Why I chose vulvoplasty?

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.

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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