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 (Figure 1). A full-thickness scrotal skin graft was harvested to construct vaginal cavity over a vaginal dilator. Both testicles were removed, and a Lowsley retractor was used to dissect the space between the prostate and rectum (Denonvillier's area) to create the neovaginal cavity. The corpus spongiosum was separated, the corpora cavernosa dissected, and the glans' neurovascular bundle plicated and sutured to the rectus fascia. The neoclitoris was formed from dorsal portion of glans with preserved neurovasculature. The reduced, shortened, and spatulated urethra was placed below the neoclitoris (Figure 2). The skin flap was inverted and advanced into the neovaginal cavity to form its walls.The labia majora were closed in a layered fashion. An antibiotic-ointment-soaked-vaginal-pack was left in the neovagina.

The case took 420 minutes. EBL was 500 mL. Vaginal pack and foley catheter were removed on the 6th day after surgery. Vaginal self-dilation protocol was initiated after vaginal pack removal. Douching 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.