Gender-affirming surgeries for transgender women often include two primary options for genital reconstruction: vaginoplasty, which creates both external female genitalia and a vaginal canal, and vulvoplasty, which constructs external female genitalia without a functional vagina.
While vaginoplasty remains the more commonly performed procedure, some transgender women opt for vulvoplasty due to personal preferences, health concerns, or practical considerations.
A recent study1 published in The Journal of Sexual Medicine explored the factors influencing this decision and examined patients’ satisfaction with their choice.
The research, conducted between 2015 and 2017, involved interviews with transgender women who had undergone or were scheduled for vulvoplasty, as well as a review of their medical records. The findings shed light on the diverse motivations for choosing vulvoplasty and the outcomes associated with this option.
Key findings of the research
The study revealed that patients choosing vulvoplasty tended to be older, with an average age of nearly 58 years, compared to about 39 years for vaginoplasty patients. These individuals also had a higher average body mass index (BMI), which can influence surgical risk.
For some, medical professionals recommended vulvoplasty due to health concerns, such as prior prostatectomy, pelvic radiation, or other conditions that increased the risks associated with vaginoplasty.
Others chose vulvoplasty because they lacked the necessary support network for the intensive aftercare required for vaginoplasty recovery, including daily dilation to maintain the vaginal canal.
Personal preference was another key factor. Many participants cited a lack of interest in vaginal sexual activity as a reason for their choice, with some viewing the removal of male genitalia as sufficient to address their gender dysphoria.
For others, the avoidance of dilation played a significant role, as they found the prospect of lifelong dilation unappealing.
Age and timing also influenced decisions; some older patients preferred a less invasive procedure, and others opted for vulvoplasty due to shorter wait times or imminent loss of health insurance.
Perception of gender alignment
The study also highlighted how patients perceive vulvoplasty in terms of gender alignment. Most participants (82%) viewed vulvoplasty as creating a fully female appearance, while a smaller proportion (18%) saw it as a non-binary surgical option.
Regardless of perspective, the majority wanted to appear female externally and felt that vulvoplasty adequately fulfilled this goal.
Patient satisfaction with vulvoplasty is high
Patient satisfaction was high, with 93% of participants expressing contentment with both their surgical results and their decision to undergo vulvoplasty.
However, the study underscored the importance of pre-surgical counseling to address potential regret. Some participants expressed concern that they might later desire receptive vaginal intercourse, a possibility that could lead to seeking secondary surgery to construct a vaginal canal.
This secondary procedure typically requires additional tissue grafts, as the skin discarded during vulvoplasty is no longer available.
Given the potential for decision regret, the study’s authors recommended careful consideration before offering vulvoplasty widely. Counselling should focus on ensuring patients fully understand the long-term implications of their choice, including the functional and anatomical differences between vulvoplasty and vaginoplasty.
While vulvoplasty may be ideal for some individuals based on their health, preferences, or circumstances, thoughtful discussions are essential to align surgical outcomes with patients’ goals and expectations.
References
- 1.Jiang D, Witten J, Berli J, Dugi D III. Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women. The Journal of Sexual Medicine. Published online April 26, 2018:902-906. doi:10.1016/j.jsxm.2018.03.085
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