Understanding Zero Gender Dysphoria Index Post-Vaginoplasty: Demographic, Historical, and Soft Tissue Factors

PURPOSE: Both primary and revisional vaginoplasty are correlated with significantly improved patient-reported gender dysphoria. Moreover, the authors have observed clinically that some patients report zero (“fully resolved”) gender dysphoria post-surgically. The present study aims to quantify the extent to which patients report zero Gender Dysphoria Index after primary vaginoplasty and to identify patient demographic, historical, and soft tissue characteristics that may influence this outcome. METHODS: Gender dysphoria was measured using Gender Dysphoria Index (GDI), a patient-reported measure of gender dysphoria on a 0-10 Likert scale (where zero is no gender dysphoria), at a single center from October 2016 to September 2021. The GDI is in the process of validation. Data central tendency and dispersion were measured using mean ± standard deviation (SD). Univariate and multivariable logistic regression modeled zero GDI as the dependent outcome. Results are reported as odds ratios (OR) with 95% Confidence Intervals (CI) and significance was defined as p<0.05. Variables of interest included age, race, body mass index (BMI), medical and psychiatric comorbidities (hypertension, diabetes mellitus, cardiac disease, peripheral vascular disease, renal disease, HIV status, and psychiatric history), alcohol and tobacco use history, pre-operative penile length, and presence of keloid or hypertrophic scarring. RESULTS: 212 patients who underwent primary vaginoplasty and reported postoperative GDI were included in the study. The average preoperative GDI was 5.80 (±2.87), with a significant reduction to 2.86 (±2.40) in the postoperative period (p<0.001). 44 patients (20.8%) reported a postoperative GDI equal to zero. In this zero postoperative GDI subgroup, the average preoperative GDI was 5.29 (± 3.51); similarly to the overall patient cohort, GDI reduction was significant (p<0.001). Univariate binary logistic regression revealed that White patients were significantly less likely to report a GDI of zero postoperatively (unadjusted OR=0.28, 95% CI=0.14 to 0.56, p<0.001). Patients identifying as Black or Hispanic had approximately four times higher odds of reporting zero GDI postoperatively (unadjusted OR=4.32, 95% CI=1.73 to 10.8, p=0.002; unadjusted OR=4.54, 95% CI=1.69 to 12.2, p=0.003). These odds further increased when adjusting for other covariates and when compared to White patients (adjusted OR=5.52, 95% CI=2.11 to 14.4, p<0.001; adjusted OR=5.83, 95% CI=2.07 to 16.4, p<0.001). Multivariable logistic regression revealed hypertension as the only comorbidity to significantly impact the likelihood of reporting zero GDI postoperatively (adjusted OR=4.35, 95% CI=1.32 to 14.3, p=0.015). CONCLUSIONS: Zero postoperative GDI, which can be considered “fully resolved” gender dysphoria, was reported by one out of five patients who underwent primary vaginoplasty. GDI improvement following vaginoplasty was statistically significant regardless of patient demographic, historical, or soft tissue factors. Though sample size was limited, Black identity, Hispanic identity, and history of hypertension were independently associated with increased likelihood of reporting zero GDI postoperatively. In contrast, White patients had decreased odds of reporting zero postoperative GDI. Future work should identify specific factors, including provider communication, patient education, and preoperative expectations, that affect these patients’ experiences with gender dysphoria in the postoperative period.