Gender-affirming surgeries for transgender women often involve creating external female genitalia, such as a clitoral hood, labia majora, and labia minora. Additionally, the urethra is shortened to allow for seated urination.
However, there are two distinct surgical approaches when it comes to creating a vagina: vulvoplasty and vulvovaginoplasty.
While vulvovaginoplasty includes the construction of a vaginal canal for penetrative intercourse, vulvoplasty involves creating a shallow vaginal dimple without a functional canal.
Despite vulvoplasty being a viable option for some transgender women, it is not commonly recommended by medical professionals, according to a survey published in the Journal of Sexual Medicine.
This preference for vulvovaginoplasty may stem from both medical and cultural factors, as well as limited formal research on the rationale for recommending vulvoplasty.
Practitioners surveyed indicated that vulvoplasty is typically reserved for patients who have specific medical conditions, such as a history of radical prostatectomy with urinary incontinence, or for those who are unable or unwilling to manage the maintenance required for a neovagina.
Additionally, some patients simply do not wish to engage in receptive intercourse and prefer vulvoplasty for personal reasons.
A recent study surveyed 198 practitioners affiliated with the World Professional Association for Transgender Health (WPATH), with the majority based in the United States. The respondents included surgeons and other healthcare professionals specialising in transgender care.
While a significant portion of surgeons had experience performing vulvovaginoplasty, only a smaller group had performed vulvoplasty. Among those who did, the most common reason was patient request.
Approximately three-quarters of surgeons who offered vulvoplasty said they did so because it was the patient’s preferred option, while about a third cited older age or health risks as influencing factors.
Interestingly, many practitioners reported limited patient interest in vulvoplasty. About two-thirds of the respondents noted that they had never been asked about the procedure by their patients, and a similar proportion stated that they “never” recommend it.
Among those who were asked, there was significant variability in their willingness to support the procedure.
Surgeons were more likely to express definitive opinions about vulvoplasty compared to non-surgical practitioners. For instance, about 30% of surgeons supported vulvoplasty in patients aged 18 to 21, while 32% rejected it, and 38% remained unsure.
One concern raised by practitioners is whether younger patients who choose vulvoplasty may later regret their decision and request additional surgery to create a functional vaginal canal.
Some respondents observed that even patients who identify as lesbian or who initially have no interest in penetrative intercourse may later decide that a vaginal canal would help them feel ‘more complete’. This possibility underscores the importance of thorough pre-surgical counselling to ensure patients fully understand their options and the long-term implications of each procedure.
The study highlighted a significant knowledge gap in the field, with 94% of respondents stating they had not encountered peer-reviewed research on vulvoplasty procedures. This lack of data may contribute to the hesitancy among practitioners to recommend vulvoplasty, as well as the variability in opinions on its appropriateness for younger patients.
The authors of the study emphasised the need for larger, more diverse research samples, including practitioners outside of WPATH, to understand attitudes toward vulvoplasty better. They also stressed the importance of incorporating patient perspectives into future research to gain a more comprehensive view of the procedure’s role in gender-affirming care.
As the first study of its kind, this research provides valuable insights into the experiences and attitudes of medical professionals regarding vulvoplasty.
However, it also highlights the need for further investigation to clarify best practices and ensure that transgender women have access to informed, patient-centred care that respects their individual goals and needs.
References1
- 1.Milrod C, Monto M, Karasic DH. Recommending or Rejecting “the Dimple”: WPATH-Affiliated Medical Professionals’ Experiences and Attitudes Toward Gender-Confirming Vulvoplasty in Transgender Women. The Journal of Sexual Medicine. Published online March 1, 2019:586-595. doi:10.1016/j.jsxm.2019.01.316
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