International Journal of Transgenderism

ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: http://tandfonline.com/loi/wijt20

Gynecological Aspects of Transgender Healthcare

Michael A. A. van Trotsenburg

To cite this article: Michael A. A. van Trotsenburg (2009) Gynecological Aspects of

Transgender Healthcare, International Journal of Transgenderism, 11:4, 238-246, DOI:
10.1080/15532730903439484

To link to this article: https://doi.org/10.1080/15532730903439484

Published online: 19 Dec 2009.

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International Journal of Transgenderism, 11:238–246, 2009
Copyright
C Taylor & Francis Group, LLC
ISSN: 1553-2739 print / 1434-4599 online
DOI: 10.1080/15532730903439484

Gynecological Aspects of Transgender Healthcare

Michael A. A. van Trotsenburg

ABSTRACT. The role of gynecology for transgender healthcare has traditionally been limited to
hysterectomy and oophorectomy in female-to-male transsexuals (FtM). But much more health issues
within the broad spectrum of gynecology are relevant for transsexuals of both sexes. From procreation to
cancer prevention, from genital health maintenance to pelvic floor disorders, from dyspareunia to libido
loss, gynecology may play a major role for healthcare maintenance of the transgender population.
In this article several gynecological aspects are highlighted with special attention to the context of
transsexualism. The lack of knowledge of gynecologists about the special needs of this population, and
in many countries a reserved attitude of doctors toward transgender persons, still is a limiting factor of
gynecological care for transgender persons.

KEYWORDS. Transgender, gynecology, genital health

INTRODUCTION with an indisputable female connotation or due

Gynecology has traditionally been involved
in the process of gender transition in both direc-
tions, either male-to-female (MtF) or female-to-
male (FtM).
Hysterectomy and bilateral salpingo-
oophorectomy (BSO) for FtMs are routine
gynecological procedures but might be aggra-
vated because almost all candidates are either
nulliparous and have not experienced vaginal
penetration before and have considerable
vaginal atrophy caused by androgen treatment.
Total vaginectomy (colpectomy) is rarely per-
formed in biological women but is increasingly
asked for by FtMs either to get rid of an organ
to complaints derived from vaginal discharge or
for both reasons. If outer genital reassignment
is carried out, vaginectomy is mostly part of
the procedure. However, the majority of FtMs
worldwide never undergo outer genital reassign-
ment. In elderly FtMs, incontinence and pelvic
floor disorders may occasionally lead to further
involvement of gynecologists.
Referring to MtF, gynecology has been in-
volved in sex reassignment surgery (SRS) due
to its longstanding experience with vaginal age-
nesis but to date MtF SRS done by gynecol-
ogists has become an exception rather than
the rule. After completion of SRS, gynecology
might play an important role in both solving

Dr. Michael A. A. van Trotsenburg, MD, is a gynecologist/obstetrician at the Department of Obstetrics

and Gynecology of the Free University of Amsterdam (VUmc) whose specializations include endoscopy
and gynecological endocrinology. He advanced the 1999 installlation of the first Austrian out-patients’ clinic
for transgender healthcare at the Medical University of Vienna. Since 2005 he has been a member of the
Amsterdam Gender Team, succeeding Prof. L. Gooren, and since 2006 the Director of the Amsterdam Center
for Gender Dysphoria.
Address correspondence to Dr. Michael A. A. van Trotsenburg, Department of Obstetrics and Gynecology,
Center for Gender Dysphoria, Free University Medical Center (VUmc), P.O. Box 7057, 1007 MB Amsterdam,
The Netherlands. E-mail: m.vantrotsenburg@vumc.nl

238
 Michael A. A. van Trotsenburg
functional problems and maintaining genital
health.
This survey describes gynecological aspects
of transgender health care within the course
of gender transition and thereafter. Cross-sex
hormonal treatment and its special requirements
are outside the scope of this article.
MALE-TO-FEMALE
To date the technique of choice for creating
a neovagina for transsexuals is the inverted pe-
nile skin flap technique (Monstrey, Selvaggi, &
Ceulemans, 2007), mostly augmented by a pos-
teriorly pedicled perineo-scrotal flap to ensure
a diameter of the neovagina suitable for inter-
course. Because the process of shrinkage of the
neovagina is inherent to the creation of this or-
gan, patients are instructed accurately by their
surgeons about matters of dilation in order to
maintain diameter and length of the neovagina.
Some of those concerned do see the operation as
the last hurdle on a long path, and they refuse any
further medical care in order to give themselves
the appearance of normality regarding their new
gender.
Hygiene
Many transsexuals do not know how to deal
with disorders of the newly created genital struc-
tures. Counseling about genital hygiene, sexu-
ality, prevention of (sexually transmitted) gen-
ital diseases, and possible clinical symptoms
of urogenital disorders should be offered rou-
tinely after being released from postoperative
care. However, a heavy emotional strain is put
on the (newly created) genital region, some-
times leading to overcompensation on genital
hygiene.
Transsexuals are possibly more vulnerable to
infections due to missing biologic barriers. Cre-
ation of labia minora covering the introitus of
the neovagina is one of the most difficult parts of
transgender surgery and this is often not created
or only allusive. Doederlein bacilli do not colo-
nize the epithelium of the neovagina creating a
protective acid milieu, and mucus, dandruff, and
sebum can be clotted around the hair follicles of
239
the perineo-scrotal flap used for lining the poste-
rior wall. These clots might lead to discharge and
infection, which can be prevented by epilation of
the perineum and lower part of the scrotum in
good time. Last but not least, lower urinary tract
infections are more probable because the shape
of the opening of the shortened urethra is con-
structed in a gaping fashion in order to prevent
stenosis (Selvaggi et al., 2005).
In addition, MtFs may suffer from functional
disorders of the lower urinary tract caused by
damage of the autonomous nerve supply of
the bladder floor during dissection between the
rectum and the bladder and due to a change
of the position of the bladder itself (Hoebeke
et al., 2005). Kuhn, Hiltebrand, and Birkhauser
(2007) recently considered a dysfunctional blad-
der (e.g., overactive bladder and stress urinary
incontinence) quite normal after SRS.
Intercourse After SRS
In addition to emotional concerns about sex-
uality as a female with newly created organs,
and without any experience, anatomic facts also
complicate satisfying and painless intercourse.
Due to the anatomy of the male pelvis, the axis
and the dimensions of the neovagina differ sub-
stantially from a biologic vagina. The vaginal
axis from a biologic woman, measured from the
introitus to the pelvic diaphragm, is vertical and
posterior. The upper vagina changes its axis at
the level of the pelvic diaphragm and becomes
more horizontal (Barnhart et al., 2006). The axis
of the neovagina in MtFs is less vertical. The
anatomic circumstances need to be known for
satisfactory intercourse for both the transsexual
female and a male sexual partner. During in-
tercourse the erected penis might push against
the anterior wall of the vagina and against the
gaping meatus of the urethra. Because the com-
missura posterior is often pulled up, covering a
substantial part of the introitus, penetration be-
comes more difficult, potentially causing pain
to the woman. A transsexual female should be
fully aware of the specific characteristics of the
constructed genital region. Information about
anatomy and functioning of the neovagina is
a prerequisite for satisfying sexual intercourse.
(At least at the beginning) a transsexual female
240 INTERNATIONAL JOURNAL OF TRANSGENDERISM
needs to guide a sexual partner in order to make
it pleasant to both of them. Information from a
gynecologist or gynecological nurse may help
bridge the gap between expectations and physi-
cal opportunities.
Hormone-Sensitive Tissue
Supraphysiologic hormone therapy requires
an increased observation of hormone-sensitive
tissue. Posttransitionally, regular checkups at in-
tervals of one to two years constitute the mini-
mum requirement and must include genital ex-
amination.
Breast
Depending on the country of origin, 9–12%
of all women will be given a diagnosis of breast
cancer in their lifetimes and 3.5% will die of
the disease. Breast cancer in males is rare but
increasing and constitutes 0.2–1.5% of all ma-
lignant tumors in men and 1% of all breast can-
cers. Additionally men with breast cancer are
significantly at risk for a second cancer (Bagchi,
2007).
Surprisingly, only casuistic reports on breast
carcinomas in MtFs after long-term hormone
substitution have been published. In view of the
supraphysiological hormone treatment and bear-
ing in mind that most breast cancers are estrogen-
and/or progesterone-receptor positive, from an
oncologic point of view a higher percentage of
breast cancer in transsexuals would be expected
(Gooren, Giltay, & Bunck, 2008). Is breast can-
cer underreported for transsexuals? Or will the
incidence start to rise as the occult cancers reveal
themselves later and MtFs get older?
Breast cancer screening is very much in de-
bate (Jorgensen, Klahn, & Gotzsche, 2007). In
populations where there are screening programs,
these provide early detection of malignancies re-
sulting in 25% lower mortality rates. These gains
must be weighed against the losses of expense,
radiation, and false-positive diagnoses with their
accompanying anxiety and investigations.
Transsexuals often have implants mostly
placed behind the pectoral muscle because
hormone-induced gynecomastia has not resulted
in subjectively satisfying enlargement. Some-
times breast prostheses are placed subglandu-
larly making it more difficult to judge prop-
erly standard imaging techniques. In that case
mammography and ultrasound might be insuf-
ficient to detect small suspicious lesions. Mag-
netic resonance imaging (MRI) may serve as an
alternative. There is a consistent and growing
body of evidence that adding MRI provides a
highly sensitive screening strategy (sensitivity
range: 93–100%) compared to mammography
alone (25–59%) or mammography plus ultra-
sound with or without clinical breast examina-
tion (49–67%; Lalonde, David, & Trop, 2005;
Lord et al., 2007). In addition, it is worth men-
tioning that breast implants do not increase the
risk for developing breast cancer or any other
malignancy (Lipworth et al., 2008).
Summarizing, arguments for breast cancer
screening of transsexuals are by no means ro-
bust enough to be recommended. However, dis-
crepancies between the general population and
transsexuals regarding the incidence of breast
cancer is worrying. Transsexuals should always
be informed that they might be at risk for breast
cancer. If a suspicious mass is detected by self-
examination or by any imaging technique, exci-
sion should be recommended imperatively.
Prostate
Prostatectomy is not part of the recommended
surgical procedures of SRS, because prostate-
ctomy shows substantial morbidity. Therefore,
digital rectal examination of the prostate in pa-
tients older than 50 years should be manda-
tory, preferably at the start of cross-sex hor-
monal treatment. If the prostate is enlarged or
a lump palpable, patients should be referred to a
urologist for further examination; for example,
prostate-specific antigen (PSA) screening and
eventually an ultrasound-guided biopsy. Cross-
sex hormone treatment usually leads to hypotro-
phy of the prostate but not always. It is of note
that PSA screening in MtFs under anti-androgen
treatment is not valid.
For older males, benign prostatic hyperpla-
sia (BPH) is a common finding and cancer of
the prostate is not rare. For MtFs, lower urinary
tract symptoms are less often reported and only
some singular case reports have been published.
As a result of cross-sex hormonal treatment
 Michael A. A. van Trotsenburg
the prostate is hardly palpable and shrunk from
a chestnut-shaped organ to a cherry-sized or-
gan or even smaller. However, there is increas-
ing evidence that estrogen and estrogen recep-
tors play an important role in the pathogenesis
of prostate cancer (Bonkhoff & Berges, 2008).
Therefore, after SRS, examination of the female
genital region should always include palpation
of the prostate, especially in MtFs who started
cross-sex hormone therapy beyond the age
of 50.
Human Papilloma Virus Infection
(for FtM and MtF)
Infection of the genital tract in both men
and women is most frequently caused by her-
pes simplex virus (HSV) types 1 and 2, human
papilloma viruses (HPV), with approximately
40 anogenital types, and Chlamydia trachoma-
tis and has risen to epidemic levels.
HPV infections lead to anogenital cancer in
approximately 1 out of 100 of those infected, in
particular cervical cancer. Obviously, prevention
of severe cervical dysplasia or cervical cancer is
no issue for the transgender population. How-
ever, a case report of a transsexual with cervical
cancer has been published (Driák, 2004; Driák &
Samudovský, 2005). Additionally, accidental
detection of cervical stumps left in situ causes
concern: Supracervical hysterectomy is becom-
ing increasingly popular because it is a simple,
time-sparing technique with suggested, but so
far not proven, less negative impact on sexu-
ality and the pelvic floor. Patients are not al-
ways aware that a cervical stump is left behind
that warrants cytological screening. Although
supracervical hysterectomy has significant ad-
vantages in terms of technical simplification and
quicker postoperative recovery, this technique is
not suitable for FtMs. Due to considerable vagi-
nal atrophy and obvious emotional restraints, the
cervix left behind is not easily accessible for car-
rying out a pap smear.
Epidemiological data confirm the fact that
women who do not attend to organized cytolog-
ical screening have a much higher prevalence
of oncogenic HPV types than the general popu-
lation (Stenvall, Wikstrom, & Wilander, 2007).
Furthermore, genital HPV infection cannot al-
241
ways be prevented by condom use because HPV
can be transmitted also from infected skin adja-
cent to genital mucosa (Winer et al., 2006).
The association of HPV high risk types and
anogenital cancers, as well as cancers of the
mouth, the upper respiratory tract, and skin,
especially of the fingers and periungual re-
gion, is well established. Parallel to the rising
prevalence of HPV infection, increased num-
bers of high-grade dysplasia and cancer of the
vulva and the vagina among younger women
have been reported (Joura, 2002; Joura, Losch,
Haider-Angeler, Breitenecker, & Leodolter,
2000).
Ample evidence exists that cancers of the
colon, rectum, and anus are significantly asso-
ciated with high-risk serotypes, especially HPV
16, and can be considered as a consequence of
sexually or otherwise acquired infection in the
anal mucosa (Damin et al., 2007; Frisch, 2002).
Sexual behaviors and several case reports about
dysplasia and cancer of the genital region of
transgender persons make it plausible to suggest
an equally high risk compared to the general pop-
ulation (Harder, Erni, & Banic, 2002; Lawrence,
2001). Therefore, regular gynecologic examina-
tion of the neovagina originated either from pe-
nile epithelium or a sigmoid colon segment and
all adjacent tissue is strongly recommended.
Prevention of HPV-associated dysplasia or
cancer is increasingly recognized. The prospects
for prophylactic HPV vaccines are extremely
promising. The potential benefits of vaccination
to reduce the burden of recurrent respiratory pa-
pillomatosis and cancers of the vagina, vulva,
cervix, anus, penis, and head/neck have urged
many countries to approve programs to vacci-
nate young girls between 9 and 16 years of age
and young women between 16 and 26 years of
age. Many experts feel that boys and young men
should also be vaccinated. To date HPV vacci-
nation of HPV-seronegative transsexuals is not
promoted. However, if the indication for vacci-
nation is extended to adults, transsexuals will
certainly benefit.
Many (European) transsexuals still do smoke.
Unfortunately, HPV and smoking do multiply
the risks for several cancers. Progression of
dysplasia likewise seems to be associated with
smoking (Moore et al., 2001).
242 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Pap Smear
Cytologic screening (pap smear) of the vagi-
nal vault is not indicated for women who have
had a hysterectomy (Mouithys et al., 2003), and
cytologic screening of the neovagina of MtF
transsexuals is not indicated. Primary cancer of a
biologic vagina is extremely rare, accounting for
only 0.3–2% of all malignant neoplasms of the
female genital tract. However, cancer of the neo-
vagina after reconstruction for congenital agen-
esis has been described casuistically for both
squamous cell carcinoma and adenocarcinoma.
Therefore, regular examination of the entire lin-
ing of the neovagina seems recommendable. If a
lesion is considered suspicious, biopsy is recom-
mended rather than cytology. Granulation tissue
might be difficult to discriminate from suspi-
cious lesions and should also be biopsied in case
of any doubt.
FEMALE-TO-MALE
Worldwide SRS of FtMs is mostly restricted
to bilateral mastectomy and removal of the in-
ner genital organs; that is, hysterectomy and bi-
lateral salpingo-oophorectomy. Reasons for this
limitation are both financial and due to lack of
available surgical competence. Therefore, FtMs
should bear in mind that the genital structures
left in place are vulnerable for disorders, such
as hormonally induced deficiency symptoms or
sexually transmitted diseases.
No epidemiological evidence so far justifies
routine preoperative cytological screening of the
cervix in the absence of suspicious symptoms as
long as candidates for hysterectomy have not
been sexually active. The majority of FtMs are
virgins and gynecologic examination is experi-
enced as traumatic. Only for FtMs postponing or
refusing hysterectomy and with a history of sex-
ual activity should routine cytological screening
(pap smear) be recommended according to the
guidelines of the national societies of obstetrics
and gynecology.
Females with gender dysphoria show the
same prevalence for any physical comorbidity
as the average female population. Gynecological
complaints at a younger age are often hyperme-
norrhea, or dysmenorrhea, or pelvic pain. These
complaints can be hormonally induced but can
be related to other disorders (e.g., endometriosis,
fibroids, dermoid cysts, or genitourinary infec-
tions). Some authors suggest a linkage of the
polycystic ovary syndrome (PCOS) and its in-
herent hyperandrogenemia with a higher risk of
malignant transition of the ovaries (Edmondson
& Monaghan, 2001; Lobo, 1991; Terry, de Vivo,
Titus-Ernstoff, Shih, & Cramer, 2005; Wang &
Chang, 2004), but results are under debate. Some
authors even hypothesize a relationship between
PCOS and transsexualism because PCOS has
been observed more frequently in FtMs com-
pared to healthy women within their reproduc-
tive phase (Baba et al., 2007). Indeed, sporadic
case reports about ovarian cancer in transsexu-
als have been published (Dizon, Tejada-Berges,
Koelliker, Steinhoff, & Granai, 2006; Hage,
Dekker, Karim, Verheijen, & Bloemena, 2000)
but do not suggest an epidemiologic linkage
between ovarian cancer and supraphysiologic
androgen treatment. Because considerable high
serum concentrations of estradiol are frequently
observed in FtMs due to testosterone conversion
by aromatase, hormonal-dependent gynecolog-
ical disorders can be worsened by (cross-sex)
hormonal therapy. That is why it is of importance
to recognize uterine or adnexal pathology at the
start of hormonal treatment in order to dimin-
ish the chance of worsening of any concomitant
gynecologic disorder. For example, a preexist-
ing large uterus myomatosus should be treated
with nonconversible androgens and/or GnRH
agonists to prevent further growth stimulation.
Most FtMs are virgins and try to suppress the
existence of the genuine genital organs. Expo-
sure of the disliked genital tract is felt as unbear-
able. Transabdominal sonography with a full
bladder functioning as a pelvic window might
be an expedient offering a reasonable impres-
sion of the inner genital. Symptoms pointing to
genitourinary disease should always be taken se-
riously. In principle, gender dysphoria can never
be an excuse to refrain from professional exam-
ination.
Needless to say, surgical procedures follow
strict professional obligations and rules, in-
cluding preoperative examination. However, the
unique situation of FtMs might make it worth
 Michael A. A. van Trotsenburg
considering gynecological examination immedi-
ately prior to surgery during narcosis, provided
that informed consent has laid down proceedings
in case of detection of any unexpected (malig-
nant) disorder.
Hysterectomy and BSO preferably should be
performed (laparoscopically assisted) vaginally
or as a total laparoscopic procedure. Gynecolo-
gists familiar with these modern techniques are
widespread in every country but so far are not
available in every hospital. Laparotomy with a
stigmatizing (Pfannenstiel) incision should be
abandoned for routine FtM hysterectomy and
BSO. Laparotomy should only be performed
with special indications due to relevant intraab-
dominal morbidity or to solve surgical compli-
cations.
If postoperative histopathological workup re-
veals cervical intraepithelial neoplasia (CIN) III
lesions or cervical carcinoma in situ (Cis), there
is clear evidence that follow-up of the vaginal
vault must be maintained, including pap smears
of the vagina and eventually vaginoscopy with a
colposcope. Dysplasia of the cervix potentially
spreads to the fornices of the vagina. If no sus-
picious lesions are detected, there is no rationale
for routine follow-up of the vagina (Mouithys
et al., 2003).
Vaginectomy
In general, only early stages of primary vagi-
nal cancer, and by way of exception vaginal in-
traepithelial neoplasia (VaIN) stage III lesions
occupying the entire vagina, give an indication
for total vaginectomy. VaIN often accompanies
CIN or may be extensions into the vagina from
CIN. Both lesions are triggered by HPV high-
risk serotypes. However, vaginal carcinoma and
its premalignant phase, VaIN III, are rare condi-
tions. Beyond gynecologic oncology, sex reas-
signment surgery may be another indication for
total vaginectomy.
FtMs increasingly ask for vaginectomy,
either to get rid of an organ with an indisputable
female connotation or due to complaints derived
from vaginal discharge, especially associated
with sexual arousal. Some gender teams (e.g.,
Ghent/Belgium and Amsterdam/The Nether-
lands) have integrated vaginectomy into the con-
243
cept of the SRS of FtMs and have gained substan-
tial experience with this procedure. However,
vaginectomy is still not part of the routine proce-
dure and is fraught with problems, for instance,
major intraoperative bleeding or rectum or blad-
der perforation. Undoubtedly, morbidity caused
by radical vaginectomy for oncologic purposes
will be judged different from vaginectomy per-
formed in healthy young patients suffering from
gender dysphoria. That is why vaginectomy
should be indicated only if complaints are sub-
stantial. In addition, one should bear in mind that
parts of the vaginal lining can be used for metoid-
ioplasty (Hage, 1996), and not every FtM suffers
from substantial vaginal discharge. Last but not
least, not every FtM is at loggerheads with the
vagina.
To our knowledge, no paper has been pub-
lished about the special conditions of vaginec-
tomy in transsexuals or the results of vaginec-
tomies in terms of patient satisfaction. Personal
experience shows that removal of the vagina is
highly appreciated by FtMs. Complications af-
terwards did not even lead to a negative attitude
towards this procedure. For example, vaginec-
tomy leads to distraught innervations of the blad-
der floor, potentially causing temporarily loss of
detrusor sensation and incomplete emptying of
the bladder. However, these complications are
restored within days.
Vaginectomy can be performed during the
same surgical session of hysterectomy and BSO,
either abdominally or vaginally. However, this
extension is yet not recommended and is only
done by exception (Ergeneli, Duran, Ozcan, &
Erdogan, 1999). Techniques are under debate
to remove the upper parts of the vagina dur-
ing hysterectomy laparoscopically. This proce-
dure requires much more expertise than a simple
straightforward laparoscopic hysterectomy be-
cause distal ureter preparation is difficult and
challenging. More often, vaginectomy is per-
formed together with a reconstruction of the
fixed part of the urethra.
Androgen treatment often, but not always,
causes considerable changes of the vulva,
vagina, and urethra, comparable to the senile at-
rophic status of postmenopausal women. Symp-
toms, from pruritus to incontinence, are often
present but complaints are regularly suppressed.
244 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Without estrogenic stimulation, the vaginal lin-
ing gets thinner, Lactobacillus flora decrease,
and as a consequence pathogenic flora increases.
The loss of Doederlein bacilli leads to a rise in
vaginal pH, from 4.5–5.5 to 7.0–7.4, and thus the
vagina and adjacent structures become more sus-
ceptible to infection, more susceptible to trauma,
and less capable of healing (Forsberg, 1995). De-
creased estrogen slows down mitotic activity in
the epidermal basal layer, reduces the synthesis
of collagen, and contributes to thickening of the
dermo-epidermal junction.
Androgens are partially converted into es-
trogens, dependent on aromatase activity, and
sometimes leading to surprisingly high estrogen
concentrations in FtMs. In that case, vaginal dis-
charge may be the leading symptom, rather than
burning and pruritus.
FtMs have to cope with the stressful fact
that the genital tract stands under the influ-
ence of androgens and alters toward a status
with accompanying complaints due to marked
local estrogen deficiency comparable to post-
menopausal women. Marked atrophy of the ep-
ithelium can mimic dysplasia (Miller, Bédard,
Cooter, & Shaul, 1986). Transformation of the
neovaginal lining toward a nonkeratinizing mu-
cosal type squamous epithelium, as often pro-
posed, turned out to be not verifiable (Dekker,
Hage, Karim, & Bloemena, 2007).
Treatment of atrophic disorders of the
genital region is straightforward and necessary.
However, examination can be both physically
and mentally painful. Gynecologists dealing
with genital complaints of FtMs should be
aware of the conflicting feelings of a person
with a male identity and male appearance but
female genitals. Therefore, it would be helpful
if information about the (patho-)physiology of
the genital organs related to cross-sex hormonal
therapy were spread in easily understandable
terms to make FtMs aware of the fact that the
disliked female organs still need attention and
care.
If SRS is fully completed, including vaginec-
tomy and phalloplasty, gynecologic care is no
longer necessary and medical health care of the
genital region should be taken over by urologists
or andrologists if necessary.
CONCLUSION
During the conversion process, treatment of
transsexual persons is, under optimal conditions,
embedded in an overall concept. After success-
ful sex reassignment, the interdisciplinary team
disperses; however, the hormonal treatment with
relevant impact on various hormone-sensitive
tissues continues for decades. If the treatment of
transsexual persons is to fulfill quality criteria,
not only regarding diagnosis and the transitional
phase, emphasis has to be made on establish-
ing follow-up treatment, comparable to routine
health care for healthy females as long as hor-
mone replacement therapy is prescribed.
Genital health is not just an ostentatious term
but an invitation for health care providers to in-
stall low-threshold structures allowing transgen-
ders to address their problems to empathic pro-
fessionals.
For both MtFs and FtMs, gynecology can
provide a substantial positive impact on geni-
tal health concerning functional aspects of the
female genital tract, endocrinology, psychoso-
matics, and sexuality.
However, the lack of knowledge of gynecolo-
gists about the special needs of this population,
and in many countries a reserved attitude of doc-
tors toward transgender persons, still is a limiting
factor of gynecological care for transgender per-
sons. This is not inherent to this specialty but
a general observation. Therefore, more profes-
sional information about the needs and expec-
tations and background of transgender persons
should be provided to medical doctors, and trans-
gender issues should urgently be introduced into
the medical curriculum.
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