Safer Sex Post-SRS: A Brave New World

Safer Sex Post-SRS: A Brave New World, Indeed
Answers to Questions About Sexual Safety After Sex Reassignment Surgery
By Laura Jones
From Test Positive Aware Network
July/August 2008
This article is written to address questions about sexual safety after sex reassignment/realignment surgery (SRS). This is not because we assume everyone has or wants SRS, or that surgery is required in order to be fully female or male. When doing research, we discovered that there's not much information available on post-surgical sexual health, so we figured we should try to put some out there. We encourage readers with first-hand experience (whether that's your own hand or someone else's) to let us know what's been working for you with regard to safe post-op sex, or what you know works well for clients -- this article is only a start, and we look to the experts (you!) to share more information.
A word also about language used in this article: We deliberately avoided pronouns and "FTM/MTF" designations as much as possible, so as to better focus on body parts and sexual activities. This is because tissues heal more or less the same way in everyone, and viruses and bacteria don't care about gender identity, sexual orientation, or how a person calls themself before or after SRS. They only care about setting up shop in the human body, and whether what we're doing with our bodies helps or hinders them in that goal. With that in mind, let's take a cruise down SRS Lane.

Surgical Stuff
In order to discuss post-op sexual activities and risk factors, we need an understanding of what sexual reassignment/realignment surgery (SRS) entails. SRS comes in many packages -- some people opt for the full range of "top" and "bottom" procedures, while others pick and choose according to their priorities and needs. Below is a chart providing very basic information on SRS procedures, including healing times and post-op concerns.1
Since healing from SRS can be a slow process, you need to keep your new parts safe while they're getting used to the world. Risk of infection is a major concern for all who undergo SRS, but even more so for those living with HIV. SRS involves major surgeries performed on delicate parts of the body, and healing requires your body to re-wire nerve responses and recover from blood loss in addition to repairing tissues. Take care of yourself after surgery! Do not push yourself past your limits, work-wise or sex-wise! You're going to have your genitals for the rest of your life, so no need to jump on the horse before your body says it's ready to ride (if you know what I mean).
Ask your medical team when it's safe to experiment with sexual penetration, and listen to your body when you start out. If you are living with HIV and/or Hep B and C, it's especially important that you wait until your post-op bleeding and wound drainage is over before resuming sexual activity, both for your own health and that of your partner. This includes anal sex as well as genital sex, since the muscles and tissues of the entire anal-genital area are involved in SRS and must be allowed to heal too. Follow your medical team's post-op instructions carefully for optimal healing, take it slow, and use lube when you start having sex again. Traditional or Reality condoms are good protection against blood and wound fluids that might not be easily visible. For those who use sex toys, clean your toys properly before and after penetrative sex, and change condoms if alternating between anal and vaginal penetration.

Procedure Healing Time Post-Op Care Main Post-Op Concerns
Feminizing
Breast Augmentation (augmentation mammoplasty) Saline-filled implant surgically inserted under chest muscle 1-2 weeks for normal activity; strenuous activity after 3-4 weeks Keep surgical site clean; start implant displacement massage 3-5 days after surgery Infection -- check for redness, tenderness, heat, and/or discharges at incisions
Vaginoplasty Surgical creation of female genitals -- includes creation of a "neo-vagina" through penile inversion or with lining from the colon, plus one or more of the below Variable Keep surgical site clean; use Betadine douches as recommended; daily dilation exercises as recommended; follow-up exams to monitor healing Infection; loss of neo-vaginal depth/length if dilation isn't done; skin tears and pain with rough dilation or sexual penetration
Orchiectomy Removal of the testes See above See above Infection
Penectomy ("nullification") Removal of penile tissue + urethral shortening. Can be done solo if you don't want a penis or a neo-vagina. See above See above See above
Clitoroplasty Creation of a clitoris out of glans penis tissue See above See above See above
Labiaplasty Creation of labia majora and minora out of scrotal and penile skin See above See above See above
Masculinizing
Chest surgery
-- subcutaneous mastectomy or breast reduction surgery Removal of breast tissue and inframammary folds 1-2 weeks for normal activity; 3-4 weeks for strenuous activity Keep surgical site clean; tensor bandage around chest for 1 month Infection -- check for redness, tenderness, heat, and/or discharges at incisions
Hysterectomy Removal of part or all of the uterus (full hysterectomy = no cervix) Same as for natal women -- about 6 weeks Keep surgical site clean; follow-up at six weeks to check healing and remove staples See above
Oophorectomy Removal of the ovaries See above See above See above
Vaginectomy Removal of vaginal tissue, repositioning of muscles, and vaginal closure Variable Keep surgical sites clean; follow-up to check healing and function of genitals and donation sites (forearm, leg, etc.) See above
Urethral Lengthening Uses vaginal or bladder mucosa to lengthen urethra and allow urine to empty through the neo-phallus Variable See above Inability to urinate; infection
Phalloplasty Creation of a "neo-phallus" out of vaginal mucosa and forearm skin About 1 year before penile prosthesis can be implanted. See above See above
Metaidoioplasty Hormonally-enlarged clitoris, labia minora skin, and lengthened urethra create small "microphallus" Variable -- follow-up to check healing and function See above See above
Scrotoplasty Creation of scrotal sac from labia majora and minora tissue and skin About 1 year before scrotal implants can be placed See above Infection


Vaginal Stuff
Contrary to myth, neo-vaginas are not more resistant to infections than natal vaginas. Whether your neo-vagina is constructed out of your former penile and scrotal skin or from a section of your colon, your genitals are delicate and limited in their stretch capacity -- your dilation exercises will give you a good sense of what's comfortable and what is too much. While women have been known to experience some natural lubrication from urethral tissue or Cowper's and prostate gland secretions, most neo-vaginas are not self-lubricating. Therefore, lube is an even better friend than it was before SRS! The more lube used, the more comfort and the less risk of tearing.
All vaginas can end up playing host to vaginal and bacterial infections, sexually transmitted or naturally occurring. Vaginas are among yeast and bacteria's favorite places to live -- the dark, warm, enclosed environment is perfect for their breeding needs. Close proximity to the anal area also increases the odds of bacterial vaginal infections, so get used to wiping front to back now if you aren't already. Your partner/s should also use condoms on their penises or on sex toys to help further reduce your risk of neo-vaginal infection.
Herpes simplex virus (HSV I or HSV II) can be transmitted to your new genitals via oral or genital sex, or an old HSV infection may flare up as your immune system prioritizes healing from surgery. Keep an eye out for discharges, odors, tissue irritation, small sores, and/or itching or pain -- skin irritations and sores can bleed, as well as leave open pathways for HIV and bacterial infections. Douches will be prescribed to help speed your surgical-site healing, but douching can't be counted on to clear up a yeast or bacterial infection, and it won't help with herpes. If your vagina was constructed out of penile skin, you may also experience itching and discharge related to hair growth in your neo-vagina. Given all the possibilities, it's worth a visit to your doc or clinic if you notice anything unusual.

Phallic Stuff
Condoms are an important part of sexual safety for all men, including those who don't produce semen (ejaculate, jizz, spoo, cum, etc.). Neo-phallus skin needs protection from HSV and HPV, as well as yeast infections of the skin and bacterial urinary tract infections. If you have a penile prosthesis implanted as part of your SRS, condoms will also help reduce the risk of infected micro-tears as you learn how your new penis skin stretches during erection and penetrative sex (put the condom on after inflation, just like you would with any other erection). Men with "trannycocks" resulting from metaidoioplasty may find traditional condoms too large for fun or safety. A suggestion from James Cullen's "Safer Sex for Transguys" pamphlet is to "... cut a (latex or polyurethane) glove along the thumb side from the wrist down to about where your first thumb knuckle would be. The thumb of the glove becomes your condom, and the rest of the glove hangs free to cover all the other important stuff from your cock to your ass."5 Another option is to cover your own or your partner's genital or anal area with a dental dam, and then enjoy yourselves.

Everyone's Stuff
Anal sex can be enjoyed safely post-SRS healing with a few precautions. Lubricants and condoms are the easiest way to keep skin happy and body fluids contained -- water-based lubricants must be used with latex condoms, but oil- and silicone-based lubes are safe for use with polyurethane traditional or Reality condoms. Bottoms of any gender can use Reality condoms to protect their butts and their partner's penis. Tops can protect their natal- and neo-phalluses -- as well as their partner's vagina or ass -- with traditional condoms. Also use fresh condoms if alternating between anal and vaginal penetration, to reduce the risk of vaginal infections caused by butt bacteria and STIs in any area.
Sharing hormone syringes and other injection equipment carries the same risks as sharing equipment for recreational drug use, even though hormones are injected into muscle instead of a vein. Hepatitis C is of particular concern, since this virus is much more durable and easily transmitted than HIV. Please don't share equipment! Many syringe exchange programs can provide hormone-grade syringes if you run out or don't have a prescription. Please also consider the risks of using street hormones, even if you have an ongoing relationship with your supplier and bring your own injection equipment or see the equipment packages being opened. As with recreational drugs, you never know for sure what you're going to get on the street. Injected silicone can cause severe health problems, along with injection-related scarring and infections. Regardless of where you get your therapies, please keep up with regular clinical monitoring so any health complications can be addressed quickly.

Extra Stuff
Another note: Some of what you're born with, you keep. If you were born with a male body, you have a prostate gland up there in your rectum. Your prostate remains even if you have SRS, so remember to get that checked once a year and anytime you notice rectal pain, frequent urination, or any other sign of prostate trouble. If you were born with a female body and have not had a full hysterectomy, you have a cervix that needs to be screened for cervical cancer. If you are HIV-positive, follow the guidelines for prostate exams and Pap smears that are suggested for your natal gender: once a year for prostates over age 40, and once a year for cervixes (more often if you have a history of abnormal Paps). If you have no cervix, natal or neo, an annual pelvic exam is recommended, though the value of vaginal Pap screening is unclear at this time.6
Speaking of Pap smears, anyone who has receptive anal sex is now encouraged to get an anal Pap to screen for HPV-related anal cell changes and cancers. HIV-positive people are at especially high risk for developing anal cancer, due to the immune system's compromised ability to keep HPV under control. Butts are butts are butts no matter what your gender, so don't shy away from the anal probe! Once-a-year screening is recommended for everyone with a history of receptive anal sex, regardless of HIV status.7
Just as everyone has a butt, everyone has breast tissue. This means everyone needs to think about breast cancer. Even if you've had chest/top surgery to remove breasts, you need to do monthly breast self-exams and get a checkup if you notice unusual lumps or growths, especially if the lump sticks to your chest wall and can't be wiggled around. If your breasts are created via hormone therapy or "boob job" augmentation surgery, you too need to do a monthly breast self-exam. Neither testosterone nor estrogen therapy appears to increase the risk of breast cancer, but breast cancer is becoming increasingly common in general -- can't hurt to check yourself out, even if you consider your risk to be low.
That's it for now, friends. Send us some feedback from your own experience, and take care of your parts!
For a directory of surgical groups in the country and abroad that specialize in transgender work, contact the Tom Waddell Health Center in San Francisco at (415) 554-2727.
Laura Jones is a harm reduction activist based in Chicago, with a Masters in Human Sexuality pending from the University of Sydney in Australia. You can contact her at brannock@hotmail.com.