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Page 4 of 20 Kant et al. Plast Aesthet Res. 2026;13:4

Table 1. Critical aspects of the social environment

Area Potential concerns
Housing Stability of housing
Access to a toilet and bath or shower
Pets in the home (cleanliness/need for caregiving)
Private place to engage in post-surgical care needs (e.g., dilation)
Who else is present in the home (are they safe to be around/aware of surgery)?

Post-surgical support Who will care for the patient after surgery?
What is their relationship with the patient, and is it stable?
Are they aware of all necessary care, willing to assist with it, and available as needed for the full recovery period?
Can they come to a pre-surgical appointment to ask questions/express concerns?
Is a backup caregiver available, if needed?
Finances Does the patient have sufficient financial resources to sustain them through recovery (i.e., pay for housing, food, and other
essential needs)?
Assistance with applying for short-term disability, as appropriate
Assistance with applying for leave from appointment
Assessment of employment stability/ability to return to work after leave
Mental health Full mental health history, including any medications
Discussion of coping skills and any needed adaptations for post-surgery (e.g., a change from running to a sedentary
activity)
Relationship with a therapist who can be helpful in the perioperative period

of these issues are addressed in more detail below, a useful framework is that the provider generally does not
determine whether the patient can have surgery, but rather when they will be able to have it safely and
recover with as few anticipated problems as possible. However, if the patient is unlikely to ever be
appropriate or ready for surgery, this should be clearly communicated to them so that they can explore other
options.

SEXUALITY AND SURGICAL DECISION MAKING
In addition to gender affirmation, the decision to undergo genital affirmation surgery involves numerous
considerations about sexual interests and goals. Individual goals may affect both interest in having surgery
and the type of surgery that patients are considering [Table 2]. Understanding a patient’s sexual goals and
post-surgical sexual expectations is important for advising them about which, if any, procedures can help
them achieve them. When engaging in shared decision-making processes, “teach-back” methods can be used
to elicit patient understandings of these specifics and have been demonstrated in other fields to show higher
rates of both satisfaction and compliance with aftercare needs. These can similarly be grounded through
learning about how patients seek gender-affirming healthcare information (e.g., on Reddit).

It is important to start discussing patients’ sexual goals early in the consultation process. It can take time for
patients to feel comfortable having these discussions with providers, and many procedural decisions are
directly related to patient goals. If patients’ expectations cannot be met using current surgical techniques, it is
important to know that before any surgeries take place. For example, even if a phalloplasty surgeon does not
implant erectile devices, that surgeon should be confident that the patient’s goals around erectile function are
possible to be met before starting construction of the phallus, or at a minimum, that the patient will be
satisfied with having undergone surgery even if particular goals with respect to penetration cannot be
achieved. In order to facilitate the success of these conversations, behavioral health professionals should
practice having non-judgmental conversations about sexual goals that are gender and sexual
orientation-inclusive. For providers who are concerned about their ability to do so without being or
appearing uncomfortable, a Sexuality Attitude Reassessment (SAR) or similar type of self-awareness
education may be a good option for further training .
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