BackTable / Urology / Article
The Basics of Gender Affirming Surgery
Ishaan Sangwan • May 20, 2022 • 40 hits
Transgender and gender diverse patients often seek urological care when they are interested in gender affirming surgery. In order to provide sensitive and competent care for these patients, it is important to be familiar with both the terminology they may use to describe themselves, as well as the treatment options available to them.
Urologists Dr. Jennifer Anger and Dr. Aditya Bagrodia break down the essentials to providing gender affirming care. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable Urology Brief
• Common terminology used by transgender patients includes terms like cisgender, transgender, non-binary, and gender dysphoria.
• There is no universal path to a gender transition. However, hormone replacement therapy (HRT) usually precedes surgery, and pelvic surgery tends to be one of the final steps.
• The most common pelvic surgery procedures for transgender women are orchiectomy and vaginoplasty.
• The most common pelvic surgery procedures for transgender men are phalloplasty or metoidioplasty, along with hysterectomy and vaginectomy.
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Table of Contents
(1) Common Terminology used by Transgender Patients
(2) The Path to Gender Affirming Surgery
(3) Types of Pelvic Gender Affirming Surgery
Common Terminology used by Transgender Patients
It is important for gender affirming surgery providers to familiarize themselves with common terminology used by transgender and gender diverse patients. Common terms include transgender, which describes a person with a gender identity different from the one they were assigned at birth, and cisgender, which describes a person whose gender identity matches the one assigned at birth. Individuals may also identify as non-binary, which means that they don’t identify as male or female. Transgender individuals often experience gender dysphoria, which is the distress caused by the incongruence between one’s sex assigned at birth and their gender identity, often resulting in them seeking gender affirming care.
[Dr. Jennifer Anger]
So a transgender woman is a woman and is transitioning to be a woman. A transgender man is a man in the transition process would be transitioning to be a man. And pronouns are really a personal preference. So what you don't want to do is say, well, what are you really?
You know, what's your real sex? Cause that would be a form of misgendering. So the term now is assigned male at birth. So the genitals that you had at birth are considered what you're assigned at birth, and then your internal expression of your gender identity is what you would be called. So a transgender man identifies as a man. If they were assigned female at birth, or born as a girl, that's what we call it, what they're assigned at birth.
[Dr. Jennifer Anger]
So many of us who have a science background remember the molecule with two moieties on the same side of the carbon bond and that's called cis. And then trans is if you have these moieties that are across the carbon bond, which are called trans. So a cis person is someone who is, let's say, for example, me, born female, and I identify as female, and not speaking for you, but you would be considered a cis man, you're born a boy. You consider yourself a man. And so that would be considered someone who is not, transgender or non-binary for example. And just to add, non binary is a way of describing someone who may not fall on one end or the other of a spectrum. So some people will have some feminine characteristics and masculine characteristics, and they don't necessarily feel a need to identify as a cis man or a cis woman or a trans man or a trans woman, that there is sort of some fluidity with that.
[Dr. Jennifer Anger]
Yes. So gender dysphoria is the psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity. And so that is important because if someone is born in a society that accepts gender diversity, they may not necessarily have dysphoria. And I think dysphoria results from not being able to express their identity freely and also, having to be in a society where there's a great amount of stigma and marginalization, and that, I think, definitely contributes to dysphoria.
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The Path to Gender Affirming Surgery
There is no one universal path to gender transition, and the process can be individualized based on a person’s desires. Usually, the first medical intervention is to start hormone replacement therapy. For transgender women, this means estrogen along with a testosterone blocker, while for transgender men this usually means testosterone replacement therapy. Patients may choose to have gender affirming chest surgery if desired, and this typically occurs before pelvic surgery. For gender affirming pelvic surgery, the World Professional Association for Transgender Health has set criteria that require HRT and living in one’s preferred gender for at least a year, as well as two letters of support from mental health providers.
[Dr. Jennifer Anger]
So we don't usually say reassignment anymore or sex change. It's now usually termed gender affirming surgery. And so, I think it's important to know that, to transition, there are no requirements. It's very individualized. So someone can, let's say a transgender woman can say, I want to be a woman. And she then begins to live as a woman and that would be her transition. and you don't really need to do anything else other than that. But most people will have hormones, to start. So the World Professional Association for Transgender Health (WPATH) does have set criteria for gender affirming surgery.
And so as a urologist, my focus is on gender affirming pelvic surgery, and the requirements are having hormonal therapy for a year, at least, and living in one's preferred gender for at least a year. And then they need to have two letters from mental health providers that support their transition and also, that support that the patient is ready for that.
And what's important is, even though we talk about gender diversity as not being a pathology, insurance is, more likely to cover surgeries with this diagnosis code of gender dysphoria. So we still use that term quite a bit, so most of the time I'll see patients who have been on hormones already. And just a little bit of background, so what are the hormones? For transgender woman, it's usually estrogen. And then, often with a testosterone blocker, like, in Canada they use cyproterone, usually here spironolactone is used, and then some will get an orchiectomy to help reduce their need for testosterone and also avoid the need for blockers. But we also see orchiectomy as part of gender affirming pelvic surgery. So vaginoplasty, vulvoplasty, et cetera.
Types of Pelvic Gender Affirming Surgery
There are various pelvic gender affirming surgery options available to individuals, depending on their desired results. For transgender women, orchiectomy and vaginoplasty are the most common options. The prostate is typically preserved during these surgeries due to the high rate of complications associated with its removal. For transgender men, vaginectomy and hysterectomy are often performed in addition to phalloplasty or metoidioplasty. Phalloplasty creates a neophallus using a radial forearm graft, whereas metoidioplasty involves reconnecting the urethra to the existing enlarged clitoris.
[Dr. Jennifer Anger]
You know, I think, for transgender woman, it's important to know that when they have gender affirming surgery, the prostate is going to be there. It's not going to be taken out. So the only thing they would have potentially have had removed would be the testicles, right? So you know, they're all gonna have a prostate. No gender affirming surgery should be removing the prostate. At least not one that I've seen. And in the vaginoplasty surgeries, we usually preserve sphincters. It's usually mid- to distal bulb where the new urethral opening is. And then later for a prostate screening, it's actually a vaginal exam, the prostate's right there. So I don't always do an organ inventory in transgender women because it's really well, you are doing an inventory, but it's really only going to be the testicles, whether or not they've had an orchiectomy.
Now for transgender men, it's important to know that the vaginectomy is an important consideration in masculinizing surgeries. So, the main two surgeries are a phalloplasty, which is creating a phallus from usually a radial forearm free flap. You can also use an anterior thigh flap. And with those surgeries, most of the time, there's a hysterectomy, and with a vaginectomy, although some patients can have phalloplasty and preserve the vaginal canal. So that's really important to know if they wish to preserve the vaginal canal, if they're using the canal, for example. So, one thing that's important is that most transgender men who are planning surgery, have a hysterectomy and that's usually separate from the gender affirming pelvic surgery, although it can be done at the same time.
And so that's probably what you'll see after a phalloplasty. Metoidioplasty, there's no phallus, the majority of metoidioplasty is elongation of the clitoris and then recreating a urethra from vaginal wall flaps, often combined with buccal graft, depending on the technique.
Dr. Jennifer Anger
Dr. Jennifer Anger is a urologist and gender affirming pelvic surgeon at UC San Diego in California.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2022, March 16). Ep. 33 – Gender-Affirming Care: A Primer [Audio podcast]. Retrieved from https://www.backtable.com
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