Asra Vestering

This thesis addresses the evolving landscape of gender-affirming care, focusing on gynaecological gender-affirming surgeries (GGS) in transmasculine and gender-diverse (TMGD) individuals.

Chapter 1 presents a general introduction, the research aims, and the outline of this thesis. It discusses how gender incongruence is no longer classified as a mental disorder and how, in line with this shift, gender-affirming medical interventions are no longer intended to correct a biological defect but to support alignment between an individual’s gender identity and their lived experience in a society that often restricts gender diversity. Legislative reforms, such as, in 2014, the abolition of the requirement for surgical sterilisation to change the registered gender on official documents in the Netherlands, have further supported a more individualised and less binary approach to transgender care, allowing surgical decisions to reflect personal needs rather than legal mandates.

Despite increasing numbers of TMGD individuals seeking gender-affirming medical care, the gynaecological aspects of such care remain understudied. Gynaecological surgeries such as hysterectomy, ovariectomy, tubectomy, and colpectomy are commonly performed. However, little is known about individuals’ motivations for undergoing these surgeries, their lived experiences, or the impact of these procedures on gender dysphoria and quality of life.

The colpectomy is often performed in preparation for phalloplasty or metoidioplasty with urethral lengthening, as it reduces the risk of severe complications. However, the colpectomy itself also carries a considerable risk of complications, particularly when performed vaginally. Amsterdam UMC has developed a robotic-assisted laparoscopic technique to improve safety as a potential alternative.

Finally, following the removal of legal barriers, the number of individuals who choose to preserve their reproductive organs or postpone surgical decisions is growing. This trend has raised concerns about the long-term effects of testosterone on the gynaecological organs, particularly concerning cancer risks.

This thesis explores three key domains within the context of GGS: patients’ motivations and experiences, clinical outcomes and feasibility of the robotic-assisted colpectomy, and long-term oncological safety. By examining these dimensions through qualitative, clinical, and histopathological research, this work seeks to contribute to a more comprehensive understanding of how gynaecological surgeries intersect with gender affirmation and health outcomes in TMGD individuals.

In Chapter 2, presents a qualitative interview study that aimed to explore the motivations and experienced outcomes of TMGD individuals undergoing GGS. Our findings highlight how GGS, unlike more visible gender-affirming surgeries (e.g., the mastectomy), address internal conflicts related to the masculine identity by altering how the body functions, for instance, by stopping the menstrual cycle.

Based on these qualitative outcomes, questionnaires were constructed to evaluate further the experienced impact of GGS on varying domains, which is described in Chapter 3. We found that GGS can significantly alleviate gender dysphoria and improve mental well-being for TMGD individuals. At the same time, the results highlight the wide range of postoperative experiences, showing that although these procedures may be affirming for many, recovery processes differ significantly, with a small proportion of individuals reporting a negative impact on their well-being.

Chapter 4 presents a retrospective cohort study in which we compared the surgical and clinical outcomes of the robotic-assisted laparoscopic colpectomy (RaLC) combined with hysterectomy and vaginal colpectomy. The results indicated that, despite being a more complex surgery, RaLC with hysterectomy is associated with fewer severe peri-operative complications, reduced blood loss, and a shorter hospital stay compared to the vaginal colpectomy. Building on this, Chapter 5 introduces a prospective pilot study that explored the feasibility and safety of RaLC in patients who have previously undergone hysterectomy. The findings suggest that RaLC offers the benefits of shorter surgical time and lower blood loss without increasing the risk of complications, positioning it as a feasible alternative to the vaginal colpectomy in this patient population.

In Chapter 6, we studied the incidence of cervical cancer and high-grade cervical intraepithelial neoplasia (≥CIN2) in TMGD individuals using testosterone, comparing these rates to those of the general population assigned female at birth. In a cohort of 2,095 TMGD individuals, we found no cases of cervical malignancies, nor was the risk of ≥CIN2 elevated compared to the general population.

In Chapter 7, we examined the incidence of other gynaecological (pre-)malignancies (i.e., endometrial, ovarian, vulvar, or vaginal cancer) and assessed endometrial activity in TMGD individuals using testosterone. We found malignancies, and the risk of vulvar intraepithelial neoplasia (≥VIN2) was not increased compared to the general population. These findings were consistent with the participants’ relatively young age. Regarding endometrial activity, around one-third of participants showed signs of proliferative or secretory activity, aligning with previous studies. Active endometrial tissue was more common in participants using short-acting testosterone esters or transdermal testosterone gel than in those on long-acting testosterone undecanoate.

The concluding chapter of this thesis, Chapter 8, summarises the key findings and situates them within a broader clinical and scientific framework. In addition, this chapter addresses the methodological considerations and provides an overview of future clinical and scientific directions.