WPATH Standards of Care
Gender affirmation surgery for a transfeminine person is sometimes called bottom surgery. These are three surgeries that can help a patient feel more aligned with their gender identity. They are:
- vaginoplasty,
- vulvoplasty, and
- orchiectomy.
Criteria for Vaginoplasty Vulvoplasty in Transfeminine Patients
- Persistent, well documented gender dysphoria;
- Capacity to make a fully informed decision and to consent for treatment;
- be the age of majority in a given country;
- If significant medical or mental health concerns are present, they must be well controlled;
- 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones);
- 12 continuous months of living in a gender role that is congruent with their gender identity.
Vaginoplasty
During a vaginoplasty surgery, a surgeon creates both an outer and inner vagina by using skin and tissue from a penis.
- Your surgeon will use skin from the penis and scrotum to build the inner and outer labia of the vagina
- Your surgeon will create a new opening for the urethra (so you can urinate)
- Your surgeon will use tissue from your foreskin to build the new opening of the vagina (also called the introitus).
Vaginoplasty Procedure
During most vaginoplasties, your surgeon will use a skin graft to create a new vaginal canal (the inside wall of the vagina). To do this, your surgeon will take skin from your scrotum and thin it so it works well as a skin graft.
If there’s not enough skin from your scrotum to make your new vagina, then your surgeon can take extra skin from the sides of your abdomen where there won’t be a very noticeable scar.
To make your new vaginal canal, your surgeon will create a space between your rectum and bladder. Once your skin graft is inserted, your surgeon will place gauze or spongy material inside the new vaginal canal for 5 days. The gauze puts pressure on the skin graft so it grows like it should into the surrounding vaginal tissue.
Vaginoplasty & Orgasms
Many transfeminine people wonder if they’ll still be able to have orgasms after having a vaginoplasty.
Your surgeon will use skin from your penis to create a clitoris. This clitoris still has feeling, and most transgender women can have orgasm through clitoral stimulation.
How Long Will I Be in the Hospital After Vaginoplasty?
Patients are in the hospital for 5 days and mostly rest in bed. Resting will help your skin graft grow into the surrounding tissue in your vaginal canal.
Your surgeon will also place a compressive bandage on the outside of your vagina. After the outer and inner bandages are removed, most patients feel fine and can leave the hospital.
When Should I Start to Dilate my Vagina After Vaginoplasty?
Each patient’s situation is different, but we recommend waiting two weeks after your surgery before you start dilating your vagina. Waiting two weeks will let your vagina heal.
Your surgeon will give you vaginal dilators to use at home. You should dilate your vagina two to three times each day for the first six months after your surgery.
Read this instruction sheet on how to dilate your vagina after having a vaginoplasty.
Preparing for Vaginoplasty Surgery
There are several things that patients need to do before having a vaginoplasty.
Pursue hair reduction: The first thing you’ll need to do is have hair removal on your scrotum and lower penile skin. Your vaginoplasty surgeon will use this skin to create your new vaginal canal. If hair were to grow inside your new vagina, it would create hygiene problems.
Quit smoking: If you’re a smoker, it’s very important for you to quit. Smoking, vaping, or using any nicotine products decreases blood flow to the area around your genitals and will make it harder for you to heal after your surgery.
If you’re a recent smoker, we will give you a nicotine urine test to make sure you’ve been able to quit completely. Nicotine takes about a month to wash out of your system before the test results will be negative.
Weight considerations: Keep in mind that patients with a body mass index (BMI*) greater than 35 are at a higher risk for wound healing problems and complications after surgery. However, we understand that BMI is not a perfect measure of your overall health. We will discuss how your weight may affect you and the potential benefits of losing weight before surgery. If our team decides that weight loss is the best pre-surgical option for you, we will refer you to our weight management program.
For some people, vaginoplasty or vulvoplasty may not be possible because of their body shape and weight.
Physical Therapy for Vaginoplasty
Both before and after having a vaginoplasty, your surgeon will recommend that you start seeing a physical therapist. Physical therapy can help you prepare for this surgery.
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 (except for the vaginal canal).
The steps of a vulvoplasty are the same as a vaginoplasty. During a vulvoplasty, your surgeon will:
- create a clitoris out of the glans (or head) of the penis,
- create an inner and outer labia from skin on the penis and scrotum,
- create the opening of the urethra so you can urinate, and
- 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.
- Vaginoplasty creates a vaginal canal.
- Vulvoplasty creates all the parts of a vagina except for the vaginal canal.
After vulvoplasty, this means you won’t be able to have intercourse or insert a penis into your vagina.
How Do I Choose Between a Vulvoplasty vs. Vaginoplasty?
A vulvoplasty has a much easier recovery. For example, you won’t need to dilate (or stretch) your vagina.
Another reason to consider vulvoplasty instead of vaginoplasty is because of medical problems or complications. One serious complication after vaginoplasty is called rectal injury. In some cases, a rectal injury can create a hole between your rectum and vagina.
But your chances of developing a rectal injury are much lower if you have a vulvoplasty instead of a vaginoplasty.
Sex & Vaginal Intercourse
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.
How Long Will I Be in the Hospital After Vulvoplasty?
Patients usually are in the hospital for 3 days after having a vulvoplasty. Your surgical team will give you a compressive dressing that reduces inflammation (swelling) after your surgery.
Most patients rest in bed while they’re healing since the dressing is uncomfortable to walk with.
After your dressing is removed, you can leave the hospital, usually right at about 3 days.