Episode 25: Transgender Surgery

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Episode Summary:

Masculinization or feminization surgery (transgender surgery) has come a long way. Patients today receive high-quality, integrative care with excellent outcomes. The process of medical transitioning from before surgery through to full healing is discussed by a leader in this field. Awkwardly, this episode illustrates that the title “men’s health” becomes problematic when it comes to transgender health.

Episode Guest: 

Maurice Garcia, M.D., Urologist, and Associate Professor, Cedars-Sinai, Los Angeles California;  Director of the Cedars-Sinai Transgender Surgery and Health Program.

During This Episode We Discuss:

  • Current approaches to transgender individuals. Specialty centers with the necessary resources. 
  • Quality and integrative care.
  • How does the individual achieve the success they desire?
  • Important information that is presented as a matter of fact with shared decisions and goals.

Quotes (Tweetables):

“Gender affirming surgery is a broad category that includes genital affirming surgery but includes other types of surgery. Facial surgery, tracheal shaving or hyoid bone shaving surgery for transgender women, chest surgery, breast augmentation, or mastectomy (for transmen) as well as genital surgery.”

Maurice Garcia, M.D.

Recommended Resources:

Episode Transcript: 

Dr Richard Pelman (00:07):

Baseball game, day in a park with friends and family, fishing in a remote stream, work, travels, providing for loved ones, or heading out for adventures, whatever you do, whatever you enjoy, you need your health. The Original Guide to Men’s Health, as presented by the Washington State Urology Society, to help take you through the steps necessary to get the most out of life. If you have invested in a retirement plan for your future, why not invest in your body, after all it makes better sense to retire healthy and enjoy your future. These podcasts are a guide for how to take care of yourself. If you take care of your car and maintain it, why not do the same for your personal machine, your body, if you know you should, but haven’t yet, the information in these podcasts contains some easy recommendations for where, when, and how to get started. Follow the podcast, as we explore men’s health with renowned experts and embark on a journey towards better health!

Dr Pelman (01:23):

This episode of The Original Guide to Men’s Health we’re fortunate to have Dr. Maurice Garcia. Dr. Garcia is the Associate Professor of Urology at the Cedar-Sinai Center, Los Angeles. He’s the Associate Professor of Urology and Residency. He’s an Associate Professor of Urology Adjunct in the Department of Urology and Department of Anatomy at the University of California, San Francisco. And he is currently the Director of Cedar-Sinai Transgender Surgery and Health Program. Dr. Garcia completed medical school at Georgetown University. He completed his residency in Urology and Fellowship at the University of California, San Francisco, and then did further fellowship training in transgender surgery in London, UK at University College, London Hospital. Dr. Garcia. Welcome.

Dr Garcia (02:10):

Thank you very much, Dr. Pelman. It’s a pleasure to be here.

Dr Pelman (02:13):

 Let’s first look at obviously LGBTQ health, it’s huge and you are at one end of the spectrum as a reconstructive surgeon. Before we go to the particulars of gender reconstruction, let’s just talk about who might be in the population that would be of interest to hear more about that.

Dr Garcia (02:33):

Sure. A lot of the genital work that we do in sexual medicine work we do in traditional urology falls under the rubric or the heading of “men’s health.” What’s interesting about this field is that we have patients who are transgender women who were born male or assigned the male sex at birth, but who identify as women. And we have patients who were born female assigned the female sex at birth, but who identify as male. And we have to make genitals for both of them and care for the sexual function and sexual health needs of both populations. And then within that group, many of these transgender men and women, as well as gender non-binary individuals, also within this population, many patients have a diversity of sexuality. Some patients will have partners who are of the same sex. Some patients will have partners who are of the opposite sex. And some patients will have partners who are of either sex or both sexes or partners who don’t identify with either gender, my patient population that is transgender and gender non-binary people really fit well into the LGBTQ spectrum. They comprise the entire spectrum. And I think that within traditional urology one could argue that they certainly benefit from a lot of the expertise and care that we provide as part of traditional quote unquote “men’s health.” I just think we need to broaden the definition and broaden the umbrella.

Dr Pelman (04:05):

So, when we look at a population who in the past may not have been able to find resources available. We now have the ability for our population who are in need to find care, but not only care, but expert care. And where would somebody who is listening to this? Who’s saying, oh, you know, I don’t know where to go. How would they start?

Dr Garcia (04:32):

Yeah, that’s a great question. So, I guess put another way is: or one way of putting it is: how do patients find me and people that do what I do, surgeons like me. So, a lot of these patients are referred to surgeons by their LGBTQ health center. It’s typically community organizations that offer resources and some limited medical care and hormones and medications and lab tests and so forth. Others are referred to surgeons by their primary care doctors. If they see a lot of transgender patients or their endocrinologist, if they’re on hormones, cross sex hormone management is managed by endocrinologist. Honestly, a lot of the care, a lot of the patients that we see get their care and their services for that matter, by word of mouth. I think it’s fair to say that the transgender community, both in the United States and abroad is very connected by social media. It makes sense historically, they didn’t have clinics to go to or, you know, specialty clinics or anything like that. So, they looked out for each other and communicated on social media or online referring each other to good practitioners and good service.

Dr Pelman (05:50):

I know in the pediatric group where we talk about, gender reassignment, a lot of that is a congenital issue. Pediatric specialists, it’s a committee, one person doesn’t walk in with a child and say, we need to change the sex of this child for the adult population. It must be a process. If somebody hears about you. Somebody finds you, but what process do they actually go through? And is there a committee or they have to be pre evaluated before they even consider surgery. Take us through, it’s got to be a step-by-step issue.

Dr Garcia (06:24):

There is a process by which we evaluate patients, to make sure that they’re ready to go to undergo this phase of transition. So, gender transition typically starts with social transition, that is living progressively more full-time to ultimately full-time in the gender role that they identify with. So that means not only dressing but presenting as someone from the gender that they identify with and being addressed by correct gender pronouns, dressing, et cetera. And this is full time, not just at nights or on weekends, but full-time life in their gender, that social transition, another phase of transition. And it sometimes happens before social transition, sometimes after, or sometimes concurrently is a transition with use of hormones of the gender that they identify with. So cross-sex hormone therapy. And these two things are both requirements for a patient to be ready to undergo genital surgery.

Dr Pelman:

 Genital surgery, is it reversible?

Speaker 3 (07:34):

We remove anatomy permanently, anatomy that can’t be put back and these surgeries affect hormone function as well. These requirements are in place to help it, to help encourage and require people to experience life in the gender that they identify with as fully and as completely as possible before they commit to irreversible surgeries or treatments, which makes sense, these guidelines. Although a lot of governing bodies, such as Medicare and Medicaid and many commercial insurance companies adopt these as requirements. These guidelines slash requirements for readiness for surgery come from the World Professional Association for Transgender Health. WPATH, as you may know, is the leading national and international healthcare organization focused on transgender medical health and surgery or including surgery. It’s a wonderful multi-disciplinary organization that is evidence-based, and evidence and research focused to promote evidence-based medicine and health policy and care guidelines for transgender people.

Dr Garcia (08:56):

So, they came up with a Standards of Care Guidelines. The last version is version seven that can be found online. And that lists the requirements that people should meet before they undergo surgery. So, to recap for surgery, someone has to have lived in the identified-with gender for at least a year and have been taking hormones of the gender that they identify with for at least a year. And they also need surgery referral letters. These are letters from mental health providers who are effectively referring the patient to the surgeon for their surgery. These referral letters do not quote unquote “recommend surgery,” but rather they speak to the patient’s readiness for surgery. And they speak to the patients meeting the WPATH Standards of Care Guidelines, criteria for surgery, which I’ve just mentioned. These guys, these requirements include other factors such as a diagnosis of gender dysphoria.

Dr Garcia (10:00):

So, this isn’t all that distinguishes all that we do from cosmetic surgery or something like that. That’s what makes it medically necessary. These letters from mental health providers should also speak to other facets of the patient’s readiness for surgery, such as do they have stable housing? Do they have the means by which to, from a practical standpoint, undergo surgery and present for follow-up and self-care? Do they live in an environment where they can safely take care of themselves? For example, after vaginoplasty patients need to dilate and do so, if they’re living in a single room occupancy with a public bathroom, that’s not going to work. So, these are some of the things that we as care providers have to work together to identify prospectively and make sure that these patients don’t have barriers to self-care after surgery. Before we do the surgery, I should also add that these guideline requirements such as a year of social transition and a year of hormone therapy, they were presented by WPATH as guidelines, not as strict black and white laws.

Dr Garcia (11:16):

There are certain circumstances where patients can’t always meet these guidelines, and those should not preclude such patients from having surgery. And that’s an example would be someone who lives in a, in a social environment where they can’t socially transition part of the way or gradually before surgery. For example, it’s not safe for them or people who don’t can’t afford hormone therapy or don’t have access to it where they live. Certain allowances have to be made for real life. You know, people live in different parts of the country. They live in certain situations politically and economically where some things aren’t possible. And that’s exactly where the surgery referral letters from mental health providers help articulate the need for such allowances. So that patients like that aren’t meeting criteria, aren’t denied important care like surgery because they don’t meet certain criteria to the letter of “to the T.”  Again, the goal of guidelines and pre-surgery evaluation is just to identify people who on some fundamental level, aren’t really ready for this sort of irreversible part of gender transition and people who are people who have mental health issues that whether or not really sort of thinking about it correctly and stable.

Dr Pelman (12:40):

So, it’s a team and you have alluded to mental health professionals. And previously you mentioned endocrinologists, who else is involved in the team?

Dr Garcia (12:52):

Gender affirming surgery is a broad category that includes genital gender affirming surgery, but includes other types of surgery, facial surgery, tracheal shaving, or hyoid bone surgery for transgender women, chest surgery-breast augmentation, or mastectomy for trans men, as well as genital surgery. And there are even other surgeries, colorectal surgeons need to be involved for some things et cetera. So, there are lots of gynecologic surgeries, another good example of a domain that’s integral to gender affirming surgery. So, a good program. If the question is, what does a complete program look like? Then it would be a program that has surgeons from all of these different disciplines that can offer care, not all patients avail themselves of all of these types of surgeries. Some patients don’t even want genital surgery for them. The most important thing is voice surgery or chest surgery or facial surgery.

Dr Garcia (13:59):

Others only want genital surgery. So, it’s really a mixed bag. But a good comprehensive program offers surgery as well as medical and mental health services that cover all potential needs for transgender patients. And it should be an interdisciplinary program where providers kind of work together and consult one another and so forth in the community. There are a lot of very good surgeons that only do private practice types of situations, or single specialty practices. And many patients get great care from them, but then it’s on the patient to seek care from a different surgeon for a different type of service. And ideally hope that their surgeons communicate with one another and when necessary, it’s not always necessary, but sometimes when there are complex medical issues, or surgical issues, it’s actually very much to their benefit that their care team communicate.

Dr Pelman (14:56):

You have a center with integrated care. And one of the advantages of going to a center of excellence that does this is the integration, the other is the volume and the outcomes. This is not casual surgery, so impressed by your lecture today. I remember back when I started practice some of the early surgery and the results are incredible now compared to what was done. It’s obviously a specialty that has grown, but as part of that, for somebody who is going to look towards having a successful outcome, they’re probably looking towards having somebody who’s done extensive training, and you’ve done training beyond training. And go through that a little bit.

Dr Garcia (15:42):

Sure. Well, thank you very much. I think you’re highlighting an important topic, which is centers of excellence. I think that something that a center of excellence can offer, or a high-volume center, typically an academic center, but there are some sort of quasi-academic or fully academic hospital centers like Cedar Sinai, we’re not a university, but we’re an academic medical center with residency and fellowship training. The Mayo clinic, Cleveland clinic, et cetera, whatever the definition is, centers that are large and multidisciplinary or interdisciplinary have a large diversity of providers. I think, as you say, number one, they often have high volume, and you do want providers with experience for handling, not just the quote unquote primary “surgery,” but providers that are skilled and have the experience of managing some of the very diverse and complex complications that can arise from surgery. As you say, these aren’t easy surgeries and the best surgeons in the world have a lot of complications or have big complications. And they’re hard to manage. And these tertiary care centers, or centers of excellence, are often the referral destination for such patients, perhaps possibly because sometimes some complications require care, not just from someone from one discipline, but multiple disciplines to manage the problem and help the patient through with that. So, I think those are advantages of centers of excellence and reasons for them.

Dr Pelman (17:21):

 Let’s look towards a patient perhaps who isn’t really interested in surgery but wants to have something done that would fulfill a need sort of cosmetic change or a cosmetic appearance. Would your center still be appropriate?

Dr Garcia (17:40):

Yes, the care we provide it’s for the whole person and different facets of what you could call sexual medicine. And that is not just creating new genitals, but first understanding people’s sexual function needs or their sexual health needs. And then sort of coming up with ideas and offerings for them to meet those needs. So, someone, for example, who, as you suggested, doesn’t necessarily want genital reconstructive surgery to create, let’s say a penis, but rather wants to, to present better in public by having something in their pants so that their pants don’t look so that they their bodies from the outside, through their pants, don’t look devoid of normal male genitals. People like that will in the transgender and gender non-binary community will buy devices called packers. Packers are very soft, latex, effectively. They’re copies of a penis.

Dr Garcia (18:47):

They come in different sizes, but they’re a completely realistic, soft latex penis that is made expressly for the purpose of packing it into a man or an individual’s underwear so that when they wear pants, they look quote unquote “normal” from the outside as any other man would. Talking to patients, I think that part of the benefit of a packer is certainly filling that space in their clothing. But I think the other, perhaps even bigger benefit to the patient is more in their head is knowing that at least in public, they are physically intact. Even if that means being intact with a prosthetic device that takes up space and as a filler, but at least they’re complete. They’re not in a sense “naked,” of the anatomy that they feel that they should have to be normal. If that makes sense, because truthfully, unless someone has exquisitely tight pants, you can’t really tell much of the outline of a person’s normal sized penis, which in a flaccid state, we all know it doesn’t occupy a whole lot of space.

Dr Garcia (20:07):

So, I think realistically it’s not so much the visibility of the packer, but rather the reassurance of having intact genitals and an intact kind of normal and complete body for that individual, that is of the greatest importance.

Dr Pelman (20:25):

And then a patient who has fulfilled the requirements of living the gender they choose for a year, been on appropriate gender hormones for a year, received the appropriate counseling and mental health letters now presents to your office. And you could take us through a male to female or female to male, but what expectations do you set for them as far as number of surgeries and the time. 

Dr Garcia (20:55):

Let’s take feminizing surgery. For example, if a patient, a transgender woman came to me seeking that today, we would conclude the visit with, of course during the visit we talk a lot and I get a lot of information and talk about the surgeries, the risks and benefits, but let’s assume we’ve put all that behind us. And the patient concludes by saying, “I want to proceed, when can we do this?” So, there is an inherent timeline. First of all, they need to provide those for surgery, referral letters. Very often, they don’t have them in hand. They need to be written, end dated, within the last year, within the year of the surgery date. So those have to be current. Secondly, in general, all transgender people, whether they’re undergoing feminizing or masculinizing surgery need some degree of hair removal where a few exceptions transgender women almost universally need some hair removal.

Dr Garcia (21:55):

We use the skin of the penis shaft to make the back wall of the vulva and part and it’s the shaft skin itself is used to make at least part of the vaginal canal. So, if it’s hair bearing, it’s not gonna work well, what, we don’t want to make a vaginal canal with hair growing in it, that’s not good for the patient. So almost everybody has some hair somewhere on their penis shaft. They need hair removal. Now, if patients are circumcised, if a transgender woman is circumcised and she wants a vaginal canal, her penis skin shaft is not going to be enough skin. So, we will need to harvest skin from her scrotum or elsewhere on her body to construct a skin tube, and then connect that skin tube to her existing penis skin or tube of penis skin to make a lot of skin lining for her vaginal canal.

Dr Garcia (22:56):

That’s the scrotum, and as we all know it is almost always hair bearing. So, she’ll need hair removal from that as well. So, assuming she needs hair removal of the genital area, it typically takes about a year. They’re getting laser anywhere from, from nine to twelve months for laser permanent hair removal or anywhere from four months to one to two years of electrolysis. Hair removal is a big area of interest of mine. It’s very variable depending on what modalities are used. So, it takes time, it’s not quick. When hair removal is done treatments are typically done every six weeks or so to allow the hair to grow through its hair growing cycle. Then the efficacy of each treatment, it’s not complete, obviously some hairs survive, and they have to be treated the next time and the next time and the next time.

Dr Garcia (23:52):

So all in all, we’re looking at several months at a minimum of hair removal, so she will need to get that done before I can see her for her surgery. The other thing that should be accounted for and different surgeons have their own policy about this. But I ask patients to stop their hormone therapy for a few days before I want it fully washed out of their body. Before we do the surgery specifically, estrogen can facilitate or promote a deep venous thrombosis. So, we have them hold it for five half-lives of the estrogen formulation that they’re using. If people inject estrogen, those injections are typically good for anywhere from two weeks to a month. So, they need to stop their estrogen for a longer lead time before surgery.

Dr Garcia (24:48):

If they’re taking pills, five days is usually sufficient, that’s enough half-lives to make sure that we’ve gotten it completely washed out the added risks from estrogen for deep venous thrombosis. It’s not a high risk, but it’s not a zero risk. And there doesn’t seem to be any point to me to assume unnecessary risks before surgery. So, we ask them to hold it. And if it’s for a short enough time, they can typically handle it. Okay, without having any mental or mood or anxiety related effects from it. So let’s review hair removal. So they need their surgery, referral letters in order, and pre submitted. They need hair removal almost always, and they need to stop their hormones. And then let’s remember that after surgery, they’re going to be recovering for about six to eight weeks.

Dr Garcia (25:44):

 I’d say between six and eight weeks is when they kind of fully bounce back. They can move around their home and make a meal or care for themselves, but they’re not fully back on their feet, certainly to go back to work or to do heavy lifting or some of the normal physically rigorous daily activities that some of us have to do. So I think people need to be given an opportunity to get their affairs in order, whether it’s, you know, stocking up on groceries, arranging for friends or family to take turns to pop in and help out, whatever these things may be. They need to arrange time away from work. We have to be patient with our patients and consider that they have their own complicated lives and work, and work demands and so forth. So surgery scheduling takes a little bit of sensitivity and a little bit of time, but that’s roughly the window that I would expect for someone ready today before they could actually undergo the surgery.

Dr Pelman (26:43):

And that’s just one surgery in that case.

Dr Garcia (26:46):

Yeah. So most surgeons today do vaginoplasty as a single stage surgery. I can only think of one that I know that does it in two stages. It is typically one stage. I do tell patients that there’s about a 5 to 10% chance that they’re going to need an additional small revision surgery after their surgery. It’s typically outpatient, a couple of things that can happen. Some skin might migrate anterior to obstruct their vaginal canal opening. And that’s a little lip of skin that we can easily cut and closed by a Heineken closure* and get it out of the way. It’s a short simple outpatient surgery, they can get a similar obstruction of skin obstructing the urethral opening that’s also easily dealt with, but it’s important to do those things because they drive quality of life and satisfaction, but they’re small outpatient surgeries. So patients I do remind them ahead of time to if something arises, they’ll come in, we’ll get it taken care of, and they’ll go home the same day and they may need to be off work for a couple of days.

*A surgery in which a short (2-3 inch), longitudinal incision is made through the tissue and closed transversely.

Dr Pelman (27:56):

And without doing another two-hour lecture, the results leave them with the ability to have orgasm sexual sensation. And in some cases they have successful orgasm with penetration. Sometimes it’s not necessarily with penetration and you do create a clitoris, correct?

Dr Garcia (28:15):

That’s a great question because it’s of such interest to all patients and people in general, remarkably with vaginoplasty, we can create a complete, and I’ll go as far as to say a completely sensate clitoris, and by complete, I mean, so if you use the word, if one uses the word complete, I think the higher, the standard to hold that statement is well, does it work as well after surgery as it did before surgery? And what’s interesting is that I’ve asked my patients that question for a few years and invariably people, patients will tell me not only are “my orgasms are as good as before surgery.” Half of my patients will tell me they’re not only as good as, but they’re actually better. And they’ll qualify that when I sort of asked them more follow-up questions, they’ll end up qualifying it by saying, “okay, the sensation, the quality of the orgasm itself is probably the same.”

Dr Garcia (29:09):

It feels just as good, but overall, it feels much better and more satisfying to me because I can actually enjoy an orgasm that I’m getting from my body that I love as opposed to the part of my body. That for my whole life I’ve been embarrassed by it. I don’t like the look of it. I don’t like to think about it. It’s a reminder that I don’t have the right body. So when patients get their right anatomy, they find it much more fulfilling. But the short answer is yes, that erogenous sensation from the clitoris that we make its outcomes are fantastic. So how do we do that? We elevate the neurovascular bundle from the penis, and then we fashion a small button size clitoris, similar in size and shape and dimensions to assist women’s cliteracy. We make a homolog of that using a portion of the midline anterior coronal ridge of the glans.

Dr Garcia (30:06):

That little bit of tissue from the glans is in continuity with the neurovascular bundle. And we make a little clitoris and put it at the stump of the crura of the penis, which we’ve over sewn. So effectively her anatomy is normal cis anatomy. She has a clitoral shaft and a glans’s clitoris, which is what CIS women have as well. And that clitoris works quite well. What’s interesting, is that what I have found in my own research is that if you ask women what their erogenous sensation on their clitoris is after surgery, they’ll all say I can definitely feel it. And it definitely is. It’s definitely obvious to me that it’s a pleasurable sensation, but honestly it took about three to four months before it felt pleasant versus partially unpleasant. So what they meant is that it’s hypersensitive for the first three to four months.

Dr Garcia (31:00):

So it feels good, but it’s too much and they don’t really enjoy it because of that hypersensitivity. But what I discovered is that if they stimulate just anterior to the clitoris, which is where I put in the redundant portion of the neurovascular bundle, I lay it flat at midline. So it’s basically intact with one or two little stitches to the pubic symphysis, pre-pubic area. If they stimulate their neurovascular bundle directly, they get what they describe as a fantastic normal, just as good as always, orgasm without the hypersensitivity of the clitoris, the glans clitoris itself. Isn’t that interesting. 

Dr Pelman (31:43):

Of course, the neurovascular bundle isn’t laying outright, it’s covered inside. It’s covered by the new vagina, correct?

Dr Garcia (31:50):

Correct. Specifically, the neurovascular bundle there is just covered by pre pubic skin.

Dr Pelman (31:55):

And then in the rehab portion of recovery you have a set of guidelines. So, when would you say somebody is completely sort of able to go ahead and function sexually? And normally what point would you tell them? 

Dr Garcia (32:12):

So, when our patients ready for sex, well, when are they quote unquote “done with their healing.” I initially told people two months and I’ve moved the time after surgery at which I think it’s okay to go ahead and start having receptive vaginal sex to three months after surgery. That’s actually in line with a lot of science about wound healing. Three months is much closer to when wounds are virtually completely healed. We didn’t know if healing continues even after three months, but the vast majority of it is by about three months. I’ll qualify that by saying obviously if someone’s having stenosis issues of their vaginal opening or infections or anything else, it’s not a good idea to start having receptive vaginal intercourse, but provided that they’re doing well, which the vast majority are by three by two and certainly three months, they can go ahead and have it.

*Stenosis you could consider to be a hardened narrowing which makes passing through difficult.

Dr Garcia (33:07):

The reason that I extended it to three months is because I had a couple of patients get tears in their vaginal canal with receptive intercourse, you know, at the two-month mark when they started. I think it’s a good, good point to remind people that one of the few differences between the vagina that we can make for someone as compared to a vagina that a woman is born with is that their vagina is number one, not self-lubricating, the vagina that we make for them. So, they have to use a copious amount of lubrication. Cause it’s lined by just skin, which is not naturally lubricated. And secondly, the vagina that we make for them, it’s really a thin layer of skin. If you look at, if you consider a penis skin it’s quite thin and it’s very thin and delicate, that’s effectively what they have inside.

Dr Garcia (33:59):

It doesn’t have a thick muscle layer and all of the protective anatomy that a Cis-gender vaginal canal has. So I tell patients, “you can certainly have vaginal intercourse, but number one, use a lot of lube and number two, don’t adopt sexual positions or activities where your partner can his, the penis or the toy that you’re having sex with your partner can come in to your canal at a funny angle and tear it.” It’s actually entirely analogous to what we tell men who have Peyronie’s disease or penile curvature when you’re having sex, don’t assume angles where you can, reinjure your penis by bending it. So there’s a certain universality to a lot of what we do, but those are important reminders, too. 

Dr Pelman (34:51):

Patients if we wanted them to look at the number of surgeries involved in female to male, it’s more complex.

Dr Garcia (34:58):

Yes. What we refer to those as masculinizing surgeries, you know, as I mentioned earlier in my career, I used to refer to it as female to male and male to female, just because that, from a surgeon standpoint, as we’re learning this it’s the easiest way to keep it in our heads. But, I think good terms are feminizing and masculinizing because patients, when we talk publicly they’ll say if I use that, that “the male to female or female to male,” they’ll still sort of object and say, “I’m not changing to anything. I am a male or I am a female.”  But we know what we’re talking about, but with masculinizing surgeries, you’re absolutely right. Dr. Pelman, those are more complex. And those are typically staged, multi-state surgeries. So for masculinizing surgeries men have an option of either undergoing metoidioplasty, which is where we make a small penis using the small penis that they already have. 

Dr Garcia (36:00):

By that I mean their visualized clitoral structure. What used to be their clitoris. This is a good point in the conversation to remind listeners that, you know, we as surgeons and as healthcare providers want to use terminology that is culturally sensitive and, you know, gender affirming as opposed to dysphoria inducing. So men don’t like to hear atomical terms that are very strictly female. So it’s just more pleasant to use gender affirming, anatomic terms. I refer to their visualized clitoris as their micro penis. So with metoidioplasty surgery, we can make a small, very male looking penis from their micro penis. We eliminate the labia minora from the terminus of the micro penis and release the suspensory ligament and basically refashioned the skin. So it looks more like a penis. The other option for them or masculinizing genital surgery is to, is called phalloplasty where we make a full adult size penis.

Dr Garcia (37:04):

Obviously there’s not enough extra skin down there to make something that’s significantly bigger. So we import that skin as free or pedicle flat skin flaps from either the arm or the anterior thigh or the tummy. Some surgeons will do phalloplasty as a single stage. That’s making the penis and the urethra, but remember, it’s also a lot of other surgeries. So what is phalloplasty, it’s not just making a penis in a urethra, but it’s also very often eliminating/surgically removing the vaginal canal or closing it. It is making a scrotum from there. Their existing genital anatomy. It’s not very often, not all surgeons offer this, but I do. It’s eliminating the visibility of the clitoris, the micro penis. We don’t, of course, remove it or cut it off, but we hide it from view because it’s frankly, a very feminine structure.

Dr Garcia (38:01):

And it’s a reminder of the old anatomy that they want to move away from. And it’s obviously very important. It has a very important function. So we epithelialize* it, and then bury it in the subcutaneous space at the base of that big penis, I refer to that as transposition of the clitoris, we make kind of a glans or a headlike appearance on their penis and bring the urethra, their native urethral opening, and continuity with their penis urethra, their phallus urethra. So that’s a lot of surgeries all rolled into one term called phalloplasty. I believe that outcomes are a little bit better if we do it as a two-stage surgery. Other surgeons do it in one stage and some people have good outcomes in one stage. I think in general outcomes are probably better in two stages, but we have to be honest, we need evidence-based studies to really back that up.

*Make it the surface tissue

Dr Garcia (38:59):

And we don’t have that, now in my hands, two stage surgery works best. So what I do in the first stage is I’ll make the penis and the urethra, using skin from either their arm or their thigh, and basically just make the penis and the urethra and then insert them where the penis belongs. The penis, the phalluses urethra. At that point, we’ll open up to skin located at the left base of their micro penis. The urethra doesn’t see urine at all. They pee and all anatomy for the gentlemen below the penis is whatever it was before surgery. And then typically four to six months later, I’ll go back, and I’ll do second stage surgery. And second stage surgery is the following it’s vaginectomy by then they’ve had their hysterectomy, of course, but in vaginectomy we eliminate the vaginal canal.

Dr Garcia (39:48):

It is a urethral “join up”, or a complex urethroplasty to join the native urethral opening to the penis as urethra at the base of the penis. The third thing is complex scrotoplasty. So we’ll fashion a nice scrotum from their labia majora, which is the natural homologue, in a genetic female, as the natural homologue to the scrotum, in a genetic male. I’ll eliminate the majority of the labia minora, which doesn’t really have a place on a male scrotum. You know, the homologue of the labia minora on a man is the median raphe. So it’s sort of not really there. And then the fourth thing I’ll do is I will transpose the clitoris. So move the clitoris deepithelize the entire clitoris, the glans, and the shaft, and then move also the glans of the clitoris.

Transgender penis: How does female-to-male surgery work? (medicalnewstoday.com)

Dr. Garcia (40:40):

I’ll anchor it to the base of their phallus, just under the skin on the right side. The right because that’s the side that I typically mobilized the vascular pedicle from. So everything’s on that side. And then the fifth thing is I’ll do glansplasty, make a nice head shaped appearance for the penis.  I should add that when I eliminate the clitoris skin, that skin can be kept and mobilized as a flap to help with the urethroplasty, joining their native urethral opening to their penile urethra. So everything gets used, nothing is really wasted with this nice surgery, but that second state surgery. And then typically we’ll wait four to six months after that, before doing a penile prosthesis surgery, if that’s what they’d like or testicle prosthesis, not all patients want penile prosthesis. Placement is always, always, always the last surgery, because you don’t want to do that in the setting of any infection or other wounds, other surgeries.

Dr Pelman (41:42):

And both surgeries are voiding normally, they’re able to utilize urethra in its appropriate anatomic position>

Dr Garcia (41:52):

Transgender women generally don’t have any trouble with voiding. With one exception, they can have a little bit of spraying through their urinary stream. That spraying can be accounted for by a couple of things. Number one, they may not have yet learned or taught themselves how to pee. We have to consider that up until the morning that they have the catheter removed, they’ve never peed through there, through that anatomy that they now have. So they have to learn to sit on the toilet. I tell them to put their knees together a little bit and lean forward a tiniest bit, and that seems to work. But if it’s not a positional issue, then the other reason why they may spray is that it could be post-op swelling around the urethral opening. So by six or so weeks that should resolve. And if it persists, it may be that there’s a little lip of skin that blocks the stream as it comes out of the urethral opening.

Dr Garcia (42:44):

It just takes the littlest bit of any obstruction to disrupt the stream and make it spray. They’ll usually complain of, you know, their stream kind of hitting one of their inner thighs and that’s easily fixed surgically if it’s just a little bit of skin that’s in the way. Trans men, they will pee, as I said, after their first surgery, if it’s a state surgery they’ll pee through there… I don’t want to say normal, but they’re using the same anatomy they’ve always peed through between the first and the second surgery, because we don’t really touch their urethra at the first surgery, but once they have their penis and once their phalloplasty surgeries are all complete and they’re peeing from their new penis, I would say for that population, urination is a bit more fraught. Most of them pee fine. Most report, a slightly slower stream than before because a transgender man’s bladder is a bit more similar to a genetic woman’s bladder women pee at a lower pressure than genetic males.

Dr Garcia (43:46):

So I think there’s already a lower pressure to begin with. Plus the added new urethra and all of that is sort of almost like a muffler and an exhaust system. It does provide a little bit of passive obstruction to their stream, but as long as they can empty it, it works well. Phalloplasty with urethral lengthening, the Achilles heel of that whole surgery. All of the problems with phalloplasty are really centered around the urethra. We can make a nice penis, put on a prosthetic, you know, do a million things. But, making good, good plumbing from skin is just hard. They’re subject to strictures and fistulas and this and that. Most men do well, but there is a high complication rate, and they need additional regional plastic surgery. But in most cases we can get them voiding well, but it may require additional surgery. 

Dr Pelman (44:36):

That’s why you are a urological surgeon. And I guess just to emphasize in a feminizing surgery, there’s still a prostate in place. So we still screen for prostate cancer?

Dr Garcia (44:46):

That’s a very good question. Yes. We never ever, ever remove the prostate with vaginoplasty surgery. There’s really no reason to and there’s only downsides to it. You know the risks we all know as urologist of incontinence and possibly with, you know, erectile function is not really an issue because they don’t want erectile function post-surgery, but certainly incontinence and possibly some sensory nerve damage, could result from that. The other reason we don’t do it is because the prostate and the bladder form the anterior or the tissues anterior to the vaginal canal. So if we remove the prostate, there’s just less to support the vaginal canal once it’s inside, too, and is healed into place. So, yeah, we don’t remove the prostate. What we have found is that there are mainly anecdotal reports of transgender women being diagnosed with prostate cancer.

Dr Garcia (45:40):

It definitely happens. There does not seem to be a very high incidence of prostate cancer in trans women. Perhaps not surprisingly, because they’ve had their testicles removed at some point or have been on feminizing hormones and anti-androgens for a long, long time, their prostates are typically smaller than a Cis-mans. And for people, especially nowadays where young people start cross-sex hormone therapy, even before puberty let alone early in life, or in addition to early in life, their prostates are often very, very small. So the prostate is often not even an issue in terms of BPH* or other things, but they do have prostates and they can get cancer. We don’t have enough evidence-based data to really formulate guidelines about when we should start screening and how I’m working on that. That’s a subject of my research now, but until then I take a more common-sense approach.

*Benign Prostatic Hyperplasia

Dr Garcia (46:34):

I tell women, there are certainly cases of people like you with prostate cancer. So let’s not dismiss it entirely. Let’s do screens, let’s do digital exams. We can examine a woman’s prostate through her vagina or trans-rectally if she’s not had surgery or doesn’t have a vaginal canal. And secondly, let’s do lab tests. You know, like we do for the CIS male population until we have better data. It’s a simple blood test that could be added onto your other tests. We should all note that if you check a PSA* in a transgender woman, and if she’s been on hormones for a long time, it may be undetectable simply because it’s a smaller gland and the PSA produced is below the limits of detectability. So I think the sensitivity is clearly questionable for that reason, but it’s still until we have better assets, it’s still worth checking.

*PSA stands for Prostate Specific Antigen, it’s a protein detectable in bio-sex men’s blood that is derived from the prostate and plays a role in the creation of ejaculate.  

Dr Garcia (47:27):

And until we have better data, we should just, you know, they’re committed to their health, which they are because they’re seeing me or any other surgeon. A urologist should be the one to champion that part of their health. Plastic surgeons, typically, when do they ever examine prostates or think about PSA levels? And primary care doctors? It’s not that they don’t necessarily want to, but as we know from cis men, they always sometimes defer that to someone else like a urologist. So I think we really, for this population should be the champion for prostate screening.

Dr Pelman (48:03):

We can’t give a visual record in a podcast, but the visual that we had of outcomes was so superior to what I had seen as I had mentioned earlier from surgeries 20-30 years ago. And before that, I’m not sure anything existed. And so you have come up with eloquent solutions for our patients who are in need, and it’s just been a pleasure interviewing you. Thank you.

Dr Garcia (48:29):

That’s very kind of you to say, and you know what, I appreciate that. And I agree with you. We have come a long way, and I think we should give credit to the people that trained me and all the great surgeons before us, because as you know, what I’ve learned is what I’m trying to build on. On the large amount of learning that I benefited from. But that’s what I love about our field is that we have a lot of very thoughtful reconstructive surgeons that have come up with all these answers. Certainly before me, I’m trying to add a little, contribute a little bit to it, and teach others, but thank you. 

Dr Pelman (48:58):

And it has really been the goal to improve patient care.

Dr Garcia (49:01):

Care. I agree that that’s what we’re here for, to make people’s lives better and advance our field. Thank you. 

Dr Pelman:

Thank you.

Dr Pelman :

This completes another podcast chapter of the Washington State Urology Societies: “The Original Guide to Men’s Health.” This is Dr. Richard Pelman reminding you to take care of yourself. The Washington State Urology Society wishes to thank all contributors, who volunteered their time and knowledge. The information presented is the opinion of the speakers. The Society also wishes to thank Sean Fox for his invaluable technical assistance, music theme “San Juan Bells” written and performed by Dr. Dave Whiting, the podcast is the property of the Washington State Urology Society.  Reproduction and use without the express consent of the Society is strictly prohibited. For more information about men’s health visit wsus.org or visit your physician or care provider.

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