Introduction to gender-affirming surgery

Dr. Paulina Wilson is a specialty care physician board certified in urology at Inova. Dr. Wilson’s focus includes general urology; men’s health; the evaluation, surgical management and prevention of kidney and bladder stones; management of voiding issues in men and women including difficulties with urination, frequent or urgent urination, incontinence and other concerns; minimally invasive procedures for urinary incontinence; orchiectomy for gender-affirming surgery; surgical management of scrotal and testicular conditions; prevention and treatment of urinary infections; and medical and surgical management of erectile dysfunction. Her goal is to give patients high-quality, holistic, innovative and personalized care and to empower those with urologic conditions to make the best decisions for their health.

For people assigned male at birth (AMAB) who are experiencing gender dysphoria, the most important, most valuable thing we can do as providers is to have an open discussion. Rather than meeting with a patient and bringing preconceived ideas into the room about what a transfeminine person typically wants or should want, I start by seeking to understand the patient’s goals:

• What is important to you?
• What makes you dysphoric, and how can we help?

As a urologist, I offer gender-affirming orchiectomy, which is the surgical removal of both testicles. Transfeminine patients are often on hormone therapy, and these medications can have side effects. This procedure can help with those side effects. I always recommend a simple orchiectomy rather than a radical orchiectomy, which is exclusively used to treat testicular cancer.

What to do with the patient’s scrotal skin after the testicles have been removed is a separate discussion, and here too, we want to make sure we understand the patient’s needs, goals, and expectations. As a urologist, I perform scrotoplasty or scrotectomy procedures, often for other reasons. Although the procedure itself is fairly common, when it comes to gender reaffirmation, I want to make sure the patient and I are on the same page about how they want to function physically and how they want to look cosmetically. It’s important to understand that if additional bottom surgery may be desired in the future, I do advise against removal of scrotal skin, as this is typically used in those reconstructions.

It’s important to note that as a urologist, I offer removal of the testicles and scrotal skin. I don’t provide more in-depth bottom surgery for gender reaffirmation. I endeavor to make sure patients understand that before their appointment, so we don’t waste their time.

Patient-centered care

It’s important to me to communicate to patients that my practice provides inclusive and affirming care to transgender and non-binary patients, and we take steps to create a safe and supportive environment. By the time they see me, many patients have faced myriad challenges, both in their day-to-day lives and in their healthcare journeys. I want to make sure every person in the room is 100% comfortable.

I typically start by introducing myself and my personal pronouns, and I share how much I enjoy providing gender-affirming care. I explain that they are in a judgment-free environment of safety and respect. I look for nonverbal cues that patients are comfortable and happy. If something feels off at the first visit, I make sure to schedule another visit or dig a little deeper to find out what we’re missing.

Importance of partnership

Gender-affirming care needs a team approach to be successful. There are facets that are medical, surgical and psychological. I am very happy to be able to offer some of the surgical options, particularly for AMAB transfeminine patients who desire orchiectomy and/or scrotoplasty/scrotectomy.

I am proud to have developed a productive partnership with Inova Pride Clinic and Jorge A. Ramallo, MD. He does an exceptional job managing the medical considerations of gender-affirming care. He has such comprehensive expertise in the health needs of the LGBTQ+ population, leaving me to focus on the urologic considerations of gender-affirming care.

Serving an underserved population

There is so much need for gender-affirming care. Navigating this journey can be difficult and full of barriers. There have been changes in the last few years that have made getting this procedure covered by insurance easier, at least in most cases. Once I have met with the patient and we have agreed on a plan, my goal is for patients to be able to move forward with surgery efficiently. By the time they get to me, patients have already waited a long time for this.

I generally measure success and patient satisfaction as one and the same. When patients are happy at their post-op visit, and when they send me their friends as referrals, I know I have succeeded. It means a lot to be recommended in that way.

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