Feminizing Bottom Surgery

What is feminizing bottom surgery?

Feminizing bottom surgery is a surgical procedure that transforms and reconstructs some of the organs in the male reproductive system into parts of the external (outside) female reproductive system (vulva). The vulva includes:

• Labia. The labia are folds of skin that surround the urethra and vagina.
• Clitoral hood. The clitoral hood is a fold of skin that covers and protects the clitoris.
• Clitoris. The clitoris is a sensitive, pea-sized mass of tissue above the urethra; stimulation can help you achieve orgasm.
• Urethral opening. The urethra is the tube that allows pee to leave your body. It’s below the clitoris.

Feminizing bottom surgery may or may not include creating a vaginal canal (vagina).

Feminizing bottom surgery has many other names. Other names for the procedure include:

• Transfeminine bottom surgery.
• Male-to-female (MTF) bottom surgery.
• Feminizing genital surgery.
• Feminizing genitoplasty.
• Gender-affirming bottom surgery.
• Full-depth vaginoplasty.
• Zero-depth vaginoplasty (vulvoplasty).

Why is feminizing bottom surgery done?

Getting feminizing bottom surgery is a personal decision. You may feel a disconnect or emotional distress between your assigned gender and gender identity (gender dysphoria). Getting feminizing bottom surgery can help affirm your gender identity and ease gender dysphoria.

How common is feminizing bottom surgery?

Experts estimate that 5% to 13% of transgender women get feminizing bottom surgery.

What happens before feminizing bottom surgery?

First and foremost, it’s essential to find trusted, experienced healthcare providers and hospital systems. But how do you find providers and hospital systems you can trust? The following can help:

• Research your providers. You can look up providers’ medical board and license information on your state’s medical database or a national database.
• Make sure you feel comfortable talking to your providers. Your providers’ approach to your thoughts and feelings should be kind, respectful and understanding. They should give you a chance to ask questions and provide thoughtful answers. You should feel comfortable talking to them about your body and desires.
• Find providers who have experience with feminizing bottom surgery. It’s a good idea to seek out providers and hospital systems with a lot of experience with this procedure. The more experience they have, the better they are.

Providers that can help you understand the risks, benefits and steps you must take before feminizing bottom surgery include:

• Social worker. A social worker helps provide social services to you and your support system. They can also help discuss potential causes of stress you may encounter as part of your surgery and recovery.
• Psychologist. A psychologist is a mental health professional. Gender dysphoria isn’t a mental health condition, and talking to a psychologist doesn’t mean you have a mental health condition. But sometimes, mental health conditions — such as anxiety, depression and post-traumatic stress disorder (PTSD) — can accompany dysphoria and may require treatment before surgery.

You must also meet the criteria from the World Professional Association for Transgender Health (WPATH). This includes:

• Long-lasting, well-documented and professionally diagnosed gender dysphoria.
• Ability to make a fully informed decision and permit healthcare providers to provide treatment (consent).
• In some areas, you may need to be 18 or older.
• Being in control of medical or mental health conditions.
• Referrals or letters of recommendation from two qualified mental healthcare providers.
• At least 12 ongoing months of feminizing hormone therapy.

Your providers may also require the following:

• Copies of your medical records, including letters of support.
• A body mass index (BMI) less than 35.
• You don’t smoke or are able to quit smoking for at least four weeks. Smoking increases your risk of infection, slows your healing process and will affect your results.
• You have a family member or close friend who can stay with you during the procedure and while you recover at the hospital and at home.
• Laser hair removal or electrolysis on your genitals before surgery. These treatments help prevent hair growth in your vagina after surgery.
• You have realistic expectations of the surgery, recovery and potential risks.

How should I prepare for feminizing bottom surgery?

Tell your provider about any ongoing medical concerns so they can help you plan for feminizing bottom surgery. Detail any prescription or over-the-counter (OTC) medications you’re taking, including herbal supplements. Nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen (Tylenol®), blood thinners (anticoagulants) and certain herbal supplements can increase your risk of bleeding.

You should also tell your provider about any allergies you have. These include allergic reactions to:

• Medications.
• Skin cleaners, like iodine or isopropyl alcohol.
• Latex.
• Foods.

What kinds of healthcare providers make up the surgical staff for feminizing bottom surgery?

The healthcare providers on your feminizing bottom surgery team generally include:

• Reconstructive urologist. A reconstructive urologist is a surgeon who specializes in treating the urinary system and reproductive system.
• Plastic surgeon. A plastic surgeon specializes in surgical techniques that improve the function and enhance the appearance of parts of your body.
• Anesthesiologist. An anesthesiologist is a type of doctor who specializes in giving you anesthesia. Anesthesia reduces your pain during medical procedures or surgery.
• Surgical nurses. Surgical nurses help care for you before, during and after the surgery. They may also assist your surgeons as necessary.

What happens during feminizing bottom surgery?

Shortly before feminizing bottom surgery, your anesthesiologist will give you anesthesia, so you aren’t awake and won’t feel any pain.

Once you’re asleep, your surgical team will:

• Remove the testicles (orchiectomy).
• Perform a vaginoplasty. During a vaginoplasty, they’ll remove most of the penis tissue (penectomy) and create a space between your urinary bladder and rectum. They’ll then reshape and invert (turn “inside out”) the outer penis skin and insert it into the space they created to form a vagina.
• Remove a small part of the glans (tip) of the penis to create your clitoris (clitoroplasty). This includes the accompanying nerve tissue and blood vessels that allow your clitoris to have feeling.
• Perform a labiaplasty. During a labiaplasty, they’ll rearrange the scrotal skin (the pouch of skin that holds the testicles) into your labia.

How long does feminizing bottom surgery take?

It depends. Feminizing bottom surgery is a delicate procedure that takes a lot of time. Your body is unique, and the different techniques that make up the surgery can be complex. On average, it takes about five hours. But it’s a good idea to ask a healthcare provider. They can give you a better estimate according to your situation.

What happens after feminizing bottom surgery?

After feminizing bottom surgery, if you want a vagina, your surgeon will place a conformer into your vagina. A conformer is a medical object that helps your vagina keep its shape as you heal. They may also place drainage tubes to help drain any blood or fluid. A healthcare provider will then cover your incisions with bandages.

Your anesthesiologist will stop putting anesthesia into your body to keep you asleep, and you’ll move into a recovery room. In the recovery room, providers will wait for you to wake up and monitor your overall health.

Once your healthcare providers believe it’s safe, they’ll discharge you (let you go home). Most people must stay in the hospital for at least a few days after feminizing bottom surgery as they heal.

What are the benefits of feminizing bottom surgery?

One of the main benefits of feminizing bottom surgery is it helps you achieve your desired physical gender identity. Studies show that other benefits may include reductions in:

• Emotional and psychological distress.
• Smoking.
• Thinking of or entertaining suicide (suicidal ideation).

What are the risks or complications of feminizing bottom surgery?

Feminizing bottom surgery risks include:

• Changes to sexual sensation.
• Trouble emptying your bladder when you pee (urinary retention).
• A vagina that’s too shallow or small for intercourse.
• Your vaginal opening narrows or closes (vaginal stenosis).
• Breakdown of new vaginal tissue (necrosis).
• A hole that develops between your rectum and vagina (rectovaginal fistula).
• Narrowing of your urethra (urethral stricture).

The odds of these complications are rarer if you’re under the care of experienced healthcare providers in a hospital that regularly performs feminizing bottom surgery.

Other general surgery risks include:

• Anesthesia complications.
• Bleeding.
• Blood clots.
• Infection.

Is feminizing bottom surgery painful?

You’ll have some pain and discomfort after feminizing bottom surgery. But the pain is rarely unbearable. Many people manage their pain with prescription and over-the-counter pain medications. The first several days after surgery are often the most painful.

What is the recovery time after feminizing bottom surgery?

Most people spend at least a few days at the hospital. But your stay can last up to a week. After about a week, your pain and discomfort should decrease.

You won’t be able to sit down or lie on your stomach for at least two weeks. So, you’ll need to stand rather than sit and sleep or lay on your sides or back. Your providers will tell you how much walking to do to help with your recovery. Typically, you should have a limit of 3,000 steps per day the first several weeks after the procedure to promote healing and reduce complications.

It’s important to remember that your body is unique, so your recovery time might be different from others. Follow your healthcare provider’s instructions on managing pain or discomfort as you recover.

What is the outlook for people who have feminizing bottom surgery?

Studies show that most people who get feminizing bottom surgery are happy with their appearance and functionality after the procedure.

Can you still feel after feminizing bottom surgery?

Under the care of an experienced surgeon, your outlook for having feelings in your vagina and vulva — including sexual pleasure in your clitoris — is good.

How can I take care of myself after surgery?

Schedule regular follow-up appointments with your healthcare provider. They’ll check your incisions and remove your bandages, drainage tubes and any stitches. They’ll also check to see how well the area is healing.

During your recovery, it’s important to use vaginal dilators. Vaginal dilators are tube-shaped devices that you insert into your vagina to help stretch the tissue gradually. Healthcare providers will teach you how to use them. They’ll also give you instructions on how often to use them.

Your providers won’t remove your prostate during feminizing bottom surgery. So, you should schedule regular prostate exams starting at age 50. If you’re at a higher risk of getting prostate cancer, you should schedule regular exams beginning at age 45.

It’s also important to continue working with a therapist or counselor after feminizing bottom surgery. For many people, surgery is only one step in the process. A therapist or counselor can help discuss potential causes of stress to your mental health. This may include adjusting to new genitals and any recovery setbacks.

When can I go back to work?

Depending on your job, you should be able to return to work a few weeks after feminizing bottom surgery. It’s a good idea to take even more time off work if you have a more physically demanding job.

When should I call my healthcare provider?

Contact your healthcare provider immediately if you experience any of the following:

• Bleeding that seeps through your bandages.
• Unbearable pain that doesn’t go away with medication.
• Extreme swelling.
• Signs of an infection, including fever, chills or abnormal discharge from your incision sites, such as pus.
• Your stitches come out before a provider can remove them.

How much does feminizing bottom surgery cost?

Talk to your healthcare provider. The cost may depend on:

• Your health insurance coverage.
• What your provider charges for feminizing bottom surgery.
• Where you get the procedure.

A patient financial coordinator may be able to help estimate the cost of the procedure and discuss whether you’re eligible for government or other financial assistance programs.

Can I have vaginal intercourse after feminizing bottom surgery?

Yes, you can typically have vaginal intercourse three months after recovering from feminizing bottom surgery. During the vaginoplasty, your healthcare team will make sure your vagina has a good enough size and depth to allow for intercourse.

A note from Cleveland Clinic

Feminizing bottom surgery helps affirm your gender identity. Not every person who has gender dysphoria wants feminizing bottom surgery. But for some, it can ease emotional and psychological distress, boost your self-confidence and have other positive effects on your life. It’s important to find providers with a lot of experience with this type of surgery and work with a mental health provider before and after the procedure. Working with trusted providers makes you more likely to be happy with your results.