Gender-affirming surgeries (GAS) are complex procedures that have significant long-term benefits for many transgender individuals, including improved mental health, reduced gender dysphoria, and enhanced quality of life.
However, like all surgeries, gender-affirmation procedures carry inherent risks and potential long-term complications. The type and severity of risks vary depending on the specific procedure (e.g., vaginoplasty, phalloplasty, mastectomy, etc.), the individual’s overall health, and postoperative care.
1. Vaginoplasty (Male-to-Female)
Vaginoplasty is a complex surgery that involves constructing a neovagina using penile and scrotal tissue, or in some cases, segments of the colon. While the surgery often yields satisfactory results, there are potential long-term risks:
- Vaginal Stenosis: One of the most common long-term complications of vaginoplasty is vaginal stenosis, a narrowing or constriction of the neovagina. To prevent stenosis, regular dilation is necessary, often for the rest of the individual’s life. Failure to maintain a dilation schedule can lead to loss of vaginal depth and flexibility, which may require additional surgeries.
- Neovaginal Fistulas: A fistula is an abnormal connection between the neovagina and the rectum or urethra. While relatively rare, fistulas can develop long after the initial surgery and may require corrective surgical intervention to repair.
- Urinary Complications: Urinary issues such as urethral stricture (narrowing of the urethra) can occur, potentially leading to difficulty urinating, urinary retention, or an increased risk of urinary tract infections (UTIs). Some individuals may require further surgical correction or long-term management to alleviate these issues.
- Sexual Function Issues: Some individuals may experience difficulties achieving sexual arousal or orgasms, while others may face pain during intercourse (dyspareunia). These issues can be influenced by nerve damage, scarring, or changes in sensation following surgery.
- Granulation Tissue: Some patients may develop granulation tissue, which is an overgrowth of tissue at the surgical site. This tissue can cause discomfort, bleeding, or discharge and often requires treatment with silver nitrate or surgical excision.
2. Phalloplasty and Metoidioplasty (Female-to-Male)
Phalloplasty and metoidioplasty are surgeries aimed at creating a neophallus. Phalloplasty is more extensive and involves tissue grafting, while metoidioplasty modifies the clitoris into a small phallus. Both procedures come with long-term risks:
- Urethral Complications: Urethral fistulas and strictures are common complications in phalloplasty. A fistula is an abnormal connection between the urethra and the skin, which can cause urine leakage. Urethral strictures, or narrowing of the urethra, can make urination difficult and increase the risk of UTIs. These complications often require additional surgeries to repair.
- Loss of Sensation: Although nerve grafts are used during phalloplasty to provide sensation to the neophallus, some individuals may experience reduced or altered sensation in the genital area. This can affect sexual function and overall satisfaction with the surgery.
- Implant Complications: If a penile implant is placed to enable erectile function, there is a risk of implant-related complications. These include mechanical failure of the implant, infection, and erosion of the implant through the skin. These complications may necessitate implant removal or replacement.
- Scarring and Aesthetic Concerns: Scarring at the donor graft site (often the forearm, thigh, or abdomen) can be extensive. Additionally, aesthetic outcomes of the neophallus vary, and some individuals may seek revision surgeries to improve the appearance or address functional issues.
- Urinary Function: Some individuals experience persistent difficulty in urinating while standing, which is one of the desired outcomes for many trans men undergoing phalloplasty. Long-term management and adjustments to the neourethra may be necessary.
3. Mastectomy (Chest Masculinization Surgery)
Mastectomy involves the removal of breast tissue to create a more masculine chest contour. While it is generally considered a lower-risk procedure, it does carry some long-term risks:
- Scarring: Scars resulting from mastectomy can be significant, especially with double-incision techniques. While scars may fade over time, some individuals may be left with prominent or hypertrophic (raised) scars that can cause discomfort or dissatisfaction with the aesthetic outcome.
- Loss of Nipple Sensation: Many individuals experience partial or complete loss of nipple sensation following mastectomy. This occurs due to the cutting of nerves during surgery. Loss of sensation can impact body image and sexual arousal.
- Nipple Necrosis: Although rare, necrosis (tissue death) of the nipples can occur, particularly in cases where nipple grafts are used. This complication may require additional surgical interventions, including nipple reconstruction.
4. Facial Feminization Surgery (FFS) and Chondrolaryngoplasty
Facial feminization surgery (FFS) includes a range of procedures to soften masculine facial features, while chondrolaryngoplasty (tracheal shave) reduces the prominence of the Adam’s apple. Long-term risks include:
- Nerve Damage: Some FFS procedures involve manipulation of the facial nerves, which can result in temporary or permanent numbness, loss of facial movement, or asymmetry. For example, rhinoplasty (nose surgery) and jaw contouring can affect the sensory nerves of the face.
- Bone and Soft Tissue Changes: Bone and soft tissue can remodel over time, potentially altering the surgical results. For example, bone resorption or changes in facial fat distribution could affect the desired feminine appearance.
- Airway Issues: Chondrolaryngoplasty can potentially lead to voice changes or affect breathing, though this is rare. Patients might also experience prolonged throat discomfort or swallowing difficulties.
5. General Risks Common to Gender-Affirming Surgeries
Some risks are common across various gender-affirming surgeries, regardless of the specific procedure:
- Scarring and Adhesions: Almost all surgeries leave scars, and some individuals may develop adhesions (scar tissue that binds internal tissues together) that could cause discomfort or affect the mobility of skin and other tissues.
- Chronic Pain: Some individuals may experience long-term pain or discomfort at surgical sites. This could result from nerve damage, scar tissue formation, or implant complications.
- Infections: Although infections are generally acute complications, some surgical site infections or issues with implants can lead to chronic problems, requiring ongoing medical management or further surgery.
- Mental Health Impact: While many individuals experience an improvement in mental health and reduction in gender dysphoria after surgery, some may face challenges adjusting to their new body or dealing with surgical complications. Persistent dissatisfaction with surgical outcomes can contribute to anxiety, depression, or a resurgence of dysphoria.
- Long-Term Maintenance and Revision Surgeries: Many gender-correction surgeries, particularly phalloplasty and vaginoplasty, may require lifelong maintenance, such as regular dilation (in the case of vaginoplasty) or management of implants. Revision surgeries are also relatively common to address functional or aesthetic concerns.
6. Sexual Function
Long-term sexual function is another area of concern. While many individuals report satisfaction with their sexual health post-surgery, some face challenges:
- Trans Women: Some may experience changes in the ability to achieve orgasm or experience sexual pleasure, often due to nerve alterations during vaginoplasty.
- Trans Men: Phalloplasty can lead to changes in genital sensation, and while many retain sexual sensitivity, the degree and quality of sensation can vary.
Conclusion
Gender-affirming surgeries can significantly improve the quality of life for transgender individuals. However, it is crucial for patients and healthcare providers to understand and manage the potential long-term risks.
Comprehensive preoperative counseling, skilled surgical techniques, and diligent postoperative care are essential to mitigate these risks and optimize outcomes. Continued research and advances in surgical methods aim to reduce long-term complications, enhancing the safety and effectiveness of these life-changing procedures.
