• Christine Milrod, Martin Monto, and Dan H Karasic.
• Southern California Transgender Counseling, Los Angeles, CA, USA. Electronic address: info@transgendercounseling.com.
• J Sex Med. 2019 Apr 1; 16 (4): 586-595.

IntroductionRising numbers of trans women are undergoing genital surgeries, such as vulvoplasty or vulvovaginoplasty, to create a neovagina. Medical professionals who adhere to the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7, and who recommend or perform these procedures, are expected to balance best practices with patient preferences, specifically the decision to create or omit the vaginal canal. Due to a paucity of literature on gender-confirming vulvoplasty (GCV) in trans women, there has been no documentation of factors that prompt practitioners to reject or recommend the procedure.AimThe aim of the study was to provide descriptive data of WPATH-affiliated medical professionals' knowledge, experiences, and attitudes toward GCV; surgical risks, benefits, and any considerations when referring transgender women 18-21 years of age for this procedure.MethodsPurposive sampling of all physicians, surgeons, nurse practitioners, physician assistants, and registered nurses listed in the WPATH membership directory was initiated via invitational e-mails. The 32-item survey focused on demographics, medical practices, surgical techniques, and reasons for recommending or rejecting the procedure. Data analysis included frequencies and Pearson's χ2 test.Main Outcome MeasuresKey outcome measures included frequency of cases performed; reasons for recommending, rejecting, or performing GCV; and differences in attitudes toward the procedure among various medical professionals.ResultsN = 198 (20.7%) of 956 solicited professionals completed the survey. Surgeons (n = 61) comprised 30.8% of the total sample. 46 surgeons (76.7%) reported having performed vulvovaginoplasty, and 25 (41.7%) had performed GCV. "Patient request" was the most common reason for recommending or performing GCV. Surgeons were more likely to either agree and perform (30.4%), or reject (32.1%) GCV in a patient aged 18-21 than other practitioners, who were more likely to be "unsure" (68.5%). These differences were statistically significant (χ2 = 16.467 [2]; n = 193; P < .001).Clinical ImplicationsThe data identify a lack of standardized terminology and surgical techniques concerning GCV.Strength & LimitationsThis is the first exploratory study to assess medical practitioner experiences and attitudes toward a seldom documented procedure. A larger, more inclusive sample would increase the statistical strength and representative aspect of the study.ConclusionThe study shows divergence in attitudes and knowledge among medical practitioners who recommend or perform GCV, and uncertainty when the patient is 18-21 years old. The study contributes to an expanded description and specific indications of performing GCV in the updated WPATH SOC Version 8. Milrod C, Monto M, Karasic DH. Recommending or Rejecting "the Dimple": WPATH-Affiliated Medical Professionals' Experiences and Attitudes Toward Gender-Confirming Vulvoplasty in Transgender Women. J Sex Med 2019;16:586-595.Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

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