Surgical treatments

Preparation

Before being referred for surgery, you will meet with your clinician to discuss the various options that may be available to you. Surgery of any kind is a big undertaking and can be stressful physically, mentally and emotionally. You will need to ensure you are ready and prepared to cope with the process. The best way to prepare for surgery is to ensure that your body and mind are fit and well. This may involve making some lifestyle choices around exercise and using nicotine, as being overweight and smoking are risk factors for surgical complications. If this is the first time you are thinking about exercise or you have a long term health condition that may impact on your ability to exercise, you should consider contacting your GP first to ask for advice on what is appropriate for you. Further information and support can be found at: www.nhs.uk/live-well/

Body weight
The surgical teams that perform operations relevant to the service are focussed on offering their patients the best care that they can, which includes minimising risk. Some surgeons may recommend a safe body weight for surgery because of the risks associated with anaesthetic, and to optimise the chances of achieving the best results.

The risk of complications from certain surgeries, associated with a high or a low body mass index (BMI), may mean that surgery cannot be performed until an optimum BMI has been reached. Some specific surgical techniques can only be offered to people who have the right amount of fat under the skin. It is also important that body weight remains stable, before and after surgery.

Each surgeon decides based on the risk factors of their individual patient. However, as a guide, the preferred BMI is between 18 and 30. This is not to say you cannot have surgery if your BMI is higher or lower that this, but it will depend on the type of surgery, the surgeon carrying out the procedure and your own body’s characteristics. You can find out about calculating your BMI and access support to lose weight, if required, at: www.nhs.uk/live-well/healthy-weight/ This includes exercise and diet plans to help get you started.

Smoking
You can also get help with stopping smoking from the NHS. You can find advice and contact your local stop smoking support service on the NHS website. There are several services available in locations around the North East.

Stable mental health
Surgery has a big impact on any person’s physical and mental health. The impact of having surgery and a general anaesthetic can lead to people experiencing periods of low mood and distress. Surgery can also cause people to feel vulnerable, lonely or frightened, even when other things in their life are going well.

Many people in the service will struggle with their mental health from time to time but for some people this is a more significant challenge. People who are already working hard to manage their mental health will be dealing with additional stresses in the post-operative period and this could lead to complications. For example, not feeling well enough to take good care of wounds could lead to infections, or feeling more low in mood than usual could result in severe distress and difficulties coping with day to day life.

For this reason, we seek to support everyone who wishes to have surgery, to be in the best mental health that they can before their surgery. Whilst we always endeavour to promote good mental health for our service users, we understand that for some people it will not be possible for them to be in perfect mental health before surgery. Instead, we seek to help them achieve the best mental health they can that is stable and does not change significantly from day to day. In this way, they can have the surgery that they need and be capable of managing the difficult post-operative period successfully.

Where appropriate, we will offer psychological therapy to people seeking surgery who need help to achieve and maintain stable mental health. For some people this might be more usefully provided by their local mental health services.

Preparation of skin sites
For certain surgeries, particularly genital surgeries, preparation of the skin may be required. This is because, during phalloplasty and vaginoplasty operations, skin that is usually on the outside of the body is moved to a position inside the body. It is very important that these areas of skin are hair-free before surgery. Hair bearing skin inside the body could result in an unsatisfactory result.

Whether or not you need to have hair removal treatment, will depend on your body’s characteristics. This will usually be determined by the surgeon assessing you for surgery. Thereafter, you will be offered laser and / or electrolysis to the area. This process takes at least several months and may lead to a delay in you accessing surgery.

Other considerations
Before any surgery you will need to make sure that your home is a place that you can recover in successfully. In the days and weeks after surgery, you will need to be able to keep your body clean easily. You will not be able to cook or clean, do laundry or look after pets or children. You will not be able to carry bulky or moderately heavy items. There may be limitations on you reaching up to high shelves or cupboards. How long you will be advised to limit your physical activity will depend of the type of surgery you are having. Your surgeon will discuss this with you.

If you have a medical condition, it might be important that this is well controlled before you can be referred for surgery. Your surgeon will advise you on this.

If you take oestrogen you will need to stop taking oestrogen for six  weeks before surgery and this will not start again until you are up and about and moving regularly. Your doctor will organise this with you.

If you have people who can help you while you are recovering it will be useful to ask them to visit you, or to arrange to go and stay with them when you leave hospital. You may need to contact your GP and arrange to be visited by your district nurse if you need extra support after surgery.

Looking after yourself post-surgery
Everyone who has surgery can expect that they will feel physically and emotionally unwell afterwards. General anaesthetic can leave people feeling unwell for several days. In addition to this you will have had a significant change to your body, which will take time to heal and be painful. It may also take time to adjust to the way that your body has changed.

This often has a huge emotional impact while a person is recovering. It is not unusual to feel sad, tearful and overwhelmed by the process that you have been through, even though the surgery is something you have wanted for a long time. Sometimes the prospect of the recovery period can be somewhat daunting. These are all normal feelings and not usually a cause for concern. Having these feelings does not mean that you have made a mistake by having the surgery or that your motives for having it were somehow mistaken.

It can be useful to tell people who support you that you might feel like this after surgery so that they are well placed to offer you emotional and physical support. Get a good balance of rest and activity in your day. Plan treats, distractions and things to fill your time while you recover.

Choosing a surgeon
You will talk to your clinician at NRGDS about which surgeons and locations are available for you to choose from for your intended surgery. Anyone who is referred to the service can use advice and support available from the NHS Gender Dysphoria National Referral Support Service (GDNRSS). This is a separate organisation which processes your referral to your surgical provider.

NHS GDNRSS have a support line to call for information about your referral, your surgeon and practical information about the hospital you will be attending.

You can book an appointment with a nurse specialist at NHS GDNRSS to discuss these issues by calling: 01522 857 799 (open Monday to Friday 9am to 5pm).

Further information on the NHS GDNRSS:

Welcome to the NHS Gender Dysphoria National Referral Support Service (GDNRSS)

Masculinising chest surgery

Before being referred for chest surgery, you will need to meet the requirements for referral and consider the options with your clinician to decide on your preferred surgical provider. Your clinician will then discuss your care with colleagues at NRGDS to get a “second opinion” to confirm that all relevant procedures have been followed and that the referral is appropriate. Usually, support is given for referral, but in a few cases the need for further reflection or extra support is highlighted, in order to optimise the chances of the person having a positive and safe surgical outcome. When the person has two supportive opinions a referral is sent to the GDNRSS, who liaise with your chosen surgeon.

Genital surgery

Before being referred for genital surgery, you will need to meet the requirements for referral and consider the options with your clinician to decide on your preferred surgical provider. Your clinician must then refer you to another appropriate medical professional who works outside of the NRGDS team for a second opinion, to ensure all relevant procedures have been followed and that the referral is appropriate.

This external doctor, who is usually based in Edinburgh, then offers a ‘second opinion’ to the NRGDS team. The second opinion is often in support of the surgery but sometimes it highlights the need for further reflection or extra support, in order to optimise the chances of the person having a positive and safe surgical outcome. Once two supportive opinions are available, a referral is sent to the NHS GDNRSS, who liaise with your chosen surgeon.

Further information from the Gender Identity Research and Education Society (GIRES) on the options and techniques available for genital surgery:
GIRES – A guide to lower surgery for those assigned female, identifying as men, trans masculine, non-binary or non-gender
GIRES – A guide to lower surgery for those assigned male, who identify as trans women, trans feminine, non-binary or non-gender