Trans Feminine Surgeries

Introduction

Time to Read 15 mins

This section will be covering most of the common surgeries trans-feminine or non-binary people would consider. Not every surgery will be covered, as some are extremely specific. The information provided on this website is intended to be relevant for everyone.

Additionally, links and information will be provided for Ontario residents on how to access these surgeries and funding.

Breast Implants

Breast implants are one of the more common surgical procedures trans-feminine individuals are interested in.

Breast implants are covered by the Ministry of Long-Term Care (MOHLTC), which is a branch of the government that decides whether an individual gets funding for a surgery, only if the individual has been on hormones for 12 months straight and has not developed any breast tissue whatsoever (Bourns et al., 2023 p. 30).

Implants can be placed in one of two ways → 

There are two different types of implants →


Fat grafting, which involves taking fat from elsewhere on the body and using it for breast augmentation, is potentially a third option but is not covered.

Silicone implants generally have a gummier feel to them and usually look and feel slightly more realistic than saline implants, but they are the more expensive option.

Saline implants are also made of silicone but are filled with saline solution. They have a consistency similar to water, which can feel slightly less natural by comparison. Saline implants can also “ripple or wrinkle,” which occurs when the implant is inserted under a thin layer of skin and folds in the implant cause unnatural creases to form momentarily (Horton, 2017).

Saline implants are the cheaper option, but if funding is approved this difference in cost will not matter.

Risks and Longevity

Breast implants come with many risk factors, and careful consideration should be taken before committing to surgery.

Breast implants are not permanent. They typically last 10–15 years before needing to be replaced. If this timeline is not followed, an implant can rupture inside the chest, causing its contents to leak into the body and requiring immediate surgery.

Additionally, it is much harder to secure funding for implant removal or a second insertion. Patients will likely need to pay $10,000–15,000 out of pocket for these procedures (Rainbow Health Ontario, 2024 p. 2).

Any fat, tissue, and skin changes that occur during surgery are permanent and cannot be undone. If implants are removed, the skin may be permanently wrinkled or stretched.

These are some of the more common risks associated with breast implants (Rainbow Health Ontario, 2024 p. 2).



Implants 101

  1. Under the pectoralis chest muscles
  2. Just under existing breast tissue

           (Rainbow Health Ontario, 2024 p. 1)

  1. Silicone implants
  2. Saline implants
 













Additional Risks

  1. Numbness or loss of sensation in the nipples or breasts
  2. Breasts appearing too close together or asymmetrical
  3. Blood or fluid collecting in the surgical site during healing, which may need to be drained
  4. Calcification or lumps forming in the breast

Vaginoplasty

Vaginoplasty refers specifically to the removal of testes and erectile tissue for the purpose of creating a neo-vagina that includes a vaginal canal with inward depth.

There are other surgeries that involve specific removal of testes and erectile tissue, or removal combined with creation of an outward-facing neo-vagina, but vaginoplasty refers to procedures that include a vaginal canal (Rainbow Health Ontario, 2024 p. 15).

In Canada, surgeons perform penile inversion vaginoplasty (PIV). While there are other common techniques, these are not offered within Canada.

PIV involves taking the skin from the shaft of the penis and inverting it to create a neo-vagina. The average depth is 8–11 cm (approximately 3–4.5 inches), though this is completely dependent on individual anatomy (Rainbow Health Ontario, 2024 p. 16).

  1. Removal of testes if not previously completed through a stand-alone orchiectomy
  2. Deconstruction of the penis into its components, including the glans penis, blood vessels and nerves, urethra, skin, and erectile tissue
  3. Creation of vulvar structures such as the mons, labia, clitoris, clitoral hood, and urethral opening using scrotal, penile, and urethral tissue
  4. Formation of the clitoris from a small portion of the glans that remains connected to the penile dorsal nerves and blood vessels
  5. Creation of the vestibule, which is the space between the urethral opening and the clitoris, using urethral mucosa tissue
  6. Creation of space for the vaginal canal between the genitourinary tract (bladder, prostate, urethra) and the rectum
  7. The prostate remains intact and in place. The inner walls of the vagina are lined with skin from various tissues depending on the type of vaginoplasty performed 

           (Rainbow Health Ontario, 2024 p. 16)

Alternative Options

In some cases, patients may not have sufficient tissue for a standard penile inversion vaginoplasty.

Alternative options include:

  1. Penile inversion vaginoplasty with a skin graft taken from the thigh, which is available in Ontario
  2. Use of tissue from the abdominal lining or bowel to line the vaginal canal, which is not available in Ontario and requires travel

(Rainbow Health Ontario, 2024 p. 16)

 

Risks and Complications

Vaginoplasty is an intensive surgery with many risks, in addition to those associated with major surgery in general.
Possible complications include

  1. Vaginal stricture or stenosis, meaning significant narrowing or closure of the vaginal canal
  2. Vaginal remnant secondary to introital stenosis, where fluid can accumulate and lead to abscess formation, pain, fistula formation, or other complications
  3. Partial or complete graft or flap necrosis
  4. Vaginal canal displacement
  5. Hair growth inside the vagina

(Rainbow Health Ontario, 2024 p. 17)

Urological complications include:

  1. Urethral meatal stricture or stenosis (narrowing or blockage of the urethral opening)
  2. Urinary incontinence
  3. Overactive bladder
  4. Fistula formation between the vaginal canal and urethra

(Rainbow Health Ontario, 2024 p. 18)

A recto-vaginal fistula may also occur if the vaginal canal and rectum are not properly separated, allowing gas and feces to exit through the vagina.

Other risks include:

  1. Hypergranulation (overgrowth of healing tissue)
  2. Functional dissatisfaction with size, shape, or positioning of anatomy such as the vagina, clitoris, urethra, or labia
  3. Hypertrophic scarring
  4. Loss of sensation
  5. Loss of sexual function or inability to orgasm
(Rainbow Health Ontario, 2024 p. 18)

Post Operative Care

Post-operative care following vaginoplasty is extremely painful and time-consuming.

Patients must be prepared to give up approximately three months following surgery to heal. There is no flexibility around this timeline. Patients must be able to care for themselves or ideally have assistance, as returning to work or normal life before this point is not realistic.

Early Recovery

For the first week post-operation:

  1. A stent, typically a condom filled with cotton, is inserted into the vagina to keep it open
  2. A urinary catheter is inserted into the urethra to allow urination
  3. After one week, the stent is removed and dilation begins.

Dilation Process

  1. Dilation must be performed 3–4 times per day, every day
  2. A dilator is a hard plastic tube that must be inserted to maximum depth for 20–30 minutes
  3. Dilators come in three sizes; the largest must be used to allow for penetrative sex with partners of any size

Missing dilations or failing to insert the dilator fully can result in the vagina losing depth as it closes from the deepest point.

After each dilation session:

  1. A sitz bath is required
  2. Douching with saline solution is needed to remove blood and fluids
  3. All equipment must be cleaned and prepared for the next session

Each dilation cycle takes just under two hours and must be repeated 3–4 times daily for the first three months.

Dilation continues:

  1. Daily for at least one year
  2. Weekly thereafter

Exploration of the vagina may begin three months post-vaginoplasty, along with penetrative sex if the patient feels ready (Rainbow Health Ontario, 2024 p. 21–22).

Funding and Access in Ontario

Many surgeries are covered by the Canadian government. Approvals go through the Ministry of Long-Term Care (MOHLTC) (Bourns et al., 2023 p. 31).

This process is completed by a doctor who is qualified or willing to conduct a transition-related surgery visit (TRS), which may include more than one appointment.

MOHLTC requires two letters before approving gonadal or external genital surgery →

(Bourns et al., 2023 p. 33)

Additional criteria include →

(Public Health Agency of Canada, 2024; Ontario Ministry of Health, 2023)

Once both letters are completed, the doctor submits them along with a funding request form to MOHLTC. If approved, the patient may apply to a surgeon of their choice within Canada (Bourns et al., 2023 p. 33).

This is a brief overview of the funding process. For additional details, including timelines, funding expiry, and options for surgery outside of Canada, please visit:

https://camh.ca/-/media/files/transrelatedsurgery-faq-en-pdf.pdf 


  1. One letter from a doctor
  2. One letter from a registered nurse, psychologist, or registered social worker
  1. Being at least 18 years old
  2. Having a diagnosis of persistent gender dysphoria
  3. Completing 12 continuous months of hormone therapy
  4. Living for 12 continuous months in the gender role that aligns with the individual’s identity

References

Vincent, B. (2018). Transgender health: a practitioner’s guide to binary and non-binary trans patient care. Jessica Kingsley Publishers.

Ontario Ministry of Health. (2023). Gender confirming surgery. Ontario.ca.

Public Health Agency of Canada. (2024). How to access gender-affirming care: Options. Canada.ca.

Rainbow Health Ontario. (2024). Gender affirming surgery: Summary sheets, series 1 [PDF].

Horton, K. (2017). Silicone vs saline breast implants. American Society of Plastic Surgeons.

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