Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes

Abstract

Background: Different surgical procedures are available for transgender women wishing to undergo genital gender-affirming surgery.

Aim: To assess preoperative motivations, the frequency of orchiectomy procedures, and postoperative outcomes of orchiectomy in transgender individuals.

Methods: All transgender individuals who underwent orchiectomy in the period between January 2012 and January 2020 at our institution were retrospectively identified. A chart study was conducted, recording motivations, demographics, perioperative characteristics and surgical outcomes. The frequency of orchiectomy and vaginoplasty procedures during the study period were determined and compared.

Results: During the study period, an increase of performed orchiectomy procedures was observed. The orchiectomy/vaginoplasty ratio was 0.01–0.07 in the period 2012–2018 and 0.24 in 2019. A total of 43 transgender individuals were retrospectively identified. Sixteen (37%) initially wished to undergo a vaginoplasty, but did not meet institutional requirements (nonsmoker, BMI < 30kg/m²) or were not eligible for vaginoplasty surgery because of interfering somatic or mental health issues. Fourteen (33%) individuals who underwent orchiectomy regarded it as a preceding step to a future vaginoplasty procedure. Out of these fourteen, one person is now on the waiting list for vaginoplasty surgery. Thirteen (30%) others did not report a desire to pursue vaginoplasty in the future. This was mostly motivated by the absence of genital dysphoria or motivations related to their gender identity, with a desire to discontinue anti-testosterone treatment. The postoperative course was uncomplicated in 39 (91%) individuals.

Conclusion: In the Netherlands, especially in the last year, the frequency of orchiectomy procedures has increased. Reasons that people chose to undergo this procedure include: not being eligible for a vaginoplasty procedure, seeing it as a preceding step to a possible future vaginoplasty or other identity-related motivations (i.e., non-binary gender identification or absence of genital dysphoria).     

Combining total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with subcutaneous mastectomy in trans men: The effect on safety outcomes

Abstract

Background: Masculinizing mastectomy is the most requested gender affirming surgery (GAS) in trans men, followed by genital GAS. Mastectomy and total laparoscopic hysterectomy, with or without bilateral salpingo-oophorectomy (TLH?±?BSO), can both be performed in one single operation session. However, data on complication rates of the combined procedure is scarce and no consensus exists on the preferred order of procedures.

Aims: To compare safety outcomes between mastectomy performed in a single procedure with those when performed in a combined procedure and assess whether the order of procedures matters when they are combined.

Methods: A retrospective chart review was performed of trans men who underwent masculinizing mastectomy with or without TLH?±?BSO in a combined session. The effects of the surgical procedure on complication and reoperation rate of the chest were assessed using logistic regression.

Results: In total, 480 trans men were included in the study. Of these, 212 patients underwent the combined procedure. The gynecological procedure was performed first in 152 (71.7%) patients. In the total sample, postoperative hematoma of the chest occurred in 11.3%; 16% in the combined versus 7.5% in the single mastectomy group (p?=?0.001). Reoperations due to hematoma of the chest were performed in 7.5% of all patients; 10.8% in the combined versus 4.9% in the single mastectomy group (p?=?0.017). The order of procedures in the combined group had no significant effect on postoperative hematoma of the chest (p?=?0.856), and reoperations (p?=?0.689).

Conclusion: Combining masculinizing mastectomy with TLH?±?BSO in one session was associated with significantly more hematoma and reoperations compared with separately performing mastectomy. This increased risk of complications after a combined procedure should be considered when deciding on surgical options. The order of procedures in a combined procedure did not have an effect on safety outcomes.     

胆道外科手术决策的疑惑与思考

随着人民生活水平的提高和卫生条件的改善,胆道疾病的发生率明显提高,由此在手术决策中出现了越来越多困扰广大胆道外科医生的问题。本文试用哲学思想加以剖析,意在探讨胆道手术决策的问题,以期提高手术效果。     

Experiences of surgery readiness assessments in British Columbia

Abstract

Background: A surgical readiness assessment is a major step in the medical journey of trans people seeking gender-affirming surgery. Much of the peer-reviewed literature surrounding surgical readiness assessments emphasizes the perspectives of academics and clinicians, leaving the voices of trans and gender diverse patients largely unheard.

Aims: This paper foregrounds patient experiences with surgery readiness assessments to discuss the tensions, challenges and opportunities they generate.

Methods: We conducted a thematic analysis of 35 in-depth interviews with trans people who accessed or were seeking to access gender-affirming surgery in British Columbia.

Results: We developed three main themes to capture participants’ narratives of their surgical assessment experiences. The first, assessments as gatekeeping, explores the stories of people who described their assessments as outdated and even discriminatory processes. The second, assessments as a barrier to care, discusses the informational missteps, bureaucratic regulations, economic issues, and geographic concerns that made assessments difficult to access. The third, assessments as useful, includes positive stories about assessments that often involved feeling supported by an assessor and feeling prepared for the next steps.

Discussion: These narratives demonstrate how much variation exists among people’s experiences of readiness assessments for gender-affirming surgery. No matter how their actual assessment turned out, many participants approached their appointments with a great deal of anxiety and trepidation. We attributed this stress was to challenges ranging from lengthy wait times, arbitrary medical gatekeeping, a lack of access to knowledgeable and supportive providers, unclear or changing administrative processes, and insufficient communication. To address these challenges, it is crucial for the medical system to create more accessible pathways with centralized, up-to-date information for people trying to access assessments. Patients are best served by multi-disciplinary gender-affirming teams that provide individualized care.