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Page 10 of 20 Kant et al. Plast Aesthet Res. 2026;13:4

surgical team and a patient’s therapist or psychiatrist may help the patient’s external care team provide
additional support at this time, creating a temporary wrap-around model of care.

Survivors of sexual assault
There are a multiplicity of potentially overlapping reasons why genital surgeries may be especially difficult
for patients who have survived sexual violence. These include multiple pre- and post-operative genital
exams, including internal exams or placing/removing internal stents/catheters, as well as discussions of both
sexual activity and intimate behaviors involving these areas that are necessitated by post-surgical recovery. It
is particularly important to work with patients to consider how post-operative care, such as dilation, may be
impacted by a history of sexual violence and prepare coping strategies in advance to increase the likelihood
of a positive surgical outcome [72-74] .

While not all survivors of sexual violence will have issues during the perioperative period, it is important to
address such concerns proactively and in a trauma-informed way. By their nature, gender-affirming genital
surgeries occur in an intimate region of the body, and for all patients, there is a period of adjustment to
having providers routinely examining their genitals during the perioperative period. For survivors of trauma,
this can be highly activating, and may be even more so depending on the gender of the provider or the
relative power differential . It also diverges from standard trauma-informed practices that allow individuals
[2]
to opt out of genital exams when not acutely necessary, as the act of having chosen the surgery means that
such exams are important for patient safety in different parts of the perioperative process. Behavioral health
professionals can help patients work on coping skills to make such exams more tolerable [75,76] .

Additionally, recovery from genital surgery involves a range of new sensations, many of which are quite
painful, and some of which may feel replicative of injuries sustained during assault, or of the assault itself.
Vaginal packing used in vulvovaginoplasty may be experienced as prolonged sharp pressure on the rectum
and is often painful enough to make it difficult for patients to ignore. Other sensations may evoke a feeling of
pelvic “fullness”, and traumatic dissociation may exacerbate this sensation by making it difficult for patients
to orient to their surroundings and temporarily bringing them mentally back to traumatogenic events.

Similarly, while for most patients anesthesia is a neutral or even pleasant experience, the delirium induced by
medications such as propofol and ketamine can cause disorientation, and their paralytic effects may create
the sensation of being held or pinned down. Even in the absence of a history of assault, “emergence
delirium” is a well-documented adverse reaction to anesthesia that can take the form of panic and
hyperventilation .
[77]

Being prepared in advance for these potential effects and sensations may help mitigate them, and anecdotal
evidence suggests it can reduce their likelihood or help patients recognize what is happening and feel assured
that they are safe. Making a plan with patients ahead of time and communicating this to direct care staff can
be crucial to providing proper trauma-informed care, including discussing with patients why examinations
or other forms of care are taking place and asking for consent before they occur . Providers and other
[78]
medical staff should also inform patients of the reason why they are asking any question that may be
perceived as invasive as a matter of routine [79,80] [Table 5].

Addiction
While vast improvements have been made in pain management, there is always the concern in medicine that
the prescription of powerful analgesics may lead to iatrogenic harm through addiction. This is complicated
substantially for patients with a past history of addiction, the risk of which has been shown to be elevated in
transgender adults due to experiences of minority stress [81-83] . Unlike day surgeries, which may involve only