Preoperative Genital Surgery Priorities in Transgender Men

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 (0) to very important (5). The assessment was then administered to the first twenty 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

Twenty consecutive patients were administered the survey, with a 100 percent response rate. The mean age of patients was 25.5 years (SD=7.25). All patients (n=20)  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. On the five point scale, patients were most concerned about being able to stand to urinate (Mean=4.675, SD=0.52). The second most important item was erotic sensation (Mean=4.125, SD=.94), but the answers were more variable. Penis length (Mean=3.325, SD=1.24), Girth (Mean=3.274, SD=1.391), and the presence of tactile sensation (Mean=3.8, SD=1.79), were not generally considered to be important, although the responses varied highly between men. Finally, all but one patient (n=19), who was uncertain, 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.