Purpose of Vaginoplasty

Vaginoplasty—also called transfeminine bottom surgery—is a type of gender affirmation surgery in which a new vagina is created. This surgery can take up to several hours, is performed in a hospital operating room under general anesthesia, and requires that the patient stays for around five to seven days to recover in the hospital. While there are different types of vaginoplasty techniques, in transgender women, the vagina (sometimes referred to as a "neovagina") is usually made from the inverted skin of the penis.

Diagnoses Related to Vaginoplasty

When it comes to feminizing gender-affirming surgery, there is no specific diagnosis or medical condition that warrants a vaginoplasty. Rather, a vaginoplasty is an elective, or optional, surgery. In other words, a transgender woman may choose on her own to undergo this surgery as part of the process of transitioning physically to her self-affirmed gender. 

About Vaginoplasty

There are multiple vaginoplasty techniques a surgeon can use. The most common one used is called a penile inversion vaginoplasty.

This technique involves the following steps:

• Removing the testicles (called an orchiectomy), if not already done in a prior surgery
• Removing the skin from the penis and inverting it to create the vaginal lining
• Using scrotal tissue to create the labia
• Reshaping the head of the penis to create the clitoris
• In some cases, if there is not enough skin from the scrotum, using extra skin from the person's abdomen or thigh to make a vaginal canal
• Creating a new opening for the urethra to allow for urination

Common Reasons for Vaginoplasty

The reasons why a transgender woman may consider undergoing vaginoplasty include one or more of the following:

• Feeling more aesthetically affirmed in their gender as a female
• Increasing sexual functioning with a functional vagina and clitoris
• Feeling more physically and emotionally comfortable with themselves
• Feeling safer in public spaces
• Decreasing stress related to their body

Less Common Diagnoses

It's important to mention that while this article focuses on vaginoplasty as a type of feminizing gender-affirming surgery, there are some other diagnoses that may warrant a vaginoplasty.

These diagnoses include:

• Gynecologic malignancies: A vaginoplasty may be performed in a woman who has undergone a vaginectomy for vaginal cancer.
• Vaginal agenesis: A vaginoplasty may be performed in a woman born without a vagina (called vaginal agenesis). This congenital condition is often associated with a disorder called Mayer-von Rokitansky–Küster-Hauser’s syndrome.
• Congenital adrenal hyperplasia (CAH): With this rare genetic disorder, female infants are born with ambiguous or atypical external genitalia. A vaginoplasty may be performed for both cosmetic and functional purposes (e.g., sexual, reproductive, and urinary).
• Female cloacal exstrophy: A vaginoplasty made be indicated in this congenital condition where the bladder and part of the intestines are open to the outside of the body.
• Vaginal laxity: Sometimes the term vaginoplasty is used to describe a surgical procedure that tightens the vaginal canal. This may be performed in women who experience vaginal muscle separation as a result of age or childbirth. This muscle separation can contribute to sexual dysfunction, urinary incontinence, and pelvic prolapse. A vaginoplasty restores the natural shape and size of the vagina by bringing the muscles back together.

Criteria

Undergoing a vaginoplasty as a transgender patient is a major decision as well as a lifelong commitment. As a result, before undergoing the operation, most surgeons follow criteria set forth by the World Professional Association for Transgender Health (WPATH).

These criteria require that the patient has:

• Two referral letters from qualified mental health professionals
• Persistent, well-documented gender dysphoria
• Capacity for informed decision making and consent
• Age of majority (which is 18 in most states)
• Well-controlled medical and mental health conditions
• Twelve continuous months of hormone therapy, unless the patient is unwilling or unable due to a medical condition
• Twelve continuous months of living in the desired gender role congruent with the patient's gender identity
• Regular visits with a mental health professional or other medical professional is also recommended but not explicitly required for surgery

Tests and Labs

The specific tests or labs (e.g., bloodwork, an electrocardiogram, or a chest X-ray) that a patient might need before a vaginoplasty depends on their underlying medical history.

Regardless, before surgery, a patient can definitely expect to undergo the following:

• A physical exam by the surgeon along with a surgical consultation to review their medical history, their rationale for desiring the surgery, and the potential risks associated with the operation
• A consultation with a mental health professional (e.g., psychologist or psychiatrist) to ensure appropriate candidacy for the surgery
• Potential visits with physicians or specialists, such as a social worker, anesthesiologist, primary care physician, and/or endocrinologist

In moving forward, your surgical team will also advise you on various lifestyle modifications, such as:

• Permanent hair removal (genital), either by electrolysis or laser removal
• Stopping estrogen treatment prior to surgery
• Smoking cessation for one to three months prior to surgery
• Weight loss (potentially) if overweight or obese
• Seeing a pelvic physical therapist to help prepare you for the surgery

 A Word From Verywell

While an arduous journey, undergoing a vaginoplasty (which is a step far down the path of gender transition) can have long-lasting mental and physical benefits.

If you or a loved one is considering a vaginoplasty, please be thorough in your research and deliberation, especially when it comes to finding the right surgical team. You also want to be cognizant of all risks related to the surgery, and what you as a patient can expect afterward.