Background and Purpose
Genital gender confirming surgery (GCS) has been shown to significantly decrease gender dysphoria and improve the quality of life of transgender patients. A fundamental goal of reconstructive genital GCS is to provide the patient with genitals whose appearance and function are consistent with those of members of the gender they identify with.
For the female to male transsexual, surgical options include creation of a neophallus (phalloplasty) using a vascularized free-flap or pedicle flap (with or without neourethra construction and anastomosis to the native urethra). At our centers and abroad, the most commonly used free-flap is the radial forearm-flap. At our center, the most common pedicle flap we use is harvested from the suprapubic area. At our centers and at Belgium's Ghent University Hospital, anastomosis of the dominant cutaneous nerve(s) to one of the clitoral nerve bundles is performed with free-flap phalloplasties. Additional procedures are also performed: glansplasty (to give the end of the phallus a natural glans-like appearance), transposition of the denuded clitoris to the neophallus base (to consolidate erogenous sensation to the neophallus), and vaginectomy. At other centers, these are performed at time of phalloplasty, whereas at our centers, these are performed at second-stage surgery. Placement of testicular and penile prostheses, for cosmesis and erectile function, respectively, are performed at second or (at our centers) third stage surgery. Previous groups have reported that the majority of patients retain the ability to achieve orgasm following phalloplasty. However, the degree to which sexual function is preserved (i.e., quality; e.g., relative time to achieve orgasm) relative to specific GCS such as clitoral transposition and penile prosthesis placement has not been described.
Furthermore, what factors influence transgender men's decisions to undergo (and to not undergo) specific genital GCS has also not been described in the literature. Our experience among male transsexual patients seeking post-operative care at our tertiary-care medical center in the U.S. (UCSF) is that many did not undergo creation of a neourethra, clitoral transposition to the neophallus, or penile prosthesis placement. Even in our group's high-volume female to male GCS centers in the UK where we routinely perform clitoral transposition and prosthesis placement at second and third stage surgeries, respectively, a subset of patients still elect to forego these two procedures as well.
We hypothesized that a better understanding of key factors, preferences and concerns that drive transgender men's decision-making related to genital surgery, and a better understanding of sexual function following specific genital GCS, would be useful to better counsel patients pre-operatively regarding surgery options.
In this work, we sought to assess satisfaction and regret associated with patients' own female-to-male genital GCS, pre and post-operative sexual function and neophallus dimensions among a divided subset of patients that did and did not undergo clitoral transposition and penile prosthesis placement.