Surgical Management of the Transgender Patient

Loren S Schechter

• Publisher: Elsevier
• Year: 2016
• ISBN:
  9780323484084
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

Comprehensive and current, the new Surgical Management of the Transgender Patient provides coverage of the preoperative, intraoperative, and postoperative care of transgender individuals. It takes a step-by-step approach to both transmale and transfemale procedures, and presents detailed descriptions of the techniques and procedures employed by today's surgeons. Featuring full-color illustrations and photos throughout, it's a must-have resource for individuals and programs with an interest in gender confirmation surgery.

• Takes a systematic approach to the surgical management of transgender individuals, describing preoperative, intraoperative, and postoperative care.
• Features atlas-style surgical chapters.
• Provides coverage of hot topics in surgery, including metoidioplasty, chest surgery, and phalloplasty.
• Full-color design with illustrations and photos enhances your visual understanding.

Chapter 1

Introduction

Loren S. Schechter

The surgical care of individuals suffering from gender dysphoria or gender incongruence has undergone rapid transformation over the last several years. Although not all individuals with gender dysphoria need or desire surgery, many do. With an increased recognition as to the importance of surgical therapy, coupled with improved access to care resulting from expanded insurance coverage, more individuals are seeking surgery.

My first experiences caring for transgender individuals occurred during my early years as a plastic surgery resident, under the mentorship of Dr Lawrence Gottlieb. Subsequently, when I entered practice, Drs Fred and Randi Ettner, experts in the medical and psychological care of transgender persons, approached me with the goal of offering surgical treatment options for their patients. As I became more involved with the surgical care and the advocacy efforts for transgender persons, I learned about the limited resources available to this population.

During my career, I have been fortunate to work with leaders around the world, including Professor Stan Monstrey and Rados Djinovic. In addition, I was able to draw on my experience from congenital, traumatic, and oncologic cases and develop and advance techniques for gender-confirming surgeries. As of the writing of this book, no formal surgical training programs exist. This surgical text is a first step in filling the educational gap. It is my hope that surgeons will gain experience in the field of gender surgery, thereby continuing to advance operative techniques.

Box 1.1 Surgical treatment options

Surgical procedures for transwomen

• Vaginoplasty

○ Penile disassembly and inversion vaginoplasty

○ Intestinal vaginoplasty

• FFS (facial feminization surgery)

○ Brow lift (hair advancement)

○ Frontal bone reduction (burring vs osteoplastic ± onlay graft)

○ Mandible reduction (angle and/or chin)

○ Rhinoplasty

○ Malar implant

○ Lip shortening and/or augmentation

○ Hair transplantation

• Thyroid chondroplasty (“tracheal shave”)

• Breast augmentation

• Body contouring

Surgical procedures for transmen

• Chest surgery

○ Limited incision

○ Circumareolar/vertical

○ Double incision

• Metoidioplasty

• Phalloplasty

○ Radial forearm flap

○ Anterolateral thigh flap

○ Musculocutaneous latissimus dorsi flap

This text outlines many surgical therapies (Box 1.1), but it must be taken in context. The care of individuals with gender dysphoria requires a multidisciplinary approach. Although surgery often represents the culmination of an individual’s life journey, it is not undertaken in a vacuum. The surgeon must work collaboratively with mental health professionals, primary care physicians, endocrinologists, and other specialists.

Chapter 2

Background

Loren S. Schechter

Definitions

Gender Dysphoria

The term gender dysphoria describes a heterogeneous group of individuals who express varying degrees of discomfort with or disassociation from their anatomic gender. Some people with this condition, in order to manage the discrepancy or imbalance they experience, desire to possess the secondary sexual characteristics of the opposite sex.¹ Not all transgender persons have gender dysphoria. For those who do, medical and surgical therapy can play a pivotal role in relieving their psychological discomfort.^2–9

Over the past several decades, there has been significant progress in the understanding and treatment of individuals suffering from gender dysphoria. In 1984, Dr Milton Edgerton noted that, “transsexualism is a severe, and pathologic condition that is undesirable for both the patient and society…and non-surgical treatment continues to be expensive, time-consuming, and enormously disappointing.”¹⁰ Much has changed since Edgerton’s statement. Advances in the psychological, medical, and surgical care of individuals with gender dysphoria have resulted in a multidisciplinary approach, aimed at improved quality of life and destigmatization for this underserved and diverse population. In addition, social and political changes have raised awareness as to the importance of providing safe and affirming environments, free from discrimination. In 2010, The World Professional Association for Transgender Health (WPATH) released a statement calling for the de-psycho-pathologization of gender nonconformity, stating that, “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally diverse human phenomenon [that] should not be judged as inherently pathologic or negative.”¹¹

WPATH developed the Standards of Care (SOC) to help provide “the highest standards” of care for transgender individuals. The SOC state that the overarching treatment goal is “…lasting personal comfort with the gendered self, in order to maximize overall health, psychological well-being and self-fulfillment.”¹² Since WPATH published the first version of the SOC in 1979, the guidelines have been updated 6 times, reflecting increasing understanding of the transgender population and the delivery of optimal care.

Descriptions

Pyschosexual development and differentiation entails 3 major components:

• Gender identity, referring to one’s sense of belonging to the male or female sex category, a combination of both, or neither, regardless of the sex assigned at birth;

• Gender role, sexually dimorphic behaviors and psychological characteristics within the population, such as toy preferences, clothing, and mannerisms; and

• Sexual orientation, one’s pattern of erotic responsiveness as reflected in the sex of one’s partner(s).

As noted by the Institute of Medicine’s 2011 report on the health of lesbian, gay, bisexual, and transgender people, transgender individuals represent a diverse group of people who are defined according to their gender identity and presentation. This group includes persons whose gender identity differs from the sex originally assigned to them at birth or whose gender expression varies significantly from what is traditionally associated for that sex (ie, people identified as male at birth who are perceived as feminine and subsequently identify as female, and people identified as female at birth who appear more masculine and later identify as male). In addition, transgender persons may vary from or reject traditional cultural conceptualizations of gender in terms of the male-female dichotomy, or “binary.” The Institute of Medicine’s study also reported that the transgender population is varied in sexual expression and sexual orientation. Transgender people can be heterosexual, homosexual, or bisexual in their sexual orientation. Some lesbians, gay men, and bisexuals are transgender; most are not.¹³

Some transgender individuals have undergone medical interventions to alter their sexual anatomy and physiology; others wish to have such procedures in the future, and still others do not request medical or surgical intervention. In recent years, recognition that some individuals do not see themselves in the traditional male or female gender role has gained acceptance. Gender nonconforming or gender expansive describes a difference between an individual’s gender identity, role, or expression and that of cultural norms. Some, but not all, gender-nonconforming individuals experience gender dysphoria.

Epidemiology

Although early estimates on the prevalence of gender dysphoria were focused on identification of individuals for gender confirmation surgery, it was later realized that some individuals neither desired, nor were candidates for, such surgery.^7,12 Early estimates of the prevalence of transsexualism were 1 in 37,000 biological males and 1 in 107,000 biological females.¹⁴ Interestingly, approximately 3 times as many biological males as compared with biological females sought genital surgery. This historical discrepancy may exist for multiple reasons, including less accessibility, and more complicated—and expensiv...