Novas disputas e intervenções no corpo feminino: fronteiras entre ginecologia e cirurgia plástica / New disputes and interventions in the female body: divisions between gynecology and plastic surgery

Resumo Este artigo analisa tensões e disputas entre o campo da ginecologia e da cirurgia plástica estética, especialidades autorizadas a realizar a cirurgia estética genital feminina no Brasil. Utiliza material documental, incluindo artigos científicos desde a década de 1990, e sites institucionais. Enquanto ginecologistas têm se mantido mais cautelosos com a prática, defendendo sua realização apenas quando há indicações funcionais, cirurgiões/ãs plásticos/as têm sido mais influentes na disseminação do procedimento, privilegiando a dimensão estética. Argumenta-se que, para além de disputas entre campos profissionais, esse fenômeno precisa ser entendido à luz da crescente ênfase no aprimoramento de si, via recursos biomédicos, e dos imperativos de gênero.

Abstract This article analyzes the tensions and disputes between the fields of gynecology and esthetic plastic surgery, the specialties which are authorized to perform aesthetic female genital surgeries in Brazil. Documentary materials are used, including scientific articles from the 1990s onward and institutional websites. While gynecologists have remained more cautious, recommending the surgery only for functional reasons, plastic surgeons have been more influential in publicizing these procedures and emphasizing the aesthetic dimension. Beyond professional disputes, we debate whether this phenomenon needs to be understood in light of the growing emphasis on self-improvement via biomedical resources and gender imperatives.

Working towards convergence of the clinical management of differences of sex development/intersex conditions and the human rights framework: A case study.

OBJECTIVE: Medical treatments that aim to modify the appearance of the genitals in children who are born with a difference of sex development/intersex (DSD/I*) condition are highly controversial. Human Rights bodies worldwide have argued that such treatments are conflicting with the child's right of personal autonomy and should be legally restricted to the unique situation where the child's physical health is in danger. DESIGN: We here review the current status of legal initiatives in Europe that have addressed the issue of medical treatments in minors who have a DSD for which they have not been able to give personal informed consent due to their young age. PATIENTS: The management of a 3 years old child who has congenital adrenal hyperplasia (CAH) and grows up with atypical-looking genitals is discussed. RESULTS: In spite of extensive psychosocial support to the child and family from birth onwards, and good medical control of CAH, the child develops signs of emotional distress, suspected to be attributable to the genital difference. Our discussions include perspectives from the multidisciplinary DSD team caring for the child, a human rights specialist, and an intersex activist. From our discussions, we conclude that with evolving medical care, new ethical and human rights challenges are raised. A truly holistic human rights approach should not only consider physical but also mental health and psychosocial and psychosexual adaptation of the child to the medical condition, when reflecting on the acceptability of medical treatments in minors for which no personal informed consent can be obtained due to their young age. In addition it is paramount to include the meaningful participation of the child in the clinical management at the earliest possible stage. CONCLUSIONS: Continued convergence of clinical management and the human rights framework can be realised based on constructive discussions involving all stakeholders, and with the best interest of the child - and adult that they will become - as a common goal.

Women's Knowledge, Attitudes, and Practice About Female Genital Cosmetic Surgery: A Cross-Sectional Study in Saudi Arabia.

Introduction Vulvoplasty, or female genital cosmetic surgery (FGCS), refers to any surgical alteration of the vaginal or labial anatomy for aesthetic or medical reasons. It aims to restore or enhance the female genitals and can involve multiple procedures such as labiaplasty, clitoral unhooding, monsplasty, vaginoplasty, hymenoplasty, G-spot augmentation, frenuloplasty, perineoplasty, fat injections, or a combination of these. Labiaplasty is currently the most popular procedure among patients. Since the public is exploring FGCS benefits in the media, it can be foreseen that it will soon gain popularity among the population of Saudi Arabia. As a result, the purpose of this study is to assess women's attitudes and knowledge towards genital cosmetic surgeries in Saudi Arabia.  Methods This correlational cross-sectional survey was conducted in Saudi Arabia among women aged 18 years and above, using an online self-structured questionnaire distributed from April 2023 to October 2023. The sample size of 594 respondents was determined based on a minimum requirement of 500 participants, with a confidence level of 95% and a study power of 95%. A convenient sampling method was employed to select participants, and data collection was carried out through a self-administered online questionnaire distributed via various social media platforms. The survey was self-structured, and Cronbach's alpha values for all sections were greater than 0.7. These sections include demographic characteristics, sexual life and obstetric history, and women's knowledge, practices, and attitudes toward FGCS. Descriptive analysis, chi-square test, and t-test were used for data analysis using SPSS software.  Results A total of 589 eligible women were included in the study; 284 (48.2%) were from the central region, and ages ranged from 18 to 65 years, with a mean age of 33.5 years. A total of 401 (68.1%) were married, 366 (62.1%) had a bachelor degree. Two hundred and ninety-one (49.4%) participants heard about FGCS, 165 (28%) knew that it involves surgical procedures to change the appearance of the female genitalia, 144 (24.4%) said it is also known as vaginal rejuvenation or designer vagina surgery and 200 (34%) knew it can involve procedures such as labiaplasty, clitoral hood reduction, or vaginal tightening, while 190 (32.3%) reported it is sometimes done for aesthetic reasons but may also be done for medical reasons. Only 45 (7.6%) had undergone FGCS, but 112 (19%) confirmed they consider undergoing FGCS for themselves. Four hundred and ninety-eight (84.6%) participants thought that it's important to have access to support services, such as counseling or peer support, 471 (80%) expressed that it's important that healthcare providers in Saudi Arabia are knowledgeable about FGCS, 425 (72.2%) were concerned about the potential risks and complications of FGCS. Conclusion In conclusion, the current study revealed that nearly one out of five women were knowledgeable about FGCS, mainly about the nature and types of the procedure. Higher knowledge levels about FGCS were associated with younger age, higher educational levels, and women who were more likely to consider undergoing FGCS in the future.

Surgical Decision-Making for Individuals with Differences of Sex Development: Stakeholders' views.

Introduction: Advocacy and human rights organizations have called for a moratorium on elective surgical procedures until the patient is able to fully participate in the decision-making process. Due to the controversial nature surrounding surgery in differences of sex development (DSD) care, we aimed to assess the factors that teens and adults with DSD, parents, healthcare providers and other allied professionals consider pertinent to complex surgical decisions in DSD. Methods: Stakeholders (n=110) in DSD care participated in semi-structured interviews exploring features and potential determinants of successful healthcare outcomes. Audio-recordings were transcribed, coded, and analyzed using qualitative data software. Codes for "Process of Decision-Making" and "Successful Outcome-Surgery/Appearance/Function" were further searched using keywords "surgery," "procedure," and "timing." Results: Several themes were identified: 1) The nature or type of the decision being made; 2) Who should be involved in the decision-making process; 3) Timing of conversations about surgery; 4) Barriers to decision-making surrounding surgery; 5) The elements of surgical decision-making; and 6) The optimal approach to surgical decision-making. Many stakeholders believed children and adolescents with DSD should be involved in the process as developmentally appropriate. Conclusion: DSD include a wide range of diagnoses, some of which may require urogenital reconstruction to relieve obstruction, achieve continence, and/or address other anatomical differences whether cosmetic or functional. Adolescents and adults with DSD desired autonomy and to be part of the decision-making process. Parents were divided in their opinion of who should be involved in making elective surgical decisions: the child or parents as proxy medical decision-makers. Providers and other professionals stressed the importance of process and education around surgical decisions. Ongoing research examines how decision-makers evaluate tradeoffs associated with decision options.

No clitting! We need to talk about clitoris transplantation.

In the last two decades, genital transplants have emerged as another type of quality-of-life transplants. Successful allogenic transplantations of the uterus, ovary, testicle, and penis have all been reported. Yet, there is no discussion of clitoris transplantation in the medical literature, mass media, and everywhere else I searched. This surgery could be used for cisgender women who have a clitoral injury or disease or who have undergone female genital cutting. I examine the gender norms regarding sexuality and reproduction to show how they shape surgical advancements. My point in this paper is not to take a normative position on status of current genital transplantations. Rather, I highlight that their existence is due, at least in part, because they align with dominant gender norms: penis and testicle transplantations reinforce the importance of men's virility and the existence of "normal" male genitalia, whereas uterus and ovary transplantations uphold the conflation of women and reproduction and the strong valuing of women's fertility. That medical advances reflect cultural values is not a new claim. What is new in this paper is the discussion of how sexism norms-regarding the invisibility of the clitoris and the devaluing of women's sexual pleasure- has engendered various types of genital transplants, but not clitoris transplantation.

[Vulvoplasty after gender-affirmating genital surgery]. / Vulvoplastie chez les patientes en incongruence de genre.

Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.

Commentary on "From the War on Terror to the Moral Crusade Against Female Genital Mutilation: Anti-Muslim Racism and Femonationalism in the United States".

I am a practicing urologist with expertise in female genital cutting. In this commentary, I respond to Dr Dina Bader's article "From the War on Terror to the Moral Crusade Against Female Genital Mutilation." I outline the current climate around genital cutting, the various actors shaping female genital cutting (FGC) legislation, and public perceptions surrounding the issue. I conclude that legislative changes sweeping across the United States to ban FGC have a variety of motivations. Some are to lift politicians' profiles; some are to prevent destination FGC cutting domestically. The possibility of increased racial profiling or increased Islamophobia is perhaps underrecognized by liberals, and perhaps a discreet and intentional agenda for conservative lawmakers. The effect of this legislation also increases attention on the genital alteration of all children, male, female, and intersex, which could be the greatest benefit of all.

Neurological Considerations for "Nerve-Sparing" Cosmetic Genital Surgeries Performed on Children with XX Chromosomes Diagnosed with 21-Hydroxylase Congenital Adrenal Hyperplasia and Clitoromegaly.

Congenital adrenal hyperplasia (CAH) is most often caused by adrenal deficiency of 21-hydroxylase (21-OH). The resulting increase in androgens can cause clitoromegaly in fetuses with XX chromosomes. 21-OH CAH is the most common reason for cosmetic clitoroplasty in childhood. "Nerve-sparing" (NS) clitoral reduction surgeries are described as offering optimal cosmesis, while sparing sensation and nerve function. The methods used to demonstrate NS surgery efficacy, however, such as electromyography and optical coherence tomography, do not evaluate the small-fiber axons that comprise the majority of axons in the clitoris and that transduce sexual pleasure. Although some data show sparing of a portion of the main dorsal nerve trunk of the clitoris, the overall neurobiological consequences of elective clitoral reductions have received little attention. NS surgeries remove dorsal nerve branches that transduce sexual sensation, as well as the corpora cavernosa and cavernous nerve, which provide clitoral autonomic function. While most outcome studies focus on surgeons' perceptions of cosmetic results, studies that assess small-fiber function indicate significant nervous system and sexual impairment. Studies assessing children's clitoral function after surgery with vibrational testing have been ethically condemned. Decades of advocacy against medically unnecessary childhood genital surgeries have highlighted the subsequent physical and psychological harm. Recent studies with CAH patients indicate gender diversity and a lower prevalence of female gender identification than is often cited to justify feminizing surgery. The most effective and ethical NS technique for CAH may be acceptance of gender, sexual, and genital diversity as the infant develops into childhood, adolescence, and adulthood.

Abdominoplasty and Clitoris Evaluation: A Prospective Study on Sexual Pleasure in Women Undergoing Abdominoplasty.

INTRODUCTION: Being one of the most practiced procedures in plastic surgery, it is important to foster a better understanding of the effect of anatomical changes in the pubic area after abdominoplasty on sexuality in women. Since to date no study has been performed with this purpose, our aim is to evaluate the impact of the abdominoplasty on sexual pleasure and to perform an objective evaluation of changes in clitoral position and prepubic fat area after this procedure. MATERIALS AND METHODS: A prospective study has been performed in 50 women who expressed a desire to undergo abdominoplasty from January 2021 to December 2021. The primary endpoint was Sexual pleasure assessed by the "Sexuality Assessment Scale" before and 6 months after abdominoplasty in all patients. Furthermore, we evaluated the physical changes of the clitoris (clito-pubic distance, CP distance) and the prepubic fat area on magnetic resonance imaging before and 3 months after abdominoplasty. RESULTS: Patients mean age was of 42 ± 9 years, and mean body mass index of 26 ± 2 kg/m2. A significant difference (P < 0.0001) between sexual satisfaction before and 6 months after abdominoplasty (mean difference +7.4 ± 6.452) was found. Though there was no significant difference between the clito-pubic distance before and after abdominoplasty (mean difference -3.200 ± 2.499 mm; p= 0.0832), a significant difference was found in the size of the prepubic fat area before compared to after abdominoplasty (mean difference -1.714 ± 1.010 cm2; p = 0.0426). However, no significant relationship between these anatomical changes and sexual satisfaction was found. CONCLUSION: Our results show that abdominoplasty is associated with an increase in sexual satisfaction. The changes in the post-operative position of the clitoris were not statistically significant, contrarily to the size of the prepubic fat area, which was significantly modified and could partially explain the improved sexual pleasure. Authors were unable to statistically demonstrate a correlation between those anatomical modifications and sexual pleasure. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

DSD/intersex: historical context and current perspectives.

Intersex/Disorders/Differences of sex development conditions have been recognized for millennia. An organized approach was adopted in the 1960-70s using the philosophy that gender identity was fluid and malleable. Consequences of this approach were the lack of disclosure, stigmatization, and excessive surgery to "normalize" the genitalia. Often this led to quality of life issues for those patients. There have been many modifications in approach since then to avoid the problems noted. There is consensus on many of these changes (e.g. disclosure) but continued controversy on others (e.g. the benefits of early surgery). This review summarizes the historical context and the current areas of consensus and controversy.

Gender-affirming surgery for transgender Adolescents: Ethical and legal considerations.

In this paper, we consider the ethico-legal issues surrounding gender-affirming surgeries in minors, with a specific focus on English law. First, we outline and discuss the current clinical guidelines on genital surgery for minors with gender incongruence/dysphoria. Second, we consider the recent legal developments following R (on the application of) Quincy Bell and A v Tavistock and Portman NHS Trust and others, and we discuss how these might impact the ability of doctors to agree to surgical procedures when their patients are still minors. Finally, we explain why the removal of the adulthood threshold is justified. However, we argue that surgical interventions should remain differentiated from fully reversible interventions, and that clear guidance on eligibility criteria for genital surgery is needed from clinical guidelines, which, in consideration of the legal, professional and regulatory framework in which clinicians work, can provide needed reassurance regarding when it is in the best interests of competent young people to be considered suitable candidates for genital surgery.

Listening to Individuals with Differences in Sex Development or Intersex and Their Families: "Not Doing Surgery Does Not Mean Doing Nothing".

Informed decision-making and considerations of the child's best interest offer a starting place for building informed and lifelong discussions that promote the long-term interests and the well-being of individuals experiencing differences in sex development (DSD) or intersex traits. Parents require sufficient information and support to understand what "doing something and doing nothing" really means when learning about nonsurgical options. This may take the form of health literacy support, asking how parents are given access to meaningful and understandable information, as well as psychosocial support and psychological care. Timely psychological assessment and interventions that support informed decision-making actions are an essential aspect of holistic care for children and youth with DSD and their parents. Without actionable tools or approaches, parents cannot make informed decisions about their child's health and, as such, health literacy is a key attribute to aid decision making for both parents and children. As individuals with DSD become increasingly adept at building resourcefulness and gathering and applying knowledge about their bodies, limiting irreversible surgeries in childhood can afford wider life choices. To this end, an educated and informed comprehensive and helpful multidisciplinary group understands and embodies, as a whole team, the need for compassionate, emotionally supportive, and validating care in all interactions with parents of children and individuals with DSD. The paper draws on the primary author's experiences working with the charity, dsdfamilies, concluding with actionable approaches that include supporting personal knowledge through health literacy, examining team-based psychological care, and psychosocial approaches across the lifespan.

Microsurgical Gender Affirmation Surgery.

Phalloplasty in the female to male transgender patient is a complex operation aimed at creating a functional and aesthetic phallus, external genitalia, and perineum. Functional goals include standing micturition and sexual function with erogenous and tactile sensation as well as the ability to participate in penetrative intercourse. Functional genital reconstruction relies on creating of a fully lengthened urethra from local tissues as well as the provision for additional length via tissue transplantation. This manuscript will review techniques for the creation of perineal urethral segment as well as primary flaps available for the creation of neophallus. Particular emphasis is given to our preferred method of reconstruction: single-stage urethral lengthening with radial forearm flap phalloplasty including a review of surgical techniques and complications.

Genital Self-Image and Esthetic Genital Surgery.

Genital self-image describes the perception of one's genital appearance as being "normal" or "abnormal," and a disharmonious image leads to an increasing number of women seeking esthetic genital surgery each year. The concept of what constitutes "normal" is strongly influenced by the media, cultural norms, and sexual relations. In reality, the extent of normalcy is highly variable and overall patient education regarding extremes of size and shape should be provided to all patients considering surgery. When performed with appropriate training, expertise, and attention to detail in a properly selected patient, esthetic genital surgery is associated with minimal complications or sequelae.

Spanish Translation, Transcultural Adaptation, Validation and Clinical Applicability of Female Genital-Self Image Scale (FGSIS).

BACKGROUND: As female genital cosmetic surgeries have significantly increased, appropriate tools to evaluate self-esteem about women's own genitalia are necessary. AIM: to translate, culturally adapt to Spanish women and to evaluate the psychometric properties of the Female Genital Self-Image Scale (FGSIS). METHODS: FGSIS was forward and backward translated, culturally adapted into Spanish and its content evaluated through Delphi consensus. One item from the original scale was discarded after expert panel evaluation, developing the final Spanish scale (FGSIS-S) consisting of 6 items. Its psychometric properties were evaluated among 202 women attending gynecological consults through an online survey. The survey included socio-demographic data and FGSIS-S. MAIN OUTCOME MEASURE: Socio-demographic items, psychometric characteristics of the FGSIS-S (construct evaluation, internal consistency and test-retest reliability) were assessed. RESULTS: FGSIS-S proved to relate appropriately with the proposed construct (sum-content validity index 0.9, and significant inverse correlation with women concerned about their genital appearance or considering cosmetic surgery) with a 1-factor solution on exploratory factor analysis. The test proved good internal consistency (McDonald's omega 0.86) and test-retest reliability (intraclass correlation 0.86, P < .001). In 41.1% of cases, women referred concern about their genital's self-image and in 12.4% had considered undergoing cosmetic surgery. CLINICAL TRANSLATION: The validated version of FGSIS-S can help both professionals and patients, and its implementation can be easily made in gynecological consults. STRENGTHS AND LIMITATIONS: The main limitation is a self-selection bias in women attending gynecological consults, who may be more worried about their gynecological/sexual health. The sample is also a relatively homogeneous Caucasian population, with medium-high educational level, coming from gynecological consults. Strengths include the large sample size and the demographic survey that permitted evaluating the performance of FGSIS-S in the context of concern about genitals or consideration of cosmetic surgery. CONCLUSION: FGSIS-S is an adequate scale to measure women's genital image self-perception in Spanish-speaking population of Spain. Bartolomé A, Villalaín C, Bermejo R, et al. Spanish Translation, Transcultural Adaptation, Validation and Clinical Applicability of Female Genital-Self Image Scale (FGSIS). Sex Med 2022;10:100558.

Does Size Matter? Genital Self-Image, Genital Size, Pornography Use and Openness Toward Cosmetic Genital Surgery in 3503 Swedish Men and Women.

BACKGROUND: Dissatisfaction with the appearance and size of one's genitalia is a common issue, and the use of cosmetic genital surgery is increasing among people with normal genitalia. AIM: This cross-sectional study aimed to investigate the distribution of genital self-image in a large sample of males and females, and whether selected factors could predict genital self-image. METHODS: Three thousand five hundred three anonymous participants completed online questionnaires. Multiple linear regressions were used to identify the association between genital self-image and genital size (length of penis or protrusion of labia minora), consumption of sexually explicit material (SEM), sexual activity, avoidance and safety seeking behaviors, openness toward genital cosmetic surgery and age. OUTCOMES: Total scores on the Female and Male Genital Self Image Scale were used as the main outcome measures. RESULTS: Overall, 3.6% of females and 5.5% of males had a severely low genital self-image (defined as 2 SD below the mean) and 33.8% of all individuals reported dissatisfaction with the appearance of their genitalia, with 13.7% of females and 11.3% of males considering undergoing cosmetic genital surgery. Mean protrusion of labia minora and stretched flaccid penis length in the population was estimated to 0.76 cm (95% CI 0.63-0.89 cm) and 12.5 cm (95% CI 12.33-12.76 cm), respectively. A higher genital self-image score was predicted by having a larger penis or less protruding labia minora, but not by the degree of SEM consumption, although 93.6% of males and 57.5% of females had consumed SEM in the past three months. The degree of avoidance and safety seeking behaviors, sexual activity, and openness toward genital cosmetic surgery predicted a low genital self-image. Being older was associated with a better genital self-image in females. CLINICAL IMPLICATIONS: The results show that a psychological intervention may be needed as an alternative to cosmetic genital surgery for people who are dissatisfied with the appearance of their genitals. STRENGTHS AND LIMITATIONS: This is one of few available studies investigating the association between actual genital size and genital dissatisfaction. The vast sample size and high response rate are also strengths. Limitations include the cross-sectional design, and possible bias in the study sample due to self-selection. CONCLUSION: Overall, a low genital self-image and dissatisfaction with one's genitalia is relatively common and is influenced not only by genital size, but also behaviors performed to alleviate worry about one's genitals. Hustad IB, Malmqvist K, Ivanova E, et al. Does Size Matter? Genital Self-Image, Genital Size, Pornography Use and Openness Toward Cosmetic Genital Surgery in 3503 Swedish Men and Women. J Sex Med 2022;19:1378-1386.

A Single Center Case Series of Gender-Affirming Surgeries and the Evolution of a Specialty Anesthesia Team.

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth.

The Timing of Genital Surgery in Somatic Intersexuality: Surveys of Patients' Preferences.

In recent years, intersex advocates, medical ethicists, and lawmakers have increasingly demanded a delay of genital surgery that is not acutely medically necessary in patients with somatic intersexuality to the age of consent. This study provides a review of published surveys of affected patients' own opinions on this issue. In part with search of PubMed 2000-2021, 10 pertinent surveys of patients were identified: 3 from the USA; 4 from European countries; and one each from Brazil, China, and Malaysia. All were based on samples of clinic patients, most of whom had previously undergone genital surgery. The majority of both XX and XY patients with somatic intersexuality favored early surgery, with somewhat more syndrome-specific variability in XY patients. The available survey data clearly indicate that a mandatory delay of genital surgery in all patients with somatic intersexuality to the age of consent would disregard the wishes of the majority of surveyed patients. A syndrome- and syndrome severity-specific individualized approach to surgery decisions appears more appropriate.

Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results.

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty. Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18-61 years); the average of operative time was 3.3 h (range 2-5 h); the average duration of hormone therapy before surgery was 12 years (range 1-39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS. Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

'That decision really was mine '. Insider perspectives on health care controversies about intersex/diverse sex development.

After 20 years of debate on intersex care, there has been a slight movement away from the paradigm of 'optimal gender' including early genital modification to conform to predicted gender identity towards a paradigm of 'full consent' including the provision of full information about the risks, benefits and alternatives to interventions and the postponement of irreversible interventions on minors too young to give informed consent. However, controversy continues. Against this background, the aim of this study was to analyse core aspects of current debates in intersex care. Focus was placed on controversies about surgery on external genitalia; gonadectomies; the expressed wishes of patients under the age of consent; and how to deal with intersex within the family. Eight guideline-based interviews were conducted with two people with intersex/diverse sex development conditions who had been subjected to surgery, two parents of children with an intersex/dsd condition, two medical doctors, and two psychologists. Data were analysed thematically. Findings indicate that while 'full consent' influenced actions and debate, the persons involved held differing opinions about how this policy can or should be achieved. In addition, the data illustrated how concepts such as normalcy, identity and sexuality are relevant when dealing with intersex issues.