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Table 2. Sexual goals, surgical concerns, and counseling considerations in genital gender affirming surgery
Goal Related concerns Counseling recommendations

Lubricants for sexual activity and dilation are
recommended for all graft options; therefore, this should
not be a primary consideration in procedure choice [22] .
Specifically, women should be advised that peritoneal
Experience Expectations around
penetrative vaginal arousal and lubrication, and grafts do not provide sufficient lubrication to eliminate
intercourse how this affects graft choice the need for external lubricants - a common
misconception amongst patients and providers alike
Most cisgender women need to use external lubricants
during intercourse
Dilation needs after vulvovaginoplasty
Zero- or minimal-depth surgery reduces intensity of
Uncertain if post-surgical care, but it becomes more difficult to create
Vulvoplasty/Vulvovaginoplasty Vulvoplasty vs.
interested in vulvovaginoplasty a new canal at a later date - for both practical and
penetration anatomical reasons [23-25]
Pros & Cons of all options for a person’s individual sexual
goals
Determine whether related Build coping skills for dilation
to sexual trauma, practical
concerns, anxiety, or other Better to do surgery when patient is prepared to dilate
issues
Concerns about and can be successful
dilation regimen
Is patient ready for surgery, Concrete plan for addressing concerns
or do they need time to
address these issues prior Pelvic floor physical therapy consultation
to scheduling?
Penetration is not always the primary goal of individuals
interested in these types of surgery, if it is a goal at
Is phalloplasty or all [26,27]
How important is
sexual penetration? metoidioplasty more
appropriate? If penetration is not a goal, are there other reasons why
phalloplasty is more appropriate (e.g., “locker room”
appearance, bulk, etc.)
There are a variety of techniques for achieving penile
rigidity without a prosthesis (e.g., wrapping in coban
tape), but most people interested in using their phallus
for penetration will eventually at least consider an
internal prosthesis [28]
Phalloplasty/Metoidioplasty Erectile function Need for erectile device
All currently available internal prosthesis options have a
substantial risk of complications, including possible need
for multiple replacements due to device failure or erosion
of the device through the penis [29,30]
Discuss erectile function of the clitoris and if the goal is
“Spontaneous” Does patient have
erection achievable goals? erection or penetration to prioritize choice of
metoidioplasty vs. phalloplasty
Address community-driven misconceptions about
Patient understanding of ejaculation after urethral lengthening. Explain that glands
Ejaculation
procedure involved in creating semen are not present although urine
or other fluids may be expelled

EVALUATING UNCOMMON SURGICAL REQUESTS
There has been a growing conversation around genital surgery requests that fall outside the standard group
of surgeries that, by and large, are designed to replicate binary expectations around genital anatomy. While
historically many surgeons have been reluctant to consider performing such procedures, it is important to
note that what procedures are considered standard has changed over time. For example, vulvoplasty
(formerly often referred to as zero-depth vaginoplasty) used to be considered only appropriate in very
specific circumstances, but it has become more widely performed.