“Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?”

Abstract

BACKGROUND The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES Sexual orientation, gender, and age were independent predictors of interest in interventions. Results There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations.

Patient education and surgical decision-making in genital gender-affirming surgery

“…It is paramount to recognize that TGNB patients overwhelmingly desire an active role in the decision-making process [19 ▪ ]. Other recent work has explored decision-making moderators such as sociodemographic characteristics (gender identity, sexual orientation, age, and sexual behavior), short term outcomes, long-term outcomes, and postoperative maintenance [21,22]. Importantly, patient personal goals and expectations are in tension with economic and clinical considerations of surgery [23 ▪ ].…”

“…However, understanding the sociocultural background of patients remains critical. A survey of 965 TGNB patients on various penile reconstruction techniques demonstrated that gender identity, sexual orientation, and age all independently influence patient preferences [21]. These results suggest that conversations about sexual orientation, gender identity, and sexual behavior may be crucial in understanding patient's goals and expectations [21].…”

“…A survey of 965 TGNB patients on various penile reconstruction techniques demonstrated that gender identity, sexual orientation, and age all independently influence patient preferences [21]. These results suggest that conversations about sexual orientation, gender identity, and sexual behavior may be crucial in understanding patient's goals and expectations [21]. A recent study surveyed 29 TGNB individuals who had undergone shallow-depth vaginoplasty (SDV), as opposed to full-depth vaginoplasty by penile inversion [22].…”

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights

“…Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including the ability to stand to void, and for some, to have erectile function sufficient for penetrative sexual intercourse. Phalloplasty technique, individual anatomic variation, and patient preferences will determine surgical options for erectile function, however, most will require a penile implant adapted for neophallic anatomy ( 1 , 2 ).…”