This is the fourth article in the “WPATH Tapes” series on the World Professional Association for Transgender Health and the gender medical industry. Read the overview of our investigation here.
A prominent plastic surgeon referred to genital sex change surgery as an “adventure” for young individuals during a presentation hosted by the world’s most prominent professional association for gender medicine, according to video exclusively obtained by the Daily Caller News Foundation.
Dr. Alex Laungani, a Mayo Clinic-trained Canadian plastic surgeon, discussed phalloplasty procedures during two closed-to-the-public presentations at a September 2022 educational series hosted by the World Professional Association for Transgender Health (WPATH). The DCNF obtained video recordings of the educational series through a public records request. When asked at the conference about how “young” these patients may be, Laungani said “definitely age of majority.”
Phalloplasty involves a series of surgeries that can include removing the genital organs of a female, lengthening the urethra, harvesting tissue from the forearm to surgically create an artificial penile shaft and then placing penile and testicular implants into the newly created shaft. Phalloplasty is among a number of controversial procedures and treatments euphemistically referred to by activists and some doctors as “gender-affirming care.”
Laungani said he had seen an increase in the number of phalloplasties performed and acknowledged the high risk of major and gruesome complications. Despite this, Laungani said he tells his “young” patients that the procedure will be an “adventure” they will be on together to reach the patient’s goals.
“And young individuals. They’re ready to embark on the adventure. I tell them it’s going to be an adventure, we’re both together in there, because we have to get to your goals, but there’s going to be a few bumps along the way,” said Laungani. “There could be delays because of complications — definitely there will be complications. Either it’s stenosis, fistulas, or partial necrosis, wound healing delays and stuff like that.”
Laungani did not respond to the DCNF’s requests for comment, and neither did Centre Métropolitain de Chirurgie, where he works.
John Hopkins University describes urinary stenosis, the narrowing of the urethra, and fistula, the formation of a tunnel between the urethra and another part of the body, as two of the most common complications of phalloplasty.
The WPATH conference where Laungani spoke coincided with the release of WPATH’s latest clinical guidance, called Standards of Care Version 8 (SOC 8). Those guidelines recommend that all phalloplasty patients have lifelong urological follow-up.
Laungani presented a slide detailing the complications from phalloplasty, which included urinary problems and necrosis or tissue death. Laungani said some phalloplasty surgical series may have a urology complication rate as high as 80%.
“You see urology complications as much as 41%, but some series show up to 80%. I mean, that’s a lot,” said Laungani.
Dr. Eithan Haim, a general surgeon and gender clinic whistleblower from Texas, agrees with Laungani that these complication rates are “a lot.”
“This is a remarkably high number that is typically seen after the most invasive surgeries for the sickest patients,” Haim told the DCNF.
Haim said these complication rates were comparable to that of a left ventricular assist device (LVAD), a high-risk and lifesaving procedure for patients suffering from heart failure. Haim said the big difference between LVAD patients and phalloplasty patients was their underlying physical health.
“It is important to keep in mind that the high rate of complications has to be considered against the risks of the underlying disease,” Haim said. “In the case of end-stage heart failure, the benefit of LVAD far outweighs the risks because without intervention, the patient cannot survive. For this reason, the risks can be tolerated because the alternative is certain death. This point is important to make because it serves as a stark contrast to the clinical situation in Dr. Laungani’s patient population. These individuals have perfectly healthy physiological systems with no life-threatening disease that necessitates surgical intervention.”
‘The Line Is Very Thin’
During his 2022 presentation, Laungani explained that phalloplasty procedures have high complication rates despite being split into multiple procedures in an effort to provide better outcomes.
“It’s a lot to ask, for your body to have the vaginal cavity obliterated, the vaginal mucosa removed, the urethra lengthened, the phalloplasty done with the flap transposed, and then to do everything and then put the penile implant and all that,” Laungani said during a presentation. “It would be a massive rate of infection, it would be more urinary complications, so we stage everything. We do the phallus first, then we work on the urinary tract, and then we do the implants last.”
A 2023 study published in the Journal of the American Medical Association (JAMA) found the number of sex change surgical procedures performed in the U.S. nearly tripled between 2016 to 2019, with most patients being between the ages of 19 and 30. Roughly 8% of patients were between the ages of 12 to 18, the study found, and genital surgeries made up about 35% of the procedures performed among all age groups.
Another study pegged the median cost of phalloplasty at $148,540. The sex reassignment surgical industry is projected by some financial analysts to become a $5 billion industry by 2030. This rapid growth of the sex change surgery industry hinges upon insurance coverage, a topic Laungani addressed during his talk.
“So something that alters the appearance just for cosmetic purposes versus having a function. One would argue that the line is very thin between the two. And that’s the point we try to make when we have to appeal the insurance denials,” Laungani said.
“I actually wrote a paper a few years ago, saying should we consider a cosmetic or reconstructive procedure, gender affirmation surgery. And of course, to me it should be considered reconstructive in the sense that it should be covered,” Laungani said.
“I wrote that because I was very angry, actually, at the editor putting all the papers of gender affirmation in the cosmetic section. And I said if you keep doing that, what’s going to happen is that someday some insurer, especially now, you know, seeing what happens in the U.S. with a lot of fight-backs, some insurer’s gonna say ‘Well if it’s cosmetic, we’re not … we’re just going to stop covering it’ and that’s a huge danger,” said Laungani.
Haim disagreed that phalloplasty should be considered reconstructive surgery.
“The key distinction between the two is whether the procedure is directed at fixing a physiological abnormality that negatively affects normal function,” Haim said.
Haim referenced the United Healthcare Guidelines, which state that “reconstructive procedures treat a physical and/or physiological abnormality related to an injury, illness, development abnormality, or congenital anomaly to improve or restore physiologic function.” The guidelines further note that “cosmetic procedures are performed to change or improve appearance without improving physiological function.”
“Using these widely accepted definitions, Dr. Laungani’s procedures cannot be classified as either,” Haim said. “Unlike cosmetic procedures which change physical appearance but have no effect on physiological function, Dr. Laungani’s procedures come at a predictable, profoundly negative cost to normal physiological function.”
“What he is describing is not the restoration of normal physiological functioning but rather its obliteration. And it is for this same reason that they cannot be classified as reconstructive.,” said Haim.
‘The Entirety Of the Skin From The Forearm’
Laungani explained how both function and appearance are compromised during what’s called a radial forearm phalloplasty. That’s when, as Laungani notes, the radial forearm tissue is used to create the penile shaft. The tissue must be harvested with intact blood vessels and surgically connected to blood vessels in the groin in order to keep the tissue alive.
“So we’ll raise pretty much the entirety of the skin from the forearm with the radial artery that will divide here in the intact middle fossa with the veins and nerves,” Laungani said. “And then we’ll transpose that to the groin and we’ll reconnect those vessels on the femoral artery and branches of the saphenous vein so that this piece of skin now can live off different zones and could be living off of your groin area.”
After the tissue is harvested, a skin graft is placed on the forearm over the donor site which leaves a tight, noticeable scar. The procedure sometimes impairs hand and arm function, with one study finding the complications of harvesting radial forearm tissue include decreased hand strength, compartment syndrome, and skin graft failure.
After the surgery, the tissue used to create the penis can become necrotic, meaning the tissue ties, if the blood vessels weren’t properly connected to the new blood supply.
“You’re transferring a piece of tissue from somewhere else. If there was microsurgery you’ve gotta make sure that the blood flows through the artery, keeping that piece of tissue alive,” said Laungani. “The first night after phalloplasty, I still don’t really sleep well. Because if anything goes wrong, I’ve gotta be fast and act fast so we don’t lose the phallus.”
One slide in Laungani’s presentation said, on average, patients undergo six separate surgeries for radial forearm phalloplasty.
Laungani told the audience it would take approximately 1 to 1.5 years to complete a surgical phalloplasty series “if everything goes well.”
‘Why Wouldn’t I Operate On Him If He’s 14?’
During the presentations Laungani also discussed complications from double mastectomies, including tissue complications such as hematoma (collections of pooled blood), fluid pockets and wound dehiscence (separation of a surgical wound).
Double mastectomies, or the removal of a woman’s breasts, are among the most common sex change operations for teenagers and young adults. The 2023 JAMA study found that “3,215 patients aged 12 to 18 years underwent [gender-affirming surgery] and had breast or chest procedures” between 2016 and 2019. That’s compared to 405 patients from that age group who had genital surgeries during the same time period.
Laungani said he’d performed mastectomies on children as young as 14 with parental support, saying it was “the right thing to do.”
“Probably the youngest kid I operated on was 14, had great parental support, had been miserable and again not going to school and not feeling good and top surgery actually gave him his life back. He was able to reintegrate,” Laungani said. “I think, you know, if socially he can gain that, why wouldn’t I operate on him if he’s 14? It’s the right thing to do.”
Laungani said post-surgical regret was rare, and joked about “the haters” who disagreed, which received loud laughter from the audience. “Regret is rare, although haters will say differently, it doesn’t matter to us,” Laungani said.
Dr. Stanley Goldfarb of Do No Harm, a watchdog organization focused on keeping identity politics out of healthcare and medical schools, questioned Laungani’s claim about post-surgical regret when it came to children.
“There is no organized registry to keep track of detransitioners,” Goldfarb said, referring to individuals who reverted to identifying as their biological sex after transitioning.
“In reality, the data on regret after surgery for children is not available,” Goldfarb said. “One cannot extrapolate the data from adults, and even then, the data have been corrupted by lack of objectivity in the way the results are collected. When one considers children who regret the procedures that they’ve had, or even the medicalization they have undergone, it is impossible to identify those individuals who don’t report detransitioning out of embarrassment.”
Goldfarb added that the data derived from the military health care system suggests a high number of children taking sex reassignment drugs stop fulfilling their prescriptions.
“We do know that as many as 30% of children who begin on puberty blockers and other hormonal medications do not fulfill subsequent prescriptions,” Goldfarb said. “These data are derived from the military healthcare system where complete records on medication utilization are available.”
WPATH did not respond to requests for comment.
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