Approximately 2 million Americans identify as transgender/nonbinary (TGNB) according to the most recent Gallup poll in 2020.¹ Current evidence suggests that the number of adolescents and young adults who identify as TGNB (1.8% in Gen Z, 1.2% in millennials) is increasing significantly more compared to older generations (0.2% in Gen X and baby boomers).¹ As the TGNB population continues to grow, there will be an even greater need and potentially larger void regarding competent gender-affirming surgeons available for their health care needs.

Along with the increased prevalence of people who identify as TGNB, there has also been a fourfold increase in the request for gender-affirming surgery (GAS) from 2000 to 2014.² These requests for GAS have continued to increase over the last 5–10 years, as federal and private health insurance coverage of these procedures continues to expand.³ While the World Professional Association for Transgender Health still recommends the age of majority for GAS, there are increased referrals of TGNB adolescents to gender-affirming surgeons, especially for chest masculinization.⁴ Despite the high demands for TGNB health care, there continues to remain a dearth of knowledgeable and trans-competent providers and support staff who are responsive to the needs of TGNB youth.⁵ Thus, children’s hospitals across the country are responding by developing interdisciplinary programs centered on delivering this care to TGNB adolescents and young adults. As such, pediatric urologists are increasingly included in the development and execution of these programs.

This creates a tremendous opportunity for pediatric urologists to be involved in the care of TGNB adolescents and young adults. Many TGNB young adults who pursue transition start to receive their care at children’s hospitals, and there is often a desire to continue their process of transitioning there. Pediatric urologists’ strong history in genital reconstruction positions us well to participate in these procedures, allowing many to continue to transition with their health care team. The initiation of pubertal blockade includes discussions regarding fertility preservation, and pediatric urologists can further expand our role from oncofertility to this population as well. Traditional methods of obtaining semen samples via masturbation may cause significant exacerbation of dysphoria, causing more harm than good. Expanding existing oncofertility programs to include TGNB youth can allow for specimen obtainment that can produce less dysphoria, increasing patient and parent satisfaction.⁶ Pediatric urologists are being called upon to participate in these family discussions, perform tissue harvesting and can contribute to research protocols that surround these procedures. The placement of long-acting GnRH analogues for pubertal blockade is another procedure that pediatric urologists also often perform and can be expanded to TGNB youth. Genital GAS (gGAS) carries high expectations both pre- and postoperatively, and thus early surgeon participation in surgical readiness programs can help mitigate expectations and ensure postoperative adherence to treatment protocols.

The surgical techniques that are used in many aspects of gGAS are already familiar to pediatric urologists and well within our skill set. In other countries, such as Belgium and Serbia, pediatric urologists have been performing these procedures for decades. The nerve-sparing clitoroplasty that is performed for the enlarged clitoris in response to virilization is similar to how clitoroplasty and penile disassembly are performed in transfeminine gGAS. With pubertal blockade, the phallic size may be somewhere between a postpubertal phallus and an over-virilized clitoris. Current techniques for gGAS vaginoplasty also hinge on well-known techniques that pediatric urologists have been using for decades for children born with vaginal agenesis or who have vaginal stenosis after prior surgical reconstruction, such as the McIndoe procedure, Davydov procedure, intestinal vaginoplasties and buccal mucosal vaginoplasties. These procedures are analogous to penile inversion vaginoplasty, robotic peritoneal vaginoplasty, sigmoid vaginoplasty and the use of buccal mucosa in corrective procedures for vaginal stenosis.

Transmasculine gGAS is directed at neophallus creation, often with urethral lengthening, allowing people the opportunity to stand to void. Metoidioplasty utilizes the virilized clitoris to create a neophallus, and the surgical techniques mirror proximal hypospadias repairs, procedures comfortable to most pediatric urologists. Pediatric urologists can draw on their experiences with complicated hypospadias repairs for this particular reconstructive procedure, marrying many of best aspects of a variety of surgical techniques. Scrotoplasty with or without testicular prosthesis insertion may also be performed, yet another technique familiar to pediatric urologists.

Phalloplasty involving free or rotational flaps is performed in conjunction with a plastic surgical team. When urethral lengthening is included, urologists often perform this along with the degloving and burying of the clitoris, dissection of the dorsal neurovascular bundle and scrotoplasty for completion of the masculinizing GAS.

Pediatric urologists have unique opportunities to have an expanding role in caring for TGNB patients. There are ample arenas for research and continued refinement of surgical techniques in genital reconstructive surgery in this field. While there are many nuances to gGAS, these surgeries draw on many of the techniques that are in the wheelhouse of pediatric urologists. Pediatric urologists have the opportunity to be at the forefront of LGBTQI care, especially for TGNB adolescents and young adults, and should strive to be active allies for equitable health care for this community.