Interviews MTF Trans Surgeries

Why I chose vulvoplasty?

Franches

A vulvoplasty is a gender affirming genital reconstruction surgery that creates a neo-vulva. It fashions the external female genitalia but without a vaginal cavity.


Franches is a former patient of GrS Montréal et of Dr. Pierre Brassard. She is a strong proponent of self empowerment through knowledge and experimentation. Franches is also the author and publisher of HolaSoyYo.com (‘Hello, it’s me’ in Spanish), a blog where she shares her experiences and thoughts on changing gender expression.

Why a vulvoplasty? First, you can’t ask that. Asking someone why they chose a specific surgical procedure, and so much more when it has to do with genital reconstruction, is a no-no. It’s a little bit like asking someone why they plan to marry their fiancé(e) – you just don’t ask that. So, unless you have an intimate relationship with someone, don’t ask such personal questions! The decision of a genital reconstruction surgery and its variety is ultra personal, and depending on the person, it could be an extremely uncomfortable topic. Having cleared that up, let’s move on, shall we?

Why This Article/Blog Post?

One of the problems when a topic is so personal and touchy is that there are not as many people talking about it and therefore there is limited information to go on. There is some information and literature but it tends to be medical and technical in nature, meaning that it’s not written from the point of view of a patient. My main idea behind this post is to share my very personal reasons why I chose this kind of surgery. It’s not meant to convince anyone to choose one kind of surgery over another, but rather expose what I went through to decide so other people can have a point of reference of sorts. When I did my own research and soul searching before deciding, I was surprised to see that some transgender women were not aware of this alternative to a ‘traditional’ or ‘full’ vaginoplasty. Therefore, an ulterior personal motive for this post is to let people know about this option and explain my perspective.

But What is a Vulvoplasty or Vaginoplasty Without Cavity?

A vulvoplasty is a gender affirming genital reconstruction surgery that creates a neo-vulva. It fashions the external female genitalia but without a vaginal cavity. Depending on a few factors, this kind of surgery can have different names, but in essence they all mean the same:

  • Vulvoplasty
  • Vaginoplasty Without Cavity
  • Shallow / Minimal-Depth / Dimple / Limit-Depth Vaginoplasty
  • Cosmetic / Aesthetic Vaginoplasty
  • No-Depth / Zero Depth Vaginoplasty

Sometimes the name varies by surgeon or surgical centre, but more importantly, it also depends on the patient. When I did my research, I have learnt that some patients prefer to have the word ‘vaginoplasty’ in the name of their surgery as it may help with dysphoria by reaffirming their gender implying a kind of vagina. I also came across some references that explained that some patients preferred ‘Shallow / Minimal-Depth / Dimple / Limit-Depth’ over ‘No-Depth / Zero Depth’ as the inference of depth has a better connotation for some patients. For my surgery I prefer the word ‘vulvoplasty’ as I find it very descriptive. Also, due to the way I identify I don’t benefit from the word ‘vagina’ being associated to my procedure. I do make the distinction that’s what I prefer ‘for my surgery’ and not ‘for the kind of procedure’. By doing so it allows the patient to choose a name for their surgery that supports the way they see themselves.

My Personal Reasons

Oh gee! I need to catch my breath before I open up about something oh so personal! (Deep inhale!) Ok, here we go… At the beginning of this post I said that ‘you can’t ask that question’ but regardless I’ve had a few people ask me about my choice. Though I had my own reasons I never had to verbalize them before I had my surgery, so I hadn’t given much thought of how I would answer that question. Funny enough, it wasn’t until after I had that question asked a couple of times that I really looked deep inside to get a sincere answer for myself. My most sincere answer, which also happens to be the simplest, is that I chose a vulvoplasty due to the way I identify. I’ll unravel the multiple factors that made up my decision, all of which support the way I identify. I lay down the factors that influenced my decision, mostly, in order of importance to me.

Penetrative Sex

I told you I was going to get personal, didn’t I? I have zero interest in penetrative or vaginal sex. None whatsoever. I’m not attracted to guys and the chances that I would be interested in vaginal sex are practically zero. From my different decision factors, this one was probably my most important one or the second most important one. As part of my research and soul searching before deciding I had a discussion with the psychologist that did one of my surgical assessments and of course this topic came up. One of the things we talked about was that even if for some strange reason I would be interested in penetrative sex, there’s always ‘the back door’ (AKA anal sex). So, from my point of view, you could say I still have the option of some sort of penetrative sex if I so desired… somehow… but no, thanks.

Congruence With my Gender Expression

If penetrative sex was not my number one deciding factor, then being consistent with my gender expression was. My gender expression and presentation are totally female, and though my birth genitalia didn’t cause me any dysphoria, after going full time it was always on my mind. I hated the thought that someone could see something in my crotch and questioned my gender expression. Being totally genuine with myself and my gender presentation: f#$k tucking! I hated tucking, I hated how I looked, and I hated when I worried about it ever being noticed. I just wanted a total congruent appearance and my male genitalia was getting in the way of that. I always felt a little limited in my choice of garments and I wanted to get rid of that feeling of limitation. Being congruent with my gender expression was directly correlated with my wardrobe because for the most part no one gets to see my genitalia. But the outfits that I choose to wear on top of it are always of great importance to me. In my value scale, the external appearance was in a much higher position than the functionality of a neovagina.

Self-Care (Dilations & Douching)

The required life-long dilations and douching after a ‘full’ vaginoplasty made no sense to me especially since I have no interest, not even the slightest curiosity, of vaginal intercourse. If I wanted to leave the door open to ever having vaginal sex, then my decision may have been different. I don’t think I would mind the actual dilations/douching, but rather that level of commitment to life-long self-care was totally outweighed by my lack of desire for penetrative sex. To compound my decision, when I did my research, I got a strong sense that some of the post-op complications people talked about could be traced to patients not fully understanding the level of self-care a ‘full’ vaginoplasty requires. Below I’ll talk about the increased risk of complications. The aftercare of a ‘full’ vaginoplasty requires a commitment that starts with 4 dilations and douching a day for the first month post-op and continues for a few months as the soft tissue heals, then dilation/douching frequency gradually drops to once a day after 6 months and, until 1 year after surgery. After the first year post-op the frequency goes down to only once per week but needs to be maintained for life.

Recovery

Compared to my 3 previous factors, recovery ranked much lower in terms of importance to me. Though recovery from genital reconstruction surgery is tough, the thing I kept in mind is that it is ‘just a temporary phase’. But again, in the whole context of my main two factors described above, recovery was still something important for me to consider. The first 3 months after surgery from a ‘full’ vaginoplasty have a very rigid aftercare schedule comparable to a full-time job. If I wanted to achieve the external look without the full functionality of a vaginal cavity, then the difference in the self-care schedule during recovery between a vulvoplasty and a ‘full’ vaginoplasty was definitely something I considered. The recovery from a vulvoplasty is done in about 8 weeks (everyone heals at different rates so it may be shorter or longer) with a lighter maintenance schedule than a ‘full’ vaginoplasty, centred around a high level of hygiene for the surgical site instead of centred around preventing the vaginal cavity from closing.

Risk of Complications

There are always risks associated with any surgical procedure and when a procedure is more complex than others, naturally there’s too an increase risk of complications. Due to the way the cavity of a neovagina is created and the fact that it requires frequent dilations, especially during the first few months, there is a slight chance for complications that is not present if there is no cavity, ie. a recto-vaginal fistula or other minor complications. Also, in a vulvoplasty, since there is no need to insert dilators, there is less chance of complications caused by soft tissue tension created during dilation. Having less sutures, less skin surface (no need for the lining of the vagina) and no need to insert foreign objects (dilators and douche) there is a slightly lower risk of infection. In the long term, a ‘full’ vaginoplasty has the risk of a vaginal prolapse if the dilation regime is not maintained. Hygiene is always important, but in the presence of a vaginal cavity, if douching is not maintained, the risk of complications can also increase. What I’m trying to say is that my personal ratio between my desires and the risks was not worth a ‘full’ vaginoplasty for me.

Other Factors That Did Not Apply to me

Above I’ve opened up about my personal factors that I considered when deciding on my surgery, but these are not the only ones. There are a number of other factors that people may consider, but that did not apply to me or that didn’t have any effect on my decision. Here are 3 that I found some references for, but I’m fairly certain there are more that may be important for other people.

Non-Binary Surgery

People that identify as non-binary, gender non-conforming, gender fluid or somewhere else in the gender spectrum may find a vulvoplasty as a great way to support their identity.

Existing Health Concerns

If there are other health concerns or pre-existing conditions where the creation of a vaginal canal is not indicated, then a vulvoplasty may be a very attractive alternative for folks in that situation. Of course, this needs to be discussed with the primary healthcare provider and/or the surgeon.

Age

A patient’s age may be a very strong factor to consider. For someone mature, and due to the differences in recovery and self-care required, their age may be a deciding factor. Interestingly enough, for patients that are younger, their age may be of concern to the healthcare practitioners. When I was preparing to write this post, I came across a reference to a study (PDF) that looked at the attitudes of WPATH-affiliated medical professionals towards the option of a vulvoplasty for patients between 18 and 21 years of age. They found that some medical professionals had more reluctance to recommend a no-depth option to patients in this age group.

It is The Patient’s Decision

At the end of the day, the decision lays on the patient and no one else. There may be lots of personal factors that influence that decision. With the current lack of reputable sources of information or detailed information, I truly hope that me opening up can help someone. At the very least, I strongly encourage the discussion so that more people become aware of the option of a no-depth genital reconstruction surgery.

Franches

  1. Brilliant, succinct and well judged. Thank you for sharing, interesting to see many of my own thoughts mirrored here.

    Outside of dysphoria which I had, past tense no more, you express many thoughts that mirrored my own.

    It is possible that I experience some regret for my surgical option which mirrored your own.

    Yet generally they are few and fleeting.

    Thank you

  2. This is very interesting and informative! Thank you for sharing 😀

    I very definitively want a vaginal cavity, and I’ve had some people question this decision because I’m a lesbian (of course, they’re ignoring the fact that I may sometimes have a partner who is a woman with a penis). But I’ve had a desire to feel vaginal penetration for even longer than I’ve known I was trans. I think it’s really important to respect everyone’s decision and not question it for sure. There’s lots to consider, but whatever decision each person comes to is totally valid.

  3. Meghan McKie

    Franches, thank you so much for this! I have been considering vulvoplasty also, and I have to say this resonates with me so much. Aside from the tucking, which I don’t need to do because of shrinkage, all your reasons are the same ones that I consider important to me. As a parent of three kids ages six and under, combined with being in a committed marriage to a cis woman, I’m not sure that I have any true need for a full-depth vaginoplasty. Like you, I just want that physical congruence.

    • Franches

      Meghan, if you’re not sure, it’s not a bad idea to discuss the topic with the surgeon, with a therapist, and/or someone that already had the procedure. If you want to get a hold of me, let me know by leaving me a comment on my blog (the URL is listed in the text) and I’d be happy to contact you via email.

      In the pre-op consultation with Dr. Brassard, I specifically asked him if there was a way to create a cavity after the vulvoplasty. His reply was that he could by grafting skin from somewhere else like the inner thigh. I don’t know if it’s possible or how complicated would be to close a cavity after a vaginoplasty if the patient had regrets, though.

  4. Olivia Heck

    All comments have value so I’ll mine short to avoid being repetetive. I’m the oldest of any surgery candidates, over 70, I never gave up.
    From childhood on my goal was to ‘get rid of my male genitals, always in the way and bothersome. I never was in any relationship.
    So my decision was easy, just a vulvoplasty, except for hygene there is no after care.. I hope to get my turn soon , I want Dre Maude
    Belanger to the honors.

  5. Exactly the same reasons why this is the surgery I want. I’m 63 so will 65 when any surgery would be available to me and even though I’m very fit (fitter than many in their 30s) any procedure has risks and I want to minimise those and also have a short and less complex recovery as I’m on my own (I do have some marvellous, supportive friends minutes away but don’t want to burden them).
    From my research the vulvoplasty is not at all promoted because many surgeons just assume every woman wants vaginoplasty without even asking (talk about informed consent) and indeed one surgeon was very hostile about it and criticised other surgeons who even offered the option. Vulvoplasty should definitely be offered amongst the options and one girl was very excited from a post I did as this gave her a realistic chance to rid herself from a useless appendage and enable her to look forward to a gratifying sex life with her wife.

  6. maya fay

    Thank you very much for writing this blog and your thoughts. I just watched a video by Dr Z PHD (https://www.youtube.com/watch?v=URoUhPRs0h8) discussing this topic. They looked at the surgery from sexual health, do we know what we might like to try in the future, as we become comfortable with our bodies. For me I think zero depth is preferable, as when I have been asked about penetrative sex in the past I have not felt comfortable, and there are other options available, anal sex or surgery involving the peritoneum, or colon.

    I think the biggest worry I have is the number of women I spoke to about either procedure who complained of being left with a small amount of incontinence, which they had to manage through medication, further operations or incontinence pads.

  7. I found some information that was posted that hopefully I can apply to my life. I live in America I’m Australian born I’m 64 I don’t look 64, but I’m getting my surgery done at Temple Hospital in Philadelphia Pennsylvania in the United states. Dr haminian and Dr Laura Douglas are my attending urologist and plastic surgeon I’m getting a vulvaplasty. Which when I was young would never have been something I would have entertained but I think it’s best for me now since insurance is finally paying for it because transgender people and gay people have been at the bottom of the totem pole since the conception of Life at least in the United States and we often get very bad medical treatment a lot of judgment because people are either Christian or Jewish where it honestly teaches people prejudice and bigotry towards other people and when you’re in America that’s all you seem to run into is one problem after another I’ll face a lot of prejudice from the medical community in America you can’t look at me and tell them I’m transgender nor do I have a male voice coming out of a female’s face. But I’ve been told on several occasions why don’t you go to your own doctors? Anyway undergoing this transformation at 64 years old has not been something I dreamed about but the reality of what you get in America depending on who you are, is very different from the idea that when you come here you’re going to somehow be walking into Disneyland and have a chance at having all your dreams come true. I only hope and pray for the outcome I’m looking for having a functioning vagina and making sure it is quite attractive and passable the look from the plastic surgeon I’m hoping we’ll be beautiful they do not require hair removal. I’m hoping I don’t have an excessive amount of pain although I’m sure I will have some and I’m also hoping the biggest part is that I don’t have abnormal bleeding which requires a visit back to the ER or the or like when I had a tummy talk. I’m 5’8 and 3/4 I’m 230 lb which doesn’t really look like I am I have a little bit of excess puffy fat between my thighs I understand Temple but they did not remove the fat yet they caught me from my knees all the way up under my scrotum it’s hard to find competent surgeons in America anymore especially on health insurance coverage such as Medicare and Keystone first offered by Blue Cross and Blue shield as part of Medicaid insurance. Since we’re the last people in America to get our civil rights I am actually we’ll be fighting another 300 years in America just to be respected I’m waiting for our turn to have someone on the supreme Court who looks like us. But I hope and pray that everything will go well for me and for everyone around the world who knows that this dysphoria being transgender has such emotional baggage the depression the anxiety but never fitting in never finding your place never experiencing life like normal heterosexuals oftentimes is so horrible that nobody could understand what it’s like your tormented constantly because you can’t fit in you don’t feel like the person you were born it’s so bad when I look in the mirror I have no idea who I’m looking at.. can anyone out there imagine how bad it is when you feel one way inside yourself and you look in the mirror and all society can say to you is you need God in your life these are people who are so asinine, so neandertholic I’m so highly uneducated it’s scary to hear some people talk and ignorant to hear the questions that people actually ask in America they have lost their class their intellect and their compassion. But I wish everyone God’s peace a speedy recovery and they were trying to be understood by the medical community many still full short I’m not understanding what it’s like when you’re inside a body you feel you’re being held captive in it’s almost like a possession by the devil in extreme cases. Thank you for sharing the information you’ve shared I’d like to be welcome back if it’s possible? To leave my experience after the surgery is done three months after but I don’t know if my freedom of speech and freedom of expression will be allowed usually it’s not an American social media it’s not welcome we’ve been taught by Google and Facebook to seek out the truth and then deny it erase it eradicated denounce it as false information isn’t that what the Nazis once did?

  8. Marianne

    Thank you for your openess. I have been thinking a lot about having surgery. I am not interested in having a relationship with anyone anymore. I have been a widow for over twelve years and have not been with anyone since. My gender doctor has mentioned that maintenance is a issue to think about. I have a better feel about my decisions. Thank you very much for your discussion. I feel much better about my decisions.

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