine patients may be at higher risk for endometrial hyperplasia due to aromatization of exogenous testosterone to estrogen. Endometrial biopsy may be indicated prior to hysterectomy for patients at risk for endometrial hyperplasia or cancer [52]. Hypoestrogenic vaginal atrophy is associated with reversible thinning of the tissue as well as loss of collagen and microcirculation. This often leads to a decreased the elasticity and caliber of the vagina limiting surgical access and visualization from below as well as delayed wound healing [53]. Surgeons may elect to have patients use vaginal estradiol cream or estradiol rings for 2–4 weeks before hysterectomy to facilitate access and improve blood flow to the suture line. Although the use of vaginal estradiol may cause increased dysphoria for some trans masculine patients, many are willing to use estradiol vaginally for short term if they are counseled regarding the potential benefits of faster healing and quicker suture absorption. The decision to use vaginal estrogens should be made on a case to case basis. The American College of Obstetricians and Gynecologists (ACOG) recommends vaginal hysterectomy as the approach of choice. It is associated with better outcomes compared to other routes for hysterectomy. Laparoscopic hysterectomy is preferable to open abdominal hysterectomy “for those patients in whom a vaginal hysterectomy is not indicated or feasible” [54] Obedin-Maliver and colleagues demonstrated that vaginal hysterectomy is a safe and viable option for some trans masculine patients [55]. The most superior aspect of the vagina is typically excised with a total hysterectomy. Trans masculine patients who desire to retain their vagina should be counseled regarding the pros and cons of supracervical hysterectomy versus total hysterectomy. Vaginectomy can be combined with hysterectomy or performed at a later date with urethral lengthening prior to metoidioplasty or phalloplasty. Current vaginectomy techniques vary

K. T. Hsiao

among gender-confirming surgeons. Vaginectomy may be performed vaginally or laparoscopically. Robot-assisted total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and vaginectomy for trans masculine patients has been reported in the Netherlands [56]. Complications of hysterectomy and vaginectomy include but are not limited to hemorrhage, bladder or bowel damage, infection, injury to other adjacent structures, pelvic adhesions, chronic pain, and postoperative fistula formation. Distal vaginectomy may be deferred until urethral lengthening is performed to allow distal vaginal mucosa to be utilized for a neo-urethral flap. Alternately, complete vaginectomy can be performed and immediately followed by urethral lengthening, with metoidioplasty. This may be followed by phalloplasty. We recommend a minimum of 3  months healing time after hysterectomy prior to phalloplasty depending on the patient’s health and type of suture utilized to close the vagina. Hysterectomy may be combined with gender-confirming chest surgery or metoidioplasty. We do not recommend combining hysterectomy with phalloplasty on the same day as this requires an unacceptably long operative and anesthetic time for the patient. Some transgender and gender-diverse patients have requested non-binary surgeries, and surgeons should not assume that all transgender patients want to replicate cross-gender binary anatomy. Surgeons may consider the option of retention of natal reproductive organs with non-­ binary, gender-confirming surgery. Ultimately, clinicians should respect transgender patients’ right to self-determination. Thorough informed consent documents that the patient was educated and given an opportunity to review the risks, benefits, limitations, and alternatives to any gender-confirming procedure. This is an essential ethical and legal portion of the preoperative visit [57]. A discussion of fertility preservation options is a vital part of this informed consent process. Although research demonstrates that a majority of trans masculine patients are interested in parenting, most do not elect to preserve fertility by egg or ovary freezing or gonad conservation. Commonly

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cited reasons are cost, access, and not wanting to delay gender-confirming surgery. More legal advocacy is needed to succeed in having fertility preservation benefits covered by health insurance for transgender and gender-­diverse patients. There is a robust surge nationally and internationally of research on health issues for transgender and gender-diverse individuals. Clinicians and surgeons are developing evidence-based best practice guidelines for gender-confirming surgery. It is important to continue to support transgender patients’ goals of living self-determined and gender congruent lives.

References 1. Parenting intentions among transgender individuals. 17 Feb. 2017. http://online.liebertpub.com/doi/ full/10.1089/lgbt.2016.0153. Accessed 15 Jul 2017. 2. IJ TRANSGENDER  – The Desire to have Children and the ....” https://www.atria.nl/ezines/web/IJT/9703/numbers/symposion/ijtvo06no03_02.htm. Accessed 15 Jul 2017. 3. Reproductive wish in transsexual men.  – NCBI. https://www.ncbi.nlm.nih.gov/pubmed/22128292. Accessed 15 Jul 2017. 4. Transgender parenting – Williams Institute – UCLA. edu. https://williamsinstitute.law.ucla.edu/wp-­ content/uploads/transgender-parenting-oct-2014.pdf. Accessed 15 Jul 2017. 5. The ethics of helping transgender men and women have ...  – NCBI. https://www.ncbi.nlm.nih.gov/ pubmed/20173295. Accessed 15 Jul 2017. 6. Access to fertility services by transgender persons: an Ethics ... – ASRM. http://www.asrm.org/globalassets/ asrm/asrm-content/news-and-publications/ethicscommittee-opinions/access_to_care_for_transgender_persons.pdf. Accessed 12 Jul 2017. 7. Standards of Care (SOC)  – WPATH. http://www. wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926. Accessed 11 Jul 2017. 8. Endocrine treatment of transsexual persons: an endocrine society .... https://academic.oup.com/jcem/ article/94/9/3132/2596324/Endocrine-Treatment-ofTranssexual-Persons-An. Accessed 15 Jul 2017. 9. Health care for transgender individuals  – ACOG.” https://www.acog.org/Resources-And-Publications/ Committee-Opinions/Committee-on-HealthCare-for-Underserved-Women/Health-Care-forTransgender-Individuals. Accessed 15 Jul 2017. 10. WHO | Eliminating forced, coercive and otherwise involuntary .... http://www.who.int/reproductivehealth/publications/gender_rights/eliminating-forcedsterilization/en/. Accessed 16 Jul 2017.

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122 26. Prophylactic oophorectomy: preventing cancer by surgically removing .... 14 Apr 2014, http://www. mayoclinic.org/tests-procedures/oophorectomy/indepth/breast-cancer/art-20047337. Accessed 16 Jul 2017. 27. Gonadal dysgenesis and gynecologic cancer. – NCBI. https://www.ncbi.nlm.nih.gov/pubmed/20664451. Accessed 15 Jul. 2017. 28. What are the risk factors for testicular cancer. 12 Feb 2016., https://www.cancer.org/cancer/testicularcancer/causes-risks-prevention/risk-factors.html. Accessed 15 Jul 2017. 29. Ovarian tissue cryopreservation in female-to-male transgender people .... 21 Mar 2017, https://www. ncbi.nlm.nih.gov/pubmed/28372892. Accessed 15 Jul 2017. 30. A long-term follow-up study of mortality in transsexuals receiving .... 1 Apr. 2011, http://www.eje-online. org/content/164/4/635.full. Accessed 15 Jul 2017. 31. Estrogen, hormonal replacement therapy and cardiovascular disease. https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3123884/. Accessed 16 Jul 2017. 32. National LGBT Cancer Network Ovarian Cancer in Transgender Men. http://cancer-network.org/cancerinformation/transgendergender-nonconforming-people-and-cancer/ovari an-cancer-in-transgender-men/. Accessed 17 Jul 2017. 33. Evidence Points to Fallopian-tube Origins of Ovarian Cancer – Medscape. 21 Apr 2015., http://www.medscape.com/viewarticle/843469. Accessed 16 Jul 2017. 34. SGO Clinical Practice Statement: salpingectomy for ovarian cancer .... https://www.sgo.org/clinicalpractice/guidelines/sgo-clinical-practice-statementsalpingectomy-for-ovariancancer-prevention/. Accessed 16 Jul 2017. 35. Salpingectomy for ovarian cancer prevention – ACOG. https://www.acog.org/Resources-And-Publications/ Committee-Opinions/Committee-on-GynecologicPractice/Salpingectomy-for-Ovarian-CancerPrevention. Accessed 16 Jul 2017. 36. Salpingo-oophorectomy at the Time of Benign Hysterectomy: A ...  – NCBI. https://www.ncbi.nlm. nih.gov/pubmed/27500347. Accessed 16 Jul 2017. 37. Association between polycystic ovary syndrome and female-to-male .... https://www.ncbi.nlm.nih.gov/ pubmed/17166864. Accessed 15 Jul 2017. 38. The role of AMH in anovulation associated with PCOS: a hypothesis. 25 Apr 2014., https://www.ncbi. nlm.nih.gov/pubmed/24770999. Accessed 15 Jul 2017. 39. Antimüllerian hormone levels decrease in female ...  – Fertility and Sterility. https://www.fertstert.org/ article/S0015-0282(15)00125-9/fulltext. Accessed 15 Jul 2017. 40. Excessive androgen exposure in female-to-male ... – Oxford Academic. 27 Nov 2012., https://academic. oup.com/humrep/article/28/2/453/596664/Excessiveandrogen-exposure-in-female-to-male. Accessed 15 Jul 2017.

K. T. Hsiao 41. Polycystic Ovary Syndrome (PCOS) – ACOG. https:// www.acog.org/Patients/FAQs/Polycystic-OvarySyndrome-PCOS. Accessed 16 Jul 2017. 42. Long-term mortality associated with oophorectomy compared with .... https://www.ncbi.nlm.nih.gov/ pubmed/23635669. Accessed 15 Jul 2017. 43. Testosterone increases bone mineral density in female-to-male .... https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3098904/. Accessed 17 Jul 2017. 44. Live birth after autograft of ovarian tissue cryopreserved during ...  – NCBI. https://www.ncbi.nlm.nih. gov/pubmed/26062556. Accessed 15 Jul 2017. 45. Fertility options in transgender people.  – NCBI. 19 Nov 2015., https://www.ncbi.nlm.nih.gov/ pubmed/26835612. Accessed 16 Jul 2017. 46. Reconstitution in vitro of the entire cycle of the mouse female germ line. https://www.ncbi.nlm.nih.gov/ pubmed/27750280. Accessed 16 Jul 2017. 47. Choosing the route of hysterectomy for benign disease  – ACOG. https://www.acog.org/ResourcesAnd-Publications/Committee-Opinions/ Committee-on-Gynecologic-Practice/Choosingthe-Route-of-Hysterectomy-for-Benign-Disease. Accessed 17 Jul 2017. 48. Medical Necessity Statement  – WPATH. http:// www.wpath.org/site_page.cfm?pk_association_webpage_menu=1352&pk_association_webpage=3947. Accessed 17 Jul 2017. 49. Role of hysterectomy in the treatment of chronic pelvic pain. – NCBI. 50. Oophorectomy: the debate between ovarian conservation and elective .... https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3514564/. Accessed 12 Jul 2017. 51. Effect of long-term testosterone administration on the endometrium of .... 29 Jun 2009., https://www. ncbi.nlm.nih.gov/pubmed/19570144. Accessed 16 Jul 2017. 52. Histology of genital tract and breast tissue after long-­ term testosterone .... 24 Dec 2009., https://www.ncbi. nlm.nih.gov/pubmed/20122869. Accessed 16 Jul 2017. 53. Effects of long-term high dose testosterone administration on vaginal .... 4 Apr 2013., https://www.ncbi.nlm. nih.gov/pubmed/23552580. Accessed 16 Jul 2017. 54. Committee Opinion, Number 701, June 2017, Choosing the ...  – ACOG. 7 Jun 2017, https://www. acog.org/-/media/Committee-Opinions/Committeeon-Gynecologic-Practice/co701.pdf?dmc=1&ts=201 70607T2329397687. Accessed 16 Jul 2017. 55. Feasibility of vaginal hysterectomy for female-to-­ male transgender .... https://www.ncbi.nlm.nih.gov/ pubmed/28178042. Accessed 16 Jul 2017. 56. Robot-assisted laparoscopic colpectomy in female-to ...  – NCBI  – NIH. 14 Nov 2016., https://www.ncbi. nlm.nih.gov/labs/articles/27844235/. Accessed 16 Jul 2017. 57. Informed consent: an ethical obligation or legal compulsion?. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2840885/. Accessed 16 Jul 2017.

Penile Inversion Vaginoplasty

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Jess Ting and Marci Bowers

Introduction Vaginoplasty is one of the most commonly performed gender-affirming surgeries. It is frequently the first operation sought by patients undergoing male-to-female surgical transition. It eliminates a major source of discomfort and distress and enjoys a high rate of patient satisfaction. It is a unique melding of gynecology, urology, and plastic surgery and, when well-executed, can produce an outcome that is aesthetically indistinguishable from a cis-vagina and functionally able to accommodate receptive penetrative sexual intercourse, urination while sitting, and erogenous sensation.

History Widely credited with having been the “world’s first surgical change of sex,” Lili Elbe’s operation in 1933 at Dresden, Germany, ultimately resulted in the patient’s demise due to complications. Even prior to Lili Elbe, there are documented J. Ting (*) Department of Plastic and Reconstructive Surgery, Center for Transgender Medicine and Surgery, Mount Sinai Hospital, New York, NY, USA e-mail: [email protected] M. Bowers Mills-Peninsula Hospital, Burlingame, CA, USA San Mateo Surgery Center, San Mateo, CA, USA

examples of people who were gender nonconforming. For example, eunuchs, voluntarily castrated cis males, are documented as early as Biblical times. American Indians recognized more than two genders, and people who were gender nonconforming were respected and celebrated in their communities. Modern surgical history has evolved rapidly since its origins in inter-war Germany, particularly built upon the surgical innovations of gynecologist Georges Burou, who practiced in Casablanca in the 1950s–1970s. From the early simple penectomy-type operations, the surgical focus has paralleled social advances in feminist attitudes toward sexuality  – in particular, the increasing importance of clitoral sensation and aesthetic appearance of the vulva.

Embryology Although the layperson’s perception is that male and female bodies are distinct and wholly separate universes, genitalia formation has significant homology between the sexes and is better understood as a continuum between female and male. This is best appreciated by the many biologically relevant intersex conditions ranging from lack of receptor function (androgen insensitivity syndrome, 46XY) to chromosomal abnormalities (Klinefelter’s syndrome, 47XXY) to (likely) in utero estrogen exposure (hypospadias).

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_14

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Hypospadias, in particular, highlights the continuum in genitalia, whose most severe form is distinctly female in its morphology. So too, gonadal structures arise in both male and female from the gonadal ridge, the penile head and clitoris from the genital tubercle, and the labia majora and scrotum from labioscrotal folds. With the possibility of diversity within genital formation, it is hardly surprising that we are seeing unprecedented variety in degrees of “maleness” and “femaleness” on the spectrum of gender identity.

Fig. 14.2  Penile skin flap after inversion

Overview of Surgical Technique There are a variety of operative techniques for vaginoplasty. In this chapter, we focus on penile inversion vaginoplasty. The fundamental concept of penile inversion vaginoplasty is that the penile skin envelope is preserved as a pedicled skin flap and inverted into a cavity that is created between the rectum and urethra (Figs. 14.1, 14.2 and 14.3). This inverted penile skin flap becomes the lining of the vagina. Usually, the penile skin flap is extended by a full-thickness skin graft to achieve adequate depth (Fig. 14.4). The erectile portions of the penis are discarded, while a part of the glans is preserved as a sensate, island flap to become the clitoris. The urethra is shortened, and the labia majora and labia minora are formed from the skin and subcutaneous tissue adjacent to the penile base and scrotum.

Fig. 14.3  Dilator inside inverted penile skin flap

Fig. 14.4  Scrotal skin graft

 eometric Limitations of Penile G Inversion Vaginoplasty

Fig. 14.1  Penile skin flap prior to inversion

The main geometric limitation of penile inversion vaginoplasty is that the pedicle of the penile skin flap lies anteriorly in the perineum, while the vagina is situated posteriorly. Advancing the penile skin flap posterior enough for appropriate vaginal positioning results in high tension at the

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Indications We follow current WPATH standards of care for vaginoplasty.

Fig. 14.5  Backcutting the skin flap prior to insert

suture line, which can cause anterior migration of the vaginal introitus over time. This results in an aesthetically undesirable posterior vaginal skin web and angulation of the introitus, both of which interfere with penetrative intercourse. To prevent this complication, the penile flap is split in the posterior midline before it is inset (Fig.  14.5). This mitigates anterior tension on the skin flap but also decreases the effective amount of penile skin available to line the vagina. This can be compensated for by increasing the size of the skin graft. In patients with a small amount of penile skin or high BMI, the entire vaginal cavity may consist of only skin graft because of this geometric limitation.

Goals The goal of vaginoplasty is to create a vagina and external genitalia that are aesthetically and functionally similar to the cis-female genitalia. This includes creation of external genitalia such as mons pubis, labia majora, labia minora, clitoris, clitoral hood, urethra, as well as the vaginal vault itself. Functionally, the goal is to create a vagina of sufficient girth and depth for receptive penetrative sexual intercourse. Other functional goals are to create a sensate clitoris, the ability to achieve orgasm, and a shortened urethra which allows urination while sitting. The female genitalia are constructed from the existing male genital structures wherever possible. The only portions of male genitalia that are discarded are the corpora cavernosum and testes.

1 . Persistent, well-documented gender dysphoria. 2. Capacity to make a fully informed decision and to consent for treatment. 3. Age of majority in a given country. 4. If significant medical or mental health concerns are present, they must be well controlled. 5. Twelve continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones). 6. Twelve continuous months of living in a gender role that is congruent with their gender identity. 7. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

 reparation for Surgery: Medical P Clearance Patients should be medically optimized for surgery. Comorbidities should be stable and well-­ managed. In diabetic patients, HbA1c is checked, and if suboptimal, the patient is referred to an endocrinologist prior to surgery. Patients who are hypercoagulable are managed perioperatively in conjunction with a hematologist with the administration of antithrombotic agents. In patients who are seropositive for HIV, the viral load should be undetectable at the time of surgery, and the T-cell count should be adequate. The viral load and T-cell count are checked 2 weeks prior to surgery. In our series of patients, 2% of patients undergoing vaginoplasty were found to have occult HIV infection with high viral loads during the preoperative clearance. We ask that patients be free of tobacco consumption for 1  month before surgery.

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Nicotine and cotinine serum l­evels are checked 2 weeks prior to surgery. We recommend a BMI under 33 for penile inversion vaginoplasty. Patients over BMI 33 are encouraged to enter a weight loss program prior to surgery. Patients with BMI over 35–37 are required to demonstrate significant weight loss prior to scheduling a date for surgery. Patients with a BMI over 40 are contraindicated for surgery due to the markedly increased perioperative risks.

 reparation for Surgery: Social P Assessment Patients’ living situations and aftercare plans are assessed preoperatively. Patients should have safe, stable housing and a place to dilate. A private bathroom is ideal. Patients who climb more than one flight of stairs to get home are advised to find alternative living arrangements for the first few weeks after surgery. Patients are advised to have a companion for the first 2 weeks after surgery who can assist with the activities of daily living. Patients are visited daily in the postoperative period in their homes by a visiting nurse agency. Our program has trained local visiting nurses in cultural competency and the specific nursing needs of our vaginoplasty patients, and this has proven invaluable to our practice and our patients.

Age at Time of Surgery In our institution, patients over the age of 18 are able to have vaginoplasty without parental consent. Patients who are 17 years old at the time of surgery are allowed to have vaginoplasty with parental consent.

Other Considerations With the advent of pubertal suppression at young ages in the transgender population, surgeons are seeing increasing numbers of patients who present with microphallus. This presents unique chal-

J. Ting and M. Bowers

lenges for vaginoplasty as the tissues used for vaginal lining – penile skin envelope and scrotal skin – are severely lacking. Options for patients with microphallus include large full-thickness skin grafts instead of the penile skin flap to line the vagina, partial-thickness skin grafts, colon or small bowel vaginoplasty, and peritoneum lining grafts. Approximately 10% of patients in our series have had orchiectomy at the time of vaginoplasty. If the orchiectomy was done many years prior to surgery, there can be significant atrophy and shrinkage of the penis and scrotum, which makes the surgery more difficult. We advise patients not to have orchiectomy prior to vaginoplasty.

Preoperative Hair Removal Preoperative hair removal is essential. The key areas in which to remove hair follicles are the scrotum and penile shaft. We also clear a 1/2 inch area around the base of the penis. Inadequate hair removal results in hair growth inside the vagina. This is bothersome, unsightly, and difficult to correct postoperatively. We employ several electrologists for preoperative hair removal. It may take more than five sessions, each 1–2 hours long, to achieve adequate hair clearance. We have found it helpful to inject a dilute lidocaine mixture into the scrotal skin prior to electrolysis. In addition to making the electrolysis painless, it allows the electrologist to use a higher power setting and to work more efficiently. An alternative to electrolysis, we offer patients in-house laser hair removal. We utilize a dual-wavelength Alexandrite/Nd-YAG system which works well in all skin types, including dark-skinned patients. Laser treatment is virtually painless, quick, easy to perform, and, in our experience, as efficacious as electrolysis. It can take over seven sessions in some patients to achieve adequate clearance of hair using the laser. Patients with white or light gray hair are recommended to have electrolysis. Some patients have a combination of laser treatment and electrolysis. At surgery, any residual hair follicles are excised using surgical loupes

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and a small curved iris scissors. Through this multimodal approach (electrolysis, laser, and direct excision), we are able to achieve adequate hair follicle clearance in all of our patients.

Preoperative Physical Exam There are several factors that we consider when evaluating a patient on physical exam for suitability for penile inversion vaginoplasty. The first is the size and laxity of the penile skin envelope. Penile length is a major consideration. If the flaccid penile length is under 2″, making an adequate vaginal cavity may be difficult using solely scrotal skin graft. Other graft may be needed and most of the vaginal vault will consist of graft and not skin flap. Penile girth at the penile base and glans is another important factor. Even if there is sufficient penile length, small distal penile circumference is difficult to circumvent. We incise the distal end of the penile skin tube longitudinally and inset the skin graft, as a dart, in these situations. Skin elasticity is an important factor. If the skin envelope is extremely extensible and elastic, this can compensate for short length. In patients who undergo orchiectomy many years prior to vaginoplasty, it is common to see marked atrophy of the corpora cavernosum while the penile skin envelope is preserved. Another important factor is the mobility of the base of the penis. In some patients, the base of the penis is easily mobilized posteriorly to the desired location of the vagina. This makes more of the penile skin usable for vaginal lining. In other patients, particularly young and overweight patients, the skin is relatively immobile. We make note of this on the initial exam. We have observed a relationship between a history of “tucking” and how mobile and elastic the penile skin is. Patients with many years of tucking often have excessively mobile and elastic skin. This makes the surgery much easier. We note in every initial consultation whether there is a history of penile tucking. Patients who do not tuck are encouraged to do so in the period between the initial consultation and the surgery date, which can be over a year in our practice.

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Urethral Injury It is possible to injure the urethra during the creation of the vaginal pocket. When this occurs, the injury is repaired in layer and the Foley catheter is left in for an extra week. We had two patients with urethrovaginal fistulas postoperatively. They were diagnosed by pelvic exam. Both were asymptomatic and were not treated.

Rectal Injury and Fistula Rectal injury is possible during the dissection of the vaginal pocket. If recognized, the injury is repaired in layers. Colorectal surgery is consulted intraoperatively to assist. In the first author’s series of 200 primary vaginoplasties, there were no recognized intraoperative rectal injuries. After repair, the suture line is checked for integrity by insufflating the rectum with air. Even without a recognized injury to bowel intraoperatively, it is possible to develop a rectovaginal fistula. In our series of patients, there was one patient who developed a rectovaginal fistula at 5 weeks postoperatively. There was no known rectal injury in this patient. The fistula began with the passing of flatus from the vagina and progressed to frank feces. A bimanual exam revealed a 1 cm defect 5 cm proximal to the anus. This fistula was treated by placing the patient on stool softeners. The fistula healed in 2 months, but the patient became reticent with dilation and developed shortening of the vagina. This patient will be scheduled for a deepening of the vagina.

Surgical Technique 1. Surgery is usually done under general anesthesia. In rare circumstances, it is also possible to perform surgery under spinal or epidural anesthesia. 2. Dilute local anesthesia with epinephrine is used – it decreases intraoperative blood loss, intraoperative anesthetic requirements, and postoperative pain. We use a mixture of 60  cc of 1% lidocaine with 1:100,000 epi-

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nephrine and 40  cc of 0.25% Marcaine diluted with normal saline to a total volume of 300 cc. 3. The patient is positioned supine on the operating room table. After administration of general anesthesia, the patient is repositioned in the dorsal lithotomy position. Care is taken not to hyperflex the hips as this can result in neuropraxic injury of the sciatic nerve. Symmetry between the legs is verified and then the patient is prepped from umbilicus to knees. To minimize nerve compression in the arms, we fold the arms across the chest and hold them in place with a bedsheet and clamp. We use the Lindeman drape for the operative field which incorporates a sterile rectal condom (Fig. 14.6). 4. 60 cc of dilute local anesthesia is infiltrated into the scrotum and penile skin and mons pubis. 5. A butterfly-shaped incision is drawn. The lateral incisions are placed in the groin creases (Figs. 14.7 and 14.8). In a thicker or heavier patient, the scars can be placed slightly more medially to allow easier closure. Some surgeons place the lateral incisions much more medially which results in a suture line with less tension but produces scars in the center of the vulva where they are more visible. Figure 14.7 depicts the posterior aspect of the incision. The crosshair marks the position of the neovagina, which is determined by palpation. The posterior extent of the incision is placed 2 cm posterior to the neovagina position. Figure 14.8 marks the anterior extent of the incision, which usu-

Fig. 14.6  Positioning and draping

ally lies just at the ventral base of the penis. The position of this anterior incision is determined by pulling the skin at the base of the penis posteriorly and estimating how much scrotal skin can be removed while still allowing the incision to close without tension (Fig.  14.9). This is one of the critical decision points in the operation. If desired, a 1–2-cm zone of skin adjacent to the posterior incision can be deepithelialized and used to underlay the posterior suture line, providing

Fig. 14.7  Marking the site of the neovagina (cross)

Fig. 14.8  Marking of incisions

Fig. 14.9  Checking tension on the proposed anterior suture lines

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a second layer of the dermis in this vulnerable area. 6. Scrotal skin graft is harvested with the scalpel or electrocautery. In very thin patients, the skin graft can be harvested at the depth of a full-thickness skin graft. In heavier patients, varying amounts of fat can be harvested with the skin graft to prevent excessive fullness of the labia. An assistant defats and thins the skin graft on the back table using curved Mayo or Metzenbaum scissors or a scalpel. The graft can be stabilized to the back table with clamps. Residual hair follicles on the deep surface of the skin graft are excised with the iris scissors or cauterized with the Colorado tip Bovie. 7. The skin graft, which forms the deepest portion of the neovagina, is sutured around the deep end of the largest vaginal dilator using absorbable interrupted or continuous sutures to create a “sock” of skin graft (Fig. 14.10). The length of this graft can be decreased if there is a large penile inversion skin flap or increased when there is insufficient penile skin. The combined length of the penile inversion flap and the full-thickness skin graft should equal the depth of the neovaginal pocket. 8. The orchiectomy is done through the midline. Electrocautery is used to divide all but the deepest layer of tunica vaginalis. Once the correct plane is reached, it is possible to do the majority of the orchiectomy with gentle blunt dissection. The peritoneal plane is not violated, and the testes are isolated on their sper-

matic cords to the level of the external inguinal ring. Local anesthesia is infiltrated into the proximal spermatic cord, and the cords are suture ligated with 0 Vicryl and divided with the electrocautery. The proximal cord is inspected for hemostasis and then allowed to retract into the inguinal canal. Some surgeons will suture the external inguinal ring closed. 9. Degloving of the penis and isolation of the penile skin flap. An incision is made circumferentially around the distal penis, just ­proximal to the glans. A traction suture of 2–0 Vicryl is placed around the distal urethral proximal to the glans. Care is taken to preserve the dorsal vein and sensory nerves to the glans penis, as this will become the neoclitoris. Blunt dissection is used to separate the skin envelope from the deep structures of the penis. In the majority of cases, the dorsal vein is left attached to the dorsal corpora cavernosum. In a minority of cases, it is necessary to ligate and divide the dorsal vein. The separation of penile skin and deeper structures is continued until a tunnel is made to the perineal incision. The degloved penis is then delivered through the perineal incision (Fig. 14.11). Figure 14.12 demonstrates the penile skin envelope (held with the forceps) after being separated from the structural elements of the penis and before being inverted. Figure 14.13 demonstrates the penile skin envelope after inversion. The penile skin flap is inverted over the surgeon’s non-dominant fingers, and any tight fibrous bands that restrict posterior

Fig. 14.10  Scrotal skin graft sutured inside-out over a dilator

Fig. 14.11  Degloved penis. Peri-testicular fat pads are stapled to the thighs to aid visualization

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Fig. 14.12  Penile skin envelope after degloving (held with forceps)

Fig. 14.14  Passing a dilator through inverted penile skin flap to check its diameter

Fig. 14.13  Penile skin flap after inversion

Fig. 14.15  Rectal dilator in place - shortened urethra cannulated with Foley catheter

mobility of the skin flap are divided in the posterior midline with Metzenbaum scissors. The penile skin flap is then tested for posterior mobility and undermined superiorly in the mons pubis as needed to allow the skin flap adequate mobility to be inverted into the neovaginal space. The largest dilator is passed through the penile flap to insure that the width of the penile skin tube is sufficient (Fig. 14.14). 10. Isolation of the urethra and corpora cavernosa. Soft tissues in the midline are divided with the electrocautery to expose the urethra and corpora cavernosa. The bulbospongiosus muscles are divided in the midline at their origin and then dissected off the bulbar urethra and underlying corpora cavernosa. This exposes the bulbar urethra. Local anesthesia is infiltrated into the bases of the corpora cavernosa and into the interval between the bulbar urethra and bifurcating corpora cavernosa. With finger traction on the bulbar urethra, the urethra is dissected away from the corpora cavernosa with the

electrocautery. This dissection is bloodless if in the correct plane. Once sufficient length of the urethra is obtained, the urethra is divided with the electrocautery and cannulated with a 16F Foley catheter (Fig. 14.15). The bladder is emptied and then the Foley catheter is clamped. After cannulation of the urethral stump, the most proximal urethra is freed from its anterior attachments. This allows the urethral meatus to be positioned correctly in the neovagina. Insufficient dissection of these attachments results in a urethral meatus that is angulated too far anteriorly. 11. Ligation of corpora cavernosa and excision of erectile tissue of the penis. The bases of the corpora cavernosa are freed from surrounding soft tissues and then ligated with 0 Vicryl figure-of-eight sutures. The corpora cavernosa are then incised in the midsagittal plane from where the bases are ligated to the glans. With an assistant holding traction on the cut edge of the corpora cavernosum, the spongy erectile tissue inside the corpora is

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Fig. 14.16  Glans penis on its neurovascular pedicle

Fig. 14.18  Glans penis (neoclitoris) sutured at level of adductor longus tendon

Fig. 14.17  Glans penis pedicle on stretch. Dorsal corpora cavernosa and erectile tissue have been removed

Fig. 14.19  Side view of lighted retractor used during pocket dissection

dissected away from the underside of the dorsal corpora cavernosa. At the base of the corpora cavernosa, a single artery and vein in each corpora are identified and clipped. The spongiosum tissue and ventral half of the corpora cavernosa are passed off the field. Figure 14.16 demonstrates what remains of the corpora cavernosum after removal of the urethra and spongy erectile tissue. The neurovascular pedicle to the glans penis lies dorsal to the preserved section of corpora cavernosum fascia. Figure  14.17 demonstrates the preserved portions of the corpora cavernosum and glans penis on stretch. 12. The neoclitoris is fabricated from the glans penis. Various parts of the glans can be used for this purpose. Commonly, an oval portion of the dorsal glans is preserved for this purpose, and the remainder of the glans penis is discarded. This segment of glans is imbricated on its deep surface with absorbable sutures to create projection of the neoclitoris. The pedicle to the glans is folded in half and

loosely tacked to the fascia over the pubic symphysis and mons pubis. The clitoris is placed just posterior to the pubic symphysis and about 2  cm anterior to the neourethral meatus (Fig.  14.18). Alternatively, the tendon of the adductor longus can be used as a landmark for clitoral placement. 13. At this point the vaginal pocket is created (Figs. 14.19, 14.20 and 14.21). The bed is a raised and the patient placed into Trendelenburg position. A soft rubber dilator is placed sterilely into the rectum through the rectal condom (Fig.  14.22). Using an 18-g spinal needle, the plane of the neovaginal pocket is infiltrated with 150  cc of dilute anesthetic solution with 1:400,000 epinephrine. With a suture placed in the bulbospongiosus muscles placed on constant upward traction, the interval between the bulbospongiosus and superficial transverse perineal muscle is developed with Bovie electrocautery. The central tendon is usually visualized at this point and divided. This

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Fig. 14.20  Surgeon’s non-dominant hand holds rectum out of the field

Fig. 14.21  Surgeon’s view of the pocket dissection

plane can be very indistinct, and care must be taken to avoid entering the rectal wall muscles. This plane follows the bulbospongiosus muscle as it makes an almost 90 degree turn to run parallel to the rectum. This plane is avascular. If excessive bleeding is noted, it is a sign of being in the wrong plane  – either the rectal wall or urethral spongy layer. With two fingers pushing the rectal wall away from the urethra, and traction on the suture in the bulbospongiosus muscle, this plane is carefully dissected with sparing use of Bovie electrocautery on low power setting and gentle finger dissection. The side wall muscles are divided almost to the level of the pelvic bones. Large vessels that are difficult to control are encountered here and may require suture ligature. Failure to adequately divide the side wall muscles will result in early postop stricture. Once the prostate is reached, the traction suture is replaced with a fiberoptic lighted retractor, and the dissection

Fig. 14.22  A soft dilator is inserted sterilely into rectum

is continued just posterior to the prostate gland. The plane of this dissection can be either anterior or posterior to the prostate fascia, but in either layer, it is largely avascular. There is a prostate venous plexus that is left anterior to the dissection plane. These veins are large but do not bleed excessively. The important landmark at this point is the Foley balloon. The angle of dissection is adjusted until the dissection plane runs just posteriorly to the Foley balloon. The seminal vesicles are encountered in this region and are notable for a brownish coloration when cauterized. Throughout this entire dissection, two fingers are kept on rectum and the rectal dilator to avoid injury to the rectum. Once the balloon of the Foley is reached, the dissection plane becomes easier to visualize. As the peritoneal reflection is approached, the dissection plane becomes filmy. The dissection is continued with Bovie electrocautery until the pocket becomes too deep for any further cautery dissection. At this point, the rectal dilator is removed, and the pocket is serially dilated with the smallest to largest dilators using only very gentle pressure. It is possible to cause a full-thickness rectal tear with the dilators, so caution is needed. Our goal is to achieve a minimal depth of 6 inches. Usually 7 inches is attainable. 14. After the pocket dissection is complete, hemostasis is achieved with Bovie ­electrocautery. The pocket is irrigated with saline. A dilator can be left in the pocket to tamponade bleeding while the urethra is inset.

14  Penile Inversion Vaginoplasty

Fig. 14.23  Scrotal skin graft extension is sutured to end of penile skin flap

Fig. 14.24  Penile skin flap is split prior to insertion into the pocket. This releases tension on the skin flap

15. The urethra is divided in the ventral midline and trimmed to the appropriate length. There are two ways to suture the urethral/clitoral junction. The spatulated urethral wall can be split in the dorsal midline for a length of 1.5  cm, and the clitoris is exteriorized through this aperture and inset with 4–0 Monocryl interrupted sutures. Alternatively, the distal cut end of the spatulated urethra can be sutured end-to-end to the ventral cut edge of the clitoris. 16. The previously fabricated “sock” of skin graft is then attached to the end of the tube of inverted penile shaft skin with interrupted absorbable sutures (Fig.  14.23) to create the entire lining of the neovagina. In this fashion, the neovagina is lined with a combination of vascularized skin flaps and skin grafts. The proximal ventral midline of the penile flap is split until the anterior tension on the dilator is sufficiently released (Fig. 14.24). Sometimes, this split of the penile flap reaches almost to the level of the skin graft.

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17. The composite of penile inversion skin flap and skin graft is then inverted into the vaginal pocket over a dilator. There should be minimal tension on the penile skin flap when the dilator is fully inserted. Too much tension indicates that the penile flaps need to be split further. This can be done in millimeter increments with the Bovie while observing the angle and tension on the dilator. The surgeon will know sufficient tension has been released when the dilator lies perpendicular to the plane of the perineum without any manipulation. There is a balancing act between tension on the skin flap and depth of the vaginal lining. Too much splitting of the penile skin flap can result in a vaginal skin envelope that is too short. Too little splitting of the penile flap will result in excessive tension of the posterior incision. This leads over time to anterior migration of the posterior fourchette of the neovagina and the formation of a posterior “skin bridge.” 18. The posterior edge of the inverted penile flap is sutured to the midline of the perineum. The vaginal pocket is packed with vaginal packing that is coated with antibiotic ointment. 19. At this point the clitoris and urethra must be exteriorized and inset. The skin is incised in the midline with the scalpel, and the clitoris and urethra are identified through this opening. The end of the Foley catheter is delivered through this opening, and then the edges of the urethral meatus, spatulated urethra, and clitoris are inset circumferentially in this aperture with interrupted and continuous sutures. 20. The groin incisions are tailor-tacked with staples. Dogears are trimmed and then the incisions are closed in layers with absorbable sutures (Fig. 14.25). 21. The clitoral hood and labia minora can be plicated with running or interrupted horizontal mattress sutures. 22. Penrose or suction drains are placed through the incisions. 23. A pressure dressing or negative pressure wound dressing is applied (Fig. 14.26). The patient is extubated and taken to the PACU.

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Fig. 14.25  After skin closure

Postoperative Considerations Dilation is critical for the success of penile inversion vaginoplasty. It must be done 2–3 times per day for the first year. Skipping even a few days of dilation can result in strictures and loss of depth. After 1 year, the dilation schedule will depend on each individual patient’s tendency to form strictures. Some patients can dilate once per week or less and still maintain the depth and width of the vaginal cavity. Others may need more frequent dilation. Regular and frequent penetrative intercourse can lessen the need for dilation after the first year. A Foley catheter is placed intraoperatively and kept in postoperatively until the packing is removed. Vaginal packing is essential to immobilize the internal skin graft and allow good “take.” Vaginal packing also tamponades bleeding. We use cotton vaginal packing imbued with metronidazole ointment. The vaginal packing remains in place for 1 week. Our preferred postoperative dressing consists of a negative pressure wound dressing set to constant pressure at −60 mmHg. The NPWT immobilizes the surgical site and allows for safe ambulation at postop day 1. Pain is lessened by the splinting and immobilizing of the skin by the NPWT dressing. Anecdotally, the use of NPWT decreases bleeding and oozing and dramatically decreases swelling. With use of the NPWT, we were able to switch from closed suction drains to Penrose drains with no loss in efficacy and a significant decrease in drain discomfort. We have

Fig. 14.26  After placement of negative pressure dressing

also anecdotally observed a decrease in early wound dehiscence with the NPWT.  We use a U-shaped sponge so that there is no compression of the pedicle of the penile inversion flap.

Complications Wound dehiscence: In our series of patients, wound dehiscence occurred between weeks 1–4 postoperatively and varied from a small posterior dehiscence (40%) [31]. Urethral problems occur commonly after phalloplasty, and additional procedures may be required. Complications include urinary tract infection, urethrocutaneous fistula, urethral stricture, urethral diverticula, and hair within the reconstructed urethra. Symptoms may include a weak urinary stream, leakage of urine from the penile shaft or scrotum, dysuria, urinary frequency, incomplete emptying, and inability to urinate [31].

References 1. Latini JM, McAninch JW, Brandes SB, Chung JY, Rosenstein D.  SIU/ICUD consultation on urethral strictures: epidemiology, etiology, anatomy, and nomenclature of urethral stenoses, strictures, and pelvic fracture urethral disruption injuries. Urology. 2014 Mar;83(3 Suppl):S1–7. 2. Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 40th ed. London: Elsevier Churchill Livingstone; 2008: Chapter 68. 3. Chancellor MB, Yoshimura N. Physiology and pharmacology of the bladder and urethra. In: Walsh PC, et  al., editors. Campbell’s urology study guide. 2nd ed. Philadelphia: Saunders; 2002: Chapter 23. 4. Karam I, Moudouni S, Droupy S, et al. The structure and innervation of the male urethra: histological and immunohistochemical studies with three-dimensional reconstruction. J Anat. 2005;206(4):395–403. 5. Yucel S, Baskin LS. An anatomical description of the male and female urethral sphincter complex. J Urol. 2004;171(5):1890–7. 6. Yucel S, De Souza A Jr, Baskin LS.  Neuroanatomy of the human female lower urogenital tract. J Urol. 2004;172(1):191–5. 7. DeLancey JOL. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170:1713–23. 8. Strohbehn K.  Normal pelvic floor anatomy. Obstet Gynecol Clin N Am. 1998;25:683–705.

E. Kocjancic and V. Iacovelli 9. Stojanovic B, Djordjevic ML.  Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders. Clin Anat. 2015 Apr;28(3):368–75. 10. Durfee R, Rowland W.  Penile substitution with clitoral enlargement and urethral transfer. In: Laub DR, Gandy P, editors. Proceedings of the second interdisciplinary symposium on gender dysphoria syndrome. Palo Alto: Stanford University Press; 1973. p. 181–3. 11. Laub DR, Eicher W, Laub DR II, Hentz VR.  Penis construction in female-to-male transsexuals. In: Eicher W, Kubli F, Herms V, editors. Plastic surgery in the sexually handicapped. Berlin: Springer; 1989. p. 113–28. 12. Djordjevic ML, Kojovic V, Bizic M, et  al. Urethral lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap. Urology. 2009;74:349–53. 13. Djordjevic ML, Stanojevic D, Bizic M, et  al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;1306–1313(29):6. 14. Djordjevic ML, Bizic MR.  Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;1431–1438(28):10. 15. Hage JJ.  Metaidoioplasty: an alternative phallo plasty technique in transsexuals. Plast Reconstr Surg. 1996;97:161–7. 16. Rashid M, Tamimy MS. Phalloplasty: the dream and the reality. Indian J Plast Surg. 2013;46:283–93. 17. Nair R, Sriprasad S. 1129 Sir Harold Gillies: Pioneer of phalloplasty and the birth of uroplastic surgery. J Urol. 2010;183(4):e437. 18. Chang TS, Hwang WY.  Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–8. 19. Rashid M, Aslam A, Malik S, et  al. Clinical applications of the pedicled anterolateral thigh flap in penile reconstruction. J Plast Reconstr Aesthet Surg. 2011;64:1075–81. 20. Upton J, Mutimer KL, Loughlin K, et al. Penile reconstruction using the lateral arm flap. J R Coll Surg Edinb. 1987;32:97–101. 21. Song C, Wong M, Wong CH, Ong YS. Modifications of the radial forearm flap phalloplasty for female-­ to-­male gender reassignment. J Reconstr Microsurg. 2011;27:115–20. 22. Schaff J, Papadopulos NA. A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients. Microsurgery. 2009;29:413–9. 23. Ramesh S, Serjius A, Wong TB, Jagjeet S, John R. Two stage penile reconstruction with free prefabricated sensate radial forearm osteocutaneous flap. Med J Malaysia. 2008;63:343–5. 24. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty. Injury. 2008;39(Suppl 3):S62–7.

17  Urethral Anatomy and Urethral Reconstruction in Phalloplasty and Metoidioplasty 25. Ozkan O, Ozkan O. The prefabricated pedicled anterolateral thigh flap for reconstruction of a full-thickness defect of the urethra. J Plast Reconstr Aesthet Surg. 2009;62:380–4. 26. Dabernig J, Schumacher O, Lenz C, Rickard R, Turner A, Dabernig W, et  al. Modern concept for treatment of the female-to-male transsexual. Urologe A. 2007;46:656–61. 27. Young VL, Khouri RK, Lee GW, Nemecek JA.  Advances in total phalloplasty and urethroplasty with microvascular free flaps. Clin Plast Surg. 1992;19:927–38.

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28. Rohrmann D, Jakse G.  Urethroplasty in female-to-­ male transsexuals. Eur Urol. 2003;44:611–4. 29. Kim SK, Moon JB, Heo J, Kwon YS, Lee KC. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64:759–64. 30. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist’s and urologist’s perspective. Acta Obstet Gynecol Scand. 2015 Jun;94(6):563–7. 31. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47(3):398–402.

MLD (Musculocutaneous Latissimus Dorsi) Phalloplasty

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Rados Djinovic

Introduction Gender confirmation surgery in transmen presents the most demanding form of genital reconstruction. It includes the removal of female genitalia in addition to the creation of male genitalia. The penis has unique characteristics and complex anatomy, and the creation of a neophallus using present surgical techniques is still far from ideal. In spite of significant improvements in aesthetic and functional results (regarding voiding and sexual function), the creation of a “normal” penis in both the flaccid and erect states and also possessing erogenous sensation remains limited. Complication rates remain high, and this encourages us to continue to strive for additional methods and techniques. The Russian surgeon Borgoras performed the first total phalloplasty using an abdominal pedicled flap in 1936 [1]. This event stimulated other surgeons to search for better solutions, and multiple techniques using free or local flaps were developed [2–6]. However, none of these techniques were able to meet all of the goals of total phalloplasty, i.e., creation of a normal-size penis that enables safe prosthetic insertion, a good aesthetic appearance, hairless and normal skin color, good tactile and erogenous sensation, a compeR. Djinovic (*) Department of Urology, Sava Perovic Foundation – Center for Genito-Urinary Reconstructive Surgery, Belgrade, Serbia

tent neourethra with the meatus at the top of the glans, and acceptable donor site morbidity. The most widely used flap for total phalloplasty is the radial forearm flap [2, 4]. However, there are many limitations of the forearm flap, including an unsightly donor site scar, frequent urethral complications, a small size that may limit safe prosthesis insertion, a soft consistency, and, oftentimes, pale skin. For these reasons, we searched for additional solutions. We began with the musculocutaneous latissimus dorsi (MLD) free flap, and we believe this procedure can satisfy most of the above-mentioned requirements. The latissimus dorsi is a reliable flap and is often used in plastic surgery for a wide array of indications. In urology, the functional latissimus dorsi flap has been used for atonic bladder to aid with better bladder emptying [7–9]. The latissimus dorsi flap has suitable anatomy (i.e., size, volume, and length of the neurovascular pedicle) to meet the aesthetic and functional needs of penile reconstruction. This flap can be also used for penile reconstruction in the pediatric population [10].

Patients and Methods Between February 2005 and June 2017, 259 total phalloplasties using the musculocutaneous latissimus dorsi (MLD) flap were performed in transgender individuals between the ages of 18 and

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61 years (mean 27 years). Phalloplasties secondary to other indications were excluded. All patients were preoperatively evaluated by a qualified psychologist/psychiatrist and were on hormone medications for at least 6 months prior to surgery. A necessary precondition for this technique is a normal or slightly increased BMI (body mass index), so as to avoid the creation of a too thick neophallus and difficult urethral tubularization in the second stage. Hormones are discontinued 1 week before the phalloplasty and resumed no sooner than 3 weeks following surgery. The donor site is prepared preoperatively with skin massage using topical emollients at least 1  month before surgery. We believe that this helps to improve skin elasticity and direct donor site closure. In six obese patients who did not lose weight prior to surgery, donor site liposuction was performed at least 3 months before surgery in order to decrease flap thickness and enable safe flap tubularization. In some patients, liposuction of the neophallus was performed following the first stage.

Surgical Anatomy The musculocutaneous latissimus dorsi flap, first described by Baudet [11], is dependable and versatile for free tissue transfer: it has a large surface area and is easily elevated based on the thoracodorsal artery. The thoracodorsal artery, arising from the subscapular artery, provides a large, long, and reliable pedicle [12–14]. 3–5 cm after leaving the axillary artery, the subscapular artery typically divides into two branches – the circumflex scapular and the thoracodorsal artery. The thoracodorsal artery continues downward and is the dominant vessel supplying the flap. There are usually two vena comitantes accompanying the artery. These comitantes join to form a single, large thoracodorsal vein prior to entering the subscapular vein. While there are many vascular branching patterns, these patterns do not tend to affect flap elevation. The thoracodorsal nerve, a branch of the posterior cervical cord, innervates the latissimus dorsi muscle.

The neurovascular hilum is positioned approximately 8–9  cm from the axillary artery and enters the deep surface of muscle 1.5–3.0  cm medial to its anterior border. The neurovascular structures typically bifurcate and run together on the deep surface of the muscle: one branch runs vertically, parallel to the anterior border of the muscle, while the other branch runs transversely, parallel to the superior border of the muscle. A large musculocutaneous flap, up to 18  cm wide and 28 cm long, can be raised on a 3–4 cm strip of muscle after dividing several reliable perforators over the anterior intramuscular branch. Also, only skin flap without muscle can be raised by careful mobilization of the pedicle from the muscle.

Surgical Technique Total phalloplasty using an MLD flap is performed in three stages (Table 18.1). Over the last 9  years, we perform the first stage, flap transfer, concurrent with (a) removal of the female genitalia (transvaginal hysterectomy with bilateral adnexectomy, colpocleisis), (b) 5–6 cm urethral advancement, (c) perineoplasty, and (d) scrotoplasty. In our initial experience, we performed a total vaginectomy (including removal of the vaginal muscle), but we abandoned this due Table 18.1  Surgical stages of total phalloplasty using musculocutaneous latissimus dorsi flap

Stages First stage

Time between stages

Surgeries Transvaginal hysterectomy, adnexectomy colpocleisis, proximal urethroplasty, perineoplasty and scrotoplasty. Neophallus creation using musculocutaneous latissimus dorsi free flap with first stage urethroplasty 6 or > Second Second stage urethroplasty: months stage neourethral plate tubularization, implantation of testicular implants Third Penile prosthesis implantation 6 or > stage months

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to problems with bladder and rectal stability secondary to loss of vaginal muscle support. To address this problem, we now remove only the vaginal epithelium and obliterate the resulting cavity with a continuous spiral suture. Following this portion of the procedure, the patient is repositioned into lateral decubitus. Positioning is aided with the use of beanbags; the upper torso is placed in a full lateral position at 90°, and the pelvis is tilted at 20–30° to provide access to the groins. This allows simultaneous flap harvest and recipient site preparation. Care is taken that there is neither excessive, nor prolonged abduction of the upper shoulder during dissection. It is advisable to harvest the flap on the nondominant side of the arm. Flap harvest begins with marking of the anterior and superior muscle border (Fig. 18.1). The projected course of the thoracodorsal artery is outlined, and the flap is designed with its base positioned over the hilum and extending 6–7.5 cm on either side of the artery. Flap dimensions are created according to the patient’s goals and the thickness and distribution of subcutaneous fat, with the goal of normal adult penile size: 12–15 cm in width and 13–18 cm in length. Flap elevation begins with incision of the anterior skin margin down to the deep fascia overlying the serratus anterior muscle; a plane is developed between the latissimus dorsi and serratus muscles, using a combination of sharp and blunt dissection. The skin of the flap is divided inferiorly and medially, cauterizing 3–4

large posterior perforating vessels originating from the intercostal vessels. The flap is elevated proximally to expose the neurovascular pedicle. The amount of muscle harvested around the vascular pedicle depends upon flap thickness – in thin patients, more muscle is harvested and vice versa. The pedicle is identified and dissected proximally to the axillary vessels (Fig. 18.2). All major branches are identified and ligated using monofilament 5–0 and 6–0 prolene/PDS ligatures, while small branches are cauterized. The thoracodorsal nerve is identified and proximally isolated from the vessels for a length of 5–6 cm. During dissection, special care is taken to avoid injury of the long thoracic nerve, which can cause winging of the scapula. The neophallus is created while the flap is perfusing on its vascular pedicle: the flap is then tubularized leaving a 3–4-cm-wide muscle surface

Fig. 18.1  Musculocutaneous latissimus dorsi flap design

Fig. 18.2  Flap elevation on a long neurovascular pedicle

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exposed ventrally. In patients who do not request urethroplasty/urethral lengthening, the flap is completely tubularized (Fig. 18.3). Prior to transferring the flap, unfractionated heparin is administered intravenously. The subscapular artery and vein as well as the thoracodorsal nerve are divided at their origin, in order to achieve maximum pedicle length and vessel diameter. The donor site defect is closed either directly or using one or two local rotational flaps (Fig. 18.4a, b). The use of a split-thickness skin graft for donor site closure was abandoned due to nonsatisfactory aesthetic results. Concurrent with the flap harvest, a second surgical team prepares the recipient site – superficial femoral artery, saphenous (or other local) vein, as well as the ilioinguinal nerve. These are dissected and mobilized through an oblique inguinal incision. A Y-shaped incision is made on the pubis for placement of the neophallus, and a wide subcutaneous tunnel is created between the two incisions. This allows for pedicle transfer from the pubis to the groin. The neophallus is fixed to the recipient area, and microsurgical anastomoses are performed under loupe magnification between the femoral and subscapular artery (end-to-side)

a

Fig. 18.3  Onsite neophallus creation, including glans

b

Fig. 18.4 (a) Direct donor site closure. (b) Donor site closure using two rotational flaps

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Fig. 18.5  Flap transfer to the pubic region Fig. 18.7  Ventral flap covering with long labia minora/ clitoral skin flap

Fig. 18.6  Microsurgical anastomoses

and between the subscapular and saphenous vein (end-to-end) using 7/8–0 Prolene sutures (Fig. 18.5). The epineural microneurorrhaphy is then completed between the ilioinguinal and thoracodorsal nerves (Fig. 18.6). The previously extended proximal urethra is joined with the neourethral plate on the ventral surface of the neophallus – the proximal portion is formed by a flap from the labia minora, and the distal portion is constructed with a splitthickness skin graft (STSG) often from the contralateral labia minora. On occasion, a skin flap from the clitoral and labia minora skin can be sufficient to cover the entire ventral neophallus (Fig. 18.7). The neurovascular bundle of the clitoris is preserved, and the clitoris is mobilized and fixed at the base of neophallus allowing for stimulation during sexual intercourse. A 14-French Foley catheter is inserted for 2.5–3 weeks. The neophallus is fixed in an elevated position for 7 days using a specially con-

structed dressing. This positioning is important to prevent flap kinking. Flap viability is assessed by clinical examination (i.e., skin color, turgor, and capillary refill). The second stage is performed at least 6  months after the first surgery. This includes a urethroplasty performed by tubularization of the previously created neourethral plate. The urethra is constructed over a 14 silicone Foley catheter (Fig.  18.8a, b). In the majority of patients, the neourethra is joined with the proximal, pars fixa, of the previously constructed urethra. However, in situations where there is a high-risk for urethral stricture, a perineal fistula is left in place. The penile urethra is dilated for a few months, and the two urethral segments are joined during the third stage. During the urethral reconstruction, care is taken to avoid overlapping urethral and skin suture lines. The glans is designed and created over the distal 4–6  cm of the flap. The glans is constructed by tangential skin incisions which are joined subdermally with the proximal phallus (Fig.  18.9). Testicular implants are usually implanted during this stage. However, in individuals where there is a concern of urethral suture line compression, testicular implants are placed in the next stage. A suprapubic catheter remains in place for 3–4 weeks, at which time patients start to void. The penile prosthesis is placed during the third stage using an infrapubic approach. In the major-

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a

b

Fig. 18.8 (a, b) Tubularized urethroplasty with glans creation in the second stage

Some patients in our series chose to forego urethroplasty due to concerns related to potential complications. In some individuals, either a perineostomy was created or a neophallus was placed on top of a metoidioplasty; this approach minimized complications associated with a urethroplasty while allowing voiding from a standing position (Fig. 18.11).

Fig. 18.9  Glansplasty

ity of patients, a three-piece inflatable prosthesis with two cylinders is chosen. In order to place the prosthesis, the flap is partially detached from the pubis, on the contralateral side from the pedicle. Using Hegar dilators, two channels are created at the border between the muscle and subcutaneous fatty tissue. Care is taken to avoid both urethral damage and distal placement of the cylinders. Infrapubically, channels are developed parallel to the pubic rami to allow for prosthetic fixation. Proximal and distal neotunica sleeves are created from hernia mesh. These are fixed proximally to the periostium of the inferior pubic rami to stabilize prosthesis (Figs. 18.10a, b). The reservoir is placed paravesically.

Results Follow-up ranged from 6 to 140  months (mean 78  months). A complete phalloplasty (all stages) was performed in 167 patients; additional 15 patients underwent also urethroplasty, 5 patients requested perineostomy, 8 patients requested metoidioplasty with phalloplasty, and an additional 21 patients are awaiting prosthesis placement. A urethral stricture developed in 32 patients. The majority of these occurred in the penile urethra, while five occurred at the junction of the proximal and penile urethra. Nine patients developed urethral diverticula at the pubic part, and five of these were treated surgically. Eight patients developed urethral fistula: two healed spontaneously, and six required surgical treatment. Penile prostheses were implanted in 172 patients; 117

18  MLD (Musculocutaneous Latissimus Dorsi) Phalloplasty

a

177

b

Fig. 18.10 (a, b) Implantation of penile prosthesis in the third stage

length and from 11 to 17  cm in circumference. Five partial and four total flap losses occurred. The donor site healed satisfactorily in 194 patients, while in the remaining patients mild to moderate scarring occurred. Fifty-nine patients required additional scar correction in the second or third stage. Infection requiring prosthetic removal occurred in 11 patients, prosthesis protrusion in 7 patients, malleable prosthesis fracture in 6 patients, inflatable prosthesis dysfunction in 4 patients, and misplacement requiring revision in 8 patients. Fig. 18.11  Total phalloplasty with perineostomy

Discussion

Fig. 18.12  Outcome 1 year after surgery

received inflatable, three-­component; 12 received inflatable, two-­component; and 43 received malleable (Fig. 18.12). Two cylinders were implanted in all patients. Nine patients did not request penile prostheses. Penile size varied from 12 to 26 cm in

Penile construction in transgender individuals presents a great challenge for the genital reconstructive surgeon. Initially, the primary indication for phalloplasty was limited to posttraumatic individuals who required surgery to retain or reconstruct their male anatomy. Today, indications have expanded to included transgender individuals, post-oncologic defects, and/or congenital deformities such as penile agenesis, micropenis, intersex conditions, or penile damage after epispadias or hypospadias repair [15, 17]. The penis is a unique organ characterized by the presence of a vascularized urinary conduit surrounded by erectile tissue, with the capacity to achieve erogenous sensibility; the complexity of the organ makes complete phallic reconstruction elusive at this moment. The ideal phalloplasty would result in the construction of an aesthetic phallus in a single surgical stage,

R. Djinovic

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provide protective and erogenous sensibility, a volume large enough to place a prosthesis, sufficient rigidity to allow sexual intercourse, patency of the neourethra, and low donor-site morbidity. While many different surgical techniques are reported using both local tissue or microvascular tissue transfer [16], we believe that the musculocutaneous latissimus dorsi flap provides the most satisfactory outcome. The main advantage of this flap is the large surface area resulting in a penis of adequate size to permit both a urethroplasty as well as implantation of a penile prosthesis. The musculocutaneous latissimus dorsi flap is easily elevated on a long and reliable vascular pedicle. This allows a direct anastomosis between the femoral artery and the flap without interposition of a vein graft. Removal of the latissimus muscle is associated with minimal donor site morbidity, which is rarely of functional significance [14]. This is especially true when only a thin muscle strip is harvested, as in our technique. Additionally, creation of the glans gives a satisfactory aesthetic appearance. Furthermore, neophallus retraction and discoloration are less likely than when a fasciocutaneous flap is used. The donor site can be closed directly and satisfactorily in most patients if it is preoperatively prepared by superficial skin massage using skin emollients to improve elasticity. We also perform preoperative liposuction of the donor area in obese patients several weeks before flap harvesting in order to decrease flap thickness and allow easier, tension-free tubularization. Implantation of the penile prosthesis is technically easier and better tolerated in a neophallus that contains muscle; the complication rates are significantly lower as compared to other flaps [18]. The disadvantage of the MLD flap is return of mild protective sensation of the neophallus which may result in a higher risk of prosthesis extrusion. However, we addressed this problem by wrapping the proximal and distal cylinders/ rods with hernia mesh and proximal fixation to the pubic bones. The issue of sexual function in the neophallus remains problematic since the flap lacks orgasmic sensitivity; erogenous sensation

is restricted to the clitoris, which is incorporated to the base of the neophallus. Psychological motivation as well as partner cooperation is mandatory for successful sexual intercourse.

Conclusions The main goals of phalloplasty include functional reconstruction, patient satisfaction, and improved quality of life. Total phalloplasty using the musculocutaneous latissimus dorsi flap is a reliable technique that allows creation of neophallus of normal size with good aesthetic appearance and functional outcomes. The MLD flap allows urethroplasty and easy implantation of a penile prosthesis that provides successful sexual intercourse in a great majority of cases. Although the neurorrhaphy is made between sensory and motor nerves, slow development of protective sensibility is present in all patients. Erogenous sensitivity and orgasm are based on the clitoris, incorporated at the base of the penis.

References 1. Borgoras NA.  Plastic reconstruction of penis capable of accomplishing coitus. Zentralbl Chir. 1936;63:1271. 2. Chang TS, Hwang WY.  Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–8. 3. Biemer E. Penile construction by the radial arm flap. Clin Plast Surg. 1988;15:425–30. 4. Sadove RC, Sengezer M, McRoberts JW, Wells MD. One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast Reconstr Surg. 1993;92:1314–23. 5. Khouri RK, Young VL, Casoli VM. Long-term results of total penile reconstruction with a prefabricated lateral arm free flap. J Urol. 1998;160:383–8. 6. Felici N, Felici A.  A new phalloplasty technique: the free anterolateral thigh flap phalloplasty. J Plast Reconstr Aesthet Surg. 2006;59:153–7. 7. Stenzl A, Ninkovic M, Willeit J, Hess M, Feichtinger H, Schwabegger A.  Free neurovascular transfer of latissimus dorsi muscle to the bladder acontractility. I. Experimental studies. J Urol. 1997;157:1103–8. 8. Stenzl A, Ninkovic M, Kolle D, Knapp R, Anderl H, Bartsch G. Restoration of voluntary emptying of the

18  MLD (Musculocutaneous Latissimus Dorsi) Phalloplasty bladder by transplantation of innervated free skeletal muscle. Lancet. 1998;351:1483–5. 9. Stenzl A, Schwabegger A, Bartsch G, Prosser R, Ninkovic M. Free neurovascular transfer of latisstmus dorsi muscle for the treatment of bladder acontractility: II. Clinical results. J Urol. 2003;169:1379–83. 10. Djordjevic ML, Bumbasirevic MZ, Vukovic PM, Sansalone S, Perovic SV.  Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Pediatr Urol. 2006;2:333–9. 11. Baudet J, Guimberteau J, Nascimento E.  Successful clinical transfer of two free thoraco dorsal axillary flaps. Plast Reconstr Surg. 1976;58:680–8. 12. Lassen M, Krag C, Nielsen I.  The latissimus dorsi flap. An overview. Scand J Plast Reconstr Surg. 1985;19:41–51. 13. Manktelow RT. Microvascular reconstruction. Berlin-­ Heidelberg: Springer-Verlag; 1986.

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14. Cormack GC, Lamberty BG.  The arterial anatomy of skin flaps. 2nd ed., revised. Edinburgh: Churchill Livingstone; 1994. 15. Perovic S.  Phalloplasty in children and adolescent using the extended pedicle island groin flap. J Urol. 1995;154:848–53. 16. Gilbert DA, Jordan GH, Devine CJ Jr, Winslow BH, Schlossberg SM.  Phallic construction in prepubertal and adolescent boys. J Urol. 1993;149:1521–6. 17. Gilbert DA, Jordan GH, Schlossberg SM, Winslow BH.  Forearm free flap for pediatric phallic reconstruction. In: Erlich RM, Alter GJ, editors. Reconstructive and plastic surgery of the external genitalia. Philadelphia: W.B.  Saunders Company; 1999. p. 327–34. 18. Hoebeke P, de Cuypere G, Ceulemans P, Monstrey S. Obtaining rigidity in total phalloplasty: experience with 35 patients. J Urol. 2003;169:221–3.

Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

19

Walter Lin and Bauback Safa

Introduction Recent advances in societal acceptance and healthcare for transgender and gender-­nonconforming individuals have highlighted gender-affirming genital surgery as a rapidly growing subspecialty. Despite the existence of a broad spectrum of gender identification, most procedures are generally categorized as feminizing or masculinizing procedures. Regarding the genital system, masculinization requires a complex series of operations to alter primary and secondary sexual organs and characteristics, which in the fullest form may include hysterectomy, oophorectomy, urethral lengthening, scrotoplasty, and phalloplasty reconstruction. One of the major conceptual challenges entails creation of a phallus de novo where no comparable structure previously existed on the body. This new structure has incredible demands from a reconstructive standpoint. Using available tissue from the body, the phalloplasty must recreate a complex three-dimensional structure to have a natural, aesthetic appearance (Fig. 19.1). The phalloplasty must integrate with the urinary system and constitute a water-tight, leak-proof conduit that can withstand repeated Valsalva pressure stresses and caustic exposure to urine, W. Lin · B. Safa (*) The Buncke Clinic, San Francisco, CA, USA e-mail: [email protected]; [email protected]

Fig. 19.1  A flat, rectangular radial forearm fasciocutaneous flap is transformed into a complex three-dimensional, sensate organ with a functioning urethra and sexual function

allowing standing micturition. The phalloplasty is also expected to be able to maintain sufficient rigidity to achieve sexual penetration. If an erectile implant is used, the phalloplasty must withstand significant repeated deforming and shearing forces that would otherwise threaten implant extrusion or exposure. Ideally the phallus would allow for neurotization to permit erogenous sensation. To add to this, the structure is expected to last for a lifetime, spanning decades. Due to such high demands, masculinizing genital surgery with phalloplasty reconstruction requires coordination of multiple medical and surgical specialties. Typically, a team of plastic, gynecologic, and urologic surgeons are required. Reconstructive goals include the formation of an aesthetically pleasant phallus and scrotum, with

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_19

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tactile and/or erogenous sensation, that allows normal sexual function and standing micturition while minimizing donor site comorbidity.

Reconstructive Options While searching for the ideal reconstruction to fulfil such demanding criteria, numerous designs have been attempted over the prior decades. Neophallus reconstruction was first reported by Bogoras in 1936 for reconstruction in a patient with penile amputation and used a pedicled abdominally based flap. A pedicled groin flap was used in 1972 by McGregor. The myocutaneous gracilis flap was described by Orticochea in 1972. However, the advent of microsurgery allowed new possibilities using free tissue transfer. Options of historical interest include prelaminated free fibula flaps[1] and latissimus dorsi flaps [2]. However, the two most common designs that have withstood the test of time remain the tubewithin-a-tube design utilizing the radial forearm free flap (RFFF) and pedicled anterolateral thigh (ALT) flaps, both of which accommodate erogenous neurotization. The tube-within-a-tube design allows for simultaneous urethral and penile reconstruction with glans formation at the time of primary construction or in a delayed stage. The RFFF was first described in 1982 by Song et al. in China [3] and was shortly thereafter used for penile reconstruction in 1984 by Chang et al. [4] Over time, it has been found to be functional, safe, and reliable with the highest reported rates of survival among the most commonly performed free flaps [5]. Advantages include a reliable and predictable vascular pedicle, flap thickness conducive to double-­tube formation, innervation density for favorable neurotization, and vascularity allowing glansplasty at the time of double tubing. Anterolateral thigh phalloplasty provides an alternative in patients desiring a more concealed donor site, who have lower urinary demands, who are high-risk microvascular transplantation, or who prefer larger phallus size. Although ALT phalloplasty is typically done as a pedicled

flap, microvascular techniques are still required for flap innervation. Occasionally, microvascular arterial and venous anastomoses are required due to inadequate pedicle length flap or the requirement for perforator-to-perforator supercharging to prevent partial flap loss due to the large flap size.

Indications/Criteria Mental Health Due to the irreversible nature and magnitude of surgery, the World Professional Association for Transgender Health (WPATH) Standards of Care guidelines recommend two formal referral letters from qualified mental health professionals. Mental health issues must be absent or well controlled. All recommended criteria are shown in Table 19.1. The length of time required to live in a gender role congruent with the gender identity provides ample opportunity for patients to experience and socially adjust in their desired gender role before undergoing irreversible surgery. Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health proTable 19.1  WPATH Standards of Care, version 7 criteria for genital surgery Criteria for metoidioplasty or phalloplasty in transmen   1. Persistent, well-documented gender dysphoria.   2. Capacity to make a fully informed decision and to consent for treatment.   3. Age of majority in a given country.   4. If significant medical or mental health concerns are present, they must be well controlled.   5. 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones)   6. 12 continuous months of living in a gender role that is congruent with their gender identity. Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional

19  Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

fessionals may request verification that this criterion has been fulfilled – they may communicate with individuals who have related to the patient in an identity-congruent gender role or request documentation of a legal name and/or gender marker change, if applicable.

Hormone Therapy Typically, a minimum of 1  year of testosterone hormone treatment is recommended before genital surgery. Patients will notice dramatic increases in facial and body hair, muscle mass, male-­pattern baldness, clitoral enlargement, and vocal deepening. The soft tissue response to hormone is essential if urethral lengthening is desired since the hypertrophied genital tissue allows for more robust reconstruction. Formulations of testosterone are typically intramuscular or transdermal and must be prescribed by a qualified health professional due to potential adverse effects, including polycythemia vera, an abnormal lipid profile, and osteoporosis. Baseline labs and bone density scans are recommended.

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tomy. The distal vaginal mucosa is often excised directly, or in some designs the anterior vaginal mucosa may be recruited as a local flap for urethral lengthening. Due to risk of bowel injury, it is preferable to ablate the proximal vagina using electrocautery. After removal of the vaginal mucosa, the remaining vaginal vault is sutured closed upon itself to eliminate dead space with great care taken to avoid deep sutures that could damage the underlying rectum. Careful tissue handling permits the use of bulbospongiosus muscle and fascial tissue for additional urethral suture line coverage. Once the vaginectomy is complete, we proceed with urethral lengthening. In our experience, we find it essential to excise a triangular portion of mucosa surrounding the periurethral fornices (Figs.  19.2 and 19.3), which benefits twofold: this eliminates blind pouches within the

 urgical Reconstruction of the Pars S Fixa Urethral lengthening entails reconstruction of the pars fixa urethra, which is the fixed segment of urethra that extends from the native urethral meatus to the clitoral head. The technique is the same for both radial forearm and ALT phalloplasty. Local tissue is recruited for tube formation, utilizing adjacent hairless labia minora tissue. Patients with inadequate tissue response to hormonal therapy may require recruitment of peri-vaginal introitus tissue based on the retrograde blood flow from the external pudendal blood supply [6]. For patients with deficient minora tissue distally, an epidermal autograft utilizing excess minora or vaginal epithelium may be used. The first and arguably most important step of pars fixa urethral reconstruction is vaginec-

Fig. 19.2  Superiorly, the markings surrounding the periurethral fornices are shown. Inferiorly, the distal vaginal mucosa is circumferentially excised

Fig. 19.3  The periurethral fornices have been excised

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Fig. 19.6  The superiorly based labia minora flaps after elevation

Fig. 19.4  Cystoscopy view of the native urethra with two surrounding periurethral fornices. Note the tendency for catheters to get caught in the blind pouch of the peri-­ urethral fornices, which makes access to the bladder difficult and potentially dangerous

Fig. 19.7  If additional length is required, lateral strips of the clitoris are de-epithelialized, allowing the ventral surface to be included in pars fixa tubing as well

Fig. 19.5 Labia minora flap markings for pars fixa formation

urethral lengthening, which potentially can complicate future Foley insertion (Fig. 19.4), and secondly this serves to decrease urinary stasis and debris accumulation. Labia minora flaps (Fig.  19.5) are then elevated in a submucosal plane from distal to proximal (Fig. 19.6). If additional urethral lengthening is necessary, an additional 1–2 cm may be gained by utilizing the ventral clitoral epithelium in tubularization, via de-epithelizing the lateral edges of the clitoris (Fig. 19.7). The pars fixa is then formed from the labia minora flaps being tubed around the native ure-

Fig. 19.8  The medial flap edges join to form the deep surface of the neourethra

thra. First, the medial labial flaps are closed in two layers to form the deep surface of the neourethra (Fig. 19.8). The lateral flap edges are then sewn together in layers, thus forming the superficial surface of the neourethra (Fig. 19.9a,  b).

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a

b

Fig. 19.10  Coverage of the most proximal pars fixa using labia minora dermal flaps. Here, dermal flaps are freed and elevated

Fig. 19.9  The lateral edges of the labia minora flaps are sutured together from the native urethra (a) up to the clitoris (b) to form a tube

Fig. 19.11 Right-sided labia minora dermal flap, anchored to the left and covering the urethral suture line

Once urethral lengthening has been completed, we reinforce the pars fixa with local tissue flaps. The excess outer labia minora skin is trimmed, and the remaining labia minora dermal flaps then close over the origin of the pars fixa urethra in a “vest over pants” fashion, providing two additional layers of vascularized tissue overlying the takeoff of the urethral lengthening suture line (Figs. 19.10, 19.11, and 19.12). The mid and distal pars fixa are covered with bulbospongiosus musculofascial flaps (Fig. 19.13). Thus, the proximal pars fixa is reinforced with vascularized soft tissue coverage via labia minora dermal flaps in addition to bulbospongiosus musculofascial flaps prior to skin closure of the perineum and scrotoplasty. The clitoris is de-epithelialized and a dorsal clitoral nerve is identified and tagged for coaptation (Fig. 19.14). The midline position for the

Fig. 19.12  The left-sided dermal flap is then reflected over the right-sided flap

phallus is marked (Fig.  19.15), and the urethral lengthening segment and clitoris are transposed via a subcutaneous tunnel to the pubic mons in preparation for anastomosis (Fig. 19.16). Passage of a coudet catheter at this point verifies the fac-

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Fig. 19.13  Coverage of the mid- and distal pars fixa using bulbospongiosus musculofascial flaps. They are sutured together, covering the urethral suture line of the mid and distal pars fixa urethroplasty

Fig. 19.14  The clitoris is reflected toward the patient’s left, and the right dorsal clitoral nerve has been isolated

Fig. 19.15  A midline elliptical skin island overlying the pubis mons is excised at the anticipated location for phalloplasty placement

ile pathway through the urethral lengthening and is left in place in preparation for urethral anastomosis.

W. Lin and B. Safa

Fig. 19.16  Here, the lengthened urethra has been transposed. Note the excellent length gain, located above the level of the adjacent mons skin

Fig. 19.17  Markings for labia minora excision and labia majora flap elevation

Fig. 19.18 Labia majora flaps are elevated for scrotoplasty

Labia majora fasciocutaneous flaps are then used for scrotal reconstruction (Fig. 19.17). The flaps are trimmed and sutured upon themselves in layers with absorbable sutures (Figs.  19.18, 19.19, and 19.20). At this point, the phalloplasty

19  Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

Fig. 19.19  Labia majora flaps are sutured for scrotoplasty. The perineum has been closed

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flaps, utilizing the radial artery and venae comitantes and cephalic vein. However, attention to detail is given to preservation of an additional superficial vein to the urethral segment if available anatomically, as well as harvest of the lateral antebrachial cutaneous nerve (LABC) and other available sensory branches if favorable, with the exception of the dorsal radial sensory nerve (DRSN). These design details and other considerations differentiate radial forearm phalloplasty from a typical radial forearm flap in planning for pars pendulans construction and an aesthetically pleasing appearance.

Preoperative Evaluation The flap is typically harvested from the nondominant forearm. A standard Allen’s test confirms the presence of an intact palmar arch. Although it may be tempting to investigate abnormal examination results with a formal interventional radiology angiogram, these studies do not demonstrate compensatory bloodflow with radial artery occluFig. 19.20  Excess labia majora tissue is excised for a sion. Even with a diminutive or incomplete arch on angiogram, with proper patient counseling, it more desirable scrotoplasty contour is reasonable to intraoperatively clamp the radial artery at the distal wrist; if the hand regains adeflap is transposed to the pubic mons, and the quate perfusion despite radial artery clamping, required urethral anastomosis, nerve coapta- then surgery may proceed with radial forearm tion, and vascular anastomoses (if applicable) harvest. Persistently abnormal perfusion may are completed. Scrotal implants are placed in a necessitate ALT phalloplasty harvest. staged fashion after healing completes, typically During flap design, attention is closely paid to at six months postoperatively minimum. the flap thickness as determined by pinch testing, as this determines whether double-tube reconstruction and glansplasty are feasible at the time of initial reconstruction. If the flap is deemed too Surgical Reconstruction Using thin – less than 0.5 cm with pinch testing – then Radial Forearm Phalloplasty glansplasty is not offered at the time of initial phalThe radial forearm phalloplasty is constructed by loplasty because of increased risk of inadequate a second team simultaneously during pars fixa blood supply to the distal glans after coronaplasty. formation. For standing micturition, a double-­ Due to the full-thickness skin flaps required for tube design is used, allowing reconstruction of coronaplasty, the subdermal plexus is no longer the pars pendulans — the distal portion of the available to provide bloodflow to the distal glans. There is no strict upper limit to flap thickness reconstructed urethra within the phallus. The radial forearm flap used in phalloplasty that precludes reconstruction in our experience. involves elevation similar to standard forearm However, thickness quadruples with double tub-

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ing (Fig.  19.21), requiring additional skin for increased flap circumference, thus creating a larger donor defect. Furthermore, increased flap bulk inherently creates more cumulative flap edema postoperatively, which threatens flap viability. The typical optimal pinch test thickness ranges from 0.75 cm to 1.5 cm. During preoperative evaluation, note is also made of the level of hair-bearing skin. Hair removal, typically via laser or electrolysis, must be completed far ahead of surgery and decreases the risk of urethral stone formation and post void drip that occurs with the presence of large amounts of urethral hair. Fortunately, small amounts of hair are frequently asymptomatic. Patients must be counseled regarding the impact of flap elevation on existing tattoos, which in many instances may be noticeable on the external phalloplasty. If desired, tattoo removal may be completed preoperatively or postoperatively on the phalloplasty after sufficient healing, prior to nerve regeneration and sensory return. Fig. 19.21  The crosssectional view of a radial forearm flap illustrating the thickness (diameter) of the double-­tubed phalloplasty is equivalent to four times the flap thickness

Surgical Markings The double-tubed radial forearm phalloplasty flap is designed along the radial artery and just proximal to the wrist crease as shown in Fig.  19.22. Although it is tempting to harvest the most distal wrist tissue for maximum phallus length, note that placement of the flap too distally impairs wrist extension postoperatively and creates completely avoidable morbidity. The radial and dorsal flaps serve as the external surface, while internalization of the ulnar portion forms the pars pendulans urethra. When determining the maximum length of the neophallus, consideration must be given to the length of flap pedicle required from the bifurcation of the brachial artery, which is estimated using the distance from the femoral vessels to the pubic mons. In terms of flap width, the skin paddle must be wide enough to permit tensionless closure during tubing. There is no simple, specific formula used to calculate the width of the flap. Mathematically, the external flap skin should be 4π ∗ thickness. However, this calculation does not incorporate

Superficial

Inner tube

External tube Deep

Thickness of Penis (Diameter) = ~4 x flap thickness (forearm vs. thigh)

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a

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b

Fig. 19.22  The RFFF phalloplasty design is centered over the radial artery with the de-epithelialized segment placed ulnar to the FCR tendon (a, b)

Fig. 19.23  Flap design showing “whale tail” (solid outline) versus “house” (dotted line) proximal urethral extension

unaccounted, unpredictable variables of varying skin elasticity, subcutaneous tissue compressibility, and postoperative edema. As a simple rule of thumb, if the remaining forearm skin is able to be pinched together, then a sufficient amount of skin will be harvested with the flap. After determining the flap length and width, the remaining landmarks are determined. Just ulnar to the flexor carpi radialis tendon, a 1 cm strip is marked for de-epithelialization between the external and internal portions, which critically serves as the vascular bridge between the outer and inner tubes (Fig. 19.23). The proximal neourethra is designed either as a “house” or “tail” depending on the anticipated length gained with urethral lengthening, based on the soft tissue response to testosterone (Figs. 19.24 and 19.25).

Fig. 19.24  “House” urethral extension with adipofascial flap

Fig. 19.25  “Whale tail” urethral extension with adipofascial flap. Note the preservation of an additional vein along the urethral segment as well as several nerve branches

Both designs allow for obliquely oriented urethral anastomosis, but the “tail” design recruits more flap skin and is used when additional urethral length is required. However, the extent of

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“tail” length is limited by flap perfusion, which is critical to preserve as this comprises the urethral anastomosis. The urethral strip is typically 4 cm in width distally and can be widened proximally. When tubed, this design allows for comfortable passage of a 16 Fr. Foley catheter. Our group additionally harvests an adipofascial flap at the proximal urethral segment beyond the borders of the neourethra (Fig.  19.26). This provides vascularized soft tissue coverage circumferentially around the proximal neourethra and urethral anastomosis between the distal pars fixa and proximal pars pendulans urethra as discussed later in the chapter. Proximally, zigzag incisions extend from the proximal flap markings to the antecubital crease for pedicle exposure.

W. Lin and B. Safa

The radial forearm flap is raised in typical fashion under tourniquet control with additional attention to several notable nuances. The de-epithelialized skin strip is carefully harvested as thinly as possible in order to maximize preservation of the subdermal plexus for perfusion of the neourethra. The skin graft is spared for use with glansplasty later on. The urethral adipofascial flap is elevated at the proximal edge of the urethral portion (Fig. 19.26). The forearm skin is elevated off of the flap in a subdermal plane for 1–2 cm beyond the border of

the urethra. Later on, this provides vascular soft tissue coverage around the distal urethral lengthening and urethral anastomosis. The cephalic vein is harvested and traced proximally until it joins with the deep venous system via the profunda cubitalis (deep cubital vein), thus combining the superficial venous drainage with the radial artery venae comitantes (Fig. 19.27). If present, we spare the largest caliber superficial vein leading to the urethral segment (Figs. 19.25 and 19.26) and use this as a second venous anastomosis, ideally preventing venous congestion in the pars pendulans urethra. The lateral antebrachial cutaneous nerve is harvested with the flap to provide sensation to the external neophallus. Smaller branches to the medial antebrachial cutaneous nerve may run along the ulnar flap and are optional but may be used as well. (Fig. 19.25). The superficial branch of the radial nerve is preserved and left in situ in the forearm; however to avoid inadvertent thinning of the flap, the nerve is elevated with the flap and subsequently freed from the flap (Fig. 19.28). Palmaris longus tendon is often harvested up with the flap if it is in proximity to the pedicle or venous plexus; otherwise it may be spared. The radial artery and venae are traced proximally until the bifurcation of the brachial artery or until enough pedicle length has been elevated. In the rare instances where the radial artery pedicle is too short for midline positioning of the phallus, vein grafting may be required.

Fig. 19.26  “Whale tail” urethral extension with adipofascial flap. Note the preserved vein at the proximal urethral segment

Fig. 19.27 Note the profunda cubitalis, joining the cephalic vein with the radial venae, thus combining the superficial and deep venous drainage systems

Flap Harvest

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a

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b

Fig. 19.28  Branches of the dorsal radial sensory nerve are initially elevated with the flap to prevent inadvertent flap thinning, and subsequently the nerves are (a) separated from the flap and (b) left in situ

Tubing After tourniquet deflation, the flap is then double-­ tubed. The pars pendulans is tubed by joining the ulnar flap edge with the ulnar de-epithelialized strip edge, utilizing a two-layer closure with absorbable suture. Particular attention is given to shallow longitudinal bites along the dermal portion to prevent disruption of the subdermal plexus. A water leak test may be tempting, but too many additional sutures may secondarily compromise vascularity to the urethra. Fig. 19.29  Coronal ridge markings. A 1  cm wide full-­ The external flap is then wrapped around thickness skin flap is marked starting 3 cm from the dorsal the pars pendulans. The radial flap edge is then glans tip sutured to the radial de-epithelialized strip edge in two layers with absorbable suture, again taking shallow bites through the de-epithelialized portion. The external epidermis is closed with a running absorbable suture. Thus the pars pendulans is enveloped completely with the vascularized forearm flap, with staggered suture lines that decrease the risk of urinary fistula.

Glansplasty At the distal flap, the urethral tube and external tube are sutured together with interrupted monocryl. The coronal ridge is then marked using a 1 cm wide skin flap, based 3 cm from the glans tip, at a point on the dorsum opposite the external suture line (Fig. 19.29). Moving ventrally, the markings gently curve distally and taper together to join at the ventral raphe (Fig. 19.30).

Fig. 19.30  Anterior curvature and tapered width of the coronal skin flap

The coronal ridge is then incised proximally and raised sharply as a full-thickness flap in a subdermal plane up to the distal marking (Figs.  19.31 and 19.32). Absorbable sutures are

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Fig. 19.31  The coronal full-thickness skin flap is elevated in a subdermal plane

Fig. 19.34  Coronal ridge with skin graft (de-epithelialized strip) in place

Fig. 19.32  Corona elevated, prior to suturing Fig. 19.35  Phalloplasty with complete glansplasty prior to harvest from the forearm

Groin Preparation

Fig. 19.33  Coronal ridge after approximating the proximal and distal marking

then used to shape the coronal ridge circumferentially (Fig.  19.33). The skin graft is then placed over the denuded subcutaneous tissue proximal to the coronal ridge, taking care to not overly tighten the graft and constrict the glans (Fig. 19.34). At this point, the phalloplasty is left in situ until ready for flap division (Fig. 19.35).

The recipient vessels are prepared. The groin contralateral to the free flap is typically used, as this minimizes the required pedicle length to the recipient vessels. An incision is made from the femoral vessels toward the recipient site overlying the pubic symphysis and along the groin crease (Fig.  19.36). The superficial femoral artery is prepared for end-to-side anastomosis. The greater saphenous vein is prepared for end-­to-­end anastomosis (Figs.  19.37 and 19.38). If a urethral vein is available in the flap, additional smaller saphenous branches are prepared as well. At this point, the patient undergoes pars fixa and pars pendulans anastomosis.

19  Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

Forearm Donor Site Closure The forearm is typically closed by the harvesting team during urethral anastomosis. In preparation for skin grafting, the large gap between the brachioradialis-­ flexor carpi radialis (BR-FCR)

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interval must be reapproximated, and the FCR tendon must be protected (Fig. 19.39). Absorbable suture is used to close the BR-FCR interval proximally and to cover the distal FCR tendon by imbricating the surrounding flexor digitorum superficialis (FDS) musculature (Fig.  19.40). A split thickness skin graft sheet from the thigh is piecrusted and inset over the forearm. The skin graft is bolstered using a negative pressure dressing, and a volar splint is fabricated. In thin patients, the skin graft contour blends well (Figs. 19.41 and 19.42) and may be camouflaged with tattooing after complete healing.

Fig. 19.36  Groin incision for exposure to the femoral artery (dotted line) and saphenous vein

Fig. 19.39  The large gap in the BR-FCR interval and the exposed FCR tendon must be addressed before skin grafting of the forearm

Fig. 19.37  Exposure of the SFA and saphenous vein. The phalloplasty has been partially inset

Fig. 19.38  Closeup of the SFA and GSV exposure

Fig. 19.40  Closure of the BR-FCR interval proximally and imbrication of muscle over the FCR tendon distally allows for a smooth vascularized bed that will readily accept a skin graft

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Fig. 19.41  Forearm donor site, volar Fig. 19.43  Adipofascial coverage of urethral anastomosis with pars fixa and pars pendulans. The Foley catheter is visualized in the neourethra

Fig. 19.42  Forearm donor site, dorsal

Pars Fixa and Pendulans Anastomosis: RFFF A guidewire is passed through the pars fixa catheter. The RFFF phallus with pars pendulans urethra is then harvested from the forearm. A new Foley is then passed retrograde through the phalloplasty pars pendulans and then passed through the pars fixa into the bladder over the guidewire. A watertight urethral anastomosis is then meticulously completed using slowly absorbable monofilament suture. The adipofascial flap along the proximal RFFF is then used to cover the urethral anastomosis and distal pars fixa, and anchored to the surrounding tissue using monocryl (Figs.  19.43 and 19.44). The sensory nerve coaptation is performed between the dorsal clitoral nerve branch and flap nerves. At this point, the microvascular anastomoses are performed consisting of an end-to-side

Fig. 19.44  Adipofascial coverage of urethral anastomosis

anastomosis to the superficial femoral artery and end-­ to-­ end anastomosis between the conjoined flap vein and greater saphenous vein and, if available, an end-to-end anastomosis between the additional urethral vein and a tributary to the saphenous vein. Implantable venous Dopplers are routinely used in conjunction with external Doppler monitoring. The phalloplasty is inset with deep dermal and running monocryl sutures, taking care that the base is not constricted during closure (Fig.  19.45). After completion, the phalloplasty is elevated away from the side of vascular anastomosis to prevent pedicle kinking (Fig. 19.46). Patients are routinely placed on bedrest until postoperative day 4 and discharged home on postoperative day 5.

19  Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

Fig. 19.45 Phalloplasty immediately postoperatively after completion

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capture arborizing branches of the lateral femoral cutaneous nerve, which runs along the deep fascia. Pinch testing estimates flap thickness, but unfortunately this is typically too thick for double-­ tube formation, and consequently the phalloplasty must be made as a single tube. A thinned out suprafascial ALT is an option but would lack neurotization due to nerve anatomy as described. If thickness precludes double-tube formation at the time of primary phalloplasty, the patient must decide whether to forego urethral lengthening and live with a single-tube phalloplasty or proceed with staged urethral reconstruction (described in the revision section below) for inner tube formation in a delayed fashion. If thigh donor site scars are unacceptable to the patient, consideration can be given to thigh tissue expander placement medial and lateral to the anticipated flap location. At the time of flap harvest, the expanded skin may allow primary closure of the thigh, thus avoiding or minimizing the use of skin grafting.

Surgical Markings Fig. 19.46  The phallus is elevated using a specialty hammock, away from the vascular anastomosis to prevent vascular kinking

 urgical Reconstruction Using S Pedicled Anterolateral Thigh (ALT) Phalloplasty The pars pendulans using the anterolateral thigh (ALT) flap is harvested by a second team simultaneously with pars fixa formation. The ALT phalloplasty is elevated in similar fashion to standard ALT flaps with particular attention to specific considerations as detailed below.

Preoperative Evaluation Pinch testing of the thigh is performed preoperatively to estimate flap thickness. To preserve sensory capacity, the flap must be harvested in a standard fashion with the underlying fascia to

The legs are typically positioned in stirrups for pars fixa formation, and due to positioning constraints, the flap is typically harvested from the right thigh for a right-handed surgeon. Perforators are identified using standard landmarks and an external Doppler probe. The flap is centered over the perforators regardless of whether a single or double tube template is used. The design is shifted distally to maximize pedicle length (Figs. 19.47 and 19.48) to allow for midline inset of the phallus. This may require de-­epithelializing the most proximal extent of the flap to allow more distal skin paddle placement. If double tubing, the urethral segment is placed on the medial thigh in order for the longitudinal phalloplasty suture line to lay ventrally.

Flap Harvest The ALT flap is harvested in standard fashion from medial to lateral in a suprafascial plane until the

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Fig. 19.47  ALT phalloplasty flap markings Fig. 19.49  A medial perforator is prepared for anastomosis to the distal descending branch of the lateral circumflex femoral artery and venae

Fig. 19.48  ALT phalloplasty flap markings. The flap is centered over the identified perforators

lateral border of the rectus femoris is encountered, at which point a subfascial plane will allow identification of perforators and capture of the lateral cutaneous femoral nerve (LCFN) and arborizing cutaneous branches. The LCFN is identified and dissected proximally in preparation for coaptation to the clitoral nerves. The remainder of the flap is elevated from lateral to medial and intramuscular perforator dissection is completed. Aggressive defatting should not be performed during this first stage, as branches from the lateral femoral cutaneous nerves run from the fascia to the skin. If inadequate perfusion is evident, the flap may be supercharged based on additional perforators. In Figs.  19.49 and 19.50, a large medial perforator from the superficial femoral system was dissected and anastomosed to the distal descending branch of the lateral circumflex femoral artery (closeup in Fig. 19.51). The remainder of the flap was perfused by the transverse branch of the LCFA.

Fig. 19.50  The flap is well perfused after supercharging of the perforator and venae comitans to the distal descending LCFA

Fig. 19.51  Closeup of the anastomosis between the medial perforator and descending LCFA

19  Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction

Tubing The flap is either formed as a single tube or double tube in the same fashion as a radial forearm flap using absorbable suture. The pleating at the urethral opening smooths over time.

Glansplasty Glansplasty is not performed at the time of primary phalloplasty formation, since the distal blood supply would be inadequate after disruption of the subdermal plexus for corona formation. Glansplasty may be performed safely two to three months postoperatively or later.

Groin Preparation and Flap Transfer A submuscular tunnel is created deep to the rectus femoris and sartorius muscles. A subcutaneous tunnel is then made to join the incision over the pubis. The flap is then delivered carefully through the submuscular and subcutaneous tunnels into the pubis. At this point the operating microscope is brought into the field for coaptation of the lateral femoral cutaneous nerve branches to the clitoral nerve. If pedicle length is inadequate for midline phallus placement despite complete pedicle dissection proximally, then conversion to a free flap using vein grafting is recommended.

Donor Site Closure The rectus femoris and vastus lateralis are reapproximated using an absorbable quill suture. The skin flaps are advanced to reduce the wound size, using similar absorbable quill sutures. A skin graft is then harvested, meshed, and inset. The skin graft is bolstered using negative pressure therapy and compressive wraps.

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 rethral Anastomosis and Closure: U ALT The ALT phallus with pars pendulans urethra is passed under the submuscular and subcutaneous tunnel into the pubis. If a double-tube design is used, a guidewire is passed through the existing pars fixa catheter, allowing exchange for the pars pendulans catheter. A watertight urethral anastomosis is then meticulously completed using slowly absorbable monofilament suture. Regardless of a single or double-tube design, the sensory nerve coaptation is performed between a dorsal clitoral nerve branch and the lateral cutaneous femoral nerve branches. The phalloplasty is inset with deep dermal and running monocryl sutures, taking care to avoid base constriction during closure. After completion, the phalloplasty is elevated toward the left thigh to prevent kinking of the underlying pedicle.

Postoperative Management Hospitalization Postoperatively, patients are maintained on bedrest for 3 days, and activity is gradually advanced on days 4 and 5. Care must be taken to prevent fluid overload, which risks flap edema and vascular compromise. The forearm or thigh negative pressure wound vacuum devices are removed on the fifth day. For RFFF donor sites, a splint is applied for another two weeks and referral is made to a hand therapist for a range of motion and strength exercises. The patient is discharged home with the urethral catheter and suprapubic tubes. The urethral catheter is removed after 1 to 2  weeks, and the following week the patient is instructed to void, roughly 3 weeks postoperatively. If voiding is uncomplicated then the suprapubic catheter is removed one week later.

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Postoperative Revision Postoperatively, patients may occasionally seek nonurologic revision. The most common types of surgery are listed in Table 19.2. Revisions that are urologic in nature, such as urethral strictures or fistulae, are beyond the scope of this chapter.

Glansplasty and Coronaplasty In some instances, glans formation cannot be performed at the time of initial phalloplasty (Fig.  19.52a), typically because of the resulting inadequate distal blood supply after disruption of the subdermal plexus required for corona formation. Glansplasty is best performed after postoperative edema resolves and tissue regains suppleness, typically in 2–3 months. The glans is shaped as described in the radial forearm phalloplasty section using a full-­ Table 19.2  Revision surgeries following phalloplasty Revision surgeries following phalloplasty Non-urologic Urologic Fistula takedown Phallopexy Stricture takedown Glansplasty Coronaplasty Urethral tube Erectile implant Debulking Forearm fat grafting Phalloplasty fat grafting Thigh skin graft excision Tattooing

a

thickness, distally based flap that is imbricated upon itself to recreate the coronal ridge. The full thickness skin graft is typically harvested from the groin and is combined with groin scar revision (Fig. 19.52b). Even with glansplasty during primary phalloplasty formation, the coronal ridge may flatten and lose prominence over time. Coronaplasty revision may be safely performed with re-­ elevation of the coronal skin flap and full thickness skin grafting the resulting defect.

Debulking Some patients who have had ALT phalloplasty construction may desire debulking procedures. In general, direct fat excision is preferred over suction lipectomy because of lower risk of injury to the underlying urethral tube and cutaneous branches of the lateral femoral cutaneous nerve.

Urethral Tube Formation In single-tube ALT phalluses, staged urethral reconstruction requires soft, supple flap tissue with enough skin laxity to allow imbrication. After initial surgery, patients undergo flap debulking as an intermediate stage. After reaching soft tissue equilibrium, the second stage is performed wherein the flap is imbricated upon itself to form an inner urethral tube. A subsequent stage is then required for pars fixa and pars pendulans urethral anastomosis. b

Fig. 19.52  Phalloplasty before (a) and after (b) delayed glansplasty. Note the full-thickness skin graft donor site incision in the right groin

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Phallopexy

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a

Due to the pendulous nature of phalloplasty, the scar at the phalloplasty base may widen over time, causing displacement of the phallus inferiorly. Correction entails “phallopexy” re-­ suspension with scar revision and a crescentic excision superiorly as shown in Fig. 19.53 a–c.

Erectile Implant Placement

b

Several implant types are available, but the most common are semirigid rods and inflatable implants. Regardless of the type used, most groups wait until at least 6 months postoperatively due to the prerequisite development of sensation in the phallus. In general, the implants are anchored to the pubic symphysis proximally, creating support with penetrative intercourse and preventing subluxation.

Fat Grafting Fat grafting may be indicated in some instances to correct forearm donor site contour abnormalities as well as treat hypersensitivity along the dorsal radial sensory nerve attributable to thin soft tissue coverage with only a skin graft. Both are correctable with serial fat grafting in a plane directly below the skin graft. In a similar fashion, fat grafting may be desired to augment the bulk of the phalloplasty reconstruction. Due to the limited vascularity of the neophallus, care still needs to be taken to avoid the vascular pedicle even when performed in a delayed fashion.

 ther Forearm and Thigh Donor Site O Revisions Skin graft along the forearm and thigh donor sites may be excised to improve thigh contour and eliminate laxity as in Figs. 19.55 and 19.55. This can be combined with fat grafting to improve the contour and tissue quality even further.

c

Fig. 19.53  Crescent phallopexy for scar widening. (a) Widened scar. (b) Crescentic excision marked. (c) Immediate postoperative appearance

Tattooing In general, tattooing of the forearm donor site is safe after complete healing and reaching soft tissue equilibrium, generally six months postoperatively. Care should be taken to avoid the radial

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Fig. 19.54  Preoperative appearance of thigh skin graft donor site

the ventral suture line should be released to allow decompression. Diuretics may be required as well. Failure to improve mandates operative exploration for release of the phalloplasty base and possible pedicle exploration. After decompression, the flap should be left unfurled and dressed with local wound care and given time to equilibrate. A skin graft to the ­ventral surface provides temporizing wound coverage allowing discharge from the hospital. After achieving supple tissue quality, the skin graft is excised at a later surgery, typically in several months’ time.

Conclusion

Fig. 19.55 Postoperative appearance after skin graft excision and contour revision

Gender-confirming surgery comprises a rapidly growing subspecialty where demand exceeds the availability of qualified surgical specialists. With proper attention to the subtleties underlying patient selection, flap design, flap harvest, urethral reconstruction, and postoperative care, radial-forearm and anterolateral-thigh phalloplasties both provide safe, aesthetic, and functional genital masculinization.

References sensory nerve branches or areas that may cause delayed wound healing.

Potential Complications Aside from typical risks of microvascular tissue transplantation, phalloplasty reconstruction additionally has complications related to urethral fistulas, strictures, and long-term urologic complications which are beyond the scope of this chapter. However, specific care must be taken to prevent excessive postoperative edema within the phalloplasty, as this can result in a compartment-­ syndrome-­like phenomenon that can result in flap loss if left unchecked. Due to the fixed circumference at the base of the phalloplasty, flap edema may compromise venous outflow. If suspected,

1. Sadove RC, Sengezer M, McRoberts JW, Wells MD. One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap. Plast Reconstr Surg. 1993;92(7):1314–23. 2. Perovic SV, Djinovic R, Bumbasirevic M, Djordjevic M, Vukovic P.  Total phalloplasty using a musculocutaneous latissimus dorsi flap. BJU Int. 2007;100:899–905. 3. Song R, Gao Y, Song Y, Yu Y, Song Y.  The forearm flap. Clin Plast Surg. 1982;9:21–6. 4. Chang TS, Hwang WY.  Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74:251–8. 5. Doornaert M, Hoebeke P, Ceulemans P, T’sjoen G, Heylens G, Monstrey S.  Penile reconstruction with the radial forearm flap: an update. Handchir Mikrochir Plast Chir. 2011;43:208–14. 6. Takamatsu A, Harashina T. Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2009;62(3):318–25.

Management of Urethral Complications Following Metoidioplasty and Phalloplasty

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Jessica Schardein, Aaron C. Weinberg, Lee C. Zhao, and Dmitriy Nikolavsky

Key Points

1. Metoidioplasty and phalloplasty are the two genital reconstructive options for transmen. 2. Complications include urethrocutane ous fistulas, persistent vaginal cavities, and urethral strictures. 3. Urethrocutaneous fistulas and persistent vaginal cavities can be repaired in a single-­stage procedure, while repair of urethral strictures may require staged surgeries. 4. Surgery must consider the patient’s unique anatomy and be consistent with the patient’s preferences. 5. Long term follow-up with a urologist is important given the high propensity for recurrent fistulas and strictures.

Introduction

J. Schardein · D. Nikolavsky (*) Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA e-mail: [email protected]; [email protected]

It is estimated that approximately 355 individuals per 100,000 consider themselves transgender or experience gender dysphoria to a varied degree and that approximately 9.8 per 100,000 seek affirmation therapy [1]. In the USA, the specific number of individuals who identify as transgender is considered to be 1.4 million or 0.6% of the population [2]. The overall percentage of individuals who pursue gender affirmation surgery ranges from 10% to 30% [3–6]. The American Society of Plastic Surgeons (ASPS) reports that plastic surgeons, in particular, have performed over 1700 transmasculine gender affirmation surgeries in 2016, which is almost a 20% increase over the past year. Patients who pursue gender affirmation surgery may also present to a urologist at various stages of their transformation for general or specialized urologic care. The urologist should be knowledgeable about the reconstructed anatomy in order to ensure the best functional and aesthetic outcomes. This chapter focuses on urethral complications following metoidioplasty and phalloplasty and the surgical techniques used to manage these complications.

A. C. Weinberg Department of Urology, New York University School of Medicine, New York, NY, USA

Gender Affirmation Surgery

L. C. Zhao Department of Urology, NYU Langone Health, New York, NY, USA e-mail: [email protected]

Reconstructive surgery for gender affirmation must be tailored to each patient’s unique anatomy and goals. Over 98% of transmen seek-

© Springer Nature Switzerland AG 2020 L. S. Schechter (ed.), Gender Confirmation Surgery, https://doi.org/10.1007/978-3-030-29093-1_20

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ing gender affirmation surgery indicate that voiding from a standing position is an important goal [7]. External “urinary assist” devices may be used to accomplish this goal; however, many transmen will choose to undergo reconstructive surgery for construction of a neourethra [8–10]. Metoidioplasty and phalloplasty are the two main reconstructive options that involve construction of a neourethra for upright voiding.

Metoidioplasty Metoidioplasty is a less complex option compared to phalloplasty. It involves construction of a cosmetic microphallus that is capable of voiding from a standing position and engaging in penetrative intercourse. Metoidioplasty is associated with less frequent complications and allows patients to avoid the increased morbidity associated with phalloplasty. Metoidioplasty involves release of the ventral chordee and lengthening of the native urethra with local vaginal and labial flaps. This is similar to proximal hypospadias repairs in pediatric patients [11]. Additional steps include resection and obliteration of the vaginal cavity for those individuals interested in colpocleisis, tubularization of the labia minora to form the distal urethra, release and elongation of the clitoris, formation of the glans, and construction of the neoscrotum and shaft of the neophallus. The resulting neourethra consists of the proximal native urethra with the meatus connected to a distal neourethra created from the labia minora.

Phalloplasty Phalloplasty is the preferred option for patients who are interested in a phallus with increased length and girth that is capable of penetrative intercourse in addition to upright voiding. The surgery involves a combination of local and distant tissue transfers to create a neophallus with sufficient dimensions for the desired functions. Anterolateral thigh or radial forearm flaps are the

most frequently used and offer the potential for tactile and erogenous sensation [12]. The neourethra can be classified into five distinct regional segments. From proximal to distal, the segments include the native female urethra, the fixed urethra (pars fixa), the anastomotic urethra, the phallic urethra (pars pendulans), and the meatus [9, 13]. The pars fixa requires lengthening with local vaginal, labial, and/or regional flaps often in conjunction with skin or mucosal grafts [9, 14]. The anastomotic urethra is the connection between the fixed and phallic urethra. The pars pendulans may be constructed with a variety of techniques, including prelamination, prefabrication, tube-in-tube techniques, and pedicle flaps [9, 10, 13, 14].

Urologic Complications Complications include urethrocutaneous fistulas, persistent vaginal cavities, and urethral strictures. Rates of urethral complications are higher with tube-in-tube anterolateral thigh pedicled flap phalloplasty compared to radial forearm free flap phalloplasty [12].

Urethrocutaneous Fistulas A urethrocutaneous fistula is the most common urethral complication following phalloplasty. The rate of fistula formation following radial forearm free flap phalloplasty is between 22% and 75% [15–19], while fistula formation following anterolateral thigh pedicled flap phalloplasty is significantly higher [12]. Fistulas may occur anywhere along the neourethra, although they most commonly occur at anastomotic sites [15, 19]. This anatomic predilection may be related to diminished vascularity of the proximal neourethra or a discrepancy between the luminal diameter of the phallic urethra compared to the fixed urethra. A diminished luminal diameter of the phallic urethra may be the result of primary flap design or secondary to contraction. This size discrepancy may cause a relative distal obstruction of urinary flow leading to more proximal fistula

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formation [19]. Similarly, relative obstruction by urethral strictures may lead to fistula formation just proximal to the associated stricture. In this way, fistulas are commonly reported in combination with urethral strictures [19]. One series reported that 40% of patients developed both fistulas and strictures, with the fistula usually proximal to the stricture [19]. Although spontaneous closure has been reported in as many as 36% of patients within two months of diagnosis, many fistulas will require surgical repair [20].

Persistent Vaginal Cavity Communication between the neourethra and a remnant vaginal cavity is not uncommon. This complication has been found in approximately half of patients undergoing neophallic construction [21]. In the presence of distal obstruction, it is suspected that pressurized urine flows through the ventral suture lines of the fixed urethra into the obliterated vaginal cavity [21]. This connection is unlikely to spontaneously close and will often require complete cavity excision and obliteration.

Urethral Strictures A urethral stricture is another common urologic complication following genital affirmation surgery (Fig.  20.1). The incidence varies between 25% and 58% [19, 22, 23]. One large series reported that 41% of strictures occur in the anastomotic urethra between pars fixa and pars pendulans, 28% in the phallic urethra, 15% in the meatus, 13% in the fixed urethra, and 8% in multiple urethral segments [13]. Mean stricture length has been reported as 3.6 cm with a range of 0.5–15 cm [13]. The majority of urethral strictures are found in combination with fistulas, which occur most commonly at anastomotic sites where blood flow may be compromised. As such, the most common etiology of strictures is ischemia [15, 22]. Additionally, when fistula formation occurs, the resulting dense scar can lead to tissue contraction and urethral stenosis [13, 23].

Fig. 20.1  Retrograde urethrogram (RUG) and simultaneous voiding cystourethrogram (VCUG) during antegrade flexible cystoscopy through a suprapubic tract showing complete obliteration at the anastomotic urethra between pars fixa and pars pendulans

Similarly, the anastomosis between the skin of the glans and the neourethra at the level of the meatus is susceptible to contracture and subsequent meatal stenosis.

Consequences of Urologic Complications It is imperative to identify and treat urethral complications in order to avoid the consequences of chronic infection, sepsis, urinary retention, renal failure, and decreased quality of life. If a patient’s health or tissue quality is compromised, it will limit subsequent reconstructive options.

Patient Presentation Voiding symptoms are unsurprisingly the most common complaints of patients who present to the urologist following transmasculine genital reconstructive surgery. Patients may complain of dysuria, suprapubic pain, dribbling, weakened stream, straining, feelings of incomplete bladder emptying, and/or urinary retention. These symptoms should raise the suspicion for a urethral

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stricture. Leakage of urine or purulent drainage from a site other than the urethral meatus is more commonly a sign of a urethrocutaneous fistula. Leakage of urine after micturition is often due to pooling of urine in the urinary tract or a persistent vaginal cavity and is not uncommon [21].

Initial Evaluation The first step is a thorough history and physical examination. Open-ended questions help elicit information regarding medical, surgical, social, and family history and enable a more complete understanding of the issues that may affect the patient during the perioperative period. The physical examination, including evaluation of the suprapubic area and the flank regions, can provide evidence regarding infection or incomplete bladder emptying. During the genitourinary examination, the neophallus and surrounding areas should be examined entirely to assess for erythema, induration, fluctuance, fistula formation, or any other abnormality. Any areas concerning for possible fluid collections can be further evaluated with ultrasound. The urethral meatus should also be examined for patency. A urinalysis and urine culture should be collected on any patient with lower urinary tract symptoms or prior to any surgical intervention. This allows for treatment of any infection with culture-specific antibiotics. A urine sample may be collected from a urinary catheter if present, however, it is important to recognize that urine samples collected from indwelling catheters may represent colonization rather than true infections. Similarly, cellulitis visualized during the physical examination should be treated with antibiotics. A uroflow and postvoid residual should be obtained on any patient with concerns of urinary retention. Since retention has the potential to cause damage to the upper urinary tracts, bladder drainage should be performed whenever retention is encountered. Suprapubic catheterization may be necessary due to the high probability of a urethral stricture.

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Imaging, such as a retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG), can be performed for further anatomic evaluation and may help to delineate stricture and/or fistula location as well as contrast extravasation into a persistent vaginal cavity. The complex anatomy may warrant an examination under anesthesia, which also allows for urinary diversion with a suprapubic catheter, if necessary. If a urologic complication is identified, the patient should be educated regarding the risks and benefits of further reconstruction versus urinary diversion via perineal urethrostomy.

 reoperative Planning and Surgical P Preparation Once the decision to pursue surgery is made, prior operative reports should be reviewed. It is important to know details regarding any previous reconstructive efforts, including the location of vascular pedicles. Other flaps, such as gracilis muscle, can be “recycled” for use in further reconstruction, if needed. For patients with urinary retention, urinary diversion with a suprapubic catheter is the first step in management. Typically, at least a 16-French Foley catheter is placed 2–3 cm above the pubis, in the midline. A large-bore catheter not only ensures adequate drainage but also ensures that there is a reliable channel for evaluation of the bladder and proximal urethra via antegrade cystourethroscopy. A RUG can be helpful during the initial patient evaluation. When combined with antegrade and retrograde endoscopy, it provides a comprehensive view of the patient’s anatomy. This is vital to preoperative planning and surgical preparation [15]. A pediatric cystoscope or urethroscope can be used when the neourethra is unable to accommodate a standard 16-French flexible cystoscope. A guidewire can ensure safe gradual advancement of the flexible scope when there is a tortuous neourethra. A simultaneous RUG may be performed by injecting contrast through the working channel of the endoscope. This tech-

20  Management of Urethral Complications Following Metoidioplasty and Phalloplasty

nique improves safety, as it allows for direct visualization, rather than blind passage into a potentially tortuous neourethra. Antegrade cystoscopy through a mature suprapubic catheter tract can further delineate proximal anatomy. Location, length, and caliber of any strictures or fistulas as well as the presence of a persistent vaginal cavity should be noted. In addition, fluid collections or abscesses should be drained, and urine and cavity cultures should be sent to determine appropriate antibiotic treatment prior to surgery. After completing the comprehensive preoperative assessment, the patient should be counseled regarding the clinical findings and expectations for surgery. This conversation should include detailed information about the surgical risks, the possibility of multistage procedures, and the risk of partial or total loss of the neophallus. The decision of which reconstructive option to pursue should be consistent with the patient’s preferences. Perineal urethrostomy is an option for those patients who prefer a less complex surgical procedure.

Unique Surgical Considerations Reconstructive surgery after metoidioplasty and phalloplasty represents a unique surgical challenge, and there are several considerations that account for this increased complexity. These include the lack of a native corpus spongiosum to cover the urethral reconstruction, the lack of available preputial and penile skin flaps commonly used in standard penile urethral reconstruction [23], and the skin, fat, and fascia that comprise the neophallus and may not serve as an ideal recipient site for a graft [19].

Additional Surgical Considerations Anesthetic considerations include positioning of the endotracheal tube. If a buccal mucosa graft (BMG) is needed, the endotracheal tube should be placed opposite the side of graft harvest. The patient is then placed in the dorsal lithotomy

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position for access to the genitalia, suprapubic region, and thighs in case of the need for a flap harvest.

Fistula Repair Techniques Fistula repair begins with cystourethroscopy for delineation of anatomy. Both antegrade and retrograde endoscopy can be helpful during the initial stages of surgery. Exposure of the cutaneous fistula tract by probing can aide in identification of the fistula within the neourethra during cystourethroscopy. Cutaneous probing with a needle, guidewire, or lacrimal duct probe into the neourethral lumen allows for easier visualization during the endoscopic evaluation. This also allows for an understanding of the trajectory of the fistula and a measurement of the distance of the urethra from the skin surface. Dissection of the fistula tract toward the light of the intraluminal cystoscope can be performed in a “cut to the light” procedure [21]. Excision of the fistula tract can be facilitated by concentric stay sutures placed at the edges of the tract. Once the fistula tract is excised, the opening into the urethra can be closed in multiple nonoverlapping layers. Flap coverage may also be performed to decrease the risk of fistula recurrence. Flap options include a fasciocutaneous groin flap or a labial fat pad flap harvested from the neoscrotum [21]. Any communicating remnant vaginal cavity or distal stricture must be repaired or there is increased risk of fistula recurrence [24].

Techniques for Obliteration of a Persistent Vaginal Cavity A remnant vaginal cavity may not be apparent during the initial or comprehensive preoperative evaluation. During reconstructive procedures, consideration should be given to identification, excision, and obliteration of any remaining cavity (Fig. 20.2). A transabdominal robotic assisted laparoscopic approach can be used to facilitate complete removal of the remaining vaginal epi-

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a

b

Fig. 20.2 (a) RUG demonstrating the presence of a large persistent vaginal cavity (contrast is not expected to be passing through a native urethra into the bladder in a continent patient), (b) injection of epinephrine-lidocaine

thelium and reduce the risk of future fistula formation [24]. A vaginal approach may also be used, although it has an increased risk of bleeding [24].

 ndoscopic Stricture Repair E Techniques There are many options for stricture repair. Endoscopic techniques such as dilation and direct visualization internal urethrotomy (DVIU) have low rates of success, and the recurrence rate is reported as high as 88% [23]. The high recurrence rate is attributed to the lack of a corpus spongiosum and poor blood supply [21]. Still, DVIU has been proposed as a reasonable ­first-­line approach for strictures less than 3  cm in length given the reported success rate of 43.8% after first time DVIU [25]. Leaving a Foley catheter for 2  weeks following the procedure allows for healing of the urethral epithelium and may lead to improved success as well [25]. A significant risk factor for failure of endoscopic intervention is a shorter time to stricture formation following neophallus construction [25].

c

solution into the epithelium of a persistent vaginal cavity prior to redo colpocleisis, and (c) intraoperative photograph showing obliteration of a persistent vaginal cavity after de-epithelialization

Urethroplasty Techniques When endoscopic treatment fails, or patients have longer or multifocal strictures, urethroplasty is the best option. The technique of urethroplasty depends upon the location and length of the stricture. Meatotomy, Heineke-Mikulicz principle, excision and primary anastomosis (EPA), free graft urethroplasty, pedicled flap urethroplasty, two-stage urethroplasty, and perineal urethrostomy are the main techniques for treatment of urethral strictures following neophallus construction [13]. A proposed algorithm for how to choose the best approach is shown below (Fig. 20.3).

Single-Stage Anastomotic Techniques When there is a relatively short stricture, single-­ stage anastomotic techniques, without the need for additional grafts or flaps, may be possible. A short stenotic segment at the meatus may be treated with meatotomy.

20  Management of Urethral Complications Following Metoidioplasty and Phalloplasty

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Stricture

Anastomotic

Phallic +/- Anastomotic

Meatal

Reliable local tissue?*

Upright voiding desired?

Meatotomy or Meatoplasty

Yes

No

Yes

No

99.8th >99.99th