Ulcerative colitis in a transgender woman with a sigmoid neovagina: a case report.

BACKGROUND: Sex reassignment surgery (SRS) is a necessary step in transitioning into the desired gender for male-to-female transgender individuals. This study focuses on a rare complication developed following SRS, aiming to highlight potential complications associated with this procedure. CASE PRESENTATION: This report describes a 49-year-old transgender woman with a history of SRS who developed bloody diarrhea and neovaginal bleeding 10 years later. A colonoscopy revealed features compatible with ulcerative colitis, which was confirmed by a biopsy. CONCLUSIONS: The unpredictable clinical course of this phenomenon may prompt surgeons to reconsider the use of a rectosigmoid colon to create a neovagina. This case report underscores the necessity of long-term monitoring for gastrointestinal complications in transgender women post-SRS when a rectosigmoid colon segment is utilized for neovaginal construction.

Gender Self-Identification: Opinions About Transgender Women from a National Online Survey in Taiwan.

Gender self-identification (transgender) is not permitted in most Asian countries. In Taiwan, individuals recognized as transgender must meet requirements mandated by the Gender Recognition Act. Currently, lifting the requirement for proof of sex-reassignment surgery is pending. The aim of this study was to survey a large sample of Taiwanese to gain a better understanding of the general population's attitudes toward gender self-identification. A self-report survey, entitled "Opinions of Gender Self-Identification," collected demographic information and responses (agree = 1, disagree = 0) to 14 statements about transgender women and women's safety, personal rights, and the law; one statement discussed rights of transgender men to give birth; total scores ranged from 0 to 14. The online survey was distributed to non-government organizations across Taiwan and the Taiwanese islands and was available between April 16 and 30, 2022. Most of the 10,158 respondents were female (77.4%); ages of respondents ranged from 15 to > 65 years. The mean total score was 0.95 ± 2.27, indicating respondents strongly disagreed with support for transgender females; 91.56% disagreed with all statements. Although there were significant differences in scores between parents and non-parents, and those ≤ 35 years versus ≥ 36 years (p < .01), all strongly disagreed with gender self-identification. Given the majority of respondents were females, survey findings should be regarded with caution. Public acceptance of gender self-identification requires support from its residents. Our findings suggest that gender self-identification has not begun to approach even a moderate level of public support among survey respondents.

[Ethical issues of gender reassignment surgery]. / Enjeux éthiques de la chirurgie de réassignation sexuelle.

Gender reassignment raises complex ethical issues. It questions gender identity and the right to self-determination. Some highlight the right to access the medical care necessary to live according to one's perceived gender. Others worry about the potential rush into major medical decisions, especially among minors. The need for a medical diagnosis of gender dysphoria can be seen as pathologizing. The requirement for surgery for marital status change, while not mandatory in many places, remains controversial. The balance between informed consent and access to treatment, as well as stigma and discrimination, contribute to the complexity of ethical issues. Finally, the issues surrounding the competence of health professionals, the quality of care and the integration of individual needs make these decisions particularly sensitive from an ethical point of view.

Neovaginal Canal Dissection in Gender-Affirming Vaginoplasty.

PURPOSE: Gender-affirming vaginoplasty creates the vulva and vaginal canal for individuals assigned male sex at birth who have gender dysphoria. Dissection of the neovaginal space can be particularly challenging, with risk of injury to the anal and urethral sphincters, urethra and rectum. We present an anatomically based technique for vaginal canal dissection. MATERIALS AND METHODS: We retrospectively analyzed a cohort of patients who underwent gender-affirming vaginoplasty by a single surgeon between May 2016 and July 2019. We describe our technique for dissection and report relevant outcomes. RESULTS: We performed 200 vaginoplasty procedures during the study period. Patient age ranged from 15-70 years (median 41). Body mass index ranged from 16-50.5 kg/m2 (median 27). The vaginal depth ranged from 10-16 cm, with a median of 14 cm and a mean of 13.7 cm. Vaginal depth was slightly greater for patients with a body mass index of ≥30 vs <30 kg/m2 (p=0.0145). Operative complications were observed in 2 patients (1.0%) with a full thickness rectal injury and in 3 (1.5%) with a partial thickness rectal injury. Two of these patients (1.0%) had progression to a rectovaginal fistula (1 full and 1 partial thickness injury), 1 patient (0.5%) had a urethral injury, 8 patients (4.0%) had vaginal stenosis, 3 patients (1.5%) had introital stenosis and 10 patients (5.0%) had stress urinary incontinence that later resolved. CONCLUSIONS: Neovaginal canal dissection in gender-affirming vaginoplasty is technically challenging. An anatomically based approach is associated with a low complication rate at our center.

Development and Validation of Urological and Appearance Domains of the Post-Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) for Transwomen following Genital Surgery.

PURPOSE: As feminizing gender-affirming surgery becomes increasingly accessible, functional outcomes are increasingly relevant. We aimed to develop and validate the first patient-reported outcome questionnaire focusing on postoperative symptomatology and quality of life. MATERIAL AND METHODS: Questions were developed from interviews with postoperative transwomen followed by face validation from a multispecialty clinician group. The measure was co-administered with established relevant questionnaires for concurrent validity testing. Participants were asked to complete the questionnaire at baseline and at a 2-week retest interval. RESULTS: The AFFIRM questionnaire is a 33-item patient-reported outcome measure comprising Appearance, Urological and Gynecologic domains, each scored to create a composite AFFIRM score. A total of 102 women participated, with 60% completing the test-retest. The overall Cronbach's α for AFFIRM was 0.79, and domain α for AFFIRM-A, AFFIRM-U and AFFIRM-G was 0.85, 0.87 and 0.42, respectively. Test-retest demonstrated score reliability (z values -1.862 to -0.005, p >0.05) with intraclass coefficients demonstrating moderate to good absolute correlation (0.54 to 0.88). The AFFIRM-A and AFFIRM-U correlated well with the Genital Appearance Satisfaction Measure and Urinary Distress Inventory-6, respectively (ρ 0.556 and 0.618, p <0.001); 89% of participants confirmed congruence between their external genitalia and gender identity, 87.8% reported clitoral sensation and 75.6% expressed satisfaction with vaginal caliber. Reported symptoms included a misdirected urinary stream (68.9%), nocturia (51.3%), urinary frequency (29.7%) and vaginal pain (46.7%). CONCLUSIONS: Transwomen have diverse symptoms not captured by unstructured questions or cisgender questionnaires. The AFFIRM questionnaire is the first tool available to reliably evaluate outcomes following feminizing gender-affirming surgery.

Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Gender-Affirming Genital Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Services.

BACKGROUND: To date, a comprehensive state-by-state assessment of transgender transition-related health care coverage for gender-affirming hormone therapy (GAHT) and genital gender-affirming surgery (GAS) has not been reported. AIMS: The aims of this study were 1) to verify which U.S. states' Medicaid systems do/do not cover GAHT and GAS; 2) to assess the ease/difficulty for patients to determine whether GAHT and GAS are Medicaid-covered benefits; and 3) to understand possible state-related predictors of Medicaid coverage for gender-affirming care. METHODS: We reviewed the official Medicaid Handbook and website for all 51 states (+D.C.) and 5 territories to confirm whether GAHT and GAS are covered benefits. When indeterminate, we called the Medicaid office in each state, and for many, Medicaid managed care organizations (MCOs), and individual in-state providers, to confirm coverage. We recorded our experiences, number of, and duration of phone calls to confirm coverage. OUTCOMES: The main outcome was a definitive answer from the state/territory's Medicaid program or MCOs regarding whether GAHT and GAS are/are not covered benefits. Secondary outcome measures included responses we received and the total number/duration of phone calls necessary to confirm coverage. RESULTS: Only 12 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAHT in their Medicaid Handbook/webpages. We confirmed that 34 of 51 state Medicaid programs do cover GAHT, whereas 9 of 51 states' and 2 of 5 territories' do not. We could not confirm coverage of GAHT in 8 of 51 states and 3 of 5 territories. Only 26 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAS in their Medicaid Handbook/webpages. We confirmed that 25 of 51 state Medicaid programs do cover GAS, whereas 22 of 51 states' and 3 of 5 territories' do not. We could not confirm coverage of GAS in 4 of 51 states and 2 of 5 territories. Up to 12 calls, lasting up to 125 minutes, were required to confirm coverage for GAHT/GAS. CLINICAL IMPLICATIONS: Our findings indicate that important health care access barriers/disparities exist today and warrant improvement. STRENGTHS & LIMITATIONS: To our knowledge, this is the most comprehensive assessment of transgender transition-related health care coverage. Limitations include possible bias, as it could be that we were more persistent than actual patients would be to determine service coverage, and a lack of specificity regarding which specific hormone formulations or procedures are/are not covered. CONCLUSION: Our findings show that only 34 of 51 (67%) states' Medicaid programs include GAHT and 25 of 51 (49%) include GAS as covered benefits. Our experience suggests that the process to confirm coverage can be especially time-consuming and frustrating for patients. Zaliznyak M, Jung EE, Bresee C, et al. Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Genital Gender-Affirming Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Service. J Sex Med 2021;18:410-422.

Assessment of the strength and electrical activity of the pelvic floor muscles of male-to-female transgender patients submitted to gender-affirming surgery: A case series.

AIMS: To assess the strength and electrical activity of the pelvic floor muscles (PFMs) of male-to-female transgender individuals submitted to gender-affirming surgery (GAS). METHODS: A case series study was conducted from October 2016 to August 2018. Transgender women, who were scheduled for GAS, participated in the study. The volunteers were submitted to a clinical evaluation of the PFM followed by digital palpation (PERFECT method) and electromyography in the preoperative, 15, and 30 days after GAS. They responded to the International Consultation on Incontinence Questionnaire-Urinary Incontinence (UI)-Short Form to evaluate the effect of UI on quality of life and to questions related to the urinary, anorectal, and sexual symptoms. Fifteen days after the GAS, patients were instructed to perform perineal exercises at home, twice a day. RESULTS: The study sample consisted of 15 transgender women with an average age of 30.6 (SD = 6.7) years. There was a decline in median strength and sustained muscle contraction duration (PERFECT), in the electrical muscle activity (RMSmean and RMSmax) between pre-GAS and 15 days after GAS (p < 0.05). However, there was an increase in these parameters between 15 and 30 days after GAS (p < 0.05). Moreover, six patients exhibited pre-GAS UI, which continued after surgery, with a worsening of urgency symptoms and improvement in nocturia and postmicturition leakage. CONCLUSION: Strength, sustained muscle contraction duration, and PFM electrical activity may decline 15 days after GAS, returning to pre-GAS values in the first month after surgery.

Vaginoplasty tips and tricks.

Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

[Masculinizing mastectomy with nipple-areola graft autotransplantation for female-to-male transsexualism]. / Maskuliniziruyushchaya mammoplastika s autotransplantatsiei areol pri lechenii yadernoi formy zhenskogo transseksualizma.

OBJECTIVE: To develop the method of masculinizing mammoplasty with nipple grafting female-to-male transsexuals with BMI >30 kg/m2, large breast volume and severe ptosis. MATERIAL AND METHODS: There were 114 mastectomies in 57 patients with nipple grafting technique. The methods of areola grafting and scar design were modified to improve aesthetic results. Inclusion criteria were BMI >30 kg/m2, breast size B+ and severe ptosis (Regnault grade ≥2). Anonymous survey for evaluation of aesthetic outcome and quality of life was performed a year after surgery. RESULTS: Postoperative complications included hematoma (5.2%), seroma (7.9%), tangential graft necrosis (9.6%), wound dehiscence (0.8%), ligature-induced inflammation (1.7%), scar hypertrophy (12.2%). Three patients (5.2%) developed nipple hypersensivity in long-term postoperative period. Three patients (5.2%) required redo urgent surgery for hematoma. Additional surgical correction of scar hypertrophy was performed in 4 patients (7%). In a year after surgery, patients rated aesthetic postoperative result as 4.45 out of 5 scores. CONCLUSION: Masculinizing mammoplasty with areola autotransplantation is preferable for FtM transsexuals with large breast volume and severe ptosis. This surgery ensures a good aesthetic result with minimal secondary corrections and complication rate.

The Bioethical Dilemma of Gender-Affirming Therapy in Children and Adolescents.

Since the establishment of the first transgender clinic in the United States in 2007, over sixty clinics associated with children's hospitals have opened across the nation and are seeing very young children and adolescents with a diagnosis of gender dysphoria (GD). Once known as gender identity disorder, GD has been redefined by the latest version of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) not as a mental illness but as the distress experienced by individuals related to their biological sex. The widely accepted practice of gender-affirming therapy (GAT) to treat a vulnerable population despite the associated health risks, the lack of supportive scientific evidence for the pharmacological and surgical interventions, along with the unqualified claim that these interventions will decrease the rate of suicide in these individuals presents a significant bioethical dilemma. The growing trend of GD not only impacts the individuals diagnosed but also society, culture, and the integrity of the profession of medicine. This article utilizes the five-box method, an ethical decision-making framework, to address the implications of the proposed treatment. Once applied, it becomes clear that the hormonal and surgical approaches used are not scientifically or ethically justified. The patient's autonomy and preferences should be respected, yet constrained, if there exists a considerable risk to the well-being of the individual without proven benefits. The quality of life of those receiving this treatment has not been shown to be significantly improved long term, and the mental, physical, and spiritual health of individuals with GD is not thoroughly addressed in these clinics. The important social and contextual factors, on both microcosmic and macrocosmic scales, are minimized in favor of promoting an ideology. Ultimately, Catholic moral teaching reveals that this widely recommended treatment violates the body-soul union, disregards the principle of totality and integrity, and debases the dignity of humanity. SUMMARY: This article examines GAT, the paradigm used in treating individuals identifying as transgender, through the lens of an EDMF. Each stage of this widely proposed treatment - social affirmation, pubertal blockade, administration of cross-sex hormones, and sex reassignment surgery - poses harms and risks that are not fully disclosed to minors and families, creating a bioethical dilemma. Dialogue utilizing science and reasoning must be encouraged to assist individuals who experience a gender identity that rejects their biological sex. This approach would also contribute to the well-being of society.

Adverse events associated with gender affirming vaginoplasty surgery.

BACKGROUND: There is an abundance of reports on the surgical techniques for vaginoplasty surgery. However, careful review reveals a paucity of evidence-based data in addition to few reports on outcomes related to all of the varying techniques. OBJECTIVE: This study aimed to describe the perioperative adverse events related to vaginoplasty surgery for transgender women and to determine a threshold case number needed to reduce adverse events. STUDY DESIGN: This was a retrospective study of all women who underwent vaginoplasty surgery for gender affirmation at a tertiary care center. All cases were performed by a single board-certified female pelvic medicine and reconstructive surgery specialist. Women were included if 6-month outcomes were available. Once patients were identified, perioperative data were collected. Comparisons of adverse events and perioperative outcomes were made between varying threshold case numbers to determine the case number needed to significantly reduce adverse events. An a priori review of the literature was done to determine the incidence of commonly reported adverse events, and these incidences were used as a frame of reference to determine a threshold case number needed to replicate these reported incidence rates. Once this threshold was determined, outcomes were compared between cases performed before and after this threshold. RESULTS: Between December 2015 and March 2019, 76 vaginoplasty surgeries were performed. Six-month outcomes data were available for all patients. Mean age and body mass index of all patients were 41 (±17) years and 27.3 (±5.1) kg/m2, respectively. Median (range) time on hormone therapy preceding surgery was 36 (12-360) months, and 7.9% (6) of patients had undergone previous orchiectomy. Of the patients, 83.4% (71) underwent full-depth vaginoplasty, whereas the remaining patients underwent a zero-depth procedure. Median (range) surgical time was 210 (138-362) minutes. Median (range) follow-up for all patients was 12.5 (6-50) months. The incidence of any intraoperative adverse event was 2.6% (95% confidence interval, 1.8-4.1) for all patients, whereas the incidence of any immediate (<30 days) and delayed (>30 days and <6 months) postoperative event was 19% (95% confidence interval, 16.4-22.2) and 25% (95% confidence interval, 22.4-28.4), respectively. Performance of 50 cases was identified to be a threshold that reduced adverse events in both clinically and statistically significant ways. Cases performed after the first 50 cases had lower surgical times (187 (138-224) vs 240 (162-362) minutes, P<.0001), a lower incidence of delayed postoperative adverse events (15.4% vs 36%, P=.007), including a lower incidence of urinary stream abnormalities, introital stenosis, and the need for revision surgery. The incidence of intraoperative and immediate adverse events was not different between the groups. CONCLUSION: The incidence of serious adverse events related to vaginoplasty surgery is low, whereas minor events are common. After a threshold of 50 vaginoplasty surgeries, these events were reduced, including the need for revision surgery.

Perioperative considerations for transgender women undergoing routine surgery: a narrative review.

A transgender woman is a person assigned male sex at birth who identifies as a woman. With the numbers of transgender identity on the rise, encountering a transgender woman requiring routine surgery is becoming more common in anaesthetic practice. The perioperative period can be challenging for transgender women, but these challenges can be mitigated by a skilled and sensitive perioperative team. Engagement with patients and their primary physicians is important. Whilst there are anaesthetic issues relevant to both transgender women and men, there are many issues unique to transgender women. This article focuses only on considerations for the perioperative care of the transgender woman. This narrative review provides an overview of the factors influencing the safe care of the transgender woman presenting for routine surgery, including the potential social and pharmacological factors to consider, and anatomical changes to be aware of from previous gender confirming or feminisation surgeries that can influence clinical decision-making.

Outcome Measures in Gender-Confirming Chest Surgery: A Systematic Scoping Review.

BACKGROUND: The aim of this scoping review was to provide an overview of outcome measures in gender-confirming chest surgery. METHODS: A comprehensive literature search was performed in PubMed, EMBASE, CINAHL, PsycINFO, Scopus and the Cochrane Library to find studies evaluating gender-confirming chest surgery in a non-cis gender population. The systematic scoping review followed the PRISMA extension for scoping reviews. Data were charted for outcome measures including complications, reoperations, revision surgery, aesthetic outcome and patient-reported outcome measures. RESULTS: Our search yielded 849 records, which were screened on title, abstract and full text. Of these, 47 were included in the review. Feminising gender-confirming chest surgery was evaluated in 11 studies, and masculinising gender-confirming chest surgery was evaluated in 39 studies. Clinician-reported outcome categories were used in 40 studies and included complications, reoperation, revision surgery and aesthetic outcome. Categories of patient-reported outcomes were used in 29 studies and included aesthetic outcome, functional outcome and mental health parameters. The summary of outcome domains and classifications showed that there are large variations in outcome evaluation between studies. Although several studies reported on similar outcome categories, there was a high level of heterogeneity of domains and classifications of outcomes. CONCLUSIONS: Evaluation of outcomes in gender-confirming chest surgery showed large variations in reporting, and further streamlining of reporting is therefore required to be able to compare surgical outcomes between studies. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty.

INTRODUCTION: The free radial forearm (FRFA) flap is universally still considered as the gold standard technique in penile reconstruction. Typically, a considerably large flap is required, often involving almost the entire circumference of the forearm. Partial necrosis may occur at the distal-most (dorsoradial) part of the flap as a result of insufficient perfusion. AIM: To describe a new technique using the posterior interosseous artery (PIOA) to supercharge FRFA phalloplasty. METHODS: In a 12-month period, all patients having FRFA flap phalloplasty were enrolled. Perioperative, after complete flap dissection, an indocyanine green perfusion scan was performed. In case of insufficient perfusion at the distalmost part of the flap, a supramicrosurgical anastomosis was performed between the FRFA pedicle and the PIOA (artery only). MAIN OUTCOME MEASURES: Studied outcomes included the rate of marginal necrosis, surgical time, postoperative posterior interosseous nerve damage and urethral complications (fistula, stenosis or necrosis). RESULTS: A total of 27 FRFA flap phalloplasties was performed. Anastomosis of the PIOA was needed in 15 cases. No marginal necrosis was observed in these cases. There were no cases of postoperative posterior interosseous nerve damage. There were no significant differences in urethral complications (fistula, stenosis or necrosis) between the 2 groups. CLINICAL IMPLICATIONS: In selected cases where insufficient perfusion of the dorsoradial part of the flap is present, patients may benefit from arterial supercharging to prevent postoperative marginal necrosis. STRENGTH & LIMITATIONS: Strengths include a single surgeon, thus lending continuity of skill and technique, a consecutive series, and 100% short-term follow-up. Limitations include single institution series and a limited number of patients. CONCLUSION: Arterial supercharging is effective in improving perfusion of large FRFA flaps used in phalloplasty when dorsoradial hypoperfusion is detected on an indocyanine green perfusion scan. It is a technically challenging addition to the standard technique because of the small size of the vessels, the close relationship between the PIOA and the posterior interosseous nerve, and the vulnerability of the newly constructed intra-flap anastomosis. De Wolf E, Claes K, Sommeling CE, et al. Free Bipedicled Radial Forearm and Posterior Interosseous Artery Perforator Flap Phalloplasty. J Sex Med 2019;16:1111-1117.

Flap Combination Phalloplasty in Female-to-Male Transsexuals.

BACKGROUND: Although phalloplasty with a free radial forearm (RF) flap is the gold standard for sex reassignment surgery in female-to-male transsexuals, it can result in unsightly scars, lymphedema, and numbness of the hand. AIM: To introduce the concept of flap combination phalloplasty and its clinical application. METHODS: This is a retrospective chart review study of patients undergoing phalloplasty using various multiple flaps. Demographic data, surgical data, and outcomes were recorded. OUTCOMES: Of the 15 cases, 5 were urethral fistulas; 4 were venous thrombosis; 2 were urethral calculus; and 1 was a partial flap loss. RESULTS: 15 patients were included (age range 25-43 years, median 34 years). An RF flap and a deep inferior epigastric artery perforator flap combination were most frequently used. The median operative time for flap combination phalloplasty was 10.5 hours (range 6.5-12.5 hours). There was no total flap necrosis, but there was 1 case of partial flap loss. There were urethral fistulas in 5, venous thrombosis in 4, and urethral calculus in 2 cases. CLINICAL IMPLICATIONS: Flap combination phalloplasty will become the third option when both the RF flap and the anterolateral thigh pedicle flap are not useful. STRENGTH & LIMITATIONS: Flap combination phalloplasty is a complex operative procedure with a prolonged operative time, but it can provide more flap selection and reduce the morbidity at each donor site. Choosing from many different options can be beneficial to patients. CONCLUSION: Flap combination phalloplasty has a similar complication rate to other procedures and has advantages in terms of flexibility and less donor site morbidity; it may thus be an option when either the RF flap or the anterolateral thigh pedicle flap cannot be used. Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019;16:934-941.

From silicone and hormone injecting to sex reassignment surgery: the precarious road to becoming female of transgender funeral performers in Ho Chi Minh City, Vietnam.

This paper examines aspects of feminisation among a group of transwomen funeral performers in Ho Chi Minh City, Vietnam. It highlights the health hazards faced by members of this vulnerable social group as the result of the use of non-medically prescribed hormone therapy, silicone injection and sex reassignment surgery in the absence of legal provision regulating these practices. The analysis is conducted against the backdrop of overlapping discourses of sex and gender identity, class, medicalisation and politics, both locally and globally.

Celebrity Influence Affecting Public Interest in Plastic Surgery Procedures: Google Trends Analysis.

BACKGROUND: Medical decisions made by celebrities have a profound influence on medical decisions made by the general population. Google Trends (GT) is a free, online resource with virtually no barriers to use that allows for tracking of global search volumes as a proxy for determining public interest. In this study, we utilize GT to characterize the significant and measurable effects that the May 2013 announcement of Angelina Jolie's BRCA-influenced prophylactic mastectomy, May 2015 announcement of Kylie Jenner's lip augmentation, April 2017 announcement of Caitlyn Jenner's gender affirming surgery and February 2014 media attention given to Kim Kardashian's rumored buttock augmentation had on corresponding surgical procedure volumes. METHODS: GT databases of search volumes were collected for terms related to prophylactic mastectomy, lip augmentation, gender affirming surgery and buttock augmentation categories from January 2004 to March 2019 using the "related queries" feature. Mean search volumes prior to respective announcements were compared to that of the period starting 6 months after. Additionally, the percent change from the month preceding respective celebrity announcements was compared to the month of the announcement for each search term. RESULTS: For mastectomy, all terms demonstrated peak interest during May 2013. Following Jolie's announcement, interest in "mastectomy" rose 1328%, "prophylactic mastectomy" rose 324%, "BRCA1" rose 316%, "BRCA2" rose 138% and "BRCA gene" rose 354%. Long-term interest was higher after May 2013 than beforehand for all terms except "prophylactic mastectomy" (each, p < 0.001). Following Kylie Jenner's announcement, interest in "lip augmentation" rose 43%, "lip enhancement" rose 37%, "lip fillers" rose 3233%, "lip implants" rose 8% and "lip injections" rose 13%. Long-term interest was higher after May 2015 than beforehand for all terms except "lip augmentation" and "lip enhancement" (each, p < 0.001). Following Caitlyn Jenner's announcement, "gender affirming surgery" rose 119%, "gender reassignment" rose 186%, "gender reassignment surgery" rose 203% and "transgender surgery" rose 35%. Long-term interest was higher after April 2017 than beforehand for all terms except "sex change" (each, p < 0.001). Following Kardashian's rumored injections, interest in "butt enhancement" rose 34% and "butt implants" rose 100%. Long-term interest was higher after February 2014 than beforehand for all terms (each, p < 0.001). CONCLUSIONS: GT data trends correlate with shifts in real-world healthcare utilization and healthcare-related public interest caused by high-profile public events, making it a useful tool for real-time prediction of trends in public health in response to a variety of observable influences. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study.

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation after Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery.

PURPOSE: We assessed the effect of performing colpectomy before (primary) or after (secondary) gender affirming surgery with single stage urethral lengthening on the incidence of urethral fistula in transgender men. MATERIALS AND METHODS: We retrospectively reviewed the charts of all transgender men who underwent gender affirming surgery with urethral lengthening between January 1989 and November 2016 at VU University Medical Center. Patient demographics, surgical characteristics, fistulas and fistula management, and primary and secondary colpectomy were recorded. Descriptive statistics were calculated and incidence rates were compared. RESULTS: A total of 294 transgender men underwent gender affirming surgery with urethral lengthening. A urethral fistula developed in 111 of the 232 patients (48%) without colpectomy and in 13 of the 62 (21%) who underwent primary colpectomy (p <0.01). Secondary colpectomy resulted in 100% fistula closure when performed in 17 patients with recurrent urethral fistula at the proximal urethral anastomosis and the fixed part of the neourethra. CONCLUSIONS: Primary colpectomy decreases the incidence rate of urethral fistulas. Secondary colpectomy is also an effective treatment of fistulas at the proximal urethral anastomosis and the fixed part of the neourethra.

A New Technique for Coronaplasty in Penile Reconstruction.

BACKGROUND: The coronaplasty is an important step of the phalloplasty procedure as it creates a prominent coronal ridge and a constricted coronal sulcus, resulting in the transformation of a regular skin flap into a flap resembling a circumcised penis. AIM: The aim of this article is to describe our new coronaplasty technique that exploits opposing contracting forces of 2 different skin grafts to hold the shape of a thick, distally based skin flap, resulting in a natural looking neo-phallus. METHODS: A distally based flap is raised at the junction of the middle and distal thirds of the neo-phallus. The dissection continues until adequate mobilization is obtained, so the flap can stand almost perpendicular to the axis of the shaft. 2 separate full-thickness skin grafts are harvested and placed: the first at the raw undersurface of the flap, the second at the flap's donor site. To make the sulcus deeper and to define the ridge, the lower part of the graft placed on the undersurface of the distal flap is sutured with tacking sutures. Depending on the type of flap used this procedure can be done during the phalloplasty procedure itself (axial flaps) or at least 1 week later (perforator flaps). OUTCOMES: The new technique that we developed shows a more distinct coronal sulcus and coronal ridge, long-lasting results, and a more aesthetically pleasing and natural-appearing glans penis. RESULTS: The harvested distal flap is progressively thicker and not folded, resulting in a more naturally looking ridge. The donor site is deeper than other techniques, creating a well-defined sulcus. By using 2 skin grafts the opposing force vectors increase the projection of the ridge and the deepness of the sulcus. CLINICAL TRANSLATION: This technique results in a more prominent glans penis and is an important step in creating an almost naturally looking neo-phallus. CONCLUSIONS: This procedure can be applied to all different kind of flaps used for phalloplasty, both in an immediate or delayed fashion. As grafts are used, partial or complete graft lost can appear. Furthermore, attention must be paid not to incise the distal flap too deep so vascularity to the distal part of the flap will not be impaired. A continuous search to optimize the aesthetic outcome of the phalloplasty procedure is necessary and with this new coronaplasty technique we hope to raise attention and take another step toward creating "the real thing." Sommeling CE, De Wolf EJ, Salim A, et al. A New Technique for Coronaplasty in Penile Reconstruction. J Sex Med 2018;15:920-923.