Does Depth Matter? Factors Affecting Choice of Vulvoplasty Over Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women

Abstract

Background Gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. Aim Our objective is to describe the factors influencing patient choice or surgeon recommendation of vulvoplasty and to assess the patient’s satisfaction with this choice. Methods Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. Outcomes We report demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. Results In total, 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty. 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index than those seeking vaginoplasty. The majority (63%) of the patients seeking vulvoplasty chose this surgery despite no contra-indications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93% were satisfied with the surgery and their decision for vulvoplasty. Clinical Translation Vulvoplasty creates the external appearance of female genitalia without creation of a neovaginal canal; it is associated with high satisfaction and low decision regret. Conclusions This is the first study of factors impacting a patient’s choice of or a surgeon’s recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also is the first reported series of patients undergoing vulvoplasty only. Limitations of this study include its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how we offer vulvoplasty. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, with Attention for Sexual Function and Satisfaction”

“…In vulvovaginoplasty, the inner lining is made with penile skin, skin grafts, penile skin combined with skin grafts, or a bowel segment. 85,86 The base of the penis and the perineoscrotal region that will form the vaginal inner lining or will be placed around the clitoris should be depilated permanently. Otherwise, hair growth within the neovagina can cause discharge or odor.…”

ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”

“…Indications for vulvoplasty (or zero-depth vaginoplasty) include patient preference or extensive morbidity, for example, a history of rectal fistula. 81 Counselling is strongly recommended to minimize the risk of future regret. 82 Sexologists and pelvic floor physical therapists may counsel patients on dilation and aid in reducing voiding difficulties, which are not related to meatal stenosis.…”

European society for sexual medicine position statement “assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction”

“…In vulvo-vaginoplasty the inner lining is made with penile skin, skin grafts, penile skin combined with skin grafts or a bowel segment. [85,86] The base of the penis and the perineoscrotal region that will form vaginal inner lining or will be placed around the clitoris should be depilated permanently. Otherwise hair growth within the neo-vagina can cause discharge or odour.…”