Postsurgical Changes in the Neovagina

by M. Italiano

This article first appeared in the AEGIS (American Educational Gender Information Service)publication Transgender Treatment Bulletin in February 1998 1(2), page 8.
It is reprinted by permission.

Recent attempts at vaginoplasty for transsexuals have utilized a variety of techniques, including split-thickness and full-thickness skin grafts, penile inversion procedures, and sigmoid-colon methods.

Although the advantages and disadvantages of each continue to be debated, many stated advantages are are clearly exaggerated or are erroneous. For instance, Masters and Johnson's (1966) pioneering work on the artificially-constructed vagina clearly demonstrates that "the method of creating an artificial vaginal barrel is incidental, since the functional reaction patterns of artificial vaginas are identical regardless of how they are constituted" (p.101) This statement includes behavior during arousal and orgasm as well as lubrication, a subject steeped in controversy.

Some surgeons opt for the use of sigmoid-colon methods in the belief that this provides an advantage of lubrication secreted by colon mucosa. Other surgeons employ mucosal flaps from the urethra to supplement penile inversion for the purpose of providing lubrication. They believe lubrication can't be achieved by the use of skin grafts or penile inversion. This is untrue.

There is much to be learned from nontranssexual women who have had surgery for "inadequate" vaginas. From months to sometimes years after skin grafting, the graft loses all of its skin properties and adapts to its environment, becoming a mucosa which takes on "the exact cytology, gross and microscopic, of a normal vagina" (Sherfey, 1973). Masters and Johnson state, "Suffice it to say that on the basis of pure cytologic evaluation, it is impossible to differentiate the epithelial cells taken from the artificial vaginas of Subject 'A' (when under the influence of adequate hormonal replacement) or Subject 'B' from those of a normal vaginal mucosal smear" (Masters & Johnson, 1961, p. 203).

Some surgeons disagree, stating that the tissue is not mucosa, but only resembles mucosa. They are only partially correct, since the normal female vaginal tissue is not truly mucosa either. It is called mucosa only because it lines a body passageway. It contains no mucous-secreting glands (Fawcett, et. al., 1995). That is why lubrication is a transudate phenomenon, the source being dilation of the capillaries that surround the barrel and the subsequent squeezing out of fluid through the vaginal walls, which in normal and artificially constructed vaginas have been shown to be a functioning two-way membrane. (Masters & Johnson, 1966). Although Masters & Johnson note that production of lubrication usually takes longer in the artificial vagina, they also showed that some artificial vaginas are capable of lubricating as well and as rapidly as any normally constituted vaginal barrel and that two of their patients had "lubricated, in fact, more effectively than many women with normally constituted vaginas" (Masters & Johnson, 1966).

Pierce et. al. (1956) demonstrated the conversion of skin to vaginal epithelium, which after twenty years, included normal vaginal PH levels, complete loss of hair, complete loss of pigment, complete loss of sweat glands, and normal vaginal epithelial glycogen levels. They proposed, "the process is not one of metaplasia, for no new cell types are produced. Rather, there is alteration of existing cell layers and the loss of the skin organs." (p.6)

Those post-operative male-to-female transsexuals who amuse themselves with the peculiar statement that they still have a penis, but that it's just turned inside-out should note that not only do they not have a penis, but they don't even have skin of the penis any more. The histology of the tissue has changed. It also responds to hormones in an identical way as does a normal vagina, with "cyclic cornification and mucification" (Sherfey, 1973). The presence of ovaries is not a necessity. For instance, "The estrogenic and early luteal effects demonstrated by Subject 'A' are obvious, and serve as a clinical indication of adequate steroid replacement in this surgically castrated female" (Masters & Johnson, 1966, p. 203).

More impressive is a recent report by Alessandrescu et. al. (1996), who did biopsies on twelve artificially constructed vaginas and found an epithelial structure identical to that of oa normal vagina. Two examples are shown in the form of pictures using electron microscopy.

Although it may be suggested that transsexuals may respond differently than nontranssexual females with regard to the results of vaginoplasty, it is my opinion that the burden of proof that this is the case rests with the surgeons who employ such procedures as colon usage and mucosal flaps for the purposes they intend. Since the nature of their work is clinical and generally not investigative, they should at least advise their patients that future study may be necessary before the value of their technique can be substantiated.


Alesandrescu, D., et. al. (1996). Neocolpopoiesis with split-thickness skin graft as a surgical treatment of vaginal agenesis: Retrospective review of 201 cases. American Journal of Obstetrics & Gynecology, 174(1), 131-138.

Fawcett, D.W., et. al. (1994). Textbook of histology (12th ed.). New York: Chapman & Hall.

Masters, W.H. & Johnson, V.W. (1961, May-June). The artificial vagina: Anatomic, physiologic, psychosexual function. Western Jourmnal of Surgery, Obstetrics, & Gynecology,69,192-212.

Pierce, G.W., et. al. (1956, July). Changes in skin flap of a constructed vagina due to environment. American Journal of Surgery, 92,4-8.

Sherfey, M. (1973). The nature and evolution of female sexuality. New York: Random House.