Introduction

Gender affirmation surgery (formerly called sex reassignment surgery) may be sought by transgender individuals to physically change their sexual characteristics to affirm their gender identity. While not all transgender individuals choose to undergo gender affirmation surgery, surgical treatment is a medically necessary, standard-of-care intervention for gender dysphoria for many transgender patients. Gender affirmation surgery helps transgender patients transition both physically and socially, and helps alleviate the physical and emotional distress caused by gender dysphoria. Many surgical procedures including breast/chest (top) surgery, genital (bottom) surgery, and other masculinizing or feminizing facial and body procedures may be offered according to the individual’s transition goals ( Table 7.1 ). In this chapter, a brief history and the epidemiology of gender affirmation surgery are reviewed, as well as the World Professional Association for Transgender Health (WPATH) criteria for surgical treatment, recommended surgeon qualifications and training, a brief overview of the most common surgical procedures, and other perioperative considerations specific to transgender patients.

History of Gender Affirmation Surgery

Historically, Lili Elbe is regarded as one of the earliest transgender women to undergo gender affirmation surgery, and sadly died from complications related to her final surgery, a uterine transplant, in the early 1930s in Germany. The earliest accounts of a transgender man undergoing gender affirmation surgery are from the 1940s, when Michael Dillon underwent gender affirmation surgery by Sir Harold Gillies, who performed a phalloplasty using tubed abdominal flaps. In 1953, Christine Jorgenson, an American World War II veteran, drew wide media attention after she underwent male-to-female vaginoplasty in Copenhagen, Denmark, using a full-thickness penile skin graft. Shortly afterward in 1956, Dr. Georges Burou first performed the anteriorly pedicled penile inversion male-to-female vaginoplasty technique, which has since been modified and remains the primary surgical technique for male-to-female vaginoplasty.

It was not until the 1960s to 1970s when Johns Hopkins University, followed by other academic medical centers, began to offer treatment and surgery to transgender patients through its Gender Identity Clinic. Johns Hopkins University later closed the clinic in 1979 following reports of controversial outcomes, and other academic centers followed suit. Following the closure of these academic programs, gender affirmation surgery became largely privatized during the 1980s. The radial forearm free flap for phalloplasty was first described by Song et al. around this time in 1982, and shortly afterward the technique was modified by Chang and Hwang to the current tube-within-a-tube phalloplasty and urethroplasty technique. In recent years, gender affirmation surgery has experienced a resurgence in academic medical centers, with hospitals now forming centers for transgender care and providing gender affirmation surgery in high-volume, academic settings.

Epidemiology

Studies that have attempted to assess the prevalence of transgenderism in the population have been methodologically complicated by changing diagnostic criteria and terminology, the level of cultural acceptance of transgender individuals in the time and place in which the studies occurred, and access to clinical care settings for transgender patients. The vast majority of studies have been performed in the Western world (mainly Europe), with fewer studies performed in the East, and have shown widely variable prevalence of transgenderism, ranging from 0.45 to 23.6 per 100,000 people. A systematic review and meta-analysis of the available literature by Arcelus et al. showed an overall prevalence of transgenderism of 4.6 in 100,000 people; 6.8 transgender women (transwomen, assigned male sex at birth, feminine gender identity) in 100,000 people, and 2.6 transgender men (transmen, assigned female sex at birth, masculine gender identity) in 100,000 people (2.6:1 ratio of transwomen to transmen), with the overall prevalence increasing over the past 50 years. As data collection methods improve, more rigorous studies need to be undertaken to assess the prevalence of transgender people in the general population outside of clinical care settings.

In clinical experience, not all transgender patients who seek medical or hormonal care also seek surgical treatment, and individuals may choose to undergo any combination of counseling, hormonal, and surgical treatments they desire to meet their individual transition goals and needs. In a cross-sectional survey of 350 eligible transgender participants in Virginia, 57% reported receiving hormonal treatment, and only 22% reported having had chest/breast surgery (19%) or genital surgery (9%). Relatedly, the National Transgender Discrimination Survey reported 61% of 6456 eligible participants had undergone medical transition (any type of hormonal treatment), while 33% reported having undergone surgical transition (some type of transition-related surgical procedure). The majority of participants reported the desire to have some form of gender affirmation surgery in the future. In an analysis of data from the National Inpatient Sample, Canner et al. found that the incidence of genital gender-affirming surgery has increased over time, and that while most patients continue to self-pay, coverage for gender affirmation surgery by Medicare and Medicaid has increased over time. These reports, while limited by the inherent weaknesses of survey studies and large de-identified datasets, demonstrate the need for continued study into the surgical needs and preferences of transgender patients, and highlight the need for improvement in access to care, coverage for necessary gender affirmation surgical procedures, and the need for formalized training of qualified surgeons and health professionals to meet the increasing demand.

Criteria for Surgery

The WPATH (formerly the Harry Benjamin International Gender Dysphoria Association) criteria for surgical treatment are published by the association in the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People . The Standards of Care (SOC) are evidence-based, multidisciplinary best practice guidelines, formulated to assist health professionals in the care of transgender people. The WPATH SOC guide health-care professionals when determining an individual’s candidacy for gender affirmation surgery, and are intended to serve as a flexible framework that may be individualized to fit a specific patient’s needs. Criteria specific to breast/chest (top) and genital (bottom) surgery are outlined in Table 7.2 , adapted from the SOC. A referral letter from one or two (depending on the surgical procedure) qualified mental health professionals documenting the patient’s history, assessment, treatment course, and eligibility for surgery is required for breast/chest (top) and genital (bottom) surgery. While no explicit criteria exist, and no referral letter is required for other masculinizing or feminizing surgeries (e.g., facial surgery, thyroid chondroplasty, voice modification, liposuction, body contouring, body implants), a mental health professional may assist in counseling a person considering these surgeries. A thorough surgical counseling and informed consent process should always take place prior to proceeding with any surgical procedure.

Importantly, surgical candidates must have persistent, well-documented gender dysphoria, well-controlled comorbidities, and be of age and capacity to be fully informed and to consent to surgery. Additional criteria related to the use of hormone therapy and experience living in the patient’s desired gender role may also exist, depending on the procedure. Hormone therapy may be individualized or deferred in some instances if a person has a medical contraindication to hormone therapy or is unable or unwilling to take hormones. Emphasis is placed on 12 continuous months of living in the gender role congruent with the individual’s gender identity prior to undergoing genital surgery (female-to-male metoidioplasty or phalloplasty, or male-to-female vaginoplasty) to allow patients considering these procedures the opportunity to experience the social, emotional, and interpersonal changes that may occur while living in their desired gender role, prior to undergoing irreversible genital surgery.

The surgical consult visit and informed consent process for surgery should include a conversation about the individual’s goals and expectations for surgery, the risks of surgery, and the anticipated outcomes of surgery. Patients are advised that the goal of surgery is to achieve good cosmetic appearance and function; however, every patient’s body is different, and surgical results will vary from person to person. The risks of any gender-affirming surgical procedure may include bleeding or hemorrhage, the potential need for transfusion of blood products, hematoma, seroma, wound infection or abscess, wound healing issues, injury to surrounding organs, venous thromboembolism, medical complications including cardiopulmonary complications, and risks related to anesthesia. Other risks specific to the planned procedure should be emphasized, and are briefly examined in this chapter in the overview of surgical procedures section.