Introduction to Genital Gender Affirmation Surgery for Transgender Women

For transgender women, or transwomen, variations on two types of genital surgery are available: the orchiectomy and a vaginoplasty. The orchiectomy – or removal of the testes – has been reported for at least 4 thousand years – probably as a manifestation of trans identity even back then.

Gender Affirmation Surgery: Orchiectomy

Surgically, there are three different types of orchiectomy: radical orchiectomy, subcapsular orchiectomy and a simple orchiectomy.

Radical Orcheictomy: Involves removal of all of the testes, the spermatic cord and the tissue around the testes and is usually reserved for patients with testicular cancer.

Subcapsular orchiectomy: Used in patients with aggressive metastatic prostate cancer and preserves the capsule of the testes. The simple orchiectomy in which the testes and nearby attached tissues (like the epididymis) are removed is most commonly used for transwomen. Many transwomen will choose only to have this surgery done because it allows for a decreased estrogen dose and cessation of spirinolactone.

Simple orchiectomy: A relatively straightforward, outpatient procedure that takes about a half hour to perform. Many patients will have this done and not proceed to a vaginoplasty but the orchiectomy does not burn any bridges and still permits a future vaginoplasty even with a scrotal graft if needed.

Gender Affirmation Surgery: Vaginoplasty

Vaginoplasty is a surgery to revise or create a new vagina. “Vaginoplasty” is a broad phrase and imprecise. In cis-women a “vaginoplasty” can be used to create a new vagina if the vagina is congenitally absent, or to correct problems with the vagina in older women after cancer surgery or treat conditions like a dropped bladder. One of the big differences in transwomen is that, unlike most cis-women, they have extra, redundant tissue (the penis) which can be used to create the new vagina. Perhaps the phrase “vaginogenesis” or creation of a new vagina might be a better phrase.

The most common vaginoplasty is the penile inversion vaginoplasty but others include sigmoid vaginoplasty and zero-depth vaginoplasty. The penile-inversion vaginoplasty uses the skin of the penis to create a portion of the vaginal wall. usually this is not deep enough and so skin is supplemented with additional grafts or skin flaps. If not already done, an orchiectomy (removal of the testes) is done as part of the vaginoplasty. A new clitoris is created with sensation and preserving orgasms. Once recovered, patients are able to have intercourse after vaginoplasty but will have to use lubrication. Parts of the colon, usually a part downstream closer to the rectum, called the sigmoid colon, can also be used to create the new vagina. The sigmoid vaginoplasty provides nice depth and moisture but can continue to produce mucous. “Zero-depth” vaginoplasty is offered for older patients or those who want the easiest operation and one in which dilation is not necessary. However, without some depth, the external appearance is compromised.


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