Hadj-Moussa, Ohl and Kuzon have just published Feminizing Genital Gender-Confirmation Surgery (doi: doi.org/10.1016/j.sxmr.2017.11.005 ); they say it’s part 2 in a series of 3, but I can’t find part 1 (Evaluation and treatment of gender dysphoria to prepare for gender confirmation surgery) published online anywhere.

Takeouts:

Psychological and general well-being improve across the board for very high rates, even after long followups, for both men and women.

Surgery regrets are very low (<4%) and associated with predictable factors, such as incomplete hormone treatment.

For women, in the great majority of cases the standard penile inversion technique is adequate.

Major issues are very rare but minor complications are common, necessitating post-surgical care. Many women choose to undergo additional corrective surgeries.

Stop smoking.

Sexual function is generally high, and sexual satisfaction even higher. The main point of dissatisfaction is lubrication, and external lubrication is recommended.

Data on psychological and life satisfaction benefits include very positive results not just for trans women but for men, too. As usual, the authors highlight the lack of quality data, but show that, as far we can tell at this point, satisfaction rates with gender-confirm surgery are consistently high. In one high-quality study (n=232) measuring improvements on a scale of −10 (worst imaginable outcome) to 10 (best imaginable improvement), quality of life improved an average of 7.9±2.6, and satisfaction was 8.7±1.6. Another study with a long follow-up of ca. 14 years, ratings from 1 (“worse than ever” ) to 5 (“better than ever”) averaged 4.35±0.86. One study of n=47 Brazilian trans men found good improvements in psychological well-being but worse physical health—perhaps because data were collected shortly after surgery. See paper for many more positive results. Crucially, satisfaction remains high even in the face of complications (likely because the primary motive is to alleviate dysphoria, according to the authors). Still, results aren’t completely perfect: for example, up to 12.3% of trans women were dissatisfied with their post-op sexual function.

Outright regret exists but is rare, with estimates ranging from 0 to 3.8%. Factors associated with regret include:

Poor social and family support;

Late-onset gender transition;

Poor sexual function;

Suboptimal cosmetic outcome;

Concomitant mental health issues;

And non-compliance with WPATH SOC guidelines (such as waiting for hormone therapy, etc.)

In one study, every single patient expressing regret had not yet transitioned hormonally, socially, or lacked mental health support. In a similar note, the authors also highlight the importance of waiting for full breast development under hormone therapy before deciding on breast augmentation surgery; not only the changes in tissue will better support breast implants, but also breast satisfaction rates with hormone therapy alone seem to be high. One or two years on hormones may well prove to be enough to alleviate dysphoria.

For vaginoplasty, the authors review safety guidelines and some lesser-used techniques, but for the great majority of cases the current standard, penile inversion, is recommended. (This review doesn’t evaluate Dr Suporn’s particular Thai method, renowned in the trans community.) Penile inversion is a generally safe surgery; life-threatening complications are rare and risk of death is virtually 0%. However, minor complications are fairly common (the commonest being a misdirected urine stream, in up to 40% of cases; it’s treatable), and post-op care is a necessity. Something between 25% to 80% of women undergo later surgery to improve the void, or for cosmetic purposes. Fistulas only occur in ~1% of cases but are distressing for patients; they’re treatable by further surgery, or in minor cases by diet and management.

Sexual satisfaction rates are high, reaching 91.4%. Around 80% of trans women can achieve orgasms with a neoclitoris; 25% to 46.9% report not just ability to orgasm, but actually improved orgasm quality. Minimum dimensions for intercourse are almost always achieved, but must be maintained with dilation; between 76% to 100% are satisfied with depth. However, measures of sexual function used for cis women result in overall lower scores for trans women. This is probably because trans women’s primary motivation (alleviating dysphoria) compensates in subjective satisfaction for gross sexual function. Cosmetic satisfaction is also high, estimated from 78% to 100%—with better body-positive self-image scores than cis women, on average. The major area of dissatisfaction is lubrication; most trans women will require additional lubrication for pleasant intercourse. Pain during sex is also reported more often than among cis women.