Transgender Vaginoplasty: What You Need to Know

Vaginoplasty is typically performed as a final gender affirmation procedure. 

The World Professional Association for Transgender Health (WPATH) has set international requirements, accepted by the medical and insurance communities, that you must meet in order to be eligible for this surgery. They include at least one continuous year of hormone therapy and at least one year of living full-time in a gender role that aligns with your gender identity. 

You must also provide two letters of recommendation, one from your mental health clinician and one from the doctor providing your hormone therapy. These letters should attest to “persistent, well-documented gender dysphoria,” “well-controlled” medical or mental health conditions, and your ability to make an informed decision and consent to treatment. 

These requirements create hurdles that are criticized by many in the queer community, but many healthcare providers believe they prepare patients for the emotional and physical intensity of this expensive and irreversible surgery. These are the guidelines most insurance providers outline for any coverage of the surgery.

A board-certified plastic surgeon who specializes in gender confirmation surgery should follow these requirements as ethical standards of care.

RealSelf Tip: A number of surgical centers in the United States and around the world specialize in gender confirmation surgeries, with doctors and medical staff who have experience in transgender care. Gender confirmation surgery can be much less expensive in some countries than in the U.S., so many people choose to travel for their surgery. It’s essential to choose a board-certified surgeon with experience in transgender vaginoplasty and to get care at a reputable facility. 

If you choose to travel, ask your surgeon about a reputable recovery house or other lodging near the surgical center, so you can return home only when it’s safe to fly. Learn more about medical tourism and safety.

Once you’re cleared for surgery, your surgeon will require laser hair removal or electrolysis on any genital skin that will be used to create your new vaginal canal, including scrotal skin. Both hair-removal methods require multiple treatments over several months, so you’ll need to plan them up to a year in advance of your surgery date. 

You may also be asked to stop hormone therapy, including feminizing hormones like estrogen, for two weeks prior to surgery to decrease the risk of blood clots. It can be resumed two weeks after surgery, if you choose, though your regimen may change—for instance, testosterone blockers won’t be necessary after the removal of the testicles.

You’ll also have to stop smoking or vaping several weeks before surgery and avoid it for a month afterward because it can interfere with wound healing.

The gender affirmation surgery is performed under general anesthesia, so you’ll be completely unconscious. It takes two to five hours. 

For penile inversion vaginoplasty, your surgeon will: 

• Remove the testicles 
• Create the new vaginal cavity between the urethra and rectum 
• Remove the skin of the penis to create a pouch, which is then sutured, inverted, and placed into the vaginal cavity 
• Trim the penis tip (aka penile glans)—while it’s still attached to nerves and blood supply, to maintain sensation—to form the clitoris 
• Shorten and reposition the urethra  

Unused parts of the penis are removed and discarded. The prostate is left intact and in place, able to serve as an erogenous zone akin to the G-spot.

Everything is sutured together and bandaged up. A vaginal stent (a tool used to maintain vaginal width and depth during the healing process) and a catheter are inserted to ease recovery. The incision placement should hide the scars within the labial folds or pubic hair.

After surgery, three to six days of hospitalization is required, followed by another 7–10 days of downtime. If you travel for your surgery, you’ll need to stay near the surgical facility, for follow-up appointments with your surgeon as you heal.

You'll be given prescription pain medication, or you can take over-the-counter pain relievers to ease discomfort during the initial recovery stage. Swelling is normal, but you can ice the area to help bring the swelling down. 

Your surgeon will remove sutures, dressings, your catheter, and stent at your post-op appointment, about a week later.  

They’ll also give you a vaginal dilator, which resembles a dildo. Dilation is key to maintaining vaginal depth and girth. Your surgeon will provide a schedule for inserting the dilator regularly for a year. The frequency decreases over time, and you’ll receive dilators of increasing diameter. 

A typical schedule involves inserting the dilator for 10 minutes, three times a day for the first few months and then once or twice a day through the first year. Regular dilation, or penetrative sex, will be necessary for the rest of your life.

Expect to refrain from work or strenuous activity for roughly six weeks. If sitting is uncomfortable, you can use a donut-ring pillow. 

While you should shower daily and can douche to keep the area clean, avoid submerging in water, including swimming and bathing, for eight weeks. Some bleeding and discharge are normal in the first couple of months after surgery. 

You can resume sexual activity after three months. The penile inversion approach doesn't create a vaginal mucosa, so because the neovagina doesn't self-lubricate, you'll need an external lubricant for dilation or penetrative sex. You may not be able to orgasm right away, but sensation should return within several months.

RealSelf Tip: There’s no guarantee you’ll be able to orgasm after transgender surgery, but “usually at least four out of five patients are having orgasms after the surgery,” says Dr. Carlos Gonzalez Legarda, a plastic surgeon in Bogotá, Colombia, in a RealSelf Q&A.

This surgery carries the risks of all major surgeries, including infection, bleeding, blood clots, and an adverse reaction to the anesthesia.

These additional transgender vaginoplasty complications are rare:

• Fistula, an opening between the vagina and rectum 
• Tissue death (necrosis)
• Narrowing (stenosis) or closure of the vagina 
• Loss of sensation due to nerve damage 

The most common complaints after surgery are urinary incontinence and displeasure with the aesthetic result. Some patients prefer to have a second-stage labiaplasty to create a more feminized vulva, including a more defined labia minora and a deeper clitoral hood.  

In a 2016 study of 475 penile inversion vaginoplasties, the largest series reported on, the only major complications were three fistulas. Minor necrosis occurred in 24.6% of patients, with only 0.6% of patients classified as “major” necrosis requiring reoperation. Revision vaginoplasty was necessary for 14 patients. "Successful vaginal construction without the need for secondary functional reoperations was achieved in the majority of patients," researchers concluded.

• Average Cost:
• $13,575

• Range:
• $8,500 - $62,000

The out-of-pocket cost of the surgery is high, because it involves general anesthesia and a hospital stay of several days, but the price varies with surgeon experience, location, and the complexity of the procedure. 

Your insurance plan may cover this surgery in part or full, when eligibility guidelines are met. Check with your insurance company and ask your prospective surgeon for guidance on the eligibility process. 

When planning for surgery, it’s wise to also account for potential travel and lodging as out-of-pocket costs.

RealSelf Tip: “You cannot, unfortunately, select your new vagina from a catalog,” says Dr. Sidhbh Gallagher, a plastic surgeon in Indianapolis, in a RealSelf Q&A. “[Your result] largely depends on what the anatomy looks like to begin with.”

Related: I Got a Vaginoplasty at 54, and I Finally Feel Liberated