Postoperative trans women in sexual health clinics: managing common problems after vaginoplasty.

UK figures estimate that in 1998 there were 3170 people over the age of 15 years assigned as male at birth who had presented with gender dysphoria. This figure is comparable to that found in the Netherlands where 2440 have presented; however, far fewer people actually undergo sex reassignment surgery. Recent statistics from the Netherlands indicate that about 1 in 12 000 natal males undergo sex-reassignment and about 1 in 34 000 natal females. Since April 2013, English gender identity services have been among the specialised services commissioned centrally by NHS England and this body is therefore responsible for commissioning transgender surgical services. The growth in the incidence of revealed gender dysphoria amongst both young and adult people has major implications for commissioners and providers of public services. The present annual requirement is 480 genital and gonadal male-to-female reassignment procedures. There are currently three units in the UK offering this surgery for National Health Service (NHS) patients. Prior to surgery trans women will have had extensive evaluation, including blood tests, advice on smoking, alcohol and obesity, and psychological/psychiatric evaluation. They usually begin to take female hormones after 3 months of transition, aiming to encourage development of breast buds and alter muscle and fat distribution. Some patients may elect at this stage to have breast surgery. Before genital surgery can be considered the patient must have demonstrated they have lived for 1 year full-time as a woman.  1 shows a typical post-surgical result. A trans person who has lived exclusively in their identified gender for at least 2 years (as required by the Gender Recognition Act 2004) can apply for a gender recognition certificate (GRC). This is independent of whether gender reassignment surgery has taken place. Once a trans person has a GRC they can then obtain a new birth certificate. The trans person will also have new hospital records in a new name. It is good practice for health providers to take practical steps to ensure that gender reassignment is not casually visible in records or communicated without the informed consent of the user. Consent must always be sought (and documented) for all medical correspondence where the surgery or life before surgery when living as a different gender is mentioned (exceptions include an order of court and prevention or investigation of crime). 5 It is advisable to seek medico-legal advice before disclosing. Not all trans women opt to undergo vaginoplasty. Patients have free choice as to how much surgery they wish to undertake. Trans women often live a considerable distance from where their surgery was performed and as a result many elect to see their own general practitioner or local Sexual Health Clinic if they have postoperative problems. Fortunately reported complications following surgery are rare. Lawrence summarised 15 papers investigating 232 cases of vaginoplasty surgery; 13 reported rectal-vaginal fistula, 39 reported vaginal stenosis and 33 urethral stenosis; however, it is likely that there is significant under-reporting of complications. Here we present some examples of post-vaginoplasty problems presenting to a Sexual Health Service in the North East of England, and how they were managed.