DEIJAB TOOLKIT: Transgender & gender-diverse care

Working with TGD clients post-gender affirming surgery

Co-led Authors— Capstone students: Bri Guillory, OTS, Boston University and Lili Rafalski, OTS, Emory & Henry College. Created in collaboration with Adam Steuer, DHSc, OTR/L, CLT, DePaul University, College of Science and Health 08/10/2023

Occupational therapy’s ability in post–gender-affirming surgery is emerging across the globe. Occupational therapy practitioners (OTPs) should be aware of different types of gender affirmative surgeries (GAS) that are available, and the surgical considerations that may be included in care. There is a lack of standardized precautions for GAS; however, literature recommends a multidisciplinary approach to transgender health care (Coleman et al., 2022). OTPs can assist transgender and gender-diverse clients in both pre-op and post-op environments.

Gender-affirming surgeries include:

Gender-affirming facial surgeries
Hair grafting and hair removal
Voice surgery and alteration of thyroid cartilage
Gender-affirming top surgery
Gender-affirming bottom surgery (Coleman et al., 2022)

Surgical precautions & considerations

Surgical precautions and restrictions vary by clinical program and surgeon. Surgical approaches evolve and change over time which will affect level of care needed, post-surgery restrictions, and recovery time.

Possible restrictions listed below are adapted from Rush University Medical Center’s surgical guidelines (Rush, 2020), University of Utah Health’s surgical considerations (Wilkinson & Walker, 2022), UCSF Gender Affirming Health Program Guidelines (Deutsch, 2016), and Grace Physical Therapy & Pelvic Health (Grace Physical Therapy & Pelvic Health, 2020); however, other restrictions may be in place at other facilities. Always consult and confirm with the acting surgeon for restrictions, recommendations, and recovery.

Bottom surgeries

Due to the nature of bottom surgeries, there can be scar tissue in the pelvic floor musculature, difficulties in urination, pain during penetrative intercourse and self-stimulation, pain while sitting, and irritations from clothing fabric around the scar tissue. Practitioners can assist with pain management, increase range of motion, and teach ways to safely perform ADLs (Grace Physical Therapy & Pelvic Health, 2020).

Possible post-vaginoplasty movement restrictions
- Bed rest for 5 to 7 days post-surgery.
- No sitting at 90 degrees (up straight) for long periods of time to prevent pressure on the surgical site for at least 12 weeks.
- No sleeping on either side to prevent pressure on the surgical site for at least 12 weeks.
- No excessive hip abduction to prevent pulling on surgical stitches for at least 12 weeks.
- No excessive core muscle activation.
- Avoid strenuous activity for 6 to 8 weeks.
- Adaptive techniques for post-vaginoplasty.
- Sitting can be done for extended periods in a reclined position (approx. 45° decline) with knees bent.
- Donut cushions or geomat cushion with cubes taken out of the middle can alleviate direct pressure on the surgical site, especially for extended periods of time (e.g. car rides, work activity, etc).
- Log rolling while performing bed mobility.
Recovery
- Potential outpatient therapy to address sensation reintegration, remaining ADL deficits, dilation training, and sexual activity.
Post-vaginoplasty ADL and IADL impairments
- Toileting and toilet hygiene
- Bathing
- Dressing
- Functional mobility
- Sexual activity
- Driving and community mobility
- Sleep
- Medication management
- Leisure activities
- Work
Possible post-metoidioplasty movement restrictions
- No sitting at 90 degrees (up straight) for long periods of time to prevent pressure on the surgical site for at least 12 weeks.
- No sleeping on either side to prevent pressure on the surgical site for at least 12 weeks.
- No excessive hip abduction to prevent pulling on surgical stitches for at least 12 weeks.
Recovery
- Potential outpatient therapy to address sensation reintegration, remaining ADL deficits, and sexual activity.
Post-metoidioplasty ADL and IADL impairments
- Toileting and toilet hygiene
- Bathing
- Dressing
- Functional mobility
- Sexual activity
- Driving and community mobility
- Sleep
- Medication management
- Leisure activities
- Work
Possible post-phalloplasty movement restrictions
- No sitting at 90 degrees (up straight) for long periods of time to prevent pressure on the surgical site for at least 12 weeks.
- No heavy lifting.
- No sleeping on either side to prevent pressure on the surgical site for at least 12 weeks.
- No excessive hip abduction to prevent pulling on surgical stitches for at least 12 weeks.
- No weight bearing through the donor site extremity.
- No compression or pressure on surgical areas.
Post-phalloplasty ADL and IADL impairments
- Toileting and toilet hygiene
- Bathing
- Dressing
- Functional mobility
- Sexual activity
- Driving and community mobility
- Sleep
- Medication management
- Leisure activities
- Work

Masculinizing chest surgery

Due to the nature of masculinizing chest surgeries, there can be scar tissue in or around the pectoral muscles that can reduce mobility and posture in the trunk muscles (chest, ribs, and spine). Practitioners can work to manage pain, increase range of motion, and teach ways to safely perform ADLs (Grace Physical Therapy & Pelvic Health, 2020).

- Toileting and toilet hygiene
- Bathing
- Dressing
- Functional mobility
- Sexual activity
- Driving and community mobility
- Sleep
- Medication management
- Leisure activities
- Work
- Avoid raising elbows above the shoulders to prevent scar widening
- Avoid heavy lifting (more than 5 lbs) or strenuous housework
- Avoid excessive overhead activities.
- Sleep is restricted to the back with pillows to keep the head elevated to reduce swelling
- Restrictive physical activity for months post-surgery

More gender-affirming surgery considerations

Review more gender-affirming surgical considerations.

- May require a postoperative liquid diet.
- May require complete vocal rest for weeks.
- Work with a speech-language pathologist for post-operative vocal range therapy.
- Facial swelling and redness can last weeks.
- Functional mobility
- Sexual activity
- Sleep
- Medication management
- Social participation
- Leisure activities
- Work
- Grooming
- Hypotension during mobility and transfers.
- Sudden increase in pain and discomfort.
- Sudden ADL performance decline requiring assistance with many ADLs and IADLs.
- Anxiety surrounding ADL decline, dependence for mobility, increased pain.
- Other psychosocial considerations.

References & resources

View references on working with TGD clients post-gender affirming surgery.

References

Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., … Arcelus, J. (2022). Standards of care for the health of transgender and gender diverse people, version 8. International Journal of Transgender Health, 23(Suppl. 1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644

Deutsch M. (Eds.). (2016). Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2nd ed. UCSF Gender Affirming Health Program, Department of Family and Community Medicine, University of California San Francisco. transcare.ucsf.edu/guidelines

Grace Physical Therapy & Pelvic Health. (2020). PT for gender affirming surgery. Author. https://gracepelvichealth.com/services/gender-affirming-surgery/

Rush University Medical Center. (2020). Guidelines for gender-affirming surgeries. Author.

Wilkinson, N. & Walker, K. (2022). Gender affirmation surgery considerations for acute OT/PT. Author.

Resources

Keuroghlian, A. S., Potter, J., Reisner, S. L., Blasdel, G., Zhao, L. C., & Bluebond-Langner, R. (2022). Surgical Gender Affirmation. In Transgender and gender diverse health care the Fenway Guide (pp. 90–97). essay, McGraw-Hill.

PT for gender affirming surgery. Grace Physical Therapy. (2020, June 3). https://gracepelvichealth.com/services/gender-affirming-surgery/

Sharber, J. (2020). Sex after hip or knee replacement. LGBTQ+OT. https://www.lgbtq-ot.info/sex-after-hip-or-knee-replacement

Vaginoplasty

Metoidioplasty

Phalloplasty

Post-masculinizing chest surgery ADL and IADL impairments

Possible post-masculinizing chest surgery movement restrictions

Post-head and neck surgery recovery

Post-head and neck surgery ADL and IADL impairments

Post-surgical considerations for all surgeries