The Vagina Bible. Jen Gunter

      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