Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for consultation regarding gender-affirming surgical procedures. Patient reports long-standing gender dysphoria, consistent with DSM-5 criteria, characterized by a marked incongruence between experienced gender and assigned sex at birth. Patient has been on stable hormone replacement therapy (HRT) for [Duration] with [Current Regimen]. Patient denies contraindications to surgery and demonstrates realistic expectations regarding aesthetic outcomes and functional recovery.
Clinical Examination Findings
Physical examination reveals [Patient Age] phenotypic female. Secondary sexual characteristics are consistent with prolonged estrogen exposure. Skin quality is [Texture/Elasticity]. Assessment of facial/body contours, breast development (Tanner stage [Stage]), and pelvic anatomy performed. No evidence of active skin infection, significant scarring, or systemic pathology that would preclude surgical intervention. BMI is [Value] kg/m².
Treatment Protocol
Proposed surgical plan: [Procedure Name, e.g., Vaginoplasty/Breast Augmentation/Facial Feminization Surgery]. Risks, benefits, and alternatives discussed in detail, including potential for hemorrhage, infection, sensory changes, and dissatisfaction with aesthetic results. Patient verbalized understanding and provided informed consent. Pre-operative clearance obtained. Post-operative protocol includes [Specific Care Instructions] and follow-up schedule.