Development of Feminizing Genitoplasty for Gender Dysphoria

Abstract

Determining the history and development of feminizing genitoplasty is fascinating and instructive but fraught with difficulty. Earliest examples relate to practices carried out in ancient cultures. Gender reassignment surgery (GRS) developed from reconstructive procedures for congenital abnormalities. Some surgery was disguised, techniques were not recorded, and operations were carried out in secret. The aim of this article is to review the historical development of male-to-female GRS. Information was gleaned from Medline and general Internet searches. Further evidence was found by reviewing the references of early articles. A fascinating insight was also found in the autobiographies of GRS patients. The first recorded case was by Abrahams in 1931. Techniques evolved from the early vaginal absence work of Beck and Graves. Pioneers of GRS were Sir Harold Gillies in England and Georges Burou of Casablanca. In the 1950s, they both used invagination of the penile skin sheath to form a vagina. Howard Jones, of Johns Hopkins, published the second classic technique using penile and scrotal skin flaps. These two methods form the basis of male-to-female GRS today. The history of GRS reveals a struggle to improve functionality as well as cosmesis. In particular, the neovagina but also a functioning neoclitoris, which has developed from a cosmetic swelling into an innovated organ, derived from the glans penis and harvested penile neurovascular bundle. Improved function and cosmesis continue to be the aim of the gender dysphoria surgeon. However, this review suggests the future management of transwomen should address not only refinements of surgical techniques but also prospective collection of posttreatment quality-of-life issues.