Читать книгу The Vagina Bible - Jen Gunter - Страница 11

CHAPTER 3

Vaginas and Vulvas in Transition

SEX IS THE DESIGNATION OF A PERSON as male or female based on biological characteristics, such as anatomy and/or hormones. Sex can be assigned at birth or changed. Gender is your sense of who you are—male, female, both, or neither. A transgender individual is a person whose gender identity differs from their assigned sex at birth.

There are approximately 1 to 1.4 million transgender women and men in the United States. In addition to medical concerns, many face health care providers unfamiliar with the standards of medical care established by the World Professional Association for Transgender Health (WPATH)—up to 50 percent of transgender individuals report having to tell their health care provider about the specific care they need. This is marginalizing and does not inspire confidence in health care professionals.

Trans women and men also face other barriers to obtaining care. Almost 30 percent report being verbally harassed in a medical office, and 20 percent report being denied care. Negative interactions can lead to reluctance to seek care. Trans men who have a vagina and cervix may not be established with a provider who can provide cervical cancer screenings or who can diagnose and treat causes of vaginal irritation. As insurance coverage varies, many trans men and women may not have the financial resources to get all the care they need.

Whatever the reason, and there are unfortunately many, 48 percent of trans men and 33 percent of trans women delay or avoid preventative health care.

Trans Men

Vulvar and vaginal changes for trans men

Testosterone for transitioning can produce significant changes in the vulva and vagina. The clitoris will enlarge, from an average length of 1.5 cm to 4.5 cm. As the glans grows, more of it is exposed (the clitoral hood does not grow in the same way), potentially leading to increased clitoral sensitivity. Pubic hair may increase, and the pattern of distribution often changes—more hair on the thighs and possibly also hair that extends from the umbilicus (belly button) downwards.

Testosterone also causes the vaginal mucosa to become thinner and reduces lactobacilli, so the pH becomes elevated. This can start as early as three months after starting testosterone, but the peak effect may not be experienced for two years. Symptoms can include irritation, vaginal discharge, burning, pain with exams, and pain with intercourse for trans men who practice receptive vaginal sex. The lack of lactobacilli and thin vaginal mucosa increase the risk of acquiring sexually transmitted infections (STI) if exposed vaginally.

Treatment for these symptoms includes vaginal estrogen—when dosed correctly, it is not absorbed into the bloodstream and so won’t counteract testosterone’s effect on other tissues. Some trans men find vaginal estrogen acceptable, but others do not. If the physical aspect of having to place something in the vagina is the concern, a vaginal ring that releases estrogen, which should not be felt when placed correctly and requires changing every three months, may be an option. For trans men who are opposed to the idea of estrogen, vaginal DHEAS suppositories may be an option. DHEAS is a hormone that is converted to estrogen and testosterone in the vagina. More details on the medication and delivery options can be found in chapter 19.

Trans men with a cervix need cervical screening

Not all trans men have a hysterectomy (removal of uterus and cervix), and those who do often pursue that option several years after transition, so cervical cancer screening may be needed for some time. Cervical cancer screening guidelines remain the same for trans men—screening should start at age twenty-one and continue until age sixty-five (screening can stop at sixty-five if the last three tests have been normal). Cervical screening is recommended whether or not sexual activity has started and regardless of the gender of the person with whom you have had sex. A more detailed review of cervical cancer screening can be found in chapter 26.

Trans men are unfortunately less likely to get cervical cancer screening. Even more concerning, they have a ten times greater risk of having an abnormal Pap smear compared with cisgender women (those whose assigned sex at birth corresponds with their gender identity). Trans men are also more likely to have an inadequate Pap smear, meaning the cells cannot be evaluated appropriately. In one study, almost 11 percent of trans men had a Pap smear that could not be appropriately evaluated versus 1 percent of cis women. This is likely due to inflammation from testosterone or discomfort with the test, which may have affected the ability of the health care provider to adequately sample the cervix. The changes in vaginal bacteria may also increase the risk of getting human papilloma virus (HPV), the virus that causes cervical cancer.

Inadequate testing means concerning cells may not have been sampled, and so the test cannot be relied upon for accuracy. Trans men also are more likely to have delays in returning for repeat testing or following up with an inadequate sample or an abnormality because of reduced access or marginalization. Biologically, there is a higher risk for trans men, and societal factors impact access. Not a good combination.

It takes about six months for testosterone to have a negative effect on Pap smears, so if possible trans men should consider cervical cancer screening before starting testosterone. If the results are normal, that gives at least three years before more testing is needed.

Options to reduce the physical discomfort with cervical cancer screening include the following:

• HPV TESTING ALONE: This is a vaginal sample and can be done without a speculum. Many studies tell us that self-sampling is as effective as a provider obtaining the specimen, and you may feel more comfortable inserting the swab yourself. Some guidelines only recommend HPV screening alone (meaning without a Pap smear) starting at age thirty, although the American College of Obstetricians and Gynecologists (ACOG) considers HPV screening alone an acceptable option at age twenty-five.

• VAGINAL ESTROGEN: When given for 2–4 weeks before a Pap smear, it may reduce abnormal findings and pain with the exam.

It is important for every person to get the HPV vaccine, but especially so for trans men who are at great risk for insufficient screening for cervical cancer and abnormal Pap smears. (For more on the HPV vaccine, see chapter 25.) Trans men considering hysterectomy should have a discussion with their surgeon about removing the cervix (total hysterectomy) versus leaving the cervix (supracervical hysterectomy). While the latter may be technically easier for some surgeons, transition-wise it offers no benefit and means cervical cancer screening needs to continue until age sixty-five.

Menstruation and transition

Trans men who do not take hormones will still have periods. Some trans men opt for a hormone IUD for contraception, as this often leads to lighter periods. Testosterone therapy also affects periods; by two months, they are generally lighter, and they typically stop thirty-six months into testosterone therapy. However, if hormone levels are not monitored to ensure they are in the male range, periods can persist for 16 percent of trans men at six months. For trans men with intermittent access to hormones, periods can return if there are breaks in testosterone therapy. Trans men coming off hormones for fertility reasons will also start periods.

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).