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Lead

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Vaginoplasty
Part of a series on Transgender topics
     
SpecialtyPlastic Surgery, Urology, Gynecology
ICD-10-PCSZ87.890, Z43.7
CPT57335, 57291, 57292, 57295, 57296, 57426, 55970, 56800, 56805

Vaginoplasty is the construction, reconstruction, or modification of a vagina by surgery.

Vaginoplasty is one of the most common gender-affirming surgeries pursued by transgender women or transfeminine non-binary people. It can be an effective and medically necessary way for an individual to ease or eliminate feelings of disconnection or discomfort and create feelings of connection or congruence with their genitals post-surgery.[1]

Vaginoplasty is also used to treat conditions such as pelvic organ prolapse[2] and malignant growths[3] or following vaginal childbirth[4] and radiological cancer treatment,[5] with successful outcomes of improving the structure and function of the vagina.

The use and efficacy of vaginoplasty for intersex conditions[6] and for cosmetic purposes[7] have been debated.

Reasons and outcomes

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There are multiple indications for which a surgeon may perform a construction, reconstruction, or modification of the vagina. Beyond physiological and medical conditions, psychological needs and sociocultural factors play a critical role in influencing candidacy to pursue vaginoplasty, with varying degrees of positive outcomes.

Vaginal childbirth

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A vaginal delivery stretches and loosens vaginal muscles. Structural changes such as stretching or tearing can lead to symptoms like incontinence, prolapse, or discomfort during sexual activity.[8] In such cases, vaginoplasty can repair and tighten the opening and inner vaginal tissues, aiding with the restoration of a vagina's pre-pregnancy structure and functions.[4] Improved physical health and function can also positively impact sexual satisfaction.[9]

The decision to seek vaginoplasty post-vaginal delivery can be attributed to psychological and cultural reasons. Issues related to self-esteem, sexual identity, and body image after experiencing physical changes from childbirth may motivate individuals to seek surgery so as to regain a sense of comfort in their bodies.[10] These perceptions often arise due to cultural expectations of an ideal woman's genital appearance, pressuring individuals into seeking cosmetic and/or reconstructive procedures to feel accepted and "normal."[11]

Gender affirmation

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Further information: Gender-affirming surgery

Transgender individuals commonly seek vaginoplasty, a feminizing bottom surgery, as part of their gender-affirming medical care. For transgender candidates, vaginoplasty constructs a vagina that aligns with their gender identity.[12] It can be crucial in alleviating gender dysphoria and improving the individual's mental health.[13] The creation of a neovagina allows trans individuals to experience bodily functions and carry out daily activities in ways congruent with their gender, supporting the development of a positive self-image and their social transition to living as a woman.[14]

Following vaginoplasty, most transgender patients report greater quality of life and sexual health outcomes.[15][16][17][18] The self-reported rate of personal satisfaction with post-operative results is very high.[19][12] Individuals who had undergone gender-affirming surgeries such as vaginoplasty are found to be significantly less likely to experience past-month psychological distress, past-year tobacco smoking, and past-year suicidal ideation compared to those who had no history of undergoing gender-affirming surgery, offering strong evidence for the profound mental health benefits of vaginoplasty on transgender patients.[20]

Medical anomalies

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Pelvic organ prolapse

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Vaginoplasty and associated reconstructive surgeries are often required to treat pelvic organ prolapse, such as a cystocele (protrusion of the urinary bladder into the vagina) or a rectocele (protrusion of the rectum into the vagina).[21] When pelvic organs such as the bladder or rectum herniate into the vaginal canal due to weakened support structures, vaginoplasty aims to restore normal anatomy, alleviate symptoms such as incontinence and pelvic pain, and improve overall pelvic function.[22][23][24][25]

Cancer treatment

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Surgery may be involved to remove malignant tissues that may affect the structure of the vagina, such as cervical or vaginal cancer.[26] Post-surgical reconstruction, including vaginoplasty, is often necessary to rebuild the vaginal canal, especially if the structure has been significantly altered or removed during cancer treatment.[27] This is also applicable in cases where radiological treatments have caused severe scarring or narrowing of the vaginal canal.[5]

Other

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Vaginoplasty is used as part of the series of surgeries needed to treat girls and women born with a bladder located outside of their abdomen.[28][29]

Beyond restoring physical function, reconstructive vaginoplasty for medical anomalies can also significantly impact psychological well-being by improving body image and self-esteem, which are often adversely affected by the visible and functional changes caused by these conditions.[30]

Intersex conditions

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Further information: Intersex surgery

Conditions such as congenital adrenal hyperplasia can lead to virilization in women.[31] As such, the construction or reconstruction of a vagina may be used on intersex individuals depending on the initial anatomy.[32]

If a normal internal uterus, cervix and upper vagina (the Müllerian derivatives) exist, and the outer virilization is modest, surgery options would involve separating the fused labia and widening the vaginal introitus. Müllerian agenesis and complete androgen insensitivity syndrome can result in vaginal hypoplasia, or the undervelopment of the vagina ranging in severity from being smaller than normal to being completely absent. Vaginoplasty is sometimes performed to deepen the canal behind the blind vaginal pouch, with an aim to construct a normal and functional vagina.[33]

For some intersex individuals, vaginoplasty when performed with their consent helps create genitalia that is functionally or aesthetically aligned with their identified gender.[34] However, non-consensual surgeries, often performed during infancy or childhood without the person’s informed consent, can lead to long-term psychological trauma, including issues with body image, identity, and trust in medical professionals.[35]

There are ethical concerns about genital surgeries such as vaginoplasty used for intersex children who are not old enough to consent.[36][37] The decision to perform vaginoplasty on intersex individuals is heavily influenced by societal norms around gendered body parts, the binary categorization of male and female, and assumptions of cisnormativity.[38] Cultural pressures to conform to these binary norms can lead to early, non-consensual surgeries that push towards normalization of genital appearance according to binary gender norms, often at the expense of the individual's choice or best interest.[39]

Legal, ethical, and cultural debates continue to shape practices and policies surrounding intersex medical interventions. There remains no clinical consensus or clear evidence regarding surgical timing, necessity, type of surgical intervention, degree of difference warranting intervention, and evaluation method.[40][41] Such surgeries are the subject of significant contention, including multiple reports by international human rights[42][43][44][45] and health[46] institutions and national ethics bodies.[47][48]

Increasingly, there is advocacy against such practices, pushing for a shift towards medical interventions that are consensual and affirm intersex individuals' rights, self-determined identity, and agency.[49][50] This shift reflects a broader understanding of the importance of respecting bodily autonomy and recognizing the diversity of human biology without forcing conformity to traditional gender norms.[51][52]

Cosmetic concerns

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Elective cosmetic vaginoplasty, a type of "vaginal rejuvenation," seeks to alter the vaginal structure. Its purpose is to enhance the vagina's cosmetic appearance.[53] It often caters to deeper psychological needs and sociocultural factors.

Cosmetic vaginoplasty can be driven by unrealistic beauty standards or patriarchal norms concerning female bodies, genitalia appearance, and sexuality.[54] These standards and norms are often perpetuated by media portrayals of ideal body types and societal pressure to maintain a youthful appearance which is often equated to sexual desirability.[55][56] As a result, many women seek vaginoplasty in hopes of gaining confidence over their body, especially during intercourse, and reducing personal insecurities or perceived deficiencies in their sexual or physical appearance.[57]

There is no robust evidence supporting the effectiveness of female genital cosmetic surgery, especially regarding sexual enhancement.[58][59] The psychological outcomes of increased confidence and satisfaction post-surgery have not been shown consistently.[60][61] Ongoing body image concerns may persist if the underlying psychological factors are not addressed.[62] In addition, the ethical practices of elective vaginoplasty providers have come into question, particularly regarding how they market these surgeries and manage patient expectations.[63]

Because of the complex interplay of psychological, sociocultural, and ethical considerations, elective vaginoplasty has received considerable pushback from medical institutional bodies internationally.[64][65][53][66] Instead, there have been increasing advocacy efforts to recognize celebrate the natural diversity in female genital appearance.[67][68]

Techniques

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There are multiple techniques for performing vaginoplasty, and the self-reported rate of personal satisfaction with surgical results across different vaginoplasty techniques is consistently high.[18][19][69][70]

Penile inversion

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A close-up image of a neovagina's outer labia
A close-up image of a neovagina, held open to reveal inner labia
The results of a penile inversion vaginoplasty, two years after surgery. Inner labia vary aesthetically based on surgeon; here, they are very minimal. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. A faded surgical scar comes up from the perineum and follows the outer labia in a curved shape.

The results of a penile inversion vaginoplasty, two years after surgery. Inner labia vary aesthetically based on surgeon; here, they are very minimal. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. A faded surgical scar comes up from the perineum and follows the outer labia in a curved shape.Penile inversion is a very common vaginoplasty technique.[19][71] The testicles and scrotum are removed, and the glans of the penis is made into a clitoris. A canal is surgically created between the bladder and the rectum. The foreskin of the penis is inverted to form the interior walls of the neovagina. If the patient had been circumcised before surgery, skin from the scrotum may also be used to construct the walls of the neovagina after cauterizing the hair follicles. The urethra is shortened, and the mons pubis, labia majora and minora, and urethral opening are created using scrotal and urethral tissue.[72]

Side view of a vaginal dilator placed in a neovagina after vaginoplasty

Because this technique inverts the skin of the penis to form the walls of the neovagina, post-operative depth is limited by the length of the penis prior to surgery.[19] Following surgery, a patient will need to dilate the neovagina with a vaginal dilator 1-2 times daily to prevent loss of vaginal depth.[19][73] The need to dilate becomes less frequent with time, but is recommended at least once a week after the neovagina has healed completely.[73][74] Having penetrative sex can affect the amount of dilation needed, but additional lubricant is required during penetrative sex as the neovagina created through penile inversion vaginoplasty is not self-lubricating.[73]

In a small number of cases (roughly 0-5%), rectal injury can occur as an intraoperative complication.[75][76] Other common complications include meatal stenosis, urinary retention, or haemorrhage.[77][78]

Peritoneal vaginoplasty

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Transgender peritoneal vaginoplasty, also known as peritoneal pull-down or pull-through, is based on neovaginal techniques documented in the 1970s and 80s[79][80][81] for cisgender women born without a vaginal canal due to agenesis/atresia,[82][83] which were referred to as the "Davydov" procedure[83][84] or "Rothman's" method.[85] A 2022 review states, "In the last 5 years, peritoneal flap vaginoplasty has emerged as a promising technique".[86]

This form of vaginoplasty utilizes tissue of the peritoneum to form the canal lining of the neovagina.[69][83]

For trans women who had their puberty blocked, insufficient penile and scrotal skin may be available for traditional penile inversion. In such cases, peritoneal vaginoplasty remedies the issue of insufficient tissue.[69][82][83][87] Peritoneal vaginoplasty can be used as a surgical revision to increase or restore vaginal depth in persons who have had a previous vaginoplasty.[69][83][87][88][89]

This technique has been reported to provide some degree of vaginal lubrication.[82][83][84][90] This lubrication, however, is not responsive to sexual arousal, and functions more as regular vaginal discharge while not identical to natal vaginal fluids.[90]

Bowel vaginoplasty

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Bowel vaginoplasty, or colon vaginoplasty, is another common vaginoplasty technique. It is also utilised for vaginoplasty in cisgender women.[91] As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal and urethral tissue. However, in bowel vaginoplasty a segment of rectosigmoid colon is grafted into a surgically created canal to form the walls of the neovagina.[70]

As bowel vaginoplasty uses colon to construct the neovagina, post-operative depth is not dependent on the length of the penis prior to surgery. This makes it appropriate for individuals who have already undergone penectomy, orchiectomy, or who had a penis smaller than the desired depth of the neovagina prior to surgery.[19] Unlike penile inversion vaginoplasty, the neovagina created through bowel vaginoplasty is self-lubricating and does not require further dilation once fully healed.[19]

Risks and complications

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In adults, rates and types of complications with gender-affirming vaginoplasty are considered low. Necrosis of the clitoral region was 1–3%. Necrosis of the surgically created vagina was 3.7–4.2%. Vaginal shrinkage occurred was documented in 2–10% of those treated. Stricture, or narrowing of the vaginal orifice was reported in 12–15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two scrotal flaps has been described. Posterior vaginal wall is a rare complication. Genital pain was reported in 4–9%. Rectovaginal fistula is also rare with only 1% documented. Vaginal prolapse was seen in 1–2% of people assigned male at birth undergoing this procedure.[92]

The ability of emptying the bladder was affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported that voiding got worse. Those reporting a negative outcome who experienced loss of bladder control and urinary incontinence were 19%. Urinary tract infections occurred in 32% of those treated.[92]

Pelvic floor physical therapy have been shown to improve surgical outcomes and address potential complications for transgender patients undergoing vaginoplasty.[93][94]

History

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See also: Transgender history and history of intersex surgery

Reports of people seeking vaginoplasty go back to the 2nd century.[95] The first modern cases of vaginoplasty were performed in 1931 on Dora Richter[96] and Lili Elbe in Germany,[97] both of whom are trans women. The subject of the 2015 movie The Danish Girl (film), Elbe went through a total of four surgeries, including vaginoplasty. She died three months after her last operation.[98]

Christine Jorgensen, a transgender actress. was the first American recipient of gender-affirming vaginoplasty surgery. She received the procedure in Denmark in late 1952.[99]

French actress and singer Coccinelle, another famous trans woman, travelled to Casablanca in 1958 to undergo a vaginoplasty by Georges Burou. She said later, "Dr Burou rectified the mistake nature had made and I became a real woman, on the inside as well as the outside. After the operation, the doctor just said, 'Bonjour, Mademoiselle', and I knew it had been a success."[100]

The first physician to perform gender-affirming surgery, including vaginoplasty, in the United States was Los Angeles-based urologist Elmer Belt, who quietly performed operations from the early 1950s until 1968.[98] In 1966, Johns Hopkins University opened the first gender-affirming clinic in the U.S. The Hopkins Gender Identity Clinic was made up of two plastic surgeons, two psychiatrists, two psychologists, a gynecologist, a urologist, and a pediatrician.[98]

In 2017, for the first time, the United States Defense Health Agency approved payment for gender-affirming surgery, including vaginoplasty, for an active-duty U.S. military service member.[101]

See also

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References

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