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Penile Inversion Vaginoplasty (PIV)

Penile Inversion Vaginoplasty is historically the most commonly used technique to perform genital reconstruction and create feminine genitalia.


  • At least 18 years of age.
  • On hormone therapy for a minimum of 12 months (unless clinically contraindicated, supported by a letter of explanation from medical provider).
  • Control of all co-morbid concerns (high blood pressure, diabetes, anxiety, etc.).
  • 2 separate letters of recommendation from qualified professionals licensed in mental health (this includes psychiatrists, psychologists, therapists) specifying what procedure you’re being referred for (“top” or “bottom” surgery or “both”). Cannot be written by your primary care doctor or endocrinologist unless they are also licensed mental health professionals.

Prerequisite Treatments

  • We highly suggest permanent hair removal in the surgical area (the penile shaft, a one-inch minimum radius around the base of the shaft, the entire scrotum and the perineum) to prepare the tissues for grafting.
  • You must remain under the care of your mental health professional throughout the perioperative timeline in case updated or revised letters are required; referral letters are valid for 12 months from the date written.


  • As soon as possible, begin permanent hair removal in the surgical areas. When hair removal is complete, ask your mental health professionals to send letters of recommendation for surgery. Referral letters can be emailed to ChrisTina.Reed@UHhospitals.org or faxed to our office at 216-201-4034 Attn: ChrisTina Reed.
  • You will be admitted for 5–7 days after surgery. Please arrange for transportation to and from the hospital. Our policies don’t allow patients to be discharged without a friend or family member to drive them home. You can’t use public transportation, and your transportation should be present when you’re given discharge instructions.
  • Prep meals for the first week post-surgery, or arrange for help with this.


  • You’ll be discharged with all the self-care items you’ll need for the first couple weeks (bandages, feminine pads, vaginal dilators, lubricant, etc.).
  • You will receive a phone number to call in case of urgencies after office hours. Post it in a convenient place at home, visible from your place of rest. Provide it to your support person as well.
  • We’ll refer you to an affirming pelvic floor physical therapy provider who will work with you to make sure your vaginal dilation is safe and effective.
  • Your surgical team will see you in the office for post-operative checks weekly or biweekly until your surgeon plans otherwise depending on your post-operative progress.

Support Services

  • Affirming cosmetic therapy providers for hair removal
  • Licensed mental health service that’s specialized for LGBTQ+ individuals
  • Pelvic floor physical therapy providers who are intimately familiar with the specific needs for affirming pelvic reconstructive surgery
  • Perioperative volunteers who offer emotional support and can answer questions

Important: You are responsible to notify our office immediately of any interruption or changes in your insurance coverage.

Next Steps


Discuss your surgical goals with your primary care provider


Start permanent hair removal (contact our office for recommendations or referrals)


Call Central Scheduling at 216-844-5661 to schedule a surgical consultation with Shubham Gupta, MD


Establish care with two affirming licensed mental health providers (contact our office for recommendations or referrals)


Notify office via telephone 216-286-5428 or email LGBT@UHhospitals.org when hair removal is approximately 50% completed (to plan surgery date)


Ask mental health providers to send referral letters to office at fax number 216-201-4034 or email ChrisTina.Reed@UHhospitals.org


Remain in contact with office (LGBT@UHhospitals.org) with updates and questions throughout the perioperative process