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Gender Confirmation Surgery (GCS)

What is Gender Confirmation Surgery?

• Transfeminine Tr

Transmasculine Transition

• Traveling Abroad

Choosing a Surgeon

Gender confirmation surgery (GCS), known clinically as genitoplasty, are procedures that surgically confirm a person's gender by altering the genitalia and other physical features to align with their desired physical characteristics. Gender confirmation surgeries are also called gender affirmation procedures. These are both respectful terms.

Gender dysphoria , an experience of misalignment between gender and sex, is becoming more widely diagnosed.  People diagnosed with gender dysphoria are often referred to as "transgender," though one does not necessarily need to experience gender dysphoria to be a member of the transgender community. It is important to note there is controversy around the gender dysphoria diagnosis. Many disapprove of it, noting that the diagnosis suggests that being transgender is an illness.

Ellen Lindner / Verywell

Transfeminine Transition

Transfeminine is a term inclusive of trans women and non-binary trans people assigned male at birth.

Gender confirmation procedures that a transfeminine person may undergo include:

• Penectomy is the surgical removal of external male genitalia.
• Orchiectomy is the surgical removal of the testes.
• Vaginoplasty is the surgical creation of a vagina.
• Feminizing genitoplasty creates internal female genitalia.
• Breast implants create breasts.
• Gluteoplasty increases buttock volume.
• Chondrolaryngoplasty is a procedure on the throat that can minimize the appearance of Adam's apple .

Feminizing hormones are commonly used for at least 12 months prior to breast augmentation to maximize breast growth and achieve a better surgical outcome. They are also often used for approximately 12 months prior to feminizing genital surgeries.

Facial feminization surgery (FFS) is often done to soften the lines of the face. FFS can include softening the brow line, rhinoplasty (nose job), smoothing the jaw and forehead, and altering the cheekbones. Each person is unique and the procedures that are done are based on the individual's need and budget,

Transmasculine is a term inclusive of trans men and non-binary trans people assigned female at birth.

Gender confirmation procedures that a transmasculine person may undergo include:

• Masculinizing genitoplasty is the surgical creation of external genitalia. This procedure uses the tissue of the labia to create a penis.
• Phalloplasty is the surgical construction of a penis using a skin graft from the forearm, thigh, or upper back.
• Metoidioplasty is the creation of a penis from the hormonally enlarged clitoris.
• Scrotoplasty is the creation of a scrotum.

Procedures that change the genitalia are performed with other procedures, which may be extensive.

The change to a masculine appearance may also include hormone therapy with testosterone, a mastectomy (surgical removal of the breasts), hysterectomy (surgical removal of the uterus), and perhaps additional cosmetic procedures intended to masculinize the appearance.

Paying For Gender Confirmation Surgery

Medicare and some health insurance providers in the United States may cover a portion of the cost of gender confirmation surgery.

It is unlawful to discriminate or withhold healthcare based on sex or gender. However, many plans do have exclusions.

For most transgender individuals, the burden of financing the procedure(s) is the main difficulty in obtaining treatment. The cost of transitioning can often exceed $100,000 in the United States, depending upon the procedures needed.

A typical genitoplasty alone averages about $18,000. Rhinoplasty, or a nose job, averaged $5,409 in 2019.  

Traveling Abroad for GCS

Some patients seek gender confirmation surgery overseas, as the procedures can be less expensive in some other countries. It is important to remember that traveling to a foreign country for surgery, also known as surgery tourism, can be very risky.

Regardless of where the surgery will be performed, it is essential that your surgeon is skilled in the procedure being performed and that your surgery will be performed in a reputable facility that offers high-quality care.

When choosing a surgeon , it is important to do your research, whether the surgery is performed in the U.S. or elsewhere. Talk to people who have already had the procedure and ask about their experience and their surgeon.

Before and after photos don't tell the whole story, and can easily be altered, so consider asking for a patient reference with whom you can speak.

It is important to remember that surgeons have specialties and to stick with your surgeon's specialty. For example, you may choose to have one surgeon perform a genitoplasty, but another to perform facial surgeries. This may result in more expenses, but it can result in a better outcome.

A Word From Verywell

Gender confirmation surgery is very complex, and the procedures that one person needs to achieve their desired result can be very different from what another person wants.

Each individual's goals for their appearance will be different. For example, one individual may feel strongly that breast implants are essential to having a desirable and feminine appearance, while a different person may not feel that breast size is a concern. A personalized approach is essential to satisfaction because personal appearance is so highly individualized.

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American Society of Plastic Surgeons. Rhinoplasty nose surgery .

Rights Group: More U.S. Companies Covering Cost of Gender Reassignment Surgery. CNS News. http://cnsnews.com/news/article/rights-group-more-us-companies-covering-cost-gender-reassignment-surgery

The Sex Change Capital of the US. CBS News. http://www.cbsnews.com/2100-3445_162-4423154.html

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

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• Review Article
• Published: 16 May 2017

An overview of female-to-male gender-confirming surgery

• Shane D. Morrison 1 ,
• Mang L. Chen 2 &
• Curtis N. Crane 2  

Nature Reviews Urology volume  14 ,  pages 486–500 ( 2017 ) Cite this article

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• Reconstruction
• Sexual behaviour

Gender-confirming surgery is becoming a more frequently encountered procedure for urologists, plastic surgeons, and gynaecologists

Female-to-male gender-confirming surgery consists of facial masculinization, chest masculinization, body contouring, and genital surgery

Metoidioplasty (hypertrophy with systemic hormones and mobilization of the clitoris with urethroplasty) can produce a sensate microphallus

Phalloplasty can produce an aesthetic and sensate phallus with ability to micturate in a standing position and engage in penetrative sexual intercourse if proper nerve coaptation and prosthetic insertion are performed

Urethral complications following genital surgery in transmen are generally higher than 30% and include urethral fistulas and strictures; revisional urethroplasty can address most urethral complications following genital surgery

Advances in basic sciences, transgender-specific prostheses, and patient-reported outcomes will continue to offer options for improvements in gender-confirming surgery

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

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Powerpoint slide for fig. 1, powerpoint slide for fig. 2, powerpoint slide for fig. 3, powerpoint slide for fig. 4, powerpoint slide for fig. 5, powerpoint slide for fig. 6, powerpoint slide for fig. 7, powerpoint slide for table 1.

Inherent discordance of a patient's gender expression and their anatomy leading to distress

Tissue forming the nipple and surrounding areola on the breast or chest

A physical examination test to determine the patency of the palmar or plantar arches as a correlate for the dominant inflow vessel to the hand or foot. Most commonly it is used in the hand where the radial and ulnar arteries are both occluded with pressure from the examiners hand and each is released sequentially while maintaining the pressure on the other artery. The perfusion of the hand is monitored to ensure both vessels can perfuse the hand.

A person born as a male and whose gender identity is male.

Urological procedure for urethral strictures, in which the ventral aspect of the phallus is opened through the urethra. The urethra is secured to the skin and urine is diverted. A second stage completed months later is used to repair the urethra with grafted tissue over a catheter.

Flaps containing multiple tissue types (skin, bone, mucosa.) based on a single angiosome used for complex reconstruction.

Local flap used for advancing tissue generally to cover a wound, but can be used in other procedures. An incision shaped like a V is made through the subcutaneous tissue, advanced into its new position relying on subcutaneous perfusion, and closed in a Y pattern.

Closure of a urethral stricture with a longitudinal incision followed by a transverse closure.

A person born with female sexual organs, but whose gender identity is male

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Morrison, S., Chen, M. & Crane, C. An overview of female-to-male gender-confirming surgery. Nat Rev Urol 14 , 486–500 (2017). https://doi.org/10.1038/nrurol.2017.64

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Female to Male Surgery for Trans Men

As a transgender male, your goal for female to male surgery (FTM) for gender-confirmation can involve top surgery, bottom surgery, or both. You may or may not want facial procedures. It’s up to you.

Female to Male Surgery at UVA

We’re here to offer consultations, second opinions, and information to help you choose and plan. Come to us with your questions and concerns. We’ll explain:

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We want you to feel confident about the direction and quality of your care.

Charley's Gender-Confirmation Surgery

From a young age, Charley Burton knew that his body did not match his gender identity – a struggle he kept inside for 50 years. With the help of family nurse practitioner Reagan Thompson, FNP, MSN, RN, and a whole team of caring providers, Charley found a safe place to become his true self. View Charley's story transcript.

FTM Top Surgery

To give you a flatter chest, we’ll have to remove breast tissue. We might also need to move and shrink your areolas.

If you have smaller breasts, we can sometimes use liposuction, which doesn’t involve many incisions.

Larger breasts may require the “double incision” technique. This method saves the pectoralis major muscle, the most defining characteristic of a male chest.

Whatever your breast size, we will use the techniques that optimize the results.

FTM Bottom Surgery

We can give you male genitalia in two different ways:

• Phalloplasty creates a penis and urethra (to stand while urinating). We use tissue from your forearm or thigh. We do this in 2 stages.
• Metoidioplasty takes your existing genital tissue and makes it longer, turning it into a defined phallus. This needs only one surgery.

You may or may not want to also have an operation to remove your internal reproductive organs. A hysterectomy takes out your uterus, fallopian tubes, and ovaries.

Facial Masculinization

Through a combination of procedures, we can sculpt your chin, jaw, and cheeks to appear more masculine. We can also reshape your nose and make your Adam’s apple look bigger. We can use synthetic implants for this work.

Questions? See our  transgender surgery FAQs .

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Gender Confirmation Surgery

The University of Michigan Health System offers procedures for surgical gender transition.  Working together, the surgical team of the Comprehensive Gender Services Program, which includes specialists in plastic surgery, urology and gynecology, bring expertise, experience and safety to procedures for our transgender patients.

Access to gender-related surgical procedures for patients is made through the University of Michigan Health System Comprehensive Gender Services Program .

The Comprehensive Gender Services Program adheres to the WPATH Standards of Care , including the requirement for a second-opinion prior to genital sex reassignment.

Available surgeries:

Male-to-Female:  Tracheal Shave  Breast Augmentation  Facial Feminization  Male-to-Female genital sex reassignment

Female-to-Male:  Hysterectomy, oophorectomy, vaginectomy Chest Reconstruction  Female-to-male genital sex reassignment

Sex Reassignment Surgeries (SRS)

At the University of Michigan Health System, we are dedicated to offering the safest proven surgical options for sex reassignment (SRS.)   Because sex reassignment surgery is just one step for transitioning people, the Comprehensive Gender Services Program has access to providers for mental health services, hormone therapy, pelvic floor physiotherapy, and speech therapy.  Surgical procedures are done by a team that includes, as appropriate, gynecologists, urologists, pelvic pain specialists and a reconstructive plastic surgeon. A multi-disciplinary team helps to best protect the health of the patient.

For patients receiving mental health and medical services within the University of Michigan Health System, the UMHS-CGSP will coordinate all care including surgical referrals.  For patients who have prepared for surgery elsewhere, the UMHS-CGSP will help organize the needed records, meet WPATH standards, and coordinate surgical referrals.  Surgical referrals are made through Sara Wiener the Comprehensive Gender Services Program Director.

Male-to-female sex reassignment surgery

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a male-to-female sex reassignment surgery will be offered a penile inversion vaginoplasty with a neurovascular neoclitoris.

During this procedure, a surgeon makes “like become like,” using parts of the original penis to create a sensate neo-vagina. The testicles are removed, a procedure called orchiectomy. The skin from the scrotum is used to make the labia. The erectile tissue of the penis is used to make the neoclitoris. The urethra is preserved and functional.

This procedure provides for aesthetic and functional female genitalia in one 4-5 hour operation.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation. What to Expect: Vaginoplasty at Michigan Medicine .

Female-to-male sex reassignment

At the University of Michigan, participants of the Comprehensive Gender Services Program who are ready for a female-to-male sex reassignment surgery will be offered a phalloplasty, generally using the radial forearm flap method. 

This procedure, which can be done at the same time as a hysterectomy/vaginectomy, creates an aesthetically appropriate phallus and creates a urethera for standing urination.  Construction of a scrotum with testicular implants is done as a second stage.  The details of the procedure, the course of recovery, the expected outcomes, and the possible complications will be covered in detail during your surgical consultation.

Individuals who desire surgical procedures who have not been part of the Comprehensive Gender Services Program should contact the program office at (734) 998-2150 or email [email protected] . W e will assist you in obtaining what you need to qualify for surgery.

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Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

• Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
• Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
• It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
• In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon  will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

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Gender Affirmation Surgeries

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Fan Liang, M.D.

Surgeries are not required for gender affirmation, but many patients choose to undergo one or more surgical procedures. Talk with your doctor to discuss what surgical options may be right for you. The following is an overview of gender affirmation surgeries.

• Penile construction (phalloplasty/metoidioplasty) : This surgical procedure can include removal of the vagina (vaginectomy), reconstruction of the urethra and penile reconstruction. Surgeons may use either vaginal tissue or tissue from another part of the body to construct the penis.
• Vaginal construction (vaginoplasty) : This surgical procedure is a multistage process during which surgeons may remove the penis (penectomy) and the testes (orchiectomy), if still present, and use tissues from the penis to construct the vagina, the clitoris (clitoroplasty) and the labia (labiaplasty).
• Top surgery is surgery that removes or augments breast tissue and reshapes the chest to create a more masculine or feminine appearance for transgender and nonbinary people.
• Facial gender surgery can include a variety of procedures to create more feminine features , like reshaping the nose; brow lift (or forehead lift); chin, cheek and jaw reshaping; Adam’s apple reduction; lip augmentation; hairline restoration; and earlobe reduction. 
• Facial gender surgery can also include a series of procedures to create more masculine features , such as forehead lengthening and augmentation; cheek augmentation;  reshaping the nose  and chin;  jaw augmentation ; and thyroid cartilage enhancement to construct an Adam’s apple.
• Hysterectomy : This surgical procedure includes the removal of the uterus and ovaries (oophorectomy). There are options for oocyte storage and fertility preservation that you may want to discuss with your doctor. 
• Some people may combine this procedure with a scrotectomy , which is surgery to remove all or part of the scrotum. For others, the skin of the scrotum can be used in vulvoplasty or vaginoplasty ― the surgical construction of a vulva or vagina.
• The procedure reduces testosterone production and may eliminate the need for continuing therapy with estrogen and androgen-suppressing medications. Your health care practitioner will discuss options such as sperm freezing before orchiectomy that can preserve your ability to become a biological parent.

Recovery After Gender Affirmation Surgeries

Recovery time from a gender affirmation surgery or procedure varies, depending on the procedure. Talk to your doctor about what you can expect.

Treatment Caring for Transgender Patients

Fearing discrimination and hostility, transgender people are often reluctant to seek care. Discover how Paula Neira, Program Director of LGBTQ+ Equity and Education, Johns Hopkins Medicine Office of Diversity, Inclusion and Health Equity, is working to ensure that all patients — regardless of gender identity — are treated with dignity and respect.

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Should transgender athletes compete in women’s sports?

Watching the 2024 Paris Olympics reminded me of my intense love for sports. It is the nobility, beauty, strength, agility, and fairness that attract me and the audience. Performances by Simone Biles, with her majesty and strength, to Katie Ledecky’s’ power and domination, surrounded by Olympic and world record performances, often bring me to tears. These attributes have abounded in Paris, but unfortunately, something foul is also afoot.

Sexual and gender identity disorders (SGID) are a relatively rare group of medical conditions. As with most medical subjects, the science and biology of these conditions are complex. Using genes, hormones, and the presence or absence of reproductive organs, endocrinologic and embryologic textbooks devote multiple chapters and extended pages to SGID and its subtypes. Various categories use terms such as transgender, hermaphrodite, intersex, sexual dysphoria, and disorders of sexual development (DSD), characterizing and dividing these rare cases. The latter category, DSD, describes individuals with a contradiction between the karyotype or genes, hormone levels, and the appearance of their reproductive organs. SGID individuals with a male genotype who compete in women’s sports are the subject of this blog.

While these conditions are rare, many SGID individuals have the desire and talent to perform in certain sports and compete on the world stage. Those SGID individuals with a male genotype and biology often choose to be identified as a woman but perform as a man. These individuals tend to dominate their field when included in female competition. This is to be expected, as these individuals have male biology, which predicts a stronger, faster, and often more aggressive individual. When these athletes compete against women in contact sports, injury is possible.

Transgender athletes are those individuals assigned at birth as male, who have a male XY genotype or genetic profile but, because of gender dysphoria, choose to be considered female. Some choose to have gender reassignment treatments and surgeries. Renee Richards is perhaps the most well-known. She played professional tennis in the 1970s after sex reassignment surgery. Lia Thomas is a contemporary transgender woman who competes in competitive swimming.

In the boxing arena at the Paris Olympics, two DSD individuals have competed. Imane Khelif is an Algerian boxer; Lin Yu-ting is Taiwanese. Both were successful in securing a medal in their respective weight classes. Infamously, Imane Khelif’s opponent vacated her match after being humiliated on international television.

In 2022, North Carolina volleyball player Payton McNabb suffered a serious injury after a trans-identified male player spiked a ball at her head and rendered her unconscious. Last year, a trans-identified male opponent injured a female athlete during a field hockey game in Massachusetts when a ball he threw at her knocked her teeth out. Examples of other females being injured by males taking part in overseas or semi-professional women’s sports abound, occurring in soccer, rugby, hockey, and mixed martial arts.

Promoting fair and equal treatment in all female sports is something I strongly advocate. I am a proponent of the Title IX Education Amendments of 1972. Society should promote female sports. The presence of SGID individuals in female sports does not promote fair competition. Genetic and endocrine male biology predicts an unfair advantage for the SGID individual.

Besides an unfair advantage in SGID female competitions, injury is often the result. Injury can be psychological as well as physical. Losing, especially on the international scene, can humiliate, as with Imane Khelif’s boxing opponent. Reilly Gaines’s televised loss to Lia Thomas in the swimming pool is another example of the sport’s encouragement of humiliation. Gaines has talked openly about her feelings. Her advocacy on this subject is essential.

Physical injury has continued to occur. Future death in the sporting venue is only one ill-timed punch away.

Do we want to treat our women in this manner? Ask yourself, would you like your daughter competing against a biological male, risking defeat, humiliation, and injury? I feel compassion for the SGID athlete, but allowing this situation to continue is not the answer.

I envision a separate league for SGID competition. This is much like the para-athlete leagues and would allow for a fair playing field. Everyone should be able to enjoy athletic competition. However, fairness and safety are of paramount concern.

William Lynes  is a urologist and author of  A Surgeon’s Knot .

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Biden ‘gender reassignment’ surgery mandate blocked

By Peter Pinedo

Houston, Texas, Sep 3, 2024 / 16:45 pm

A U.S. district judge has placed a nationwide block on a Biden-Harris administration rule mandating that federally funded hospitals perform surgical interventions to alter the body’s appearance to mimic that of the opposite sex.

This comes after Texas and Montana sued the administration over changes it made in May to the Affordable Care Act’s section prohibiting discrimination based on sex.

The rule broadened the meaning of “sex” to include “gender identity.” This meant that federally funded hospitals were required to perform so-called “gender reassignment” surgeries or face a range of penalties including having their funding removed.

Texas and Montana argued that the change violated portions of state law that prohibit such surgical interventions performed on minors’ sexual and reproductive organs and ban Medicaid funding for these operations.

The two states argued that the Biden administration has given them “an impossible choice” to either “violate and abandon state law or risk devastating financial loss.”

The ruling, issued on Aug. 30 by Judge Jeremy Kernodle for the Eastern District of Texas, expanded an earlier court decision that blocked the mandate for hospitals in Texas and Montana. Kernodle said the Biden administration’s mandate is “unlawful” in all hospitals, not just those in Texas and Montana.

Texas Attorney General Ken Paxton called the ruling a “major victory for Americans across the country.”

“When Biden and Harris sidestep the Constitution to force their unlawful, extremist agenda on the American public, we are fighting back and stopping them,” Paxton said.

Jennifer Carr Allmon, executive director of the Texas Catholic Conference of Bishops, told CNA that the Texas bishops are “grateful” for the nationwide stay.  

Catholic experts respond to Pope Francis on repelling migrants being ‘a grave sin’

Allmon said that gender transition surgeries are “not authentic health care” because these procedures “interrupt natural developmental processes and can result in infertility and other serious health risks, especially for children, all of which may be irreversible.”

“Health care providers must be free to refuse to perform these harmful interventions without risk of penalty,” she said. “The Texas Catholic Conference of Bishops advocates for health care that is oriented toward honoring the dignity of each person while respecting the religious liberty and conscience rights of medical professionals.”

The Biden administration will likely appeal the ruling to the Fifth Circuit Appellate Court.

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Procedure: Male to Female Gender Reassignment Surgery (MTF GRS)

Male-to-female gender reassignment surgery (MTF GRS) is a complex and irreversible genital surgery for male transsexual who is diagnosed with gender identity disorder and has a strong desire to live as female. The procedure is to remove all male genital organs including the penis and testes with the construction of female genitalia composed of labia major/minor, clitoris and neovagina simultaneously.   

The patient who is fit for this surgery must strictly follow the standard of care set by the World Professional Association of Transgender Healthcare (WPATH) or equivalent criteria; Express desire or live in another gender role (Male gender) long enough, under hormonal replacement therapy, evaluated and approved by a psychiatrist or other qualified professional gender therapist.  

Apart from genital surgery, the patient would seek other procedures to allow them to live as female smoothly such as breast aesthetic surgery, facial feminization surgery, body contouring, hair removal, voice change surgery, etc.

Interested in having this procedure?

Useful Information

Ensure you consider all aspects of a procedure. You can speak to your surgeon about these areas of the surgery in more detail during a consultation.

The surgery is quite complicated and only a handful of surgeons are able to perform this procedure. It can be completed in one stage or more stages depending on techniques and surgeons. The average surgical time ranges between 5-8 hours. There are several options of neovaginal construction depending on the type of tissue, single or in combination, such as penile skin, scrotal skin, large intestine, small intestine, or peritoneum.   

The procedure is done under general anesthesia and might be combined with spinal anesthesia for faster recovery by reducing the usage of anesthetic gas.  

Inpatient/Outpatient

The patient will be hospitalized as an in-patient for between 5-14 days depending on the technique and surgeon. The patient will have a urinary catheter at all times in the hospital.  

Additional Information

What is the recovery process.

During hospitalization, the patient must be restricted in bed continuously or intermittently for several days between 3-5 days. After release from the hospital, the patient can return to their normal lives but not have to do physical exercise during the first 2 months after surgery. The patient has to do vaginal dilation continuously for 6 months to maintain the neovagina canal until completely healed and is ready for sexual intimacy.  

What are the results?

With the good surgical technique, the result is very satisfying with an improved quality of life. The patient is able to live in a female role completely and happily either on their own or with their male or female partners.  

What are the risks?

The most frequent complication of MTF GRS is bleeding, wound infection, skin flap or graft necrosis, urinary stenosis, neovaginal contracture, unsightly scar or deformed genitalia,  vaginal fistula, etc. The revision procedures to improve external appearance are composed of secondary labiaplasty/ urethroplasty/ perineoplasty/ and vulvaplasty. The other revision procedure is secondary vaginoplasty to help the patient able to have sexual intimacy with the partner.  

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Sexuality after Male-to-Female Gender Affirmation Surgery

1 Department of Urology, University Hospital Essen, University Duisburg-Essen, Germany

2 Department of Urology, Kliniken Essen-Mitte, Essen, Germany

3 General Practice van Hal, Essen, Germany

R. Rossi Neto

4 Clinica Urologia, General Hospital Ernesto Simoes Filho, Salvador, Brazil

B. Hadaschik

Male-to-Female (MtF) gender affirmation surgery (GAS) comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all 254 MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between 2004 and 2010. In total, we received 119 completed questionnaires after a median of 5.05 years since surgery. Of the study participants, 33.7% reported a heterosexual, 37.6% a lesbian, and 22.8% a bisexual orientation related to the self-perceived gender. Of those who had sexual intercourse, 55.8% rated their orgasms to be more intensive than before, with 20.8% who felt no difference. Most patients were satisfied with the sensitivity of the neoclitoris (73.9%) and with the depth of the neovaginal canal (67.1%). The self-estimated pleasure of sexual activity correlated significantly with neoclitoral sensitivity but not with neovaginal depth. There was a significant correlation between the ease with which patients were able to become sexually aroused and their ability to achieve orgasms. In conclusion, orgasms after surgery were experienced more intensely than before in the majority of women in our cohort and neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than neovaginal depth.

1. Introduction

Male-to-female (MtF) gender affirmation surgery (GAS) comprises the resection of all clearly defining features of male genitalia. The aim is the formation of a perineogenital complex in appearance and function as feminine as possible [ 1 ] with a sensitive clitoris to enable orgasms. GAS should be performed by a surgeon with specialized competence in genital reconstructive techniques [ 2 ]. The aim is to “create a perineogenital complex as feminine in appearance and function as possible” [ 1 ]. There is a broad agreement that GAS has a positive impact on gender dysphoria [ 3 – 13 ]. The inversion of penile skin is used by most gender surgeons. While some trans ∗ and gender nonconforming people do not require surgical therapy to express their preferred gender role and identity, others see GAS as a pivotal step to relieve their gender dysphoria [ 14 ]. GAS might reduce risk of stigmatization and discrimination in venues like swimming pools and health clubs or when dealing with authorities [ 2 , 15 ]. Without doubt surgery has a positive effect on subjective wellbeing and sexual function [ 16 – 18 ].

Sexual orientation can change after GAS [ 19 ] but little is known about changes of orgasmic experience after GAS. Bartolucci et al. found a positive impact of cross gender hormone replacement therapy on sexual quality of life in transgender who had not undergone GAS yet [ 20 ]. However effects of GAS in this field remain unclear so far. This study aimed to evaluate the effect of GAS on sexuality and satisfaction with sexual life of MtF-transgender patients.

2. Material and Methods

2.1. participants.

Our study cohort comprised all 254 MtF patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between 2004 and 2010, as has been previously reported [ 6 ]. Transsexualism was diagnosed by two independent mental healthcare professionals competent to work with gender dysphoric adults in accordance with 10th version of the International Classification of Diseases (ICD-10). All patients were contacted by mail using their last known address and asked if they would be willing to answer the questionnaire. In cases of invalid addresses the local residents' registration offices were contacted in order to reconsign a new questionnaire. Patients who had not sent back the questionnaire could not be followed up due to previous anonymization.

2.2. Statistics

Statistical calculation was performed using Statistical Package for the Social Sciences (SPSS 21.0). Fisher's exact test and Chi Square were used to compare categorical and ordinal variables in independent samples. The Mann–Whitney U test was used to compare satisfaction scale distribution of two independent samples. This nonparametric test was used in preference to the t-test because the Shapiro–Wilk test indicated that distribution was not normal. Spearman's correlation analysis was performed.

In total, 119 completed questionnaires were received, all of which were included in the evaluation (response rate 46.9%). Due to anonymization of the questionnaires, it was not possible to obtain information on patients' ages. However, the average age of a comparable cohort of patients at our department between 1995 and 2008 [ 21 ] was 36.7 years (16 to 68 years). Not all patients completed the questionnaire, so for some questions the total number of responses was not 119. The results are given in absolute numbers and percentage in relation to total participants or number of answers. After a median of 5.05 years (standard deviation: 1.6 years; range: 1 to 7 years) since surgery, 67 participants (56.3% of the total cohort) did not encounter sexual intercourse on a regular basis at the time of questioning (which depicts 67.7% of those who answered that question). Twenty of the 119 patients (16.8%) did not answer this question. Of those who answered the question nearly a quarter (n = 24; 24.2%) reported a mean frequency of one to three times per month, seven (7.1%) stated a frequency of one to three times per week, and one woman (1.0%) stated a frequency of over three times per week. Time since GAS did not correlate with the frequency of intercourse and the self-rated intensity of orgasms. There was neither an association of the extent to which women felt female themselves nor with the degree to which they felt considered as women with time since surgery.

In our cohort, 18 (15.1% of all participants) patients refused to answer regarding sexual attraction related to the self-perceived gender. Of those who answered (n = 101), slightly more of the patients (n = 38; 37.6%) indicated a sexual attraction towards women than towards men (n = 34; 33.7%). 23 women (22.8%) were attracted by both men and women and six (5.9%) neither by men nor by women ( Figure 1 ). In total, 38 subjects (41.3%) were highly satisfied, 30 (32.6%) were satisfied, 18 (19.6%) were not satisfied, and six (6.5%) were highly unsatisfied with the sensitivity of the neoclitoris ( Figure 2 ). This question was not answered by 27 individuals (22.7% of all participants). When asked how satisfied the women were with the depth of the neovaginal canal, 19 were very satisfied (20.9%), 42 (46.2%) were satisfied, 23 (25.3%) were unsatisfied, and seven (7.7%) were very unsatisfied, with 28 (23.5% of all participants) not answering the question ( Figure 3 ). We asked our patients whether it was easy to get sexually aroused. In total 91 women responded to this question, and about a quarter (n = 28; 23.5% of all participants) declined to answer. Of these 91 women 22 (24.2%) stated that this was always easy; for 43 (47.3%) it was mostly easy; for 15 (16.5%) it was seldom easy; and for eleven women (12.1%) it was never easy to get sexually aroused. The modality as to how orgasms were achieved is shown in Figure 4(a) (absolute numbers of patients; n = 119) and Figure 4(b) (percentages expressed in relation to total answers; n = 126). The majority of participants achieved an orgasm with masturbation, followed by sexual intercourse and “other” not further specified sexual practices. 29 women (24.4% of all participants) did not answer that question. Of those who answered that question (n = 77), 43 women (55.8%) quoted that orgasms were more intense after GAS compared with those experienced before surgery, 18 (23.4%) women stated that it was less intense than before, and 16 (20.8%) felt no difference. Frequency of achieved orgasms changed in our cohort after GAS. Of all 119 patients 41 (34.5%) refused to answer that question. Of the residual 78 women 41 (52.6%) indicated that orgasms were achieved less frequently, 21 women (26.9%) reported more frequent orgasms, and for 16 women (20.5%), frequency did not change. In order to gather information on patients' general satisfaction with their sex lives, they were asked to place themselves on a Likert scale ranging from 0 (“very dissatisfied”) to 10 (“very satisfied”). Nearly a quarter of participants either selected scores from 0 to 3 (n = 29; 24.4%), from 4 to 6 (n = 30; 25.2%), or from 7 to 10 (n = 29; 24.4%) or refused to answer (n = 31; 26.1%). Figure 5 shows a detailed illustration. We received feedback regarding pleasure of sexual activity from 88 women (73.9%). Of these respondents 31 (35.2%) stated that sexual activity was always pleasurable; 44 (50.0%) said it was sometimes pleasurable and 13 (14.8%) never felt pleasure with sexual activity. In our cohort, there was a significant correlation between the ease of getting sexually aroused and the ability to achieve an orgasm (r s = 0.616, p = 0.01). The better the sexual arousal, the easier it was to achieve an orgasm. The correlation between arousal and sensitivity of the neoclitoris was less distinctive but still significant (r s = 0.506, p = 0.01). The self-estimated pleasure of sexual activity was significantly correlated with the sensitivity of the neoclitoris (r s = 0.508, p = 0.01) but not with the depth of the neovaginal canal (r s = 0.198, p = 0.079); i.e., neoclitoral sensitivity seems to contribute to the enjoyment of sexual activity to a greater extent than the depth of the neovagina.

Sexual orientation related to the self-perceived gender.

Satisfaction with neoclitoral sensitivity.

Satisfaction with neovaginal depth.

Modality as to how orgasms were achieved (multiple answers possible). (a) Absolute number of patients. MB = masturbation; SI = sexual intercourse; OT = other (not further specified); NO = no orgasm; NA = no answer. (b) Modality as percentage of answers.

Patients' general satisfaction with their sex lives. Likert scale ranging from 0 (“very dissatisfied”) to 10 (“very satisfied”).

4. Discussion

Overall, subjective satisfaction rates can be expected to be 80% and higher after GAS [ 22 ]. Löwenberg reported a general satisfaction with the outcome of GAS to be even over 90% [ 10 ]. Studies often stress the emphasis on functional or aesthetic aspects after GAS [ 5 – 7 , 23 – 25 ] or, at best, on sexual quality of life before GAS [ 20 , 26 ]. To our best knowledge, this is the first study placing a particular focus on sexual life after MtF GAS.

In our study, sexual attraction was referred to the self-perceived sexual identity on the basis of self-identification. Accordingly, we used the term “heterosexual” or “homosexual” when participants reported on sexual attraction towards men (natal men as well as transmen) and women, respectively. Due to the existing stigmatization of homosexual and lesbian individuals in a heteronormative community or to patients' wish for social desirability, it is possible that reports on the prevalence of homosexuality (gay and lesbian) are underestimations. A representative study with over 14.000 men and women in Germany reported on a prevalence of 4% of men and 3% of women who self-identified as “gays”. Another 9% of male and 20% of female heterosexual participants felt sexually attracted by the same sex without identifying themselves as gay [ 27 ]. International surveys found a prevalence of homosexuality in up to 3% with regional and age-dependent variations [ 28 – 32 ]. In our study, the percentage of homosexuality (gay and lesbian) related to self-perceived gender was much higher. This could be because the interviewees knew the interrogators well, had generally revealed their sexual orientation beforehand, and had no fear of societal stigmatization. There is also the possibility that the rate of homo- and bisexuality is, in fact, higher in transsexuals compared with nontranssexuals. [ 33 ] Lawrence found a change in predominant sexual attraction in 232 MtF transsexuals before and after genital reassignment [ 19 ]. In her study, 54% and 25% of participants reported a gynephile orientation before and after surgery, respectively. Androphilic orientation changed from 9% preoperatively to 34% postoperatively. Regarding asexuality, we followed the definition of Prause and Graham who found that asexuality is defined to be a lack of sexual interest or desire, rather than a lack of sexual experience [ 34 ]. In our cohort, in total 6% of the women self-identified as asexual. Bogaert reported on approximately 1% asexual individuals of a total sample size of over 18.000 (nontranssexual) British residents, with more women being asexual than men [ 35 ]. He found both biological and psychosocial factors contributing to the development of asexuality. Prause and Graham found significantly lower sexual arousability and lower sexual excitation in asexual individuals with a prevalence of 4% [ 34 ]. A reduced sensitivity of the neoclitoris could therefore be a prognostic factor for asexuality. Our results support this assumption. The sensitivity of the neoclitoris correlated with the ability of sexual arousal and achieving an orgasm, as well as with the self-estimated pleasure of sexual activity. In our cohort, satisfaction with the sensitivity of the neoclitoris was higher than with the depth of the neovaginal canal. This could be due to the time of questioning, which was a median of 5.05 years after GAS. While neoclitoral sensitivity is unlikely to diminish, it is more likely that the neovaginal canal shrinks over time. Of the subjects 6% reported a stenosis of the neovagina and 45% a loss of initial neovaginal depth [ 25 ]. The longer the period after GAS is, the more prevalent the stenosis of the neovaginal canal seems to be [ 36 ]. Ineffective dilatation of the neovaginal canal is obviously a key factor contributing to neovaginal stenosis. Over half of all patients (58%) do not use vaginal dilators appropriately, which is a major reason for this kind of long-term complication [ 36 ].

Postsurgical sexuality plays an important role in overall satisfaction and depends substantially on the functionality of the neovagina [ 5 , 6 ]. Satisfaction with functionality ranges between 56% and 84% [ 7 , 9 , 10 , 37 , 38 ]. Previously, we reported a satisfaction rate with functionality, including satisfaction with depth and breadth of the neovagina and the satisfaction with penetration or intercourse, to be 72% (“very satisfied” and “satisfied”) or 91% (including also “mostly satisfied”) [ 6 ]. The self-reported enjoyment of sexual activity correlated significantly and to a greater extent with neoclitoral sensitivity than with neovaginal dimensions, which was not significant. Though genital dimensions were not surveyed in our study, penile size often exceeds the depth of the vaginal canal in natal women without causing problems with, or pain during, sexual intercourse. However in contrast to a skin derived vaginal canal of transgender women the vagina of natal women is able to expand 2.5 to 3.5 cm in length when sexually stimulated [ 39 ]. Neoclitoral sensitivity is usually assessed by means simply of asking the women and can be biased by the patients' wish for social desirability. In this retrospective study we could not rule this out. However, we previously introduced a measurement tool to assess semiquantitatively the sensitivity with a customary brush and a tuning fork [ 40 ] which could be used for future studies on this topic. Though the rate of women, who were able to achieve an orgasm, was lower in the present study than in an earlier cohort from our department [ 9 ], our data aligns well with comparable studies of a similar size [ 11 , 19 , 41 – 43 ]. Interestingly, Dunn et al. found a similar rate of natal women who were unsure or not able to achieve an orgasm during intercourse (16%) or masturbation (14%) [ 44 ]. In total 55.8% of the women in our study rated their orgasms postoperatively as more intense than before surgery, one in five women (20.8%) felt no difference, and 23.4% reported less intense orgasms after surgery. These results are roughly in line with a study by Buncamper et al. [ 45 ]. Since it is very unlikely that handling of the neurovascular bundle during surgery will make the neoclitoris more sensitive than the glans penis was before, a possible explanation could be that postoperative patients were able to experience orgasm for the first time in a body that matched their perception. Furthermore, a decline in sexual desire after sex reassignment therapy (hormonal and surgical) could contribute to an altered orgasmic experience [ 46 ]. Interestingly, in their systematic review, Guillamon et al. reported on results of three longitudinal studies showing a transformation in the brain morphology of MtF after initiation of cross sex hormonal therapy towards a more female morphology [ 47 ]. Moreover, receiving hormonal treatment was one of the factors related to a better subjective perception of sexual quality of life [ 20 ]. Rolle et al. registered a cerebral modification after sex reassignment in fifteen MtF transsexual individuals towards a more female cognitive response [ 48 ]. It is unclear whether this could explain differences in subjective orgasm experience before and after GAS. Further prospective studies with a larger sample size are needed to validate this preliminary aspect.

5. Limitations

The study was limited by its retrospective character with a response rate below 50%. Suicide is a very unlikely reason for nonparticipation since the suicide rate after successful GAS is not higher than in the general population [ 49 ]. However, contacting trans-female patients for long-term follow-up is generally difficult [ 3 , 37 , 50 – 54 ] particularly in countries like Germany where there is no central registration. Another reason is that patients often move following successful surgery [ 5 ]. Response rates to surveys in retrospective research in this field are between 19% [ 54 ] and 79% [ 55 ]. With 49%, Löwenberg et al. achieved a similar response rate in a follow-up inquiry of a comparable cohort [ 10 ]. Another bias could be that the answers represent patients' wishes for social desirability, rather than the reality of their situation. However, this cannot be verified retrospectively.

6. Conclusion

To our best knowledge, this was the first study to survey sexuality after MtF GAS in a very detailed way. In the majority of women, orgasms after surgery were experienced more intense than before. In our cohort, neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than the depth of the neovaginal canal.

Acknowledgments

The authors acknowledge support by the Open Access Publication Fund of the University of Duisburg-Essen. This study has been conducted without external funding. Expenses have been financed by the Clinic for Urology, University Hospital Essen, University Duisburg-Essen, Germany.

Conflicts of Interest

The authors declare that they have no potential conflicts of interest.

Ethical Approval

All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Parts of the data were presented as an abstract at the 2nd Biennial Conference “Contemporary TransHealth in Europe: Focus on Challenges and Improvements” 2017 in Belgrade, Serbia.

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Female sex as a negative predictor of outcomes of ankle arthrodesis: a retrospective comparative monocentric study

Affiliations.

• 1 Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389, Frankfurt, Germany. [email protected].
• 2 Department of Foot and Ankle Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389, Frankfurt, Germany.
• 3 Institute for Medical education and clinical simulation, Goethe University Frankfurt, 60590, Frankfurt, Germany.
• 4 Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, 60590, Frankfurt, Germany.
• 5 Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg, University Mainz, 55131, Mainz, Germany.
• 6 Department for Trauma and Orthopaedic Surgery, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, 60389, Frankfurt, Germany.
• PMID: 39238021
• PMCID: PMC11378585
• DOI: 10.1186/s13018-024-05045-8

Background: End-stage post-traumatic osteoarthritis of the ankle joint may require arthrodesis if conservative treatment fails and a decision against total ankle replacement is made. We aimed to compare the sex-specific differences in outcomes and objectify them using validated specific scores.

Methods: Between 2010 and 2021, 221 patients underwent ankle arthrodesis at our institution, including 143 men (MAA) and 78 women (FAA). In addition to demographic data, the aetiology of osteoarthritis, the Foot Function Index (FFI-D), the Olerud-Molander Score (OMAS), and the Short Form-12 questionnaire (SF-12) were collected in this monocentric study. The mean follow-up time was 5.8 years. End-stage osteoarthritis was mostly due to ankle fractures as a result of sprains, falls, and road traffic accidents.

Results: Post-operatively, the mean FFI-D for pain was 17.3 (MAA: 14.7; FAA 22.2) and 43.9 for function (MAA: 41.1; FAA 49.5); the mean OMAS was 58.2; and the mean SF-12 physical component score was 42.5. Women achieved significantly worse results in all scores; only the mental component summary of the SF-12 did not differ between the sexes (p > 0.05). Approximately 34% of women stated that the result in terms of gait pattern was worse than expected (MAA 16.1%; p < 0.05). Again, significantly more men stated that the result was better than expected (MAA: 48.3%; FAA: 31.5%, p < 0.05).

Conclusions: The fact that the clinical results were significantly worse in women after ankle arthrodesis should be considered when determining the indication. However, the expectations of men and women also need to be individually adjusted.

Keywords: Ankle arthrodesis; Post-traumatic osteoarthritis; Sex-specific differences; Trauma and orthopaedic research.

© 2024. The Author(s).

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Conflict of interest statement

The authors declare no competing interests.

Flow chart of the study

Relationship between preoperative expectations in…

Relationship between preoperative expectations in men and women and the actual gait pattern…

Postoperative radiographic findings of a…

Postoperative radiographic findings of a 53-year-old men, treated with tibiotalar arthrodesis in 2-screw…

Postoperative radiographic findings of a 58-year-old women, treated with tibiotalar arthrodesis in 3-screw…

• Minnig MCC, Golightly YM, Nelson AE. Epidemiology of osteoarthritis: literature update 2022–2023. Curr Opin Rheumatol. 2024;36(2):108–12. 10.1097/BOR.0000000000000985 - DOI - PMC - PubMed
• El-Adly W, Adam FF, Kamel MS, Osman AE. Functional and radiographic assessments of post-traumatic asymmetrical ankle osteoarthritis treatment using supramalleolar osteotomies. Eur J Orthop Surg Traumatol. 2024;34(2):1095–101. 10.1007/s00590-023-03773-x - DOI - PMC - PubMed
• Kjellsson S. Do working conditions contribute differently to gender gaps in self-rated health within different occupational classes? Evidence from the Swedish Level of Living Survey. PLoS ONE. 2021;16:e0253119. 10.1371/journal.pone.0253119 - DOI - PMC - PubMed
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Significant preoperative anxiety associated with perceived risk and gender in cataract surgery.

1. Introduction

2. materials and methods, 2.1. study design and population, 2.2. measures, 2.3. statistical analysis, results of the stai and mmse test questionnaires, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Floros, G.; Kandarakis, S.; Glynatsis, N.; Glynatsis, F.; Mylona, I. Significant Preoperative Anxiety Associated with Perceived Risk and Gender in Cataract Surgery. J. Clin. Med. 2024 , 13 , 5317. https://doi.org/10.3390/jcm13175317

Floros G, Kandarakis S, Glynatsis N, Glynatsis F, Mylona I. Significant Preoperative Anxiety Associated with Perceived Risk and Gender in Cataract Surgery. Journal of Clinical Medicine . 2024; 13(17):5317. https://doi.org/10.3390/jcm13175317

Floros, Georgios, Stylianos Kandarakis, Nikolaos Glynatsis, Filaretos Glynatsis, and Ioanna Mylona. 2024. "Significant Preoperative Anxiety Associated with Perceived Risk and Gender in Cataract Surgery" Journal of Clinical Medicine 13, no. 17: 5317. https://doi.org/10.3390/jcm13175317

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