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Brad Figler: Thank you so much. This is a topic that's really near and dear to my heart, so I'm really grateful to be able to give this talk today and really grateful to LUGPA for putting this panel together, so thanks. All right, I have no disclosures.

Transgender issues have been all over the news recently. We hear about renewed efforts by state legislatures to ban gender-affirming care in limited bathroom access and acts of violence targeting transgender people. But there's also a lot of good news for transgender folks, including advances in and improved access to healthcare. My goal today is to provide an overview of gender-affirming care and bottom surgery so that regardless of your specialty or practice type, you can take great care of these patients when you do see them.

I'll start with a primer and what it means to be transgender, including some basic terminology and epidemiology. I'll then talk a little bit about what we at UNC have done to address challenges specific to this patient population and ensure that we're providing them with high quality care. I'll then go over bottom surgery in some detail so that you have a better understanding of who's having surgery, when they're having surgery, and what's being done. There's a lot of genital anatomy in this talk, so beware.

This is some basic terminology. Cis-gender is when gender identity is congruent with birth sex. Transgender is when gender identity is not congruent with birth sex. As you can see in the figure on the bottom right, a trans-female would be someone who is assigned male at birth but identifies as female, a trans-male would be someone who is assigned female at birth but identifies as male, and then gender non-conforming individuals don't identify as strictly male or female.

Gender dysphoria refers to the distressed caused by gender identity that doesn't match the sex assigned at birth. Gender-affirming surgery and hormones are an attempt to make the body consistent with the patient's gender identity. Top surgery generally refers to breast reduction for masculinizing patients and breast augmentation for feminizing patients, and then bottom surgery refers to vaginoplasty, or the creation of a vagina, for trans-female patients, and then metoidioplasty or phalloplasty in order to create a phallus for male patients.

There a lot of transgender patients in this country, according to a 2015 survey, there are approximately 1.4 million transgender people in this country, or 0.6% of the population. These patients use the healthcare system. 50% are on hormones and 25% have had gender-affirming surgery. These numbers probably changed since 2015, but we don't have more recent data.

There are many barriers to medical care for transgender patients. They are more likely to live in poverty, which makes it much harder to access our healthcare system. When they do have insurance, the rate of denials is high. In that survey, it was 55% for gender-affirming surgery and 25% for gender-affirming hormones. Insurance coverage for transgender care has improved significantly since 2015, but continues to be a barrier. Many transgender patients have had a negative experience with a healthcare professional and avoid medical care for fear of being mistreated. And finally, there's just not enough qualified healthcare professionals. So these patients are here, they need medical care, and there are a lot of barriers to accessing medical care.

Recognizing that this is a vulnerable population with unique medical and social needs, we started the UNC Transgender Health Program in 2019. Our mission is to improve access to UNC Health for transgender patients in the region, support growth of transgender services at UNC, and to support coordination and quality of care for transgender services at UNC.

Operationally, we focus on access, coordination and education. We attempt to work with all the great people across our healthcare system who are interacting with or impacting our patients in order to improve the experience, outcomes, and efficiency. We have an incredible team and we're growing. Among other things, our team helps ensure that the first person our patients interact with when they reach out to UNC is gender-affirming and knowledgeable. Taking together, I believe the Transgender Program levels the playing field, so that despite some unique medical and social needs, our patients are able to navigate our healthcare system and get the care that they need.

I'll kind of switch gears now and talk about bottom surgery. The world Professional Association for Transgender Health, or WPATH, recommends these prerequisites for surgery. It's worth noting that patients must have been living in their preferred gender role for 12 months before undergoing bottom surgery. That's important because surgery really is the final step in for these patients, not something that happens early on in the transition. Other preoperative considerations include smoking and nicotine cessation, control of blood sugars, social support, fertility preservation if desired, and hair removal. These are figures that we give our patients so they can coordinate with their hair removal technicians.

Vulvoplasty is the creation of external female genitals, typically includes orchiectomy, creation of labia minora from the penile skin, creation of labia majora from the scrotal skin, creation of a clitoris, from the glans penis and erectile tissue, and creation of a perineal urethrostomy. Vaginoplasty is a vulvoplasty plus the creation of a vaginal canal. Our goal for these surgeries is to create natural-appearing female genitals that require minimal maintenance, allow for an unobstructed urine stream, erogenous sensation, and in the case of a vaginoplasty, receptive penetrative intercourse. I'll start with a video of a vaginoplasty just to give you some context and then I'll discuss the various steps in more detail after you've seen the video.

Video: Skin is incised sharply. Scrotal skin is removed and will later be used as a full thickness skin graft. Orchiectomy is performed with generous cord block. Dartos fascia divided in the midline. Corpus spongiosum is mobilized. Denonvilliers' fascia is incised, allowing the prostate and the rectum to be separated. Space for the vaginal canal is created with blunt dilation. The Bulbospongiosus muscle is resected.

The urethra is mobilized off the erectile bodies and divided distally. The remaining urethra is spatulated and resected. A dorsally-based W-shaped segment of the glans penis is used to form the glans clitoris. Penile skin flaps are developed. Bipolar electrocautery is used to preserve the microvasculature of the flap. Distal penile skin forms the dorsal hood. Ventral tunica albuginea is resected. Corpora cavernosa are folded and tunica albuginea is closed. The folded tunica albuginea is secured to pubic periosteum and covered by Scarpa's fascia. The distal urethra is resected.

Approximately, the urethra is secured to the clitoris and then spatulated ventrally. Corpus spongiosum is closed and secured to the clitoral hood. Excess corpus spongiosum is excised and the defect is closed. Posterior perineal flap is secured to the perineal body. Penile skin flaps are advanced to the posterior perineum. The clitoral hood is completed. Vestibular and urethra meatus are secured to adjacent skin. Skin edges are approximated. The skin graft is placed in the vaginal canal, then trimmed and secured to the introitus. Incisions are closed with absorbable suture. A foam bolster is placed in the vaginal canal and covered with cotton gauze, which is secured with absorbable suture.

Brad Figler: Okay. Post-operatively, patients are discharged on day 1 or 2. We encourage early and frequent ambulation. There's no bedrest. Bolster dressing and catheter are removed on post-operative day 6. We begin dilation 2 to 4 weeks and then follow patients closely for 1 year after surgery.

I'll switch gears again now and talk about masculinizing bottom surgery, metoidioplasty and phalloplasty. Masculinizing bottom surgery is often confusing and I think it's because there's so many options. Generally speaking, patients need to decide if they want a phalloplasty, which is a larger penis and a more invasive surgery, or metoidioplasty, which is a smaller penis and a less invasive surgery. Another big decision is whether they want urethra lengthening, which is where the urethra is extended from the native meatus to the tip of the phallus so they can stand to void. So the choice of surgery depends on the patient's goals, patient-specific factors like obesity, diabetes, or vascular disease, and their risk tolerance. Once again, before discussing too many details, I'll show you a video just to give you a general sense of what happens during masculinizing bottom surgery. This is a metoidioplasty.

Video: We begin with the U-shaped incision in the labia minora, which will become the urethra. Vaginal epithelium is cauterized and the canal is closed. The labia minora is mobilized so they can be moved anteriorly and tubularized. Labia minora are approximated dorsally, then ventrally. Adjacent tissue is closed over the urethra to prevent fistulas. Penile skin and urethra closures are completed. Labia majora are mobilized inferiorly and laterally. The perineum is closed. Labia majora rotated 180 degrees to create a pouch-like scrotum in the anterior peritoneum.

Brad Figler: Okay. I like to think of masculinizing bottom surgery as a puzzle. There are six puzzle pieces and you can assemble the puzzle pieces in any number of ways. The pieces are the penis, the glans penis, scrotum, penile urethra, pars fixa, which is the region between the native urethra and the penile urethra in the vaginectomy. I'll describe each puzzle piece in detail and then talk about different ways of putting the puzzle piece together.

There many ways of creating the penis. The most common are the radial forearm free flap, anterolateral thigh flap, or ALT in metoidioplasty, which is the video that you just watched In terms of phalloplasty, the radial forearm free flap is by far the most common approach because it's reliable and results in physiologic length and girth. For the scrotoplasty, we utilize what we call Ghent scrotoplasty after the group in Ghent, Belgium that described it. The scrotum is constructed from anteriorly-based labia majora flaps that are rotated 180 degrees to form a pouch-like scrotum in the anterior perineum. Vaginectomy is performed by excising or fulgurating the vaginal epithelium and then performing a colpocleisis.

The most common approach to glansplasty is a Norfolk technique after the surgeons at EVMS who described it. The skin and the distal penis is advanced 1 centimeter distally, the edge of the flap is sutured to the base, and then the defect is covered with a full thickness skin graft. For a radial forearm free flap, the urethra is typically created with a tube within a tube technique in which one part of the flap is rolled into a tube for the urethra, and the rest of the tube is wrapped around the first tube to form the phallus. In a metoidioplasty, the distal clitoral skin is tubular to form the penile urethra.

In a phalloplasty, the pars fixa, or bulbar urethra, is usually formed from simple tubularization of a labia minora. In a metoidioplasty, the pars fixa is formed either from a combination of a buccal graft in a labia minora flap, or from bilateral anteriorly-based labia minora flaps.

Once you have the puzzle pieces, you have a choice about how you want to put those pieces together. As a single stage staged with the phalloplasty first or staged with metoidioplasty first. At UNC, our preference is for phalloplasty first, though we do perform metoidioplasty first, particularly when the patient feels they may reach their goal after metoidioplasty and not move on to phalloplasty. Thanks again for the opportunity to speak.