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Gender dysphoria occurs when there is a conflict between the sex you were assigned at birth and the gender with which you identify. This can create significant distress and can make you feel uncomfortable in your body.

People with gender dysphoria may want to change the way they express their gender. This can mean changing the way they dress, social transition (using the pronouns and public restroom associated with their affirmed gender), medical or surgical transition, or some combination of the two.

People with gender dysphoria feel that the sex they were assigned at birth does not match the gender with which they identify. For example, someone born with reproductive organs and other physical characteristics of a male may identify as female. The word "dysphoria" means significant discomfort and dissatisfaction, and gender dysphoria can begin to manifest as early as childhood in some people. Other symptoms include:

1) Distress
2) Anxiety
3) Depression
4) Negative self-image
5) Strong dislike of their sexual anatomy
6) Strong preference for toys and activities associated with the other gender (in children)

The distress related to this condition has been associated with an increased risk of substance abuse, self-harm behaviors, and suicide attempts. This is mainly due to the increased risk of discrimination for individuals who are transgender or gender non-conforming.

Gender dysphoria was sometimes called "gender identity disorder" and "transsexualism," but these terms are outdated and may be considered offensive. Gender dysphoria is not the same as homosexuality, which refers more to sexual orientation than gender identity. It is also different from gender non-conformity, which refers to engaging in behaviors that do not conform to gender norms or stereotypes.

You must meet certain criteria to be diagnosed with gender dysphoria, and these criteria vary depending on your age. To be diagnosed with gender dysphoria as a teenager or adult, you must have experienced significant distress for at least six months due to at least two of the following:

1) A marked incongruence between your experienced and expressed gender and your primary or secondary sex characteristics
2) A strong desire to be rid of your primary or secondary sex characteristics
3) A strong desire for the primary or secondary sex characteristics of the other gender
4) A strong desire to be of the other gender
5) A strong desire to be treated as the other gender
6) A strong conviction that you have the typical feelings and reactions of the other sex

The goal of treatment for gender dysphoria is to address the distress and other negative emotions associated with having a gender that does not align with the sex you were assigned at birth. It is important to remember that the problem is not your gender identity, but the discomfort associated with it. This is why treatment for gender dysphoria is best achieved through a team approach with doctors from different specialties, including psychology, social work, endocrinology, urology, and surgery. Treatment options include:

Psychological/psychiatric counseling: Some people who suffer from gender dysphoria do not wish to undergo medical or surgical transition. For example, you may want to live and be recognized as your affirmed gender without using hormones or undergoing gender affirmation surgery. An experienced therapist can help support you through all parts of your gender identity journey. Similarly, in our country, multidisciplinary follow-up for at least one year is required. The mental health professional is essential in this evaluation, which aims, above all, at the diagnostic and therapeutic safety of the patient.

Hormone therapy: For people who want to develop more physical characteristics of their affirmed gender, supplemental hormones can help. In children, puberty-blocking hormones can suppress the physical changes associated with puberty until they and their parents are ready to affirm their gender. In adults and adolescents who have already gone through puberty, hormones can help stimulate the development of gender-affirming physical characteristics.

Surgery: Procedures such as chest reconstruction or breast augmentation ("top" surgery) and metoidioplasty, phalloplasty, or vaginoplasty ("bottom" surgery) can be part of the gender affirmation process. People who choose to undergo surgery usually do so after first going through other steps in their gender affirmation journey, such as taking hormone supplements and managing the associated legal issue. Surgery should be the last step in the transgender process, as ultimately, it is the only part of the process considered irreversible.

MTF surgery includes a series of procedures that feminize male anatomy and genital characteristics. Professor Tiago Rosito strongly believes in a personalized approach to help patients achieve their goals with feminizing surgery. It can be performed completely (vaginoplasty, genitoplasty, orchiectomy) or in stages: orchiectomy for hormonal blockade and genitoplasty (creation of the vulva and clitoris) with or without vaginoplasty (vaginal cavity).

Penile inversion vaginoplasty is the most commonly performed type of MTF vaginoplasty. The testicles are removed (Orchiectomy), and the scrotal skin is used to make the labia majora (Labioplasty). The sensory nerves of the glans penis and the corresponding skin are preserved and used to make a clitoris. The skin of the penis and, in most cases, urethral grafts are used to make a wider vagina. The urethra is shortened and placed in the female position. The sensitive urethral mucosa is placed between the labia minora.

Penile inversion vaginoplasty is considered the gold standard (the most recognized technique worldwide) and is usually a one-stage procedure. However, secondary procedures are occasionally performed to maximize the aesthetic appearance of the vulva.

Robotic-assisted peritoneal flap vaginoplasty has several names: Davydov vaginoplasty and peritoneal traction are the most well-known alternative terms. The peritoneum is the inner lining of the abdomen. Through several small incisions in the abdomen, robot-assisted laparoscopy is performed to reconfigure the peritoneum in the pelvis. This will create the inner half of the vaginal canal. The rest of the vaginoplasty is a standard penile inversion vaginoplasty. Professor Tiago Rosito's team performed the first robotic vaginoplasty in Latin America in 2023, making it the reference center for this technique in Brazil and Latin America.

Robotic surgery seems to be heading towards becoming the new gold standard in gender affirmation surgery and offers multiple advantages:

1) Creation of a deep vaginal cavity even in patients with small penises
2) Less bleeding
3) Less need for postoperative dilation
4) Faster recovery
5) Lower risk of intestinal complications

It is the surgical technique in which a portion of the large intestine (sigmoid colon) is used to create the neovagina. This technique is mainly used for secondary vaginoplasties, when the first procedure with penile skin or peritoneum did not work or there was a total loss of the vagina. Sigmoid surgery is associated with frequent secretion from the neovagina and all the risks associated with the use of intestinal portions, such as fistulas, colostomy, among others.

Technique in which free skin grafts, usually from the lower abdomen, are used to create the vagina. In transgender patients, it is an option for secondary vaginoplasty, as is the intestine.
In patients with Mayer-Rokitansky Syndrome, which consists of congenital vaginal agenesis, this technique is performed by Prof. Rosito as the gold standard.

Pure feminizing genitoplasty involves the creation of a female external genitalia from the penis and scrotal sac, bilateral orchiectomy but without the creation of a vagina. It is a surgery with lower rates of serious complications that are normally associated with a vagina. Labiaplasty and clitoroplasty are performed. The final appearance resembles a Cis woman but without the ability to be penetrated.

In the techniques used by Prof. Rosito, prior permanent hair removal is rarely necessary. This is because we use the penile inversion vaginoplasty technique proposed by Prof. Perovic, in which the urethra is also formed with a portion of the urethra. We do not use the scrotal sac for the construction of the vagina, only for the creation of the labia majora.

The same applies when opting for robotic vaginoplasty, which does not require the use of the scrotal sac for the creation of the vagina, and consequently, it will not have hair.

Procedure that involves the removal of the testicles for hormonal control. The surgery is performed very carefully so as not to compromise future vaginoplasty or Pure Genitoplasty. After this procedure, the use of testosterone blockers is no longer necessary.

Surgery is never the first step in gender transition. It is something that happens after you have already explored medical and social transition options. People who choose to undergo vaginoplasty usually do so after completing other steps in the gender affirmation process, such as taking hormone supplements. To qualify for vaginoplasty, you must be at least 18 years old and meet certain criteria of the transgender process as directed by the 2019 CFM resolution.

Vaginoplasty requires significant recovery time and ongoing self-care. You should expect to spend about a week in the hospital after surgery and return for many follow-up appointments after discharge. Since the healing process can take time, you should not engage in strenuous physical activities or heavy lifting for the first six weeks after vaginoplasty.

You will likely also need to urinate through a catheter for one to two weeks after surgery. Your clinical team will provide detailed instructions on how to care for the catheter and how to check for signs of infection at the surgical site, such as redness and swelling. You will likely be able to walk and engage in light activities within a week after surgery and be healed enough to return to all activities in about six weeks. This surgery has a very long healing process, which can take 12 to 18 months. Sexual intercourse is rarely allowed before 2 months post-surgery.

Unlike other gender affirmation surgeries, vaginoplasty requires a lifelong commitment to aftercare. If you undergo vaginoplasty, you will initially have to dilate the vagina several times a day to keep it open. Eventually, this may be reduced to several times a week, depending on a variety of factors. Your care team will explain in detail how to do this.

Transgender men require specialized and multidisciplinary care due to the multiple surgical procedures they may undergo in their masculinizing transition. Our center is prepared to offer a range of treatment options. We offer the Metoidioplasty (Meta), Phalloplasty, urethroplasty, scrotoplasty, hysterectomy, and vaginectomy procedures.

What is metoidioplasty?

Or "meta" for short, is a good option for those who do not want to undergo phalloplasty. The average length of a phallus after metoidioplasty is about 4-6 cm. This is long enough to direct a stream while standing.

Metoidioplasty surgery usually involves releasing a hormonally enlarged clitoris, urethroplasty (lengthening the urethra to the tip of the phallus), covering the phallus with neighboring skin, vaginectomy, and scrotoplasty. However, urethral lengthening, vaginectomy, and scrotoplasty are all optional.

Our surgeons are proficient in many different types of metoidioplasty to best suit the patient's anatomy. We take into account the size of the clitoral hood, urethral plate, and neighboring tissue to maximize the aesthetic outcome. Our surgeons also perform a complete vaginectomy to create an anatomically male perineum.

It is possible to have phalloplasty after metoidioplasty, but the reverse is not true. We offer metoidioplasty as a gender affirmation procedure for eligible patients aged 18 or older who have lived full-time in their identified gender for at least 12 months as defined by the transgender process.

Our qualified team includes specialists in plastic surgery, urology, nursing, and physical therapy who work together to provide a comprehensive set of options for transgender men.

Surgery is never the first step in gender transition. It is something that happens after you have already explored medical and social transition options. People who choose to undergo metoidioplasty usually do so after completing other steps in the gender affirmation process, such as taking hormone supplements and undergoing chest surgery. To qualify for metoidioplasty.

Although they have different functions, the clitoris and penis are derived from the same tissue. Metoidioplasty takes advantage of this fact by creating a penis from the clitoris after it has been enlarged with testosterone therapy. Often, a scrotoplasty (surgical creation of a scrotum from the labia majora) is performed at the same time. Metoidioplasty may also include the surgical construction of a glans and lengthening of the urethra. The first option improves the resemblance to a cisgender man's penis. The second allows you to urinate standing up. It is possible to have phalloplasty after metoidioplasty, but the reverse is not true.

Metoidioplasty can take 2 to 5 hours and you may need to stay in the hospital for one or two days. Since the healing process can take time, you should not engage in strenuous physical activities or heavy lifting for the first 6 weeks after metoidioplasty.

If you undergo urethral lengthening as part of metoidioplasty, you will likely also need to urinate through a catheter for 3 to 4 weeks after surgery. Your clinical team will provide detailed instructions on how to care for the catheter and how to check for signs of infection at the surgical site, such as redness and swelling. You will likely be able to walk and engage in light activities within a week after surgery, and be healed enough to return to all activities in about 6 weeks. This surgery has a very long healing process, which can take 12 to 18 months.

Urethroplasty (urethral lengthening), Vaginectomy (removal of the vagina), and Scrotoplasty (creation of the scrotum) are usually performed in conjunction with Metoidioplasty.

Scrotoplasty is performed using rotational flaps of the labia majora so that the scrotum is anterior in the anatomical male position. Testicular implants can be placed 6 months after scrotoplasty to minimize the risk of implant erosion. If the patient desires a larger scrotum, tissue expanders can be placed before scrotoplasty.

What is phalloplasty?

Phalloplasty is the surgical creation of a penis. In this procedure, surgeons collect one or more "portions" of skin and other tissues from a donor site on your body (forearm, thigh, abdomen, or back) and use them to form a penis and a urethra.

Our surgeons believe that the standard of care in phalloplasty uses the lateral thigh (anterolateral thigh - ALT) or lower abdominal flaps as donor areas. These portions heal well with good sensation due to the robust blood supply and innervation without the need for microsurgical anastomoses.

Like metoidioplasty, urethral lengthening, scrotoplasty, and vaginectomy can be performed at the same time or at separate times. Once appropriate healing has been achieved, a penile implant can be inserted into the phallus to allow penetrative sexual intercourse.

Professor Rosito offers phalloplasty as a gender affirmation procedure for eligible patients aged 18 or older who have lived full-time with their identified gender for at least 12 months. Our qualified team includes specialists in plastic surgery, urology, physical therapy, and nursing who work together to provide a comprehensive set of options for transgender men.

Gender affirmation surgeries are a group of surgical procedures that some transgender and gender-diverse people use to help affirm their gender identity. Phalloplasty is available for transgender men, or those who identify as trans masculine. It involves the surgical creation of a penis from skin and other tissue harvested from another part of the body.

Surgery is never the first step in gender transition. It is something that happens after you have already explored medical and social transition options. People who choose to undergo phalloplasty usually do so after completing other steps in the gender affirmation process, such as taking hormone supplements and undergoing chest surgery.

Phalloplasty involves taking one or more "flaps" of skin and other tissue from donor areas such as the thigh. Before surgery, you will need to undergo permanent laser hair removal or electrolysis on your donor site. It is also crucial that you stop smoking completely for at least 3 months before the operation. To be ready for phalloplasty, patients also need to undergo a hysterectomy and vaginectomy, which must be completed at least 3 months before phalloplasty. During phalloplasty, the surgeon removes the flaps and uses them to create a penis and urethra. The donor area will be covered with a skin graft from your thigh, which will heal on its own. This procedure usually occurs during a single long surgery, which can last between 8 and 12 hours.

Phalloplasty is a complex surgical procedure that requires significant recovery time and ongoing self-care. You should expect to spend about a week in the hospital after surgery and return for follow-up appointments after discharge. Since the healing process can take time, you should not engage in strenuous physical activities or heavy lifting for the first 6 weeks after phalloplasty. You will likely also need to urinate through a catheter for the first three to four weeks after surgery. Your clinical team will provide detailed instructions on how to care for the catheter, as well as the surgical wounds at the donor site and graft, and how to check for signs of infection, such as redness and swelling.

You will likely be able to walk and engage in light activities within a week after surgery and be healed enough to return to all activities in about 6 weeks. This surgery has a very long healing process, which can take 12 to 18 months. Phalloplasty typically involves multiple sequential surgeries over several months.

A primary surgical goal for many who have FTM Surgery is to stand to urinate. To allow this, a Urethral Lengthening (UL) procedure, or urethroplasty, is necessary.

How it is done: The opening for the native urethra is positioned in the perineum. Neighboring tissue is used to extend the urethral opening to the tip of the phallus.

For those who have Metoidioplasty with Urethral Lengthening, neighboring tissue is used to reconstruct the urethra.

With phalloplasty, a tube-in-tube urethra is created and connected to the lengthened urethra.

Recovery: After urethral lengthening, a suprapubic catheter tube is left in place for 2-4 weeks (average of 3 weeks) and is removed once emptying through the tip of the phallus. This tube goes from the skin of the lower abdomen to the bladder and diverts urine away from the urethra, allowing it to heal.

Possible Complications: For patients who are not interested in standing to urinate (i.e., they want a phallus and have little or no dysphoria around being able to stand to urinate), Urethral Lengthening is not necessary. This may reduce the risk of postoperative complications, as the most common complications after UL for Metoidioplasty or Phalloplasty are:

Urethral Stenosis - Narrowing of the opening causing difficulty urinating, including weak urine flow, straining to urinate, and inability to empty the bladder.

Fistula - Abnormal communication between the urethra and the external skin, causing urine to exit the phallus and elsewhere, i.e., scrotum, perineum.

This occurs, in general, in 10-20% of patients. A handful of patients choose not to have urethral lengthening and do not have urethral complications. In these patients, they urinate through their original urethra, which is located in the perineum. For patients who choose scrotoplasty without UL, the urethra is behind the scrotum.

Penile implant surgery can be performed about 9 months after phalloplasty, once ideal wound healing has occurred. It involves the insertion of a semi-rigid or inflatable penile implant into the phallus. The rigidity of the penile implant allows the patient to achieve penetrative sexual intercourse.

Testicular Implant Surgery can be performed in conjunction with Penile Implant Surgery, once good wound healing has occurred. This is usually about 9 months after scrotoplasty surgery.