Chapter 9: Surgical Gender Affirmation

INTRODUCTION

Surgical interventions to affirm cultural and gendered roles in society, such as testicle removal, predate the Western conception of the gender binary and contemporary medical models of gender identity. The first gender-affirming surgical program in Western medical practice is considered to have been Magnus Hirschfield’s Institute for Sexual Science, commencing gender-affirming procedures in 1922.¹ Early conceptions of the goal of gender-affirming surgery were to “correct” the external form to a discrete female or male appearance. Surgical intervention was treated as a required aspect of gender affirmation in many contexts, a legacy that continues today as jurisdictions require sterilization or other surgery for name or gender marker changes on official government-issued documentation. Simultaneously, surgery was withheld from the majority of treatment-seeking patients who were deemed poor surgical candidates for reasons that would now be considered inappropriate, such as not being heterosexual in their identified gender. Assessment for gender-affirming surgery has been explored in transgender studies, a field of inquiry whose foundational texts describe the social and medicolegal impact of power relations between medical professionals and transgender and gender diverse (TGD) patients seeking surgery.²

As the etiology of gender dysphoria has evolved, we now understand that a process of medical gender affirmation is personalized to the individuals’ needs rather than approximating a singular ideal of “female” or “male” bodies. In turn, this evolving clinical understanding has impacted the clinical framework of gender-affirming surgery, in which the goal is to alleviate the specific source of incongruence for the individual patient rather than correct the body to a cisnormative form.³ In addition to genital surgical procedures, gender-affirming surgery is now available for primary and secondary sex characteristics throughout the body. Meanwhile, expanding funding through health coverage mechanisms has increased access to gender-affirming surgery for populations who seek it.⁴ A diverse set of surgical interventions is becoming more widely available to an increasingly heterogeneous group of patients. Supporting TGD patients before and throughout the lifespan after surgery in this evolving landscape is an interdisciplinary practice we explore in this chapter.

TIMING AND CHOICE OF SURGERY

Although overall improvement in the quality of life has been demonstrated in TGD patients undergoing surgery, there is no inherent need to include surgical interventions as an aspect of gender affirmation.⁵ In the absence of measures that would plausibly identify specific characteristics of patients who derive greater benefit from surgery, patient request is the ultimate surgical indication.⁶ Gatekeeping is a term used in TGD care to describe an overly stringent approval process that withholds interventions from patients who do not conform to sanctioned care access pathways or personal gender narratives. The Standards of Care (SOC) put forth by the World Professional Association for Transgender Health (WPATH) state that certain once-commonplace approval processes, such as requiring a minimal time in psychotherapy before receiving biomedical treatment, could inhibit meaningful engagement in care and be counterproductive.^7...