success rate of gender reassignment surgery

ORIGINAL RESEARCH article

Male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

$\nGabriel Veber Moiss da Silva$

1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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New study shows transgender people who receive gender-affirming surgery are significantly less likely to experience psychological distress or suicidal ideation.

April 28, 2021

success rate of gender reassignment surgery

BOSTON, April 28, 2021—A new study published today in JAMA Surgery found that gender-affirming surgery is associated with improved mental health outcomes among transgender people. The study was authored by researchers at Harvard Medical School, Harvard T.H. Chan School of Public Health, The Fenway Institute at Fenway Health, and the Department of Psychiatry, Massachusetts General Hospital. It is the first large-scale, controlled study to demonstrate an association between gender-affirming surgery and improved mental health outcomes and adds important new knowledge to the field as there is little high-quality evidence regarding the mental health effects of gender-affirming surgery.

“There is great demand among transgender and gender diverse people for gender-affirming surgery, and thanks to recommendations by professional associations and clinical support for gender-affirming surgical care, these treatments are much more common today than they were even just 10 years ago,” said study lead author Anthony N. Almazan, a fourth-year medical student at Harvard Medical School. “But until now there has been limited evidence that these surgeries result in better mental health outcomes.”

The study, titled “Association Between Gender-Affirming Surgeries and Mental Health Outcomes,” compared the psychological distress, substance use, and suicide risk of 3,559 transgender people who had undergone gender-affirming surgery with those of 16,401 transgender people who desired gender-affirming surgery but had not yet undergone any. It found that transgender people who had received one or more gender-affirming surgical procedures had a 42% reduction in the odds of experiencing past-month psychological distress, a 35% reduction in the odds of past-year tobacco smoking, and a 44% reduction in the odds of past-year suicidal ideation.

This study also found that people who received all of the gender-affirming surgeries they desired had significant reductions in the odds of every adverse mental health outcome examined, including past-year suicide attempts and past-month binge alcohol use. Furthermore, compared to people who only received some of the gender-affirming surgeries they desired, people who received all of their desired surgeries experienced even more profound mental health benefits across every outcome.

Recent attempts to test the theory that gender-affirming surgeries are associated with better mental health outcomes among transgender and gender diverse people have yielded mixed results. A 2010 meta-analysis of 1,833 transgender and gender diverse people across 28 studies concluded that there was “low-quality evidence” that gender-affirming surgery would result in positive mental health outcomes. Although a 2019 study of 2,679 transgender people demonstrated an association between gender-affirming surgery and reduced utilization of mental health treatment, a correction to the study issued in 2020 reported no mental health benefits after comparison with a control group of transgender people who had not yet undergone surgery.

“These results are incredibly important for the evolving field of transgender health care. Although clinicians have long supported the provision of gender-affirming medical and surgical care, the practice has been challenged by health insurers asking for more evidence showing its efficacy,” said study senior author Dr. Alex S. Keuroghlian, who directs the National LGBTQIA+ Health Education Center at The Fenway Institute and the Massachusetts General Hospital Psychiatry Gender Identity Program. “In light of this study’s results, gender-affirming surgeries should be made available for transgender and gender diverse people who seek them, and we should work to remove barriers to gender-affirming surgery such as insurance exclusions for such care.”

The study uses data from the 2015 U.S. Transgender Survey (USTS) conducted by the National Center for Transgender Equality , which is the largest dataset containing comprehensive information on the surgical and mental health experiences of transgender and gender diverse people. The USTS survey includes responses from over 27,000 transgender people living in all 50 U.S. states, the District of Columbia, U.S. territories, and U.S. military bases abroad. Adjustments were made for exposure to other types of gender-affirming care such as counseling, pubertal suppression, and hormone therapy. Adjustments were also made for sociodemographic factors including age, education level, employment status, household income, and race.

“Association Between Gender-Affirming Surgeries and Mental Health Outcomes” is available here .

Tags: Gender identity , The Fenway Institute , Trans Health , Transgender Health

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Preparation and Procedures Involved in Gender Affirmation Surgeries

If you or a loved one are considering gender affirmation surgery , you are probably wondering what steps you must go through before the surgery can be done. Let's look at what is required to be a candidate for these surgeries, the potential positive effects and side effects of hormonal therapy, and the types of surgeries that are available.

Gender affirmation surgery, also known as gender confirmation surgery, is performed to align or transition individuals with gender dysphoria to their true gender.

A transgender woman, man, or non-binary person may choose to undergo gender affirmation surgery.

The term "transexual" was previously used by the medical community to describe people who undergo gender affirmation surgery. The term is no longer accepted by many members of the trans community as it is often weaponized as a slur. While some trans people do identify as "transexual", it is best to use the term "transgender" to describe members of this community.

Transitioning

Transitioning may involve:

Social transitioning : going by different pronouns, changing one’s style, adopting a new name, etc., to affirm one’s gender
Medical transitioning : taking hormones and/or surgically removing or modifying genitals and reproductive organs

Transgender individuals do not need to undergo medical intervention to have valid identities.

Reasons for Undergoing Surgery

Many transgender people experience a marked incongruence between their gender and their assigned sex at birth. The American Psychiatric Association (APA) has identified this as gender dysphoria.

Gender dysphoria is the distress some trans people feel when their appearance does not reflect their gender. Dysphoria can be the cause of poor mental health or trigger mental illness in transgender people.

For these individuals, social transitioning, hormone therapy, and gender confirmation surgery permit their outside appearance to match their true gender.

Steps Required Before Surgery

In addition to a comprehensive understanding of the procedures, hormones, and other risks involved in gender-affirming surgery, there are other steps that must be accomplished before surgery is performed. These steps are one way the medical community and insurance companies limit access to gender affirmative procedures.

Steps may include:

Mental health evaluation : A mental health evaluation is required to look for any mental health concerns that could influence an individual’s mental state, and to assess a person’s readiness to undergo the physical and emotional stresses of the transition.
Clear and consistent documentation of gender dysphoria
A "real life" test : The individual must take on the role of their gender in everyday activities, both socially and professionally (known as “real-life experience” or “real-life test”).

Firstly, not all transgender experience physical body dysphoria. The “real life” test is also very dangerous to execute, as trans people have to make themselves vulnerable in public to be considered for affirmative procedures. When a trans person does not pass (easily identified as their gender), they can be clocked (found out to be transgender), putting them at risk for violence and discrimination.

Requiring trans people to conduct a “real-life” test despite the ongoing violence out transgender people face is extremely dangerous, especially because some transgender people only want surgery to lower their risk of experiencing transphobic violence.

Hormone Therapy & Transitioning

Hormone therapy involves taking progesterone, estrogen, or testosterone. An individual has to have undergone hormone therapy for a year before having gender affirmation surgery.

The purpose of hormone therapy is to change the physical appearance to reflect gender identity.

Effects of Testosterone

When a trans person begins taking testosterone , changes include both a reduction in assigned female sexual characteristics and an increase in assigned male sexual characteristics.

Bodily changes can include:

Beard and mustache growth
Deepening of the voice
Enlargement of the clitoris
Increased growth of body hair
Increased muscle mass and strength
Increase in the number of red blood cells
Redistribution of fat from the breasts, hips, and thighs to the abdominal area
Development of acne, similar to male puberty
Baldness or localized hair loss, especially at the temples and crown of the head
Atrophy of the uterus and ovaries, resulting in an inability to have children

Behavioral changes include:

Aggression
Increased sex drive

Effects of Estrogen

When a trans person begins taking estrogen , changes include both a reduction in assigned male sexual characteristics and an increase in assigned female characteristics.

Changes to the body can include:

Breast development
Loss of erection
Shrinkage of testicles
Decreased acne
Decreased facial and body hair
Decreased muscle mass and strength
Softer and smoother skin
Slowing of balding
Redistribution of fat from abdomen to the hips, thighs, and buttocks
Decreased sex drive
Mood swings

When Are the Hormonal Therapy Effects Noticed?

The feminizing effects of estrogen and the masculinizing effects of testosterone may appear after the first couple of doses, although it may be several years before a person is satisfied with their transition. This is especially true for breast development.

Timeline of Surgical Process

Surgery is delayed until at least one year after the start of hormone therapy and at least two years after a mental health evaluation. Once the surgical procedures begin, the amount of time until completion is variable depending on the number of procedures desired, recovery time, and more.

Transfeminine Surgeries

Transfeminine is an umbrella term inclusive of trans women and non-binary trans people who were assigned male at birth.

Most often, surgeries involved in gender affirmation surgery are broken down into those that occur above the belt (top surgery) and those below the belt (bottom surgery). Not everyone undergoes all of these surgeries, but procedures that may be considered for transfeminine individuals are listed below.

Top surgery includes:

Breast augmentation
Facial feminization
Nose surgery: Rhinoplasty may be done to narrow the nose and refine the tip.
Eyebrows: A brow lift may be done to feminize the curvature and position of the eyebrows.
Jaw surgery: The jaw bone may be shaved down.
Chin reduction: Chin reduction may be performed to soften the chin's angles.
Cheekbones: Cheekbones may be enhanced, often via collagen injections as well as other plastic surgery techniques.
Lips: A lip lift may be done.
Alteration to hairline
Male pattern hair removal
Reduction of Adam’s apple
Voice change surgery

Bottom surgery includes:

Removal of the penis (penectomy) and scrotum (orchiectomy)
Creation of a vagina and labia

Transmasculine Surgeries

Transmasculine is an umbrella term inclusive of trans men and non-binary trans people who were assigned female at birth.

Surgery for this group involves top surgery and bottom surgery as well.

Top surgery includes :

Subcutaneous mastectomy/breast reduction surgery.
Removal of the uterus and ovaries
Creation of a penis and scrotum either through metoidioplasty and/or phalloplasty

Complications and Side Effects

Surgery is not without potential risks and complications. Estrogen therapy has been associated with an elevated risk of blood clots ( deep vein thrombosis and pulmonary emboli ) for transfeminine people. There is also the potential of increased risk of breast cancer (even without hormones, breast cancer may develop).

Testosterone use in transmasculine people has been associated with an increase in blood pressure, insulin resistance, and lipid abnormalities, though it's not certain exactly what role these changes play in the development of heart disease.

With surgery, there are surgical risks such as bleeding and infection, as well as side effects of anesthesia . Those who are considering these treatments should have a careful discussion with their doctor about potential risks related to hormone therapy as well as the surgeries.

Cost of Gender Confirmation Surgery

Surgery can be prohibitively expensive for many transgender individuals. Costs including counseling, hormones, electrolysis, and operations can amount to well over $100,000. Transfeminine procedures tend to be more expensive than transmasculine ones. Health insurance sometimes covers a portion of the expenses.

Quality of Life After Surgery

Quality of life appears to improve after gender-affirming surgery for all trans people who medically transition. One 2017 study found that surgical satisfaction ranged from 94% to 100%.

Since there are many steps and sometimes uncomfortable surgeries involved, this number supports the benefits of surgery for those who feel it is their best choice.

A Word From Verywell

Gender affirmation surgery is a lengthy process that begins with counseling and a mental health evaluation to determine if a person can be diagnosed with gender dysphoria.

After this is complete, hormonal treatment is begun with testosterone for transmasculine individuals and estrogen for transfeminine people. Some of the physical and behavioral changes associated with hormonal treatment are listed above.

After hormone therapy has been continued for at least one year, a number of surgical procedures may be considered. These are broken down into "top" procedures and "bottom" procedures.

Surgery is costly, but precise estimates are difficult due to many variables. Finding a surgeon who focuses solely on gender confirmation surgery and has performed many of these procedures is a plus. Speaking to a surgeon's past patients can be a helpful way to gain insight on the physician's practices as well.

For those who follow through with these preparation steps, hormone treatment, and surgeries, studies show quality of life appears to improve. Many people who undergo these procedures express satisfaction with their results.

Bizic MR, Jeftovic M, Pusica S, et al. Gender dysphoria: Bioethical aspects of medical treatment . Biomed Res Int . 2018;2018:9652305. doi:10.1155/2018/9652305

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The World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-nonconforming people . 2012.

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T'sjoen G, Arcelus J, Gooren L, Klink DT, Tangpricha V. Endocrinology of transgender medicine . Endocr Rev . 2019;40(1):97-117. doi:10.1210/er.2018-00011

Unger CA. Hormone therapy for transgender patients . Transl Androl Urol . 2016;5(6):877-884. doi:10.21037/tau.2016.09.04

Seal LJ. A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria . Ann Clin Biochem . 2016;53(Pt 1):10-20. doi:10.1177/0004563215587763

Schechter LS. Gender confirmation surgery: An update for the primary care provider . Transgend Health . 2016;1(1):32-40. doi:10.1089/trgh.2015.0006

Altman K. Facial feminization surgery: current state of the art . Int J Oral Maxillofac Surg . 2012;41(8):885-94. doi:10.1016/j.ijom.2012.04.024

Therattil PJ, Hazim NY, Cohen WA, Keith JD. Esthetic reduction of the thyroid cartilage: A systematic review of chondrolaryngoplasty . JPRAS Open. 2019;22:27-32. doi:10.1016/j.jpra.2019.07.002

Top H, Balta S. Transsexual mastectomy: Selection of appropriate technique according to breast characteristics . Balkan Med J . 2017;34(2):147-155. doi:10.4274/balkanmedj.2016.0093

Chan W, Drummond A, Kelly M. Deep vein thrombosis in a transgender woman . CMAJ . 2017;189(13):E502-E504. doi:10.1503/cmaj.160408

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Colebunders B, Brondeel S, D'Arpa S, Hoebeke P, Monstrey S. An update on the surgical treatment for transgender patients . Sex Med Rev . 2017 Jan;5(1):103-109. doi:10.1016/j.sxmr.2016.08.001

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Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

1 University of Michigan Medical School, Ann Arbor
2 Section of Plastic Surgery, University of Michigan, Ann Arbor
3 Michigan Institute for Clinical Health Research, Ann Arbor, Michigan
4 Institute for Healthcare Policy and Innovation, Ann Arbor
5 Seattle Children’s Hospital, Seattle, Washington
Invited Commentary Low Rate of Regret After Gender-Affirming Mastectomy Ian T. Nolan, MD; Brielle Weinstein, MD; Loren Schechter, MD JAMA Surgery

Question What is the rate of regret and satisfaction with decision after 2 years or more following gender-affirming mastectomy?

Findings In this cross-sectional study of 139 survey respondents who underwent gender-affirming mastectomy, the median satisfaction score was 5 on a 5-point scale, with higher scores indicating higher satisfaction. The median decisional regret score was 0 on a 100-point scale, with lower scores indicating lower levels of regret.

Meaning This study’s findings indicate low patient-reported long-term rates of regret and high satisfaction with the decision to undergo gender-affirming mastectomy, although the need exists for condition-specific instruments to assess satisfaction with decision and decisional regret for gender-affirming surgery.

Importance There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments.

Objective To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy.

Design, Setting, and Participants For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020.

Exposure Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy.

Main Outcomes and Measures Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders.

Results A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses.

Conclusions and Relevance In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.

Invited Commentary Low Rate of Regret After Gender-Affirming Mastectomy JAMA Surgery

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Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study

Affiliations.

1 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Paris Diderot university, Sorbonne Paris, Paris, France; Plastic and aesthetic surgery department, hôpital Tenon, Paris, France.
2 Plastic and reconstructive surgery, Conception hospital, 147, boulevard Baille, 13005 Marseille, France.
3 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France.
4 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Paris Diderot university, Sorbonne Paris, Paris, France.
5 Plastic and aesthetic surgery department, hôpital Tenon, Paris, France.
6 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Plastic and reconstructive surgery, François-Mitterand hospital, 14, rue Paul-Gaffarel, 21079 Dijon, France. Electronic address: [email protected].
PMID: 30269882
DOI: 10.1016/j.anplas.2018.08.002

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Keywords: Chirurgie de changement de sexe; Complications postopératoires; Follow-up; Postoperative complications; Sex reassignment surgery; Suivi.

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U.S. sees threefold increase in gender-affirming surgeries in 3 years

Between 2016 and 2019 more than 48,000 patients -- about half of them between 19 and 30 years of age -- underwent some form of gender-affirming (GAS) surgery, researchers found. Photo by Engin Akyurt/Pixabay

The number of Americans undergoing gender-affirming surgery is on the rise, new research reveals, almost tripling between 2016 and 2019 alone.

During that period, more than 48,000 patients -- about half of them between 19 and 30 years of age -- underwent some form of gender-affirming (GAS) surgery, researchers found. Advertisement

About 4,500 of those procedures were performed in 2016. By 2019, that figure rose to a high of 13,000, a number that dipped only slightly in 2020.

"A lot of scare pieces are being written about how many trans people there seem to be all of a sudden, but this is not about a skyrocketing number of people who all of a sudden are trans and all of a sudden are seeking these procedures," said Kellan Baker , a transgender healthcare policy expert. "This is about the fact that before 2016 it was just not possible for many of these patients to get the medical care they needed because of discriminatory exclusions." Advertisement

The study's lead author, Dr. Jason Wright , pointed to several possible reasons for the rapid increase. One, he said, is a greater awareness of the procedures among patients and healthcare providers.

"And there is a growing body of literature that the procedures are generally safe and associated with high satisfaction," said Wright, chief of gynecologic oncology at Columbia University College of Physicians and Surgeons in New York City.

"There have also been a number of initiatives to improve insurance coverage for these operations, which likely make them more accessible to patients," he added.

Gender-affirming surgery is one of the treatments -- alongside behavioral therapy and hormonal therapy -- available to patients struggling with gender dysphoria.

Gender dysphoria occurs when the gender a person is assigned at birth doesn't match the gender with which one identifies.

Certain breast, chest, cosmetic, facial and genital reconstruction surgeries are intended to help.

Researchers cite previous studies that found such procedures can alleviate the depression and anxiety that accompany gender dysphoria. They also boost quality of life and overall satisfaction levels, those studies have found.

To learn how many Americans are now embracing gender-affirming surgery, Wright's team reviewed a national database of surgical procedures in almost 2,800 hospitals in 35 states. The researchers also combed a second database that covers a large swatch of inpatient admissions in community hospitals across 48 states. Advertisement

Between 2016 and 2020, just over 48,000 gender-affirming procedures were performed.

They included breast reconstruction, repositioning and size adjustments; nipple reconstruction; male or female genital reconstruction; cosmetic facial procedures; hair removal or transplantation; liposuction and/or collagen injections.

Broken down year by year, the patient pool rose from 4,552 in 2016 to a peak of 13,011 in 2019. In all, 12,818 patients had gender-affirming surgery in 2020, the final year of the study.

Over the entire period, just over half (52%) of the patients were between 19 and 30 years of age, while about 22% were between 31 and 40. Fewer than 8% were between the ages of 12 and 18.

Most lived in the West (46%) or the Northeast (26%). About two-thirds underwent a single GAS procedure. More than a quarter of patients had two.

While all forms of gender-affirming surgery rose, breast and chest surgeries were most common. About 57% of patients had that type of surgery, with breast reconstruction being the most popular option.

About one-third (35%) of patients underwent genital reconstruction, with older patients more likely to choose this option. About 14% underwent cosmetic or facial operations.

Characterizing the spike in GAS surgeries as "remarkable," Wright said more study is needed. Advertisement

"There is clearly a need to further explore the very rapid rise in the number of procedures performed each year," he said, in order to get a better handle on exactly what's behind it.

Meanwhile, Baker, executive director of the Whitman-Walker Institute, a health policy think tank in Washington, D.C., had a straightforward explanation for the trend.

In the past, insurers often refused to cover gender-affirming surgery. That changed dramatically in 2016, when the Obama administration clarified in regulation that the Affordable Care Act bars discrimination in insurance coverage and healthcare against transgender people.

"But when you remove that exclusion," Baker said, "it then makes it possible for providers to provide care. And it makes that care much more accessible and affordable to patients."

In other words, he said, the trend is no mystery.

"Trans people have always been here," Baker said. "The numbers we're seeing now just reflect the fact that people have finally gotten some legal recognition, social visibility and the ability to be open about who they are and to get the medical care they need."

He is concerned, however, about ongoing efforts in many states to legislatively restrict access to transgender care.

"That would not be a positive thing," Baker said. "It would reflect going back to a state of unmet need. Gender dysphoria is a real and serious condition. And not treating it is not an option." Advertisement

The findings were published Wednesday in JAMA Network Open .

More information

There's more about gender-affirming surgery at the Cleveland Clinic .

Study finds high patient satisfaction, low regret after gender-affirming mastectomies
Pediatrician group reaffirms support for gender-related care for minors
Studies confirm benefits of gender-affirming care for transgender people

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Ryan T. Anderson, Ph.D.

Former Visiting Fellow, DeVos Center

Key Takeaways

McHugh points to the reality that because sex change is physically impossible, it frequently does not provide the long-term wholeness and happiness that people seek.

Unfortunately, many professionals now view health care—including mental health care—primarily as a means of fulfilling patients’ desires, whatever those are.

Our brains and senses are designed to bring us into contact with reality, connecting us with the outside world and with the reality of ourselves.

Sex “reassignment” doesn’t work. It’s impossible to “reassign” someone’s sex physically, and attempting to do so doesn’t produce good outcomes psychosocially.

As I demonstrate in my book, “ When Harry Became Sally: Responding to the Transgender Moment ,” the medical evidence suggests that sex reassignment does not adequately address the psychosocial difficulties faced by people who identify as transgender. Even when the procedures are successful technically and cosmetically, and even in cultures that are relatively “trans-friendly,” transitioners still face poor outcomes.

Dr. Paul McHugh, the university distinguished service professor of psychiatry at the Johns Hopkins University School of Medicine, explains :

Transgendered men do not become women, nor do transgendered women become men. All (including Bruce Jenner) become feminized men or masculinized women, counterfeits or impersonators of the sex with which they ‘identify.’ In that lies their problematic future.

When ‘the tumult and shouting dies,’ it proves not easy nor wise to live in a counterfeit sexual garb. The most thorough follow-up of sex-reassigned people —extending over 30 years and conducted in Sweden, where the culture is strongly supportive of the transgendered—documents their lifelong mental unrest. Ten to 15 years after surgical reassignment, the suicide rate of those who had undergone sex-reassignment surgery rose to 20 times that of comparable peers.

Indeed, the best scientific research supports McHugh’s caution and concern.

Here’s how The Guardian summarized the results of a review of “more than 100 follow-up studies of post-operative transsexuals” by Birmingham University’s Aggressive Research Intelligence Facility:

[The Aggressive Research Intelligence Facility], which conducts reviews of health care treatments for the [National Health Service], concludes that none of the studies provides conclusive evidence that gender reassignment is beneficial for patients. It found that most research was poorly designed, which skewed the results in favor of physically changing sex. There was no evaluation of whether other treatments, such as long-term counseling, might help transsexuals, or whether their gender confusion might lessen over time.

“There is huge uncertainty over whether changing someone’s sex is a good or a bad thing,” said Chris Hyde, the director of the facility . Even if doctors are careful to perform these procedures only on “appropriate patients,” Hyde continued, “there’s still a large number of people who have the surgery but remain traumatized—often to the point of committing suicide.”

Of particular concern are the people these studies “lost track of.” As The Guardian noted, “the results of many gender reassignment studies are unsound because researchers lost track of more than half of the participants.” Indeed, “Dr. Hyde said the high drop-out rate could reflect high levels of dissatisfaction or even suicide among post-operative transsexuals.”

Hyde concluded: “The bottom line is that although it’s clear that some people do well with gender reassignment surgery, the available research does little to reassure about how many patients do badly and, if so, how badly.”

The facility conducted its review back in 2004, so perhaps things have changed in the past decade?

Not so. In 2014, a new review of the scientific literature was done by Hayes, Inc., a research and consulting firm that evaluates the safety and health outcomes of medical technologies. Hayes found that the evidence on long-term results of sex reassignment was too sparse to support meaningful conclusions and gave these studies its lowest rating for quality:

Statistically significant improvements have not been consistently demonstrated by multiple studies for most outcomes. … Evidence regarding quality of life and function in male-to-female adults was very sparse. Evidence for less comprehensive measures of well-being in adult recipients of cross-sex hormone therapy was directly applicable to [gender dysphoric] patients but was sparse and/or conflicting. The study designs do not permit conclusions of causality and studies generally had weaknesses associated with study execution as well. There are potentially long-term safety risks associated with hormone therapy but none have been proven or conclusively ruled out.

The Obama administration came to similar conclusions. In 2016, the Centers for Medicare and Medicaid Services revisited the question of whether sex reassignment surgery would have to be covered by Medicare plans. Despite receiving a request that its coverage be mandated, it refused, on the ground that we lack evidence that it benefits patients.

Here’s how the June 2016 “ Proposed Decision Memo for Gender Dysphoria and Gender Reassignment Surgery ” put it:

Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results—of the best designed studies, some reported benefits while others reported harms. The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding, and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up.

The final August 2016 memo was even more blunt. It pointed out:

Overall, the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints, potential confounding (a situation where the association between the intervention and outcome is influenced by another factor such as a co-intervention), small sample sizes, lack of validated assessment tools, and considerable lost to follow-up.

That “lost to follow-up,” remember, could be pointing to people who committed suicide.

And when it comes to the best studies, there is no evidence of “clinically significant changes” after sex reassignment:

The majority of studies were non-longitudinal, exploratory type studies (i.e., in a preliminary state of investigation or hypothesis generating), or did not include concurrent controls or testing prior to and after surgery. Several reported positive results but the potential issues noted above reduced strength and confidence. After careful assessment, we identified six studies that could provide useful information. Of these, the four best designed and conducted studies that assessed quality of life before and after surgery using validated (albeit non-specific) psychometric studies did not demonstrate clinically significant changes or differences in psychometric test results after [gender reassignment surgery].

In a discussion of the largest and most robust study—the study from Sweden that McHugh mentioned in the quote above—the Obama Centers for Medicare and Medicaid Services pointed out the 19-times-greater likelihood for death by suicide, and a host of other poor outcomes:

The study identified increased mortality and psychiatric hospitalization compared to the matched controls. The mortality was primarily due to completed suicides (19.1-fold greater than in control Swedes), but death due to neoplasm and cardiovascular disease was increased 2 to 2.5 times as well. We note, mortality from this patient population did not become apparent until after 10 years. The risk for psychiatric hospitalization was 2.8 times greater than in controls even after adjustment for prior psychiatric disease (18 percent). The risk for attempted suicide was greater in male-to-female patients regardless of the gender of the control. Further, we cannot exclude therapeutic interventions as a cause of the observed excess morbidity and mortality. The study, however, was not constructed to assess the impact of gender reassignment surgery per se.

These results are tragic. And they directly contradict the most popular media narratives, as well as many of the snapshot studies that do not track people over time. As the Obama Centers for Medicare and Medicaid pointed out, “mortality from this patient population did not become apparent until after 10 years.”

So when the media tout studies that only track outcomes for a few years, and claim that reassignment is a stunning success, there are good grounds for skepticism.

As I explain in my book , these outcomes should be enough to stop the headlong rush into sex reassignment procedures. They should prompt us to develop better therapies for helping people who struggle with their gender identity.

And none of this even begins to address the radical, entirely experimental therapies that are being directed at the bodies of children to transition them.

Sex Change Is Physically Impossible

We’ve seen some of the evidence that sex reassignment doesn’t produce good outcomes psychosocially. And as McHugh suggested above, part of the reason why is because sex change is impossible and “it proves not easy nor wise to live in a counterfeit sexual garb.”

But what is the basis for the conclusion that sex change is impossible?

Contrary to the claims of activists , sex isn’t “assigned” at birth—and that’s why it can’t be “reassigned.” As I explain in “When Harry Became Sally,” sex is a bodily reality that can be recognized well before birth with ultrasound imaging. The sex of an organism is defined and identified by the way in which it (he or she) is organized for sexual reproduction.

This is just one manifestation of the fact that natural organization is “the defining feature of an organism,” as neuroscientist Maureen Condic and her philosopher brother Samuel Condic explain. In organisms, “the various parts … are organized to cooperatively interact for the welfare of the entity as a whole. Organisms can exist at various levels, from microscopic single cells to sperm whales weighing many tons, yet they are all characterized by the integrated function of parts for the sake of the whole.”

Male and female organisms have different parts that are functionally integrated for the sake of their whole, and for the sake of a larger whole—their sexual union and reproduction. So an organism’s sex—as male or female—is identified by its organization for sexually reproductive acts. Sex as a status—male or female—is a recognition of the organization of a body that can engage in sex as an act.

That organization isn’t just the best way to figure out which sex you are. It’s the only way to make sense of the concepts of male and female at all. What else could “maleness” or “femaleness” even refer to, if not your basic physical capacity for one of two functions in sexual reproduction?

The conceptual distinction between male and female based on reproductive organization provides the only coherent way to classify the two sexes. Apart from that, all we have are stereotypes.

This shouldn’t be controversial. Sex is understood this way across sexually reproducing species. No one finds it particularly difficult—let alone controversial—to identify male and female members of the bovine species or the canine species. Farmers and breeders rely on this easy distinction for their livelihoods. It’s only recently, and only with respect to the human species, that the very concept of sex has become controversial.

And yet, in an expert declaration to a federal district court in North Carolina concerning H.B. 2 (a state law governing access to sex-specific restrooms), Dr. Deanna Adkins stated, “From a medical perspective, the appropriate determinant of sex is gender identity.” Adkins is a professor at Duke University School of Medicine and the director of the Duke Center for Child and Adolescent Gender Care (which opened in 2015).

Adkins argues that gender identity is not only the preferred basis for determining sex, but “the only medically supported determinant of sex.” Every other method is bad science, she claims: “It is counter to medical science to use chromosomes, hormones, internal reproductive organs, external genitalia, or secondary sex characteristics to override gender identity for purposes of classifying someone as male or female.”

In her sworn declaration to the federal court, Adkins called the standard account of sex—an organism’s sexual organization—“an extremely outdated view of biological sex.”

Dr. Lawrence Mayer responded in his rebuttal declaration: “This statement is stunning. I have searched dozens of references in biology, medicine and genetics—even Wiki!—and can find no alternative scientific definition. In fact, the only references to a more fluid definition of biological sex are in the social policy literature.”

Just so. Mayer is a scholar in residence in the Department of Psychiatry at the Johns Hopkins University School of Medicine and a professor of statistics and biostatistics at Arizona State University.

Modern science shows that our sexual organization begins with our DNA and development in the womb, and that sex differences manifest themselves in many bodily systems and organs, all the way down to the molecular level. In other words, our physical organization for one of two functions in reproduction shapes us organically, from the beginning of life, at every level of our being.

Cosmetic surgery and cross-sex hormones can’t change us into the opposite sex. They can affect appearances. They can stunt or damage some outward expressions of our reproductive organization. But they can’t transform it. They can’t turn us from one sex into the other.

“Scientifically speaking, transgender men are not biological men and transgender women are not biological women. The claims to the contrary are not supported by a scintilla of scientific evidence,” explains Mayer.

Or, as Princeton philosopher Robert P. George put it, “Changing sexes is a metaphysical impossibility because it is a biological impossibility.”

The Purpose of Medicine, Emotions, and the Mind

Behind the debates over therapies for people with gender dysphoria are two related questions: How do we define mental health and human flourishing? And what is the purpose of medicine, particularly psychiatry?

Those general questions encompass more specific ones: If a man has an internal sense that he is a woman, is that just a variety of normal human functioning, or is it a psychopathology? Should we be concerned about the disconnection between feeling and reality, or only about the emotional distress or functional difficulties it may cause?

What is the best way to help people with gender dysphoria manage their symptoms: by accepting their insistence that they are the opposite sex and supporting a surgical transition, or by encouraging them to recognize that their feelings are out of line with reality and learn how to identify with their bodies?

All of these questions require philosophical analysis and worldview judgments about what “normal human functioning” looks like and what the purpose of medicine is.

Settling the debates over the proper response to gender dysphoria requires more than scientific and medical evidence. Medical science alone cannot tell us what the purpose of medicine is.

Science cannot answer questions about meaning or purpose in a moral sense. It can tell us about the function of this or that bodily system, but it can’t tell us what to do with that knowledge. It cannot tell us how human beings ought to act. Those are philosophical questions, as I explain in “ When Harry Became Sally .”

While medical science does not answer philosophical questions, every medical practitioner has a philosophical worldview, explicit or not. Some doctors may regard feelings and beliefs that are disconnected from reality as a part of normal human functioning and not a source of concern unless they cause distress. Other doctors will regard those feelings and beliefs as dysfunctional in themselves, even if the patient does not find them distressing, because they indicate a defect in mental processes.

But the assumptions made by this or that psychiatrist for purposes of diagnosis and treatment cannot settle the philosophical questions: Is it good or bad or neutral to harbor feelings and beliefs that are at odds with reality? Should we accept them as the last word, or try to understand their causes and correct them, or at least mitigate their effects?

While the current findings of medical science, as shown above, reveal poor psychosocial outcomes for people who have had sex reassignment therapies, that conclusion should not be where we stop. We must also look deeper for philosophical wisdom, starting with some basic truths about human well-being and healthy functioning.

We should begin by recognizing that sex reassignment is physically impossible. Our minds and senses function properly when they reveal reality to us and lead us to knowledge of truth. And we flourish as human beings when we embrace the truth and live in accordance with it. A person might find some emotional relief in embracing a falsehood, but doing so would not make him or her objectively better off. Living by a falsehood keeps us from flourishing fully, whether or not it also causes distress.

This philosophical view of human well-being is the foundation of a sound medical practice. Dr. Michelle Cretella, the president of the American College of Pediatricians—a group of doctors who formed their own professional guild in response to the politicization of the American Academy of Pediatrics—emphasizes that mental health care should be guided by norms grounded in reality, including the reality of the bodily self.

“The norm for human development is for one’s thoughts to align with physical reality, and for one’s gender identity to align with one’s biologic sex,” she says. For human beings to flourish, they need to feel comfortable in their own bodies, readily identify with their sex, and believe that they are who they actually are. For children especially, normal development and functioning require accepting their physical being and understanding their embodied selves as male or female.

Unfortunately, many professionals now view health care—including mental health care—primarily as a means of fulfilling patients’ desires, whatever those are. In the words of Leon Kass, a professor emeritus at the University of Chicago, today a doctor is often seen as nothing more than “a highly competent hired syringe”:

The implicit (and sometimes explicit) model of the doctor-patient relationship is one of contract: the physician—a highly competent hired syringe, as it were—sells his services on demand, restrained only by the law (though he is free to refuse his services if the patient is unwilling or unable to meet his fee). Here’s the deal: for the patient, autonomy and service; for the doctor, money, graced by the pleasure of giving the patient what he wants. If a patient wants to fix her nose or change his gender, determine the sex of unborn children, or take euphoriant drugs just for kicks, the physician can and will go to work—provided that the price is right and that the contract is explicit about what happens if the customer isn’t satisfied.

This modern vision of medicine and medical professionals gets it wrong, says Kass. Professionals ought to profess their devotion to the purposes and ideals they serve. Teachers should be devoted to learning, lawyers to justice, clergy to things divine, and physicians to “healing the sick, looking up to health and wholeness.” Healing is “the central core of medicine,” Kass writes—“to heal, to make whole, is the doctor’s primary business.”

To provide the best possible care, serving the patient’s medical interests requires an understanding of human wholeness and well-being. Mental health care must be guided by a sound concept of human flourishing. The minimal standard of care should begin with a standard of normality. Cretella explains how this standard applies to mental health:

One of the chief functions of the brain is to perceive physical reality. Thoughts that are in accordance with physical reality are normal. Thoughts that deviate from physical reality are abnormal—as well as potentially harmful to the individual or to others. This is true whether or not the individual who possesses the abnormal thoughts feels distress.

Our brains and senses are designed to bring us into contact with reality, connecting us with the outside world and with the reality of ourselves. Thoughts that disguise or distort reality are misguided—and can cause harm. In “ When Harry Became Sally ,” I argue that we need to do a better job of helping people who face these struggles.

This piece originally appeared in The Daily Signal

Neither federal lawmakers nor courts should have the power to redefine what it is to be a man or a woman for all Americans. Learn more about policies that curb government overreach with Solutions .

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What Is The Best Age For LASIK Eye Surgery?

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What Is The Best Age For LASIK Eye Surgery?

What is lasik, how old do you have to be to get lasik, what is the best age to get lasik, who should not have laser eye surgery, frequently asked questions (faqs).

If you’re tired of wearing glasses or dropping your contact lenses in the sink, you might consider LASIK (laser-assisted in situ keratomileusis) surgery. This procedure can help correct vision issues and eliminate the hassle of glasses or contacts for qualifying candidates. However, determining the best age and whether you’re eligible for LASIK eye surgery can be tricky.

Keep reading to find out about the best age to have LASIK, who should consider the surgery, who shouldn’t and more.

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LASIK is a vision correction surgery often used to improve myopia (nearsightedness), hyperopia (farsightedness) and astigmatism (a misshapen cornea). This type of surgery uses a laser to reshape the cornea—the outer surface of the eye—for clearer vision, says Ami Vadada, M.D., a board-certified ophthalmologist in New York and clinical spokesperson for the American Academy of Ophthalmology.

According to the U.S. Food and Drug Administration (FDA), individuals must be 18 or older to get LASIK surgery [1] When is LASIK not for me? . U.S. Food & Drug Administration. Accessed 6/1/2024. . “The age minimum exists because the eyes continue to change and develop until around 18 to 21 years old. Performing LASIK before the eyes have fully matured could lead to vision changes and the need for additional surgery later,” explains Eduardo Besser, M.D., a board-certified ophthalmologist at Angeles Eye Institute in Culver City, California, and a clinical instructor at UCLA Jules Stein Eye Institute.

Dr. Besser says that in addition to age, other important factors for LASIK eligibility include:

A stable vision prescription for one to two years
Healthy corneas with sufficient thickness for LASIK
Refractive errors (nearsightedness, farsightedness or astigmatism ) that are treatable with LASIK
No active eye diseases or infections
Good health overall

Is There an Age Limit for LASIK Surgery?

There is no maximum age limit for LASIK as long as vision is stable. However, the surgery may not be as effective in older adults due to eye changes that can occur with aging, says Dr. Vadada. For example, presbyopia, an age-related condition that makes it difficult to see things up close, occurs after age 40. LASIK cannot treat presbyopia, but it can correct one eye for distance and the other eye for near viewing (monovision).

Cataracts (clouding of the lens in the eye) that affect vision can disqualify an individual from LASIK. Dry eyes, which tend to be more common after 65, may also make someone a less ideal candidate for LASIK, since the procedure can exacerbate the condition.

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The best age to get LASIK is generally between 25 and 40 years old, according to Dr. Besser, as most people within this range have stabilized vision prescriptions and healthy eyes, making them ideal candidates. “This age range allows individuals to enjoy the benefits of LASIK for many years without the complications that can arise from age-related eye conditions,” he adds.

AGE RANGES	WHAT TO CONSIDER

LASIK may not be suitable for everyone. Experts recommend scheduling an examination with a LASIK surgeon to determine eligibility. In general, Dr. Besser recommends the following groups consider avoiding LASIK surgery:

Children and teenagers under 18 years old, as their eyes are still developing and vision can change rapidly
Older adults with age-related eye conditions like cataracts and other corneal issues
Individuals with unstable vision or rapidly changing prescriptions
Those with eye conditions like glaucoma, keratoconus, herpes infections or severe dry eyes
People with uncontrolled diabetes
Individuals with autoimmune diseases like AIDS, lupus or rheumatoid arthritis, which can affect healing
Patients with thin corneas or large pupils, which can increase risks
People taking medications that can affect vision stability or healing, like steroids or immunosuppressants
Pregnant or nursing people, as hormonal changes can affect vision stability

“Patients with unrealistic expectations of achieving ‘perfect vision’ should be cautioned, as LASIK cannot guarantee 20/20 vision for everyone,” adds Dr. Besser.

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At what ages is LASIK not recommended?

LASIK is generally not recommended for individuals under 18 due to ongoing eye development or for those whose vision isn’t stabilized, according to Dr. Besser. Older adults with conditions like cataracts or severe presbyopia may not be ideal candidates.

Is LASIK worth it for a 21-year-old?

“LASIK can be worth it for a 21-year-old if their vision prescription has been stable for at least a year,” says Dr. Besser. This age group can benefit from many years of clear vision, but it’s crucial to ensure that their eyes have fully matured and stabilized.

When is LASIK not for me?. U.S. Food & Drug Administration. Accessed 6/1/2024.
How the Eyes Work. National Eye Institute. Accessed 6/3/2024.
What is Refractive Surgery?. American Academy of Ophthalmology. Accessed 6/3/2024.
LASIK—Laser Eye Surgery. American Academy of Ophthalmology. Accessed 6/3/2024.
What is Photorefractive Keratectomy (PRK)?. American Academy of Ophthalmology. Accessed 6/3/2024.
LASIK eye surgery. National Library of Medicine. Accessed 6/3/2024.
What is Presbyopia?. American Academy of Ophthalmology. Accessed 6/3/2024.
Dry Eye. American Optometric Association. Accessed 6/3/2024.
When is LASIK not for me?. U.S. Food & Drug Administration. Accessed 6/3/2024.
Moshirfar M, Bennett P, et al. Laser In Situ Keratomileusis (LASIK). Treasure Island (FL): StatPearls Publishing. 2023.
Cataracts. Mount Sinai. Accessed 6/5/2024.
Should you have LASIK if you have cataracts?. American Academy of Ophthalmology. Accessed 6/5/2024.
Questions to Ask When Considering LASIK. American Academy of Ophthalmology. Accessed 6/5/2024.
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Eye Drops For Contacts Wearers
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Conjunctivitis (Pink Eye): Symptoms And Treatments
Internal Stye: Symptoms And Treatments
At-Home Stye Remedies
What Are Cataracts?
LASIK Eye Surgery
How Much Does LASIK Cost?
Is LASIK Covered By Insurance?
Lens Replacement Surgery
How Much Does Cataract Surgery Cost?

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Information provided on Forbes Health is for educational purposes only. Your health and wellness is unique to you, and the products and services we review may not be right for your circumstances. We do not offer individual medical advice, diagnosis or treatment plans. For personal advice, please consult with a medical professional.

Forbes Health adheres to strict editorial integrity standards. To the best of our knowledge, all content is accurate as of the date posted, though offers contained herein may no longer be available. The opinions expressed are the author’s alone and have not been provided, approved or otherwise endorsed by our advertisers.

Heidi Borst is a freelance journalist, healthcare content writer and certified nutrition coach with a love of all things health and wellness. Her work has appeared in The New York Times, The Washington Post, National Geographic, Good Housekeeping, MSN, Yahoo and more. Based in Wilmington, North Carolina, Borst is a lifelong runner and general fitness enthusiast who is passionate about the physical and mental benefits of sleep and self-care.

Macy Alcido is a freelance writer based in New York City. She discovered her love for health reporting while attending the Columbia Journalism School, and has since contributed health-related stories to HuffPost, Psychiatric Times and Verywell. Macy also reported on health topics as a junior news writer at theSkimm, while covering a variety of topics including pop culture, politics and tech.

As a cornea specialist and board-certified ophthalmologist, Dr. Knezevic specializes in cataract surgery, LASIK, dry eye and corneal disease. He practices at the Macy Eye Center in Los Angeles, in addition to being a part of the medical staff at Cedars-Sinai Medical Center and a voluntary clinical instructor of ophthalmology at UCLA. Dr. Knezevic has published many peer-reviewed articles, presented at national conferences and written a number of book chapters on the topics of dry eye, corneal surgery and cataract surgery. He has performed an extensive number of sight-saving surgeries abroad, and has been a visiting physician in both India and Nepal. Dr. Knezevic is an active member of numerous local, regional and national organizations.

Man is wide awake during trailblazing kidney transplant procedure at Northwestern Memorial

John nicholas, 28, remained awake while undergoing a kidney transplant procedure on may 24 at northwestern memorial hospital in chicago, illinois..

A Chicago man was wide awake as he witnessed Northwestern Medicine surgeons place his childhood best friend's kidney inside of him during a cutting-edge kidney transplant procedure .

John Nicholas, 28, underwent the surgery on May 24 and "felt no pain" as doctors decided against general anesthesia, and instead opted for a spinal anesthesia shot, the Chicago-based healthcare system said Monday in a news release.

Nicholas was discharged from the hospital and at home less than 24 hours after the procedure, which took under two hours to complete, according to the healthcare system. The normal hospitalization for kidney transplant patients at Northwestern Memorial Hospital is typically two or three days, Northwestern Medicine said.

"This is the first case at Northwestern Medicine where a patient was awake during an entire kidney transplant procedure and went home the next day, basically making this an outpatient procedure," Dr. Satish Nadig, one of the transplant surgeons at Northwestern Medicine who performed the procedure, said in the release. "Our hope is that awake kidney transplantation can decrease some of the risks of general anesthesia while also shortening a patient’s hospital stay."

Kidney transplants: Procedures usually last 10 to 15 years. Hers made it 50, but now it's wearing out.

Patient says kidney transplant procedure was 'pretty cool experience'

Dr. Vicente Garcia Tomas, an anesthesiologist who assisted during the procedure, said, "Doing anesthesia for the awake kidney transplant was easier than many C-sections."

"For John’s case, we placed a spinal anesthesia shot in the operating room with a little bit of sedation for comfort," Tomas said in the release. "It was incredibly simple and uneventful, but allowed John to be awake for the procedure, improving the patient experience."

Nadig called the procedure an "incredible experience" because doctors were able to show Nicholas what his new kidney looked like before placing it inside his body.

“It was a pretty cool experience to know what was happening in real time and be aware of the magnitude of what they were doing,” Nicholas said in the release. “At one point during surgery, I recall asking, ‘Should I be expecting the spinal anesthesia to kick in?’ They had already been doing a lot of work and I had been completely oblivious to that fact. Truly, no sensation whatsoever."

John Nicholas receives a kidney from one of his 'ride or die' friends

Nicholas needed the transplant after his kidney function declined in 2022 due to his ongoing battle with Crohn's disease, which began when he was 16 years old, according to the healthcare system. He was able to avoid dialysis and manage his kidney inflammation by using medication for years until it became clear he would eventually need a transplant, Northwestern Medicine said.

Finding a donor was challenging as his mother initially was supposed to give him her kidney, but she was unable to donate following a breast cancer diagnosis, according to the release. Nicholas would then reach out to his childhood friends who he had known since they attended elementary school in Zionsville, Indiana, and 29-year-old Pat Wise was one of them, the healthcare system said.

"I was in my kitchen cooking dinner and John sent a message that read, ‘My doctor says it’s time for me to start looking for kidney donors.’ I stared at my phone and without hesitating, filled out the form that night,” Wise said about receiving the text from Nicholas, per the release. “John is a good friend. He needed a kidney, and I had an extra one. I had to at least explore the potential of being his donor.”

Once Wise was declared a match, he traveled from Alexandria, Virginia to Chicago where surgeons removed one of his kidneys and transplanted it into Nicholas, according to Northwestern Medicine.

“I have been blessed with a friend group that has stayed together from such a young age,” Nicholas said in the release. “We always called ourselves ‘ride or die’ friends, and this example shows that we have each other’s backs. It meant the world to me. It’s truly been life-changing.”

Procedure 'opens up a whole new door' for future kidney transplants

Nicholas, who had to limit salt intake before the procedure, is now eager to enjoy a couple of slices of pizza and have more energy to ride his bicycle around Chicago, according to the release.

“When John agreed to be the first known patient at Northwestern Medicine to undergo an awake kidney transplant and be discharged home the next day, he knew the benefits outweighed the risks, and because of him, he’s now helping to move the field of transplantation forward,” Dr. Vinayak Rohan, a surgeon who helped perform the procedure, said in the release.

Northwestern Medicine is now looking to establish the AWAKE Program (Accelerated Surgery Without General Anesthesia in Kidney Transplantation) for patients who want to undergo the operation but can not have general anesthesia because they're at high risk for complications or other reasons.

“It really opens up a whole new door and is another tool in our toolbelt for the field of transplantation,” Nadig said in the release.

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Plast Reconstr Surg Glob Open
v.9(3); 2021 Mar

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis

Samyd s. bustos.

From the * Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

Valeria P. Bustos

† Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.

Andres Mascaro

‡ Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Weston, Fla.

Pedro Ciudad

§ Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru

Antonio J. Forte

¶ Division of Plastic and Reconstructive Surgery, Mayo Clinic, Jacksonville, Fla.

Gabriel Del Corral

∥ Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C.

Oscar Javier Manrique

** Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Strong Memorial Hospital, Rochester, N.Y.

Associated Data

Supplemental Digital Content is available in the text.

Background:

Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes.

A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed.

After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%–2%] of fistula, 11% (95% CI 8%–14%) of stenosis and/or strictures, 4% (95% CI 1%–9%) of tissue necrosis, and 3% (95% CI 1%–4%) of prolapse. Overall satisfaction was 91% (81%–98%). Regret rate was 2% (95% CI <1%–3%). Average neovaginal depth was 9.4 cm (7.9–10.9 cm) for the penile skin inversion and 15.3 cm (13.8–16.7 cm) for the intestinal vaginoplasty.

Conclusions:

Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

INTRODUCTION

Transgender is a term that includes the many ways that people’s gender identities can differ from the sex they were assigned at birth. Unfortunately, the transgender population has largely suffered from transgender-related discrimination in healthcare and employment, and from high rates of mental illness, particularly anxiety and depression, in addition to violence and health-related problems. 1 , 2 This population expresses their gender identity in many different ways. Some use their dress or behavior (gender expressions) to live as the gender that feels appropriate for them, and many undergo medical or surgical treatment to change their body, so that it matches their gender identity. Surgical treatment, particularly genital or bottom surgery, is often the last and most considered step for transgender patients. 3 The role of surgery has shown to be essential and medically necessary to alleviate patients’ gender dysphoria, which is the distress caused by the discrepancy between a person’s gender identity and the sex assigned at birth. 4 – 10

For transgender women, genital surgery involves vaginoplasty, which entails the surgical reconstruction of all the anatomical structures of the female external genitalia and the creation of a functional vaginal canal. The Standards of Care from the World Professional Association for Transgender Health clearly defines the criteria for vaginoplasty in transfemale patients, which includes the following: persistent, well-documented gender dysphoria, capacity to make a fully informed decision and to consent for treatment, age of majority, control of significant medical or mental health concerns, 12 continuous months of hormonal therapy as appropriate, and 12 continuous months of living in a gender role that is congruent with their gender identity. 3

In general, vaginoplasty aims to create a functional feminine vulva, a deep and wide enough vagina, a hooded sensate clitoris, and labia minora and majora with acceptable cosmesis and sexual sensation. A number of surgical techniques have been described; however, the most commonly used technique is still the penile skin inversion with or without skin graft. Although less common, intestinal-based techniques, including colon or small bowel conduits, have also been reported. These may have specific indications; for instance, patients with micropenis, penile hypoplasia (<8 cm), or poor skin quality or elasticity due to prolonged hormonal treatment may not be suitable for penile skin inversion and other options such as intestinal conduits may be more appropriate. 11 , 12

Although there are still financial and social barriers to healthcare access for this particular population worldwide, the need for surgical gender-affirming care is increasing remarkably. This may be explained due to increased awareness of the needs of transgender and gender-nonbinary (TGNB) patients, and availability and accessibility to gender care centers. In 2015, the US Transgender Surgery sampled over 27,000 TGNB Americans and found that one fourth had undergone one or more gender affirmation surgeries (GAS). 13 , 14 A total of 12% of respondents had undergone vaginoplasty and/or labiaplasty, and 54% responded they wanted to have it someday. Therefore, both academic and private centers are facing an increased demand for transfemale vaginoplasty.

The need of a state-of-the-art review on surgical and patient-reported outcomes has been previously addressed by Manrique et al. 5 However, this upward trend in gender affirmation surgeries has also impacted the number of published articles on this topic over the past years about this surgical procedure. In this study, we aim to conduct an updated, comprehensive systematic review of the literature of papers in transfemale vaginoplasty with meta-analysis of complications and patient-reported outcomes.

Search Methodology

Based on the PRISMA guidelines, a comprehensive research of several databases from each database’s inception was conducted on July 15, 2020. 15 The databases included PubMed, Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process and Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Web of Science, and Ovid Cochrane Central Register of Controlled Trials. A comprehensive research strategy using the same strategy from our previous study was conducted. 5 This was previously designed and conducted by experienced librarians with input from the study’s principal investigator. Controlled vocabulary with keywords was conducted to update the previous search and include studies from 2017 to 2020 of vaginoplasty in transgender and nonbinary population who reported our outcomes of interest.

The search terms were formulated using the PICO structure. Participants included transfemale patients. The intervention was vaginoplasty, bottom male-to-female surgery, or transfemale genital surgery. Comparisons addressed the specific technique used. Outcomes included complications, functional or aesthetic patient-reported outcomes. The strategy is available in Supplemental Digital Content 1 . (See pdf, Supplemental Digital Content 1, which displays the s earch strategies, http://links.lww.com/PRSGO/B611 .) All search results were combined in EndNote, a bibliographic management tool, and duplicates were removed.

Study Selection

We conducted a 2-stage screening process with the help of the online software Covidence. 16 Search strategy results were exported from EndNote into XML format and uploaded to Covidence. 16 Two researchers (S.S.B and V.P.B) conducted the first screening by reviewing titles and abstracts, and selected the ones relevant to the research question. Then, the second screening was conducted by the same researchers reviewing the full-text form of the remained articles. The studies included were those that met the inclusion and exclusion criteria. Conflicts in this stage were solved by a third reviewer (O.J.M.), who moderated a discussion and made final decision. Eligible criteria were based on our previous systematic review and meta-analysis by Manrique et al. 5 Inclusion criteria were all articles that included studies with sample size more than 5 patients, only transfemale vaginoplasty procedures studied, publication year 1985 or more, articles reporting at least 1 outcome measurement, and a follow-up time of at least 1 year. The exclusion criteria were all studies with surgical techniques for partial reconstruction of the vagina or vaginoplasty corrections, surgical techniques only for the creation of neoclitoris or labiaplasty, and unspecified surgical technique, non-English publications, cancer-related publications, trauma-related publications, and congenital-related publications.

Data Extraction and Synthesis

The included studies were analyzed in detail. We extracted information regarding the name of the first author, year of publication, and follow-ups time (minimum, maximum, and SDs variables). Major complications categorized as fistulas, vaginal and urethral stenosis and strictures, tissue necrosis, and prolapse were identified. For fistulas outcomes, vaginorectal and vesicovaginal fistulas were included. Stenosis and strictures outcomes included introital, stroma, urethral, and vaginal. Both partial and complete strictures were taken into account. The tissue necrosis outcome included necrosis of the urethra, glans, clitoris, and labia. Rectocele, urethral, or mucosal prolapse was included in the prolapse outcome.

Patient-reported outcomes were analyzed as proportions and percentages. Overall results, function, and aesthetic satisfaction outcomes were identified as the number of patients who reported such variables. Aesthetic outcome included perception of vaginal appearance as feminine. Satisfied included “very satisfied” and “mostly satisfied” in the included studies.

The ability to have orgasm, regret rate, and the patient-reported outcomes were analyzed as proportions and percentages. In addition, we extracted information about the vaginal cavity length, its mean, minimum and maximum values, and SD.

Quality Assessment

The Newcastle-Ottawa Scale was used to assess quality of nonrandomized studies in meta-analyses was used to assess the risk of bias in the included studies. A nonrandomized study can be ranked 9 stars on items related to: the selection of the study groups (4 points), comparability of the exposed and unexposed groups (2 points), and the ascertainment of outcomes of interest (3 points).

Statistical Analysis

The data were analyzed, and outcome estimations in this meta-analysis were conducted in Stata Software/IC (version 16.1). 17 We divided the studies in 2 major groups of interest: penile inversion technique and intestinal vaginoplasty. Given the heterogeneity between studies, we conducted a logistic-normal-random-effect model. The study-specific proportions with 95% exact confidence intervals (CIs) and overall pooled estimates with 95% Wald CIs with Freeman–Turkey double arcsine transformation were performed. The effect size and percentage of weight were presented for each individual study. To evaluate heterogeneity, I 2 statistics was used. If P value <0.05 or I 2 >50% significant heterogeneity was considered.

A total of 154 articles were identified in the updated search. The first screening process generated 36 articles, and the second screening yielded 11 articles, which were included in the systematic review and meta-analysis. We compiled these data to the one of the previous systematic review and meta-analysis of Manrique et al 5 as shown in Figure Figure1. 1 . A total of 57 studies were included in the systematic review and 52 in the meta-analysis. All included studies were assigned either a low- or moderate-quality design. (See pdf, Supplemental Digital Content 2, which displays the quality assessment of included studies, http://links.lww.com/PRSGO/B612 .)

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PRISMA flowchart.

Study Characteristics

A total of 4680 cases were represented in this systematic review. A total of 39 (75%) studies used the penile skin inversion technique with or without scrotal flap 18 – 54 and 11 (21.2%) studies used bowel pedicle flaps, of which 7 (13.5%) used sigmoid or rectosigmoid, 3 (5.8%) used ileal, and 1 (1.9%) used transverse colon as conduit. 55 – 67 One study (1.9%) reported both techniques, 68 and another study (1.9%) reported outcomes using amnion grafts with and without fibroblasts. 69 A total of 3930 (84.0%) cases used the penile skin inversion technique with or without scrotal graft or skin graft, whereas 726 (15.5%) cases used bowel pedicle flaps. One study reported 24 (0.5%) vaginoplasty cases using amnion grafts. The average number of cases per study was 90 with the smallest study including 7 cases and the largest study including 475. Table Table2 2 shows the differences between the findings of our previous meta-analysis and the current study.

Differences between the Previous and Current Metanalysis

		Manrique et al 2018	Current Study	Differences

Fistula	Overall	2% (1%–6%)	1% (<0.1%–2%)	−1%
	PSI	1% (%–4%)	1% (<0.1%–2%)	=
	IBV	6% (%–20%)	2% (<0.1%–9%)	−4%
Stenosis and strictures	Overall	14 (10%–18%)	11% (8%–14%)	−3%
	PSI	13% (9%–18%)	10% (8%–14%)	−3%
	IBV	17% (10%–29%)	14% (5%–26%)	−3%
Tissue necrosis	Overall	1% (0%–6%)	4% (1%–9%)	+3%
	PSI	1% (0%–6%)	5% (1%–10%)	+4%
	IBV	NR	1% (<0.1%–9%)	—
Prolapse	Overall	4% (2%–10%)	3% (1%–4%)	−1%
	PSI	3% (1%–8%)	2% (1%–4%)	−1%
	IBV	8% (2%–43%)	6% (1%–14%)	−2%

Overall results	Overall	93% (79%–100%)	91% (81%–98%)	−2%
	PSI	91% (75%–100%)	87% (78%–94%)	−4%
	IBV	100% (96%–100%)	99% (97%–100%)	−1%
Function outcome	Overall	87% (75%–96%)	87% (77%–94%)	=
	PSI	88% (71%–99%)	87% (74%–96%)	−1%
	IBV	86% (75%–95%)	86% (75%–95%)	=
Aesthetic outcome	Overall	90% (79%–98%)	90% (84%–94%)	=
	PSI	91% (78%–99%)	90% (84%–95%)	−1%
	IBV	86% (69%–94%)	86% (69%–94%)	=
Ability to have an orgasm	Overall	70% (54%–84%)	76% (64%–86%)	+6%
	PSI	68% (52%–83%)	73% (60%–84%)	+5%
	IBV	89% (72%–96%)	95% (88%–99%)	+6%
Regrets	Overall	1% (<1%–3%)	2% (<1%–3%)	+1%
	PSI	2% (<1%–4%)	2% (<1%–4%)	=
	IBV	0%	0% (<1%–20%)	=

	Overall	12.2 cm (10.2–14.2 cm)	10.9 cm (9.2–12.8)	−1.3 cm
	PSI	10.7 cm (8.8–12.5 cm)	9.4 cm (7.9–10.9)	−1.3 cm
	IBV	15.3 cm (14.3–16.4 cm)	15.3 cm (13.8–16.7cm)	=

Data shown as pooled value and 95% confidence interval.

IBV, intestinal-based vaginoplasty; PSI, penile skin inversion; =, no change.

Authors	Year of Publication	No. Cases	Mean Follow-up (mo)	Reported Complication Outcomes
Amend	2013	24	41.0	Y
Goddard	2007	233	1.9	Y
Hess	2014	119	62.6	N
Krege	2001	66	NS	Y
Perovic	2000	89	56.0	Y
Reed	2011	250	NS	Y
Rossi	2012	332	24.3	Y
Kim	2003	28	60.8	Y
Djordjevic	2011	27	47.7	Y
Wu	2009	11	14.2	Y
Zhao	2011	19	35.1	Y
Bouman	2016	42	3.2	Y
Lenaghan	1997	59	NS	Y
Morrison	2015	83	2.2	Y
van der Sluis	2016	24	289.6	Y
Rehman	1999	57	0.1	N
Jarolim	2009	134	NS	Y
Hage	1996	60	9.6	Y
van Noort	1993	16	16.6	Y
Huang	1994	121	NS	Y
Bouman	1988	67	NS	Y
Fang	1991	9	NS	Y
Eldh	1993	20	NS	Y
Buncamper	2015	49	49.9	Y
LeBreton	2016	28	14.6	Y
Raigosa	2015	60	24.3	Y
Buncamper	2016	475	94.9	Y
Wangiraniran	2015	395	NS	Y
Sigurjonsson	2016	80	44.6	Y
Papdopulos	2017	47	19.3	N
Manrique	2018	15	146.0	N
Imbimbo	2009	139	NS	N
Namba	2007	7	NS	Y
Siemssen	1997	11	30.6	Y
Wagner	2009	50	36.5	Y
Blanchard	1987	22	53.5	N
Rubin	1993	13	3.5	Y
Small	1987	11	0.7	Y
Zavlin	2017	40	135.6	N
Stein	1990	14	22.1	N
Lindemalm	1986	13	14.1	N
Manrique	2019	40	12.4	Y
DiSumma	2019	38	NS	Y
Mukai	2019	18	NS	N
Ferrando	2020	76	12.0	Y
Levy	2019	240	2.9	Y
Kaushik	2019	386	34.0	Y
Nijhuis	2020	42	13.0	Y
Thalaivirithan	2018	30	18.0	Y
Seyed-Forootan	2018	24	36.0	Y
Gaither	2018	330	3.0	Y
Manero	2018	97	12.6	Y

N, no; NS, not specified; Y, yes.

Complications

Overall pooled data including both surgical techniques showed the following complication rates: 1% (95% CI <0.1%–2%, I 2 = 65.8%) of fistula, 11% (95% CI 8%–14%, I 2 = 87.3%) of stenosis and/or strictures, 4% (95% CI 1%–9%, I 2 = 94.3%) of tissue necrosis, and 3% (95% CI 1%–4%, I 2 = 77.2%) of prolapse (Fig. (Fig.2 2 ).

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Object name is gox-9-e3510-g002.jpg

Meta-analyses of different types of complications. Fistula (A), tissue necrosis (B), stenosis and strictures (C), and prolapse (D) are depicted.

Subgroup meta-analysis showed the following outcome complications for the penile skin inversion technique with or with our scrotal flaps: 1% (<0.1%–2%, I 2 = 57.5%) of fistula, 10% (8%–14%, I 2 = 85.5%) of stenosis and strictures, 5% (1%–10%, I 2 = 93.9.0%) of tissue necrosis, and 2% (1%–4%, I 2 = 78.1%) of prolapse. Complications for intestinal vaginoplasty were as follows: 2% (<0.1%–9%, I 2 = 83.3%) of fistula, 14% (5%–26%, I 2 = 91.7%) of stenosis and strictures, 1% (<0.1%–2%) of tissue necrosis in 1 study, and 6% (1%–14%, I 2 = 76.4%) for prolapse. Complications reported for the 2 surgical techniques had an I 2 value greater than 50% representing considerable heterogeneity.

Patient-reported Outcomes

Satisfaction rates were 91% (81%–98%, I 2 = 94.8%), 87% (77%–94%, I 2 = 88.6%), and 90% (84%–94%, I 2 = 69.4%) for overall, functional, and aesthetic outcomes, respectively (Fig. (Fig.3). 3 ). For the penile skin inversion technique, patient-reported outcomes showed a satisfaction rate of 87% (78%–94%, I 2 = 88.3%) for overall satisfaction, 87% (74%–96%, I 2 = 90.9%) for functional outcomes, and 90% (84%–95%, I 2 = 71.0%) for aesthetical outcomes. For the intestinal vaginoplasty technique, patient-reported outcomes showed a satisfaction rate of 99% (97%–100%) for overall satisfaction, 86% (75%–95%, I 2 = 55.3%) for functional outcomes, and 86% (69%–94%) for aesthetic outcomes.

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Object name is gox-9-e3510-g003.jpg

Meta-analyses of different types of patient-reported outcomes. Overall satisfaction (A), functional outcomes (B), and aesthetic outcomes (C) are depicted.

Overall, the ability to achieve orgasm was 76% (64%–86%, I 2 = 93.1%). In the subgroup analysis, the ability to achieve orgasm was 73% (60%–84%, I 2 = 92.8) for the penile skin inversion technique and 95% (88%–99%) for intestinal vaginoplasty (Fig. (Fig.4 4 ).

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Object name is gox-9-e3510-g004.jpg

Meta-analysis of ability to achieve orgasm.

The overall regret rate was 2% (95% CI <1%–3%, I 2 = 0%). The regret rate was 2% (95% CI <1%–4%, I 2 = 0%) for the penile inversion technique and <1% (95% CI <1%–20%) for the intestinal-based vaginoplasty group (Fig. (Fig.5 5 ).

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Object name is gox-9-e3510-g005.jpg

Meta-analysis of regret rates.

Vaginal Cavity Dimensions

Fifteen studies reported vaginal cavity length (Fig. (Fig.6). 6 ). The average neovaginal length for both surgical techniques was 10.9 cm (9.2–12.8 cm, I 2 = 93.5%). In the subgroup analysis, the average length was 9.4 cm (7.9–10.9 cm, I 2 = 84.6%) for the penile skin inversion technique and 15.3 cm (13.8–16.7 cm, I 2 = 0.0%) for the intestinal vaginoplasty group.

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Object name is gox-9-e3510-g006.jpg

Meta-analysis of depth of neovagina. Weights are from random effects analysis.

The gender confirmation process involves a comprehensive treatment program including endocrine therapy, psychological treatment, breast surgery, facial surgery, and genital confirmation surgery. 5 Of all treatment modalities, genital surgery is generally the final stage of the gender confirmation process and is associated with significant improvement in both mental and sexual quality of life. 5

Various techniques have been described for transfemale vaginoplasty; most of these techniques have been adapted from procedures designed to treat vaginal agenesis 70 An optimal or ideal technique has not yet been determined due to the lack of sufficiently large comparative studies. However, penile inversion using a pedicle penoscrotal skin flap seems to be the first-line approach, as it is technically less complex and invasive when compared to other techniques while providing great cosmetic and functional results. Nevertheless, patients with penile hypoplasia (penile shaft less than 8 cm) pose a challenge to the surgeon, as they usually do not have sufficient penile skin to create the neovaginal cavity. In such cases, skin grafts from the lower abdomen or thighs are necessary. Additionally, intestinal transposition vaginoplasty emerges as a reasonable option, in which rectosigmoid or ileal segments are isolated (through open or minimally invasive approach) and transferred into the neovaginal space. The advantage of using an intestinal conduit is its length, texture, lubrication, and appearance similar to a natural vagina. However, it should be noted that an abdominal surgery is required, and there is a risk of colitis, peritonitis, intestinal obstruction, junctional neuroma, introital stenosis, mucocele, and constipation. 71 Furthermore, colonic mucosa is more vulnerable to sexually transmitted diseases and further screening for colon cancer is required. 71 , 72

Various grafts such as pedicle genital or nongenital skin flaps have also been described. 11 , 12 , 70 , 72 – 74 Skin graft vaginoplasty is not limited by a vascular pedicle. This ensures that there can be significantly more skin harvested if required to line the neovaginal cavity. Nonetheless, a circumferential skin graft tends to scar and contract leading to neovaginal stenosis in 33%–45% of cases, representing a real disadvantage of this technique. 72 , 73 In addition, undesirable scarring and hypopigmentation of donor sites are also major drawbacks. Hence, this approach is less likely to be utilized in current surgical practice. However, skin grafting may be used as an adjunct of other approaches, for instance when there is not enough tissue for the creation of the neovagina from penile skin alone. 70 Other options for reconstructing a neovagina are emerging, and include, but are not limited to the use of buccal mucosa, amnion grafts, or decellularized tissue. 11

In our analysis, the vast majority of studies included penile skin inversion with or without scrotal flaps. However, with the updated search, we included 2 studies reporting intestinal-based vaginoplasties, one of which was the largest retrospective study among this group including a total of 386 sigma-lead rectosigmoid colon vaginoplasties in India. 67 Only 1 study with amnion grafts was identified but not included in the meta-analysis. In general, quality of the studies was either low or moderate. Most of them were retrospective studies with no control group.

The largest study within the intestinal-based vaginoplasty group was conducted by Kaushik et al 67 in India and included a total of 386 sigma-lead rectosigmoid vaginoplasty. They reported a 20.2% complication rate of which the majority were minor complications (97.4%). A total of 11.4% required reoperations: 2.6% due to introital stricture and mucosal prolapse and 8.8% for elective minor aesthetic enhancement. Satisfaction was reported as 4.7 over a 5-point scale.

Slight changes were identified in this updated meta-analysis as compared with the previous meta-analysis. The differences between studies in complication rates and in patient-reported outcomes including overall, functional, and aesthetic outcomes, ranged from 1 to 4 percentage points. This reflects a stable prevalence among these outcomes, which may be translated as neither an improvement nor a decline in surgical quality standards. From all the complications of interest, fistula had the lowest rate with only 1% (<0.1%–2%), whereas stenosis and strictures had the highest rate with 11% (8%–14%). For stenosis and strictures, intestinal-based vaginoplasty had the highest complication rate with 14% (5%–26%) compared with the penile skin inversion technique with 10% (8%–14%). However, stenosis rates were lower compared with the previous meta-analysis.

Interestingly, the ability to achieve orgasm after both vaginoplasty techniques increased compared with the previous meta-analysis: from 70% (54%–84%) to 76% (64%–86%), respectively. The intestinal-based vaginoplasty technique reported the highest ability to achieve orgasm with 95% (88%–99%) compared with the penile skin inversion technique with 73% (60%–84%). This may be translated as an improvement in surgical techniques in preserving genital sensation.

Very low regret rates have been a common denominator among transfemale patients who undergo vaginoplasty. The prevalence of regret was almost the same as our previous meta-analysis, with only 1 point of difference: 1% (<1%–3%) and 2% (<1%–3%), respectively. For vaginal length, there was a 1.3 cm of difference compared with our previous report. Hence, no important changes were presented with regard to these 2 outcomes.

Gender confirmation surgery, and genital surgery particularly, does not fall within a single specialty’s scope of practice. 74 A multidisciplinary approach is typically required, involving endocrinology and psychology. It is essential to integrate mental health professionals, who are knowledgeable about the assessment and treatment of gender dysphoria and physical and sexual health in the preoperative and postoperative setting. The overall focus is to help maximize the patient´s psychological and physical state to improve quality of life. 3 , 75

CONCLUSIONS

Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of TGNB patients with gender dysphoria. To improve quality of care, a multidisciplinary approach is always necessary. Over the next several years, we will see an increase demand for these procedures, so adequate surgical training, clinical/surgical experience and research outcomes are very much needed, as we continue to strive to provide the best care possible for a population in need.

ACKNOWLEDGMENT

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Supplementary Material

Published online 19 March 2021

This is an invited article for the transgender mini-series.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. All authors have completed the ICMJE uniform disclosure form.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com .

Efficacy and Safety of Endoscopic Stricturotomy in Inflammatory Bowel Disease-Related Strictures: A Systematic Review and Meta-Analysis

Original Article
Published: 26 June 2024

Cite this article

Fouad Jaber 1 ,
Laith Numan 2 ,
Mohammed Ayyad 3 ,
Mohamed Abuelazm 4 ,
Muhammad Imran 5 ,
Majd M. AlBarakat 6 ,
Aya M. Aboutaleb 7 ,
Ubaid Khan 8 ,
Saqr Alsakarneh 1 &
Mohammad Bilal 9 , 10

Background and Aim

Luminal strictures, common in inflammatory bowel disease (IBD), especially Crohn’s disease (CD), are typically treated with endoscopic balloon dilatation (EBD). The newer endoscopic stricturotomy (ESt) approach shows promise, but data is limited. This systematic review and meta-analysis assess the effectiveness and safety of ESt in IBD-related strictures.

A comprehensive literature search was conducted until November 2023 for studies assessing ESt efficacy and safety in IBD. Primary outcomes were clinical and technical success, with secondary endpoints covering adverse events, subsequent stricture surgery, additional endoscopic treatments (ESt or EBD), medication escalation, disease-related emergency department visits, and hospitalization post-ESt. Technical success was defined as passing the scope through the stricture, and clinical success was defined as symptom improvement. Single-arm meta-analysis (CMA version 3) calculated the event rate per patient with a 95% confidence interval (CI). Heterogeneity was evaluated using I 2 .

Nine studies were included, involving 640 ESt procedures on 287 IBD patients (169 CD, 118 ulcerative colitis). Of these, 53.3% were men, with a mean age of 43.3 ± 14.3 years and a mean stricture length of 1.68 ± 0.84 cm. The technical success rate was 96.4% (95% CI 92.5–98.3, p-value < 0.0001), and the clinical success rate was 62% (95% CI 52.2–70.9, p-value = 0.017, I 2 = 34.670). The bleeding rate was 10.5% per patient, and the perforation rate was 3.5%. After an average follow-up of 0.95 ± 1.1 years, 16.4% required surgery for strictures post-ESt, while 44.2% needed additional endoscopic treatment. The medication escalation rate after ESt was 14.7%. The disease-related emergency department visit rate was 14.7%, and the disease-related hospitalization rate post-procedure was 21.3%.

Our analysis shows that ESt is safe and effective for managing IBD-related strictures, making it a valuable addition to the armamentarium of endoscopists. Formal training efforts should focus on ensuring its widespread adoption.

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Abbreviations

Crohn’s disease

Inflammatory bowel disease

Endoscopic balloon dilation

Endoscopic stricturotomy
Ulcerative colitis

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Department of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA

Fouad Jaber & Saqr Alsakarneh

Division of Gastroenterology and Hepatology, Saint Louis University School of Medicine, Saint Louis, MO, USA

Laith Numan

Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, NJ, United States

Mohammed Ayyad

Faculty of Medicine, Tanta University, Tanta, Egypt

Mohamed Abuelazm

University College of Medicine and Dentistry, The University of Lahore, Lahore, Pakistan

Muhammad Imran

Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan

Majd M. AlBarakat

Faculty of Medicine, Zagazig University, Zagazig, Egypt

Aya M. Aboutaleb

Faculty Of Medicine, King Edward Medical University, Lahore, Pakistan

Division of Gastroenterology and Hepatology, University of Minnesota Medical Center, Minneapolis, MN, USA

Mohammad Bilal

Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA

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L.N. conceived the idea. F.J. and M.A. designed the research workflow. F.J. and M.A. searched the databases. M.A., M.M.A., A.M.A., and U.K screened the retrieved records, extracted relevant data, assessed the quality of evidence, while F.J and M.A. resolved the conflicts. F.J. performed the analysis. M.A., and F.J. wrote the final manuscript. M.B., L.N., and S.A supervised the project. All authors have read and agreed to the final version of the manuscript.

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Jaber, F., Numan, L., Ayyad, M. et al. Efficacy and Safety of Endoscopic Stricturotomy in Inflammatory Bowel Disease-Related Strictures: A Systematic Review and Meta-Analysis. Dig Dis Sci (2024). https://doi.org/10.1007/s10620-024-08533-3

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DOI : https://doi.org/10.1007/s10620-024-08533-3

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ORIGINAL RESEARCH article

Introduction

Patients and Methods

Hormonal Therapy

Operative Technique

Postoperative Care and Follow-Up

Statistical Analysis

Patient Demographics

Postoperative Results

Conclusions

Data Availability Statement

Ethics Statement

Author Contributions

Conflict of Interest

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Preparation and Procedures Involved in Gender Affirmation Surgeries

Transitioning

Reasons for Undergoing Surgery

Steps Required Before Surgery

Hormone Therapy & Transitioning

Effects of Testosterone

Effects of Estrogen

When Are the Hormonal Therapy Effects Noticed?

Timeline of Surgical Process

Transfeminine Surgeries

Transmasculine Surgeries

Complications and Side Effects

Cost of Gender Confirmation Surgery

Quality of Life After Surgery

A Word From Verywell

Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy

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