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From Male to Female—
Preparation and Surgical Tips
Sexual Medicine Society of North America
April 7, 2016
Dana A. Ohl, MD, FECSM
Professor of Urology
Head, Division of Andrology and Urologic Health
University of Michigan
Disclosures
None
Presented by:
Gender Dysphoria (DSM V)
 Gender dysphoria refers to discomfort or
distress that is caused by a discrepancy
between a person’s gender identity and that
person’s sex assigned at birth (and the
associated gender role and/or primary and
secondary sex characteristics) (Fisk, 1974;
Knudson, De Cuypere, & Bockting, 2010b).
Demographics
• 2001 survey (U.S. surgeons)
• 1170 genital
reassignments per year1
• 63% MTF, 37% FTM
• 2003-2009 data
• 0.1-0.5% of the U.S.
population is transsexual2
(300,000-1.5M individuals)
1.
2.
Category
Lifetime
prevalence
Total
population
Self-defined
transsexual
man/woman
1:987
303,951
Diagnosed
with Gender
Identity
Disorder
1:1974
151,976
Underwent
genital
reassignment
surgery
1:3134
95,724
Horton, MA. “The Prevalence of SRS Among US Residents.” 2008. http://www.tgender.net/taw/thb/THBPrevalence-OE2008.pdf
Gates, GJ. “How many meople are lesbian, gay, bisexual, and transgender?”, UCLA, 2011. http://williamsinstitute.law. ucla.edu/wpcontent/uploads/Gates-How-Many-People-LGBT-Apr-2011.pdf
EUROPE
8 January 2015 Last updated at 14:01 ET
Russia says drivers must not have 'sex disorders'
Russia has listed transsexual and transgender people among those who will no longer qualify for driving licences.
Fetishism, exhibitionism and voyeurism are also included as "mental disorders" now barring people from driving.
The government says it is tightening medical controls for drivers because Russia has too many road accidents.
"Pathological" gambling and compulsive stealing are also on the list. Russian psychiatrists and human rights lawyers have
condemned the move.
The announcement follows international complaints about Russian harassment of gay-rights activists.
In 2013 Russia made "promoting non-traditional lifestyles" illegal.
Valery Evtushenko at the Russian Psychiatric Association voiced concern about the driving restrictions, speaking to the BBC
Russian Service. He said some people would avoid seeking psychiatric help, fearing a driving ban.
The Association of Russian Lawyers for Human Rights called the new law "discriminatory". It said it would demand clarifications
from the Russian Constitutional Court and seek support from international human rights organisations.
But the Professional Drivers Union supported the move. "We have too many deaths on the road, and I believe toughening medical
requirements for applicants is fully justified," said the union's head Alexander Kotov.
However, he said the requirements should not be so strict for non-professional drivers.
Mikhail Strakhov, a Russian psychiatric expert, told BBC Russian that the definition of "personality disorders" was too vague and
some disorders would not affect a person's ability to drive a car safely.
More videos from the BBC
Public interest
Relative frequency of Google searches for “transgender”
in the state of Michigan, Jan 2007-Apr 2015
Vocabulary
• Biological or Genetic Sex – reproductive anatomy and
secondary sex characteristics (male or female)
• Gender Identity - psychological identity along the gender
spectrum (masculine, feminine, “agender”)
• Sexual Orientation – preferred gender of sexual partners
• Transgender - identify as, or desire to live and be accepted
as, a member of the biological sex opposite to that assigned
at birth
- transman, transwoman, gender variant, and/or gender
incongruent are now preferred terms
- Use pronouns for target gender
World Professional
Association for
Transgender Health
(WPATH)
• Membership : patients, providers, networks,
support groups
• Being Transsexual, Transgender, or Gender
Nonconforming is a Matter of Diversity, Not
Pathology
• Standards of Care
– Version 7 from 2011
– definitive treatment guidelines for providers
WPATH Standards of Care
• Designed to protect both
patient and provider
• “Lasting personal comfort
with the gendered self in
order to maximize overall
psychological well-being
and self-fulfillment.”
• “Roadmap” to surgical
sex reassignment
WPATH SOC v7
Requisites for Sex Reassignment
Surgery
• Consolidation of gender identity; continuing mental
stability
• Age 18*
• Chest surgery (mastectomy, breast augmentation)
– 12 months continuous hormone therapy for breast
augmentation
– 1 letter of readiness
• Genital surgery (vaginoplasty, phalloplasty)
– 12 months successful continuous real life experience
– 12 months of hormonal therapy
– 2 letter of readiness from mental health professionals
WPATH - SOC
• A departure from the SOC
may be justified by:
– A patient’s unique anatomic,
social, or psychological situation
– An experienced health
professional’s evolving method
of handling a common situation
– A research protocol
– Lack of resources in various
parts of the world
– The need for specific harmreduction strategies
Male to Female (MTF):
Penile Inversion Vaginoplasty
Natal male genitalia
Marking scrotal-perineal flap
Male to Female (MTF):
Penile Inversion Vaginoplasty
Dissection down to bulbospongiosus m.
Orchiectomy
Male to Female (MTF):
Penile Inversion Vaginoplasty
Degloving of the penis
Retraction of penis into perineum
Male to Female (MTF):
Penile Inversion Vaginoplasty
Isolation of the neurovascular bundle Bundle and neoclitoris lifted off corpora
Male to Female (MTF):
Penile Inversion Vaginoplasty
Isolation of urethra and bulbospongiosus m.
Mid-urethral transection
Male to Female (MTF):
Penile Inversion Vaginoplasty
Penile skin bisected
Neoclitoris formed and anchored
Male to Female (MTF):
Penile Inversion Vaginoplasty
Penile shaft skin pulled posteriorly
Penile inversion to form neovagina
Male to Female (MTF):
Penile Inversion Vaginoplasty
Urethra and flaps sutured into place
Construction of labia majora
Vaginal packing
Male to Female (MTF):
Penile Inversion Vaginoplasty
Tips for a Successful Program
• Mental Health team is the key
– Our patients enter the program via mental health
– Mental Health professional guide patients
through the process
– Must have two separate evaluations
– Surgeons have contact with the patients only
after they are well into the process
Presented by:
Tips for a Successful Program
• EMPHASIS ON
MULTIDICIPLINARY CARE
–
–
–
–
–
Therapist
Primary care (incl hormones)
Specialty care
Second opinion
Surgical Referrals
•
•
•
•
Plastic Surgeon
Urologist
Gynecologist
ENT
– Other providers (electrolysis,
speech therapy)
• Program coordinator tracks
all patients
• Mental Health Team
– Readiness for surgery
• Core Team
– Surgical Transition
Tips for a Successul Program—
Learning Curve
Tips for a Successful Program—
Standards of Care
Presented by:
Tips for a Successful Program—
Keep an Open Mind
What Tin Man REALLY Wanted
Presented by: