We present the first gender affirming surgery (GAS) performed in a Philippine government hospital for a patient with gender dysphoria (GD), a condition recognized by the DSM-V and ICD-10 as causing distress due to the mismatch between gender identity and assigned sex. This paper aims to demonstrate the safe and competent provision of GAS within the public health sector and to improve local awareness of GD and its management.

The patient was positioned in dorsal lithotomy under general anesthesia.. An inverted-V incision was made 4 cm above the anus. A full-thickness scrotal skin graft was harvested to construct vaginal cavity over a vaginal dilator. After extending the incision vertically, both testicles and spermatic cords were removed at the level of the external inguinal ring. Blunt dissection in the Denonvillier’s area, was done using a Lowsley retractor to establish a neovaginal cavity between the prostate and rectum (Figure1). The bulbospongiosus and ischiocavernosus muscles, and urethral bulb spongiosa, were resected. The corpus spongiosum was separated, the corpora cavernosa dissected, and the glans' neurovascular bundle plicated and sutured to the rectus fascia.(Figure 2). The neoclitoris was surgically created using the dorsal portion of the glans penis, with the blood supply and nerves maintained via the dorsal neurovascular pedicle, including Buck's fascia. Following a reduction in the size of the corpus spongiosum, the urethra was shortened and spatulated; it was then placed 1 cm below the neoclitoris in the midline and secured with 4-0 absorbable sutures. A layered closure was performed to suture the penile skin flap to the scrotal perineal flap, and the scrotal skin graft was integrated into the penile flap using multiple W-plasty closures. The skin flap was inverted and advanced into the neovaginal cavity to form its walls. (Figure 3). Two (2) Jackson-Pratt drains were placed. The labia majora were closed in a layered fashion. An antibiotic-ointment-soaked-vaginal-pack and lubricating jelly was left in the neovagina, and a tailored compression bandage.

The case took 420 minutes. EBL was 500 mL. Vaginal pack and foley catheter was removed on the 6th day after surgery. She was given with 4 silicone dilators of the same length with progressive diameter and thickness. Vaginal self-dilation protocol was initiated after vaginal pack removal. The smallest dilator was gently inserted inside the neo-vaginal canal using water based sterile lubricant for for 15mins. Douching three to four times a week was initiated for the first month, until discharge lessens. The patient was followed up weekly for the 1st month then monthly thereafter. No noted complications such as vaginal hematoma, fistula, graft failure, infection, incontinence, and regret.

Although the Philippines exhibits a degree of LGBTQI+ inclusivity, access to gender affirming care is severely limited by factors like insufficient healthcare policies, a scarcity of trained professionals, absence of legal gender identity recognition, and financial burdens. This case, detailing the first publicly subsidized GAS in the Philippines, highlights the importance of making such treatments more accessible to enhance the physical and mental health of transgender Filipinos.