Traditional gender-affirming surgeries, like phalloplasty and penile inversion vaginoplasty, are designed to create genitalia that match a person’s identified gender, often as male or female. However, some people, such as those who identify as nonbinary, bigender, or agender, may want a unique approach that doesn’t follow this traditional binary model.

These patients might want to keep some parts of their original genitalia or pursue entirely different surgeries, like removing all external genitalia and creating a new type of urethral opening. These options, known as individually customized gender-affirming surgeries, can help people achieve a better match between their bodies and their identities, easing gender dysphoria and improving mental and physical well-being. As the demand for these procedures grows, it’s important for healthcare professionals to understand and support these unique needs.

Therefore, the authors of a new publication in the Journal of Sexual Medicine set out to describe surgical techniques for less commonly performed gender-affirming genital procedures, in order to present them to the larger medical community.

According to the authors, patients seeking customized gender-affirming genital surgeries may come with a clear idea of what they want, or they may need information on what is surgically possible. Before surgery, the authors recommend that a comprehensive team, including a primary care provider, endocrinologist, and mental health professionals, work together to ensure the patient is physically and mentally prepared.

The following three customized gender-affirming genital surgeries were described in this publication:

1. Phallus-Preserving Vaginoplasty (PPV):
   This surgery creates a vaginal canal while keeping the patient’s native penis intact. It’s mainly chosen by those who want a vagina but do not feel uncomfortable with their penis. The goal is to allow for receptive intercourse and maintain some erectile function if desired.
2. Vagina-Preserving Phalloplasty (VPP):
   This procedure creates a neophallus (new penis) without removing the native vagina. It is suitable for those who wish to have a penis but also want to keep their vagina for sexual purposes. Options include making the penis capable of penetration and/or urination while standing.
3. Removal of Genitalia with Perineal Urethrostomy:
   This surgery involves removing most or all external genitalia (e.g., penis, testicles, or vagina) and creating a new urinary opening in the perineum (area between the legs). It may be an option for individuals who do not wish to have traditional genital structures and desire a smoother appearance.

During each consultation, the patients discussed their goals, including which genital features to keep, create, or remove, and their desired appearance and sexual function. They were also informed about risks and the permanent nature of the procedure. After surgery, follow-up was closely monitored with in-person and virtual appointments to provide continuous support for optimal recovery and well-being for the patients.

In conclusion, this publication aimed to raise awareness about individualized genital gender-affirming surgeries and educate people on potential complications and postoperative care. There is currently no standard assessment for these procedures, so collaboration between healthcare providers and patients is crucial. Patient satisfaction with these surgeries is thought to be high, but further research is needed for a clearer picture. Ultimately, the goal of these authors was to help align surgical techniques with each patient’s unique needs to reduce gender dysphoria and support their identity and embodiment goals.

References:

• Ascha, M., Rigsby, S., Shoham, M., Akhavan, A. A., Swanson, M., Streed, C. G., Gurjala, A., Morrison, S. D., Pang, J. H., & Satterwhite, T. (2024). Individually customized gender affirming genital procedures: Techniques and considerations. The Journal of Sexual Medicine, 21(9), 827–834. https://doi.org/10.1093/jsxmed/qdae075