Plastic Surgery Sexy Surgery
Authors:   , Özer Mujde 
Published: May 2023

Describing sexual-wellbeing from a holistic, salutogenic and emic perspective is introduced in this thesis.

PART 1 focusses on requested genital alterations.
Chapter 2 gives a comprehensive overview about labiaplasty and its’ definitions, natural variations, motivations (of both women as surgeons’), surgical techniques, outcomes, ethical aspects and recommendations.
Chapter 3 focusses on penile augmentation, experienced penile size and motivations to request penile augmentation, counselling and treatment. Non-surgical treatments are preferred over surgical procedures.
Foreskin reconstruction has been sought throughout history. Chapter 4 provides an overview of possible interventions for these men seeking. Although rarely studied, results of non-surgical methods of foreskin reconstruction suggest good results with minimal adverse-effects.
Chapter 5 shows motivations of men seeking foreskin reconstruction, their treatment trajectory and their experiences. Their experience of impairment of body integrity, feeling mutilated, aiming to increase penile glans sensitivity, having issues with cultural/religious identity and going to great lengths to reconstruct their foreskin.

PART 2: INNOVATIONS IN GENITAL GENDER AFFIRMING SURGERY (gGAS)
In Chapter 6 shows that the BPES-flap may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than skin grafting.
Chapter 7 illustrates, the surgical refinements, after exploring the needs and desires of men for their metoidoioplasty. This extended metoidioplasty without urethral lengthening with autoaugmentation scrotoplasty with a suprapubic adipocutaneous flap is an option for those desiring retained phallic sensibility (video article).

PART 3 DECISION AID FOR MASCULINIZING GENITAL GAS
To facilitate shared decision-making a decision-aid (DA) for gGAS in transmen (DA-GST) is developed, together with transmen during a qualitative focus group study (Chapter 8).
After implementation, it was evaluated, by a cross-sectional study using mixed methods, measuring decisional conflict and decisional confidence (Chapter 9).

PART 4 SEXUAL WELLBEING AFTER GENDER AFFIRMING SURGERY
Chapter 10 contains a systematic review on SW after GAS. Sexual topics were extracted and sexual themes identified by thematic analysis. Functional aspects of sexuality are assessed most frequently. Self-developed questionnaires were used most frequently to assess SW. The validated questionnaires used, were not validated for trans. A comprehensive conceptualisation of SW is still lacking and no valid tool exists for assessing SW in trans.
Through open qualitative interviews, analysed with thematic analysis, Chapter 11 focuses on SW from the point-of-view of trans themselves, questioning what SW entails and how it’s experienced. Inductive coding and thematic analysis were used. Four domains on SW were identified: 1) Description of SW, 2) Conditions for SW, 3) Factors affecting SW, and 4) Experienced SW.

PART 5 GUIDELINES AND ETHICAL DILEMMAS IN GENDER AFFIRMING SURGERY
Chapter 12: ESSM Position Statement “Sexual-wellbeing After Gender Affirming Surgery”, provides a comprehensive list of clinical recommendations on SW after GAS in treatment seeking trans. The available evidence suggests positive results regarding SW following GAS.
Chapter 13 deliberates on the new classification of gender incongruence within the ICD-11 and examines the ethical questions that may arise from a gender surgical point-of-view.
To conclude, there are lacunas in the prevailing knowledge on the effects of genital surgery on SW. SW in trans has not been prioritized, and well validated instruments to measure SW in trans are lacking
Our results show that shifting from the frame of the HCPs/researchers, towards also that of the care-seeker is very valuable and provides a better adaptation to their needs of developed tools and refinements.
More research applying a holistic, salutogenic and emic and etic perspectives in research and clinical care is needed, as well as the development of valid measures of SW in trans. Our hypothesis is that this will contribute to more patient satisfaction with (sexual) results of requested genital surgery and (g)GAS.