By C. Emi Bretschneider, MD, and Cecile Ferrando, MD, MPH
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Gender affirming surgery, such as hysterectomy, may complement hormone therapy in order to reduce gender dysphoria and improve quality of life for transgender men (persons born female who identify as men). Prior research in this field has focused on more on feasibility than on outcomes. In this study, we presented surgery rates and outcomes data for the largest sample size of transgender men undergoing hysterectomy yet to be established in the literature.
Although there are studies that discuss the psychosocial and sexual effects of these gender-affirming surgeries, there were no large, multi-institutional studies that examined perioperative outcomes of hysterectomy in transgender men. Evaluating surgical outcomes is important because many of these patients do not have a gynecologic disease that would traditionally indicate hysterectomy.
Hysterectomy in Transgender Men
In the United States, the incidence of transgenderism is approximately 0.4%. As a result of this incongruence between birth sex and self-identified gender, many of these patients experience gender dysphoria. Medical management is sometimes successful in treating gender dysphoria, and gender affirmation surgery is also an option. In transgender men, common surgical options include chest reconstruction, hysterectomy and bilateral salpingo-oophorectomy.
During the three-year study period (2013-2016), 159,736 hysterectomies were reported in the American College of Surgeons’ National Surgical Quality Improvement database. Only a very small percentage (0.3%) of these hysterectomies were performed for transgender males.
Data analysis indicates that gender identity disorder is the most common diagnosis related to hysterectomy in transgender men. More than half of the procedures were laparoscopic. The remaining procedures were laparoscopic-assisted vaginal hysterectomy and abdominal hysterectomy.
The incidence of complications was low at 3.1%, which is similar to the incidence of complications experienced by cis-gender women (a person who identifies as female and whose sex at birth was female) undergoing hysterectomy. After controlling for potential confounding variables, transgender male status was not significantly associated with postoperative complications.
The rate of complications following hysterectomy was similar between transgender men and cis-gender women even in light of the fact that the transgender male population is significantly younger and has fewer major medical comorbidities than the cis-gender female population.
Not surprisingly, we found that minimally invasive approaches were associated with a lower incidence of postoperative complications. This suggests that surgeons should plan a minimally invasive approach to performing surgery when performing hysterectomy when feasible, regardless of a patient’s gender identity.
Future studies might examine the effect of preoperative testosterone use in this population. We were unable to determine which patients had preoperatively used testosterone, and we recognize the important effect that exogenous hormones can have on perioperative outcomes, such as delayed tissue healing and potential cardiovascular or hematologic events.
Comprehensive Transgender Care
Comprehensive care for transgender patients involves a wide spectrum of services, ranging from routine medical visits to the physical transition process. Few hospitals are equipped to provide such care. Even fewer hospitals offer surgical care for patients wishing to undergo gender affirmation surgery. Over the last several years, we have been actively expanding the services Cleveland Clinic offers to gender and sex-minority patients.
At Cleveland Clinic, we offer routine medical care, tailored specifically to patients’ needs, as well as transition-specific services, including psychiatric assessment and therapy, hormone therapy and surveillance at one of two sites in Greater Cleveland. We also offer gender-affirming procedures, including gender affirmation surgery.
Our team follows the World Professional Association for Transgender Health guidelines to ensure patients are appropriate surgical candidates. We require that patients live full time as their self-affirmed gender for more than one year, that they have undergone cross-sex hormone therapy for at least one year, and that they have letters of support for surgical transition from two mental health professionals who are well-versed in transgender patient care. Patients who have met these criteria are deemed appropriate surgical candidates. They cannot be smokers or be excessively overweight, and they must be medically optimized for surgery if they have medical comorbidities.
Our volume of patients from Greater Cleveland increases each month, and with this growth, we continue to expand our caregiver team to be able to accommodate our patients’ needs.