gender reassignment surgery dilators

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• Dilation after gender-affirming surgery

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Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

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Vaginoplasty for Gender Affirmation

Featured Experts:

Fan Liang, M.D.

Andrew Jason Cohen, M.D.

Vaginoplasty is a surgical procedure for  feminizing  gender affirmation. Fan Liang, M.D. , medical director of the Johns Hopkins Center for Transgender and Gender Expansive Health , and Andrew Cohen, M.D. , director of benign urology at Johns Hopkins' Brady Urological Institute , review the options for surgery.

What is vaginoplasty?

Gender affirming surgery can be used to create a vulva and vagina. It involves removing the penis, testicles and scrotum.

During a vaginoplasty procedure, tissue in the genital area is rearranged to create a vaginal canal (or opening) and vulva (external genitalia), including the labia. A version of vaginoplasty called vulvoplasty can create a feminine-appearing outer genital area with a shallow vaginal canal.

What are the different types of vaginoplasty?

There are two main surgical approaches for this gender affirming surgery.

Vaginoplasty with Canal

This surgery is also known as full depth vaginoplasty. Vaginoplasty with canal creates not only the outer vulva but also a complete vaginal canal that makes it possible for the person to have receptive vaginal intercourse.

Vaginoplasty with canal requires dilation as part of the recovery process in order to ensure a functioning vagina suitable for penetrative sex. There are two approaches to full depth vaginoplasty.

For penile inversion vaginoplasty , surgeons create the vaginal canal using a combination of the skin surrounding the existing penis along with the scrotal skin. Depending on how much skin is available in the genital area, the surgeon may need to use a skin graft from the abdomen or thigh to construct a full vaginal canal.

Robotic-assisted peritoneal flap vaginoplasty , also called a robotic Davydov peritoneal vaginoplasty or a robotic peritoneal gender affirming vaginoplasty, is a newer approach that creates the vaginal canal with the help of a single port robotic surgical system.

The robotic system enables surgeons to reach deep into the body through a small incision by the belly button. It helps surgeons visualize the inside of the person’s pelvis more clearly and, for this procedure, creates a vaginal canal.

There are several advantages to this surgical technique. Because using the robotic system makes the surgery shorter and more precise, with a smaller incision, it can lower risk of complications. Also, the robotic vaginoplasty approach can create a full-depth vaginal canal regardless of how much preexisting (natal) tissue the person has for the surgeon to use in making the canal.

Not every surgical center has access to a single port robotic system, and getting this procedure may involve travel.

Vulvoplasty

This procedure may be called shallow depth vaginoplasty, zero depth vaginoplasty or vaginoplasty without canal. The surgeons create feminine external genitalia (vulva) with a very shallow canal. The procedure includes the creation of the labia (outer and inner lips), clitoris and vaginal opening (introitus).

The main drawback to this approach is the person cannot have receptive vaginal intercourse because no canal is created.

There are advantages, however. Because this is a much less complicated approach than vaginoplasty with canal, vulvoplasty can mean a much shorter operation, with less time in the hospital and a faster recovery. Vulvoplasty also involves less risk of complications, and does not require hair removal or postoperative dilation.

Do I need to have hair removal before vaginoplasty? When should I start?

Permanent hair removal (to remove the hair follicles to prevent regrowth) before surgery is recommended for optimal results. Patients are advised to start hair removal as soon as possible in advance of vaginoplasty, since it can take three to six months to complete the process. The hair removal process readies the tissue that will be used to create the internal vaginal canal. For people who are not able to complete the hair removal in advance, there may be residual hair in the canal after surgery.

How long is vaginoplasty surgery?

Most vaginoplasty surgeries last between four and six hours. Recovery in the hospital takes three to five days.

Illustrated Vaginoplasty Surgery

Vaginoplasty.

1 of 4 in series. Enlarged image .

2 of 4 in series. Enlarged image .

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4 of 4 in series. Enlarged image .

Recovery After Vaginoplasty

After surgery, you will be admitted to the hospital for one to five days. You will spend most of this time in bed recovering. Your care team will monitor your pain, and make sure you are healing appropriately and are able to go to the bathroom and walk.

On average, it can take six to eight weeks to recover from a vaginoplasty. Every person’s recovery is different, but proper home hygiene and postoperative care will give you the best chance for a faster recovery. Patients who have had vaginoplasties need to stay within a 90-minute drive of the hospital for four weeks after surgery so doctors can follow up and address any issues.

Consistent daily dilation for the first three months is essential for best outcome. Before you go home, you will be taught how to dilate if you have a vaginoplasty with canal. You will be given dilators before discharge to use at home.

What is dilation after vaginoplasty?

Part of the healing process after vaginoplasty involves dilation — inserting a medical grade dilator into the vagina to keep your vaginal canal open as it heals. The hospital may provide you with a set of different sized dilators to use.

A doctor or therapist from your care team will show you how to dilate. This can be difficult at first, but professionals will work with you and your comfort level to help you get accustomed to this aspect of your healing process. You will begin dilating with the smallest dilator in the dilator pack. You continue to use this dilator until cleared to advance to the next size by your care team.

During the first few weeks after surgery, you must dilate three times a day for at least 20 minutes. It is very important that you continue dilating, especially during your immediate postoperative period, to prevent losing vaginal depth and width. Patients continue to use a dilator for as long as the care team recommends. Some patients may need to dilate their whole lives.

Is dilation after vaginoplasty painful?

Dilation should not be a painful process. At first, you may feel discomfort as you learn the easiest angles and techniques for your body. If you feel severe pain at any time during dilation, it is important to stop, adjust the dilator, and reposition your body so you are more comfortable. It is also important to use lubricant when you dilate. A pelvic floor therapist can work with you to help you get used to this aspect of recovery.

Will I have a catheter?

Yes. While you are in the hospital, you will have a Foley catheter in the urethra that will be taken out before you go home.

Will I have surgical drains?

Yes, your surgeon will place a drain while you are in the operating room, which will be removed before you leave.

Can I shower after vaginoplasty surgery?

Yes. It is very important to clean the area to prevent infections. You can gently wash the area with soap and water. Never scrub or allow water to be sprayed directly at the surgical site.

Is going to the bathroom different?

It is important to remember for the rest of your life that when wiping with toilet paper or washing the genital area, always wipe front to back. This helps keep your vagina clean and prevents infection from the anal region.

You may notice some spraying when you urinate. This is common, and can be addressed with physical therapy to help strengthen the pelvic floor. A physical therapist can help you with exercises, which may help improve urination over time.

Is the vagina created by vaginoplasty sexually functional?

Yes. After vaginoplasty that includes creation of a vaginal canal, a person can have receptive, penetrative sex.

You must avoid any form of sexual activity for 12 weeks after surgery to allow your body to recover and avoid complications. After 12 weeks, the vagina is healed enough for receptive intercourse.

What will my vagina look like?

Vulvas and vaginas are as unique as a fingerprint, and there are many anatomic variations from person to person. Surgical results vary, also. You can expect that the surgery will recreate the labia minora and majora, a clitoral hood and the clitoris will be under the hood. Make sure you discuss your concerns with your surgeon, who can help you understand what to expect from your individual surgical results.

What is the average depth of a vagina after vaginoplasty?

The depth of a fully constructed vaginal canal depends on patient preferences and anatomy. On average, the constructed vaginal canal is between 5 and 7 inches deep. Vaginal depth may depend on the amount of skin available in the genital area before your vaginoplasty. This varies among individuals, and some patients may need skin grafts.

Newer robotic techniques may be able to increase the vaginal depth for those people with less existing tissue for the surgeon to work with.

Will I need any additional surgery after vaginoplasty?

You may need additional surgical procedures to revise the appearance of the new vagina and vulva. Later revisions can improve aesthetic appearance, but these are not typically covered by insurance.

Vaginoplasty Complications

Vaginoplasty is safe, overall, and newer techniques are reducing the risks of problems even further. But sometimes, patients experience complications related to the procedure. These can include:

• Slow wound healing
• Narrowing of the vaginal canal (regular dilating as prescribed can lower this risk)

Some rare complications may require further surgery to repair:

• A fistula (an abnormal connection between the new vagina and the rectum or bladder)
• Injury to the urethra, which may require surgery or a suprapubic catheter
• Rectal injury (very rare) may require a low-fiber diet, a colostomy or additional surgery.

Be sure to discuss your concerns with your surgeon, who will work with you for optimal results.

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Use It or Lose It: The Importance of Dilation Following Vaginoplasty

Julie Vu with her set of Soul Source dilators. Source: YouTube.

Vaginoplasty is a Gender Reassignment Surgery procedure that transforms the transgender person's genitalia into female genitals, including a neo-vagina. Post-operative vaginal dilation is an integral part of the initial surgery recovery and the regular maintenance of a transgender person's neo-vagina. Typically, dilation begins a few days after surgery and is almost always required for life. Without proper dilation, the skin graft inside the vagina tends to contract which leads to narrowing, shortening or closure of the neo-vagina . This is an irreversible result—one cannot regain the original vaginal depth by simply resuming or doing more dilation. Dilation may not be pleasant but it's essential to follow your surgeon's dilation protocol in order to prevent loss of depth of your new vagina.

Dilation Explained

The purpose of dilation is to maintain the depth of the neo-vagina. Dilation helps prevent contraction of the skin graft inside vagina and also improves the elasticity of vaginal wall in order to comfortably accommodate penetrative sex.

Dilation involves inserting a lubricated dilator into the neo-vagina and keeping it in there for a specified amount of time. The size of dilator and the length of dilation time varies depending on the surgeon's protocol and patient's needs. Your surgeon will advise about the proper use and frequency of post-op dilation and it's important to follow their advice above all as it may be specific to your case.

Initially, one can expect dilation to take up to 2-2.5 hours per day, with the time and frequency decreasing after you reach 18-24 months post-op. Yes, it's a commitment!

"All I wanted to do was sleep, but I couldn't sleep since I had to wake up and dilate endlessly. It was so much dilation that I would dream about it many nights." — Autumn Asphodel

Dilation is also not as comfortable as one might hope. "[The dilators are] hard, they're plastic, they're cold, they're uncomfortable to be inside you,' said Julie Vu on YouTube .

Does Sex Count? There's some debate as to whether or not sexual intercourse can count as a dilation session. 'If [after a year post-op] you have sex once every week, you're good to go, you don't have to dilate with these instruments,' says Vu. Maddy McKenna concurs , "The only bonus it that if I have a sexual companion, 30 minutes of sex counts as 30 minutes of dilation."

"You have to dilate once a week for the rest of your life, unless you're having sex," says Nomi Ruiz , a transgender singer and host of the podcast Allegedly NYC . "So now when I'm not having sex, it's kinda sad, because you're really reminded of it. You're like, 'Oh, God, I have to dilate now because I'm not getting laid. Fuck.'" However, sexual intercourse in place of dilation may not be sufficient. This is something that you should discuss with your surgeon.

To begin, patients dilate with the largest dilator that comfortably fits inside the neo-vagina. As the weeks progress after surgery, larger dilators are introduced and the length of time with the largest dilator is gradually increased.

"So, there are four dilator sizes I have. The first one is 1?", the second one is 1¼", the third is 1?", and the largest one is 1½". I don't use the first one at all anymore. But, I have to start with the second one and then work up to the largest one. I can't just use the third or fourth one without working up to it. UHHHHH, I hate the largest one so much. It tears me up, literally. I just wanna throw it out the window. [Glass break]" — Autumn Asphodel

Dilation Isn't Fun But It's Worth It

"The only part in my vagina self-care regimen that differs from a natal vagina is that I have to dilate. When I first came out of surgery, my body naturally registered my neo vagina as a wound and, because of that, it wanted to heal and close up. No thank you!" — Maddy McKenna

When dilation isn't done according to the recommended routine, the skin graft inside the vagina can contract and close up which leads to the shortening—and even closure—of the neo-vagina. Unfortunately, once this happens it can't be fixed by simply resuming or doing more dilation. A revision surgery is usually necessary.

"Vaginal openings are similar to pierced ears in that if you don't use earrings regularly, the piercings will eventually close," says Dr. Rumer . "So we always say, 'DILATE!!! DILATE!!! DILATE!!!'"

" [Dilation is] very important. Very important. Can't say that enough. Your vagina will close up if you don't dilate. I did have a patient who didn't dilate for two weeks. She went back to the doctor, and she had closed up. And they couldn't reverse back. So, it's very important. Not to scare you, but just do it." — JD Davids

Dilation Tips

Follow your surgeon's dilation guidelines!

Find ways that help make the process go by faster.

"I dilated a lot to TV shows. They tell you to dilate for 20 minutes a day. But you're so scared that it's going to close up that you probably dilate -- well, I dilated till like an hour. I would watch the Atlanta Housewives, and I would get in my bathtub. Because at first it was the only place that I could dilate. So, I would get my pillow. I would sit in my tub. I would have my iPad, and I would watch The Real Housewives of Atlanta while I was dilating. I'd watch the whole episode. Then I was done." — Nyala Moon

Use a lot of lube. (Water-based, not silicone.)

Stretch before and after dilating.

"All that dilating made my hip get out of place because it's an uncomfortable position to be in multiple times a day. So, it's always best to stretch before and after." — Autumn Asphodel

You will need several towels or waterproof pads to place under you while dilating. Chux pads or puppy training pads are a good solution if you don't have laundry facilities.

You can take a painkiller after dilating, but not before because it would increase the chance of hurting yourself.

Try urinating or having a bowel movement before your dilation session as it can make it more comfortable.

More dilation tips at Transgender Map »

WATCH: Dr. Gabriel Del Corral's Dilation Instructional Video (sign-in required)

"The average canal can be anywhere between four and six and a half, seven inches. Certainly with good discipline using the dilators, you'd be able to accommodate a regular sized penis. It just takes work after a Vaginoplasty. It takes a lot of discipline. And it takes a lot of time to be able to dilate three times a day for the first couple months post-surgery." — Dr. Gabriel Del Corral

WATCH: Dr. Heidi Wittenberg on Basic Equipment & Positioning to Optimize Dilation

Where to Buy Dilators

You should receive everything you need to dilate before you leave the hospital or recovery facility, from your surgeon. You will use several dilators of different lengths and widths during your recovery and beyond.

Dr. Rumer provides a Dilator Kit for patients, which includes dilators made specifically for trans women by Soul Source . $40-55 each.

Note on materials: Some believe that dilators shouldn't be made out of silicone or other soft materials. Dilators should be rigid and hard enough to provide the rigidity necessary to stretch forming scar tissue.

This section contains affiliate links.

BioMoi's Silicone Vaginal Trainers with BioCote Protection (Full Set) The "best quality" vaginal dilators on the market, made of US Platinum silicone. $129.99.

VuVa Smooth Set of 5 dilators made of medical grade polycarbonate plastic, with Instructions and pouch. Made in the USA.

VWell Set of 5 dilators made of silky smooth medical grade silicone, BPA and paraben-free.

Amielle Care Set of Vaginal Dilators Set of 4 graduated dilators with a universal handle to make insertion and removal easier, lubricant and a discreet bag.

Vaginal Trainer Set These dilators are smooth and comfortable, easy to control, light-weight, latex-free, washable and safe. 6 gradual sizes plus an ergonomic solid-lock handle. HopeandHer.com

Expandable Dilators

Milli - Gradual expansion from from 15mm to 40mm, with 25mm total achievable expansion. Optional vibration, charging case. $395.

ZSI 200 NS Expander - In?atable cylinder made of biocompatible silicone. Lengths available: 90 mm & 120mm. Diameter: 40mm. No retail sales, must be purchased by a surgeon.

Last updated: 02/04/21

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Vaginoplasty procedures, complications and aftercare

Introduction.

The most common vaginoplasty technique is some variation of the penile inversion procedure. In this technique, a vaginal vault is created between the rectum and the urethra, in the same location as a non-transgender female between the pelvic floor (Kegel) muscles, and the vaginal lining is created from penile skin. An orchiectomy is performed, the labia majora are created using scrotal skin, and the clitoris is created from a portion of the glans penis. The prostate is left in place to avoid complications such as incontinence and urethral strictures. Furthermore, the prostate has erogenous sensation and is the anatomic equivalent to the "g-spot." Great care is taken to limit the external scars from a vaginoplasty by locating the incisions appropriately and with meticulous closure. Typical depth is 15 cm (6 inches), with a range of 12-16cm (5-6.5 inches); in comparison, typical vaginal depth in non-transgender females is between 9-12cm (3.5 to 5 inches). In the case of prior circumcision a skin graft, typically scrotal in origin, may be required. If there is insufficient skin between the penis and the scrotum to achieve 12cm (5 inches) of depth, a skin graft from the hip, lower abdomen or inner thigh may be used. Resultant scarring at the donor site may be minimized or hidden using standard techniques. Because the penile inversion approach does not create a vaginal mucosa, the vagina does not self-lubricate and requires the use of an external lubricant for dilation or penetrative sex.

Scrotal skin has abundant hair follicles and it is possible to transfer skin with sparse hair growth into the vagina unless hair is removed in advance. Some surgeons rely on treating all the visible hair with aggressive thinning of the skin and cauterization of visible hair follicles at the time of surgery. However, since hair grows in stages this approach might not adequately address dormant follicles. The most reliable method of preventing hair growth in the vagina is to perform scrotal electrolysis, at least three full clearings 8-12 weeks apart, depending on electrologist preference and hair type and distribution. Surgeons should provide a diagram of the specific area for clearance.

A common outcome of penile inversion vaginoplasty performed in a single stage (a "one-stage" vaginoplasty), with penile skin positioned between scrotal skin, is labia majora that are spaced too far apart. There may also be minimal if any clitoral hooding (except in heavier patients) and the labia minora may be insufficient after one operation. Although there are different variations of the one-step procedure, it has been the author's experience that these previously mentioned deficiencies are common. This constraint is due to factors inherent to the penile inversion approach and the limitations of the blood supply. From the standing position and with the legs together, most results appear acceptable; however, upon direct examination or intimate view, the deficiencies discussed above will be apparent. In order to adequately address these deficiencies, the author believes that a second operation is required. A secondary labiaplasty provides an opportunity to bring the labia majora closer to the midline in a more anatomically correct location, provide adequate clitoral hooding, and define the labia minora. In addition, there are many variables that can affect healing and the final result. Specifically, this secondary procedure also allows the surgeon to deal with differences in healing, such as revision of the urethra, correction of any vaginal webbing or persistent asymmetries, or revise scars that are unsatisfactory. These revisions will improve functionality and the final outcome for the patient and might not otherwise be addressed.

Immediate postoperative considerations

Gauze packing or a stenting device is placed in the vagina intraoperatively and remains in place for 5-7 days. Once removed, the patient is instructed in vaginal dilation, with dilators generally provided by the surgeon; dilation schedules vary between surgeons. Table 1 shows sample postoperative instructions, and Table 2 shows dilation instructions and a sample dilation schedule.

Dilation Instructions

Source: Brownstein & Crane Surgical Services

Please be aware that each person's dilation schedule may vary.

• Prior to insertion into the vagina, ensure the dilator is clean.
• Clean the dilator with warm water and antibacterial soap. Rinse well and dry with a clean paper towel or cloth.
• Apply Surgilube or KY Jelly to the dilator prior to insertion. Only use water based lubrication.
• Avoid silicone-based lubricants.
• Gently insert dilator into the vagina at an angle of 45 degrees until under the pubic bone, and then continue inserting straight inward.
• Expect to feel a small amount of resistance and tenderness. Stop immediately if there is too much resistance or severe pain.
• Insert the dilator into the full depth of the vagina (until you feel moderate pressure or resistance) and leave in place for 10 minutes. You should be inserting until only one or two white dots remain outside of the vagina.
• Start dilating three times daily for three months on the day the vaginal packing is removed.
• You may start using the next size dilator after three months of dilating. You should use the next size for three months.
• Dilation frequency: 0-3 months after surgery 3 times/day for 10 minutes each time, 3-6 months after surgery 1/day for 10 minutes each time, more than 6 months after surgery 2-3/week for 10 minutes each time, more than 9 months 1-2x/week.
• If the vagina begins to feel tight, increase the frequency of the dilation schedule.
• You should use soap and water to cleanse the vaginal canal after each dilation.

Immediate risks include bleeding, infection, skin or clitoral necrosis, suture line dehiscence, urinary retention or vaginal prolapse. Fistulas from the rectum, urethra or bladder usually present early on.

Acute bleeding usually originates from the urethra and most often can be controlled with local pressure. If local pressure is unable to achieve hemostasis, then placing a larger catheter (20F) in the urethra alone may stop the bleeding. If necessary, placing a suture around the bleeding site (with the catheter in place) will stop the bleeding in almost all cases. It is not unusual for localized hematomas to spontaneously drain through the vagina or suture line. This usually occurs a week or greater after surgery as the hematomas liquefy. The blood characteristically appears dark and old, and is not accompanied by clots. Although frightening to the patient, no treatment is indicated.

The genitalia and perineum have an excellent blood supply, so infections should be rare and seldom require more than a broad-spectrum antibiotic. Skin slough or loss is also rare, and should be treated conservatively. Separation of the suture line can occur, most often at the posterior perineum due to the pressure and stretching that occurs with dilation. Separations should be treated conservatively with antibiotic ointment, most will heal without consequence. Dilation should not be discontinued, and is critical at this stage. Failure to adequately dilate in the immediate postoperative period will likely result in severe vaginal stenosis. No attempt at immediate secondary closure of the dehiscence is indicated since it is a contaminated wound and would likely fail. In some cases, dehiscence may result in the development of a posterior web, which can be easily revised at a later stage.

Partial or complete clitoral necrosis may occur and should be treated conservatively with antibacterial ointments. In the majority of cases, the neurovascular bundle and a portion of the clitoris is still present and will usually maintain good sensitivity.

Urinary retention due to swelling and/or temporary peripheral nerve injury (neuropraxia) should be treated with replacement of a catheter for 5-7 days. Flomax is helpful, and this is almost always temporary. Early strictures are very rare.

A patient may lose a portion of the added skin graft and pass it out through the vagina. This usually occurs at least 2 weeks from surgery, and typically due to excessive skin grafting into the vagina. It is not accompanied with bleeding and the sloughed skin appears nonviable. Recovery is uneventful and patients should continue to dilate. A more severe scenario is expulsion of the entire vaginal skin lining, which occurs earlier (usually within the first postoperative week) and is frequently accompanied with at least some bleeding. While uncommon, in most cases it is a disastrous complication and the patient will require surgical intervention, typically one year later to re-line the vagina.

Delayed / long-term postoperative maintenance and considerations

Adherence to the dilation regimen is critical to healing and maintaining vaginal depth and girth. After the initial healing period, dilation must continue regularly for at least one year postoperatively. The depth and the width of the vagina should be checked regularly as one tapers down the dilation schedule. If it is noticed that vaginal depth or width are diminishing either by patient report or in-office examination, the dilation schedule should be increased. If the patient experiences difficulty with dilation due to discomfort, instillation of lubricant ahead of the dilator with either a 3cc syringe, or the applicator device supplied with vaginal antifungals may be helpful. Patients may develop a sensitivity to the preservative in the water based lubricant; simply changing the brand of lubricant is often an effective solution.

Loss of vaginal girth due to inadequate dilation can often be remedied by increasing dilation frequency; loss of vaginal depth is more difficult to address by dilation alone. Persistent pain or otherwise problematic dilation should be discussed with the surgeon. Other possible causes of painful or inadequate dilation include a small pelvic inlet or muscle spasm and vaginismus. Approaches may include but are not limited to botulinum toxin injections, removal of webbing at the entry of the vagina, and/or a referral to a physical therapist that specializes in pelvic pain and pelvic floor issues.

The vagina is skin-lined and under normal conditions is colonized with a combination of skin flora as well as some vaginal species; a study of vaginal flora in a mix of transgender women with and without symptoms of odor and discharge found Staphylococcus, Streptococcus, Enterococcus, Corynebacterium, Mobiluncus, and Bacteroides species to be most common. Lactobacilli were found in only 1 of 30 women, and candida was not found. There was no correlation between the presence of vaginal symptoms and any one particular species.[1] These findings suggest that vaginal discharge and odor in transgender women is unlikely to due to common causes in non-transgender women such as bacterial dysbiosis or candida; indeed the lack of a mucosa or low pH are consistent with this study's findings of rare lactobacilli and no candida. In most cases discharge is most likely due to sebum, dead skin or keratin debris, or retained semen or lubricant.

Since the vagina does not contain a mucosa, routine cleaning or douching with soapy water should be adequate to maintain hygiene. Initially the patient should douche daily during frequent dilation. Douching can be reduced to 2-3 times a week when dilation is less frequent. If odor or discharge persists, an examination for lesions or granulation tissue should be performed. Use of a solution of vinegar or 25% povidine iodine in water for 2-3 days may help in cases of flora overgrowth or imbalance, after which the patient can return to regular soap and water cleaning. If the drainage and odor persist, an empiric 5-day course of vaginal metronidazole is reasonable.

It is reasonable to consider a yearly visual pelvic exam to screen for lesions, granulation tissue, or undesired loss of depth and girth, though no evidence exists to support this recommendation. Since the vagina is skin lined, there is a risk of developing the same skin cancers that occur on the penile and scrotal skin (squamous cell, basal cell, melanoma). Other skin disorders such as psoriasis can also affect the vagina and should be treated similarly. If indicated, a prostate exam may be performed endovaginally since the rectal approach may be obscured by the new presence of the vaginal walls in between the rectum and the prostate.

A far less common approach to vaginoplasty is the use of either colon or small bowel to line the vaginal vault. This technique has the advantages of diminished need for dilation, greater depth and is naturally self-lubricating. However, this approach requires abdominal surgery with a risk of serious or even life-threatening complications. The primary indication for an intestinal approach is the revision of prior penile-inversion vaginoplasties. Since the secretion is digestive there is a risk of malodor and frequent secretions, and secretions are constant rather than only with arousal. Wearing panty liners or pads may be necessary for the long term. Bacterial overgrowth (diversion colitis) is common and may present with a greenish discharge, treatment includes. The bowel lining is also not as durable as skin. Use of intestinal tissue also places the vagina at risk of diseases of the bowel including inflammatory bowel disease, arterio-venous malformations (AVM) or neoplasms; screening or diagnostic evaluations for these conditions should be performed as indicated.

The most common fistula is a rectovaginal fistula. These usually occur at the midline within 5 cm of the vaginal opening, and are almost universally the result of a surgical injury to the rectum. Small fistulas may only pass flatus, while larger fistulas can allow stool to drain through the vagina. A temporary diverting colostomy may be required for hygiene. Dilation should continue to avoid closure of the vagina, with the plan to repair the fistula in a minimum of 6 months.

Urethrovaginal fistulas present with urine leakage from the vagina. The majority of cases do not need or require immediate intervention, and in most cases the patient will still be continent. The patient should be counseled that they will be more susceptible to urinary tract infections--particularly after intercourse. Voiding promptly after intercourse and/or acidifying the urine with juices or cranberry pills is usually adequate preventive care. Fistulas between the bladder and vagina are the least common, but are the most difficult to manage. A foley catheter in the bladder will divert a majority, but not all of the urine; in general surgical intervention will be required.

Granulation tissue

Granulation tissue in the vagina is the result of delayed healing and is common. The need for frequent dilation in the early post-operative period exacerbates the problem by causing repeated trauma to the area of granulation. The typical complaint is of mildly blood-streaked yellowish discharge. In most cases this will heal as the need for frequent dilations diminishes over time. If persistent, regular silver nitrate treatments and topical treatment of steroid cream (triamcinolone) or medical grade honey (Medihoney) will speed the healing. Silver nitrate can be applied to granulation areas until cautery is observed with resultant grey scabbing and coagulation. Steroid creams or honey can be applied on the tip of the dilator. Long term, the penile skin lined vagina should be very durable.

Urinary tract infections (UTIs)

Urinary tract infections are not uncommon, since the urethra is shortened during a vaginoplasty. Proper hygiene and hydration are generally adequate preventive measures. A patient who has recurrent urinary tract infections should be evaluated for a urethral stricture. A simple diagnostic test is to attempt to pass a 16F catheter into the bladder to rule out strictures, including post-bulbar or meatal stenosis. Patients with a mucosal flap causing a large meatus will require meticulous hygiene and possibly prophylaxis. Most patients will see a reduction in their ability to hold larger volumes of urine over longer times as a consequence of the involution of the prostate. Rarely some may even experience urgency incontinence. Bladder relaxants like tolterodine or darifenacin are helpful in these cases.

Sensation and orgasm

No major sensory nerves should have been divided during surgery, so sensitivity should not be adversely affected after vaginoplasty. In an outcome study published in 2002, 86% of the author's patients were orgasmic.[2] Pre-operative functionality is an important indicator, though it is possible that a previously anorgasmic patient will be orgasmic following vaginoplasty. The combination of prolonged estrogen/anti-androgen therapy and orchiectomy during surgery may result in a reported decline in libido for some patients, which is discussed elsewhere in these guidelines.

• Weyers S, Verstraelen H, Gerris J, Monstrey S, dos Santos Lopes Santiago G, Saerens B, et al. Microflora of the penile skin-lined neovagina of transsexual women. BMC Microbiol. 2009;9(1):102.
• Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003 Aug;32(4):299-315.

Medical Referral Disclaimer

The CoE is unable to respond to individual patient requests for medical guidance. If you need medical advice, please contact your local primary care provider. If you need clarification, seek a second opinion locally or have your provider contact us for more information.

Vaginoplasty: Male to Female (MTF) Genital Reconstructive Surgery

What is vaginoplasty.

Vaginoplasty is a surgical procedure during which surgeons remove the penis and testicles and create a functional vagina. This achieves resolution of gender dysphoria and allows for sexual activity with compatible genitalia. The highly sensitive skin and tissues from the penis are preserved and used to construct the vaginal lining and build a clitoris, resulting in genitals with appropriate sensations. Scrotal skin is used to increase the depth of the vaginal canal. Penile, scrotal and groin skin are refashioned to make the labia majora and minora, and the urethral opening is relocated to an appropriate female position. The final result is an anatomically congruent, aesthetically appealing, and functionally intact vagina. Unless there is a medical reason to do so, the prostate gland is not removed.

University Hospitals has the only reconstructive urology program in the region offering MTF vaginoplasty and other genital gender affirmation surgical procedures. Call 216-844-3009 to schedule a consultation.

Penile Inversion Technique for Vaginoplasty

Penile inversion is the most common type of vaginoplasty and is considered the gold standard for male to female genital reconstruction. This type of gender affirmation surgery can last from two to five hours and is performed with the patient under general anesthesia.

The skin is removed from the penis and inverted to form a pouch which is then inserted into the vaginal cavity created between the urethra and rectum. The urethra is partially removed, shortened and repositioned. Labia majora and labia minora (outer and inner lips), and a clitoris are created. After everything has been sutured in place, a catheter is inserted into the urethra and the area is bandaged. The bandages and catheter will typically remain in place for four to five days. For some patients, a shallow depth vaginoplasty is recommended. This allows for a functional vagina but removes the need for vaginal dilation and douching.

Outcomes after vaginoplasty are excellent, and patients can expect to have aesthetic outcomes and sexual functionality similar to that for cis-women (people that were assigned female sex characteristics at birth and identify as female).

Complications after vaginoplasty are rare, but patients are advised to talk to their doctor about postsurgical risks and how to best manage them.

Things to Consider Before Having a Penile Inversion Vaginoplasty

• Given that the skin used to construct the new vaginal lining may have abundant hair follicles, patients are recommended to undergo hair removal (either electrolysis or laser hair removal) prior to the vaginoplasty procedure to eliminate the potential for vaginal hair growth. A full course of hair removal can take several months.
• Patients with fertility concerns should talk to their doctor about ways to save and preserve their sperm before having a vaginoplasty.
• It is always recommended that patients talk with a therapist in the months leading up to surgery to ensure they are mentally prepared for the transition.
• In accordance with the World Professional Association of Transgender Health (WPATH) standards of care, patients are required be on appropriate cross-gender hormone therapy for a year, live in the gender-congruent role for a year, and have 2 mental health letters endorsing their suitability for surgery.

Postoperative Care of Your New Vagina

To ensure that your newly constructed vagina maintains the desired depth and width, your UH surgeon  will give you a vaginal dilator to begin using as soon as the bandages are removed. Use the dilator regularly according to your surgeon’s recommendations. This will usually involve inserting the device for ten minutes several times per day for the first three months. After that, once per day for three months followed by two to three times a week until a full year has passed.

Furthermore, regular douching and cleaning of the vagina is recommended. Your surgeon will give you general guidelines for this as well. Approximately 1 out of 10 people who have a vaginoplasty end up requiring a second, minor surgery to correct some of the scarring from the first surgery and improve the function and cosmetic appearance.

Most genital gender affirmation surgeries are covered by insurance. In cases where they are not, your surgeon’s office will guide you through the self-pay options.

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Sex and sexual health tips for transgender women after gender-affirming surgery

Lower gender-affirming surgery for trans women will mean they need to wait until the surgical site heals before having sex. Using lubricant and taking additional steps to protect against contracting sexually transmitted infections (STIs) can also help during the healing process.

Three options for lower gender-affirming surgery for transgender women include:

• Orchidectomy : This involves the removal of the testes. It can be a stand-alone procedure or occur during a vaginoplasty.
• Vaginoplasty: This involves removing the penis, testicles, and scrotum and creating a vaginal canal and labia. The surgeon will also create a clitoris using a portion of the glans penis.
• Vulvoplasty: This creates a vulva, including the mons pubis, labia, clitoris, and urethral opening. People may opt for this surgery if they are uninterested in receptive vaginal sex or do not wish to maintain the dilation and aftercare regime necessary after vaginoplasty. People may also refer to this option as a minimal depth vaginoplasty.

This article discusses how long recovery can take and when people can have sex after gender-affirming surgery.

It also looks at what to expect during sex after surgery and tips for hygiene, contraception , and protection from infections.

When can a person have sex after surgery?

According to Johns Hopkins Medicine , people can have receptive intercourse or take part in any sexual activity 12 weeks after a vaginoplasty. Sexual activity before this may lead to delayed wound healing and complications.

After an orchidectomy, it may take 1–2 days for people to become fully mobile again. They may be able to return to work a few days to a week after surgery.

Full recovery from an orchidectomy may take 2–8 weeks . For a few weeks following surgery, people will not be able to carry out certain activities such as driving or heavy lifting. The area of surgery will need to fully heal before people can have sex.

A healthcare professional can advise people when it is safe for them to have sex after gender-affirming surgery.

Will it be possible to achieve orgasm?

Following surgery, it can take time for people to recover and start to experience orgasms.

When people undergo a vulvoplasty, the surgeon forms a clitoris from the head of the penis. This means most people will still be able to experience orgasms through clitoral stimulation.

Johns Hopkins Medicine states that people may experience clitoral sensation after a vaginoplasty, although it can vary for each individual. Nerve regeneration may begin around 3 weeks following surgery, but in some cases, it may take a year or more to regain sensation.

People may experience a shooting or tingling sensation as the nerves regenerate, which should decrease over time.

In a 2017 study , 84 participants had rectosigmoid vaginoplasty. A post-surgery interview found that 79 of the participants had had sexual intercourse, and 72 had experienced orgasm.

Some reported infrequent symptoms, such as pain after sex and vaginal spotting , but these improved within 6 months.

A 2016 study of 22 people who had undergone a vaginoplasty and clitoroplasty found that 86% of participants could experience orgasm after surgery.

In addition, research from 2017 involving 28 transgender women found that pressure and vibration provided the best results for genital sensitivity after gender-affirming surgery.

How will it affect libido?

Transgender women may experience a decrease in sex drive after gender-affirming surgery.

According to a 2020 article , people can stop taking anti- testosterone medication and may experience a decreased sex drive following an orchidectomy.

Hormone replacement therapy may help maintain a regular sex drive.

Vaginal depth and lubrication

Vaginal depth after a vaginoplasty can vary for each person and depend on the amount of skin in the genital area before surgery.

An average vaginal depth after a vaginoplasty is 4–6 inches . For comparison, the average depth of a cisgender female’s vagina measures from 3.5 to 5 inches .

In people who have a rectosigmoid vaginoplasty or colovaginoplasty, the vagina may have more depth.

The University of California, San Francisco Medical Centre notes that the most common vaginoplasty technique uses the penile inversion procedure. This does not create a vaginal mucosa. As a result, the vagina will not self-lubricate, and a person will need to use lubricants to undergo dilation or have penetrative sex.

Another vaginoplasty technique uses the colon or small bowel to line the vagina, which will result in a self-lubricating vagina. However, it is a far less common procedure that may lead to serious and possibly life threatening complications.

When using lubrication, people should use a water or silicone-based lube with latex condoms, as oil-based lubricants can damage latex.

Aftercare and dilation

After a vaginoplasty, people need to use a vaginal dilator to stretch the vaginal canal and keep it open. Following surgery, people may need to dilate twice each day for a minimum of 15 minutes. This helps prevent loss of vaginal depth and width.

A healthcare professional will provide instructions on how to safely and correctly use a dilator. Although people may experience some discomfort when they begin dilating, they should not experience any severe pain.

If people experience pain when dilating, they will need to stop and readjust the dilator and body position. People will also need to use lubrication during dilation.

An orchidectomy can cause testosterone levels to drop. A sudden drop in testosterone may lead to mood swings or low energy following surgery.

To help prevent this, people may want to discuss mild testosterone replacement options with a healthcare professional to allow a more gradual reduction in testosterone.

People may need to use plenty of lubricant to make sex feel more comfortable and prevent any tears. They may also find the rest of the genital area, including the anus, is more tender following surgery.

Contraception and STIs

According to the Terrence Higgins Trust , surgery can increase the risk of contracting STIs , as any unhealed skin can allow infections to pass more easily into the body.

If people have had a vaginoplasty that uses part of the colon, a mucus membrane will line the vagina, making it easier for STIs to pass through.

If people have had a vaginoplasty that uses penile and scrotal skin, the vagina is less susceptible to STIs, but any unhealed skin can still be a risk factor.

Dilation of the vagina can also cause bleeding, so it is important to use a condom for any sex following dilation.

Using a condom during sex can help protect from STIs. People can use an external condom over a penis or sex toy and an internal condom inside a vagina. An internal condom may not suit everyone, as using an internal condom will depend on vaginal depth.

People can also use a dental dam during oral-vaginal sex. Regular testing can help to prevent passing on or contracting STIs from a sexual partner.

If people have not had an orchidectomy or vasectomy, they will need to use contraception for any penetrative sex with a partner who is able to get pregnant and is not using contraception.

If people are taking estrogen or other hormone therapy, these will not provide enough contraceptive protection, so they will need to use other contraceptive methods.

Learn more about sexual health for transgender women here.

Hygiene tips

After a vaginoplasty, it is important to keep the genital area clean and free of infection .

People will need to keep the outside of the vagina dry. It may be useful to place an absorbent pad between the labia to soak up any excess moisture.

Once the genital area is allowed to get wet, people should use soap and water to gently wash the area. It is important to avoid scrubbing or allowing shower spray to reach the surgical site.

Johns Hopkins Medicine states that people will need to douche using a non-fragranced vaginal douche , beginning 8 days after surgery. Depending on how much vaginal discharge people have, douching may be required 1–2 times each week. More frequent douching may be necessary if there is a large amount of discharge.

Following an orchidectomy, people may experience some mild discomfort, bruising, and swelling around the area of surgery. Some bleeding may occur, although this is rare . People may need to apply topical antibiotics to prevent infection.

People will need to speak with a healthcare professional to check when they can bathe the area of surgery following an orchidectomy.

It can take time to heal, recover, and adjust to sex and intimacy after gender-affirming surgery.

If people are experiencing any physical or emotional issues regarding surgery, they can speak with a doctor, a mental health professional, or a sex therapist.

• Sexual Health / STDs

How we reviewed this article:

• Can transgender women have orgasms after gender-reassignment surgery? (n.d.). https://issm.info/sexual-health-qa/can-transgender-women-have-orgasms-after-gender-reassignment-surgery
• FAQ: Vaginoplasty. (n.d.). https://www.hopkinsmedicine.org/center-transgender-health/services-appointments/faq/vaginoplasty
• Kim, S-K., et al . (2017). Is rectosigmoid vaginoplasty still useful? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300923/
• LeBreton, M., et al. (2016). Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women. https://www.jsm.jsexmed.org/article/S1743-6095(16)30859-1/fulltext
• Meltzer, T. (2016). Vaginoplasty procedures, complications and aftercare. https://transcare.ucsf.edu/guidelines/vaginoplasty
• Orchiectomy. (n.d.). https://transcare.ucsf.edu/orchiectomy
• Orchiectomy. (n.d.). https://www.transhub.org.au/orchiectomy
• Orchiectomy. (n.d.). http://www.phsa.ca/transcarebc/surgery/gen-affirming/lower-body-surgeries/orchiectomy#Post--surgery
• Safer sex and sexual health for trans feminine people. (n.d.). https://www.tht.org.uk/hiv-and-sexual-health/sexual-health/trans-people/trans-feminine/safer-sex
• Sigurjónsson, H., et al. (2017). Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery. https://www.jsm.jsexmed.org/article/S1743-6095(16)30857-8/fulltext
• Vaginoplasty / vulvoplasty. (n.d.). https://healthcare.utah.edu/transgender-health/gender-affirmation-surgery/vaginoplasty.php
• van der Sluis, W. B., et al . (2020). Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes. https://www.tandfonline.com/doi/full/10.1080/26895269.2020.1749921

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Related Coverage

There is no age limit on when a person can transition. Learn more about how to do so here.

Transgender is a term to refer to those who have a different gender identity than the one assigned to them at birth. Learn more here.

Estrogen hormone therapy can cause physical, sexual, reproductive, and emotional changes. Learn more about how it affects the body here.

IU School of Medicine surgeons perform a variety of gender affirming surgeries at our clinical affiliates for patients over 18 years of age. Our team will work with you to learn your goals and to develop an individualized plan to meet your needs. We currently offer:

chest reconstruction

breast augmentation

orchiectomy

vulvoplasty

vaginoplasty

voice surgery

facial feminization surgery

metoidioplasty

phalloplasty

hysterectomy and oophorectomy

Surgeons work together with other specialists to provide a coordinated, safe approach to medical and surgical care. All of our providers follow the World Professional Association for Transgender Health (WPATH) Standards of Care.

WPATH Standards of Care

Chest Reconstruction

Chest reconstruction is a common top surgery among transgender and non-binary patients who were assigned female at birth (AFAB). A plastic surgeon removes your mammary and fat tissue to create a masculine chest. The nipples are repositioned and resized, if desired.

Your care team will work closely with you to understand your goals and will recommend the best surgical approach to meet your needs. We offer several different types of chest reconstruction procedures, including double incision with nipple grafts, buttonhole and peri-aeriolar incisions (keyhole), using liposuction to help with contouring and prevention of “dogears.” The team will work with you to help pick the right technique at the time of your consultation.

Chest reconstruction surgery requires general anesthesia, and is performed as an outpatient procedure, meaning there is no hospital stay after surgery. After surgery you must wear a compression vest for at least four weeks. Drains are used for peri-aeriolar incision surgery. Foam bolsters are also placed on the chest to protect nipple grafts. The bolsters and/or drains will be removed one week after surgery. Most people are able to resume regular daily activities after one month with no restrictions.

Breast Augmentation

Breast augmentation is usually for transgender women and transfeminine spectrum non-binary people. It is also often called feminizing augmentation mammoplasty. We will give your chest a female appearance by placing implants underneath your natural breast tissue or pectoral muscle. Your care team will discuss the implant type (silicone or saline), size and shape to match your body and your desires during your consultation.

A small incision will be made in the crease underneath each breast or around the nipple. A pocket is made underneath the breast or pectoral muscle to give each breast a natural teardrop shape. Often, an additional incision will need to be made around the nipple to lift the breast and nipple into a more feminine position (mastopexy).

Some patients can benefit from fat grafting from the belly, hips or thighs in conjunction with implant surgery to achieve additional fullness in specific areas of the breast. This procedure is not currently covered by insurance.

Orchiectomy

The gender health team offers this surgery as part of gender affirming care for transfeminine patients. Orchiectomy (testicle removal) requires general anesthesia and is a low-risk, outpatient procedure, meaning there is no hospital stay after surgery.

A small incision is made in the scrotum along the median raphe (line in the midline of the scrotum). This approach does not affect future bottom surgery choices. It is common to see a small amount of bruising and swelling and experience mild discomfort. Rare risks include skin infection and a large bruise (hematoma). The recovery process is brief, and most patients are able to resume work and most daily activities within a few days. In those who do not want any further bottom surgeries, the scrotum can also be removed.

Vulvoplasty

The vulva is the outside part of the vagina. A vulvoplasty is a type of surgery that uses skin and tissue from a penis to create all of the outside parts of a vagina. Vulvoplasty does not create the internal vaginal canal.

The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your provider will:

• create a clitoris out of the glans (head) of the penis
• create a labia minor and labia majora from skin on the penis and scrotum
• create the opening of the urethra so you can urinate
• create the introitus (opening of the vagina)

The only thing that’s different between a full vaginoplasty and a vulvoplasty is the internal part of the vaginal canal. This means you will not be able to insert a penis or toys into your vagina. 

Vaginoplasty

Vaginoplasty involves creating a vagina, clitoris, labia majora, and labia minora. The procedure is effective both for people who have and those who have not had orchiectomy in the past. Removal of the testes is required as a part of vaginoplasty.

We perform vaginoplasty under general anesthesia. Most people spend six to seven full days in the hospital after surgery. Recovery from vaginoplasty can take up to three months, and requires intensive post-operative care. It is important to have both someone who can help take care of you after surgery as well as the privacy you need to take care of yourself.

You will need the privacy to dilate at least 30 minutes twice a day. Dilation involves inserting a medical dilator into the vagina. This is important because the vagina will close if people do not dilate.

The gender health team has pioneered an approach using the peritoneal lining, the tissue that lines your abdominal wall and covers most of the organs in your abdomen. The peritoneal lining is hairless and pink. While the peritoneal vaginoplasty does provide moisture, it is not self-lubricating. Patients will still need to use water-based lubricant for intercourse and dilation. This is a new procedure, and we are still gathering data about the procedure's long-term safety and efficacy.

How do I choose between vulvoplasty vs. vaginoplasty?

A vulvoplasty has a much easier recovery. It has a shorter hospital stay and does not require the lifelong maintenance of performing dilations to maintain the vagina.

Some patients know that they’re not interested in having vaginal intercourse. For these patients, a vulvoplasty may be a better choice.

After a vulvoplasty, you can still have orgasms through clitoral stimulation, just like with vaginoplasty. During a vulvoplasty, your surgeon will create a clitoris from the glans or head of the penis.

Metoidioplasty

Metoidioplasty is a procedure for patients who desire a penis. Your surgeon will remove the vagina in those that experience dysphoria from this organ, then release the clitoris from the ligament that holds it in place to lengthen it. Tissue grafting is used to create the penis. The result is a neophallus that can become erect. We are one of the only centers that offer this surgery at the same time as a hysterectomy.

We can perform this procedure with or without extending the urethra to allow urination out of the tip of the penis. The provider can also create a scrotum and insert testicular implants depending on your preference. After metoidioplasty, you will have a three to four day hospital stay. You will go home with a tube in your stomach to help drain your urine, as well as a catheter in the penis. Recovery can take six to eight weeks. Problems with urinary flow are very common, but often resolve on their own.

Phalloplasty

With phalloplasty, a surgeon will create a penis out of skin from somewhere on the body. Faculty at IU School of Medicine currently offer several different techniques. These include the radial forearm flap (RFF) phalloplasty, Anterolateral Thigh (ALT) flap, and Suprapubic.

Phalloplasty can involve several procedures in addition to the creation of a penis. We can close the front pelvic opening (vaginectomy). This often requires a hysterectomy as well.

Urethral lengthening creates a urethra that allows urination from the tip of the penis. Scrotoplasty creates a scrotum. We can perform one or both of these procedures during phalloplasty. Neither is required.

All options for phalloplasty require multiple surgical procedures. Some procedures involve a hospital stay. Some stages of phalloplasty require a hospital stay for up to a week, if not longer.

If you are interested in phalloplasty, we start with a complete consultation. IU School of Medicine providers will discuss the pros and cons of each procedure and help you decide what is right for you. Your care team will be there every step of the way to support you. It is our goal to make sure you feel comfortable and confident with your decision and satisfied with your results.

Hysterectomy and Oophorectomy

Hysterectomy is the removal of the uterus and ovaries. This surgery is part of gender affirming care for transmasculine patients. There is no hospital stay after surgery. Most people recover within two to four weeks. This can be in combination with metoidioplasty or top surgery.

You will have a complete consultation prior to scheduling surgery. At this appointment, your provider will discuss the surgery, review the role of removing the ovaries (oophorectomy) and the route of removing the uterus. For most patients a minimally invasive approach is offered via laparoscopy (making very small incisions on the abdomen).

Should I remove my ovaries?

This is a very personal decision. There is conflicting evidence on the role of the estrogen produced by the ovaries on the risk of heart disease or osteoporosis. Keeping an ovary can mean that you continue to experience cyclic hormonal symptoms, even without a uterus or menstruation.

The ovaries contain eggs for reproduction. Even without a uterus you can still use the eggs for a pregnancy. If you are interested in having children it may be beneficial to keep your ovaries. Your provider will discuss these options in your initial visit and in the surgical planning.

It is likely there is little or no benefit to keeping the ovaries for patients who are not interested in future reproduction and who intend to continue on long term testosterone therapy until at least age 50.

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• > Context, Principles and Practice of TransGynecology
• > Vaginal Dilators and Dilating after Vaginoplasty

Book contents

• Context, Principles, and Practice of Transgynecology
• Copyright page
• Contributors
• Abbreviations
• Section A Contextual Transgynecology
• Section B Practicing Transgynecology
• Chapter 9 Gynecological Office Medicine for Trans and Gender Diverse People
• Chapter 10 Features of Imaging in Transgender Persons
• Chapter 11 Benign Gynecological Conditions in Transgender and Gender Diverse People
• Chapter 12 Urogynecological Disorders
• Chapter 13 Painful and Frequent Micturition
• Chapter 14 Diagnostics and Treatment of Gynecological and Nongynecological Causes of Pelvic Pain
• Chapter 15 Gynecological Attention to the Prostate
• Chapter 16 Vaginal Dilators and Dilating after Vaginoplasty
• Chapter 17 Transenology
• Section C Gynecological Surgery for Transgender Males
• Section D Sexuality and Contraception
• Section E Fertility and Reproduction
• Section F Impact of Gender-affirming Hormonal Therapy on Genital Organs
• Section G Screening and Prophylaxis
• Transgynecology Index

Chapter 16 - Vaginal Dilators and Dilating after Vaginoplasty

from Section B - Practicing Transgynecology

Published online by Cambridge University Press:  22 December 2022

Dilators, stents, trainers, or probes utilized after gender affirmation surgery need to be rigid, non-porous, easy to clean plastic or glass devices and are used to keep the vaginal canal open after surgical creation of a neovagina. Dilators have been used within the specialty of gynecology for several conditions including vaginal agenesis, iatrogenic stenosis, vulvovaginal inflammatory conditions, vaginismus, and post-surgical stenosis. Transgender people who undergo genital gender-confirming surgery, specifically vaginoplasty, are required to dilate to maintain an open vaginal canal after surgery and prevent stenosis. Gynecologists often have had little training on how to guide patients through this therapy. It is common to seek care from a local reproductive healthcare professional after vaginoplasty, as patients frequently must travel for surgery and return home for long-term recovery. This illustrates a growing need for gynecologists to familiarize themselves with the post-operative care of transgender patients after vaginoplasty.

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• Vaginal Dilators and Dilating after Vaginoplasty
• By Rixt AC Luikenaar , Richard A. Santucci , Ashley N. DeLeon
• Edited by Mick van Trotsenburg , Sigmund Freud PrivatUniversität, Wien , Rixt A. C. Luikenaar , Rebirth Health Center, Utah , Maria Cristina Meriggiola , Università di Bologna
• Book: Context, Principles and Practice of TransGynecology
• Online publication: 22 December 2022
• Chapter DOI: https://doi.org/10.1017/9781108899987.020

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• Health Conditions

Vaginoplasty: Gender Confirmation Surgery

A vaginoplasty is a medical procedure that constructs or repairs a vagina. It treats a variety of medical conditions and can be a form of gender affirming surgery.

For transgender and nonbinary people interested in gender confirmation surgery, a vaginoplasty is the process during which surgeons construct a vaginal cavity between the rectum and the urethra. The goal of the vaginoplasty is to create a vagina out of penile tissue — one with the depth and appearance of a biologically developed vagina.

Penile inversion procedure

The most common vaginoplasty technique is a penile inversion procedure. In this technique, penile skin is used to construct the vaginal lining. The labia majora are created using scrotal skin, and the clitoris is built from the sensitive skin at the tip of the penis. The prostate is left in place, where it can serve as an erogenous zone similar to the G-spot.

In some cases, there is not enough skin to achieve the necessary vaginal depth, so surgeons will take a skin graft from the upper hip, lower abdomen, or inner thigh. Scarring from the donation site is typically hidden or minimal.

The use of skin grafting to build the vulva is a topic of controversy among plastic surgeons. Some believe that the extra skin allows for a better cosmetic appearance. Others believe that functionality should not be sacrificed. Skin from donation sites is never as sensitive as skin from the genitals.

The penile inversion vaginoplasty is considered the gold standard genital reconstruction technique among plastic surgeons, and it is recommended by the Center of Excellence for Transgender Health .

Colon procedure

There is another technique that uses the lining of the colon instead of penile skin. Research on the outcomes of this surgery is limited.

One positive aspect of this procedure is that the tissue is self-lubricating, whereas vaginas made from penile tissue are dependent upon artificial lubrication. Because of the associated risks, however, colon tissue is typically used only in the event of a failed penile inversion.

Many people who have a vaginoplasty end up having a second surgery to improve the cosmetic appearance of the labia. A second surgery, called a labiaplasty, provides an opportunity for surgeons to work with healed tissue, where they can correct the positioning of the urethra and vaginal lips. According to the Center of Excellence for Transgender Health , a secondary labiaplasty, which is much less invasive, ensures the best cosmetic results.

What happens during the procedure?

On the morning of your surgery you will meet with your surgeon and an anesthesiologist. They will give you an overview of how the day is going to play out. They will probably give you an antianxiety medication or another sedative to help you relax. Then they will bring you to the operating room.

During your penile inversion vaginoplasty, you will be under general anesthesia, lying on your back with your legs up in stirrups.

The procedure is complex, involving delicate tissue, vasculature, and nerve fibers. Here are some of the broad strokes:

• The testicles are removed and discarded.
• The new vaginal cavity is carved out in the space between the urethra and the rectum.
• A penile prosthesis (surgical dildo) is inserted into the cavity to hold the shape.
• The skin is removed from the penis. This skin forms a pouch which is sutured and inverted.
• A triangular piece of glans penis (the bulbous tip) is removed to become the clitoris.
• The urethra is removed, shortened, and prepared for repositioning before the remaining parts of the penis are amputated and discarded.

Everything is sutured together and bandages are applied. The whole procedure takes two to five hours. The bandages and a catheter typically remain in place for four days, after which time postoperative steps should be taken.

Risks and complications

There are always risks associated with surgery, but vaginoplasty complications are rare. Infections can usually be cleared up with antibiotics. Some immediate postsurgical risks include:

• skin or clitoral necrosis
• rupture of the sutures
• urinary retention
• vaginal prolapse

Preparing for surgery

Some of the skin around the scrotum is hairy, as are the areas where skin grafts are taken from. Talk to your surgeon about where your new vaginal skin will be harvested. You may choose to complete a full course of electrolysis to eliminate the potential for vaginal hair growth. This can take several weeks or months.

Follow your surgeon’s instructions on the night before and morning of your surgery. Generally, you should not eat or drink anything after midnight on the night prior to going under anesthesia.

Other presurgery tips:

• Talk to other people who have gotten bottom surgery about their experiences.
• Talk with a therapist or counselor in the months prior to your surgery to mentally prepare yourself.
• Make plans for your reproductive future. Talk to your doctor about your fertility preservation options (saving sperm samples).
• Make a postoperative plan with your family and friends; you will need lots of support.

How much does it cost?

The average cost for a penile inversion vaginoplasty is around $20,000 without insurance. This includes a few days in the hospital, plus anesthesia. However, this is only for one surgery. If you want a secondary labiaplasty, the costs increase.

Many people who get vaginoplasties also undergo breast augmentation and facial feminization surgeries, which are very expensive. You should also keep in mind the cost of electrolysis, which can add up to thousands of dollars.

Costs will vary depending on your insurance coverage, where you live, and where you get your surgery done.

The long-term success of your vaginoplasty will depend largely on how well you follow the postoperative instructions. Your surgeon will give you a vaginal dilatator to begin using as soon as your bandages are removed. This dilation device must be used daily for at least one year to maintain the desired vaginal depth and girth.

Your surgeon will provide you with a dilation schedule. Typically, it involves inserting the dilator for 10 minutes, three times per day for the first three months and once per day for the next three months. Then, you’ll do it two to three times per week for at least one year. The diameter of the dilator will also increase as the months go by.

Recovery do’s and don’ts

• Don’t take a bath or submerge yourself in water for eight weeks.
• Don’t do strenuous activity for six weeks.
• Don’t swim or ride a bike for three months.
• Showering is fine after your first postoperative visit.
• Do sit on a donut ring for comfort.
• Don’t have sexual intercourse for three months.
• Do apply ice for 20 minutes every hour of the first week.
• Don’t worry about swelling.
• Do expect vaginal discharge and bleeding for the first four to eight weeks.
• Do avoid tobacco products for at least one month.
• Be careful of pain medication; take it only as long as absolutely necessary.

How we reviewed this article:

• Buncamper ME,et al. (2015). Aesthetic and functional outcomes of neovaginoplasty usingpenile skin in male‐to‐female transsexuals. DOI: https://doi.org/10.1111/jsm.12914
• Buncamper ME,et al. (2016). Surgical outcome after penile inversion vaginoplasty: A retrospectivestudy of 475 transgender women. DOI: https://doi.org/10.1097/PRS.0000000000002684
• BuncamperME, et al. (2017). Penile inversion vaginoplasty with or without additional full-thicknessskin graft: To graft or not to graft? DOI: https://doi.org/10.1097/PRS.0000000000003108
• HorbachSE, et al. (2015). Outcome of vaginoplasty in male‐to‐female transgenders:A systematic review of surgical techniques. DOI: https://doi.org/10.1111/jsm.12868
• Maleto female price list. (n.d.). http://www.thetransgendercenter.com/index.php/mtf-price-list.html
• Meltzer T. (2016). Vaginoplasty procedures,complications and aftercare. http://transhealth.ucsf.edu/trans?page=guidelines-vaginoplasty
• MTF vaginoplasty:What patients need to know before choosing a technique. (n.d.). http://www.mtfsurgery.net/mtf-vaginoplasty.htm
• Preparing forgender affirmation surgery. (n.d.). http://www.hopkinsmedicine.org/health/articles-and-answers/ask-the-expert/preparing-for-gender-affirmation-surgery-ask-the-experts
• Sigurjonsson H, et al. (2016).Solely penile skin for neovaginal construction in sex reassignment surgery.DOI: http://doi.org/10.1097/GOX.0000000000000761
• What is avaginoplasty? (n.d.). https://www.plasticsurgery.org/cosmetic-procedures/vaginal-rejuvenation/vaginoplasty
• Van der Sluis WM, et al. (2016). Revision vaginoplasty:A comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thicknessskin graft vaginoplasty. DOI: https://doi.org/10.1097/PRS.0000000000002598

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Home » Blog » How does dilation work after Gender Confirmation Surgery?

How does dilation work after Gender Confirmation Surgery?

Both the patient and the surgeon share a key responsibility in achieving the best surgical outcome and maintaining functional vaginal depth following gender confirmation surgery (GCS). During your procedure, your surgeon utilises the penile and scrotal flaps safely to create the maximum depth of the vaginal canal and form the internal lining of the vagina.

As the patient, it is your responsibility to ensure you strictly follow the Vaginal Dilation Schedule to maintain the depth and calibre of your vagina. The stretching effect from vaginal dilation can prevent wound contraction, in addition to providing optimal elasticity of the vaginal walls to accommodate penetration. Without adequate and consistent dilation, the skin inside the vagina will shrink and contract, which may ultimately lead to shortening and/or narrowing of the vaginal canal; this is known as stenosis.

A shortened vaginal canal resulting from contraction inside the vagina is an irreversible process which means you cannot regain your original vaginal depth by resuming or increasing vaginal dilation.

Everything you need to know about Gender Confirmation Surgery

According to our surgeon’s GCS technique, packing will be used to stabilise the skin flaps inside the vagina, which is then removed at approximately 5 days post-operation. When the vaginal pack is removed, a speculum is inserted into the vagina to examine the healing of the skin flaps.

Following this, your first vaginal dilation will be demonstrated by your surgeon or a senior member of the clinical team. Your vaginal depth will be confirmed by the measurement scale on the dilator shaft; this is measured at the point of the vaginal opening.

You will be provided with a set of vaginal dilators prior to your discharge from the hospital. These dilators will vary in diameter and you will be advised by your surgeon or a senior member of the clinical team which sized dilators to use during your vaginal dilation. It is recommended that you continue with daily vaginal dilation up to 3 months following your GCS. After 3 months, once a week or alternative weeks as required is acceptable. Once vaginal intercourse is commenced, you may only need to dilate once a month as necessary.

Dilation essentials

Wash your hands and dilators both before and after vaginal dilation using warm water and mild soap. The use of water-based lubricating jelly is mandatory for the first year following your surgery to prevent tearing of the delicate skin inside the vagina. Prior to commencing dilation, plenty of lubricating jelly must be applied to the tip and shaft of the dilator, as well as the vaginal opening to ease insertion. Please re-apply more lubricating jelly during dilation if necessary.

Lie on your back in a semi-recumbent and comfortable position with your knees slightly bent. Position the lubricated dilator against the vaginal opening. Slowly push the dilator at an angle toward your lower back or tailbone until it occupies the full depth of your vagina. Whilst inserting the dilator, slow and gentle rotation can help expand the vaginal opening.

Gentle and constant pressure is required in order to sufficiently stretch the skin and maintain vaginal depth. You should frequently check the measurement scale on the shaft of the dilator to ensure you are maintaining depth with at least the smallest size dilator supplied. You must not attempt to push or force the vaginal dilator against the end of your vaginal canal to increase existing depth; this can result in tearing of the vaginal wall, bleeding, or a vaginal fistula.

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ORIGINAL RESEARCH article

Male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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14. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol. (2018) 199:760–5. doi: 10.1016/j.juro.2017.10.013

15. Dy GW, Sun J, Granieri MA, Zhao LC. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. (2018) 19:36. doi: 10.1007/s11934-018-0795-y

16. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. (2013) 64:141–9. doi: 10.1016/j.eururo.2012.12.030

17. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med . (2015) 12:1499–512. doi: 10.1111/jsm.12868

18. Hadj-Moussa M, Ohl DA, Kuzon WM. Feminizing genital gender-confirmation surgery. Sex Med Rev. (2018) 6:457–68.e2. doi: 10.1016/j.sxmr.2017.11.005

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22. Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol . (2010) 72:214–31. doi: 10.1111/j.1365-2265.2009.03625.x

23. Castellano E, Crespi C, Dell'Aquila C, Rosato R, Catalano C, Mineccia V, et al. Quality of life and hormones after sex reassignment surgery. J Endocrinol Invest . (2015) 38:1373–81. doi: 10.1007/s40618-015-0398-0

24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Hours of operation, vaginoplasty.

Learn more about gender affirmation surgery:

Interested in this surgery?

Please complete the following surgical interest form and submit it to our LGBTQ+ Services team.

Surgical Interest Form

Overview of Vaginoplasty

Vaginoplasty is a gender-affirming, feminizing, lower surgery to create a vagina* and vulva (including mons, labia, clitoris, and urethral opening) and remove the penis, scrotal sac and testes.

What is the procedure for vaginoplasty?

• The scrotum and testes are removed.
• The glans is made into a clitoris.
• Space for the vagina is dissected between the bladder and the rectum.
• Skin from the shaft of the penis* is inverted to create the inner walls of your vagina.
• Extra skin may be taken from the scrotum* to line your vagina. The hair roots on the skin graft will be cauterized.
• The urethra is shortened.
• Vulva are created using scrotal and urethral tissue.
• A temporary urinary catheter is inserted into the bladder.
• A temporary prosthesis/stent is inserted in the vagina.

Do I need to have hair removal before vaginoplasty ?

Hair removal is highly encouraged and recommended prior to penile inversion vaginoplasty (full depth vaginoplasty). The scrotal skin will be used to make the neo vagina. If you do not do hair removal, there will be hair inside the vagina. This can make post operative care more difficult and place you at increased risk for post op infection. The surgeon will not do any hair removal during the surgical procedure. Ask an LGBTQ+ Patient Advocate about resources for hair removal.

** Hair removal is not required for minimal depth vaginoplasty.

Do I need to stop taking hormones before vaginoplasty?

Your surgeon will discuss this with you at your pre-visit.

How long will my hospital stay be?

You will be admitted to the hospital for 3 days following your surgery.

What medications will I be prescribed after surgery?

You will likely receive painkillers and antibiotics to prevent infection. Your surgeon will provide you with a list of medications to avoid for the first month. Do not resume taking hormones until your surgeon has advised you to do so.

What should I expect during the healing process?

• Bleeding during the first 48 hours following surgery
• Itchiness and small shooting electrical sensations as nerve endings heal
• Bruising can spread from your belly to your thighs and takes 3-4 weeks to settle down
• A bit of spraying when you urinate which usually improves over time
• Swelling of your labia which can take up to 6 weeks to resolve
• Brown/yellow vaginal discharge for the first 6-8 weeks
• Your vulva will approach its final appearance at 4 months
• Numbness that will improve over the first few months, and can take up to 18 months to resolve
• Red, dark pink or purple scars that take up to one year to fade

What will my post-operative routine look like?

A urinary catheter will be in place for the first five days after surgery to allow you to pass urine while your urethra heals. Sometimes people still aren’t able to urinate when the catheter comes out, due to swelling around the urethra. This situation can easily be resolved with a second catheter that will remain in place for a week and be removed by your physician when you go home. You’ll be encouraged to drink lots of fluids to prevent urinary tract infections.

A prosthesis/stent will be placed in your vagina during surgery and will remain there for 5 days to make sure the skin grafts stay in place. When it’s removed, you will begin dilating and douching. A vaginal douche is a process of rinsing the vagina by forcing water or another solution into the vagina to flush away vaginal discharge or other contents. You will be given a set of vaginal dilators of different sizes. You’ll use them to maintain vaginal depth and width and promote healing.

Initially, you’ll dilate several times a day and over the first year the amount of time spent dilating will be gradually reduced. After you have completely healed, you will only need to dilate about once a week. The frequency depends on how much penetrative sex you have. For the first two months after surgery, you will take sitz baths. A sitz bath is a way to soak your surgical site to keep it clean. You’ll want to wear thin maxi pads for about one month to manage post-operative bleeding and discharge.

What check-ups will be needed after my hospital stay?

The number of check-ups needed varies from person to person. If possible, see your primary care provider about a week after and then every 2-4 weeks for the first few months. When you visit your surgeon or primary care provider, they should check your surgical sites to make sure there are no infections or wound healing problems. They will ask questions about dilating, bleeding, vaginal discharge, fever, pain and how you are feeling emotionally and physically.

How long will it take for me to get back to my usual activities?

Recovery time varies from person to person, so always follow the advice of your surgeon. Many people begin to feel more comfortable during the second week after their surgery. You’ll need plenty of rest in the first two weeks. It’s common to be back to your usual activities, including work, in six to eight weeks. Some activities, such as driving, heavy lifting, exercise, sex and soaking in hot tubs, may be restricted in the post-operative period. Your surgeon will give you advice about when it is okay to resume these activities. Complete recovery can take up to one year.

What complications are associated with vaginoplasty?

All surgical procedures involve some risks, including negative reactions to anesthesia, blood loss, blood clots and infection. These complications can, in extreme cases, result in death. It’s important to discuss these risks in detail with your surgeon. Your surgical care team will take a wide variety of steps to prevent these problems, detect them if they arise and respond to them appropriately.

They will also inform you about what you can do to minimize your risks. The list below includes some of the complications associated with vaginoplasty in particular. It does not replace a thorough consultation with your surgeon.

This is when blood collects in the surgical site, causing pain, swelling and redness. Smaller hematomas can be drained, but larger ones require removal through surgery.

Abscess Formation

An abscess is a collection of pus. It’s caused by a bacterial infection. It can be treated with antibiotics or drained by the surgeon.

This is when clear fluid accumulates in the surgical site. Small seromas may need to be aspirated, or sucked out, once or more by the surgeon.

Loss of Sensation

You may have small areas of numbness. Your ability to achieve orgasm could decrease. Loss of clitoris is a remote possibility.

Rectovaginal fistula

This is when an abnormal path between the rectum and vagina is created. Surgery would be needed to correct this.

May be correctable with various treatments, including additional surgery.

Injury to the Nerves or Muscles in the Legs

Can lead to numbness or a change of sensation in the skin of the legs. In very rare cases, it can lead to difficulty moving the leg which needs correction through surgery.

Unsatisfactory Size or Shape of the Vagina, Clitoris or Labia

Outcomes that are quite different from what was expected may require surgical revision.

Urological Complications

Examples include:

• fistulas (flow of urine to areas other than urethra opening)
• stenosis (narrowing of the urethra, causing difficulties urinating)
• strictures (blockage of the urethra, causing difficulty urinating).

It is common to have spraying or dribbling when urinating until your swelling settles down. If these problems don’t resolve on their own, they may require additional surgery.

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September 04, 2019 | Caroline Knight

Why Using Dilators is Important After Gender Confirmation Surgery

Today, more people than ever are unhappy with their gender and choose to opt for gender confirmation surgery. Although this is not a decision to be taken lightly, it’s becoming increasingly common. You might also have heard gender confirmation surgery referred to as sex reassignment surgery or genital reassignment surgery; when a man changes to female gender (MtF), the operation is called vaginoplasty.

As you might imagine, vaginoplasty is an incredibly complex operation that requires a great deal of aftercare to ensure long-term success. Anyone who is considering gender confirmation surgery should be aware of the aftercare implications, and we’re here to help with that. One of the most important aspects is the use of vaginal dilators , which we’ll also cover in this article.

Post-operative care for gender confirmation surgery

After MtF gender confirmation surgery (vaginoplasty), each person takes a variable amount of time to recover. It is normal to experience some soreness and swelling, and believe it or not, a ‘neo vagina’ is also susceptible to yeast infections and urinary tract infections… so consistent care is needed to prevent these.

After gender confirmation surgery, it is normal for either gauze packing or a stenting device to be placed inside the neo vagina, to be kept in place for up to a week afterward. After this is removed, it is time to start using vaginal dilators . Vaginal dilation is incredibly important after vaginoplasty, but different surgeons will recommend different protocols. Below we’ll offer a common guideline for transgender dilation.

Why are dilators important after gender confirmation surgery?

Post gender confirmation surgery, your body is likely to register your vagina as a wound, and therefore try to heal it. This would result in some shrinkage at the very least – if not total closure and/or development of scar tissue. For this reason, transgender dilation therapy is crucial; it can prevent all of these possibilities from happening.

You will want to maintain the depth and width of your new vagina, so your surgeon is likely to recommend using dilators a few days after surgery is complete. From this point, you will need to keep using the vaginal dilators ongoing - but less often as time goes on, of course.

Guidelines for using a dilator after vaginoplasty

Your surgeon should have the final say on this, so do check with them before starting dilation therapy. Also ensure that you are using the right sized dilators, according to your surgeon’s recommendation.

• Clean your dilator with warm soapy water, then rinse and dry it (the same goes after each use!)
• Use a water-based lubricant to coat the dilator before insertion
• Gently insert your dilator at a 45 degree angle; when it is under the pubic bone, continue insertion in a straight direction
• Once you have inserted it fully and are experiencing some resistance, leave the dilator in place for ten minutes
• Dilate three times each day for a period of three months, as soon as the gauze has been removed
• After three months, stat using a larger dilator for a further three months
• At between three and six months, use the dilator once per day for ten minutes
• After six months, use it two or three times per week for ten minutes
• After nine months, use it once or twice per week

Note that if your neo vagina seems tight at any point, you can increase the frequency of dilation. It’s also important to stop dilator therapy if you are experiencing excessive resistance, pain or tenderness – a little is normal, a lot is not.

A final word on genital reassignment surgery

We thought you might be interested in this helpful tip for resuming sexual intercourse: you may find the Ohnut ring useful, since this intimate wearable helps your partner to control the depth of penetration. Using an Ohnut ring means you’re less likely to feel any pain, and your partner will barely notice it.

The bottom line is that gender confirmation surgery requires regular self-care, so you’ll need to be disciplined with your dilator use. VuvaTech stock a range of vaginal dilators and we’re always happy to help, so feel free to ask if you have any questions!

Other VuVa Helpful Links:

7 Reasons for a Tight Vagina and How to Loosen 

How to use Vaginal Dilators 

How to Relax Vaginal Muscles, Vaginismus & Sex 

Vaginal Stretching - Keeping in Shape with Dilators 

Do Dilators Really Work? Yes, and They can Improve Your Sex Life!

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• Review Article
• Published: 24 September 2021

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review

• Luca Ongaro   ORCID: orcid.org/0000-0001-5649-4095 1 ,
• Giulio Garaffa   ORCID: orcid.org/0000-0001-9834-5098 2 ,
• Francesca Migliozzi 1 ,
• Michele Rizzo 1 ,
• Fabio Traunero 1 ,
• Marco Falcone 3 ,
• Stefano Bucci 1 ,
• Tommaso Cai   ORCID: orcid.org/0000-0002-7234-3526 4 ,
• Alessandro Palmieri 5 ,
• Carlo Trombetta 1 &
• Giovanni Liguori   ORCID: orcid.org/0000-0003-2431-5296 1  

International Journal of Impotence Research volume  33 ,  pages 726–732 ( 2021 ) Cite this article

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• Quality of life
• Translational research

Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the “Y” shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9–13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien–Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.

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Luca Ongaro, Francesca Migliozzi, Michele Rizzo, Fabio Traunero, Stefano Bucci, Carlo Trombetta & Giovanni Liguori

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Ongaro, L., Garaffa, G., Migliozzi, F. et al. Vaginoplasty in Male to Female transgenders: single center experience and a narrative review. Int J Impot Res 33 , 726–732 (2021). https://doi.org/10.1038/s41443-021-00470-3

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Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results

Gabriel veber moisés da silva.

1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

Maria Inês Rodrigues Lobato

2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

Dhiordan Cardoso Silva

Karine schwarz, anna martha vaitses fontanari, angelo brandelli costa.

3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Patric Machado Tavares

Antonio rebello horta gorgen, renan desimon cabral, tiago elias rosito, associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

The initial circumferential subcoronal incision.

The de-gloved penis being passed through the scrotal opening.

The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

The inverted penile skin flap.

The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Patient demographics.

HIV, human immunodeficiency virus .

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Gender Affirmation Surgery

Gender affirmation surgery refers to procedures that help people transition to their gender. Gender-affirming options may include facial surgery, top surgery or bottom surgery. Most people who choose gender affirmation surgeries report satisfaction with results, including the way their body looks and works and improved quality of life.

What is gender affirmation surgery?

Gender affirmation surgery includes several procedures that may help your body better align with your gender identity. Unlike sex assigned at birth (either male or female), gender identity is the way you understand your body and present yourself to others.

Gender affirmation surgery may be an option if your sex assigned at birth differs from your gender identity (gender incongruence). It may help if you experience psychological distress because of gender incongruence ( gender dysphoria ).

Why is gender affirmation surgery done?

Gender affirmation surgery may be a part of transitioning, or “coming out” to others (and yourself) if you’re transgender , nonbinary or gender diverse. Surgeries exist that:

• Enhance or lessen physical characteristics associated with being assigned male at birth (AMAB).
• Enhance or lessen physical characteristics associated with being assigned female at birth (AFAB).
• Change the way your genitals look.

Surgery is just one possible way to transition.

Nonsurgical gender-affirming options

There are nonsurgical gender-affirming medical options, too, including:

• Feminizing hormone therapy : Increases feminine characteristics, such as bigger breasts, rounded hips and a higher voice.
• Masculinizing hormone therapy : Increases masculine characteristics, such as facial hair, muscle mass and a lower voice.
• Puberty blockers : Delay the development of secondary sex characteristics that develop during puberty . Examples include changes in facial structure, breast growth and facial hair.
• Voice therapy : Teaches speaking and communication skills that allow you to express your gender.
• Laser hair removal : For removing facial or body hair.

Not every trans or gender-diverse person’s journey involves medical transitioning. Expressing your gender identity may also (or only) involve nonmedical changes, like:

• Choosing a new name.
• Using different pronouns (she/her, he/him, they/them, etc.).
• Changing your style (hairstyle, clothing, makeup, etc.).

What are the types of gender affirmation surgery?

Surgery types include:

• Facial reconstructive surgery to make facial features more masculine or feminine.
• Vocal surgery to change your voice pitch.
• Chest or “top” surgery to remove breast tissue for a more masculine appearance or enhance breast size and shape for a more feminine appearance.
• Genital or “bottom” surgery to transform and reconstruct your genitals.

Examples of gender-affirming surgery for people AFAB, such as for transgender men and transmasculine nonbinary people, include:

• Facial masculinization surgery : Reshapes the bones and tissues in your face to produce features such as a wider forehead, angular cheeks, a more pronounced jawline and an Adam’s apple .
• Masculinizing top surgery : Removes breast tissue to create a natural-looking flat (or flatter) chest.
• Hysterectomy : Removes the uterus . It may happen alongside surgery to remove your ovaries ( oophorectomy ).
• Vaginectomy : Removes the vagina . This may be an option if you don’t desire bottom surgery, like metoidioplasty or phalloplasty. These procedures often involve using vaginal tissue to reconstruct your genitals.
• Metoidioplasty : Uses the clitoris to form a penis. Before surgery, you’ll take testosterone to enlarge the clitoris to the size of a micropenis (a penis that’s less than about 2.57 inches long). This procedure usually happens alongside scrotoplasty.
• Phalloplasty : Uses a flap of skin from another part of your body to form an average-sized penis (about 5 to 6 inches). It usually happens alongside scrotoplasty.
• Scrotoplasty : Reshapes part of the labia majora (outer lips of the vulva ) into a scrotum. Once you heal, you may choose to get silicone gel or saline implants that look and feel like testicles ( testicular prosthesis ).

Examples of gender-affirming surgery for people AMAB, such as transgender women and transfeminine nonbinary people, include:

• Facial feminization surgery : Reshapes the bones and tissues in your face to produce features such as a lower hairline, fuller cheeks, rounded jaw and smaller Adam’s apple.
• Feminizing top surgery : Adds saline or silicone implants (and sometimes fat tissue from elsewhere on your body) under your breast tissue to create rounded, fuller breasts.
• Orchiectomy : Removes the testicles. No longer having testicles reduces how much testosterone your body produces. This means you may need less feminizing hormone therapy. It may happen alongside surgery to remove the scrotum (scrotectomy).
• Penectomy : Removes the penis. This may be an option if you don’t want to preserve the tissue for feminizing surgeries, such as vaginoplasty or vulvoplasty.
• Vaginoplasty : Uses penile tissue and other genitalia to form a vaginal canal. Surgery may also involve constructing labia ( labiaplasty ) and a clitoris ( clitoroplasty ).
• Vulvoplasty : Constructs the parts of a vulva (including the mons, labia and clitoris) but not a vagina.

How common is gender affirmation surgery?

Approximately 25% to 35% of trans and nonbinary people in the United States receive gender affirmation surgery. According to a 2023 study, the most common surgeries are top surgeries, followed by bottom surgeries and facial reconstruction surgeries.

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Procedure Details

How should i prepare for gender affirmation surgery.

You’ll work with healthcare providers to ensure you meet the criteria for gender-affirming surgery, according to the World Professional Association for Transgender Health (WPATH) standards of care. This organization promotes evidence-based care for transgender and gender-diverse people.

Many insurance companies require you to submit documentation related to WPATH criteria before they cover surgery costs.

Criteria include:

• Providing informed consent . You’ll need to demonstrate that you understand what’s involved. This includes what happens during surgery and how it’ll affect your life. These effects extend to your desire to have biological children. Many surgeries cause temporary or permanent infertility . Your provider will explain fertility preservation options , like freezing your eggs or sperm.
• A history of gender incongruence . You may need to produce health records demonstrating a history of gender incongruence (usually a year or more).
• A mental health evaluation . You may need a letter of support from a qualified mental health provider (therapist, psychiatrist or social worker ). They’ll work with you to determine the safest and healthiest options for embodying your gender. If you have gender dysphoria, they can help diagnose and treat related conditions, like anxiety and depression .
• Hormone therapy . In some cases, you may need to be on hormone therapy before surgery. Depending on the procedure and desired outcomes, hormones can cause changes in your body that make surgery more effective.

To prepare for the procedure, your provider will review your medical history to ensure you’re in good physical health. They may perform various tests, including:

• A physical exam .
• Blood tests .
• Imaging tests.

What happens during gender affirmation surgery?

Your healthcare provider will walk you through what’ll happen during surgery. For many people, gender affirmation surgery is a combination of procedures. For example, you may have both an orchiectomy and a vaginoplasty, a hysterectomy and a phalloplasty, etc.

Regardless of the procedure, your surgeon will administer anesthesia so you don’t feel any pain. Depending on the surgery, your surgeon will:

• Remove or restructure organs or tissue.
• Construct new structures out of existing tissue.
• Insert implants or tissue grafts.

They may also place drains to remove fluid from wounds or a Foley catheter to help you pee.

Reach out to your provider if you have any questions about the specifics.

How long does gender-affirming surgery take?

Some procedures take place in a single day, while others require several surgeries spread out over time. For example, top surgery usually takes one day. But a phalloplasty is usually spread out over several surgeries.

Even if surgery only takes a day, you may need to return to your provider for additional changes (revision surgery) depending on how satisfied you are with the results. Choosing a healthcare provider with extensive experience performing a particular surgery will reduce the likelihood you’ll need a revision.

It’s essential to talk to your healthcare provider beforehand so you understand:

• How many surgeries you’ll need.
• How long (approximately) each surgery will last.
• When you should expect to see full results.

What types of healthcare providers make up a gender affirmation surgery team?

The following healthcare providers may make up your gender affirmation surgery team:

• Urologist .
• Gynecologist .
• Plastic surgeon .
• Otolaryngologist .
• Anesthesiologist .
• Speech-language pathologist (SLP).
• Physical/occupational therapists.
• Nurses, nurse practitioners, physician assistants.
• Trainees (residents and fellows).

What happens after gender affirmation surgery?

You’ll need to take extra care of yourself as you heal. This may mean asking friends or family to help during recovery. After surgery, you’ll need to:

• Care for wounds, catheters and drains . Follow your healthcare provider’s guidance on how to wash your wounds and monitor for infection. Make sure you understand how to care for catheters and drains if you have them.
• Wear compression garments . You may need to wear compression bandages or garments to reduce swelling, so wounds heal faster.
• Take medicines as prescribed . This includes reaching out to your healthcare provider if you need help managing pain.
• Avoid reaching or straining . Before surgery, rearrange your living space so you don’t have to strain to reach objects you need. This can prevent injuries once you return home.
• Monitor your eating patterns . Discuss nutritious food options that will facilitate healing with your healthcare provider.
• Adjust your routine . For example, you may need to stick with sponge baths for a while and limit exercise. You may need to avoid certain sexual activities until you’ve healed completely. Follow your provider’s instructions.

Risks / Benefits

What are the benefits of gender affirmation surgery.

Gender affirmation surgery may help in those areas where your gender feels out of sync with your body. Surgery can enable you to become more satisfied with your:

• Appearance , including changes in the way your face, chest or genitals look.
• Gender expression , including how you look, sound and do routine things (like peeing standing up or sitting down).
• Sexual function , including engaging in sexual activities in ways that align with your gender.

What are the risks or complications of gender affirmation surgery?

Different procedures carry different risks. For example, individuals who have bottom surgery may have changes to their sexual sensation or trouble with bladder emptying. In general, significant complications are rare, as long as an experienced surgeon performs the procedure.

With any surgery, there’s a small risk of complications, including:

• Side effects of anesthesia .

Recovery and Outlook

What is the recovery time.

Recovery times vary based on what procedures or combination of procedures you have:

• Cheek and nose surgery : Swelling lasts for around two to four weeks.
• Chin and jaw surgery : Most swelling fades within two weeks. It may take up to four months for swelling to disappear.
• Chest surgery : Swelling and soreness last for one to two weeks. You’ll need to avoid vigorous activity for at least one month.
• Bottom surgery : Most people don’t resume usual activities until at least six weeks after surgery. You’ll need weekly follow-up visits with your healthcare provider for a few months. These visits ensure you’re healing well.

After surgery, it’s a good idea to continue seeing a mental health professional with a background in transgender care. They can support you as you adjust to life after surgery.

What is the outlook for people who have gender affirmation surgery?

Research consistently shows that people who choose gender affirmation surgery experience reduced gender incongruence and improved quality of life. Depending on the procedure, 94% to 100% of people report satisfaction with their surgery results.

Gender-affirming surgery provides long-term mental health benefits, too. Studies consistently show that gender affirmation surgery reduces gender dysphoria and related conditions, like anxiety and depression.

What is the regret rate for gender-affirming surgery?

Very few people who have gender-affirming surgery regret their decision. Research tracking the outcomes following gender affirmation surgeries shows that among people who opt for gender-affirming surgery, only 1% regret having the procedure.

When To Call the Doctor

When should i see my healthcare provider.

Attend all follow-up visits to ensure you’re healing. Reach out to your provider if you notice signs of a complication, including:

• Bleeding for more than a few days after surgery.
• Pain that doesn’t go away after several weeks or intense pain.
• Signs of infection, such as a wound that changes color or doesn’t heal.

Also, talk to your surgeon about routine aftercare. Depending on your anatomy, you may need regular visits with a gynecologist or a urologist. You may need routine checks for conditions like breast cancer , cervical cancer or prostate cancer . It’s essential to understand how surgery affects your care plan moving forward.

Additional Common Questions

What’s the difference between gender affirmation surgery and gender (sex) reassignment surgery.

Gender reassignment is an outdated term for gender affirmation surgery. The new language, “gender affirmation,” is more accurate in terms of what the surgery does (and doesn’t) do. No surgery can reassign your gender — who you know yourself to be. Instead, gender-affirming surgery changes your physical body so that it better aligns with how you understand (and wish to express) your gender.

A note from Cleveland Clinic

All gender-affirming surgeries are major procedures. There are several steps involved and healthcare providers you’ll likely meet with, including your primary care provider, a mental health specialist and a surgeon. Assembling the right care team makes all the difference when it comes to your surgery results and your care experience.

Research the providers you choose carefully. Pick a mental health professional with expertise in treating transgender and gender-diverse people. Find a surgeon with several years of experience performing the surgery you want. Ask about their track record of achieving positive results. This may be one of the most important procedures of your life. Choose a team that can deliver the best possible care.

Last reviewed on 12/13/2023.

Learn more about our editorial process .

The Role of Dilators in Penile Inversion Vaginoplasty

The role of dilators for gender reassignment surgery (grs).

It's essential to recognize that undergoing gender confirmation surgery (also known as sex reassignment surgery or genital reassignment surgery) to change your physical sex as an adult is an immensely significant choice in ones life. This path requires a profound reservoir of inner strength to embrace your true self. We extend our warmest congratulations and celebration, regardless of where you currently stand on this transformative journey.

Penile inversion vaginoplasty is a gender-affirming surgical (GRS) procedure that transforms the genital anatomy of transgender women, creating a neovagina from existing penile and scrotal tissues. This complex and life-changing surgery offers individuals an opportunity to align their external appearance with their internal gender identity. 

As a crucial part of the post-operative care and healing process, dilators play a significant role in maintaining the success of the procedure. We will dive into the importance of dilators in penile inversion vaginoplasty, their proper usage, and the impact they have on patients' lives.

Understanding Penile Inversion Vaginoplasty

Penile inversion vaginoplasty is a surgical technique that involves using penile and scrotal tissues to create the neovaginal canal. The procedure includes removing the testes, penile skin inversion, and shaping the neoclitoris. The result is a neovagina that is aesthetically and functionally similar to cisgender female genitalia.

Vaginal Dilation after Penile Inversion Vaginoplasty

Vaginal dilation plays a crucial role in your healing journey following vaginoplasty. These dilations are essential for maintaining the openness of the vaginal canal and preventing a condition called vaginal stenosis, which involves the scarring and narrowing of the vaginal walls. After the procedure, the newly formed vagina has a tendency to undergo closure due to the body's natural response to healing, which involves scarring. However, in this context, this healing process can be counterproductive to your desired outcome.

Typically, individuals undergoing male-to-female (MtF) gender confirmation surgery initiate vaginal dilation within a few days post-surgery and often maintain the practice to varying extents throughout their lifetime.

Your surgeon will provide you with guidance on the proper and safe utilization of vaginal dilators, including selecting an appropriate size and establishing a recommended frequency for post-operative vaginal dilation to uphold the health of your neo vagina. In the event that this information is not shared, it's important to proactively seek clarification and ask for these essential details. 

Following your gender confirmation surgery (GCS), it is advisable to maintain a routine of daily vaginal dilation for up to three months. Subsequently, transitioning to a schedule of once a week or every other week, based on your individual needs, is considered appropriate. As you initiate vaginal intercourse, your dilation frequency may further decrease, potentially requiring only a monthly session as needed.

Are you interested in acquiring premium-quality Gender Reassignment Surgery (GRS)  dilators?

Urology Health Store Canada has Canada's best selection of medical dilators. UHS's selection of vaginal dilators gives the patient or user the choice between materials, shapes and sizes. They all have been skillfully crafted by a pelvic floor health physical therapists to ensure they are of medical quality and also allow you to have a secure experience during dilator therapy for your neo-vagina.  Urology Health Store offers dilators from popular brands like Medintim (Vagiwell), Intimate rose and VuVaTech. 

The Vagiwell® 6 by Medintim has been specifically designed to be used following MTF gender confirmation surgery.

Purchase GRS Dilator 

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QUINN JACKSON, MD, MPH, NICOLE T. YEDLINSKY, MD, AND MEREDITH GRAY, MD

Am Fam Physician. 2024;109(6):560-565

Published online May 14, 2024.

Author disclosure: No relevant financial relationships.

Gender-affirming surgery includes a range of procedures that help align a transgender or gender diverse person's body with their gender identity. As rates of gender-affirming surgery increase, family physicians will need to have the knowledge and skills to provide lifelong health care to this population. Physicians should conduct an anatomic survey or organ inventory with patients to determine what health screenings are applicable. Health care maintenance should follow accepted guidelines for the body parts that are present. Patients do not require routine breast cancer screening after mastectomy; however, because there is residual breast tissue, symptoms of breast cancer warrant workup. After masculinizing genital surgery, patients should have lifelong follow-up with a urologist familiar with gender-affirming surgery. If a prostate examination is indicated after vaginoplasty, it should be performed vaginally. If a pelvic examination is indicated after vaginoplasty, it should be performed with a Pederson speculum or anoscope. After gonadectomy, patients require hormone therapy to prevent long-term morbidity associated with hypogonadism, including osteoporosis. The risk of sexually transmitted infections may change after genital surgery depending on the tissue used for the procedure. Patients should be offered the same testing and treatment for sexually transmitted infections as cisgender populations, with site-specific testing based on sexual history. If bowel tissue is used in vaginoplasty, vaginal bleeding may be caused by adenocarcinoma or inflammatory bowel disease. ( Am Fam Physician . 2024;109(6):560-565. Copyright © 2024 American Academy of Family Physicians.)

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Gentle, safe, discreet care for postsurgery and beyond

We don’t need to tell you that changing your physical sex as an adult by undergoing gender confirmation surgery (aka sex reassignment surgery or genital reassignment surgery) is a huge decision. It takes genuine inner strength to become who you are and we want to congratulate and celebrate you, wherever you are on your journey. If you’re preparing to take the last step to transition from male to female (MtF) with gender confirmation surgery, The Pelvic Hub can help you take care for yourself after surgery, and help you maintain your neo vagina in the long term.

Written by Emma McGeorge

Related Conditions

Want to learn more about related conditions? Follow the links below to gain a better understanding of the symptoms and treatments.

After Your SRS Surgery

Each person’s experience of MtF gender confirmation surgery— and the recovery that follows— is different. Everyone heals at a different pace. As with any surgery, it’s normal to have symptoms like swelling and soreness.

Vaginas are complex things, and generally higher maintenance than penises. Your neo vagina may be susceptible to yeast infections and urinary tract infections, just like a natal vagina is.

Dilation Therapy for Transgender Patients

After surgery, it’s normal for your body to register your neo vagina as a wound. And similar to with a new piercing, your body will try to heal. Because of this, your neo vagina may start to shrink or develop scar tissue called granulation.

Dilation therapy is an absolute must to keep your neo vagina functional, to minimize scars from forming in your vaginal lining, and to prevent you from losing vaginal depth and width. Usually, MtF transgender patients start using vaginal dilation a few days after surgery and continue to use vaginal dilators, to some degree, for the rest of their lives.

Your surgeon will let you know how to safely use a vaginal dilators, what size to use, and how often you need to employ post-operative vaginal dilation to maintain your neo vagina. If they don’t, you should definitely ask.

Recommended Products for Post-Op Care

We love that these products can help you take care of yourself discreetly from home. However,  we always recommend that you check with your surgeon or physician before using any products on your neo vagina or inside your vaginal opening.

Natural cooling relief

Reusable   perineal cooling pads   are perfect for cooling the most sensitive and delicate area of your body. Comfortable, cooling and discreet, they are perfect for reducing pain and swelling post-surgery. Also great if you’re prone to yeast infections or urinary tract infections.

Comfortable sitting

You may need a little help sitting without pain in the first few weeks after surgery. A foldable travel pelvic cushion or deluxe foldable travel pelvic cushion are uniquely designed to take the pressure off your neo vagina, helping you sit a little more comfortably.

Gentle, worry-free sex

Using an intimate wearable that allows you to control the depth of penetration into your neo vagina during sex can help you manage any pain you may experience during sexual intercourse. The   Ohnut   is designed to not just comfortably accommodate penetrative sex but also to feel just like skin. It’s so comfortable (like a gentle hug) you and your partner will barely notice it’s there. And because you no longer have to worry about whether penetration will hurt, this wearable allows both you and your partner to focus on what matters most, connection, enjoyment, and fun.

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They can also be chilled to help with post-surgical swelling, or used at room temperature. Always check with your surgeon or physician before using any dilator in your neo vagina to make sure you have the size, technique and frequency that is safe for your body, as dilation involves inserting into your neo vaginal canal for maintaining vaginal depth. Your doctor can recommend a dilation regimen that will provide you the most support during the healing process and beyond.

Invest in your health and yourself

Gender confirmation surgery is a big investment, and it doesn’t end when you leave the hospital. It’s  important to take gentle care of yourself after surgery and in the long term.

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What Is Gender Affirmation Surgery?

Surgery to change the appearance of your body is a common choice for all kinds of people. There are many reasons that people might want to alter their appearance. For transgender or gender nonconforming people, making changes to their bodies is a way of affirming their identity.

A trans person can choose from multiple procedures to make their appearance match their self-identified gender identity. Doctors refer to this as gender "affirmation" surgery.

Trans people might decide to have surgery on their chest, genitals, or face. These surgeries are personal decisions, and each person makes their own choices about what is right for them.

Learn more about gender affirmation surgery and how it helps trans people.

What Does It Mean to Be Transgender or Nonbinary?

Transgender is a word to describe people whose gender identity or gender expression doesn't match the sex they were assigned at birth. Typically, parents and doctors assume a baby's gender based on the appearance of their genitals. But some people grow up and realize that their sense of who they are isn't aligned with how their bodies look. These people are considered transgender.

Trans people may identify as a different gender than what they were assigned at birth. For example, a child assigned male at birth may identify as female. Nonbinary people don't identify as either male or female. They may refer to themselves as "nonbinary" or "genderqueer."

There are many options for trans and nonbinary people to change their appearance so that how they look reflects who they are inside. Many trans people use clothing, hairstyles, or makeup to present a particular look. Some use hormone therapy to refine their secondary sex characteristics. Some people choose surgery that can change their bodies and faces permanently.

Facial Surgery

Facial plastic surgery is popular and accessible for all kinds of people in the U.S. It is not uncommon to have a nose job or a facelift . Cosmetic surgery is great for improving self-esteem and making people feel more like themselves. Trans people can use plastic surgery to adjust the shape of their faces to better reflect their gender identity.

Facial feminization. A person with a masculine face can have surgeries to make their face and neck look more feminine. These can be done in one procedure or through multiple operations. They might ask for:

• Forehead contouring
• Jaw reduction
• Chin surgery
• Hairline advancement
• Cheek augmentation
• Rhinoplasty
• Lip augmentation
• Adam's apple reduction

Facial masculinization. Someone with a feminine face can have surgery to make their face look more masculine. The doctor may do all the procedures at one time or plan multiple surgeries. Doctors usually offer:

• Forehead lengthening
• Jaw reshaping
• Chin contouring
• Adam's apple enhancement

Top Surgery

Breast surgeries are very common in America. The shorthand for breast surgeries is "top surgery." All kinds of people have operations on their breasts , and there are a lot of doctors who can do them. The surgeries that trans people have to change their chests are very similar to typical breast enhancement or breast removal operations.

Transfeminine. When a trans person wants a more feminine bustline, that's called transfeminine top surgery. It involves placing breast implants in a person's chest. It's the same operation that a doctor might do to enlarge someone's breasts or for breast reconstruction .

Transmasculine. Transmasculine top surgery is when a person wants a more masculine chest shape. It is similar to a mastectomy . The doctor removes the breast tissue to flatten the whole chest. The doctor can also contour the skin and reposition the nipples to look more like a typical man's chest.

Bottom Surgery

For people who want to change their genitals, some operations can do that. That is sometimes called bottom surgery. Those are complicated procedures that require doctors with a lot of experience with trans surgeries.

Transmasculine bottom surgery. Some transmasculine people want to remove their uterus and ovaries. They can choose to have a hysterectomy to do that. This reduces the level of female hormones in their bodies and stops their menstrual cycles.

If a person wants to change their external genitals, they can ask for surgery to alter the vaginal opening. A surgeon can also construct a penis for them. There are several techniques for doing this.

Metoidioplasty uses the clitoris and surrounding skin to create a phallus that can become erect and pass urine. A phalloplasty requires grafting skin from another part of the body into the genital region to create a phallus. People can also have surgery to make a scrotum with implants that mimic testicles. ‌

Transfeminine bottom surgery. People who want to reduce the level of male hormones in their bodies may choose to have their testicles removed. This is called an orchiectomy and can be done as an outpatient operation.

Vaginoplasty is an operation to construct a vagina . Doctors use the tissue from the penis and invert it into a person's pelvic area. The follow-up after a vaginoplasty involves using dilators to prevent the new vaginal opening from closing back up.

How Much Does Gender Affirmation Surgery Cost?

Some medical insurance companies will cover some or most parts of your gender-affirming surgery. But many might have certain "exclusions" listed in the plan. They might use language like "services related to sex change" or "sex reassignment surgery." These limitations may vary by state. It's best to reach out to your insurance company by phone or email to confirm the coverage or exclusions.

If your company does cover some costs, they may need a few documents before they approve it.

This can include:

• A gender dysphoria diagnosis in your health records. It's a term used to describe the feeling you have when the sex you're assigned at birth does not match with your gender identity. A doctor can provide a note if it's necessary.
• A letter of support from a mental health professional such as a social worker, psychiatrist , or a therapist.

Gender affirmation surgery can be very expensive. It's best to check with your insurance company to see what type of coverage you have.

If you're planning to pay out-of-pocket, prices may vary depending on the various specialists involved in your case. This can include surgeons, primary care doctors, anesthesiologists, psychiatrists, social workers, and counselors. The procedure costs also vary, and the total bill will include a number of charges, including hospital stay, anesthesia, counseling sessions, medications, and the procedures you elect to have.

Whether you choose facial, top, or bottom or a combination of these procedures, the total bill after your hospital stay can cost anywhere from $5,400 for chin surgery to well over $100,000 for multiple procedures.

Recovery and Mental Health After Gender Affirmation Surgery

Your recovery time may vary. It will depend on the type of surgery you have. But swelling can last anywhere from 2 weeks for facial surgery to up to 4 months or more if you opted for bottom surgery.

Talk to your doctor about when you can get back to your normal day-to-day routine. But in the meantime, make sure to go to your regular follow-up appointments with your doctor. This will help them make sure you're healing well post-surgery.

Most trans and nonbinary people who get gender affirmation surgery report that it improves their overall quality of life. In fact, over 94% of people who opt for surgery say they are satisfied with the results.

Folks who have mental health support before surgery tend to do better, too. One study found that after gender affirmation surgery, a person's need for mental health treatment went down by 8%.

Not all trans and nonbinary people choose to have gender affirmation surgery, or they may only have some of the procedures available. If you are considering surgery, speak with your primary care doctor to discuss what operations might be best for you.

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Trump Falsely Claimed Kids Go to School and Come Back with 'Sex-Change Operations'

The former u.s. president repeated this claim during a september 2024 campaign speech delivered in tucson, arizona., jordan liles, published sept. 13, 2024.

About this rating

During the final stretch of former U.S. President Donald Trump's presidential campaign in 2024, a claim that attempts to tap into transphobia and U.S. parents' fears over what happens in schools without their knowledge or approval emerged as a recurring talking point.

On multiple occasions, Trump alleged — without citing evidence — that children have gone to school and returned home later having received gender-affirming surgeries, or that school officials somehow "changed the sex" of children.

For instance, while speaking to a crowd in Tucson, Arizona, on Sept. 12, 2024, Trump spoke of what he called "transgender insanity" occurring in the U.S., and then said, "Can you imagine your child goes to school and they don't even call you, and they change the sex of your child?"

The crowd's negative reaction suggested they believed he had described a documented scenario.

Trump: Can you imagine your child goes to school and they don't even call you and they change the sex of your child. pic.twitter.com/yuBORGBwY8 — Acyn (@Acyn) September 12, 2024

However, we uncovered no evidence of children going to school to receive any sort of sex-change operation or gender-affirming surgery. For this reason, and another we'll mention shortly, we rated this claim as "False."

Before the remark on Arizona, on Sept. 9, Trump said during a Wisconsin campaign rally, " Can you imagine you're a parent and your son leaves the house and you say, 'Jimmy, I love you so much, go have a good day in school,' and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?"

In an article that also debunked the assertion, NBC News reported:

About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare. In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers. Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

Days before the Wisconsin speech, on Aug. 30, Trump uttered the same claim in slightly different words during a discussion with Tiffany Justice, co-founder of the conservative organization Moms for Liberty. 

Justice brought up the subject of children identifying as transgender, telling Trump, "There's been an explosion in the number of children who identify as transgender, and children are being taught that they were born in the wrong body. It's an incredibly abusive message to send. So let's talk a little bit about some of the things that you might be able to do as president."

Trump answered, "Well, you can do everything. President has such power. It does. It has such power."

Moments later, he added, "But the transgender thing is incredible. Think of it. Your kid goes to school and comes home a few days later with an operation. The school decides what's going to happen with your child. And you know, many of these childs [sic] 15 years later say, 'What the hell happened? Who did this to me?' They say, 'Who did this to me?' It's incredible."

Readers can watch these remarks in this video from the LiveNOW from Fox YouTube channel beginning at the 38:11 mark:

There's No Evidence of Children Receiving Gender-Affirming Surgeries at School

CNN extensively reported on this claim about children supposedly going to school and receiving gender-affirming surgeries, as well as other statements Trump made during the discussion with Justice. The article featured interviews with medical professionals who refuted the idea of childrens' surgeries being secretly carried out by or with the involvement of schools.

For example, Dr. Meredithe McNamara , an assistant professor of pediatrics specializing in adolescent medicine at the Yale School of Medicine, told CNN, "Of course everything in this statement is false," in reference to Trump's remark about children going to school and supposedly coming home "a few days later with an operation." By email, we asked McNamara whether she had ever seen evidence of even one such surgery occurring inside a U.S. school. She answered, "No, I absolutely have not."

In CNN's reporting, the network also said Justice responded to its correspondence, saying in part, "Are kids getting surgery in school? No they're not." CNN further reported that Trump's campaign shared no evidence of any such activity occurring inside schools.

Snopes contacted other professionals in the field of pediatrics and the Trump campaign, but we did not yet receive responses.

We reached out to Moms for Liberty by email to ask further questions. In response, we received several statements, including one scolding CNN for not including part of the organization's correspondence that detailed five court cases involving lawsuits about schools assisting students in "socially transitioning" from one gender to another. To be clear, none of the five cases involved children undergoing medical operations inside of schools.

Trump Tied Olympic Athletes' Genders into the Claim

On at least two speaking occasions, Trump connected the false claim about surgeries taking place inside schools with references to Algerian female boxer Imane Khelif and Taiwanese female boxer Lin Yu-ting — who were accused of transitioning from male to female to cheat and win gold medals at the 2024 Paris Olympics. However, as we previously reported , Khelif was assigned female at birth, meaning she has always lived as a woman. Yahoo Sports published the same about Lin.

For further reading, we previously reported about a false rumor claiming 2024 Democratic vice-presidential nominee and Minnesota Gov. Tim Walz signed a bill allowing "gender reassignment surgery for children" in his state.

"About." Moms for Liberty , https://www.momsforliberty.org/about/.

Baker, Katie J. M. "When Students Change Gender Identity, and Parents Don't Know." The New York Times , 22 Jan. 2023, https://www.nytimes.com/2023/01/22/us/gender-identity-students-parents.html.

Beacham, Greg. "Boxer Lin Yu-Ting Wins Gold, Following Imane Khelif to Conclude an Olympics Filled with Scrutiny." The Associated Press , 10 Aug. 2024, https://apnews.com/article/olympics-2024-boxing-lin-khelif-28d3e1a46ed8fe5c1aa6cd612e2561ca.

Dale, Daniel. "Fact Check: Trump Falsely Claims Schools Are Secretly Sending Children for Gender-Affirming Surgeries | CNN Politics." CNN , 4 Sept. 2024, https://www.cnn.com/2024/09/04/politics/donald-trump-fact-check-children-gender-affirming-surgery/index.html.

"FULL REMARKS: Trump Attends Moms for Liberty 2024 Summit." YouTube , LiveNOW from FOX, 30 Aug. 2024, https://www.youtube.com/watch?v=86clTu93p50.

"Imane Khelif's Olympic Gold Inspires Algerian Girls to Take up Boxing." The Associated Press , 5 Sept. 2024, https://apnews.com/article/algeria-boxing-imane-khelif-567f5ea9f008642010e6cf8fef7245c4.

"IOC 'saddened by Abuse' of 2 Boxers over Gender." ESPN.com , 1 Aug. 2024, https://www.espn.com/olympics/story/_/id/40702393/ioc-saddened-abuse-two-boxers-gender-paris-olympics.

Kasprak, Alex. "Olympic Boxer Imane Khelif Is Neither Trans Nor Male." Snopes , 6 Aug. 2024, https://www.snopes.com//news/2024/08/05/imane-khelif-not-trans/.

Leicester, John. "IOC Calls Tests That Sparked Vitriol Targeting Boxers Imane Khelif and Lin Yu-Ting Impossibly Flawed." The Associated Press , 4 Aug. 2024, https://apnews.com/article/olympics-2024-imane-khelif-lin-yuting-boxing-13e9529195585404c7b03c96f97dd634.

Rascouët-Paz, Anna. "Walz Didn't Sign Bill Permitting 'Gender Reassignment Surgery for Children.'" Snopes , 12 Aug. 2024, https://www.snopes.com//fact-check/walz-gender-reassignment-surgery-children/.

The Associated Press. "Moms for Liberty Fully Embraces Trump and Widens Role in National Politics as Election Nears." KNSI , 3 Sept. 2024, https://knsiradio.com/2024/09/03/moms-for-liberty-fully-embraces-trump-and-widens-role-in-national-politics-as-election-nears-2/.

"Transgender Surgeries & Gender Affirmation." Mount Sinai Health System , https://www.mountsinai.org/locations/center-transgender-medicine-surgery/care/surgery.

Wetzel, Dan. "Lin Yu-Ting, Boxer Embroiled in Gender Controversy, Wins Olympic Gold Medal in 57kg Women's Final." Yahoo Sports , 10 Aug. 2024, https://sports.yahoo.com/lin-yu-ting-boxer-embroiled-in-gender-controversy-wins-olympic-gold-medal-in-57kg-womens-final-194703156.html.

By Jordan Liles

Jordan Liles is a Senior Reporter who has been with Snopes since 2016.

Article Tags

Trump repeats false claims that children are undergoing transgender surgery during the school day

Former President Donald Trump repeated his false claim that children are undergoing transition-related surgery during their school day, worsening fears among some conservatives that educators are pushing children to become transgender and aiding transitions without parental awareness.

“Can you imagine you’re a parent and your son leaves the house and you say, ‘Jimmy, I love you so much, go have a good day in school,’ and your son comes back with a brutal operation? Can you even imagine this? What the hell is wrong with our country?” Trump said Saturday at a campaign rally in Wisconsin, a vital swing state. 

Trump made similar remarks — saying children were returning home from school after having had surgical procedures — the previous weekend at an event hosted by Moms for Liberty, a parent activist group that has gained outsized influence in conservative politics in recent years.

Asked by one of the group’s co-founders how he would address the “explosion in the number of children who identify as transgender,” Trump said: “Your kid goes to school and comes home a few days later with an operation. The school decides what’s going to happen with your child.”

There is no evidence that a student has ever undergone gender-affirming surgery at a school in the U.S., nor is there evidence that a U.S. school has sent a student to receive such a procedure elsewhere. 

About half the states ban transition-related surgery for minors, and even in states where such care is still legal, it is rare . In addition, guidelines from several major medical associations say a parent or guardian must provide consent before a minor undergoes gender-affirming care, including transition-related surgery, according to the American Association of Medical Providers . Most major medical associations in the U.S. support gender-affirming care for minors experiencing gender dysphoria. For those who opt for such care and have the support of their guardians and physicians, that typically involves puberty blockers for preteens and hormone replacement therapy for older teens.

A spokesperson for Trump’s campaign did not substantiate his claims and pointed NBC News to reports about parents’ being left in the dark about their children’s gender transitions at school. 

“President Trump will ensure all Americans are treated equally under the law regardless of race, gender or sexual orientation,” said the spokesperson, Karoline Leavitt.

Kate King, president of the National Association of School Nurses, said that even when it comes to administering over-the-counter medication such as Advil or Tylenol, school nurses need explicit permission from a physician and a parent.

“There is no way that anyone is doing surgery in a classroom in schools,” she said when she was asked about Trump’s remarks.

Trump’s claims stand out even amid years of allegations by conservative politicians and right-wing media pundits that teachers, Democratic lawmakers and LGBTQ adults are “grooming” or “indoctrinating” children to become gay or transgender. 

The practice of labeling LGBTQ people, particularly gay men and trans women, as “groomers” and “pedophiles” of children had been relegated to the margins for decades, but the tropes resurfaced during the heated debate over Florida’s so-called Don’t Say Gay law, which Gov. Ron DeSantis signed in March 2022. The law limits the instruction of sexual orientation and gender identity in school and has been replicated in states across the country.

At the Republican National Convention in July, at least a dozen speakers — including DeSantis and Rep. Marjorie Taylor Greene, R-Ga. — mentioned gender identity or sexuality negatively in their speeches, according to an NBC News analysis. DeSantis, for example, alleged that Democrats want to “impose gender ideology” on kindergartners.

Nearly 70% of public K-12 teachers who have been teaching for more than one year said topics related to sexual orientation and gender identity “rarely or never” come up in their classrooms, according to a recent poll from the Pew Research Center. Half of all teachers polled, including 62% of elementary school teachers, said elementary school students should not learn about gender identity in school.

Trump vowed last year that if he is re-elected he would abolish gender-affirming care for minors, which he equated to “child abuse” and “child sexual mutilation.” This year, Trump also said he would roll back Title IX protections for transgender students “on day one” of his potential second presidential administration.

His campaign website says he would, if he is re-elected, cut federal funding for schools that push “gender ideology on our children” and “keep men out of women’s sports.”

More broadly, Trump has promised to eliminate the Education Department, claiming that doing so would give states more authority over education.

During his first administration, Trump barred trans people from enlisting in the military — which he has vowed to do again if he is re-elected — and rolled back several antidiscrimination protections for LGBTQ people. 

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Matt Lavietes is a reporter for NBC Out.