Introduction

In recent years, there has been a rise in referrals for gender incongruence assessment globally, including in Denmark. Estimating the transgender and gender-diverse population remains challenging, with estimates ranging from 0.02% to 4.5% of the adult population. Individuals experiencing gender incongruence often face psychological vulnerabilities, including depression, anxiety, and increased risk of suicide attempts, alongside reduced quality of life and higher rates of substance abuse.

Genital gender-affirming surgery (gGAS), including procedures like vaginoplasty and vulvoplasty, is a treatment for many with gender incongruence. Studies indicate that gGAS significantly improves quality of life and mental health outcomes, reducing distress and suicidal ideation. However, in Denmark, the public health system currently only offers certain procedures, like penoscrotal vaginoplasty and orchiectomy for individuals assigned male at birth, while excluding options like vulvoplasty.

Current Danish guidelines prioritize a “binary” outcome for bottom surgery, prohibiting gender nonconforming configurations, such as a constructed vulva without a vagina or both a penis and a vagina. The potential demand for expanding treatment options, like vulvoplasty, remains unexplored in Denmark.

Methods

The authors of a new study aimed to quantify the demand for offering vulvoplasty as a gGAS in Denmark. Participants included transgender and gender-diverse individuals assigned male at birth, aged 18 and above. An online questionnaire covering various aspects of transition was developed and distributed through transgender forums and clinics. Data collection occurred between September 1 and October 31, 2022.

Before distribution, the survey underwent testing and debriefing with stakeholders from the target group. Approval was obtained from the North Denmark Region to collect sensitive personal data, and participants provided written informed consent before participating. The questionnaire included closed-ended and open-ended questions about vulvoplasty.

Results

In the data analysis, the primary outcomes included respondents’ preferred surgeries and, when vulvoplasty was chosen, their reasons for choosing vulvoplasty. Secondary outcomes covered demographic variables like age, gender identity, and transition pathway.

Statistical analysis compared groups preferring vaginoplasty and vulvoplasty. Of 134 respondents, 35 (26.1%) preferred vulvoplasty, with 22 choosing vulvoplasty as their only preferred surgery and 13 choosing vulvoplasty or vaginoplasty.

Reasons for choosing vulvoplasty included perceived lower risk, avoidance of dilation, and not needing a vagina. Respondents preferring vulvoplasty were on average 5 years older than those preferring vaginoplasty.

Prior bottom surgeries for the participants included vaginoplasty (9 respondents), vulvoplasty (3 respondents, done in the United Kingdom), and orchiectomy (5 respondents). Of 21 respondents desiring future bottom surgery, 8 were on a waiting list for vaginoplasty.

Discussion & Conclusion

The results of this study showed there may be a demand for vulvoplasty among transgender and gender-diverse individuals assigned male at birth in Denmark. While Danish guidelines for bottom surgery currently do not offer vulvoplasty, this research sought to understand the preferences and motivations of transgender and gender diverse individuals.

Specifically, the results showed that 26.1% of study respondents preferred vulvoplasty, with most citing lower perceived risk as the primary reason. However, interestingly, individuals with a neovagina were satisfied with it. Only a small number of participants had been declined vaginoplasty primarily for somatic reasons. Whether any of these individuals would have been able to undergo vulvoplasty is unknown, but none chose vulvoplasty as their preferred surgery.

Due to limitations such as small sample size and potential selection bias, drawing strong conclusions about these results is challenging. Still, the study suggests an unmet need for vulvoplasty and constructive bottom surgery in Denmark’s transgender and gender-diverse population, advocating for patient-centered approaches and further qualitative research to better understand evolving needs over time.

References:

• Aaen, E. K., Kesmodel, U. S., Pop, M. L., & Højgaard, A. D. (2024). Requests for vulvoplasty as gender-affirming surgery: A cross-sectional study in Denmark. The Journal of Sexual Medicine, 21(3), 262–269. https://doi.org/10.1093/jsxmed/qdae003