Use of puberty blockers in transgender girls, effects on genital tissue development, and vaginoplasty options

 

Background and description of the issue

GnRH analogue medications such as Lupron, Decapeptyl, and Supprelin LA have been in use since the early 1990s to halt natal pubertal development at Tanner stage 2 or 3 in transgender adolescents with persistent gender dysphoria (de Vries & Cohen-Kettenis, 2012), and entered wider usage in clinical practice in the 2000s. Following the administration of blockers, adolescents who elect to continue transitioning will later receive cross-sex hormone therapy and gender-affirming surgeries as desired.

One concern raised with increasing frequency in recent years involves the effect of early intervention with puberty blockers on genital tissue growth in adolescent trans girls, and the impact on their future options for vaginoplasty surgery. Because construction of the neovagina typically involves primarily using the penis and scrotum as a source of genital tissue, underdevelopment of these organs may leave little material available for this method of vaginoplasty, potentially necessitating alternative approaches to this surgery using other methods.

 

Recognition of the issue in literature

It is possible for transgender girls who’ve used puberty blockers to receive vaginoplasty – genital tissue underdevelopment by no means rules out this surgery. One important point to remember is that vaginoplasty, the surgical construction or reconstruction of a vaginal canal, is not a surgery limited only to trans women: cis women affected by certain congenital conditions, illnesses, or injuries can require vaginal reconstruction as well, and they do receive these surgeries via various methods even without penile and scrotal tissue to use for these purposes. Trans girls have had successful vaginoplasties since the arrival of blockers as a treatment option for trans adolescents:

  • Cohen-Kettenis & van Goozen (1997), the seminal paper introducing puberty blockers as a treatment for trans youth, includes 7 post-blocker, post-vaginoplasty trans women.
  • Smith, van Goozen, & Cohen-Kettenis (2001) includes a further 7 trans women who received vaginoplasty after using puberty blockers.
  • de Vries et al. (2014) includes an additional 22 post-blocker trans women who’ve received vaginoplasty.
  • A press release in September of 2014 reported that California surgeon Gary Alter performed a successful vaginoplasty on a 16-year-old trans girl who had been taking cross-sex hormones since age 11 and had not experienced normal genital development.

Furthermore, potential issues with vaginoplasty due to tissue underdevelopment following use of puberty blockers have been explicitly recognized and explored in the relevant medical literature for over a decade. This includes de Vries, Cohen-Kettenis, & Delemarre-van de Waal (2006):

If a MTF adolescent has taken GnRH analogues from an early age it is possible that not enough penile skin will be available to allow for a deep vagina using the penile inversion method. In that case, additional skin may need to be used from other parts of the body, such as the groin or abdominal wall. This will be evaluated by the surgeon as part of treatment planning.

Gijs & Brewaeys (2007):

A final argument against the hormonal suppression for MFs is that in a non-normal pubertal phallic growth, the penile tissue available for vaginoplasty may be less than optimal. However, appropriate techniques exist to overcome the shortage of tissue.

Spack (2009):

Will there be enough scrotal skin for vaginal reconstruction if a genetically male child never goes through puberty? The surgeons say that this is not a problem because they can always use tissue expanders.

Hembree (2011):

The skin of the penis and scrotum are used in the construction of a vagina and labia during genital surgery for transsexual women (MtF). The amount of male genital tissue available at Tanner stage 2 is limited and may alter the techniques required for genital reconstruction at age 18. Surgeons have published good results in adolescents following puberty suppression and estrogen administration at age 16.

de Vries & Cohen-Kettenis (2012):

Trans girls who began puberty suppression at a young age often have insufficient penile skin for a classical vaginoplasty and need an adjusted surgical procedure using colon tissue.

Milrod (2014):

One of the disadvantages in adolescent girls who have been treated with GnRH analogues at an early age is the possibility of insufficient skin for penile inversion vaginoplasty. Several authors refer to autologous skin grafting from donor sites, tissue expanders, or the use of sigmoid colon tissue as viable solutions to this problem. For teenagers who begin gonadal treatment during midpuberty or later, this may not be a concern as there is generally enough tissue available for the construction of a neovagina.

And Colebunders et al. (2017):

An intestinal vaginoplasty is a good alternative technique in cases in which insufficient skin is available. A lack of penile and scrotal skin is often present in young transwomen who started hormonal therapy (puberty blockers) at a young age. … Zhang et al showed that laparoscopic-assisted vaginoplasty using a pedicled ileum or a sigmoid segment is effective in reconstructing a vagina. The advantages of using a rectosigmoid transplant are not only the length it provides but also the texture and appearance, which is more similar to the vaginal lining and its natural lubrication. Although the natural lubrication with the production of mucus is usually regarded as an advantage, it can lead to excessive discharge, especially when the ileum is used.

“It is possible”, “may need”, “this is not a problem”, “may alter the techniques required”, “published good results”, “possibility”, “viable solutions” – these are not phrases that suggest vaginoplasty is at all impossible for trans girls after use of puberty blockers, or even that the limitations of genital underdevelopment are a universal feature among these girls. As noted in literature, some will require adjusted surgical techniques, and some will not. Not only is this not always a problem for trans girls using puberty blockers, it is not only a problem for trans girls using puberty blockers: trans women who transition in adulthood, without ever having used blockers, may also sometimes require modified vaginoplasty surgeries due to the same limitations as a result of genital atrophy induced by cross-sex hormones.

 

Known successful vaginoplasty techniques following adolescent transition

Surgeons, endocrinologists, and other medical experts working with trans adolescents and adults have published the results of modified vaginoplasty procedures when insufficient penile and scrotal tissue is available for the typical approach to this surgery. Bouman et al. (2016a) and a team of surgeons working at Amsterdam’s VU University Medical Center, where puberty blockers were first routinely used for trans adolescents, report having successfully performed an alternative procedure using intestinal tissue on over 40 trans women with penoscrotal hypoplasia (insufficient genital tissue) from 2007 to 2015:

After 1 year, all patients had a functional neovagina with a mean depth of 16.3 ± 1.5 cm. Primary total laparoscopic sigmoid vaginoplasty is a feasible gender-confirming surgical technique with good functional outcomes for transgender women with penoscrotal hypoplasia.

The authors also note that a variety of techniques are available in cases of tissue underdevelopment, many of which have been used for vaginoplasty in cis women as well:

In our Center of Expertise on Gender Dysphoria, a growing group of young transgender women seeking vaginoplasty have previously been treated with puberty-suppressing hormones. This hormonal regimen may result in penile and scrotal hypoplasia, making standard penoscrotal inversion vaginoplasty not feasible. Alternatives, such as nongenital skin grafts, pedicled local musculocutaneous flaps, peritoneum, and pedicled intestinal segments, can be used as vaginal lining grafts, each with its own disadvantages. Intestinal vaginoplasty has become a technique for vaginal (re)construction, mainly described and indicated for biological women with absence of a functional vagina. In transgender women, the technique is used mainly as a secondary deepening procedure after failed penile inversion vaginoplasty. Autologous intestinal tissue as graft type provides sufficient neovaginal depth and lubrication, and it has no tendency to shrink. Based on currently available literature, intestinal vaginoplasty seems associated with low rates of adverse events.

They further add that the intestinal vaginoplasty procedure has been their center’s standard of care for all trans women with penoscrotal hypoplasia since 2007:

In this study, the surgical outcomes and prospective follow-up of primary total laparoscopic sigmoid vaginoplasty, our standard technique since November of 2007 for transgender women with penoscrotal hypoplasia, are described. … Penoscrotal hypoplasia was defined as a penile length less than 8 cm and an insufficient amount of scrotal skin to further line the neovaginal cavity to achieve functional depth.

Trans women who’ve received this modified vaginoplasty procedure have reported “satisfactory functional and esthetic results of the neovagina and a good quality of life” (Bouman et al., 2016b), and in a review of the literature, Bouman et al. (2014) concluded that alternative approaches of intestinal vaginoplasty are “a safe procedure with a beneficial outcome”.

Additionally, Milrod & Karasic (2017) surveyed a number of vaginoplasty surgeons with experience operating on trans youth with genital underdevelopment, who reported a number of alternative methods such as skin grafts, implanted scrotal tissue expanders prior to surgery, and the use of a donated acellular tissue matrix to form the vaginal canal:

There was little concern over the younger adolescent and her ability to physically withstand the invasive procedure compared with a middle-age or elderly patient; however, almost all surgeons remarked on the penoscrotal hypoplasia or limited penile shaft size that would ensue after the use of puberty-suppressing gonadotropin-releasing hormone analogues, sometimes for as long as 3 years. Two surgeons who reported operating on minors commented, “they are coming in after being put on blockers, so they have 11-year-old genitalia” (surgeon 9) and “you are really doing vaginoplasty on a micropenis” (surgeon 16). Most participants emphasized that the surgical techniques were the same for all patients no matter the age; of those who had performed the procedure on several minors, the use of flank skin grafts most commonly resolved the problem of inadequate tissue availability. In other reported measures, surgeon 2 implanted a scrotal tissue expander that required periodic infusion during 2 months, and surgeon 14 used donor tissue matrix (LifeCell, Branchburg, NJ, USA), deeming it “nicely successful” and thereby avoiding patient exposure to external flank scarring. The alternative procedure of using sigmoid- or ileum-derived grafts to create the neovagina was seen as a last resort by a few participants who stated diversion colitis, excessive secretion, persistent odors, and potential leakage of stool into the peritoneum as some of the concomitant morbidities.

 

Additional results of alternative vaginoplasty techniques in trans women

Results of the intestinal vaginoplasty procedure performed in place of standard penile-inversion vaginoplasty have been published by several additional surgical teams, encompassing both trans women who’ve used puberty blockers and those who have not. Salgado et al. (2018) report the results of 12 trans women who underwent intestinal vaginoplasty from 2014 to 2017, finding that this produced “satisfactory vaginal depth that is both sexually functional and pleasing to the patient”. The surgical team now offers this as their standard of care for all trans women with a certain degree of genital underdevelopment:

Many techniques are used in the creation of the neovaginal canal. Though there is no single optimal technique, inversion vaginoplasty with penile-scrotal flaps is the preferred and most commonly practiced method among surgeons. However, sufficient penile-scrotal skin is not always available because of limitations in either patient anatomy or patient expectations for vaginal depth. Additionally, it is becoming more common for younger patients to undergo hormonal blockade in anticipation of gender transition. Though this forestalls the distressing aspects of going through puberty incongruent with one’s gender, it may limit the amount of tissue for penile-scrotal based vaginoplasty. Patients who require revision of a failed primary vaginoplasty encounter a similar problem where sufficient tissue must be derived from elsewhere. Full-thickness skin grafts, local flaps, musculocutaneous flaps, peritoneum, and various segments of intestinal tissue have been previously described as alternative sources for vaginal reconstruction. . . .

12 consecutive patients underwent primary sigmoid colon vaginoplasty from 2014 to 2017. Our patient cohort was on average 47 +/− 15.4 years of age and had a BMI of 26.8 +/− 4.9, and all were white with the exception of one Hispanic patient. Each patient was on a cross-gender estrogen regimen. All patients had an average penis length on stretch of 4.01 +/− 0.76 inches or 10.2 +/− 1.9 centimeters. . . .

Sigmoid vaginoplasty is a reliable technique for achieving satisfactory vaginal depth that is both sexually functional and pleasing to the patient. The procedure is a collaborative undertaking that requires a skilled laparoscopic surgeon, transgender medicine team, and plastic surgeon to work with the patient to optimally achieve their goals. It is now our standard of care to offer this surgery to our transfemale patients with phallus length of less than 4.5 inches or 11.4 centimeters.

Manrique et al. (2018) report on another approach to intestinal vaginoplasty used in 15 trans women, with a 12-year followup finding that “all patients achieved normal sexual function”:

In this article, the authors present the clinical outcomes and sexual function evaluation when using the pedicle transverse colon flap for gender-confirmation surgery in transgender women. This is a retrospective chart review of all transgender women who underwent gender-confirmation surgery using the pedicle transverse colon flap. Demographics, procedure specifics, and surgical outcomes were recorded and analyzed. Sexual function was measured using the Female Sexual Function Index and the Female Genital Self-Image Scale 1 year after surgery. Fifteen patients underwent gender-confirmation surgery using the aforementioned technique. The average age of the patients was 20 years (range, 18 to 32 years), and the average operating room time was 10.1 hours (range, 8 to 12.5 hours). The average length and width of the flaps were 15 and 2.8 cm, respectively. During a 12-year follow-up, two complications were reported: one patient had pain caused by narrowing at the introitus, which required intervention, and one patient had an excessive amount of secretions in the first month, which subsided 3 months after surgery. The mean Female Sexual Function Index score was 28.6 (range, 24 to 31). All patients achieved normal sexual function as indicated by a Female Sexual Function Index score of 25 or more. For the Female Genital Self-Image Scale, the mean total score was 20.0 ± 4.5 (range, 7 to 28). The pedicle transverse colon flap is another valuable alternative method for vaginoplasty with promising results and minor complications.

Djordjevic, Stanojevic, & Bizic (2011) additionally reported the results of intestinal vaginoplasty in 86 patients, including both cis women and trans women. In this study, intestinal vaginoplasty was used as a secondary procedure for trans women in cases where an initial vaginoplasty was unsuccessful, requiring removal of the entire nonfunctional neovagina and replacement with an intestinal segment. The authors found overall satisfactory results for this procedure:

Contrary to other techniques, rectosigmoid vaginoplasty results in a self-lubricating and good-sized neovagina, which does not require postoperative dilatation for extended periods of time. Use of rectosigmoid colon as a pedicled flap for the creation of a neovagina is effective since sufficient length may be obtained with excellent blood supply that could prevent complications such as contractions, shrinkage, or narrowing. This segment is thick-walled, large in diameter, and can tolerate trauma better than small bowel, bladder, or skin grafts. Postoperative management is simple and easy. Mucous production decreases dramatically after 3–6 months regardless of length of sigmoid segment. Although sufficient to provide adequate lubrication, it was neither excessive nor irritating to our patients. Dilation or calibration of the introital anastomosis is temporary and well tolerated.

 

Summary

Genital underdevelopment in trans women who’ve used puberty blockers, and its possible impact on the surgical procedures needed for vaginoplasty in this group, are known phenomena that have already been extensively covered in the literature by medical teams working with these patients. These professionals, including those working at the center that pioneered the use of puberty blockers for trans adolescents, have consistently reported good results and satisfactory surgical outcomes for a variety of alternative vaginoplasty procedures, many of which have already been in widespread use for some adult trans women who have not used puberty blockers. This is an issue that has been effectively addressed for decades, with broad agreement that genital underdevelopment does not pose an obstacle to trans women receiving vaginoplasty surgery of similar quality to traditional procedures.

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References

  • Bouman, M.-B., van der Sluis, W. B., Buncamper, M. E., Özer, M., Mullender, M. G., & Meijerink, W. J. (2016a). Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plastic and Reconstructive Surgery, 138(4), 614e–623e. [Abstract]
  • Bouman, M.-B., van der Sluis, W. B., van Woudenberg Hamstra, L. E., Buncamper, M. E., Kreukels, B. P. C., Meijerink, W. J., & Mullender, M. G. (2016b). Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. Journal of Sexual Medicine, 13(9), 1438–1444. [Abstract]
  • Bouman, M.-B., van Zeijl, M. C., Buncamper, M. E., Meijerink, W. J., van Bodegraven, A. A., & Mullender, M. G. (2014). Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function. Journal of Sexual Medicine, 11(7), 1835–1847. [Abstract]
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About Zinnia Jones

My work focuses on insights to be found across transgender healthcare, public health, psychiatry, and history of medicine, integrating these many perspectives and guided by the lived experiences of trans people. I live in Orlando with my family, and work mainly in technical writing.
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