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Gender-Affirming Surgeries in Transgender and Gender Diverse Adolescent and Young Adults: A Pediatric and Adolescent Gynecology Primer

  • Frances Grimstad
    Correspondence
    Address correspondence to: Frances Grimstad, MD, MS, Division of Pediatric and Adolescent Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA. Phone: (617) 355-7648.
    Affiliations
    Division of Gynecology, Department of Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 02115 Boston, Massachusetts

    Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts
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  • Elizabeth R. Boskey
    Affiliations
    Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts

    Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 02115 Boston, Massachusetts
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  • Amir Taghinia
    Affiliations
    Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
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  • Oren Ganor
    Affiliations
    Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts

    Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
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Published:April 11, 2021DOI:https://doi.org/10.1016/j.jpag.2021.03.014

      ABSTRACT

      Transgender and gender diverse adolescent and young adults (AYA) may seek gender-affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, or requiring GAS aftercare, or those seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams. With this knowledge, reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.

      Introduction

      Transgender and gender diverse (TGD) individuals are those whose gender identity differs from their assigned sex at birth. Gender affirmation (the processes that individuals use to align their presentation with their gender identity) may include 1 or more of the gender-affirming surgeries (GAS) (Table 1) sought by a growing number of adolescents and young adults (AYA).Although most GAS are deferred until age of majority, those who provide care for AYA TGD patients may need to engage in early counseling on these topics for patients who intend to seek GAS later in life.
      Table 1Selected Gender-Affirming Surgeries (GAS)
      Masculinizing

      • Chest reconstruction*

      • Clitoral release

      • Metoidioplasty*

      • Phalloplasty*

      • Scrotoplasty*

      • Hysterectomy (with or without bilateral salpingoophorectomy)*

      • Vaginectomy
      Feminizing

      • Facial feminization

      • Tracheal shave

      • Breast augmentation*

      • Vaginoplasty (also zero-depth vaginoplasty)*

      • Labiaplasty*

      • Orchiectomy*
      Masculinizing or feminizing

      • Body contour procedures
      *Surgeries addressed in this review.
      Many GAS are integrally related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians may participate in discussions regarding counseling, procedure timing, and postoperative care and support. As the first multidisciplinary GAS team in a pediatric institution (including urologists, a gynecologist, plastic surgeons, and a social worker), we recognize the integral role of reproductive health clinicians (including obstetrician and gynecologists and related subspecialties, as well as clinicians in other specialties such as adolescent medicine and family medicine who provide sexual and reproductive health) in the perioperative care of our patients, particularly around postoperative pelvic, sexual, and reproductive health.
      • Grimstad F
      • Boskey E
      Empowering transmasculine youth by enhancing reproductive health counseling in the primary care setting.
      ,
      • Grimstad F
      • McLaren H
      • Gray M
      The gynecologic exam of the transfeminine person following penile inversion vaginoplasty.
      This article reviews types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers. Our goal is to help PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams.

      Presurgical Considerations

      Before a patient seeks a formal consultation for GAS, several steps occur. The patient needs to identify a desire for GAS. When seeing TGD patients, we recommend asking about any past or desired medical or surgical therapies for gender affirmation, and their personal timeline related to those goals (if known) (Table 2). It is important to remember that every person's process of gender affirmation is unique and may not include social, medical, or surgical processes. Open-ended questions are critical, and clinicians should be aware that some patients may frame their goals as achieving gender euphoria rather than reducing gender dysphoria.
      • Benestad EEP
      From gender dysphoria to gender euphoria: an assisted journey.
      ,
      • Rachlin K
      Medical transition without social transition: expanding options for privately gendered bodies.
      In other words, rather than seeking gender-affirming care to relieve distress, some patients seek gender-affirming care as a way to feel better about and more satisfied with their body and gender. This reflects the fact that some transgender individuals are not experiencing functional limitations related to their gender identity discordance (gender dysphoria) but could still achieve improved function and happiness with therapy (gender euphoria).
      Table 2Questions Related to Gender Affirmation History and Goals
      Gender Affirmation History Questions• For the purpose of affirming your gender or addressing gender dysphoria…
        • Have you ever taken any medication? (eg, menstrual suppression, puberty blockers, testosterone, anti-androgens)?
        • Have you undergone any procedures? (eg, chest masculinization, facial feminization)?
      • Do you desire to or plan to undergo any gender-affirming medical therapies or procedures in the future for the purpose of affirming your gender or addressing gender dysphoria?
      Family-Building Questions

      • When you look to the future, do you envision having a family? If so, do you envision having children?

      • Do you desire those children to be biologically linked?

      • Do you have a desire to carry a pregnancy?
      Clinicians should also assess the stability of patients’ GAS goals and whether those goals are a reflection of internal distress (eg “I've never felt like my breasts fit”) or external distress (eg “People tease me because they don't know if I'm a boy or a girl.”). Those who discuss only external forms require further assessment, as they may not be realistic about the likely impacts of surgery on their identity or interpersonal interactions. Similarly, patients who believe that any given surgery will fix all of their problems should be encouraged to explore what aspects of their gender goals surgery will not change and how they will feel after the procedure if and when their current distress is not fully resolved. Patients with unrealistic expectations about surgery may be more likely to experience significant postprocedure depression.
      • Honigman RJ
      • Phillips KA
      • Castle DJ
      A review of psychosocial outcomes for patients seeking cosmetic surgery.
      TGD patients may also need to fulfill other requirements outlined in the World Professional Association of Transgender Health Standards Of Care (WPATH SOC) or from their insurance company(ies) (eg, diagnosis of gender dysphoria, documentation of time on gender-affirming hormone therapy (GAHT), time lived in affirmed gender, and/or letters from medical or mental health clinicians, which PAG clinicians may be able to write).
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      Hair removal may be required in advance of GAS, particularly genital surgeries, either by laser or electrolysis. Hair removal can take many months and may require substantial expense, as insurance coverage is uncommon. Smoking should also be addressed prior to GAS, as smoke exposure is a significant risk factor for soft tissue ischemia and wound complications.
      When working with patients seeking chest surgeries, PAG clinicians should discuss the desire for persistent nipple sensation as well as whether patients have any interest in future breast/chest feeding and help them to weigh those priorities. Finally, clinicians should discuss what sexual health care, cancer screenings, and related care will be like after surgery, to address any questions or concerns.
      When working with patients seeking genital surgeries, PAG clinicians are well placed to discuss patients’ sexual goals and expectations for postoperative function. Discussions of sexual goals should include whether patients have a goal of being able to use their genital anatomy to perform insertional intercourse or to receive insertional intercourse, either with another person or using toys. This will determine both the type of genital surgery that is most appropriate for the surgery and which elements of the surgery should be included. In particular, patients interested in metoidioplasty should be counseled that they are unlikely to be able to engage in insertive intercourse with their new anatomy.
      • Ganor O
      • Taghinia AH
      • Diamond DA
      • et al.
      Piloting a genital affirmation surgical priorities scale for trans masculine patients.
      For patients who have sexual penetration as a priority, phalloplasty is likely to be a better option for masculinizing genital surgery, although patients should be counseled that this will require the use of either an external or internal erectile device.
      • Rooker SA
      • Vyas KS
      • DiFilippo EC
      • et al.
      The rise of the neophallus: a systematic review of penile prosthetic outcomes and complications in gender-affirming surgery.
      Those who currently use their vagina for insertive sex and/or wish to do so in the future should be counseled that there are limited data suggesting an increased risk of urethral complications when genital affirmation surgeries are performed without vaginectomy, but that it may be reasonable to accept that increased risk after discussion with their surgeon.
      • Jolly D
      • Wu CA
      • Boskey ER
      • et al.
      Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes.
      PAG clinicians should also encourage patients to think about whether and how they will discuss their surgery and identity with future romantic and sexual partners. Nonsexual functional goals to be discussed include the ability to stand to urinate, or to wear tight bathing suits with or without having any genital protuberances.
      Of all GAS, genital surgeries are also most likely to have an impact an AYA fertility options. Although current guidelines recommend counseling on fertility preservation prior to any gender-affirming intervention that could affect procreative potential, we take a broader approach around engaging in a discussion around future parenthood to better understand our patients’ present family goals and desires related to genetic linkage (Table 2).
      • Grimstad F
      • Boskey E
      Empowering transmasculine youth by enhancing reproductive health counseling in the primary care setting.
      ,
      • Tasker F
      • Gato J
      gender identity and future thinking about parenthood: a qualitative analysis of focus group data with transgender and non-binary people in the United Kingdom.
      ,
      • von Doussa H
      • Power J
      • Riggs D
      Imagining parenthood: the possibilities and experiences of parenthood among transgender people.
      Patients who desire fertility preservation should be referred to an appropriate clinic. For those who have testes who desire the option of genetically linked offspring in the future, they can bank sperm.
      • Nahata L
      • Chen D
      • Moravek MB
      • et al.
      Understudied and under-reported: fertility issues in transgender youth—a narrative review.
      This is best done prior to initiation of GAHT because of the effects of feminizing GAHT on decreasing sperm quantity and quality; however, early research is exploring the feasibility of this following discontinuance of GAHT.
      • Alford AV
      • Theisen KM
      • Kim N
      • et al.
      Successful ejaculatory sperm cryopreservation after cessation of long-term estrogen therapy in a transgender female.
      Another emerging option involves sperm banking at the time of orchiectomy.
      • Schneider F
      • Scheffer B
      • Dabel J
      • et al.
      Options for fertility treatments for trans women in Germany.
      A urologist skilled in this technique should be involved for counseling and performance. For those with ovaries who desire the option of genetically linked offspring, egg retrieval prior to or following temporary discontinuance of testosterone is the most common approach.
      • Nahata L
      • Chen D
      • Moravek MB
      • et al.
      Understudied and under-reported: fertility issues in transgender youth—a narrative review.
      This can still be done following gender-affirming hysterectomy if ovaries are not removed (see Hysterectomy section below for more information) or masculinizing genital surgeries. Finally, a growing number of AYA can access puberty blockers (gonadotropin-releasing hormone analogs) prior to undergoing GAHT.
      • Lopez CM
      • Solomon D
      • Boulware SD
      • et al.
      Trends in the use of puberty blockers among transgender children in the United States.
      Those who use blockers prior to Tanner II/III followed by GAHT have gonads that have not gone through the endogenous puberty to have gametes that can be retrieved. For these patients, gonadal tissue preservation is presently the only method available.
      • Nahata L
      • Chen D
      • Moravek MB
      • et al.
      Understudied and under-reported: fertility issues in transgender youth—a narrative review.

      GAS Considerations in AYA

      A growing number of GAS are performed in AYA.
      • Olson-Kennedy J
      • Warus J
      • Okonta V
      • et al.
      Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts.
      Depending on surgeon requirements and local regulation, few surgeries may be performed before the age of majority; however current WPATH SOC guidelines recognize that care must reflect individual needs and not arbitrary age limits.
      • Grimstad F
      • Boskey E
      How should decision-sharing roles be considered in adolescent gender surgeries?.
      • Milrod C
      How young is too young: ethical concerns in genital surgery of the transgender MTF adolescent.
      • 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.
      The most important part of AYA pre-surgical assessment is understanding why the patient is interested in the particular surgery and why they are interested in it now. Private conversations are essential to ensure that the patient's own desires, not those of their family or caregivers, are heard. Patients must also process the risks of surgery and commit to any necessary postoperative care.
      AYA may have unique surgical timing needs related to their education or career trajectory. Some youths may attend school, or may be about to start at a new school, in which case their desire for surgery may in part center around optimizing safety and socialization in these spaces. For those who are above the age of majority, having surgery before aging out of parental health insurance may be important, because not all insurance companies cover gender affirmation procedures.
      • Terris-Feldman A
      • Chen A
      • Poudrier G
      • et al.
      How accessible is genital gender-affirming surgery for transgender patients with commercial and public health insurance in the United States? Results of a patient-modeled search for services and a survey of providers.
      AYA are likely to have different support structures than older surgical patients. For some it will carry elements of greater stability, but for others it will not. For example, AYA are more likely to be in the process of transitioning from their family or origin into different living arrangements, which may increase or decrease support. All of these should be repeatedly assessed and taken into account when planning both for procedures and for postoperative recovery. We strongly encourage the early integration of social work into perioperative planning to ensure that these issues are identified and addressed long before surgery.
      Nonsterilization procedures are generally viewed more favorably by the medical and ethical community as appropriate prior to the age of majority. There has been a growing recognition that chest surgery can be valuable to TGD youths who have significant chest dysphoria.
      • Olson-Kennedy J
      • Warus J
      • Okonta V
      • et al.
      Chest reconstruction and chest dysphoria in transmasculine minors and young adults: comparisons of nonsurgical and postsurgical cohorts.
      However, AYA may also desire to undergo genital affirmation surgeries, which can include sterilizing procedures. Each municipality, hospital, and surgeon varies in their approach to sterilization procedures prior to the age of majority.
      • Milrod C
      How young is too young: ethical concerns in genital surgery of the transgender MTF adolescent.
      ,
      • 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.
      However, in an era when the concepts of parenthood and fertility preservation are becoming more nuanced, AYA patients and their families may seek out clinicians willing to consider performing a sterilizing procedure prior to the age of majority for person-specific reasons, such as prior to going to college. Consideration of this may require involvement of an ethics committee or legal representatives, and PAG clinicians as reproductive and sexual health experts may be asked to weigh in. Currently, data regarding the risk of regret following sterilization in TGD persons are cross-sectional, and each study is influenced by the local laws regarding gender affirmation and sterilization. As such, we do not know the true incidence of regret in TGD persons when not influenced by legal barriers for gender affirmation, and how this may be influenced by demographics such as age, race/ethnicity, geographic location, nationality, or insurance status. Despite this, there have been a few studies done that have documented regret in some patients, suggesting the risk is not null and should be discussed with patients.
      • Auer MK
      • Fuss J
      • Nieder TO
      • et al.
      Desire to have children among transgender people in Germany: a cross-sectional multi-center study.
      However, it is important to separate regret about fertility from regret about undergoing gender affirmation procedures that affect fertility. Some individuals find affirming their gender more important than sacrificing their fertility goals, and may regret the fertility consequences of a procedure or treatment while not regretting the decision to have undergone it.
      • Nahata L
      • Tishelman AC
      • Caltabellotta NM
      • et al.
      Low fertility preservation utilization among transgender youth.
      • De Sutter P
      • Verschoor A
      • Hotimsky A
      • et al.
      The desire to have children and the preservation of fertility in transsexual women: a survey.
      • Chen D
      • Simons L
      • Johnson EK
      • et al.
      Fertility preservation for transgender adolescents.
      • Persky RW
      • Gruschow SM
      • Sinaii N
      • et al.
      Attitudes toward fertility preservation among transgender youth and their parents.

      GAS Techniques, Outcomes, and Care Considerations for the PAG Clinician

      Transmasculine Surgeries

      Chest reconstruction

      Masculinizing chest reconstruction is the most common GAS sought by TGD individuals.
      • James SE
      • Herman JL
      • Rankin S
      • et al.
      The Report of the 2015 U.S. Transgender Survey.
      Chest surgery has been shown to improve dysphoria, quality of life, and both mental and physical health.
      • Agarwal CA
      • Scheefer MF
      • Wright LN
      • et al.
      Quality of life improvement after chest wall masculinization in female-to-male transgender patients: a prospective study using the BREAST-Q and Body Uneasiness Test.
      ,
      • Owen-Smith AA
      • Gerth J
      • Sineath RC
      • et al.
      Association between gender confirmation treatments and perceived gender congruence, body image satisfaction, and mental health in a cohort of transgender individuals.
      Masculinizing chest surgery is a single-stage operation involving the removal of glandular breast tissue and the creation of a masculinizing chest and adjusted size and location of the nipple−areola complex (NAC). The procedure can often be performed in the outpatient setting using a variety of well-described techniques.
      • Bluebond-Langner R
      • Berli JU
      • Sabino J
      • et al.
      Top surgery in transgender men: how far can you push the envelope?.
      ,
      • Frederick MJ
      • Berhanu AE
      • Bartlett R.
      Chest surgery in female to male transgender individuals.
      The most common postoperative complications are bleeding, infection, fluid collection, and wound healing problems, including NAC graft failure.
      • Cuccolo NG
      • Kang CO
      • Boskey ER
      • et al.
      Masculinizing chest reconstruction in transgender and nonbinary individuals: an analysis of epidemiology, surgical technique, and postoperative outcomes.
      Scars can change as an AYA grows or undergoes weight changes, and can also undergo pigmentation changes. Patients with scar concerns should be referred to their surgeon or another plastic surgeon specializing in chest reconstruction. Loss of nipple−areola sensation can occur, and patients should be counseled appropriately. Although there are no cures or remedies, clinicians can acknowledge and provide psychosocial support to patients who are disturbed by this issue. Chest reconstruction is different from a double mastectomy done for malignancy purposes because it does not remove all glandular tissue.
      • Deutsch MB
      UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.
      Case reports have been published of patients who have lactated following pregnancy; however, this ability should not be expected.
      • MacDonald T
      • Noel-Weiss J
      • West D
      • et al.
      Transmasculine individuals’ experiences with lactation, chestfeeding, and gender identity: a qualitative study.
      Post−chest reconstruction patients also still carry a risk for breast cancer, although this risk appears to be less than that of cisgender women.
      • de Blok CJM
      • CM Wiepjes
      • Nota NM
      • et al.
      Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands.
      Routine self-examinations and screenings are recommended.
      • Deutsch MB
      UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.
      Any masses should be worked up per the updated guidelines.

      Hysterectomy

      PAG clinicians may be asked to participate in conversations about (or the performance of) hysterectomy, which may be performed alone for gender affirmation or as a prerequisite for masculinizing genital surgery. Gender-affirming hysterectomies can be safely performed in a minimally invasive approach, including vaginally.
      • Marfori CQ
      • Wu CZ
      • Katler Q
      • et al.
      Hysterectomy for the transgendered male: review of perioperative considerations and surgical techniques with description of a novel 2-port laparoscopic approach.
      • Obedin-Maliver J
      • Light A
      • de Haan G
      • Jackson RA.
      Feasibility of Vaginal Hysterectomy for Female-to-Male Transgender Men.
      • Reilly ZP
      • Fruhauf TF
      • Martin SJ.
      Barriers to evidence-based transgender care: knowledge gaps in gender-affirming hysterectomy and oophorectomy.
      Although hysterectomies have traditionally included oophorectomies by default, this practice is now changing.
      • Grimstad F
      • Boskey E
      Empowering transmasculine youth by enhancing reproductive health counseling in the primary care setting.
      We strongly believe that patients, particularly AYA TGD patients, should be counseled separately on the hysterectomy and the option for concomitant oophorectomy. There are numerous reasons why patients might choose to retain 1 or both of their ovaries at the time of hysterectomy (Table 3). Regardless of that decision, we recommend that any hysterectomy be done with a risk-reducing bilateral salpingectomy.
      ACOG
      Committee opinion no. 774: opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention.
      Table 3Ovarian Management at Time of Hysterectomy
      Patient Reasons for Ovarian Removal*Patient Reasons for Ovarian Retention*
      • Dysphoria associated with ovaries

      • Personal/family history of increased risk of ovarian cancer (eg BRCA)

      • Recurrent ovarian cyst/mass formation (even on testosterone)
      • Future use of oocytes (particularly if unsure about future fertility decisions)

      • Future use of (back-up) sex steroids

      • Minimization of potential surgical risk
      *May chose to remove both, neither, or only one.
      Adapted from Grimstad and Boskey.
      • Grimstad F
      • Boskey E
      Empowering transmasculine youth by enhancing reproductive health counseling in the primary care setting.

      Metoidioplasty and phalloplasty

      The 2 most common transmasculine genital GAS are metoidioplasty and phalloplasty, with or without urethral lengthening and/or scrotoplasty.
      • Frey JD
      • Poudrier G
      • Chiodo MV
      • et al.
      A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male transgender genital reconstruction: is the “ideal” neophallus an achievable goal?.
      Both procedures usually involve vaginectomy, which necessitates a prior hysterectomy. When seeing an AYA who has had any genital GAS, it is important to ascertain whether the person has undergone a concomitant hysterectomy, vaginectomy, and/or unilateral or bilateral oophorectomy. Retained structures should be assessed appropriately (Table 4).
      Table 4Clinical Care of Retained Reproductive Anatomy in Patients Undergoing Masculinizing Bottom Surgery
      Organs PresentRoutine Care Tips
      Ovaries- No additional surveillance is required (either following testosterone use or following masculinizing genital surgery)
      • Grimstad FW
      • Fowler KG
      • New EP
      • et al.
      Ovarian histopathology in transmasculine persons on testosterone: a multicenter case series.


      - Annual examinations should include palpation of adnexa

      - Concerns for masses should be assessed with imaging (for ultrasound, transabdominal can be used to start
      • Stowell JT
      • Grimstad FW
      • Kirkpatrick DL
      • et al.
      Imaging findings in transgender patients after gender-affirming surgery.
      )
      Uterus- Cervical cancer screening required (harm reduction modifications studied for patient comfort include blind swabs with HPV primary screening
      • Potter J
      • Peitzmeier SM
      • Bernstein I
      • et al.
      Cervical cancer screening for patients on the female-to-male spectrum: a narrative review and guide for clinicians.
      ,
      • Reisner SL
      • Deutsch MB
      • Peitzmeier SM
      • et al.
      Test performance and acceptability of self- versus provider-collected swabs for high-risk HPV DNA testing in female-to-male trans masculine patients.
      )

      - No additional endometrial surveillance is required
      • Grimstad FW
      • Fowler KG
      • New EP
      • et al.
      Uterine pathology in transmasculine persons on testosterone: a retrospective multicenter case series.
      Vagina (native)- No additional surveillance is required

      - Speculum examinations may be difficult due to bottom surgery−related changes in external genital architecture and/or atrophy related to testosterone (shared decision making should be used with the patient to identify the best approach for vaginal evaluation when indicated; for example, using a small Pederson speculum, blind swabs for any infectious testing, and consideration of in-office vaginoscopy for assessment of lesions)
      HPV, human papillomavirus.
      *Note on pregnancy: Pregnancy risk is related to anatomy (must have uterus and ovaries) and behavior, and not to identity, which is why it is necessary for clinicians to ask questions regarding present anatomy of the patient and partners rather than just gender identity and sexual orientation.
      • Bungener SL
      • Steensma TD
      • Cohen-Kettenis PT
      • et al.
      Sexual and romantic experiences of transgender youth before gender-affirmative treatment.
      ,
      • Copen CE
      • Chandra A
      • Febo-Vazquez I
      Sexual behavior, sexual attraction, and sexual orientation among adults aged 18-44 in the United States: data from the 2011-2013 National Survey of Family Growth.
      Testosterone is not an approved form of birth control.
      • Krempasky C
      • Harris M
      • Abern L
      • et al.
      Contraception across the transmasculine spectrum.
      Most metoidioplasty techniques allow the patient to void while standing, and create a foreshortened phallus using the hormonally enlarged clitoris and urethral elongation using vulvovaginal tissues on the ventral aspect of the neophallus.
      • Djordjevic ML
      • Stojanovic B
      • Bizic M
      Metoidioplasty: techniques and outcomes.
      Phalloplasty takes this procedure 1 step farther by placing a shaped soft-tissue flap on top of the lengthened urethra and anteriorized clitoris to create the closest semblance of male anatomy. The neo-phallus base is typically anterior to the native vulvar vestibule on the inferior aspect of the mons. One of the clitoral sensory nerves is mobilized, and ilioinguinal or ilihypogastric nerves can also be used for additional sensory input.
      The genital surgery literature reports generally satisfactory outcomes, with low regret, although validated instruments are yet not incorporated.
      • Garcia MM
      • Christopher NA
      • De Luca F
      • et al.
      Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience.
      ,
      • Wierckx K
      • Van Caenegem E
      • Elaut E
      • et al.
      Quality of life and sexual health after sex reassignment surgery in transsexual men.
      The most commonly reported concerns are high urethral complication rates, including strictures, fistulae, and diverticula.
      • Morrison SD
      • Shakir A
      • Vyas KS
      • et al.
      Phalloplasty: a review of techniques and outcomes.
      ,
      • Ascha M
      • Massie JP
      • Morrison SD
      • et al.
      Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery.
      • Jun MS
      • Santucci RA.
      Urethral stricture after phalloplasty.
      • Heston AL
      • Esmonde NO
      • Dugi DD
      • et al.
      Phalloplasty: techniques and outcomes.
      Any urinary concerns should be handled by the original surgeon or a trained urologist. Signs of hematuria, pain, difficulty voiding, or urine leaking from anywhere along the shaft or genitals may be signs of these conditions. Treatment can vary, but usually requires surgical intervention and often staged repair using grafting and local flaps.
      • Santucci RA.
      Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence.
      After scrotoplasty with testicular implants, these implants can migrate or erode.
      Erectile devices are needed to achieve erection after phalloplasty. Clinicians can explore patients’ functional goals and refer them to clinicians skilled in GAS or erectile dysfunction. Currently available internal prostheses have a high failure rate in phalloplasty patients, with a significant risk of device erosion. To minimize the risk of erosion, surgeons must await near full sensory return after phalloplasty before recommending prosthetic placement.
      Patients who have undergone metoidioplasty or phalloplasty report improvement in sexual satisfaction. Most report satisfaction with maintenance of erogenous sensation and ability for desired penetration, as well as decreases in experiencing sexual aversion and low sexual desire.
      • Frey JD
      • Poudrier G
      • Chiodo MV
      • et al.
      A systematic review of metoidioplasty and radial forearm flap phalloplasty in female-to-male transgender genital reconstruction: is the “ideal” neophallus an achievable goal?.
      ,
      • Kerckhof ME
      • Kreukels BPC
      • Nieder TO
      • et al.
      Prevalence of sexual dysfunctions in transgender persons: results from the ENIGI Follow-Up Study.

      Transfeminine Surgeries

      Breast augmentation

      Feminizing hormones alone may increase the breast size of transfeminine individuals, but many still request breast augmentation to feel comfortable in their bodies after GAHT. This is, in part, due to changes that occur during a testosterone-dominated endogenous puberty, such as broadening of the chest. Breast augmentation with silicone or saline implants is the most common approach for chest feminization. Implant placement is most commonly under muscle or the breast parenchyma, and incision types vary. Breast augmentation can be also achieved by autologous fat grafting; however, this may need to be repeated multiple times because of the limited fat take and high absorption rate. TGD patients with breast implants should be managed similar to their cisgender counterparts. Complications can include implant-related issues including capsular contracture, extrusion, leaks, rupture, hematoma, seroma, and infection.

      Vaginoplasty

      The most common genital GAS for transfeminine individuals is penile inversion vaginoplasty (PIV; other techniques that include the bowel and peritoneum will not be reviewed here).
      • Horbach SER
      • Bouman M-B
      • Smit JM
      • et al.
      Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques.
      The typical PIV procedure begins by excising the perineal and scrotal skin, which is removed and shaped as a dome. The orchiectomy is then performed (if fertility preservation is chosen, the testes are sent for sperm harvesting and preservation, although these procedures remain experimental
      • Schneider F
      • Scheffer B
      • Dabel J
      • et al.
      Options for fertility treatments for trans women in Germany.
      ). A roughly 15-cm-long cavity is then created anterior to the rectum and posterior to the bulbar urethra and the prostate. This space is lined with penile, scrotal, and perineal skin. The urethra is shortened and inset. Labia minora and majora flaps are also designed from the distal penile skin and from the lateral scrotum, respectively. A growing number of TGD AYA are using puberty blockers (gonadotropin-releasing hormone analogs) prior to Tanner II/III, followed by GAHT.
      • Lopez CM
      • Solomon D
      • Boulware SD
      • et al.
      Trends in the use of puberty blockers among transgender children in the United States.
      This will result in hypoplastic genital tissues and may, but does not always, influence the vaginoplasty technique used.
      Those who have undergone vaginoplasty will require routine neovaginal care.
      • Grimstad F
      • McLaren H
      • Gray M
      The gynecologic exam of the transfeminine person following penile inversion vaginoplasty.
      Annual pelvic examinations for asymptomatic patients following PIV are not required, but may be performed for symptoms or patient concerns.
      • Deutsch MB
      UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People.
      ,
      • Grimstad F
      • McLaren H
      • Gray M
      The gynecologic exam of the transfeminine person following penile inversion vaginoplasty.
      ,
      ACOG
      Committee opinion no. 754 Summary: the utility of and indications for routine pelvic examination.
      As the direction is different than that of a native vagina, a single-digit examination prior to speculum insertion can be helpful to appreciate the angle and path. Anoscopy or vaginoscopy can be considered; however, we find that our patients are able to tolerate an average-size Pederson speculum.
      Short-term complications of PIV include infection, partial flap loss, dehiscence, fistulae, delayed wound healing, and rectal or urethral injury.
      • Ferrando CA
      Vaginoplasty complications.
      Long-term complications are similar but also include strictures and prolapse. Any concern for these should be referred to a surgeon skilled in PIV. Lifelong dilation is required following PIV, unless a patient is engaging in regular vaginal receptive intercourse, to avoid stenosis.
      • Grimstad F
      • McLaren H
      • Gray M
      The gynecologic exam of the transfeminine person following penile inversion vaginoplasty.
      Patients may ask their PAG clinicians for help in assessing their dilation progression. Dilation frequency should be increased if loss of either depth or width is found. If vaginal webbing or strictures are noted on examination, they should be addressed by a skilled surgeon.
      Douching is necessary in a PIV neovagina, as the keratinized epithelium does not self-clean. We recommend beginning with a non-scented douche (eg, soap and water, vinegar, or 25% povidone-iodine) 2-3 times per week, and increasing in frequency for any increase in foul odor or discharge or after insertional intercourse or dilation. For any other douching option, we recommend trying the mixture on external skin first to assess for sensitivity before using it in the neovagina. If discharge or odor is not resolved by douching, clinicians should assess for other causes (eg, granulation tissue or lesions).
      • Grimstad F
      • McLaren H
      • Gray M
      The gynecologic exam of the transfeminine person following penile inversion vaginoplasty.
      Suture lines within the neovagina are at risk for granulation tissue formation (eg, due to repeated trauma from insertional intercourse or dilation) and should be managed as per standard for granulation tissue.
      • Hirotsu K
      • Kannan S
      • Brian Jiang SI
      Treatment of hypertrophic granulation tissue: a literature review.
      Despite hair removal, some hairs may remain in the neovaginal cavity. These can cause pain during sexual penetration or dilation and may become infected or ingrown. Management should be done by a skilled electrologist.
      Up to half of patients may report voiding dysfunction, diverting streams, or recurrent urinary infections (UTI) following PIV.
      • Ferrando CA
      Vaginoplasty complications.
      Although uncomplicated UTIs can be treated as per standard cisgender female guidelines, recurrent UTIs should be referred to a urologist for evaluation of possible stricture.
      The prostate remains in situ following PIV and is along the anterior vaginal wall. A prostate that is tender, boggy, or enlarged may be a sign of prostatic inflammation or infection.
      • Bickley LS
      • Szilagyi PG
      • Hoffman RM
      Bates’ Guide to Physical Examination and History Taking.
      Because PAG clinicians may not be as familiar with prostatic examinations, we recommend referral to someone skilled in performing them for evaluation.
      Patients can also experience dyspareunia or vaginismus from dilation or insertional intercourse. The pelvic floor muscles can be palpated through the vagina, and there are a growing number of gender-affirming pelvic floor physical therapists available to collaborate in the management of this care. Finally, residual erectile tissue may be present if the erectile bodies are not completely excised, and can become engorged on arousal. Magnetic resonance imaging can confirm the presence of erectile bodies, which may be palpable on a digital examination in the labia or along the vagina. If residual erectile tissue is found, the patient should be referred to a PIV surgeon.
      Sexual function after vaginoplasty is diverse, and most studies are limited by having incomplete data on how preoperative functioning and goals differ or change following surgery.
      • Dy GW
      • Nolan IT
      • Hotaling J
      • et al.
      Patient reported outcome measures and quality of life assessment in genital gender confirming surgery.
      In general, studies show that most patients report satisfaction, including ability to achieve orgasm, following vaginoplasty, but highest-risk sexual concerns include arousal difficulties, low sexual aversion, and low sexual desire.
      • Kerckhof ME
      • Kreukels BPC
      • Nieder TO
      • et al.
      Prevalence of sexual dysfunctions in transgender persons: results from the ENIGI Follow-Up Study.
      ,
      • Manrique OJ
      • Adabi K
      • Martinez-Jorge J
      • et al.
      Complications and patient-reported outcomes in male-to-female vaginoplasty–where we are today: a systematic review and meta-analysis.
      Some sexual function concerns may be remediable with appropriate sex education and counseling around responsive rather than spontaneous arousal patterns and appropriate use of sexual lubricants. Individuals who are used to specific types of physiologic response as an indication of arousal (ie, erection) may need to learn new ways of understanding their sexual desire. In addition, transgender women can benefit from providers normalizing the use of sexual lubricants among all women during sexual penetration, including cisgender ones.

      Dermatosis and Infections in TGD AYA Undergoing GAS

      Sexually transmitted infection (STI) risk is related to anatomy and behavior and not to identity; clinicians should ask about present anatomy of the patient and partners rather than only gender identity and sexual orientation. The Centers for Disease Control and Prevention (CDC) guidelines on special populations recommend focusing on anatomy- and orifice-specific approaches to STI screening.
      • Workowski K
      • Bolan G.
      Centers for Disease Control and Prevention.
      Genital warts can still occur, and all genital squamous tissues are at risk for human papillomavirus (HPV) malignancy.
      • Bollo J
      • Balla A
      • Rodriguez Luppi C
      • et al.
      HPV-related squamous cell carcinoma in a neovagina after male-to-female gender confirmation surgery.
      • de Araújo LA
      • De Paula AAP
      • De Paula H
      • et al.
      Human papillomavirus (HPV) genotype distribution in penile carcinoma: association with clinic pathological factors.
      • Guimerà N
      • Alemany L
      • Halec G
      • et al.
      Human papillomavirus 16 is an aetiological factor of scrotal cancer.
      We encourage all of our patients up to age 45 years to undergo the HPV vaccination to minimize the impact of HPV on their genitals and risk of transmission to partners.
      • Meites E
      • Szilagyi PG
      • Chesson HW
      • et al.
      Human papillomavirus vaccination for adults: updated recommendations of the advisory committee on immunization practices.
      As the neogenitalia are typically made using skin flaps, they are still at risk for dermatosis and infections of the native tissues (eg cellulitis, psoriasis). Lesions should be addressed as for the donor site and followed appropriately. For patients who have undergone vaginoplasty, gonorrhea and chlamydia can colonize urethral tissue that is present at the neo-introitus.
      • Weyers S
      • Verstraelen H
      • Gerris J
      • et al.
      Microflora of the penile skin-lined neovagina of transsexual women.
      Urine STI testing has not been validated in persons with neogenitalia, but it is reasonable to begin there. For those who have a native or neo vagina, vaginal sampling is also reasonable.

      Conclusion

      As increasing numbers of TGD AYA undergo GAS, PAG clinicians will encounter patients presenting for preoperative counseling, requesting referrals to GAS clinicians, requiring GAS aftercare, or seeking general sexual and reproductive health care who have a history of GAS. Some GAS are specifically related to sexual and reproductive health, and PAG clinicians are well positioned as experts in AYA sexual and reproductive health, particularly with patients with genital and anatomic diversity, to provide care in this area. PAG clinicians can become skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.

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