What Is the Ideal Neophallus? Response to Frey et al. (2017): An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient

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With great interest we have read the literature reviews on genital reconstructive techniques applied to female-to-male transgender individuals by Frey et al.1,2 Over time, many different surgical techniques have been developed for male genital reconstruction and a comprehensive overview of these techniques is currently lacking. Hence, we applaud the authors for providing an overview of literature on this topic. Indeed, it is true that studies on metoidioplasty and phalloplasty are scarce, and good quality studies evaluating the techniques with regard to clinical results and patient outcomes are virtually absent. Thus, we fully support the authors’ call to all centers providing this care to collect high-quality validated data on outcome measures for individual techniques and patient-reported outcomes. Nevertheless, we would like to put these outcomes into a different perspective. Frey et al.1,2 state that the notion of an “ideal” bottom surgery outcome has not been articulated from the perspective of patients. By lack of an up-to-date standard, they revert to a definition of the “ideal neophallus” as described by Hage and De Graaf3 in 1993. However, by using this standard, or even by seeking one standard for the “ideal neophallus,” they ignore major advances that have occurred in the (transgender) health care domain since 1993. We suggest that there is no such thing as “one ideal neophallus.” Indeed, more than 20 years back, genital surgeons treating transgender men sought to create a perineogenital complex resembling that of a biological male in appearance and function. Yet, we are fully aware that large variation exists in appearance as well as function of normal biological male genitalia. The various surgical techniques for male genital reconstruction also produce different outcomes with regard to appearance and function. In our opinion, health care professionals should not be looking for “one ideal neophallus,” but for “the ideal solution for each individual patient.” Ideally, the gender surgeon has a broad surgical armamentarium, such that several different surgical options can be realized. Choosing the best individual solution from multiple surgical options is challenging for both patient and surgeon. Each surgical technique has its specific advantages, disadvantages, and risk of complications. The best choice depends on the individuals’ specific wishes, his physical condition and ability to cope with the burden of surgery, donor-site morbidity, and possible adverse events. Weighing all these issues to come to a tailor-made treatment requires shared decision making between the health care professionals and the patient. For this reason, we are developing a tool, together with transmen, to support in the decision-making process. This project entitled “Development of patient decision aid for gender confirming surgery in female-to-male transgender individuals” is funded by the European Society of Sexual Medicine. We propose that the outcomes of gender confirming surgery should not be held to 1 single standard.

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