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Hysterectomy for the Transgender Man
Introduction
The World Professional Association for Transgender Health (WPATH) considers hysterectomy with or without salpingectomy and/or oophorectomy a medically necessary gender-affirming surgery for trans men interested in the procedure. The reasons for surgery are diverse: a sense of organs feeling incongruent with one’s gender identify, to promote further masculinization, to assist with changing legal documents, avoiding gynecology visits and prevention of gynecologic problems, or for specific gynecologic issues such as pelvic pain, cramping, bleeding, tumors, cysts, or endometriosis.
The psychological benefits of gender-affirming surgery are well-documented. Cases of regret are rare. In cases of female-to-male gender-affirming surgery, sexual function appears to improve. Over half of all transgender men surveyed desire hysterectomy in the future, with approximately 21% having had the procedure already.
Mistrust and mistreatment between the transgender community and the health-care system are well-established. Approximately half of transgender persons can recall having to educate their providers regarding care, with 19% surveyed being refused care altogether. Given the experience of discrimination and the lack of appropriate providers, many have avoided the health-care system. By understanding the experiences of transgender patients in the health-care system, providers can better understand their reasons for requesting gender-affirming surgery. In this chapter, we will review various perioperative considerations for surgeons performing hysterectomy in the transgender man ( Table 14.1 ).
Table 14.1
Perioperative Considerations for Hysterectomy in the Transgender Man
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ASA , American Society of this Anesthesiologists.
Preoperative Considerations
As with cisgender patients, preoperative counseling is critical in the transitioning patient. A thorough preoperative assessment should include a discussion about the mode and extent of surgery, coordination with other health-care providers, review of postoperative care and expectations, and assessment of the patient’s support system.
World professional association for transgender health criteria
Several criteria for genital surgery exist, but most surgeons follow those put forth by the WPATH. Patients are candidates for surgery if they meet the following criteria: well-documented gender dysphoria, capacity to give informed consent, age of majority in the patient’s country, well-controlled medical and/or mental health concerns, and 12 months of hormonal therapy when able ( Table 14.2 ). They also recommend preoperative evaluation and letters of support for the surgery by two separate mental health professionals trained in transgender care. This so-called requirement has been contended by some as of late, as many see a second letter as unnecessary and overly burdensome for patients. This recommendation may change in the future. WPATH also recommends starting hormonal therapy prior to genital surgery to “introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes an irreversible surgical intervention.” They also affirm that living in their self-identified gender role will allow the transgender man to experience a number of various life events and establish a support system. Surgeons may find themselves using these guidelines a as a framework only and adapting them based on their working relationship with the patient, as well as the extent of the surgery being considered.
Table 14.2
World Professional Association for Transgender Health Criteria for Undergoing Genital Surgery in the Transgender Patient
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