Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States

J Sex Med. 2017 Apr;14(4):624-634. doi: 10.1016/j.jsxm.2017.02.007. Epub 2017 Mar 17.


Background: A rising number of female-affirmed transgender adolescents are being treated with gonadotropin-releasing hormone analogues and subsequently cross-sex hormones at early or mid-puberty, with vaginoplasty as the presumed final step in their physical transition. But, despite the minimum age of 18 years defining eligibility to undergo this irreversible procedure, anecdotal reports have shown that vaginoplasties are being performed on minors by surgeons in the United States, thereby contravening the World Professional Association for Transgender Health (WPATH) standards of care (SOC).

Aim: To explore surgeons' attitudes toward ethical guidelines in the SOC; any professional experiences of performing vaginoplasty on transgender minors; views of surgical risks, benefits, and harm reduction measures; and perceptions of future challenges and concerns in this area of surgical practice.

Methods: A qualitative semistructured interview approach was used to collect data from 13 male and 7 female surgeons who perform transgender vaginoplasty in the United States.

Outcomes: Professional experiences and attitudes toward vaginoplasty in transgender minors were analyzed using the constant comparative method applied to 20 individual interview transcripts.

Results: While there was close agreement concerning surgical techniques, proper patient selection, and predictive elements of postoperative success, attitudes toward the SOC and the reliance on the guidelines varied. The sole practitioner model is gradually giving way to a more holistic team approach, with patient responsibility dispersed among different professionals. Different approaches to surgical training, professional standards, and fellowship programs were suggested. Several participants expressed a need for centralized data collection, patient tracking, and increased involvement of the WPATH as a sponsor of studies in this emergent population.

Clinical implications: Drawing on surgeons' attitudes and experiences is essential for the development of standards and practices. A more precise and transparent view of this surgical procedure will be essential in contributing to the updated version 8 of the WPATH SOC.

Strengths and limitations: The abundant data elicited from the interviews address several meaningful research questions, most importantly patient selection criteria, surgical methods, and issues critical to the future of the profession. Nevertheless, the limited sample might not be representative of the surgical cadre at large, particularly when exploring experiences and attitudes toward vaginoplasty in minors. A larger participant pool representing WPATH-affiliated surgeons outside the United States would improve the generalizability of the study.

Conclusion: Taken together, the study and its findings make a significant contribution to the planned revision of the WPATH SOC. Milrod C, Karasic DH. Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States. J Sex Med 2017;14:624-634.

Keywords: Adolescent; Gender Confirming Surgery; Surgeon; Transgender; Vaginoplasty; World Professional Association for Transgender Health.

MeSH terms

  • Adolescent
  • Attitude of Health Personnel*
  • Female
  • Gynecologic Surgical Procedures / methods
  • Humans
  • Male
  • Physician-Patient Relations*
  • Practice Patterns, Physicians'*
  • Surgeons
  • Transgender Persons
  • Transsexualism / surgery*
  • United States
  • Vagina / surgery*