Vaginoplasty

Vaginoplasty is a surgical procedure in which the penis and testicles are removed, and the remaining skin tissue is used to construct a neovagina, labia and clitoral structure. The result is not a functional vagina in the biological sense: there is no uterus, no ovaries, no vaginal lubrication and no self-cleaning mucous membrane. It is the cosmetic and functional construction of a body part that superficially resembles a vagina, with permanent medical consequences.

Techniques

The standard technique is penile inversion vaginoplasty: the skin of the amputated penis is turned inside out to line the walls of the newly created cavity. If there is insufficient skin available (for example, after puberty blockers, because the penis has remained underdeveloped), additional scrotal skin or a segment of intestine is used (sigmoid or colonic vaginoplasty). An intestinal segment produces its own mucus but carries additional risks: abdominal surgery, the possibility of intestinal leakage and, in rare cases, diversion colitis in the intestinal segment used.

Complications: concrete and partly permanent

In public information, complication rates are often presented in overly reassuring terms (“rare with experienced surgeons”). The medical literature paints a different picture:

• Necrosis of the neoclitoris or parts of the skin flap can occur and may result in permanent loss of sensation and cosmetic damage.
• Strictures and stenosis (narrowing of the neovaginal opening or the entire canal) are common complications. Treatment requires repeat surgery or aggressive dilation.
• Fistula formation, particularly rectovaginal fistulas (connections with the rectum), is a serious complication. Repair is difficult and not always completely successful.
• Urinary tract problems: meatal stenosis, incontinence, spraying during urination and chronic infections.
• Loss of sensation: partial or complete reduction of sensation in the genital area. The ability to orgasm varies; complete loss does occur.
• Granulation tissue, signs of prolapse, poor cosmetic results, chronic pain and lasting dissatisfaction are among the possible outcomes.

Lifelong dilation requirement

The neovagina is a wound that the body tries to close. To keep the canal open, the patient must dilate for life — inserting a dilator, initially several times a day and eventually reducing this to weekly dilation. If dilation is neglected, the canal can narrow significantly or close within weeks, making further surgery the only option. This lifelong obligation is regularly given insufficient emphasis in preoperative information. For people with physical limitations, psychological problems or aging bodies, dilation can become a serious burden. Pelvic floor physiotherapists can help with aftercare; an overview is available at genderexperts.nl.

Fertility and sexuality

Vaginoplasty makes the patient permanently sterile: no more sperm cells are produced after orchiectomy. Any desire to have children requires freezing sperm in advance — something that may already have been reduced or made impossible by prior hormone use. Sexual function changes profoundly. Penetrative sex through the neovagina is possible but not comparable to sex for cisgender women: there is no natural lubrication, lubricant is always necessary, and sensitivity depends heavily on the surgical outcome.

Irreversible

The procedure is completely irreversible. Reconstruction of male genitalia after vaginoplasty is barely possible; detransitioners who have undergone this procedure live with the consequences. Along with phalloplasty, it is one of the most definitive medical interventions known to modern medicine. In the United Kingdom, the question has been raised as to whether the NHS is violating the UK anti-mutilation law through transgender surgery.

Requirements in the Netherlands

The procedure is performed in the Netherlands at Amsterdam UMC. Requirements generally include a diagnosis, at least one year of hormone treatment and a stable situation. The skin used in the operation must be depilated beforehand; see electrolysis. The procedure is covered by the basic health insurance package. Waiting times are long. See also Waiting times and care pathway, Detransition and Cass Review.