Gender Confirmation Surgery (skip if you’re squeamish)

Dear Reader,

With this post, I’m going to get into a medical procedure (surgery) which reconfigures a person’s genitals. I’m going to include links to pictures and discuss body parts graphically (in a clinical manner. If you’re squeamish or don’t really want to see this, please skip this post; it’s ok, I understand.

livescience-gender-reassignment-130826bAlright, if you’re still reading, I’m writing about Gender Confirmation Surgery (GCS) from a Male-to-Female (M2F) perspective. There are procedures for those seeking Female-to-Male (F2M) such as metoidioplasty, phalloplasty and breast reduction; I think those are very interesting topics, but not something I can relate to on a personal level. I’d rather a person with a direct interest in those procedures write about them, as I’m sure they could do a much better job than I could; if anyone wants to write a guest post, please reach out to me – I’d love to have someone do that! Ok, disclaimers are finished. Let’s get on with it!

As a transgender person, I’m seeking to align myself with the gender I know myself to be. So far, this has included HRT, having my name legally changed, coming out at work and socially, and generally just living my life the way I feel matches who I am. But while all of this has been life changing, it hasn’t been enough. So I have decided to pursue Gender Confirmation Surgery (GCS), and specifically, orchiectomy and vaginoplasty by means of penile inversion. (I get into the decision itself in a different post)

Gender Confirmation?

If this seems like a lot of words that don’t make sense, it’s actually not so complicated. Gender Confirmation Surgery doesn’t describe a single procedure, but rather a whole menu of procedures of which one or a few may be needed. In the past, these were called Sexual Reassignment Surgery (SRS) or colloquially, a Sex Change. These terms have fallen out of favor as we have come to understand the circumstances better, and have refined our language to reflect our new understanding. For a transgender person, their gender does not match the one assigned at birth. Nothing changes for the person’s gender – they are the gender they always have been; these surgeries only affirm and confirm the person’s sense of their gender by aligning their bodies with their gender.

Surgery

While there are many other medical interventions available, each has its limitations. While HRT can affect secondary sex characteristics (body & facial hair, muscle tone, breast tissue growth, etc), it has very little effect on the primary sex characteristics – genitals and gonads. For those to change, surgical intervention is usually required. As the genitals and gonads are located on the lower half of the body,  surgeries for these areas is often called “bottom surgery”. For M2F people, bottom surgery seeks to align the genitals with what is typically found on female bodies – a vulva and vagina. The procedure involves multiple steps, each focusing on relocating and reshaping the existing tissues. In this surgery, very little tissue goes to waste – generally just the testes and the erectile tissue within the penis.

Vaginoplasty: Penile Inversion Procedure (get ready to squirm!)

steps-of-penile-skin-inversion-vaginoplasty-used-with-permission-of-xochitl-vinajaThe procedure begins with an incision down the centerline of the scrotum from the base of the penis and a catheter is inserted into the urethra. The muscles making up the pelvic floor are separated to make a path for the neovagina to pass through and into the body. The ductus deferens are cut and the testes removed (and sent to pathology for examination). Then a radial incision is made on the skin of the penis just under the glans and the penis skin is dissected from the shaft. The degloved penis is pulled through the skin into the scrotal opening and is further dissected: the corpora cavernosa are separated and cut off at the base and discarded; the urethra and the glans cap connected to the neurovascular bundle are retained. The glans is reduced by removing epithelial tissue — this becomes the neoclitoris and is placed at the base of the corpora cavernosa via a small incision in the skin which had been at the top of the base of the penis. Another small incision is made about 1 cm below there and the urethra is passed through and cut at skin level and both are sutured into place. The penile shaft skin is sutured together at the glans end (sometimes additional skin is attached to give extra depth, then pulled inside out such that the epidermis is on the interior of the resulting tube. This is fed between the pelvic floor muscles and form the neovagina. A stent or packing is inserted to hold the shape of the neovagina for the first week. Skin from the base of the penis is reformed to make labia minora, and scrotal skin used to make labia majora, which closes the body back up. Sometimes excess scrotal skin is used to add depth to the neovagina before the skin is inverted and inserted.

Simple, right?

Hello? Are you still there? Did I scare you off?

If you’re still here, you might be interested in the following:

A YouTube video with the procedure shown using CGI:

Anatomy of Genital Reaffirmation Surgery (PDF)

Modifications and Alternatives

While penile inversion is currently the most common method, there are other techniques for vaginoplasty. One is the use of peritoneal tissue (harvested laparoscopically) to augment the skin from the penis shaft, another involves the resection of a segment of the sigmoid colon, which is then repurposed to form the vaginal canal. The former is a relatively new technique, which has some promise of enabling the vagina to self-lubricate. The latter also creates a self-lubricating vagina, but is a much more invasive procedure with a more difficult recovery. I understand that some surgeons incorporate tissue from the urethra which would otherwise be discarded into the neovagina, since urethral tissue is mucuosal and can also provide some lubrication.


So what do you think? Are you ready to sign up? Or are you squirming and feeling uncomfortable about what happens in this surgery? For me, I’m engrossed in this – I find it quite interesting, and I have no reservations about having this done to me. But I’ll understand if you pass on this for yourself.

In the future, I’ll get into why I’m pursuing this and what I expect to come of it. Feel free to send me your questions and comments – I read all of them and try to respond to each one.

Until then, I’m constantly becoming more…

Me

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