Surgery

  • Female-to-male genital reconstruction surgery has a high negative outcome rate, including urethral compromise and worsened mental health. Expand
    Female-to-male genital reconstruction surgery has a high negative outcome rate, including urethral compromise and worsened mental health.

    The results of a 2021 international survey [1] of 129 female-to-male patients who underwent genital reconstruction surgery support anecdotal reports that complication rates following genital reconstruction are higher than are commonly reported in the surgical literature. 

    Complication rates, including urethral compromise, and worsened mental health outcomes remain high for gender affirming penile reconstruction. In total, the 129 patients reported 281 complications requiring 142 revisions.

    Another paper [2] found a 70% complication rate in one type of female-to-male genital reconstruction surgery.

    Even with the “radial forearm free flap” method of creating a synthetic penis — “considered by many as the gold standard for phalloplasty” [3] — there are high rates of complications, with up to 64% urethroplasty related complications [4].

    REFERENCES

    [1] Robinson, I.S., Blasdel, G., Cohen, O., Zhao, L.C. & Bluebond-Langner, R. (2021). Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 18 (4): 800-811. [Link]

    [2] Bettocchi, C., Ralph, D.J. & Pryor, J.P. (2005). Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95:120–4. [Link]

    [3] Rashid, M. & Tamimy, M. S. (2013). Phalloplasty: The dream and the reality. Indian J Plast Surg 46 (2): 283-293. [Link]

    [4] Fang, R.H., Lin, J.T. & Ma S. (1994). Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 15: 349–52. [Link]

  • Medical transition puts both males and females at risk of infertility. Expand
    Medical transition puts both males and females at risk of infertility.

    A wide-ranging study [1] found that gender-related drug regimens place patients at risk of infertility:

    Suppression of puberty with gonadotropin-releasing hormone agonist analogs (GnRHa) in the pediatric transgender patient can pause the maturation of germ cells, and thus, affect fertility potential. Testosterone therapy in transgender men can suppress ovulation and alter ovarian histology, while estrogen therapy in transgender women can lead to impaired spermatogenesis and testicular atrophy. The effect of hormone therapy on fertility is potentially reversible, but the extent is unclear.

    On surgeries, the study noted that cross-sex surgery

    that includes hysterectomy and oophorectomy in transmen or orchiectomy in transwomen results in permanent sterility.

    REFERENCES

    [1] Cheng, P.J., Pastuszak, A.W., Myers, J.B., Goodwin, I.A. & Hotaling, J.M. (2019). Fertility concerns of the transgender patient. Transl Androl Urol. 8 (3): 209-218. [Link]

  • Genital surgeries tend to reduce the capacity for orgasm in males, and may do so in females. Expand
    Genital surgeries tend to reduce the capacity for orgasm in males, and may do so in females.

    One study showed that around 30% of male-to-female genital surgeries result in the inability to orgasm [1].

    Figures on female-to-male transitioners are less clear. However, a clinical follow-up study [2] of 38 transmen – 29 of whom had received phalloplasty, and 9 metoidioplasty – found that reported loss of orgasmic capacity was more marginally common than reported gain of orgasmic capacity.

    The negative intrapsychic and interpersonal consequences of anorgasmia (the inability to climax) is well-documented, and applies equally to transgender individuals [3].

    REFERENCES

    [1] Manrique, O., Adabi, K., Martinez-Jorge, J., Ciudad, P., Nicoli, F. and Kiranantawat, K. (2018). Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty—Where We Are Today. Annals of Plastic Surgery 80 (6): 684-691. [Link]

    [2] van de Grift, T., Pigot, G., Kreukels, B., Bouman, M., & Mullender, M. (2019). Transmen’s Experienced Sexuality and Genital Gender-Affirming Surgery: Findings From a Clinical Follow-Up Study. Journal Of Sex & Marital Therapy 45 (3): 201-205. [Link]

    [3] Levine, S. (2018). Informed Consent for Transgendered Patients. Journal Of Sex & Marital Therapy, 45(3), 218-229. [Link]

  • Vaginoplasty can result in fistula, stenosis, necrosis, prolapse and even death. Expand
    Vaginoplasty can result in fistula, stenosis, necrosis, prolapse and even death.

    Male-to-female genital surgery (vaginoplasty) is associated with significant long-term complications: there is a 2% risk of fistula, 14% risk of stenosis (abnormal narrowing), 1% risk of necrosis (tissue death) and 4% risk of prolapse [1].

    One systematic review [2] found an overall complication rate of 32.5%.

    A Dutch study [3] of 55 (out of an original 70) adolescents treated with puberty blockers, cross sex hormones, and genital surgery, showed that among 22 male-to-female patients who underwent vaginoplasty, one adolescent died as a result of necrotizing fasciitis after the surgery.

    REFERENCES

    [1] Manrique, O., Adabi, K., Martinez-Jorge, J., Ciudad, P., Nicoli, F. and Kiranantawat, K. (2018). Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty—Where We Are Today. Annals of Plastic Surgery 80 (6): 684-691. [Link]

    [2] Dreher, P.C., Edwards, D., Hager, S., Dennis, M., Belkoff, A., Mora, J., Tarry, S. & Rumer, K.L. (2018). Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management. Clin Anat. 31 (2):191-199. [Link]

    [3] de Vries, A., McGuire, T., Steensma, E., Wagenaar, T., Doreleijers, P. & Cohen-Kettenis, P. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. [Link]

  • Around 1 in 5 vaginoplasty surgeries lead to corrective surgery. Expand
    Around 1 in 5 vaginoplasty surgeries lead to corrective surgery.

    A systematic review [1] of neo-vagina surgeries found a re-operation rate of 21.7% for non-esthetic reasons.

    A Brazilian paper [2] found a somewhat lower, but similar, reoperation rate of 16.8%.

    REFERENCES

    [1] Dreher, P.C., Edwards, D., Hager, S., Dennis, M., Belkoff, A., Mora, J., Tarry, S. & Rumer, K.L. (2018). Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management. Clin Anat. 31 (2):191-199. [Link]

    [2] Moisés da Silva, G.V., Lobato, M.I.R., Silva, D.C., Schwarz, K., Fontanari, A.M.V., Costa, A.B., Tavares, P.M., Gorgen, A.R.H., Cabral, R.D. & Rosito, T.E. (2021). Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Frontiers in Surgery 8. [Link]

  • There is evidence that up to a quarter of transgender genital surgeries result in incontinence. Expand
    There is evidence that up to a quarter of transgender genital surgeries result in incontinence.

    A systematic literature review [1] found that 21% of male-to-female patients and 25% of female-to-male patients suffered from incontinence as a result of transgender genital surgery.

    One recent study [2] estimates the number of post-operative transsexuals suffering stress incontinence to be 23%. This study was not a literature review, and almost all of the participants were male-to-female.

    REFERENCES

    [1] Nassiri, N., Maas, M., Basin, M., Cacciamani, G.E. & Doumanian, L.R. (2020). Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res. [Link]

    [2] Kuhn, A., Santi, A. & Birkhäuser, M. (2011). Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals. Fertil Steril. 95: 2379-82. [Link]

  • Only 5%-10% of transwomen get genital surgery, compared to 25%-50% of transmen. Expand
    Only 5%-10% of transwomen get genital surgery, compared to 25%-50% of transmen.

    A 2019 paper [1] reports that “Genital GCS is generally less common than chest surgery, with prevalence rates of about 25–50% for transgender men and 5–10% for transgender women […] For transgender women, genital GCS comprises a number of procedures, including vaginoplasty (most commonly intestinal or penile inversion) with labiaplasty and/or clitoroplasty, penectomy, and orchiectomy. Transgender women report bottom surgery at rates between 5–13% […]. Even more transgender women desire bottom surgery in the future: between 45–54% […]”

    REFERENCES

    [1] Nolan, I. T., Kuhner, C. J. & Dy, G. W. (2019). Demographic and temporal trends in transgender identities and gender confirming surgery. Translational Andrology and Urology, 8 (3). [Link]