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Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study

  • Iris J. de Brouwer
    Affiliations
    Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands

    Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands

    Amsterdam Public Health Institute, Amsterdam, the Netherlands
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  • Els Elaut
    Affiliations
    University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium

    Ghent University, Department of Experimental-Clinical and Health Psychology, Ghent, Belgium
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  • Inga Becker-Hebly
    Affiliations
    University Medical Center Hamburg-Eppendorf, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Hamburg, Germany
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  • Gunter Heylens
    Affiliations
    University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium
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  • Timo O. Nieder
    Affiliations
    Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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  • Author Footnotes
    § shared last author
    Tim C. van de Grift
    Correspondence
    Corresponding Author: Tim C. van de Grift, Amsterdam UMC location VUmc, Depts. of Plastic, Reconstructive and Hand Surgery and Medical Psychology, De Boelelaan 1117 (ZH 4D120), 1081HV, Amsterdam, the Netherlands, Tel: (31) 20-444-3520.
    Footnotes
    § shared last author
    Affiliations
    Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands

    Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands

    Amsterdam Public Health Institute, Amsterdam, the Netherlands
    Search for articles by this author
  • Author Footnotes
    § shared last author
    Baudewijntje P.C. Kreukels
    Footnotes
    § shared last author
    Affiliations
    Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands

    Amsterdam Public Health Institute, Amsterdam, the Netherlands
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  • Author Footnotes
    § shared last author
Open AccessPublished:September 18, 2021DOI:https://doi.org/10.1016/j.jsxm.2021.08.005

      ABSTRACT

      Background

      While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.

      Aim

      To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.

      Methods

      As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants’ aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.

      Outcomes

      Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.

      Results

      Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.

      Clinical Implications

      Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.

      Strengths & Limitations

      We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.

      Conclusion

      These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail.
      IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921–1932.

      Key Words

      INTRODUCTION

      When transgender individuals experience distress due to a discrepancy between their gender identity and sex assigned at birth (generally referred to as gender dysphoria), medical transition is often desired.
      • Byne W
      • Karasic DH
      • Coleman E
      • et al.
      Gender dysphoria in adults: An overview and primer for psychiatrists.
      Medical transition may include hormone treatment and/or gender-affirming surgeries (GAS), involving several masculinizing or feminizing surgical procedures.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      The most recent study on prevalence of GAS in the United States, a nonclinical survey with the largest convenience sample to date, with 27,715 respondents, reported that 25% of their transgender respondents performed at least one form of GAS, with chest surgery, mastectomy or breast augmentation being more common than genital surgery, metoidioplasty, phalloplasty or vaginoplasty.

      James S, Herman J, Rankin S, et al. The report of the 2015 US transgender survey. 2016.

      ,
      • Nolan IT
      • Kuhner CJ
      • Dy GW.
      Demographic and temporal trends in transgender identities and gender confirming surgery.
      In clinical studies, GAS has shown to positively influence the quality of life and mental health of many transgender individuals.
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      • Passos TS
      • Teixeira MS
      • Almeida-Santos MA.
      Quality of life after gender affirmation surgery: a systematic review and network meta-analysis.
      • Nobili A
      • Glazebrook C
      • Arcelus J.
      Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis.
      In any kind of surgery, especially in plastic and reconstructive surgery, appropriate postoperative care is necessary for a good result.
      • Neves JC
      • Jiménez RM
      • Tagle DA
      • et al.
      Postoperative care of the facial plastic surgery patient—Forehead and blepharoplasty.
      Some GAS procedures are known to carry high risks of complications and extensive recovery processes.
      • Salibian AA
      • Levitt N
      • Zhao LC
      • et al.
      Preoperative and postoperative considerations in gender-affirming surgery.
      Good-quality aftercare is thought to improve the aesthetic and functional outcomes of GAS: adequate wound care promotes healing and lifelong dilation is fundamental in maintaining the opening in the pelvic diaphragm,
      • Jiang DD
      • Gallagher S
      • Burchill L
      • et al.
      Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty.
      which both are of importance for satisfaction with surgical results.
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      ,
      • Salibian AA
      • Levitt N
      • Zhao LC
      • et al.
      Preoperative and postoperative considerations in gender-affirming surgery.
      ,
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.
      Furthermore, routine cancer screening, long-term postoperative monitoring of breast implants after breast augmentation, and evaluation of sexual function are some of many examples of care that could be applied after gender-affirming procedures.
      • Salibian AA
      • Levitt N
      • Zhao LC
      • et al.
      Preoperative and postoperative considerations in gender-affirming surgery.
      Satisfaction with the results of surgery is beneficial for quality of life and in reducing psychological symptoms.
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      Reported reasons for dissatisfaction after surgery include long-term complications and unfavorable functional or aesthetic outcomes, however it was also associated with the presence of psychological symptoms and life dissatisfaction at baseline.
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      The interaction between health care professionals and transgender individuals affects treatment satisfaction.
      • Hines DD
      • Laury ER
      • Habermann B.
      They just don't get me: A qualitative analysis of transgender women's health care experiences and clinician interactions.
      Many transgender individuals however, still face barriers to care due to lack of knowledge, transphobia or misgendering, therefore it is important to integrate gender-affirmative health care in any, specialist or general, care setting.
      • Reisner SL
      • Radix A
      • Deutsch MB.
      Integrated and gender-affirming transgender clinical care and research.
      ,
      • Ansara YG
      • Hegarty P.
      Methodologies of misgendering: Recommendations for reducing cisgenderism in psychological research.
      As far as we know, a direct link between socioeconomic status and surgical satisfaction has not been reported, however earlier research showed a strong influence of socioeconomic position on quality of life.
      • Motmans J
      • Meier P
      • Ponnet K
      • et al.
      Female and male transgender quality of life: socioeconomic and medical differences.
      Targets for aftercare could be coping with unfavorable postoperative outcomes alongside attention for mental health challenges. Mental health services are considered to be helpful in the transitioning process by most treatment-seeking transgender (TSTG) individuals
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.
      ,
      • Eyssel J
      • Koehler A
      • Dekker A
      • et al.
      Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey.
      as they may give support, assist adaptation and promote mental health and self-growth. According to the Standards of Care by the World Professional Association for Transgender Health (WPATH), surgeons ought to ensure direct aftercare and consultation with other health care providers after GAS. Practically, an aftercare plan should be developed together with TSTG individuals before performing surgery.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      However, it remains unspecified what this aftercare plan should address, nor what standardized aftercare in general should entail. A majority of TSTG individuals mention the desire for post-GAS aftercare according to recent Dutch and German community sample studies.
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.
      ,

      Zorgvuldig Advies. Onderzoeksrapport ervaringen en behoeften van transgenders in de zorg 2019, Available at: https://zorgvuldigadvies.nl/wp-content/uploads/2019/11/Onderzoeksrapport-ervaringen-en-behoeften-van-transgenders-in-de-zorg-v.1_compressed-2.pdf. Accessed May 11, 2020.

      While aftercare is viewed as pivotal to good treatment outcomes, a substantial share of transgender individuals receives limited clinical follow-up,
      • Meyer III WJ.
      World Professional Association for Transgender Health's standards of care requirements of hormone therapy for adults with gender identity disorder.
      which may be the result of insufficient capacity. Also, little is known about the individual experiences and needs for care in the period after GAS from transgender individuals’ perspectives. Given the view that aftercare is key for the outcome of gender-affirming treatments and the lack of studies, the first aim of the current study is to assess the aftercare needs of transgender individuals who have received GAS. The second aim is to examine which kind of individual characteristics (sociodemographic and clinical) were associated with these needs. Lastly, we aim to get further understanding on the whats and hows of optimal aftercare, based on open-text answers.

      METHODS

       Procedure

       Study Procedure

      In 2007, the European Network for the Investigation of Gender Incongruence (ENIGI) was initiated by 4 clinics providing gender-affirming care, located in Amsterdam (the Netherlands), Ghent (Belgium), Hamburg (Germany), and Oslo (Norway). In this study protocol, all individuals attending one of these clinics for gender-affirming treatments were invited to fill out a standardized series of questionnaires.
      • Kreukels B
      • Haraldsen I
      • De Cuypere G
      • et al.
      A European network for the investigation of gender incongruence: The ENIGI initiative.
      The present study was a follow-up study of a part of this cohort, and the full study design can be found elsewhere.
      • Van De Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Effects of medical interventions on gender dysphoria and body image: a follow-up study.
      Ethics approval was granted by the local ethics committees in Amsterdam, Ghent and Hamburg, therefore only these clinics participated in this follow-up study.
      For the present ENIGI follow-up data collection, all individuals of 17 years or older who were admitted for gender-affirming treatments between 2011 and 2013 in 1 of the 3 clinics (ENIGI follow-up wave 2), were invited to fill out an online follow-up survey between September 2017 and April 2018.
      • Kreukels B
      • Haraldsen I
      • De Cuypere G
      • et al.
      A European network for the investigation of gender incongruence: The ENIGI initiative.
      Candidates were invited, regardless of whether or not they had received GAS and received a reminder when not responding. Participation was voluntary and not rewarded with any voucher. All participants provided their informed consent, online or in written form.

       Postoperative Procedure

      At the time this study was conducted, postoperative care in Amsterdam included outpatient clinic visits at 2–3 weeks and 3 months after most procedures, as well as at 6 months, and additionally at 1 and 2 years afterwards for genital surgery. During consultations, recovery, function and individuals’ questions were assessed, as well as the indication for additional care or secondary corrections. Individuals could contact the hospital for additional appointments. After surgery, individuals would visit the endocrinologist once every 2 years, whereas psychologist and physiotherapist visits were scheduled on indication only. For most individuals, all care was conducted in the same multidisciplinary center.
      Postoperative care in Ghent included an outpatient clinic visit 1 week after surgery for chest surgery, with a follow-up visit at 6 months. For genital surgery, an outpatient appointment was routinely scheduled 10 days after surgery, with follow-up every 3–6 months during the first year. During the hospital stay, a visit of the psychologist was routinely scheduled after genital surgery. At least one consultation with the psychologist/psychiatrist was planned 2–3 months after surgery. Individuals could contact the team for additional appointments for surgical or psychological aftercare, if needed.
      At the time of data collection, unlike today, the vast majority of transgender individuals in Hamburg did not yet receive surgery in the Hamburg University Medical Center. German participants in the current sample have been operated in multiple clinics with different postoperative protocols. The description of postoperative care below only applies to those who underwent (genital) surgery at the University Medical Center Hamburg. However, genital surgery was (and still is) performed as a 2-step procedure. Usually, the follow-up surgery took place 6 months after main surgery. In between, 2 outpatient visits were scheduled. The first visit took place 4–6 weeks after main surgery and the second visit shortly before follow-up surgery. Subsequently, outpatient visits were recommended 3 months after follow-up surgery and then about once a year if required. The surgeons were also available by email to answer questions about aftercare if requested. Postoperative care in Hamburg routinely included visits by psychologists exclusively for genital surgery. For other surgical procedures such as mastectomy or breast augmentation, the psychological consultation was carried out if required.
      Other than these standard aftercare protocols, actual received aftercare was not formally evaluated, and it was assumed that participants followed aforementioned procedures. As some aftercare consultations or procedures were on request or on indication only, it should be noted that the received aftercare and knowledge about aftercare possibilities could be different between participants. Moreover, there was no data on any additional care outside of the received standard care that was organized by participants themselves (eg, complementary medicine or coaching).

       Participants

      A total of 543 individuals were invited for this ENIGI follow-up study of whom 349 (64.3%) both consented and filled out the questionnaires. For the current study, only participants that had received GAS and filled out all outcome measures were included for analyses. In total, 260 participants were included (the Netherlands n = 149, Belgium n = 72, Germany n = 39) of which 126 (48.5%) were assigned male at birth (trans feminine) and 134 (51.5%) were assigned female at birth (trans masculine). Earlier nonresponder analysis on the ENIGI follow-up data showed that study participants were significantly older and more educated than nonparticipants.
      • Kerckhof ME
      • Kreukels BP
      • Nieder TO
      • et al.
      Prevalence of sexual dysfunctions in transgender persons: Results from the ENIGI follow-up study.
      No data collection on the aftercare received was collected as part of this study. Thus, we assume that participants followed the aforementioned postoperative procedures of the center where they were receiving treatments.

       Outcome Measures

       Background and Surgical Treatment Data

      Data on sociodemographic characteristics, such as age, country, sex assigned at birth, gender identity ([trans] masculine, [trans] feminine, in between, other), educational level (lower, intermediate, higher) and income level (below, around, or above poverty line) was collected. Participants filled out what type of surgery they had received. Data on surgery was verified using patient records. Furthermore, participants were asked whether they had experienced any surgical complications, and whether they had further (surgical) treatment wishes (no, unsure, yes). Also, participants were requested to rate their surgical satisfaction for each procedure, ranging from 1 (very unsatisfied) to 5 (very satisfied). Psychological symptoms were measured using the Symptom Checklist 90 (SCL-90) Global Severity Index (GSI).
      • Derogatis L.R.
      • Unger R.
      Symptom checklist-90-revised.
      The SCL-90 is a self-report inventory, assessing psychological distress symptoms on a 5-point Likert scale, ranging from zero (no symptoms) to 4 (severe symptoms).
      • Derogatis L.R.
      • Unger R.
      Symptom checklist-90-revised.
      The GSI reflects the global severity of distress by calculating the average of all answered items, where a lower score indicates less symptoms. The GSI was only calculated for participants with <10% missing answers, which was the case in 96.2% of the participants.

       Aftercare Needs

      Participants rated whether they experienced any of 3 predefined aftercare needs, such as (additional) assistance during surgical recovery, (additional) sessions with a mental health professional, and/or (additional) physiotherapy for the pelvic floor. Participants could rate 1 or multiple of these 3 options. These predefined aftercare needs were self-constructed. Study participants were also asked to further elaborate on their aftercare needs in 2 open-ended questions: a first one asking if participants had any other aftercare needs to add to the predefined options, and a second one asking participants to elaborate on what they had missed regarding aftercare in general.

       Statistical Analyses

      In order to reduce the number of treatment groups in the analysis due to the high variability in treatment trajectories, some groups were combined and/or variables were recoded. Participants were categorized into most common (surgical) treatment combination groups, according to an earlier study
      • Kerckhof ME
      • Kreukels BP
      • Nieder TO
      • et al.
      Prevalence of sexual dysfunctions in transgender persons: Results from the ENIGI follow-up study.
      : for trans feminine participants these were (i) hormone treatment and breast augmentation and (ii) hormone treatment, vaginoplasty, with or without breast augmentation, and for trans masculine participants these were (i) mastectomy only, (ii) hormone treatment and mastectomy, (iii) hormone treatment, mastectomy and phalloplasty and (iv) hormone treatment, mastectomy and metoidioplasty. For regression analysis, an additional dummy variable was created: (i) chest surgery only; or (ii) (chest and) genital surgery. Surgical complications were combined into 1 variable, which subdivided participants with (any) postoperative complications and those with none. A mean surgical satisfaction score was calculated for masculinizing and feminizing surgeries combined. Dummy variables were created for country variables, in which the Netherlands was used as reference category, being the largest group.
      Sociodemographic, surgical treatment characteristics and predefined aftercare needs were described using means (SD) and frequencies (%). Multiple binary logistic regressions were conducted to determine the sociodemographic and clinical characteristics associated with aftercare needs. Based on literature and clinical experience, the following factors were included: age, country, sex assigned at birth, gender identity, education, income level, chest and/or genital surgery, surgical complications, surgical satisfaction, further treatment wishes, and psychological symptoms (measured via the SCL-90 GSI). Factors were eliminated based on likelihood ratios using a backwards stepwise approach with P <.10 as cut-off. Predictive factors were reported as odds ratios (ORs) and 95% confidence intervals (CIs). The sum of aftercare needs was associated similarly using backwards linear regression. Results were reported as beta coefficients and t-values. P values of <.05 were considered significant. All analyses were performed using SPSS statistics version 26.
      Due to overlap between answers to the 2 open-ended questions and their manageable size, the qualitative data of the answers was analyzed combined using thematic analysis (grounded theory). Data analysis took place in 2 rounds: in the first round half of the data was used to generate a hypothetical framework with major, minor and mini themes (using Excel) until consensus was reached between 2 researchers (IJdB, TCvdG). In the second round, the other half of the data was used for internal validation. Illustrative quotes were selected for each theme. The final themes were confirmed by all authors.

      RESULTS

       Sociodemographic and Surgical Treatment Characteristics

      The sample characteristics are displayed in Table 1. The sample had a mean age of 36.4 years (SD: 12.8). Of the 126 trans feminine participants receiving feminizing surgeries, 9 (7.1%) received hormones and breast augmentation and 117 (92.9%) hormones, vaginoplasty and optionally breast augmentation. Of the 134 trans masculine participants receiving masculinizing surgeries, 2 (1.5%) received mastectomy only, 96 (71.6%) hormones and mastectomy, 28 (20.9%) hormones, mastectomy and phalloplasty, and 8 (6.0%) hormones, mastectomy and metoidioplasty. In addition, 22 (17.5%) transgender women received thyroid cartilage reduction, 12 (9.5%) vocal cord surgery, and 16 (12.7%) facial feminization surgery. Of the transgender men, 106 (79.1%) received ovariohysterectomy, 19 (14.2%) testicle construction, 9 (6.7%) an erection prosthesis, and 3 (2.2%) vocal cord surgery. Overall, surgical satisfaction was high (mean surgical satisfaction score 4.18), and the mean surgical satisfaction score was between 4 and 5 for all the different treatment groups.
      Table 1Participant characteristics
      All (n = 260)
      Age, M (SD)36.4 (12.8) (n = 254)
      Country, n (%)
      - The Netherlands149 (57.3)
      - Belgium72 (27.7)
      - Germany39 (15)
      Sex assigned at birth, n (%)
      - Male126 (48.5)
      - Female134 (51.5)
      Gender identity, n (%)
      - Man93 (35.8)
      - Woman92 (35.4)
      - Trans masculine29 (11.2)
      - Trans feminine27 (10.4)
      - In between16 (6.2)
      - Other0 (0)
      - Missing3 (1.2)
      Education level, n (%)
      - Lower66 (25.4)
      - Intermediate85 (32.7)
      - Higher109 (41.9)
      Income level, n (%)
      - Below poverty line55 (21.2)
      - Around poverty line55 (21.2)
      - Above poverty line150 (57.7)
      Treatments received trans feminine participants, n (%)
      - Hormones and breast augmentation9 (7.1)
      - Hormones, vaginoplasty, with or without breast augmentation117 (92.9)
      Treatments received trans masculine participants, n (%)
      - Mastectomy only2 (1.5)
      - Hormones and mastectomy96 (71.6)
      - Hormones, mastectomy and phalloplasty28 (20.9)
      - Hormones, mastectomy and metoidioplasty8 (6)
      Surgical complications
      Participants with any complication after 1 or more surgeries.
      , n (%)
      127 (48.8)
      Surgical satisfaction
      Mean of feminizing and masculinizing surgeries combined.
      ,
      Scores range from 1 (very unsatisfied) to 5 (very satisfied).
      , M (SD)
      4.18 (0.75) (n = 258)
      Further treatment wish
      - No100 (38.5)
      - Unsure60 (23.1)
      - Yes100 (38.5)
      SCL-90, GSI, M (SD)0.59 (0.64) (n = 250)
      low asterisk Participants with any complication after 1 or more surgeries.
      Mean of feminizing and masculinizing surgeries combined.
      Scores range from 1 (very unsatisfied) to 5 (very satisfied).

       Aftercare Needs

      Among the participants, 169 (65%) reported the wish for additional postoperative care (Figure 1). The most frequently mentioned aftercare need was (more) assistance in surgical recovery (n = 123, 47%), followed by consultation with a mental health professional (n = 93, 36%), and physiotherapy for the pelvic floor (n = 52, 20%). Of the 123 participants that wished for (more) assistance in surgical recovery, 50 (40.7%) had received masculinizing surgeries (32 (26%) mastectomy, 15 (12.2%) mastectomy and phalloplasty, and 3 mastectomy and metoidioplasty (2.4%)) and 73 had received feminizing surgeries (3 (2.4%) breast augmentation, and 70 (56.9%) vaginoplasty with/without breast augmentation). Furthermore, of the 52 participants that wished for physiotherapy for the pelvic floor, 23 had received masculinizing surgeries (12 (23.1%) mastectomy, 8 (15.4%) mastectomy and phalloplasty, and 3 (5.8%) mastectomy and metoidioplasty) and 29 had received feminizing surgeries (1 (0.01%) breast augmentation, and 28 (53.8%) vaginoplasty with/without breast augmentation). Among all those reporting additional aftercare needs, 94 (36.2%) reported 1, 51 (19.6%) reported 2, and 24 (9.2%) reported all 3 predefined aftercare needs.
      Figure 1
      Figure 1Aftercare Needs Frequencies:
      Wish for (additional) assistance in surgical recovery: Quoted (n = 123)/Not Quoted (n = 137).
      Wish for (additional) sessions with a mental health professional: Quoted (n = 93)/Not Quoted (n = 167).
      Wish for (additional) physiotherapy for the pelvic floor: Quoted (n = 52)/Not Quoted (n = 208).

       Predictive Factors

      Table 2 describes the factors associated with aftercare needs. A higher score of psychological symptoms (SCL-90) predicted the needs for consultation with a mental health professional (OR = 2.40, CI 1.49–3.84), for physiotherapy for the pelvic floor (OR = 2.06, CI 1.23–3.44), and for (additional) assistance in surgical recovery (OR = 1.65, CI 1.04–2.62). Lower surgical satisfaction was associated both with the need for (additional) assistance in surgical recovery (OR = 0.61, CI 0.42–0.89) and for consultation with a mental health professional (OR = 0.61, CI 0.42–0.88). Furthermore, receiving genital surgery specifically was a strong predictor for requesting physiotherapy for the pelvic floor (OR = 4.92, CI 1.88–12.88), as well as for (additional) assistance in surgical recovery (OR = 2.55, CI 1.47–4.44). Lastly, German participants scored higher on the need for physiotherapy for the pelvic floor (OR = 2.90, CI 1.23–6.86).
      Table 2Factors associated with aftercare needs, Odds Ratio (95% CI)
      P < .05.
      Sessions with a mental health professional (n = 242)Physiotherapy for the pelvic floor (n = 242)Assistance in surgical recovery (n = 242)Sum of quoted aftercare needs (1, 2, or 3)
      P < .001.
      (n = 242)
      Test statisticsΧ2 = 27.08, df = 2,

      R2= 0.15, P < .001
      Χ2 = 24.67, df = 5,

      R2 = 0.15, P < .001
      Χ2 = 27.48, df = 3,

      R2 = 0.14, P < .001
      F = 14.57, df = 4,

      R2 = 0.20, P < .001
      Constant B (SE)0.06 (0.94)-4.97 (1.73)-0.37 (1.08)0.72 (0.46)
      Country
      Only chest = 1, (Chest +) Genital = 2.
      - Netherlands vs Germany2.90 (1.23–6.86)
      Only the factors that remained after elimination based on likelihood ratios using a backwards stepwise approach are shown.
      0.15 (2.48)
      Only the factors that remained after elimination based on likelihood ratios using a backwards stepwise approach are shown.
      Chest/Genital Surgery
      P < .01.
      4.92 (1.88–12.88)
      Linear regression, beta coefficients displayed (t-value).
      2.55 (1.47–4.44)
      Linear regression, beta coefficients displayed (t-value).
      0.21 (3.50)
      Linear regression, beta coefficients displayed (t-value).
      Surgical Satisfaction0.61 (0.42–0.88)
      Linear regression, beta coefficients displayed (t-value).
      0.61 (0.42–0.89)
      Only the factors that remained after elimination based on likelihood ratios using a backwards stepwise approach are shown.
      -0.20 (-3.37)
      Linear regression, beta coefficients displayed (t-value).
      SCL-90, GSI2.40 (1.49–3.84)
      Netherlands = 0, Belgium/Germany = 1.
      2.06 (1.23–3.44)
      Linear regression, beta coefficients displayed (t-value).
      1.65 (1.04–2.62)
      Only the factors that remained after elimination based on likelihood ratios using a backwards stepwise approach are shown.
      0.27 (4.48)
      Netherlands = 0, Belgium/Germany = 1.
      low asterisk Only the factors that remained after elimination based on likelihood ratios using a backwards stepwise approach are shown.
      Linear regression, beta coefficients displayed (t-value).
      Netherlands = 0, Belgium/Germany = 1.
      § P < .05.
      ǁ Only chest = 1, (Chest +) Genital = 2.
      P < .01.
      # P < .001.

       Qualitative Findings

      The open-text answers on the different aftercare needs have been clustered and presented per theme with illustrative quotes in Table 3. Thematic analysis revealed the following 4 domains in aftercare needs: provision of care, additional psychological care, improvement of organization of care and surgical technical care. In correspondence with the quantitative findings, guidance in surgical recovery was mentioned most frequently, which was classified as a sub-theme of provision of care. Going from the quotes, by this, participants generally indicated a desire for more information about the consequences of surgery and clearer instructions on postoperative recovery, for example “what are you allowed to do and what not” (Table 3). A second frequently mentioned theme included the wish for more mental health aftercare, in particular sessions with the psychologist regarding life after transition and how to deal with surgical recovery. One participant stated that psychological follow-up on the impact of the surgery would be particularly helpful. Another important aspect of provision of care was the wish for compassionate aftercare as demonstrated by health care professionals (eg, feelings of sympathy or more personal contact), with 1 participant mentioning that “though-love was sometimes experienced as unpleasant” (Table 3). In the organizational domain, good access to care was most frequently mentioned, the illustrative quote with this sub-theme mentioned that “you have to organize your follow-up every one or two years yourself,” which suggests that participants often experienced barriers when seeking aftercare (Table 3). Efficiency and the possibility of regional care, with participants mentioning the possibility of hormone prescription or monitoring of serum hormone levels by the general practitioner, were also mentioned within this domain, which implied that with regard to aftercare, not only the content is of importance but also the accessibility. Attention to surgical technical matters, such as postoperative complications, scar care and dilation were least frequently mentioned. However, dilation was also a part of physiotherapy for the pelvic floor which was mentioned more frequently.
      Table 3Aftercare needs (regarding aftercare was there something you missed? + The following would help in care after surgery…)
      Major themeMinor themeMini themen=Quotes (country
      The Netherlands (NL), Belgium (BE), Germany (GER).
      , age, sex, surgery)
      Provision of careGuidanceSurgical recovery19“Now and then, I would have wanted clearer instruction on what I was and was not allowed to do after surgery, and how to dress.” (BE, 27, Transgender man, Mastectomy + Metoidioplasty)
      Further treatments13“Questions and support regarding further treatments. Apart from the vaginoplasty I had to organize everything myself.” (NL, 27, Transgender woman, Vaginoplasty)
      Compassion15“Sometimes I experienced the ‘tough-love’ of the nurses and the surgeons at appointments as unpleasant.” (NL, 23, Transgender woman, Breast Augmentation)
      Communication8“Clear communication” (BE, 48, Transgender man, Mastectomy + Phalloplasty)
      Additional mental health carePsychologyLife after transition18“With the indication for mastectomy, my treatment was completed and I had no further appointments. In retrospect, further psychiatric / psychotherapeutic care, especially in this phase of my life, would have made sense to me.” (GER, 22, Transgender man, Mastectomy)
      During surgical recovery14“Follow-up on the impact of surgery (mostly the psychological effects of anesthesia).” (NL, 50, Transgender woman, Breast Augmentation)
      New gender role5“Sometimes I say: 'It really begins after the surgery.' The initiating, internalizing, and learning to live your gender. I would have liked more aftercare for this.” (NL, 51, Transgender woman, Breast Augmentation)
      Sexology7“Help with discovering your own sexuality.” (NL, 36, Transgender woman, Vaginoplasty)
      Peer support4“It wasn't until long after discharge from the hospital that I found out that it is possible to have a visit from a "companion" who already has post-surgery experience. I would have liked to have known about this earlier so that I could have asked that person any questions I might have had.” (NL, 42, Transgender man, Mastectomy)
      Social work2“Tips on how to deal with everyday situations, such as love, work, school.” (NL, 24, Transgender woman, Vaginoplasty)
      Improvement of organization of careAccessibilityAccess to care10“You are not being contacted for follow-up, but instead you have to organize your follow-up every one or two years yourself. Personally, I do not do this.” (BE, 25, Transgender man, Mastectomy + Phalloplasty)
      Efficiency8“Psychologically speaking; at times I need it, the waiting lists for psychological support are very disappointing. As a result I choose not to make an appointment.” (BE, 40, Transgender man, Mastectomy + Phalloplasty)
      Regional care provision5“It would be nice if hormone prescription could be done by the general practitioner after X years.” (NL, 27, Transgender man, Mastectomy)
      Home care3“Support at home just after surgery. I do have family or a partner who can do this, however I think this should largely be arranged by the care center.” (NL, 31, Transgender woman, Vaginoplasty)
      Surgical technical carePostoperative complications7“Insufficient information about possible complications, expected outcomes and contact details if necessary.” (BE, 37, Transgender man, Mastectomy + Phalloplasty)
      Scar care5“More advice about aftercare, how to take care of the scar, and how to deal with corrections. They speak lightly of this.” (NL, 29, Transgender man, Mastectomy)
      Dilation4“Clearer instructions about the how and why of dilatation.” (BE, 51, Transgender woman, Vaginoplasty)
      OtherPositiveContact5
      Missed nothing80
      Other tips4“My health insurance denied reimbursement of movement and dance therapy, while this could have helped me integrating the emotions I experienced on a physical level.” (GER, 30, Transgender man, Mastectomy)
      Negative10
      low asterisk The Netherlands (NL), Belgium (BE), Germany (GER).

      DISCUSSION

      In transgender health care, gender-affirming surgery is one of the cornerstones of medical transition to many treatment-seeking transgender individuals. GAS generally has positive impact on quality of life and mental health,
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      • Passos TS
      • Teixeira MS
      • Almeida-Santos MA.
      Quality of life after gender affirmation surgery: a systematic review and network meta-analysis.
      • Nobili A
      • Glazebrook C
      • Arcelus J.
      Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis.
      yet long-term outcomes may also depend on adequate aftercare. In the WPATH's Standards of Care, surgeons are advised to establish an aftercare plan in cooperation with TSTG individuals before surgery.
      • Meyer III WJ.
      World Professional Association for Transgender Health's standards of care requirements of hormone therapy for adults with gender identity disorder.
      Still, little is known about the aftercare needs of this group and how to bring these into practice. This study investigated aftercare needs experienced by a large multicenter cohort of TSTG individuals that had received GAS. The participants of this study had been offered some form of aftercare, however the actual aftercare treatments received per participant were not formally studied. Nearly two-third of the participants from all 3 countries expressed the need for additional postoperative care, which is in line with the reported needs in nonclinical studies.
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.

       Assistance in Surgical Recovery

      Almost half of the participants expressed the need for (additional) assistance in surgical recovery, this was also frequently mentioned in the open text answers. More complex surgeries, including GAS, involve higher risks of postoperative complications.
      • Hadj-Moussa M
      • Agarwal S
      • Ohl DA
      • et al.
      Masculinizing genital gender confirmation surgery.
      ,
      • Hadj-Moussa M
      • Ohl DA
      • Kuzon Jr, WM.
      Feminizing genital gender-confirmation surgery.
      Genital GAS for trans feminine individuals includes vaginoplasty, during which a neovaginal canal is constructed from autologous tissue.
      • Pan S
      • Honig SC.
      Gender-affirming surgery: Current concepts.
      Penile inversion vaginoplasty remains the most commonly performed technique, after which lifelong dilatation and scheduled douching of the neovagina are mandatory to maintaining it functioning optimally.
      • Hadj-Moussa M
      • Ohl DA
      • Kuzon Jr, WM.
      Feminizing genital gender-confirmation surgery.
      It is therefore important that these commitments are appropriately discussed pre- and postoperatively.
      • Pan S
      • Honig SC.
      Gender-affirming surgery: Current concepts.
      Complications such as loss of sensation, disappointing cosmesis, excessive bleeding and prolonged pain will result in higher patient dissatisfaction.
      • Schardein JN
      • Zhao LC
      • Nikolavsky D
      Management of vaginoplasty and phalloplasty complications.
      ,
      • Massie JP
      • Morrison SD
      • Van Maasdam J
      • et al.
      Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty.
      Genital surgery for trans masculine individuals may entail the construction of a neophallus and urethral lengthening, which is a significant challenge because no optimal substitutes are available for erectile, fascial or urethral tissue.
      ,
      • Djordjevic ML.
      Novel surgical techniques in female to male gender confirming surgery.
      Urologic complications are among the most common complications after metoidioplasty and phalloplasty.
      • Schardein JN
      • Zhao LC
      • Nikolavsky D
      Management of vaginoplasty and phalloplasty complications.
      ,
      • Kocjancic E
      • Acar O
      • Talamini S
      • et al.
      Masculinizing genital gender-affirming surgery: Metoidioplasty and urethral lengthening.
      To reduce the likelihood or severity of post-GAS complications it is important that transgender individuals know what symptoms to pay attention to, in order to optimize complication management,
      • Schardein JN
      • Zhao LC
      • Nikolavsky D
      Management of vaginoplasty and phalloplasty complications.
      as well as when to seek additional care. Clarity on the do's and don'ts during the recovery period may lead to better long-term functional and aesthetic outcomes. As transgender care is highly complex and calls for a multidisciplinary approach, individuals will require closer and more accustomed guidance in surgical recovery than those from other surgical populations.
      • Tollinche LE
      • Walters CB
      • Radix A
      The perioperative care of the transgender patient.
      However, it has been observed that transgender individuals are in general more able to navigate (after) care once they are further progressing through their treatment trajectory.
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.
      A qualitative study on postoperative recovery after abdominal and gynecological surgery in cisgender individuals demonstrated that the recovery experience was influenced by receiving regular appropriate information, support and encouragement from hospital staff and family, and by being given the time to recover.
      • Allvin R
      • Ehnfors M
      • Rawal N
      • et al.
      Experiences of the postoperative recovery process: An interview study.
      This knowledge could be used to give substance to the surgical aftercare plan of the Standards of Care and/or clinical guidelines, which should take a compassionate approach as well as provide adequate information at various moments in the transitioning process regarding surgical recovery, potential complications and how to act upon this.

       Psychological Support

      (Additional) consultations with a mental health professional after surgery were frequently desired by participants, which is in line with previous studies focusing on mental health care during the whole transitioning process.
      • Mayer TK
      • Koehler A
      • Eyssel J
      • et al.
      How gender identity and treatment progress impact decision-making, psychotherapy and aftercare desires of trans persons.
      ,
      • Eyssel J
      • Koehler A
      • Dekker A
      • et al.
      Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey.
      ,
      • Davies A
      • Bouman WP
      • Richards C
      • et al.
      Patient satisfaction with gender identity clinic services in the United Kingdom.
      • Bockting W
      • Robinson B
      • Benner A
      • et al.
      Patient satisfaction with transgender health services.
      • Simeonov D
      • Steele LS
      • Anderson S
      • et al.
      Perceived satisfaction with mental health services in the lesbian, gay, bisexual, transgender, and transsexual communities in Ontario, Canada: An Internet-based survey.
      TSTG individuals have been found to be more at risk for mental health symptoms than the general population
      • Dhejne C
      • Van Vlerken R
      • Heylens G
      • et al.
      Mental health and gender dysphoria: A review of the literature.
      ,
      • Bockting WO
      • Miner MH
      • Swinburne Romine RE
      • et al.
      Stigma, mental health, and resilience in an online sample of the US transgender population.
      . Furthermore, psychological problems may exacerbate when an individual undergoes surgery.
      • Nickinson RS
      • Board TN
      • Kay PR.
      Post-operative anxiety and depression levels in orthopaedic surgery: A study of 56 patients undergoing hip or knee arthroplasty.
      On the other hand, for many TSTG individuals GAS is often a long-awaited procedure that generally contributes positively to mental wellbeing. In a recent systematic review, most studies demonstrated improved mental health post-GAS, although even after GAS, many studies still found poorer psychological well-being among TSTG individuals compared to the general public.
      • Wernick JA
      • Busa S
      • Matouk K
      • et al.
      A systematic review of the psychological benefits of gender-affirming surgery.
      Psychotherapy can help individuals get through their transition and adapt to their changed life
      • Reisner SL
      • Poteat T
      • Keatley J
      • et al.
      Global health burden and needs of transgender populations: a review.
      and it could also be beneficial for individuals in coping with disappointing (aesthetic or functional) outcomes. Our qualitative findings suggested that during psychological sessions there should be a focus on how to cope with surgical recovery and life after medical transition. The WPATH's Standards of Care describe in detail in what ways mental health care can be supportive for transgender individuals, and also how psychotherapy can be helpful at many stages of life.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      As psychological consultations may not be scheduled by standard, especially after GAS, this may be experienced as a barrier to get additional mental health care after surgical transition. Also, post-transition psychological care may be dependent on health care-system characteristics, such as required diagnoses, reimbursement and (skilled) provider capacity. Based on the results reported in this study, the surgical plan in the Standards of Care and/or clinical guidelines should clearly mention the possibility and need for psychological aftercare.

       Physiotherapy for the Pelvic Floor

      One-fifth of the participants mentioned (additional) need for physiotherapy for the pelvic floor. Vaginoplasty results in a significant change in the pelvic floor anatomy, a complex area with important urinary, intestinal and sexual functions.
      • Jiang DD
      • Gallagher S
      • Burchill L
      • et al.
      Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty.
      ,
      • Raizada V
      • Mittal RK.
      Pelvic floor anatomy and applied physiology.
      ,
      • Bharucha AE.
      Pelvic floor: Anatomy and function.
      Trans feminine individuals must perform dilation of the neo-vaginal canal to avoid stenosis,
      • Pariser JJ
      • Kim N.
      Transgender vaginoplasty: Techniques and outcomes.
      which requires direct relaxation of the pelvic floor muscles. To improve outcomes and reduce anxiety, transgender individuals need to learn to connect to and work with their altered anatomy.
      • Jiang DD
      • Gallagher S
      • Burchill L
      • et al.
      Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty.
      ,
      • Manrique OJ
      • Adabi K
      • Huang TC-T
      • et al.
      Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes.
      Earlier research demonstrated a high incidence of preoperative pelvic floor problems in trans feminine individuals, indicating both preoperative and postoperative physiotherapy would be beneficial.
      • Jiang DD
      • Gallagher S
      • Burchill L
      • et al.
      Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty.
      ,
      • Manrique OJ
      • Adabi K
      • Huang TC-T
      • et al.
      Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes.
      Furthermore, previous literature has highlighted significant improvements in symptoms after follow-up with physiotherapy.
      • Manrique OJ
      • Adabi K
      • Huang TC-T
      • et al.
      Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes.
      • Pauls RN
      • Crisp CC
      • Novicki K
      • et al.
      Pelvic floor physical therapy: Impact on quality of life 6 months after vaginal reconstructive surgery.
      • Rosenbaum TY
      • Owens A.
      Continuing medical education: the role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME).
      Therefore, the inclusion of recommendations for pre- and/or postoperative physiotherapy for the pelvic floor in trans feminine individuals should be considered for clinical guidelines regarding GAS. Furthermore, metoidioplasty or phalloplasty can require urethral lengthening and also come with a significant anatomical change in the pelvic area.
      • Hadj-Moussa M
      • Agarwal S
      • Ohl DA
      • et al.
      Masculinizing genital gender confirmation surgery.
      Publications on the effect of GAS with urethral lengthening on lower urinary tract function found high complication rates, with varying results in lower urinary tract function postoperatively and after complication treatment.
      • Veerman H
      • de Rooij F
      • Al-Tamimi M
      • et al.
      Functional outcomes and urological complications after genital gender affirming surgery with urethral lengthening in transgender men.
      ,
      • Hoebeke P
      • Selvaggi G
      • Ceulemans P
      • et al.
      Impact of sex reassignment surgery on lower urinary tract function.
      Inability to relax the pelvic floor muscle after genital surgery can result in LUTS and urinary retention, for which relaxation exercises can be beneficial.
      • Garcia M.
      217 Design and early clinical experience with a smartphone-based biofeedback app to improve pelvic floor muscle training (Kegel Exercises) and routine neovagina self-care after transgender gender affirming surgery.
      In urology, pre- and postoperative pelvic floor muscle training is proven to be an effective treatment for urine incontinence after a radical prostatectomy in men.
      • Patel MI
      • Yao J
      • Hirschhorn AD
      • et al.
      Preoperative pelvic floor physiotherapy improves continence after radical retropubic prostatectomy.
      ,
      • Strączyńska A
      • Weber-Rajek M
      • Strojek K
      • et al.
      The impact of pelvic floor muscle training on urinary incontinence in men after radical prostatectomy (RP) – A systematic review.
      As the long-term effects of GAS on lower urinary tract function are largely unknown, long-term follow-up of these trans masculine individuals is preferred. There is a lack of evidence regarding pre- and postoperative physiotherapy for the pelvic floor after masculinizing genital surgery, which should be further evaluated, as it seems beneficial to prevent or alleviate postoperative urological problems.

       Predictive Factors

      We found that individuals with lower psychological wellbeing upon clinical entry required more extensive aftercare. We observed that lower surgical satisfaction was associated with the need for (additional) assistance in surgical recovery and psychological consultation after surgery. According to a previous study, psychological symptoms and surgical dissatisfaction are also associated: individuals with lower psychological wellbeing at the start of transition may experience surgical outcomes more negatively.
      • van de Grift TC
      • Elaut E
      • Cerwenka SC
      • et al.
      Surgical satisfaction, quality of life, and their association after gender-affirming surgery: A follow-up study.
      Possibly, this group may engage less in self-care which may influence surgical outcomes, and they may have a poorer support system which may affect their resilience. These hypotheses, however, should be studied further. In the present study, receiving genital surgery was associated with the need for (additional) assistance in surgical recovery and physiotherapy for the pelvic floor as well. This is understandable, as these complex procedures carry more risk for complications and require a longer recovery period.
      • Hadj-Moussa M
      • Agarwal S
      • Ohl DA
      • et al.
      Masculinizing genital gender confirmation surgery.
      ,
      • Hadj-Moussa M
      • Ohl DA
      • Kuzon Jr, WM.
      Feminizing genital gender-confirmation surgery.
      Surgeons should keep these predictive factors in mind for the establishment of a patient-specific aftercare plan. This means more extensive and intensive guidance during surgical recovery and/or tailored postoperative psychological follow-up for transgender individuals with lower surgical satisfaction, with lower psychological wellbeing, and those undergoing genital surgery. For the latter group, in particular trans feminine individuals, (additional) physiotherapy for the pelvic floor after genital surgery has been suggested before, as it may be effective in solving pelvic floor problems.
      • Manrique OJ
      • Adabi K
      • Huang TC-T
      • et al.
      Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes.
      • Pauls RN
      • Crisp CC
      • Novicki K
      • et al.
      Pelvic floor physical therapy: Impact on quality of life 6 months after vaginal reconstructive surgery.
      • Rosenbaum TY
      • Owens A.
      Continuing medical education: the role of pelvic floor physical therapy in the treatment of pelvic and genital pain-related sexual dysfunction (CME).
      As stated priorly, pelvic floor physiotherapy for trans masculine individuals seems effective,
      • Garcia M.
      217 Design and early clinical experience with a smartphone-based biofeedback app to improve pelvic floor muscle training (Kegel Exercises) and routine neovagina self-care after transgender gender affirming surgery.
      however, it remains an important subject of further study as literature is scarce.

       Limitations

      This research was subject to several limitations. Firstly, this study included participants from 3 different European countries, all with their own aftercare facilities, different conditions on health care reimbursement and sociocultural characteristics. One example is the difference in access to virtual care, which was only provided in Germany via optional email contact. The use of postoperative virtual care is proven to be beneficial in multiple ways (eg, patient satisfaction, access to care),
      • Williams AM
      • Bhatti UF
      • Alam HB
      • et al.
      The role of telemedicine in postoperative care.
      and this could influence the needs experienced by German participants. Nevertheless, there were no differences in aftercare needs between the different countries, as country was not one of the significant predictors. Secondly, we did not formally assess the actual received aftercare, and assumed that participants followed the standard aftercare protocol of their specific medical center. As some aftercare procedures or consultations were on request or on indication only, received aftercare could differ greatly between participants. We can therefore not compare received care with the expressed aftercare needs. Also, some participants stated a need for physiotherapy for the pelvic floor, even when they had not received genital surgery, which may suggest an issue with the understanding of this question. One possible explanation for this could be that some participants responded affirmatively to all aftercare need questions, even when the answer did not correspond with their recovery. In this study there is also no specific report on aftercare needs of nonbinary transgender individuals, as there were only 16 participants who identified their gender as other than (trans) male or female. This may be due to the fact that binary transgender individuals are more prone to undergo surgical procedures than nonbinary transgender individuals.
      • Koehler A
      • Eyssel J
      • Nieder TO
      Genders and individual treatment progress in (non-) binary trans individuals.
      Therefore, aftercare needs may differ for nonbinary transgender individuals. This study had an attrition rate of 35.7%, which is in line with most follow-up studies.
      • Gijs L
      • Brewaeys A.
      Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges.
      Possible ways to minimize this in further research could be to create more options for participation (eg, in person interviews or online) or to stimulate community engagement in study design, recruitment and promotion.
      • Owen-Smith AA
      • Woodyatt C
      • Sineath RC
      • et al.
      Perceptions of barriers to and facilitators of participation in health research among transgender people.
      Additionally, a previous nonresponder analysis showed the participating cohort to be older and more educated compared with the nonresponders. These factors could be of influence on self-sustainability: older and/or more educated participants may be more capable in getting the specific help they need and therefore require less postoperative support than those who are younger and less educated. Lastly, for the purpose of the analysis different groups were pooled, possibly this may have obscured findings on specific less-frequent surgical procedures. Future analysis may be improved by using a more granular approach.

      CONCLUSION

      In this study, we highlighted a number of specific aftercare needs after GAS as well as characteristics associated with those needs that health care providers should be aware of. The results of this study emphasize the needs expressed by TSTG individuals for health care providers to include more emphasis on guidance during surgical recovery, postoperative psychological support, and physiotherapy for the pelvic floor. The present WPATH's Standards of Care (v7) indicate development of an aftercare plan by surgeons and TSTG individuals, although concrete specifications are lacking. According to the results of this study, such a surgical plan and other clinical guidelines regarding GAS should include the provision of adequate information for each procedure, clear postoperative instructions, continuity of care and contact with health care providers, and the recommendation for physiotherapy for the pelvic floor following genital surgery. It is important to mention, however, that clinical capacity matters such as the growing waiting-lists for treatment also have an influence on the ability of clinics to provide the requested aftercare. Lastly, health care providers should clearly mention the possibility of psychological aftercare, especially for those at risk of poorer mental health outcomes.

      STATEMENT OF AUTHORSHIP

      Iris J. de Brouwer: Conceptualization, Methodology, Validation, Formal Analysis, Writing – Original Draft, Writing – Review & Editing, Visualization; Els Elaut: Validation, Investigation, Data Curation, Writing – Review & Editing; Inga Becker-Hebly: Validation, Investigation, Data Curation, Writing – Review & Editing; Gunter Heylens: Validation, Investigation, Writing – Review & Editing ; Timo O. Nieder: Validation, Investigation, Writing – Review & Editing; Tim C. van de Grift: Conceptualization Methodology, Validation, Formal Analysis, Investigation, Writing – Original Draft, Writing – Review & Editing, Visualization, Supervision; Baudewijntje P.C. Kreukels: Conceptualization Methodology, Validation, Investigation, Data Curation, Writing – Original Draft, Writing – Review & Editing, Visualization, Supervision, Project Administration.

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