Abstract: Preoperative Genital Surgery Priorities in Transgender Men

Abstract

Many transgender men seek surgical interventions to create male genitalia. Such procedures are often referred to as “bottom surgery”. Phalloplasty and metoidioplasty are the most common procedures. Phalloplasty involves the surgical creation of a penis from a local or free-flap while metoidioplasty makes uses the body of the hormonally-enlarged clitoris as the penile shaft. Currently, there is no standardized tool to assess individual goals and expectations for bottom surgery. In this study, our group has designed and administered a questionnaire to determine the preoperative priorities of transgender men seeking phalloplasty and metoidioplasty. METHODS: A literature review was conducted in order to identify areas of importance to patients seeking phalloplasty and metoidioplasty. Primary areas of relevance were found to be size, sensation, interest in penetrative sex, ability to urinate standing up, types of sensation, and maintenance of orgasmic function. This information was used to construct an assessment of genital surgery priorities for transmasculine patients. Most questions were structured as five item Likert scales with values ranging from very unimportant to very important. The assessment was then administered to the first eight patients seeking phalloplasty or metoidioplasty at our center. EXPERIENCE: Use of the formal assessment increased the information available to the surgical team. Regular multidisciplinary team meetings about patients showed that patients regularly disclosed priorities on the formal assessment that they did not bring up during the clinical exam. The team also found that the assessment tool encouraged additional questions from patients about sexual concerns that did not spontaneously arise elsewhere in the discussion. RESULTS: Eight consecutive patients were administered the survey, with a 100 percent response rate. The mean age of patients was 26 years (SD=4.5). All patients (n=8) reported full comprehension of the questions, and both patients who were uncertain of which procedure they wanted stated that it helped clarify their goals and allowed them to choose the most appropriate surgical procedure. Patients reported a variety of goals for genital surgery. All patients (n=8) rated being able to stand to urinate as “very important”. Three patients stated that being able to penetrate a sexual partner was “very important”, with the rest of the answers ranging from “unimportant” to “neutral”. There was no consensus on the importance of length or girth of the desired phallus. Three patients rated erotic sensation, and three patients tactile sensation, as “very important.” All patients stated that they had been able to climax through clitoral stimulation, information that will allow for contextualizing sexual function after surgery. CONCLUSIONS: Using a standardized measure improves both patient and clinician understanding of patient priorities around genital surgery. Our findings demonstrate the diversity of patient priorities and consequently emphasize the importance of assessing individual goals in the preoperative period. Of note, our data suggest that transgender men, as a group, value the ability to stand to urinate more highly than they do sexual function. We hope to further assess the range of patient goals for surgery and also prospectively assess how orgasmic function is affected by genital surgery procedures.