While tampons and menstrual cups may offer more discretion than pads, they can be painful to insert due to the vaginal inflammation from testosterone—especially if the flow is light. We do not have any data on how testosterone impacts the risk of toxic shock syndrome.
Reusable period underwear may be an option for trans men with lighter periods who do not want to use pads, tampons, or cups. While period underwear offers the discretion of no visible pad, if it needs changing when you are away from home the only option is to carry the used underwear around in a plastic bag, which negates a lot of the discretion. See chapter 17 for more information on these options.
Trans Women
Vulvar and vaginal surgery
Surgery can create labia, a clitoris, and a vagina (vaginoplasty). The glans penis is used to create a clitoris, and both the new clitoris and stimulation of the prostate with vaginal penetration contribute to sexual pleasure. After surgery, approximately 75 percent of trans women report they are sexually active vaginally, and the ability to orgasm ranges from 70 to 84 percent.
The scrotum is used to create labia, but the optimal technique for vaginoplasty has not yet been identified. Tissue from the penis, colon, and peritoneum (a layer of mucus that lines the abdominal cavity and, among other things, keeps your organs from sticking together) have all been used. Sometimes skin from other body parts is needed as well. Other techniques that are being investigated involve tissue from the mouth (buccal mucosa), amnion (from the placenta), and tissues that have been specifically treated called decellularized tissues. A review of the best technique is beyond this book, but the choice depends on many factors, including underlying health, length of the penis (whether there is enough tissue), and both patient and surgeon preference.
The most common procedure in the United States involves penile tissue with the addition of scrotal or other skin as needed. The average range of vaginal length for cis (cisgender) women is 6.5–12.5 cm—as vaginal length is not related to sexual satisfaction, most surgeons aim for a vaginal length in the mid-range of 9–10 cm. Given the anatomic considerations, there is not always space to create a depth of 10 cm, so what can be achieved may vary. Penile tissue is not self-lubricating, but some people feel that sexual stimulation may be superior, as penile skin is sexually responsive.
A vagina constructed from penile skin is colonized with bacteria routinely found on the skin. Vaginal symptoms, such as discharge and odor, are not related to the same conditions that affect cis women such as yeast or bacterial vaginosis. Discharge is usually due to skin secretions, such as sebum and skin cells.
If discharge and odor are concerns, routine cleaning or douching with water and sometimes a mild cleanser may be indicated, as the new vagina is not mucosa and does not have lactobacilli. Many surgeons recommend douching during the time when dilation is needed daily to remove retained lubricant and the skin cells shed due to the friction. The appropriate management of vaginal odor is not established, but if douching with water has not been sufficient, some recommend douching for a few days with a 25 percent poviodine iodine in water solution. Another option is a course of vaginal antibiotics, typically metronidazole, to reduce odor-forming bacteria.
The advantage of colon and peritoneum tissue is that they are self-lubricating. This requires abdominal surgery, although this can almost always be accomplished with small incisions via the operating telescope (la-paroscopically). Discharge can be significant when colon tissue is used for the new vagina.
A vaginoplasty is medically a big procedure. If, for health reasons, someone is not able to tolerate this surgery, then a vulva and clitoris can be created and a small depression made for the vagina. Externally, there is no difference in appearance. This is also an option for trans women who do not want to receive vaginal penetration.
Some important considerations before vaginoplasty include the following:
• PERMANENT PUBIC HAIR REMOVAL ON AND AROUND THE SCROTUM: If hair removal is not permanent, it can regrow inside the vagina, causing cysts, vaginal discharge, and odor. Complete hair removal can take up to a year, and electrolysis is the only truly permanent method.
• STOPPING ALL NICOTINE PRODUCTS FOR THREE MONTHS BEFORE AND AFTER THE SURGERY: All tobacco products impair wound healing, as they reduce blood flow in small blood vessels. Success of vaginoplasty depends on establishing blood flow, and the use of tobacco can lead to loss of the graft inside the vagina and scarring.
• DILATION IS NEEDED AFTER SURGERY TO MAINTAIN THE LENGTH AND WIDTH OF THE VAGINA: For most trans women this will be a lifelong commitment, but it is especially important in the first year after surgery. If there is too much pain to dilate, it is very important to speak with your surgeon immediately. Scarring with loss of width or length can occur very quickly and is surgically challenging to correct.
Pain with sex and dilation can be due to vaginal scarring and/or spasm of the pelvic floor muscles, which are the muscles that wrap around the vagina (see chapters 2 and 34). Pain and/or manipulation from surgery can lead to muscle spasm. In both situations, scarring and spasm, it can feel as if the dilators are hitting a blockage.
STIs after vaginoplasty
If penile tissue is used to create the vagina, it is likely not susceptible to infection with gonorrhea or chlamydia, but the urethra can still get infected due to the proximity to the vagina. Transmission of viral STIs, like herpes, HPV, and HIV, is likely possible, but understudied.
BOTTOM LINE
• Trans men with a cervix are at a higher risk of having an abnormal Pap smear and of inadequate screening for cervical cancer.
• While everyone ages 9–45 should have the HPV vaccine, trans men should consider HPV vaccination and cervical cancer screening before medical transition, if possible.
• Trans men taking testosterone can develop vaginal discharge and pain; it may take up to two years to develop.
• Trans women have different causes of vaginal discharge and odor than cis women.
• Pain with sex for trans women can be due to stenosis of the vagina or muscle spasm (see chapter 34).
CHAPTER 4
Female Pleasure and Sex Ed
IT IS VERY DIFFICULT IN OUR SOCIETY to have non-sophomoric discussions about sex. Because of this, it is women who typically suffer. Female anatomy is erroneously labeled as “dirty,” and from an early age, girls are given messages about what a patriarchal society has determined a “nice” girl should and should not do.
Not knowing your anatomy, how it works and how to make it work, is disempowering and puts women at a disadvantage in a sexual relationship. Many heterosexual women learn about sex from male partners, who are often uneducated or undereducated themselves about the mechanics of female orgasms. Every OB/GYN I know has had at least one male partner ask them to point out their partner’s clitoris (meaning the clitoral glans) during an exam. On one hand, it’s great he is interested. On the other hand, “Come on, dude, you’ve been together for ten years.” Women who partner with women are less likely to have that disadvantage.
Where can women turn for accurate information about sex or to find out if what they are experiencing is normal, a technique issue, or a medical concern? In one study, only 63 percent of OB/GYNs routinely asked about sexual activity, 40 percent asked about sex problems, and 29 percent asked if a woman’s sex life was satisfying. This is a problem.
Some doctors, even OB/GYNs, find discussing sex difficult because they haven’t received much, if any, training in this type of conversation. For others, there is a time crunch in the office. Sometimes there are truly no medical therapies (think pills or injections) to