Introduction: Gender affirming, transmasculine genital reconstructive surgeries (TMGRS), including metoidioplasty and phalloplasty, are complex, high-risk procedures associated with decisional conflict. We sought to explore decisional needs in individuals who have considered or had TMGRS to inform surgical decision support development.
Methods: We used a mixed-methods, exploratory design involving semi-structured interviews and online gender health survey which included validated measures of gender congruence, decisional conflict, and quality of life. Participants included transmasculine or non-binary individuals assigned female at birth at various stages of TMGRS decision making recruited from two geographically varied study sites. Semi structured interviews were conducted (n=26) with community developed interview guides based on the Ottawa Decision Support Framework. Interviews lasted one hour and were recorded and transcribed for coding and analysis using mixed deductive and inductive (grounded theory) methods. Survey data were collected from interviewees plus additional participants (N=39), analyzed with descriptive statistics, and triangulated with interview data to explore themes and subgroup variations.
Results: Mean age of all participants was 34(18-65); 44% were pre, 25% were post, and 31% had decided against TMGRS. Two-thirds of participants reported current or past depression, anxiety, and PTSD alone or in combination. Affirmation of gender identity, standing to urinate, and comfort using male bathrooms emerged as highly important factors for deciding to undergo TMGRS in both surveys and interviews. Forty percent of respondents reported decisional conflict on the survey; interview data showed that TMGRS decisional conflict related to balancing the desire to resolve gender dysphoria against the potential for complications with urinary and sexual function, potential loss of sensation, and unknown aesthetics. Decisional conflict decreased as knowledge of surgical options increased. Insurance coverage, age, social support, and comorbidities influenced the timing of TMGRS decisions and preference for metoidioplasty over phalloplasty.
Conclusions: This study highlights the key factors important to TMGRS decision-making and offers new insights into the complex relationship between decisional conflict and knowledge of surgical risks and options.