BACKGROUND: Transgender individuals seeking gender-affirming surgeries (GAS) are often denied or delayed by mental health professionals (MHPs). Studies on the gatekeeping of GAS have been mainly conducted in the Global North and primarily focus on the perspectives of health professionals. This case study from India incorporates health professional, community, advocate, and activist perspectives to contribute new evidence about MHP gatekeeping in GAS. The study aims to examine the role of power and gender in MHP gatekeeping of GAS in India.
METHODS: A qualitative multi-method case study including thematic analyses of key informant interviews (n = 9) and policy analysis using the policy triangle framework.
RESULTS: Health professionals and transgender persons participate in the construction, performance, and reproduction of gender indicating the persistence of gender normativity in India which enables gatekeeping by MHPs. However, evidence suggests some signs of a change from binormativity to a culturally intelligible and historically familiar \"trinormativity\".
CONCLUSIONS: To understand MHP gatekeeping, there is a need to contextualise this example of biopower within the larger social construction of gender within which MHPs operate. A transition from binormativity to \"trinormativity\" enables MHP gatekeeping of transgender persons seeking GAS. This risks creating new forms of gender-related oppression, such as new hierarchies and class differences between the gender binary and the \"third gender\".

OBJECTIVE: To explore the experiences of care surrounding hysterectomy as part of gender affirming surgery.
METHODS: An in-depth reflexive thematic analysis from accounts by 10 out of 12 people was undertaken. Experiences were then mapped to the surgery journey as a template for developing system responsiveness.
RESULTS: No one person\'s experience of the procedure was affirmed across the entire surgery journey. Transgender health literacy was central to inclusive practice as it mediated bodily autonomy being upheld. The physical care environment influenced the experience, for example, the waiting room was marginalizing (intimidating), with a gendered clinic name and toilets. Some participants took a female support person/partner so that \"people looking would assume that I was there supporting her, not the other way around.\" Communication misalignments were evident around information provided/understood about fertility and ovarian preservation. Participants were also placed in the position of both receiving care and providing education: \"I also shouldn\'t have to be going in there for treatment, and then being expected to educate the medical professional that\'s meant to be helping me… I\'m not getting paid to give you a TED talk on how my trans body works.\" The experiences mapped across the surgery journey highlighted multiple levels of service provision development needed to foster inclusive practice, for example, from workforce education to healthcare policy.
CONCLUSIONS: Healthcare for transgender people can be unsafe and inequitable. Increasing transgender health responsiveness across the surgery journey will facilitate better alignments in communication and uphold bodily autonomy, leading to safer and inclusive practice.

BACKGROUND: Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark.
OBJECTIVE: In this study we sought to quantify the need for offering vulvoplasty in Denmark.
METHODS: An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022.
RESULTS: Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it.
RESULTS: A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future.
CONCLUSIONS: Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered.
UNASSIGNED: Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated.
CONCLUSIONS: The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.
Our aim was to evaluate transgender women\'s sexual function and lubrication after vaginoplasty by penile skin inversion.
We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.
The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.
This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion\'s GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.

To identify perioperative outcomes of transgender orchiectomy (TGO) and to broadly compare outcomes of TGO to cisgender orchiectomy (CGO) for nononcologic indications.
Using the National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2020, a retrospective study was performed on patients with ICD-9/10 codes for gender dysphoria, testicular torsion, and testicular pain who underwent simple orchiectomy. Demographics and surgical outcomes were summarized. Welch two-sample t test and chi-square test were used for group analysis. A trend analysis was performed for temporal trends of these surgeries.
246 patients underwent TGO and 997 patients underwent CGO (607 testicular torsion, 390 testicular pain). Overall complication rates between TGO and CGO did not differ for testicular torsion (3.7% vs 4.4%, P = .6) or testicular pain (3.7% vs 5.9%, P = .2). No differences in patient characteristics were seen within the TGO group when comparing those who experienced complications to those who didn\'t. From 2015 to 2020, TGO cases significantly increased by, on average, 9.5 cases per year (95% CI: 6.3-12.7, P = .001), while CGO had showed no significant temporal change.
Standalone TGO can be performed safely in an outpatient setting with an acceptable complication profile in medically diverse patients.

Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.

Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information.
(1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid.
This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework.
Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables.
We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to \"pass\" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing.
The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty.
This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway.
This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.
To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.
As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants\' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.
Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.
Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.
Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.
We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.
These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail.

OBJECTIVE: Previous research on genital gender-affirming surgery lacked to build a framework that took various surrounding factors into account. E.g., transgender health care services are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). The present study investigated the effects of different structural and clinical aspects of gender-affirming genital surgery on psychosocial outcomes.
METHODS: We surveyed former transgender and gender-diverse people who completed a vaginoplasty between 2014 and 2018. 45 participants were included in the study. We calculated hierarchical linear regression analyses to assess the relationship between psychosocial outcome measures (gender congruence, mental health, quality of life) and different aspects of gender-affirming genital surgery (e.g., setting of service delivery). To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identify predictors that are actually related to the outcomes.
RESULTS: A non-responder analysis revealed no systematic bias in the recruitment procedure. Treatment satisfaction was a significant predictor for gender congruence. Moreover, we found the setting of service delivery (centralized, decentralized) to predict psychological health and the physical health dimension of quality of life. The effect sizes of our models were moderate to high, and models explained up to 26% of the total variance with a power up to 0.83.
CONCLUSIONS: The present study is an exploratory attempt into the manifold relationships between treatment-related factors (e.g., aesthetic outcome), the setting of service delivery, and their effects on gender-affirming genital surgery.

Introduction The passage of the Affordable Care Act improved access to gender-affirming care but positioned insurers as the primary gatekeepers of treatment. Insurers have developed criteria for coverage approval that result in barriers to care for some individuals. In this study, the author sought to understand the experiences of individuals seeking insurance coverage for gender-affirming top surgery. This report summarizes the role of navigators in facilitating access to coverage. Methods This study is based on semistructured, in-depth interviews with 30 transgender and gender diverse people assigned female at birth. The participants were diverse in age, race and ethnicity, geographic location, type of insurance coverage, and care setting. Thematic analysis was used to examine key influences on the coverage-seeking process. Results Participants identified navigation as a key domain. Analysis centered on 3 themes: navigators improving access to care; the contribution of lesbian, gay, bisexual, transgender, queer plus (LGBTQ+) health centers in facilitating access; and the role of informal navigators in furthering the inequitable distribution of care. Participants reported that navigators improved the likelihood of insurance coverage for gender-affirming surgeries and reduced health care inequities based on sociodemographic characteristics. Conclusion Nonstandardized criteria among insurers promote inequitable access to health care because approval relies on consumer ability to navigate complex systems and adequate economic resources to fulfill criteria. Improved access to navigators would reduce barriers to gender-affirming care.