© Springer-Verlag Italia 2015
Carlo Trombetta, Giovanni Liguori and Michele Bertolotto (eds.)Management of Gender Dysphoria10.1007/978-88-470-5696-1_2323. Quality of Life After Sexual Reassignment Surgery
(1)
Clinica Urologica, Università di Torino – Citta della Salute e della Scienza, C.so Bramante, Turin, 10126, Italy
Keywords
TranssessualismGender disphoriaQuality of lifeSex reassignment surgery23.1 Introduction
Quality of life (QoL) is a multidisciplinary and transversal topic that includes a variety of aspects related to medical, social, political, and economic sciences. It is a broad concept that concerns the well-being of a person or a community, comprehending physical and mental health, occupational satisfaction, social integration and economic welfare.
Sex reassignment surgery (SRS) in patients with gender dysphoria affects not only physical modifications in the aesthetics and function of the genitalia, but also allows many changes in lifestyle and sexual behaviour and, last but not least, allows a complete transition to another social, familiar and sexual role. Therefore, taking into account QoL means treating not only the surgical issues, but also the psychological and social aspects. Many factors can be considered to be determinants of QoL after SRS. We can distinguish between physical/biological factors, directly depending on the surgical procedure and its functional outcomes, and social/relational factors.
23.1.1 Physical Determinants of Quality of Life
The first factor influencing QoL is satisfaction with the outcomes of treatment, which is intended to be a meeting of expectations. Objective results have no absolute value, but have to be considered in relation to the patient’s expectations, and it is important to consider not only the results of the surgical procedure, but also the effects of hormonal treatment, which is the main factor influencing the general aspect of the subject [7, 14, 17]. Therefore, before surgery it is mandatory for the whole inter-disciplinary medical team to give the patient exhaustive and clear information about results that are reasonably achievable from both an aesthetic and a functional point of view.
In the immediate postoperative period QoL mainly depends on the presence of complications and aesthetic imperfections; even if severe complications are quite rare, many subjects present with mild imperfections that require minor interventions, in a few cases repeated, performed on an outpatient basis. In some cases, other surgical procedures, in both the genital and extragenital areas, are scheduled ab initio after SRS. All these procedures, despite their minimal invasiveness, can increase the “medicalisation” of the subject and delay the resumption of a normal and satisfying life.
SRS procedures have a major component of reconstructive surgery. As after other reconstructive procedures, SRS requires care and maintenance in the postoperative period, but also in the long term, that in some cases can be negatively perceived by the subject, thus affecting QoL. In the long term, the acquisition of good genital function, allowing intercourse to the satisfaction of the subject and their partner, is the major determinant of QoL among factors related to the biological outcomes of surgery.
23.1.2 Social and Relational Determinants of Quality of Life
Among the determinants of quality of life after SRS, a key role is played by social and labour integration. The level of integration depends mainly on the subjective disposition of the patient, but also undoubtedly on society. Still, nowadays, despite there being less prejudice in most countries, full integration and total acceptance by society do not occur in all cases. In subjects with more pronounced social rejection marginalisation, loss of self-esteem and depression can occur and, in some extreme situations, cases of suicide have been reported. Equally important is the construction of a stable sexual relationship or family nucleus.
The acquisition of genital and body appearance consistent with the psychological sex is not always an adequate condition to establish a stable relationship (heterosexual or homosexual based on the sexual orientation of the subject). The physical changes of the genitalia provided by SRS can induce psychological reactions in the subject or in the partner that in some cases can lead to the termination of a relationship already present before surgery or make it difficult to start a new relationship. These situations, described in the literature, are mostly transient and tend to normalise, but they can have a negative impact on quality of life.
In general, we can say that complete immersion in the new gender role, good social and labour integration and a satisfactory sexual life are essential determinants of overall self-satisfaction with the new body image and thus of a high quality of life. Normally, good identification of the new phenotype that is completely appropriate to the psychological sex requires a good psychological balance and the completion of a structured course in tandem with specific multidisciplinary experience in the field. The dissertation on the determinants of quality of life, especially biological determinants, needs a separate approach for male to female and female to male transsexuals.
23.2 Quality of Life After Male to Female Sexual Reassignment Surgery
23.2.1 Physical Determinants of Quality of Life After Male to Female SRS
Sex reassignment surgery in male to female (MtoF) transsexuals is extremely important for people who undergo it, and also for the expectations and satisfaction they have with regard to surgical intervention [45]. The transsexual patient, during his path toward intervention, creates in his imagination a “virtual vagina”, a sort of “how I wish it were”, that is often far from the reality of what can reasonably be achieved; generally, she refers to the surgeon before surgery an idea and a desire for perfection in the symmetry of the anatomy, an obsession regarding the depth of the neovagina and the need to have sensitivity so as to experience orgasm that can also clash with reality. Therefore, it is crucial to carry out a preoperative interview with these people in order to clarify the possibilities and limitations of genital reconstructive surgery in order to formulate some credible expectations. In the chapters below are discussed the aspects that should be pointed out during preoperative interview, with a particular regard to the real possibilities of surgery, to prevent those misunderstandings that are often at the basis of postoperative unsatisfaction and poor quality of Life.
23.2.2 The Aesthetic Appearance of the Neovulva
From an anatomical point of view, the vulva of female 46, XX is characteristically pear-shaped and begins with a raised area, called the mound of Venus, in the upper part of the pubic symphysis and it extends downwards along the ischio-pubic branches, ending about 1 cm from the anus. The mound of Venus, formed by a thick pad of skin and adipose tissue, continues downward with two skin folds that are generally equal and symmetrical, called the labia majora. The mound of Venus and the labia majora have a well-developed covering of hair. Below, there are two other skin folds, equal but not always symmetrical, that are free of follicles, thinner than labia majora, and called the labia minora; these converge and are joined at the top by a small tubercle formation representing the female erectile organs, known as the clitoris. After sexual development, the labia minora can be contained by the labia majora, but more frequently they protrude. This anatomical premise of the female anatomy emphasises that in principle, surgery aims to satisfy all the morphological aspects of a “true” vulva, making the mound of Venus using the dorsal part of the tunica albuginea of the penis, the labia majora using scrotal skin, the labia minora using the foreskin and a portion of the glans, and the neoclitoris, reconfiguring the glans, whose vascularisation and innervation (the dorsal neurovascular bundle) are preserved to ensure that sensitivity is maintained [16, 18]. However, it is not always so simple to reconstitute the perfect anatomy, there may be limits for anatomical reasons. For example, in people who are overweight or even obese, the mound is not so prominent; in the presence of a small amount of scrotal skin or underweight people, the labia may be poorly represented. It is very important to talk about the hair distribution of the vulva. Often, MtoF transsexuals use permanent hair removal to prevent growth of hair in the neovagina. It is important to emphasise pre-operatively that hair removal should affect only the penile and scrotal areas, obviously avoiding the pubic area, as the regrowth of hair there helps to hide any scars that are created [35].
23.2.3 Maintaining a Sensitive Neo-clitoris
An important goal of surgical intervention is to make a neoclitoris with sensitivity. The neoclitoris can be reconfigured from the glans, which is disassembled from the tip of the corpora cavernosa of the penis, taking care to save its vascular supply and nerve connections, which run in the dorsal penile neurovascular bundle. This specification, namely the extreme respect of the neurovascular bundle, is mandatory in order to ensure and maintain the sensitivity of the neoclitoris [36, 39]. It is important to point out to people who are undergoing surgery that the neoclitoris may be subject to change in size during the first few months postoperatively; this is to prevent them from requiring to a reduction of a neoclitoris that is considered hypertrophied too soon. It is sometimes possible that the surgical trauma leads to the formation of small, but very hard eschars of neoclitoris. Patients are often scared by this temporary outcome, and this may lead to an anxious status with worsening of QoL if the surgical team has not informed the patient that it is generally a partial necrosis of the mucosa of the neoclitoris (as can happen to the glans after plaque surgery with a prosthetic penis implant for induratio penis plastica [IPP] in men) that resolve spontaneously within a few weeks. Both the patient and the surgical team have to keep calm and avoid any therapeutically aggressive behaviours.
23.2.4 Micturiction in Sitting Position
A typical aspect that differentiates a man from a woman is the possibility of voiding in standing position. It is important for the QoL of MtoF patients to be able to achieve micturition in a sitting position; from a surgical point of view this goal can be achieved by placing the urethral neomeatus in the orthotopic position. Most of the penile urethra is sacrificed, but a portion of about 4 cm in length is spared, spatulated and fixed to the pelvic floor so as to contribute to the effect of the mucous neovulva and to prevent the stenosis of the urethral neomeatus, which constitutes one of the most frequent complications of this surgery. A forwarded neomeatus can cause a horizontal stream and lead to considerable discomfort postoperatively.
23.2.5 Capacity of the Neovagina
One of the major concerns of MtoF transsexuals is having the deepest vagina possible. A psychosocial consideration: the obsession with size is a typically male concern. Perhaps, this is a “genetic” reminder that remains in genetically XY neo-women? That said, there are anatomical and anthropometric limits that affect the neovaginal depth. The neovagina is obtained by opening a hole in the prostato rectal space, after cutting the central tendon of the perineum, and then developing a plane to the front of the rectum that stops at the peritoneal reflection, above the prostate and seminal vesicles. This part of the surgery, often very challenging owing to tissue adhesions and the small size of the prostate because of oestrogen administration and androgen-suppressive therapy is not the only conditioning element: in fact, the cavity created needs to be covered with penoscrotal skin. Thus, when we are facing penoscrotal hypoplasia, with a scarce amount of usable skin, there is a risk of obtaining a cutaneous channel shorter than surgical dissection would allow; this defect can be overcome by creating a skin graft, recovering scrotal skin not used to make up labia majora. The final outcome of the intervention is important for adequate neovaginal depth to ensure satisfactory intercourse, but not all; in fact, there are some aspects of peri- and postoperative management of the neovagina by the neowomen that are critical to the long-term maintenance of surgical results. At the end of the intervention, a cylindrical silicone expander is positioned in the neovaginal cavity, to drain any secretions through a central channel, but especially to maintain the skin lining of the neovaginal wall and contribute to haemostasis [38]. This expander is kept in place for the first 5 postoperative days and is then removed. At this point, it is crucial that the person becomes autonomous in the management and placement of the expander, as for the first month after surgery the subject has to keep it in place during the night and occasionally, but regularly, during the day. Then, the patients has to carry out self-dilation twice a day with four cylinders of plastic material, that are rigid, increasing in calibre and length, with a generally flat tip, so as to add tension to even the most distal part of the neovagina.
The “maintenance” of the neovagina is an important task given to the patient, and this can be perceived as a limitation of the QoL in the first few weeks after surgery, but the patient should learn that her neovagina requires continuous care that has to be seen as a sort of personal hygiene protocol rather than as a long medicalisation period.
23.2.6 Complications and Imperfections
For many aspects related to QoL, SRS is the main goal for those who have undergone it. On the other hand, it is also a starting point, as the new condition can be a source of small or large problems to avoid with appropriate behaviours, to retouch or to repair. In fact, in a variable but still considerable percentage of cases (58 % in our series), the intervention of conversion is not unique and definitive, but is followed by other procedures that are more or less complex, performed for a wide range of imperfections, and the more frequent of them are listed below.
Asymmetry of the labia majora: this is the most evident problem for neowomen, although it is not very frequent. Before any retouching, which can be performed in a one-day surgery setting, at least 6 months must have passed since SRS, so that tissues and scars are suitably stabilised.
Hypertrophy of the neoclitoris: sometimes, the neoclitoris is too large and too protruding from the floor of the labia minora. In this condition, the continuous tactile stimulation due to the contact with underwear can be annoying. Therefore, a small revision needs to be carried out under local anaesthesia to reduce its size or to provide further cover with the creation of a so-called clitoral hood.
Stenosis of the urethral neomeatus: this is the most frequent functional complication. A technical device that we have adopted and which permitted a significant reduction in its incidence was a large urethral spatulation (which is used as a plate of the vulvar neovestibulus), associated with the fixation of the free half of the neomeatus to the skin with everting sutures. Any use of small urethral dilators postoperatively allows this risk to be minimised. If it is necessary to correct a stenosis, meatoplasty with a vertical incision at 6 o’clock complete with everting sutures to the skin provides a perfect resolution.
Micturition complications: it may happen infrequently that the urethral neomeatus is too high or too far forwards, so that it affects the urinary stream in a horizontal direction. The practical consequences are obvious. The retraction of the urethral neomeatus is a simple and rapid procedure that is performed with a vertical incision of the further neomeatus and spatulation of the urethra down to the orthotopic position. Stress incontinence due to sphincteric lesions is extremely rare.
Introital stenosis: the stenosis of neovaginal introitus is a bad functional complication that does not allow patients to have satisfactory coital sexual activity. It is mostly due to a lack of compliance with the neovaginal expansion programme, which is not performed with the right frequency or for the period of time required daily; sometimes, they can be the result of hypertrophic scar healing, which affects the appearance of retracting keloids. The management of this complication is essentially surgical, sectioning the scar tissue and retracting the introitus (usually, two lateral incisions are sufficient); sometimes the correcting procedure requires the interposition of autologous tissue (skin in an island flap) or heterologous grafts (small intestine porcine obmucosa) to provide a better enlargement of the introitus. Essential to keep the introitus open during the healing process is the use of a vaginal expander for approximately 5 days postoperative before returning to the regular expansion programme.
Stenosis of the neovagina: this represents the most feared complication for both the surgeon and transsexual people. For this reason, it is absolutely imperative before surgery to emphasise the importance of postoperative dilatation, which represents, in fact, the only way of preventing this dramatic complication, provided that the intervention has given adequate depth. In our series, this complication is present in 3 of the patients on whom we operated, which had not complied with the requirements given to them on vaginal dilatation. Over the last few years, growing experience has been taken up by several centres on the use of MRI to diagnose, objectivate and evaluate the severity of neovaginal stenosis [4, 8, 38]. The importance of the recommendations on the expansion can be better understood in the light of what needs to be done to repair the stenosis; a new vaginoplasty means undergoing a major operation via a combined vaginal–abdominal pathway, to reconfigure the vaginal canal with an ileal loop or colon.
23.2.7 Postoperative Rehabilitation and Sexual Activity
The ability to have satisfactory sexual intercourses is definitely one of the major factors conditioning the QoL. To achieve this goal, the proper management of the neovagina in the peri- and postoperative period is essential, and the surgeon must be very clear and incisive in making the neowoman understood in the need to be regular and consistent with the expansions that are performed even every day for the first few months after surgery. These expansions can be replaced by sexual activity: approval at the start of sexual activity is generally given 2 months after surgery. From this point of view, in our series, regular sexual activity is reported by 52 % of our transsexuals; more than half of these have reported reaching orgasm.
We have recently reported that MtoF transsexuals, who underwent SRS as well as genital surgical feminisation, tend to assume female cerebral features. In our opinion this study underlines the beneficial effects of SRS to the patients, who react to the genital surgery conversion with a cerebral femininisation. These two effects tend to solve the typical conflict of this disorder: the discrepancy between cerebral and physical features leading to an effective improvement of their QoL [33].
23.2.8 Social and Relational Determinants of Quality of Life After Male to Female SRS
23.2.8.1 Social and Labour Integration After SRS
Gender dysphoria patients may encounter many social and relational problems in their lives; these problems do not necessarily disappear after SRS. The most difficult obstacle to overcome, from the beginning of the Real Life Test, is the social re-integration of transsexual patients. During this phase, in fact, the individual must adapt his life, social and professional aspects, according to the definitive transitional genre. The ambiguity that characterises these patients, their physical appearance and the way they relate to the world around them induce reactions of unease, discrimination and exclusion in society. In fact, in the general population a need to protect the status quo and the psychological and social balance is often present, that can support discriminatory attitudes towards those who disturb the norm. Discrimination and exclusion influence the overall QoL of transsexual patients and specifically all areas of everyday life, such as work, study, relational life and housing research. From a social point of view, data from the available literature argue that SRS gives rise to a significant general improvement in the QoL of transsexual patients compared with their condition before surgery (approximately 70–90 % of patients are socially satisfied) [29, 32]. After SRS, data also show a marked improvement in self-destructive and antisocial behaviours frequently found in patients who have not undergone surgery [32]. However, comparing the patient’s QoL after SRS with that of the general population, it is evident that the QoL of the former is still lower [10, 25, 29]. In particular, from the available literature data it is evident how MtoF patients have a more difficult and troubled process of socio-professional reintegration. These obstacles in part derive from a difficulty in establishing interpersonal relationships and perhaps from a minor ability to adapt themselves to the society; these difficulties are compounded by the fact that these people often feel singled out and observed for their outward appearance [29]. In the field of labour integration, discrimination and social rejection towards transsexuals (sometimes due to feelings of fear) often interfere with the objective evaluation of their real abilities and skills, shifting more attention to their “different” condition. This can make it difficult to search for employment, leading to non-assumption/unemployment phenomena, and for those who do have a job, to mobbing, unequal treatment through to dismissal. The available literature data are conflicting regarding the effects of SRS on the scope of employment. Some studies support the notion that after surgery there is no significant improvement in the employment situation and consequently with job satisfaction. Others, however, reported an improvement (30–60 % of cases), in terms of patient satisfaction, with regard to this area [22, 29, 32]. In some series, up to 90 % of patients in stable employment reported that they have not been the victim of any prejudice, but, on the contrary, they have been understood and supported by colleagues both before and after surgery [22]. On the other hand, there are published data that represent more difficulties integrating into the workplace: up to 20 % of patients reported that they were forced to change jobs because of personal embarrassment from colleagues or because of discrimination and isolation phenomena. These dynamics seem to be more frequent among MtoF patients [32].
Related posts:
Psychological Characteristics and Sexuality of Natal Males with Gender Dysphoria
Epidemiologic Considerations on Transsexualism
The Hot Questions of Prepubertal Gender Dysphoria in Girls
Surgical Therapy: Possible One-Step Solutions
Total Phallic Reconstruction in Female-to-Male Transsexuals by the Pedicle Anterolateral (ALT) Flap
Imaging
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