Medical Support for the Family of the Intergender Newborn

There is no medical reason to operate on infant genitals if urination is unobstructed. Reconstructive surgery can be done with better results after puberty, when the organs are adult-sized. It is easier to face childhood being different than to face adulthood with parts that don't work and can't be repaired. Operating on infant-size genitalia often leaves the individual with no sensation. Scar tissue can build up, leaving an appearance that is not cosmetically desirable. To date only one study has been performed to do a followup. Dr. David Thomas, a pediatric urologist in Leeds, England, did a follow-up study on 12 infants; all had surgery that was unsatisfactory in some way and in 5 of the 12, the relocated sensitive tissue had withered and died. Post-surgical infants can also be more prone to urinary tract and other infections. Studies done on children with various differences have shown that the child's level of adjustment depends less on the severity or obviousness of the difference and more on the presence of family support.

FTM Surgery

Chest Reconstruction Procedures

Bilateral mastectomy is performed by liposuction if the breasts are very small, keyhole if they are small, and double incision if they are medium or larger. In the keyhole procedure, the surgeon makes an incision around the areolar ring, inserts a liposuction device, and vacuums out the fatty tissue. The mammary glands are left intact. Small deposits of fatty tissue may remain in the chest (this can be reduced by a technique called feathering), or the finished areola (after sealing the incision site) may be too large in comparison with the typical male chest. Scarring is minimal and nipple sensation is retained. In the drawstring technique, the areolar ring is lifted away without disconnecting the nerves, the fatty tissue is suctioned out, the excess skin is trimmed and then pulled taut toward the center of the opening like a drawstring bag, and the nipple is reattached covering the opening. Disadvantages are the same as for keyhole above, plus the nipple placement may be unnaturally low on the chest. In the double incision procedure, each breast is opened horizontally across the chest below the nipple. The top panel of skin is peeled back to expose the chest muscle wall, and the breast and fatty tissue is cut and scraped away. The top skin panel is then brought down smooth and the skin is trimmed and sutured to the lower panel at the incision. The nipples are trimmed then grafted into place. This procedure leaves a long ‘W’ shape scar. Disadvantages are loss of nipple sensation, scarring and nipple size, shape, appearance or placement. The procedure usually requires two to three weeks rest, limited shoulder activity for three months and wearing a compresion vest. Time off from work varies from two to six weeks. Regardless of which technique is used, touch-up procedures to clean up any residual fatty tissue, puckering, or excessive scarring may be needed.

Mastectomy, Bilateral Periareolar

This procedure involves the removal or reduction of the breasts by making a small incision around the nipple and removing most of the tissue and fat from under the skin. This results in a chest shape that appears more masculine but does not completely approximate the male chest in that nipple size and position may be more female in appearance. This is often not feasible for trans men with breasts larger than A or B cup or breasts that are significantly ptotic, and in general the larger and more ptotic the breast, the worse the outcome. Subsequent procedures to alter the location and contour of the nipple may be needed.

Mastectomy, Bilateral Complete with Nipple and Areola Reconstruction

This procedure involves removal of the breasts by making incisions below the breasts, performing a complete mastectomy, resizing the nipple/areola complex (NAC) and grafting it into a more typical male position. Compared with periareolar mastectomy, there are larger scars, more damage to sensation of the chest (and permanent loss of sexual sensation in the nipples,) and more danger of losing the grafted nipple permanently due to subsequent necrosis and sloughing. The result, while less aesthetically pleasing because of scars more closely resembles a true male chest in contour, nipple size and location. This procedure may be done on trans men with even quite large and ptotic breasts and may afford them the best aesthetic result overall.

Mastectomy, Bilateral Complete with Nipple Pedicle

This procedure is similar to the bilateral complete mastectomy with NAC reconstruction however, instead of removal of the NAC, it is left in place via a stalk of tissue, and is threaded through the chest at a more normal position. This is a more complex technique and may not give as ideal cosmetic results as reconstruction of the NAC, but it may allow for preservation of sexual sensation to the nipples. sible.

Genital Reconstruction and Related Procedures

Polycystic Ovary Syndrome (PCOS) is a medical condition that affects from 1 to 5% of the natal female-bodied population; yet it is estimated that 25% of FTM people are afflicted with the syndrome. In 70% of PCOS cases, the condition is accompanied by elevated levels of dehydroepiandrosterone. In more than 50% of cases another adrenal androgen, 11beta hydroxy androstenedione, is elevated. These substances increase the risk of heart disease and hypertension. The symptoms of PCOS may include hirsutism (in the absence of androgen treatment), irregular or absent menses, dysmenorreah (painful menses), obesity, and, rarely, true virilization. However, many people show no obvious symptoms. Persons with PCOS are at increased risk for endometrial hyperplasia (overgrowth of the lining of the uterus), endometrial cancer, and breast cancer. Polycystic ovaries and uterine fibroids, which may or may not be related to PCOS, are common in FTM people and may be aggravated by testosterone therapy. Combined with exogenously administered testosterone, the effects of the hormonal imbalances inherent in PCOS could lead to serious lipid metabolism alterations and consequent heart disease. The diagnosis of PCOS might constitute a justification for hysterectomy and salpingo-oophorectomy. FTMs prior to starting testosterone should have pelvic and/or transvaginal ultrasound to look for cystic ovaries and fibroids, and a blood test to determine any elevation of adrenal androgens. In FTMs, surgery to remove the uterus and polycystic ovaries is indicated. Hysterectomy and salpingo-oophorectomy procedures may be performed through an abdominal incision, through a vaginal entry, or using laparoscopy. See Balen, A.H., et al. (1993) Polycystic ovaries are a common finding in untreated female-to-male transsexuals. Clinical Endocrinology, 38(3), 325-329.

Hysterectomy with Bilateral Salpingo-Oophorectomy

This is essentially the same procedure performed in cisgender women which involves removal of the uterus, both ovaries, and both fallopian tubes. Removal of these organs decreases (but does not eliminate) the risk for subsequent gynecological tumors. Since transgender males historically have had difficulty securing adequate and sensitive gynecological preventative care, removal of these organs may be the only way that the risk of advanced ovarian, uterine, or cervical cancer is acceptably decreased. Risks include incontinence, injury to bladder or bowel, formation of abdominal adhesions (and the subsequent risks of chronic pain and bowel obstruction that come with any abdominal surgery.) Additionally, with oophorectomy any chance of further reproduction (even with assisted reproductive technology) is completely eliminated unless ovarian tissue banking or embryo banking is used.

Colpoplasty

This is a newer procedure to reconstruct the perineum that involves closure of the perineal opening of the vagina while opening the cervical end of the vaginal vault into the abdominal cavity. This results in an 'inversion' of the vagina and has less operative risk than full vaginectomy.

Colpocleisis

In this procedure, the mucosa of the vagina is ablated and the muscular walls of the vagina are fused together. Little or no vaginal mucosa unaccessible for monitoring remains as it does with colpoplasty.

Genital reconstruction falls into two types: phalloplasty and metoidioplasty.

Metoidioplasty

This procedure involves the creation of a very small penis by extending and repositioning the clitoris that has been enlarged by testosterone therapy. The resultant penis is generally able to gain erections naturally. As with any genital surgery however, the risk to sexual function is significant and this or any genital surgery may rarely result in sexual dysfunction. Additionally, this surgery cannot be performed until the individual has been on hormonal therapy for two or more years and the clitoris has enlarged sufficiently to produce the largest possible penis for the patient. Testosterone propionate ointment 0.2% may be applied directly to the clitoris to enhance size (this is still an experimental treatment). The clitoris is a micropenis that is bent down. By releasing this string on the ventral side of the clitoris it can be longer and the labia minora can be used to make the micropenis larger. Clitoral release can obtain more length once the suspensory ligaments are cut by the surgeon proceeding beneath the pubic bone and advancing the crura (or “legs” of the clitoris out). These “legs” can be repositioned forward with respect to the pubic bone and a flap of abdominal skin can be used to cover the newly exposed tissue on the shaft. The risk with metoidioplasty is that when the surgeon advances the crura out, it is possible that the pudendal nerve may be damaged and the organ rendered numb. The advantages are that the penis, though small, is otherwise normal in appearance, with a natural glans and foreskin, and the scrotum can be sized appropriately for the patient’s body. Another advantage is that the FTM can have natural erections and orgasm (unless the pudendal nerve is damaged). The scrotum is formed by joining the labia majora and using silicone testicular implants. Metoidioplasty can be performed on an outpatient basis and costs $4,000 to $10,000. Each procedure requires about 10 days of absolute rest, and one to three weeks when it may be necessary to limit activity.

Metoidioplasty With Urethroplasty

This procedure is a metoidioplasty as above with the additional of an extension of the urethra which is generally created from harvested vaginal mucosal tissue so that patients may urinate while standing. Risks include fistula formation, incontinence, and recurrent urinary tract infections with resulting risk of damage to the entire urinary tract.

Free Flap Forearm Phalloplasty

The free tissue flap transfer (FTFT) technique uses skin and muscle from the forearm, groin, or thigh with nerves and blood vessels connected to the groin. FTFT is $150,000, plus months in revisions. This procedure involves construction of a phallus from tissue of the forearm as well as vaginal tissue to form the neo-urethra. The forearm tissue including nerves and vasculature are grafted after the neo-phallus is formed into a tube around a catheter. The neo-urethra is attached to the native urethra and allows for urination while standing. The nerves of the clitoris are sometimes attached to the grafted cutaneous nerves and hopefully will grow into the neo-phallus after surgery allowing for some retention of sexual arousal and gratification. Some surgeons, however, leave the clitoris intact beneath the neo-phallus or within the constructed neo-scrotum so that it can be stimulated independently of the neo-phallus. Phalloplasty often requires multiple surgeries and up to a year of recovery. Moreover, the significant scarring and risk to function of the forearm and hand (as well as the risks of any genital surgery for sexual dysfunction and urinary complications) make the procedure unacceptable for many transgender men. Lastly, in general, phalloplasty is significantly more expensive than metoidioplasty so it may not be an option for many trans men even if it is the procedure they may prefer.

Abdominal Pedicle Flap Phalloplasty

The first phalloplasty for an FTM was in 1948. This procedure is similar to the forearm flap technique except that the donor site is tissue on the abdomen or waist. The tissue is rolled into a tube and, over a period of up to two months, is progressively shaped and separated from all of its original blood supply except for the small pedicle that attaches it to the lower abdominal wall. Later, when the phallus has developed a reliable blood supply, it is further detached to hang in the groin area and subsequently shaped to look more like a typical male penis. The main advantage is trading a more readily apparent forearm scar for a less visible scar on the abdominal wall. Again multiple procedures are required and recovery can be prolonged. This is probably the least common of the currently used genital reconstructions for transsexual males in the United States.

Penile Erectile Prosthesis Implantation

Often techniques like those used in impotent cisgender men, can be performed after completion and full healing from phalloplasty to achieve erectile function. Complications can include component failure, device erosion or migration, sizing problems, and auto-inflation. Infection occurs in approximately 2-3% of primary implant surgeries and may require removal of the prosthesis and result in significant scarring of the neo-phallus. An alternative is used in Sweden. Erection is obtained by using a special kind of stiff condom with a support in it.

Scrotoplasty With Insertion of Testicular Expanders

This procedure produces a male appearing scrotum from skin and soft tissue of the labia. Subsequent insertion of testicular expanders that can be enlarged slowly over months increases the size of the neo-scrotum until it can accommodate typical male size scrotal implants. This is an additional procedure to either phalloplasty or metoidioplasty but frequently is performed with them in transgender males who pursue genital reconstruction.

A Patent Urethra

Voiding while standing is a priority for female to male surgery. In order to reach this goal a competent urethra has to be constructed. The urethra wall is lined with mucous membranes and contains a relatively thick layer of smooth muscle tissue. It also contains numerous mucous glands, called "urethral glands," that secrete mucus into the urethral canal. In female anatomy the urethra is about 4 cm long. In male anatomy the urethra is about nine inches in length. A new urethra with mean length of 18 cm has to be reconstructed. Urethral surgery has complications of fistula formation and stenosis development. In order to investigate these urological complications in total phalloplasty the files of 26 consecutive patients were reviewed. During a study period from August 1993 till August 1998, 26 patients underwent free sensate radial forearm flap phalloplasty, which was part of a one stage procedure for gender reassignment surgery (mastectomy, hysterectomy, colpectomy, phalloplasty). Fourteen patients developed 25 fistulae. Of these, 15 fistulae healed spontaneously. Ten patients developed 11 urethral strictures or stenoses. Four were meatal stenoses and 7 were at the junction of the perineal to the phallic urethra. In total 11 patients (42%) underwent a major surgical procedure under general anesthesia to correct a complication. In total 18 patients (69%) developed a urological complication. All patients out of this study group void while standing without stenosis and without fistula. Although a high complication rate is described, these complications are relatively easily treated with high success rate. ISSN 1434-4599 Introduction Editors: F. Pfaefflin, E. Coleman W. Bockting Assoc. Editors: R. Ekins D. King Editorial Board © Copyright Published by XVI Harry Benjamin International Gender Dysphoria Association Symposium 17 - 21 August 1999, London Reflections on "Transsexualism and Sex Reassignment" 1969 -1999

An Interview with Gunnar Kratz at the Karolinska Institute in Stockholm, Sweden on Tissue Engineering for Urethral Lengthening

To engineer the tissue of a urethra we put a urinary catheter into the bladder, and wash the bladder with saline. This is done as an out patient procedure. From this bladder wash one can isolate the three different cell types: the urethral cells, the smooth muscle cells and the fibroblast and we can cultivate these three cell types individually. Then we can put the three cell types together into three layers, then we have a membrane of tissue. Then we put a catheter on it, and make a tube of it by suturing the two edges to each other with a an absorbable suture. Then you have a long tube, you have to connect it to the external meatus on the old urethra, You have to do it like a sleeve, we say, we are doing a "sleevage" to diminish the risk of leakage when connecting the new urethra to the old urethra. We put one of the tubes a little bit inside the other tube. The pressure inside the urethra is what causes the fistula, and to prevent this, you have to make very strong anastomosis.