Objective
The American College of Obstetricians and Gynecologists has urged general gynecologists to become competent in caring for female-to-male transgender individuals and has also published guidelines. The specific introital effects of a dominant testosterone milieu in trans men have been studied incompletely, but there is some recognition that gender-affirming hormone therapy suppresses estrogen production and has a high likelihood of producing symptoms of estrogen deficiency in the genital tract. The introital changes that cause extreme sensitivity could disturb sexual intimacy and make speculum insertions painful enough to lead the trans male patients to delay visits for necessary healthcare.
Study Design
An open convenience survey targeted transgender men who were assigned female at birth; were at least 18 years of age and taking testosterone; and identified as masculine, trans masculine, trans male, or female-to-male individuals. Flyers posted in Portland, Oregon, linked the participants to the anonymous, web-based survey that adhered to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) that used Research Electronic Data Capture (REDCap) electronic data capture tools. Pain was scored using visual analog scales (VAS). The survey was discontinued once 100 trans men with a vagina (“front hole”) completed it. Legacy Health’s institutional review board approved the study. Descriptive analyses included logistic regression.
Results
From March 2017 through July 2018, 100 qualifying individuals engaged the survey, and 4 other surveys were concluded after describing vaginal obliteration with metoidioplasty. Eighty-four percent of the individuals resided in Oregon. Table 1 presents the survey results and Table 2 presents representative quotes. The terms preferred for self-identification were “male” in 32%, variations of “trans” status in 40%, and gender fluid terms in 24%. The prevalence of insertional pain with intimacy was 51% (mean VAS score, 53±22), and the prevalence of pain with speculum insertions was 43% (mean VAS score, 66±22). Two-thirds of the respondents with pain felt that it would be valuable to correct their pain. Pain exacerbated the dysphoria related to gynecologic examinations, and 50% who delayed healthcare visits did so because of previous speculum pain. After controlling for the age when starting testosterone, the odds of delaying healthcare were 2.55 times higher (95% confidence interval, 1.07–6.07; P =.034) in the respondents with penetrative pain than in the respondents who did not report pain with penetration. Six respondents who reported getting an anxiolytic for the examination noted speculum pain scores of 80–90 (VAS). Seven respondents reported suggestions of estrogen products for their vulvovaginal conditions; 4 respondents were given local topical lidocaine before examinations. In the study respondents, there was no significant correlation between the duration of time since initiating testosterone and the pain scores. No data were collected about the details of the testosterone regimens.
| Characteristic | Value |
|---|---|
| Age (y) | |
| 18–20 | 11 (11) |
| 20–30 | 52 (52) |
| 30–40 | 29 (29) |
| 40–50 | 8 (8) |
| Age at recognizing accurate gender (y) | |
| <10 | 24 (24) |
| 11–20 | 60 (60) |
| 21–30 | 10 (10) |
| 31–40 | 2 (2) |
| 41–50 | 1 (1) |
| Missing | 3 (3) |
| Age at initiation of testosterone therapy (y) | |
| 15–20 | 37 (37) |
| 21–30 | 47 (47) |
| 31–40 | 10 (10) |
| 41–50 | 6 (6) |
| Duration of time on testosterone | |
| <5 | 72 (72) |
| ≥5 | 28 (28) |
| Previous bilateral oophorectomy | |
| Yes | 14 (14) |
| No | 86 (86) |
| Do you receive sexual stimulation from yourself or partner? | |
| Yes | 94 (94) |
| No | 6 (6) |
| If yes, do you receive “front hole” (vaginal) penetration from yourself or partner? n=94 | |
| Yes | 68 (72.3) |
| No, I don’t favor penetration | 15 (16.0) |
| No, because penetration hurts | 11 (11.7) |
| If yes, how do you receive vaginal penetration? n=68 | |
| Penetration with finger | 61 (90) |
| Penile penetration | 5 (7) |
| Penetration with an object | 2 (3) |
| Prevalence of those endorsing pain with any “front hole” penetration, n=94 | 51% |
| Mean pain score with penetration (VAS) a , b 53±22 range: | 18–100 |
| Did stimulation with penetration cause pain before you began testosterone? n=100 | |
| Yes | 20 (20) |
| No | 63 (63) |
| Not sure | 12 (12) |
| Never had penetration | 5 (5) |
| Do you have pain with the placing of a speculum (the metal or plastic duckbill tool) n=98 | |
| I have never had a speculum exam | 14 (14) |
| No, it was uncomfortable, maybe, but not painful | 48 (49) |
| Yes, it caused pain | 36 (37) |
| Mean pain score with speculum (VAS) a , b 66±22 range: | 7–100 |
| Have you delayed a healthcare visit because of fear about a speculum exam? n=100 | |
| Yes | 48 (48) |
| No | 52 (52) |
| If you had fears, was it because of experiencing pain previously? n=48 | |
| Yes | 24 (50) |
| No | 24 (50) |
| Have you asked doctors about your pain with penetration or with speculum exams? n=83 | |
| Yes | 21 (25) |
| No | 62 (75) |
| Reasons for pain given to survey takers who asked their provider: | |
| “Cervical polyps” “vaginal wall thinning” “deterioration” “atrophy” “just average discomfort” “a UTI” “lack of lube” “atrophic vaginitis” “I may have nerve problems, damaged tissue that can be removed surgically” “sensitive scarring” “dryness & small vagina” | |
| Did your provider give you a medication to help you with the speculum? | |
| An oral anxiolytic | 5 |
| Numbing liquid, cream or spray | 4 |
| Has your provider suggested or ordered medication for home use? | |
| Estrogen product | 7 |
| Lidocaine product | 2 |
| Do you use what they suggested? | |
| Yes | 4 |
| No | 2 |
| Sometimes | 4 |
| Would it be valuable to you to correct the problem of penetration pain? | |
| Yes | 30 (30) |
| No | 22 (22) |
| Missing | 48 (48) |
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
