Let's Talk About The S Word: Sex After Vaginoplasty
By: Ashley DeLeon, MD
Sex after vaginoplasty? How to start … both figuratively and literally. This is a topic of much discussion amongst my patients, so I am hoping to shed some light for your burning questions you have been too embarrassed to ask. I have compiled a list of the top 5 things that we receive questions about that I think patients and their partner(s) should know. Of course, all of this is with the disclaimer that when it comes to sex, it should always be practiced safely and between consenting adults!
1. The Early Bird: In the case of sex after vaginoplasty, the early bird does NOT get the worm. So, wait a little while. I don’t mean wait for that special someone as many of us were advised growing up, although, that’s good advice too. More specifically, wait before engaging in sexual intercourse after your surgery. This is a big operation with a lot of moving parts and your body needs time to heal properly. Healing is essential for you to thoroughly enjoy the interaction and will also help to prevent any complications from occurring from premature intercourse. Typically, I tell my patients to wait at least twelve weeks after surgery before trying out their new equipment. This gives enough time for the skin graft to fully heal inside the vaginal canal, which means for those first three months, the only thing going inside your shiny new canal should be your dilator provided to you after surgery. In addition, I also prefer my patients to refrain from receiving oral sex until they are three months out as well. Now, I know what you’re thinking … no fun Dr. D! But if you recall the age-old adage that says dogs’ mouths are cleaner than ours, it will start making sense why we have this rule. Human mouths harbor millions of bacteria that have a symbiotic relationship with the owner of that mouth, but perhaps not so symbiotic when those bacteria are introduced to another person who still has fresh suture lines and surgery wounds. Infection is the big concern here, and a bad infection can damage if not completely destroy a patient’s labia, resulting in a less than optimal cosmetic result. And unless you’re a hardcore cat lover, nobody likes an ugly kitty…but I digress. So, unless your partner is planning to use a dental dam (sheet of latex that can be used in the mouth while performing cunnilingus), I’d recommend holding off on oral sex as well until you’re further along in the recovery process. This, of course, does not apply to giving oral sex. Give all you want during your recovery, just don’t receive! Remember, 12 weeks is a minimum. In fact, when I asked a specific patient what her biggest recommendation would be for this blog she said, “Don’t rush it. Give yourself a few more months than the minimum.” Bottom line: Abstain for a long as possible but for at least three months and when you start, be nice and easy until you’re comfortable piloting your new pleasure craft. Okay, I know: I shouldn’t have lead with telling you to wait. Now you don’t even want to keep reading since the first point is NFL….no fun league. Necessary evil. Sorry ladies!
2. The Big O: Here’s the good news, you can have orgasms as early and often as you would like after vaginoplasty! Now I know I said no penetrative intercourse and no receiving oral sex so you’re probably feeling like I’m contradicting myself, but I’m here to tell you, there are a multitude of ways to achieve orgasm while still following the rules above. Masturbation via clitoral stimulation is one of them. Whether it be your (or someone else’s) CLEAN hands, or your favorite vibrator, etc., this is a safe way to gently stimulate yourself after vaginoplasty while still in the healing phase. Also, it is not unusual for my patients to tell me after they start their dilations that they had their first orgasm just simply dilating! How awesome is that? Imagine being able to orgasm just by following doctor’s orders! I’m not going to lie: trans women have a 50% chance of being able to orgasm with penetration only… aka no clitoral stimulation. Seems unfair? Well, welcome to womanhood. It’s the exact same for the cis female population so you’ll just have to focus on your clitoris and get creative solo or with your partner like the rest of us. Also remember that erotic sensation is very psychological. We have specific types of sensory nerves throughout our bodies to feel touch, pressure, temperature, pain, etc., but there is no such thing as a nerve specifically for erogenous sensation. That’s created by the way your regular sensory nerves interact with your mind. So, it never hurts to keep trying. Once you have healed from your surgery, you can begin having penetrative intercourse and receive oral sex to regain your mojo and your best “O face!”
3. The Size Queen: I often get questions about vaginal depth and penis size. Two common questions from my patients are can they tear their canal during penetrative intercourse, and will their vagina be large enough to accommodate a penis? Obviously, you should never do anything that is painful or unenjoyable. I have not had a patient have significant tearing issues with intercourse yet, as long as they wait the appropriate time to heal and are dilating diligently to keep their canal open. For starters, we make all of our vaginal canals 12-15 centimeters in depth which is around 5-6 inches. Make no mistake, this is the average size of a cis female’s vaginal canal and also the average size of a cis male’s penis … despite what many want to believe. In addition, going any deeper when creating the canal would risk getting into the abdomen where the intestines live. So, we at the Crane Center prefer to stick with what works and is safe. Keep in mind you are able to gain both girth and depth with dilations. Although, a surgically created vaginal canal will not experience vaginal tenting (changing size and shape when you are aroused) you can definitely change the size of your canal over time with your dilator as the skin that we line the neovagina with has elasticity to it. I have some patients who like to work up to the largest dilator size to get a larger diameter of their canal and others that like to stay at a smaller dilator size to remain “tighter.” You have the control and it’s all up to you and your preferences. Either way, your canal is functional so you should not be afraid to use it … that’s precisely what it’s there for!
4. The Squeaky Wheel Gets the Oil: Okay, so here’s the deal on lubrication: After a one-stage penile inversion vaginoplasty, the vaginal canal is lined with skin. This is the same skin that you see everywhere else on your body such as your arms, legs, etc. This is different than the mucosa-like tissue you have lining your mouth and rectum and that cis females have in their vaginas. Mucosa produces natural lubrication. Skin does not. Therefore, it is imperative to use lubrication when inserting anything into your vaginal canal! Fine, lube it up, but with what type of lubricant? Skin cells die as they make their way to the surface and eventually slough off, a process called exfoliation. The skin lining your vaginal canal is also shedding dead skin cells and this is exactly why you always need to choose water-based lubricants, not silicone! Silicone may have won in the sensation department (at least in mine!) but they are notoriously difficult to remove. With your vaginal canal being lined with skin, it has no innate way to wash the silicone away as mucosa would, so it is even more difficult to remove from surgically created canals lined with skin. Unfortunately, silicone mixes with these dead skin cells sloughing off and creates an unpleasant discharge for patients. This natural sloughing process also helps to illustrate the importance of cleaning out your vaginal canal after using it. Warm soapy water works just fine for maintenance after activity, but we do recommend using a formal douche once a week as well. Bottom line: Always select a water based lubricant for vaginal penetration and be sure you are using copious amounts. What’s a slip and slide without water anyway? Personal hygiene is now more important than ever so be sure you are caring for your vagina so it can take care of you (and others!)
5. Deliveries in the Rear: Okay, now to bring up the rear with my last point … anal sex. Whether you think it’s taboo or a mainstay to your sexual lifestyle, I would definitely recommend waiting for twelve weeks until you are completely healed before receiving anal penetration. The vaginal canal is created literally millimeters away from your rectum, same as cis females. Once things are healed, however, it is fine to participate in anal sex, if interested. Whether you were familiar with anal sex prior to vaginoplasty or not, it will feel different after surgery. I recommend starting out slow, even for those who have significant prior experience with anal. You should always start smaller, use lots of lubrication (silicone is best for this one in my opinion … unless condoms are in the mix), and see what feels good. It’s important you are able to relax during anal intercourse to avoid injury and create an enjoyable experience. Last, but not least, being a former general surgeon who spent many a late night fishing various objects out of patients’ rectums or even removing patient’s colons to get to it … please, please, please, if using toys, pick ones that are safe to use in your rectum with mechanisms in place to avoid getting it lost in your colon. These toys typically have rings or flat bases to keep them from going past the point of no return. If you have questions about whether something is safe to use for this, always ask! Or how about this? Use commonsense. It is much less embarrassing to ask someone before than it is to explain to the ER doctor that you lost something in your bottom. You can thank me later for that clinical pearl!
Ultimately, sex is a mixed bag with all kinds of yummy treats and others that may not be so much. We are all unique and beautiful snowflakes, and this couldn’t be truer when discussing sex. People enjoy an infinite number of things and everyone is different. So, feel free to experiment to find what works best for you and what you enjoy the most. If you have questions, ask. If you face challenges, know there are resources out there that can help. Gynecologists, sex therapists and pelvic floor physical therapists are often great resources to utilize. Most physicians who care for the transgender community have referral lists for these types of providers who are trans friendly so they can give you a start and steer you in the right direction. You should also discuss engaging in sexual activity with your primary care doctor to ensure you are protecting yourself appropriately from sexually transmitted diseases. And as always, practice safe and consensual sex. Sex after vaginoplasty can pose challenges no doubt, so it’s helpful to be knowledgeable going into it. Don’t forget to ask questions, ask for tips and tricks from other trans women too, and most of all be safe and enjoy yourself!
Dr. Ashley DeLeon started her education at the University of Kansas for her undergraduate and subsequent Doctor of Pharmacy degrees. She then received a national scholarship to attend The University of Texas at Austin Department of Graduate Studies to do post-doctorate work in outcomes research while teaching at both The University of Texas at Austin School of Pharmacy and School of Nursing. After receiving her medical degree, Dr. DeLeon completed her surgical residency at The University of Texas at Austin Dell Medical School. She then practiced general surgery in Austin, Texas including advanced laparoscopic and robotic surgeries, comprehensive abdominal and pelvic procedures, breast and endocrine surgeries, and trauma surgery. Dr. DeLeon takes a special interest, however, in gender affirmation surgery and with her expertise in pelvic anatomy and vast experience in breast surgery she elected to pursue advanced fellowship training in transgender surgery with Dr. Curtis Crane. She finds working in this field both fascinating and rewarding and, after completion of her training, became a valuable full-time partner of Dr. Crane’s team performing FTM Top Surgery, Orchiectomy, Vulvoplasty and Vaginoplasty.