Background and purpose
Genital gender confirming surgery (GCS) has been shown to significantly decrease gender dysphoria and improve the quality of life of transgender patients (1,2). A fundamental goal of reconstructive genital GCS is to provide the patient with genitals whose appearance and function are consistent with those of members of the gender they identify with.
For the female to male transsexual, surgical options include creation of a neophallus (phalloplasty) using a vascularized free-flap or pedicle flap (with or without neourethra construction and anastomosis to the native urethra). At our centers and abroad, the most commonly used free-flap is the radial forearm-flap (3). At our center, the most common pedicle flap we use is harvested from the suprapubic area. At our centers and at Belgium’s Ghent University Hospital (4), anastomosis of the dominant cutaneous nerve(s) to one of the clitoral nerve bundles is performed with free-flap phalloplasties (3,5,6). Additional procedures are also performed: glansplasty (to give the end of the phallus a natural glans-like appearance), transposition of the denuded clitoris to the neophallus base (to consolidate erogenous sensation to the neophallus), and vaginectomy. At other centers (4), these are performed at time of phalloplasty, whereas at our centers, these are performed at second-stage surgery. Placement of testicular and penile prostheses, for cosmesis and erectile function, respectively, are performed at second (4) or (at our centers) third stage surgery. Previous groups have reported that the majority of patients retain the ability to achieve orgasm following phalloplasty (3,7,8). However, the degree to which sexual function is preserved (i.e., quality; e.g., relative time to achieve orgasm) relative to specific GCS such as clitoral transposition and penile prosthesis placement has not been described.
Furthermore, what factors influence transgender men’s decisions to undergo (and to not undergo) specific genital GCS has also not been described in the literature. Our experience among male transsexual patients seeking post-operative care at our tertiary-care medical center in the U.S. (UCSF) is that many did not undergo creation of a neourethra, clitoral transposition to the neophallus, or penile prosthesis placement. Even in our group’s high-volume female to male GCS centers in the UK where we routinely perform clitoral transposition and prosthesis placement at second and third stage surgeries, respectively, a subset of patients still elect to forego these two procedures as well.
We hypothesized that a better understanding of key factors, preferences and concerns that drive transgender men’s decision-making related to genital surgery, and a better understanding of sexual function following specific genital GCS, would be useful to better counsel patients pre-operatively regarding surgery options.
In this work, we sought to assess satisfaction and regret associated with patients’ own female-to-male genital GCS, pre and post-operative sexual function and neophallus dimensions among a divided subset of patients that did and did not undergo clitoral transposition and penile prosthesis placement.
Materials and methods
We evaluated a random selection of female-to-male transgender patients who had previously undergone pedicle-flap suprapubic phalloplasty [(SP); N=10] and radial artery forearm-flap phalloplasty [(RAP); N=15]. We included a cohort of patients from earlier in our center’s series that had undergone surgery without cutaneous nerve to unilateral clitoral nerve anastomosis, and, for comparison, a more current cohort of patients who had undergone cutaneous nerve to clitoral nerve anastomosis, which is now standard practice for our group. The only criterion for eligibility was that the patient had to be able to present, in person, at our clinic for evaluation. All patients were evaluated by interview and physical exam by a single surgeon (MMG) in our clinic (Institute of Urology; London, UK).
Patient’s surgical records were queried regarding patient age, date of surgery, and surgical data that included: phalloplasty type (suprapubic or radial forearm free-flap phalloplasty, flap length, whether or not the clitoris was transposed to the base of the neophallus at subsequent surgery, whether or not the patient had undergone penile prosthesis, and what type of prosthesis was used (inflatable or malleable).
During interviews, all patients were queried regarding the following domains: (I) overall satisfaction with the outcome of their genital GCS (likert scale, 1-10); (II) whether patient has sufficient overall regret for the outcome of their genital GCS to wish that they had never started genital GCS; and (III) overall satisfaction with final phallus length (likert scale, 1-10); (IV) which ideal is more “important” to the patient: “above average” penile length or girth, or neither/equal? and (V) which does the partner think is more “important” for his partner: “above average” penile length or girth, or neither/equal?
The following specific domains of sexual function, before and after GCS, were queried: (I) whether they were able to achieve orgasm before GCS surgery, and afterwards; (II) whether after transposition of the clitoris to the neophallus, they were still able to achieve orgasm with direct stimulation of the buried clitoris site; (III) after clitoral transposition, did direct stimulation of the buried clitoris site yield equal or delayed time to orgasm? (IV) whether they masturbate with their phallus; and (V) whether, following penile prosthesis placement, they were still able to achieve orgasm with direct stimulation of the clitoris (native location or where buried).
All subjects were instructed regarding how to use the smart-phone App “MedMeasure!” (Android Google Play and Apple® iTunes: https://itunes.apple.com/us/app/medmeasure!/id654898049?mt=8) to measure their own phallus length and width by photographing their phallus in the flaccid or erect state. [subjects placed a British 1£ coin (whose diameter is known by the App) upon the dorsal surface of the mid-shaft].
Phallus measurements, from tip to the dorsal circumferential scar at the base, were then performed (flaccid, and if a prosthesis was present, also erect), using the MedMeasure! App and the coin as an internal reference object.
Study subjects and follow-up
Mean age and follow-up of patients that underwent pedicle-flap SP was 35.1 and 2.23 years. For those who underwent RAP phalloplasty without and with cutaneous nerve to clitoral nerve anastomosis, it was 34 and 6.8 years, and 39.2 and 2.24 years, respectively (Table 1).
Surgical procedures: clitoral transposition and penile prosthesis placement
Over half of patients of all three groups underwent transposition of the clitoris to the neophallus. While only one of ten patients of the group that underwent SP had undergone penile prosthesis placement (this device was already explanted due to malfunction by time of present evaluation), 2/3 of patients that underwent RAP had elected to proceed with penile prosthesis placement (Table 2).
Subject interview responses (Table 3)
Neophallus flap length was measured intra-operatively; girth was not. Length and girth measurement values at follow-up are shown in Table 3.
Neophallus measurement App
Neophallus length measurements using the MedMeasure! App correlated to actual-lengths on the ruler within the image by ±<4.5% of the value measured by a ruler (Figure 1).
At our high volume female to male genital GCS center in London, UK, we now routinely stage phalloplasty and neourethra-urethral anastomosis +vaginectomy +clitoral transposition, over two separate surgeries, as compared to a single stage surgery as is performed at leading European centers (4). This is because our experience has been that doing so allows for more optimal wound healing of the neophallus and neo-urethra before additional pelvic surgery, and has resulted in fewer post-operative complications (e.g., infection, fistulae) and improved cosmesis of glansplasty. Furthermore, staging clitoral transposition surgery allows us to bury the denuded clitoris in a more superficial location just below the skin surface of the neophallus at the base (5). Other centers bury the denuded clitoris beneath the base of the neophallus [i.e., upon the surface of the pubic symphysis (3)]. It is not possible to compare outcomes between the two techniques, as quality of erogenous sensation has not been described by others (8), but, we believe that placing it more superficially renders it more accessible to direct stimulation, and so, may better facilitate and preserve erogenous sensation.
Staging genital surgery also presents patients with the opportunity to carefully consider any additional surgeries—such as vaginectomy, clitoral transposition to the neophallus, and penile prosthesis placement. In the U.S., the fact that very few surgeons offer F to M surgery overall, and an even fewer number offer phalloplasty combined with neourethra creation and/or vaginectomy and/or clitoral transposition and/or penile prosthesis. As more surgery is offered in the U.S. and abroad, patients will face greater choices regarding surgical options.
The results of our work show that while patients are, overall, quite satisfied with their decision to undergo genital GCS, those that did not undergo clitoral transposition to the neophallus or penile prosthesis placement related that the driving reason for foregoing surgery was a concern that they risked losing erogenous sensation and the ability to achieve orgasm. They also related regret—equally for perceived unfavorable cosmesis (likely related to underlying gender dysphoria), and, the fact that without clitoral transposition, erogenous sensation remains consolidated outside of their new phallus. Our present work suggests that, provided that patients have experienced clitoral orgasm before surgery, clitoral transposition does not result in a subsequent loss of ability to achieve orgasm with direct stimulation of the clitoris site. Similarly, no patient that underwent penile prosthesis placement, and had experienced orgasm at least once before prosthesis placement surgery, reported diminished likelihood of achieving orgasm after prosthesis placement.
Querying patients about sexual function before surgery is exceedingly important, as pre-op function undoubtedly influences post-op sexual function, and, because doing so is an opportunity to prepare patients for surgery and manage expectations post-op. In our series, we found that almost all men report masturbating their neophallus [consistent with other reports (9)] regardless of whether they have undergone clitoral transposition and can achieve orgasm with stimulation of only the phallus. This suggests, and is echoed by comments from many of our patients, who relate the added “purely psychological” pleasure that self-stimulation of their phallus provides to them, and which “enhance” orgasm quality.
In our experience, many patient’s report lack of familiarity with their genitals (e.g., use for sex, exploratory touching), and this may be likely attributable to their gender dysphoria. Such lack of familiarity may predict for poorer sexual function post-op: two of the three patients that had never experienced orgasm before surgery reported an inability to achieve orgasm after their surgery. For one of these men, religious beliefs precluded pre-marital sexual activity. The other man (also un-partnered) reported attempting masturbation, but an inability to achieve it due to “not knowing how to do it” or “what to look for”. Based on our experience from the present work, we now routinely query our patients pre-op regarding past sexual function, and encourage them to familiarize themselves, pre-op, with the location and stimulation of erogenous sensation of their genitals.
Our results related to neophallus measurements after surgery is reassuring in that it suggests that phallus length appears to not change significantly after surgery. The greater mean decrease in length among patients who underwent RAP versus those who underwent SP phalloplasty may reflect the greater incidence of subsequent local infections (related to the creation of a neourethra and/or penile prosthesis placement) in the former group, which likely leads to scarring of phallus tissues and decreased length. It is useful to be able to counsel patients that their phallus length will most likely shorten, though likely only by a small degree (mean 1-2 cm.) post-op, and, that with an inflatable penile prosthesis, only a modest increase in girth (mean 0.77 cm.) and, surprisingly, a very small decrease in length (mean –0.43 cm.) can be expected. Phallus length measured with the MedMeasure! App was highly accurate relative to use of a ruler, and it is reasonable to expect to be able to collect accurate phallus length and width measurement data from patients remotely using this App.
Similar to how some natal (CIS) men ascribe a significant degree of importance to achieving an ideal penis size, many trans men also request large neophallus dimensions. As our study shows, at least half of all trans men themselves valued above average penile length. Interestingly, despite this, 80% of these same trans men felt that their female partners would value above average girth over length. Patients can be reminded of well-powered national studies of erect penile length all show that mean flaccid and erect penile lengths are generally around 8.85 and 12.89 cm respectively (10), and that, depending on the type of phalloplasty they undergo, their neophallus may likely be well above average for flaccid length and within average ranges for erect length. Furthermore, patients who request a particularly long neophallus length can be reminded that an especially long phallus may not adequately support the inflatable penile prosthesis cylinder(s), causing for example, cylinders to buckle more easily in the erect state and/or wear-out at an accelerated rate. Longer inflatable cylinders require longer filling (pumping) time, and longer malleable prostheses are more challenging to obscure with clothing. Furthermore, while the most common manufacturers’ inflatable prostheses will accommodate an especially long phallus, patients should consider that, owing to the fact that the degree to which the proximal end of the inflatable prosthesis can be concealed is limited in a transgender man, when an especially long phallus requires use of prosthesis rear-tip extenders, it becomes much more likely that the patient will be able to feel the firm/pointed point of entry of the tubing into the cylinder—which many find uncomfortable and un-aesthetic. Lastly, patients should also be reminded that if they elect to undergo a urethral lengthening procedure post-phalloplasty, a longer phallus will require a longer neourethra, and the availability of an especially long non hair-bearing suitable segment of skin for this must be taken into account.
Limitations of our study include relatively small sample size for subgroups and that only subjects who presented to be able and inclined to present to our clinic were evaluated. These limitations could certainly result in sampling bias. Future studies, already underway by our group, should include a larger sample size with more balanced subgroups (e.g., inclusion of patients will malleable prostheses, etc.).
In conclusion, our study suggests that sexual function/ability to achieve orgasm related to the clitoris is not lost following clitoral transposition surgery or penile prosthesis placement following clitoral transposition surgery. Overall, F to M genital GCS is associated with exceedingly high overall satisfaction and, in our series, without any overall regret. Neophallus dimensions remain relatively stable over time after phalloplasty, and length and girth do not change significantly with penile prosthesis placement. We believe that the aforementioned data is useful to inform patients and help guide their expectations related to surgery.
Funding: Author (Maurice M. Garcia) and manuscript publication supported by National Institutes of Health (NIH) and National Institute of Child Health and Human Development (NICHD) K08 Mentored Clinician Scientist Grant Award, #10713482.
The authors (all) wish to thank Vera Henriques and Sara Richardson of St. Peter’s Andrology Centre for administrative assistance throughout the course of the study.
Conflicts of Interest: The University of California has filed U.S. and International Patent applications for intellectual property (IP) related to the smartphone image-based measurement App, MedMeasure! Used in this work: U.S. Patent Number 61548750. This IP was licensed by author Maurice Garcia, as required by the University of California in order to proceed to program (create) the App and made it available—as no such App currently exists. This App is currently available on Apple iTunes Store and Android Google Play App store. The App is free, though upgrades that allow one to perform measurements similar to those described in this manuscript [e.g., use of a wide variety of coins or a ruler to calibrate the caliper, does require an in-app purchase (cost =0.99 cents)]. No other App currently available on iTunes or for Android smartphones affords the ability to measure actual distance on a 2-D camera image, and it is for this reason that the authors used the App designed by their group (M. Garcia). The authors have added “Patents Pending” to the text to reflect the patents-pending status of the App.
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