Gender Confirmation Surgery: Principles and Techniques for an Emerging Field

Preface
Contents
Contributors
1: History, Societal Attitudes, and Contexts
	The Concept of Transsexualism
	Incidence and Prevalence of Transsexualism
	Cultural Extent of Transsexualism
	The Benjamin View
	The Gender Clinics of the 1960s and 1970s: John Money’s Paradigm
	Hegemony of the Mental Health Model and Demise of the Clinics
	Reassignment, Change, or Affirmation?
	References
2: Etiology of Gender Dysphoria
	Introduction
	Historical Background
	Early Theories
	Environmental Theories
	Anatomical Postmortem Studies
	Prenatal Hormonal Influences
	Genetic Influences
	Neurodevelopmental Cortical Hypothesis
	References
3: History of Gender Identity and Surgical Alteration of the Genitalia
	Introduction
	Ancient History
	Modern Era (Nineteenth Century to Today)
	Gender Surgery in Popular Culture
	References
4: Language and Terminology in Transgender Health
	Diagnostic Codes in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)
	Diagnostic Codes in the World Health Organization’s International Classification of Diseases (ICD)
	WPATH and the Standards of Care
		Terminology from a Western Perspective
			Cisgender Person
			Gender
			Gender Affirming
			Gender Identity
			Gender Expression
			Genderqueer
			Gender Stereotypes
			Gender Incongruence
			Gender Dysphoria
			Gender Transition
			Intersex
			Sex
			Sex Assigned at Birth
			Sexual Orientation
			Transcultural Competence
			Transgender Person
			Transgender Man
			Transgender Woman
		Terminology from a Non-Western Perspective
		Gender Affirming Medical Interventions
	References
5: The Mental Health Assessment for Surgery
	WPATH Standards of Care and the Mental Health Assessments for Surgery
	The Initial Interview
	The Second Assessment
	References
6: Primary Care for the Transgender and Gender Nonconforming Patient
	Introduction
	Hormonal Therapy
	Care of the Adolescent
	Prevention and Care
	Surgery
	Conclusion
	References
7: Hormone Therapy for Transgender Women
	Introduction
	Principles of Hormone Therapy
	Treatment Regimens
	Long-Term Monitoring and Potential Adverse Events
	Surgical Considerations
	Conclusions
	References
8: Hormone Therapy for Transgender Men
	Introduction
	Principles of Hormone Therapy
	Treatment Regimens
	Long-Term Monitoring and Potential Adverse Events
	Surgical Considerations
	Conclusions
	References
9: Medical Management of the Adolescent Individual with Gender Dysphoria
	Introduction
	Puberty
	GnRH Agonists
	Gonadotropin-Releasing Hormone Agonist Treatment
	Gender-Affirming Hormone Treatment
	Conclusion
	References
10: Male-to-Female Breast Augmentation and Body Contouring
	Introduction
		Preoperative Care and Medications
	Breast Augmentation
		Breast Augmentation Background
		Differences in Male and Female Chests
		Breast Augmentation Preoperative Assessment
		Breast Augmentation Surgical Approach
		Breast Augmentation Postoperative Care
		Breast Augmentation Complications
		Breast Augmentation Postoperative Considerations
		Breast Augmentation Additional Approaches
	Body Contouring
		Body Contouring Background
		Differences in Male and Female Body Habitus
		Body Contouring Preoperative Assessment
		Body Contouring Surgical Approach
		Body Contouring Postoperative Care
		Body Contouring Complications
		Body Contouring Special Considerations
	Conclusions
	References
11: The Importance of Facial Gender Confirmation Surgery
	Secondary Sex Characteristics and Their Role in Gender Dysphoria
	Impact of Facial Gender Confirmation Surgery
	Historical Aspects of Facial Gender Confirmation Surgery
	Patient Perspective
	Current Evidence and Controversies
	Conclusion
	References
12: Facial Gender Affirmation Surgery: Facial Feminization Surgery and Facial Masculinization Surgery
	Background
	Feminization of the Hairline
	The Forehead
		Forehead Type I
		Forehead Type II
		Forehead Type III
		Forehead Type IV
	Rhinoplasty
	Upper Lip
	The Jaw
	The Thyroid Cartilage
	Other Procedures
	Conclusion
	References
13: Fertility Preservation Options for Transgender and Trans Masculine Patients Planning Hysterectomy
	References
14: Penile Inversion Vaginoplasty
	Introduction
	History
	Embryology
	Overview of Surgical Technique
	Geometric Limitations of Penile Inversion Vaginoplasty
	Goals
	Indications
	Preparation for Surgery: Medical Clearance
	Preparation for Surgery: Social Assessment
	Age at Time of Surgery
	Other Considerations
	Preoperative Hair Removal
	Preoperative Physical Exam
		Urethral Injury
		Rectal Injury and Fistula
	Surgical Technique
	Postoperative Considerations
	Complications
15: Intestinal Vaginoplasty
	Introduction
	Techniques
		General Approach
		Harvesting of Intestinal Segment and Re-Establishing Bowel Continuity
		Creating Vaginal Pouch
		Creating Neo-Introitus Between Anorectum and Urethra, Securing the Pouch to the Neo-Introitus, and Fixing the Neovaginal Pouch to Prevent Prolapse
		Techniques for Sigmoid Vaginoplasty
			Simple Sigmoid Harvest
			Simple Sigmoid Harvest with Rotation (Distal Sigmoid Retro-Folding)
			Proximal Sigmoid Advancement with Distal Bowel Resection and Preservation of Mesenteric Continuity
			Sigmoid Advancement with Distal Mesenteric Transection
		Techniques for Cecal Vaginoplasty
		Repairs After Failed Penile/Scrotal Vaginoplasty
			Resection of Failed Skin Vaginoplasty with Creation of Intestinal Neovagina
			Repairs of Fistula Between Rectum and Skin Neovagina
	Discussion
	References
16: Chest Masculinization Surgery
	Introduction
	Criteria for Surgery
	Preoperative Considerations
	Selection of Surgical Technique
	Surgical Preparation
	Periareolar Technique
	Concentric Circular Technique
	Double Incision Free Nipple Graft Technique
	Free Nipple Grafting
	Liposuction
	Nipple Reduction
	Complications and Revisions
	References
17: Urethral Anatomy and Urethral Reconstruction in Phalloplasty and Metoidioplasty
	Anatomy of the Urethra
	Male Urethra [1–5]
		Macroscopic and Microscopic
		Vascular Anatomy
		Lymphatics
		Innervation
	Female Urethra [1–3, 5, 6]
		Macroscopic and Microscopic
		Vascular Anatomy
		Lymphatics
		Innervation
		Contiguous Structures
	Urethral Construction in Metoidioplasty and Phalloplasty
		Metoidioplasty [9]
		Phalloplasty
		Prelamination and Prefabrication [16]
		Local Tissue Flaps [16]
		Complications and Urethral Problems in Transmen
	References
18: MLD (Musculocutaneous Latissimus Dorsi) Phalloplasty
	Introduction
	Patients and Methods
	Surgical Anatomy
	Surgical Technique
	Results
	Discussion
	Conclusions
	References
19: Radial Forearm (RF) and Anterolateral Thigh (ALT) Phalloplasty Reconstruction
	Introduction
		Reconstructive Options
	Indications/Criteria
		Mental Health
		Hormone Therapy
	Surgical Reconstruction of the Pars Fixa
	Surgical Reconstruction Using Radial Forearm Phalloplasty
		Preoperative Evaluation
		Surgical Markings
		Flap Harvest
		Tubing
		Glansplasty
		Groin Preparation
		Forearm Donor Site Closure
	Pars Fixa and Pendulans Anastomosis: RFFF
	Surgical Reconstruction Using Pedicled Anterolateral Thigh (ALT) Phalloplasty
		Preoperative Evaluation
		Surgical Markings
		Flap Harvest
		Tubing
		Glansplasty
		Groin Preparation and Flap Transfer
		Donor Site Closure
	Urethral Anastomosis and Closure: ALT
	Postoperative Management
		Hospitalization
	Postoperative Revision
		Glansplasty and Coronaplasty
		Debulking
		Urethral Tube Formation
		Phallopexy
		Erectile Implant Placement
		Fat Grafting
		Other Forearm and Thigh Donor Site Revisions
		Tattooing
	Potential Complications
	Conclusion
	References
20: Management of Urethral Complications Following Metoidioplasty and Phalloplasty
	Introduction
	Gender Affirmation Surgery
	Metoidioplasty
	Phalloplasty
	Urologic Complications
	Urethrocutaneous Fistulas
	Persistent Vaginal Cavity
	Urethral Strictures
	Consequences of Urologic Complications
	Patient Presentation
	Initial Evaluation
	Preoperative Planning and Surgical Preparation
	Unique Surgical Considerations
	Additional Surgical Considerations
	Fistula Repair Techniques
	Techniques for Obliteration of a Persistent Vaginal Cavity
	Endoscopic Stricture Repair Techniques
	Urethroplasty Techniques
	Single-Stage Anastomotic Techniques
	Single-Stage Substitution Techniques
	Staged Techniques
	Perineal Urethrostomy
	Challenges of Reconstructive Surgery
	References
21: Strategies to Optimize Sexual Function with Feminizing and Masculinizing Genital Gender-Affirming Surgery
	Introduction
	Predicting Sexual Function After Genital GAS
	Pre-surgery Domains that Affect Sexual Health
		Medical History
	How Being Sexually Functional Can Impact Quality of Life
	Cedars-Sinai Pre- and Post-genital Gender-Affirming Surgery Sexual Function Rehabilitation Protocol
		Before Surgery
		Early After Surgery
	Sexual Function After Feminizing Genital GAS
		Surgical Considerations to Maximize Genital-Erogenous Sensation
			Preservation of the Ilioinguinal Nerve and Genital Branch of the Genitofemoral Nerve
			Construction of the Neoclitoris
			Maximal Preservation of the Neurovascular Bundle
			Erogenous Sensation of the Vulva
		We Hypothesize that Erogenous Sensation of the Vulva Arises from Three Factors
			Erogenous Sensation Related to the Prostate and Vaginal Canal
		Practical Considerations for Patients Regarding Sexual Function After Vaginoplasty
			Location of Erogenous Sensation
			Vaginal Lubrication and Hygiene
			Risk of Injury: Vaginal Depth, Male Partner Penile Length, and Sexual Positions
	Sexual Function After Masculinizing Genital GAS
		Surgical Considerations to Maximize Genital-Erogenous Sensation
		Inflatable Penile Prosthesis Type and Size
		Practical Considerations for Patients Regarding Sexual Function After Phalloplasty
	References
22: Postoperative Care from the Primary Care Perspective
	Introduction
	Masculinizing Chest Surgery
	Masculinizing Genital Surgery
	Feminizing Breast Surgery
	Feminizing Genital Surgery
	Sexual Health
	Behavioral Health
	Conclusion
	References
23: Religious Attitudes Toward Gender-Confirming Surgery
	Protestant and Other Christian Responses to Gender Transition
		Mainline Protestants and Resources for Affirmation
		Non-affirming Perspectives: Three Theological Problems
		Other Christian Traditions
		Impacts on Patients and Families
		Recommendations for Surgeons
	Neo-Pagan, New Age, and Eclectic Spirituality: A Rising Trend
	Catholic Positions Regarding Gender-Confirming Surgery
		A Diversity of Christian Views
		Gender Identity and Homosexuality
		Catholic Moral Theology and the Ethics of Sterilization
		Official Catholic Teaching
		Medical and Theological Discussion
	Jewish Teaching Regarding Gender-Confirming Surgery
		Introduction
		Sex and Gender in Jewish Thought
		Non-genital GCS
		Genital GCS
		Conclusion
	Islamic Theology and Gender-Confirming Surgery
		Introduction
		Intersex, Transsexual, and Transgender Individuals
		GCS and Islamic Theology of Opponents and Defenders
		Khomeini and Shiʿa Theology of GCS
		Al-Τ̣anṭāwī and His Cautionary Position Toward GCS
		Muslim World League’s Fatwa
		The Approach of Malaysia’s Council of Islamic Religious Affairs to GCS
		Conclusion
	Buddhist Attitudes Toward Gender-Confirming Surgery
	References
24: Establishment of a Gender Confirmation Program
	Multidisciplinary Treatment Model
	Educational Philosophy
	Education Model
	Quality Parameters
	Overview of Surgical Procedures
		Vaginoplasty
		Phalloplasty
		Genital Surgery: Metoidioplasty and Phalloplasty
	Conclusion
	References
Index