Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women
David Jiang, MD; Jonathan Witten, MD; Jens Berli, MD; Daniel Dugi III, MD, FACS
FIRST PUBLISHED: April 26, 2018 – The Journal of Sexual Medicine
Vaginoplasty and vulvoplasty are two forms of male-to-female gender-affirming surgery. The former involves the creation of a vagina as well as external female genitalia (the vulva). With the latter, only the external genitalia are created. No vagina is formed.
Transgender individuals may choose vulvoplasty over vaginoplasty for several reasons. They may have concerns about the risks of vaginoplasty (such as rectal injury or the formation of recto-vaginal fistulas). They might not want to do daily dilation to keep the new vagina stretched. Or, they might not be interested in using a neovagina during sexual activity.
In addition, some patients prefer to not have full female anatomy and consider vulvoplasty to be a non-binary surgery.
This study discusses the authors’ experiences with performing vulvoplasty along with patients’ satisfaction or regrets about choosing it. It also examines patients’ feelings about vulvoplasty as a non-binary surgical option.
Between March 2015 and December 2017, telephone interviews were conducted with patients who had either completed vulvoplasty or were scheduled to have it. Medical records were also reviewed.
Of 486 patients evaluated for feminizing surgery, 30 either underwent vulvoplasty (16 patients) or were scheduled for the procedure (14 patients). Another 206 either completed vaginoplasty (64 patients) or were scheduled for it (142 patients).
Twenty-five patients participated in telephone interviews.
Highlights of the data include the following:
- Age. The vulvoplasty patients tended to be older than vaginoplasty patients, with mean ages of 57.9 and 39.2, respectively.
- Body mass index (BMI). Vulvoplasty patients had a higher mean BMI (30.4) than vaginoplasty patients (27.4).
- Reasons for choosing vulvoplasty. Vulvoplasty was recommended by clinicians to 11 patients because of health or social concerns, such as previous radical prostatectomy, pelvic radiation, or an inadequate support network for recovery. The remaining 19 had no medical concerns.
The 25 patients reached by telephone cited the following reasons for choosing vulvoplasty over vaginoplasty:
- No interest in vaginal sexual activity (17 patients). Some patients said they simply wanted their “birth defect” (i.e., male genitalia) removed.
- Health issues/less risk (11 patients)
- No dilation (9 patients). After vaginoplasty, patients must self-dilate daily to keep the new vagina open. Some patients did not want to do this and chose vulvoplasty.
- ge (8 patients).
- Timing (2 patients). One patient was concerned about the loss of health insurance and elected vulvoplasty because it could be scheduled more quickly. Another did not want to wait for pre-surgical hair removal.
(Note: Participants could give more than one reason.)
- Non-binary surgery. Most patients (82%) considered vulvoplasty to be “completely female,” and 18% considered it a non-binary option. Most wanted to appear female externally.
- Satisfaction. Ninety-three percent of patients were satisfied with their surgery, and 93% were satisfied with their decision of vulvoplasty.
Decision regret is a concern for vulvoplasty patients, and they should be counseled accordingly. While erogenous sensation of the clitoris is possible after both vaginoplasty and vulvoplasty, patients undergoing the latter may become interested in receptive intercourse with the relief of gender dysphoria. Creating a vagina after vulvoplasty is possible, but tissue for the new vagina needs to be harvested from another site or created from an intestinal segment. (Excess genital skin that would normally be used for the new vagina is typically discarded after vulvoplasty.)
Because of the potential for decision regret, the authors “have refrained from widely offering vulvoplasty.” The procedure has been discussed mainly with patients who request it, patients who have medical or social co-morbidities, or elderly patients.
“We caution that vulvoplasty must not be seen as the alternative to performing a difficult vaginoplasty,” the authors wrote, adding, “Vulvoplasty must be the right choice for the patient, and it requires careful consideration and discussion.”