More than half of trans women who have 'bottom' surgery are in so much pain years later they need medical attention, a study suggests.
Up to a third of patients also struggled to use the toilet or suffered sexual issues 12 months after the operation, which sees patients transitioning from male to female given a surgically constructed vagina.
Researchers from the Women's College Hospital (WCH) in Ontario, Canada, analyzed the medical records of 80 patients who sought care from the clinic between three months and five years after having the operation.
In the latest study, Canadian researchers looked at the medical records of patients who sought care between 2018 and 2020 at WCH's newly opened Postoperative Care Clinic.
All 80 patients had the original vaginoplasty procedure outside of the Women's College health system but were experiencing symptoms that needed follow-up care.
Some had traveled as far as India and Thailand to have the operations, which the researchers say may explain the relatively high number of medical complaints.
The most common symptoms reported by post-op patients were pain (53.5 percent), bleeding (42.5 percent) and dilation issues (46.3 percent).
Severe side effects were much rarer, but in 12 cases - or 15 percent - patients experienced vaginal stenosis, the narrowing and shortening of the vagina.
In two other cases, patients had severe infections around the surgical site, and another two were hospitalized with mental health problems.
Much more common were minor outcomes like difficulty urinating (22.5 percent), sexual problems (33.8 percent), and poorly healing wounds (21.3 percent).
A total of 15 patients (18.8 percent) also told the clinic they were dissatisfied with the appearance of their new vulva and wanted some cosmetic revision.
Most complaints of ongoing pain were treatable with topical medication or more regular check-ups.
Although classified as 'minor' in medical records, many of these symptoms had the potential to grow into much more serious difficulties had patients not sought treatment, the study emphasized.
For this reason, 'surgical centers should be providing ongoing post-operative care, especially in the first year after surgery,' researchers urged.
This is especially crucial given the rise in popularity of the procedure in recent years and its high cost, which can push those seeking the surgery to cheaper and less well-regulated surgeons overseas.
The above map shows the population of transgender adults and children across America in 2020, according to the Williams Institute at the University of California, Los Angeles. Its estimate for children aged 13 to 17 has doubled since 2017. It shows the highest population is in southern states, followed by those along the east coast
Bottom surgeries such as vaginoplasties and phalloplasties - genital reconstruction undergone by women transitioning to men - cost around $25,000.
'It is quite clear from the most up-to-date studies that vaginoplasty and other genital surgeries don’t work in the way that people hope they will,' says Stella O'Malley, psychotherapist and director of campaign group Genspect.
'The reason why there is so many problems is because this is an incredibly difficult surgery. Young vulnerable people need to know about the challenges they will face post surgery but few of them do.'
The latest study was published in the journal Neurourology and Urodynamics.
In Canada, the first country to collect and publish data on gender diversity from a national census, 100,815 transgender individuals make up 0.33 percent of over-15s.
There are approximately 1.6 million transgender and non-binary adults living in the US, which makes up around 0.5 percent of the adult population.
Gender-affirmative care for US adults and adolescents can include a number of medical, behavioral and social changes, as well as surgery.
For adolescents who have not yet gone through puberty, puberty-blocking medication can suppress the release of the sex hormones testosterone and estrogen, which halts the development of secondary sex characteristics like breasts and facial hair.
Whether or not original puberty was blocked, trans adults and adolescents can also begin hormone therapy, which essentially initiates the puberty of their gender identity. These hormones can be taken as pills, patches and gels, and are taken continuously throughout adulthood, or until the desired physical traits are achieved.
Surgical options include facial, chest and genital altering procedures, and are generally the last step of the transition process.
According to the World Professional Association for Transgender Health, anyone seeking bottom surgery is recommended to have completed certain criteria such as: reaching the age of adulthood in their location; having persistent, diagnosed gender dysphoria; having the capacity to make an informed decision; and completing 12 continuous months of hormone therapy while living the congruent gender identity.
Vaginoplasty - the procedure undergone by patients in the new study - is a particularly invasive procedure, requiring a surgery during which the penis and testicles are removed and a functional vagina is created.
The most common form of vaginoplasty is a Penile Inversion, whereby skin removed from the penis is inverted to form a pouch and inserted into a cavity created between the urethra and rectum. The urethra is then partially removed, shortened, and repositioned.
The surgery tends to take between two to five hours, and is done under general anesthesia.
For female-to-male genital reconstruction, doctors can construct a penis by using a flap of skin, fat, nerves and arteries - usually taken from the arm or thigh - and grafting it on to the groin. In some cases, surgeons will lengthen the urethra to allow for urination from the tip of the penis, or add testicle implants and an erectile device.