When Josh Roth, MD joined faculty at Indiana University School of Medicine Department of Urology in 2020, he brought with him an increased focus on pediatric urology, transitional urology in adult patients with congenital genitourinary abnormalities and gender health. After completing his urology residency at IU, Roth stayed on for a year of pediatric urology fellowship training before completing a year of genitourinary reconstruction fellowship training at the University of Minnesota. His unique skillset has enabled him to provide cutting-edge gender health treatment through the school’s partnership with Indiana University Health and Riley Hospital for Children.
Below, Roth answers some questions about the growing specialty and the importance of providing excellent care for his patients.
Gender health as well as gender affirmation/confirmation surgeries is a relatively new and growing multidisciplinary field. Can you go through the different members of a successful gender health team?
In terms of physician support, a successful team requires a dedicated urologist, plastic surgeon, obstetrician-gynecologist, dedicated medical/pediatrics arm, dedicated psychologists, endocrinologists and adolescent medicine specialists. Additionally, dedicated administrative support, nursing and a surgical nurse navigator are all instrumental to our success.
What specific roles does the urologist play in the gender health team? At what point do you get involved in management?
The urologists are involved for genital gender affirmation surgery. I typically become involved as patients are close to meeting or have met World Professional Association of Transgender Health (WPATH) guidelines for gender-affirming surgery. This means that they have been on hormones for at least one year, lived in their experienced gender for at least a year and have letters of support from two mental health professionals and their hormone-prescribing doctor indicating that they have a diagnosis of gender dysphoria and are mentally and emotionally prepared to undergo their gender-affirmation surgery.
What gender confirmation and affirmation surgeries are you doing at IU Health? What surgical subspecialties do you collaborate on and what surgeries have they been performing?
We perform orchiectomy, vulvoplasty, penile inversion vaginoplasty, sigmoid vaginoplasty, robotic peritoneal vaginoplasty, metoidioplasty, suprapubic phalloplasty and revision surgeries, as well as penile and testicular prosthetic implants. We are eagerly recruiting a microvascular plastic surgeon for other types of phalloplasty.
What novel surgical techniques to gender confirmation and/or affirmation surgery has your team pioneered?
Michael Koch, MD and I have developed a novel approach for peritoneal vaginoplasty allowing for the peritoneum to line the entirety of the vaginal canal. Briefly, the peritoneum is mobilized from the urachus down to the bladder, tubularized and then pulled through a perineal incision where it is sewn to the neointroitus.
Additionally, we are one of the few centers that offer combination hysterectomy and metoidioplasty.
Approximately how many patients have received these surgeries? Do you have any preliminary results?
We have performed close to 25 peritoneal vaginoplasties in the past year. So far, patients have done extremely well. They report easy dilation with good depth and width. Patients report good functional outcomes as well as good orgasmic function.
What is the most satisfying part of being a gender health specialist?
It is extremely satisfying to help people in need. It is unique to have a patient population that is coming to see you because they are interested in having such a life-changing surgery performed. The look on peoples’ faces when we remove the dressings is one of the most satisfying moments of my job. It’s really nice to be able to take our urologic training to help a vulnerable population feel safe and comfortable in their own bodies.
Gender health is something that is seeing increasing media coverage. As a physician who regularly provides care to transgender patients, can you describe some of the biggest public misconceptions regarding gender health?
Transgender individuals have the same struggles and successes as everyone else. I think that they also have a lot of unique obstacles and it takes a tremendous amount of strength for them to continuously “come out” and exist in a world where not everyone understands gender dysphoria. I am constantly inspired by my patients’ courage and devotion. It is also really remarkable to see the dysphoria fade as they recover from surgery. This is truly life-saving surgery. The rates of regret are low, the rates of satisfaction are high, high-risk behaviors subside and suicide rates drop. These are tangible and objective outcomes that should help to dispel the concerns regarding gender-affirmation surgery and transgender health in general.
Learn more about IU School of Medicine Department of Urology areas of expertise.
