Transgender men or transmasculine nonbinary people may choose to undergo oophorectomy or hysterectomy as a part of their medical transition. For gynecologists, the preparation and considerations for this procedure as gender affirmation surgery are slightly different than those involved when treating cisgender female patients with cancer or other conditions that warrant removing the ovaries or uterus. By identifying the differences and staying informed, OB/GYNs can help to better prepare their patients and address any barriers to care.
Oophorectomies, Hysterectomies and Gender Dysphoria
A gynecologist may need to counsel patients about oophorectomy vs. hysterectomy procedures to ensure each patient understands their options. Patients may opt for this procedure regardless of their intent to undergo genital surgery, such as a metoidioplasty or phalloplasty. Compared to cisgender female patients undergoing an oophorectomy, trans men are more likely to be younger and have fewer major medical comorbidities, according to existing research.
One study published in Obstetrics & Gynecology surveyed 521 transgender men undergoing a hysterectomy. Gender identity disorder was the most commonly specified diagnosis related to hysterectomy in these patients, at nearly 21 percent of respondents. Some patients may have a gynecologic indication for surgery in addition to gender dysphoria. Another study found that of 134 transgender men who had undergone hysterectomy, 58 percent had the procedure as "preventive" while 26 percent had a pre-existing medical concern.
The surgical procedure is performed similarly for trans men and cisgender women; however, the gynecologist should discuss different approaches with the patient. Vaginal hysterectomy leaves no abdominal scarring, but this approach could exacerbate gender dysphoria. A vaginal approach may also be more difficult in patients taking testosterone due to vaginal atrophy.
In the Obstetrics & Gynecology study, more than half of patients underwent laparoscopic hysterectomy. The complication rates were similar between transgender men and cisgender female patients undergoing the procedure, with minimally invasive surgery leading to fewer complications.
Preparation for Surgery
To prepare for gender affirmation surgery, whether a hysterectomy or oophorectomy, gynecologists should carefully discuss with patients everything involved in the procedure and help them set realistic expectations for life after surgery. Note what long-term gynecologic screenings will still be needed and what type of follow-up care to expect.
The World Professional Association for Transgender Health (WPATH) provides standards of care with guidelines for surgery. The patient should:
- Have persistent, well-documented gender dysphoria.
- Have the ability to provide informed consent.
- Be the age of majority in their state or country.
- Have undergone 12 months of continuous hormone therapy.
However, many states and countries impose additional legal or medical hurdles for patients seeking these surgeries.
WPATH also recommends that transgender patients undergoing gender-affirming surgery also have two referrals from qualified mental health professionals. However, the American College of Obstetricians and Gynecologists notes that an informed consent process is often adequate for surgery. Providers' main responsibility is to ensure that surgery is the right option for the patient and that the patient understands the potential long-term implications for fertility and health.
WPATH's standards of care note that long-term follow-up with mental health and medical professionals is important to good outcomes.
How Gynecologists Can Better Care for Trans Patients
A survey in the Journal of Women's Health found that less than half of OB/GYNs had medical training in caring for transgender patients. This lack of knowledge may lead to more discomfort in knowing how to care for transmasculine patients and how to counsel them before surgery.
Gynecologists and other medical providers can prepare to care for transgender patients by learning more about gender-affirming surgery and patient considerations necessary to provide informed consent. Have open conversations with patients, and if you are unsure about their pronouns or preferred language, ask. Use the patient's preferred terms for body parts to foster a comfortable environment and shared decision-making.
Transgender patients may receive follow-up or ongoing care from mental health professionals or primary care in addition to their gynecologist. OB/GYNs can partner with the patient's other providers and learn how to discuss surgery, expectations, outcomes and ongoing medical needs comfortably in order to ensure the patient receives seamless long-term care.
