Cultural Considerations Regarding Glansplasty

Sir: With increased awareness surrounding transgender issues, plastic surgeons are participating more frequently in gender-affirming operations.1 Phalloplasty aims to create a phallus out of existing tissue and has been shown to have a dramatic impact on transmale patient quality of life.2 The goals of phalloplasty vary based on patient preference but generally aim to enable urination in the standing position; create a neophallus that is similar in length, circumference, and aesthetics to a natal phallus; allow tactile and erogenous sensitivity; and support rigidity with or without a penile implant. A variety of flaps have been pioneered to meet these goals, and many of them allow for glansplasty to approximate a corona.3 However, not all transmale patients may desire the appearance of a circumcised phallus after glansplasty. A recent study on global male circumcision estimates that 37 to 39 percent of the male population is circumcised.4 Reasons for not being circumcised are many and include religious and cultural beliefs, inability to assess providers offering the procedure, and personal wishes. Although there are documented health benefits of circumcision, these are not significant enough for universal newborn circumcision to be recommended.4 Cultural and religious reasons for not desiring a circumcised-appearing penis may similarly apply to transmen seeking phalloplasty. When planning gender-affirming surgery, it is paramount that the surgeon considers each patient’s aesthetic goals, which may be influenced by any combination of intersecting personal, cultural, and ethnic values.5,6 Facial and breast surgery have made important advances in this realm, which should be extended into gender-affirming surgery, including with genital surgery. With the current lack of patient-reported outcomes data in gender-affirming surgery, it is important to consider what each patient may desire with phalloplasty on a case-by-case basis, including the potential to resemble an uncircumcised penis.6 Although reconstruction of foreskin is not currently an option, foregoing glansplasty is certainly possible and can more closely resemble an uncircumcised penis. Further studies are needed to characterize the desire for glansplasty within different gender diverse populations, and to characterize the aesthetic and functional desires of transmen seeking phalloplasty generally. Using what information is available, surgeons should take into account individual patient goals to develop a surgical plan that is informed by patient anatomy, individual preference, and ethnically or culturally informed aesthetic standards to achieve a result that is concordant with patient-desired outcomes. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Ian NolanNew York University School of MedicineNew York, N.Y. Christopher S. Crowe, M.D.Benjamin B. Massenburg, M.D.Division of Plastic SurgeryDepartment of SurgeryUniversity of Washington School of MedicineSeattle, Wash. Jonathan P. Massie, M.D.Division of Plastic SurgeryDepartment of SurgeryFeinberg School of Medicine at Northwestern UniversityChicago, Ill. Richard A. Santucci, M.D.Brownstein and Crane Surgical ServicesGreenbrae, Calif. Shane D. Morrison, M.D., M.S.Division of Plastic SurgeryDepartment of SurgeryUniversity of Washington School of MedicineSeattle, Wash.