1, 3, 6 Department of Gynaecology, University Hospital of Ghent, Ghent, Belgium
2, 7 Department of Urology, University Hospital of Ghent, Ghent, Belgium
4 Department of Plastic Surgery, University Hospital of Ghent, Ghent, Belgium
5 Department of Endocrinology, University Hospital of Ghent, Ghent, Belgium
8 Department of Radiology, University Hospital of Ghent, Ghent, Belgium

Objectives:
To assess feasibility and diagnostic performance of prostate examination through transvaginal palpation and transvaginal ultrasound in transsexual women (TSW).

Methods:
Fifty TSW who were at least 6 months’ posttransition were recruited in a University Hospital. Speculum examination and digital vaginal examination were performed by a gynecologist. Transvaginal ultrasound of the prostate was performed by a radiologist. The information gathered included: ease of insertion of the speculum, vaginal length, palpability of the prostate, vaginal mobility and presence of scar tissue, ease of introduction of the ultrasound probe, ability to visualize prostate and seminal vesicles, echogenicity of the peripheral zone and the central gland, presence of calcifications and delineation of prostatic capsule, attitude toward gynecologic examinations, and anticipated and experienced painfulness of the different examinations.

Results:
Speculum examination was possible in all but 1 patient and was easy in 78 % of the patients. Median vaginal length was 7 cm. A regular digital vaginal examination was possible in 44 % of the patients, the vagina was rather mobile and with limited scar tissue on average. In 48 % of the patients, the prostate was palpable. In 94 % of the patients, the prostate was visible on transvaginal ultrasound. Mean prostate volume was 14 mL, calcifications were present in 33 %, and none had cysts. Capsule of the prostate was well delineated in 74 % and seminal vesicles were visualized in 80 %. All examinations were very well tolerated and nearly painless.

Conclusions:
Gynecologic examination and prostate assessment were acceptable to TSW. Transvaginal palpation of the prostate is of poor clinical value, yet transvaginal ultrasound allows for proper evaluation of the prostate status.

Background:
In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy.

Methods:
A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure.

Results:
The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating.

Conclusions:
Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated.

1, 6, 7 Department of Urology, Ghent University Hospital, Ghent, Belgium
2, 3, 4 Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium
5 Department of Sexology, Ghent University Hospital, Ghent, Belgium

Objectives:
To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency.

Methods:
Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction.

Results:
There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed.

Conclusions:
This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.

1, 4, 5 Department of Paediatric Urology and Urogenital Reconstruction, Ghent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium
2, 3 Department of Plastic, Reconstructive and Aesthetic Surgery, Ghent University Hospital, De Pintelaan 185, B-9000 Gent, Belgium

Objectives:
Severe penile inadequacy in adolescents is rare. Phallic reconstruction to treat this devastating condition is a major challenge to the reconstructive surgeon. Phallic reconstruction using the free radial forearm flap (RFF) or the pedicled anterolateral thigh flap (ALTF) has been routinely used in female-to-male transsexuals. Recently we started to use these techniques in the treatment of severe penile inadequacy.

Methods:
Eleven males (age 15 to 42 years) were treated with a phallic reconstruction. The RFF is our method of choice; the ALTF is an alternative when a free flap is contraindicated or less desired by the patient. The RFF was used in 7 patients, the ALTF in 4 patients. Mean followup was 25 months (range: 4–49 months). Aesthetic and functional results were evaluated.

Results:
There were no complications related to the flap. Aesthetic results were judged as “good” in 9 patients and “moderate” in 2 patients. Sensitivity in the RFF was superior compared to the ALTF. Four patients developed urinary complications (stricture and/or fistula). Six patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed due to infection or erosion.

Conclusion:
In case of severe penile inadequacy due to whatever condition, a phalloplasty is the preferred treatment nowadays. The free radial forearm flap is still the method of choice. The anterolateral thigh flap can be a good alternative, especially when free flaps are contraindicated, but sensitivity is markedly inferior in these flaps.

A comprehensive and important text for health care professionals

Gender variance is widely misunderstood, and few medical texts examine the social, legal, emotional, historical, biological, and economic issues involved. Principles of Transgender Medicine and Surgery provides medical and health care guidelines and comprehensive information on all aspects of treatment of gender diverse individuals. This one-of-a-kind resource examines a full range of relevant data important to health care professionals. Each chapter addresses a different aspect of care, written by an authority on that sub-specialty. This practical guide instructs both novices and experienced practitioners on the state-of-the-art treatments and knowledge.

Principles of Transgender Medicine and Surgery presents the foremost international specialists on the issues, offering their expert knowledge on the wide spectrum of issues encountered by gender diverse individuals. In this handy text, professionals of all types can get important information about various aspects of transgender health care. This essential text is extensively referenced, and includes numerous photos, tables, and figures to clearly illustrate information.

Topics in Principles of Transgender Medicine and Surgery include:

• etiology
• primary medical care
• evidence-based preventive care
• hormone treatment of adults and juvenile transsexual patients
• general principles of surgical therapy
• reassignment surgery
• mental health issues
• developmental stages of the coming out process
• reproduction issues
• fertility issues
• karyotyping and genetics
• intersex individuals
• gender identity disorders
• aging and the care of elderly transgender patients

Principles of Transgender Medicine and Surgery is an essential guide for health care professionals, educators, students, patients, and patients’ families.

• Introduction
• Early Theories of the Etiology of Transsexualism
• Recent Theories of the Etiology of Transsexualism
• The Current Status of the Attempt to Identify the Etiology of Gender Variation

• Introduction
• The Spectrum of Gender Identity and Expression
• Transgender Health Care
• Ten Principles of Transgender Medical Care
• Conclusion

• Introduction
• Challenges in Providing Preventive Care to the Transgendered Population
• Evidence-Based Transgender Health Care
• Preventive Care Recommendations
• Conclusion

• Introduction
• General Principles of Treatment
• Hormonal Sex Reassignment
• Side Effects of Hormonal Sex Reassignment
• Sexual Function After Sex Reassignment
• Regrets After Sex Reassignment
• Juvenile Gender Dysphoria

• Introduction
• Controversies Surrounding Surgery
• Ethical and Legal Challenges
• Financial Aspects
• Surgeries for Gender Reassignment
• Conditions for Surgical Interventions
• Standards of Care of the Harry Benjamin International Gender Dysphoria Association

• History of Male-to-Female Surgery
• Male-to-Female Gender Reassignment Surgery: An Overview

• History of Female-to-Male Surgery
• Subcutaneous Mastectomy
• Phalloplasty
• The Importance of a Multidisciplinary Approach

• Mental Health Issues in the History of Sex Reassignment
• Practical Aspects of Clinical Care
• Writing Recommendations and Reports

• Introduction
• Coming Out As a Developmental Process
• Conclusion

• Introduction
• Transpeople and Their Children
• Ethical Arguments in Favor of Fertility Preservation
• Cryopreservation of Sperm in Transwomen
• Donor Inseminations in Partners of Transmen
• Cryopreservation of Oocytes, Embryos, or Ovarian Tissue in Transmen
• Future Possibilities

• Introduction
• What Is a Karyotype?
• What Is a Variant Karyotype?
• Chromosomal Variance, Phenotypic Variance, and Gender Identity
• Variant Karyotypes or Forms of Intersex in the Transgender Population
• Is Gender Identity Genetic?
• Intersexed or Transgendered?
• Recommendations
• Conclusion

• Introduction
• Intersexuality Defined
• Typical Sexual Differentiation Process
• Intersex Syndromes and Related Conditions
• Appendix A

• Introduction
• Classification
• Epidemiology
• Clinical Picture
• Appendix A: DSM-IV Criteria for Gender Identity Disorder in Children and Adolescents

• Introduction
• Successful Aging and its Predictors: The Concept of “Aging Well”
• Transgender Aging and Health Care
• Transgender Aging and Social Adjustment
• Graceful Exits: Living and Dying Well
• Conclusion

Department of Plastic Surgery, University Hospital of Ghent, Ghent, Belgium. selvaggigennaro@yahoo.it

Learning Objectives:
After studying this article, the participant should be able to discuss:

1. The terminology related to male-to-female gender dysphoria.
2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria.
3. The surgical goals of sex reassignment surgery in male-to-female transsexualism.
4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.

Background:
Gender identity disorder (previously “transsexualism”) is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.

Methods:
The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.

Results:
Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.

Conclusions:
This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.