When the National Center for Transgender Equality carried out a survey of more than 27,000 transgender people in 2015, roughly 33% of responses came from trans women. When asked about the steps they would like to take as part of a physical transition, these women listed a variety of procedures, including hair removal, voice training, facial feminization surgery and breast augmentation. Twelve percent reported that they had undergone vaginoplasty or labiaplasty; 54 percent answered that they "want [this affirmation surgery] someday," while the remainder were uncertain or did not want these surgeries.
Gynecologists should expect to encounter and support trans women and other transfeminine patients, such as femme nonbinary people who were assigned male at birth, with a variety of gynecological needs. Here's how OB/GYNs can support transfeminine patients after gender affirmation surgery, in both the short and long term.
Understanding Transgender Surgery Outcomes and Options
In addition to patients with vaginas, you may see those who have neovaginas, or vaginas that have been surgically created through a vaginoplasty. They may have also undergone related procedures, such as vulvoplasty (creation of external genitalia, including labia and clitoris) and orchiectomy (removal of the testicles). These surgeries are typically performed after the patient has undergone social transition, such as using a new name or pronouns, and hormone replacement therapy.
While these procedures are relatively safe and effective when performed by an experienced surgeon, they do carry a risk of complications and require follow-up care. Gynecologists play a crucial role in this care — your patients may come to you directly with questions and concerns.
Vaginoplasty, Vulvoplasty and Orchiectomy
A vaginoplasty procedure involves creating a neovagina from the patient's penile tissue, scrotal tissue or skin grafts from the upper thigh. A vulvoplasty involves creating external genitalia, often from the patient's scrotal tissue. It is often performed in conjunction with a vaginoplasty.
Vaginoplasty requires a long-term commitment and ongoing care. Patients must first dilate their vagina multiple times a day to keep it open, eventually performing dilations a few times a week. According to research published in the American Journal of Obstetrics and Gynecology, complications can range from mild to major and can include bleeding, fistula, recurrent urinary or vaginal infections, problems with voiding and pain with intercourse. Rarely, neovaginal prolapse can occur, which requires referral to a subspecialist.
Performed before or in conjunction with a vaginoplasty, an orchiectomy involves surgical removal of one or both of the testicles. The most significant side effect of orchiectomy is a sharp decrease in testosterone — usually a welcome result for patients seeing as it may allow them to decrease their dose of estrogen or other feminizing hormones.
Screening Transfeminine Patients
Following gender affirmation surgery, transfeminine patients should undergo certain routine health screenings, according to research published in the International Journal of Gynecological Cancer. As with cisgender female patients, these include regular breast exams and mammography, as well as vaginal and vulvar exams and screening for sexually transmitted infections.
Ultrasound may be particularly beneficial in helping gynecologists assess the prostate in transfeminine patients who retain one. For example, research published in Facts, Views and Vision suggests that transvaginal ultrasound appears to have higher clinical value and patient preference than digital palpation for prostate examination in trans women who have undergone vaginoplasty.
When caring for trans patients, it's important to demonstrate that you and your practice are both welcoming and informed. You can start by sharing your own pronouns and asking your patients for theirs. This, along with a comfortable, gender-neutral environment and well-trained support staff, will signal to patients that your office is a safe space for all trans patients.
