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Women's Health Education Program Scholars' Projects

Prevention of Morbidity in Individuals with a History of Male-to-Female Sex Assignment Surgery

Katherine Thompson, WHEP Scholar

WHEP Scholar Katherine Thompson
Drexel University College of Medicine, Class of 2020

The transgender community is a vulnerable population at increased risk for a number of adverse health outcomes including surgical complications, development of cancers, and chronic disease. In addition to the psychosocial challenges associated with being transgender, these patients are also at increased risk for medical comorbidities that health care providers cannot prevent or manage unless they are aware of their patient’s transgender status. Male-to-female (MtF) transgender individuals are at risk for the same medical conditions as a biologic male at their age, in addition to the risks of taking estradiol hormone therapy. Likewise, female-to-male (FtM) transgender patients are at the same risks as a biologic female, in addition to the risks of taking testosterone. Health care providers can endeavor to prevent morbidity in MtF transgender patients who have undergone sex assignment surgery with a collaborative patient-physician relationship, routine medical management, and cancer screening.

Male-to-female (MtF) transgender patients who undergo sex assignment surgery may face serious complications. These may include surgical failure and impact from resultant altered anatomy. MtF transgender patients are at risk for the chronic diseases to which biologic males of their age are predisposed, including cardiovascular disease and prostate cancer. They also face health risks associated with taking estradiol hormone therapy, such as breast cancer and thromboembolism. These risks are compounded by the barriers to quality health care that are faced by transgender patients.

It is estimated that 1 in 30,000 adult males and 1 in 100,000 adult females seek sex assignment surgery. Male-to-female surgery involves the elimination of the male sexual organs, creation of a neovagina, repositioning the urethral meatus, and clitorolabioplasty. There are generally fewer complications in MtF sex assignment surgery than in FtM surgery because less urethral reconstruction is required. As with all surgeries, there remains the risk of infection, excessive bleeding, and injury to surrounding structures, in this case the ureters, bladder, prostate, rectum, pudendal vessels, and pudendal nerves.

Individuals who have undergone MtF sex assignment surgery have a unique risk profile that includes several cancers. Epidemiologic studies have yet to be conducted to accurately estimate the prevalence of cancer development in the transgender population; however, numerous cases have been reported. In addition to age-associated cancer risk, transgender individuals are also at risk for cancers related to sex assignment surgery and hormone therapy. According to a systematic review of 43 cancer cases in transgender patients, there have been 20 breast, 8 prostate, 2 neovaginal, and 1 testicular cancer cases in transgender women. In transgender men, 18 breast, 5 ovarian, 4 uterine/cervical, and 1 vaginal cancer cases have been reported [BJOG. 2018; 125(12): 1505-12]. Hormonal therapy with estradiol carries the risk of breast cancer in addition to numerous other medical risks, including thromboembolism and cardiovascular mortality.

The complications associated with sex assignment surgery can be devastating. The treatment of surgical complications generally involves additional surgeries, which put the patient at risk for further complications. The development of cancers, which can be deadly in and of themselves, can lead to significant complications throughout the treatment process. Chemotherapy carries the risk of iatrogenic immunosuppression, placing patients at increased risk for infection that can lead to sepsis and multi-organ failure. Radiation therapy can irreversibly damage vaginal tissue, leading to the formation of fistulae or the development of vaginal stenosis. Loss of the neovagina can understandably lead to significant psychologic distress in these patients since they have undergone a considerable struggle to have sex assignment surgery.

In summary, transgender patients, especially those of color, are at an increased risk for multiple health morbidities associated with sex assignment surgery, hormone therapy, and being a member of an underserved minority community. Creating an open, inclusive environment among health care workers will facilitate trust and collaboration between the transgender community and the medical profession. Routine follow-up for medical management of these patients can lead to early identification and treatment of precancerous lesions, STIs, surgical failure, cardiovascular disease, and mental illness. Multi-center collaboration in large-scale research studies has the potential to provide much needed epidemiologic data on transgender health. Well-defined, evidence-based guidelines for the long-term medical management and cancer screening for transgender patients have the potential to decrease significant morbidity and mortality among this vulnerable population.

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