Tag Archives: neovagina

Orgasm after Vaginoplasty

Orgasm and sexual pleasure are important goals of gender reassignment surgery (GRS). Most trans women report being able to orgasm after penile-inversion vaginoplasty with clitoroplasty using the glans penis.* However, some are not able to orgasm and some report difficulty orgasming.

Two large studies found that 18% of trans women were not able to orgasm by masturbation after surgery. In one of the studies an additional 30% of the women had difficulty orgasming from masturbation.

The number of women who couldn’t orgasm went down to 14% or 15% when they included all sexual activities.

Other recent studies** have found numbers of anorgasmic women ranging from 0% to 52%, although most results were close to 18%.

It is clear that a significant percentage of trans women are not able to orgasm after this type of vaginoplasty, but it is not clear exactly how many.

SOME RECENT STUDIES OF ORGASM AFTER GRS

There were five studies where the women had clearly been sexually active:

Lawrence, 2005 – anonymous questionnaires from 232 trans women, 227 answered the question on orgasm by masturbation:

18% were never able to achieve orgasm by masturbation.

15% were rarely able to orgasm with masturbation.

15% were able to orgasm less than half the time by masturbation.

However, it seems that only 15% were completely unable to orgasm. “About 85% of participants who responded to questions about orgasm were orgasmic in some manner after SRS [GRS].” 

Imbimbo et al., 2009 – 139 trans women (93 questionnaires at clinic, 46 phone interviews):

14% of the trans women complained of anorgasmia

18% of the trans women were never able to orgasm by masturbation (out of 33 women who masturbated)

33% of the trans women were never able to orgasm by vaginal intercourse and 25% seldom orgasmed this way (out of 60 women having vaginal intercourse)

22% of the trans women were never able to orgasm by anal sex and 13% seldom did (out of 75 women having anal sex)

56 women had oral sex, but the study gives no numbers for orgasm.

Buncamper et al., 2015 – 49 trans women completed questionnaires:

10% had not had orgasm after surgery, although they had tried.

Selvaggi et al., 2007 – 30 trans women were personally interviewed by a team of experts:***

15% had not experienced orgasm after surgery during any sexual practice.

Giraldo et al., 2004  – 16 trans women were given structured interviews at follow-up visits:

0% had problems – all the women reported the ability to achieve orgasm

Note: This study is about a modification to the technique for creating a clitoris.

There is one study where 18% of the women never orgasmed after surgery, but it is not clear if they were sexually active or not:

Hess et al., 2014 – 119 trans women completed anonymous questionnaires, 91 answered the question “How easy it is for you to achieve orgasm?”:

18% said they never achieve orgasm

19% said it was rarely easy for them to achieve orgasm

The other studies above asked about sexual activity or gave the women an option to say the question did not apply or they had not tried. This one did not.

On the other hand, some people did not answer the question, so perhaps women who were not sexually active skipped the question on orgasm.

There are three studies that only give brief information on how many women could orgasm; it is not clear what is going on with the rest of the women.

Perovic et al., 2000 – 89 trans women were interviewed:

It looks like 18% had not experienced orgasm during vaginal sex, but it is possible that some of the women were not sexually active.

“Information on sensitivity and orgasm was obtained by interviewing the patients; the sensitivity was reportedly good in 83, while 73 patients had experienced orgasm.”

and

“If the penile skin is insufficient, the creation of the vagina depends on the urethral flap, which also provides moisture and sensitivity to the neovagina. The results of the interviews showed that orgasm was mainly dependent on the urethral flap.”

Goddard et al., 2007 – 70 trans women were interviewed by a telephone questionnaire; 64 of them had had a clitoroplasty:

It looks like 52% of the women with clitorises were not able to achieve clitoral orgasm, but again it is not clear if they were sexually active.

“Clitoral sensation was reported by 64 patients who had a neoclitoris formed and 31 (48%) were able to achieve clitoral orgasm.”

14% of the women complained of “uncomfortable clitoral sensation.”****

Wagner et al. (2010), – 50 trans women completed a questionnaire:

It looks like between 17% and 30% were not able to achieve clitoral orgasm.

“Of the 50 patients, 35 (70%) reported achieving clitoral orgasm” but

“90% of the patients were satisfied with the esthetic results and 84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm.” 

If we look only at the group having regular intercourse, 17% of them are not having clitoral orgasms. But were the women not having intercourse masturbating and unable to orgasm? If so, they were also sexually active and the 30% number is the relevant one.

The study gives very little information on the questionnaire and results, but it seems surprising that 83% of the women were having clitoral orgasms from sexual intercourse; that is not typical in cis women.

A final study asked about pleasurable sexual intercourse, not orgasm:

Salvador et al., 2012 – 52 trans women participated in the study. It is unclear how they were surveyed, but based on this earlier study, it could have been a combination of a questionnaire and interview.

8% did not consider vaginal sex pleasurable.

However, only one woman said sexual intercourse was unsatisfactory (2%) while 10% of the women said it was average; presumably some of the women who said it was average also said it was pleasurable and some did not.

About Orgasms

Freud believed that women had vaginal and clitoral orgasms; unfortunately he also believed that vaginal orgasms were superior and mature women should give up clitoral orgasms. In the 1960s Masters and Johnson showed the physiological basis for clitoral orgasms in the lab; they argued that orgasms during intercourse were also clitoral orgasms, just harder to achieve. More recently, some sexologists have shown that some women have G-spot orgasms during intercourse, although not all experts believe in them.

For most women it is easiest to have an orgasm from masturbation or clitoral stimulation. Most women are not able to have clitoral orgasms during vaginal intercourse without additional clitoral stimulation. Some women experience other types of orgasms during vaginal intercourse.

Although trans women’s biology is somewhat different from cis women’s, their clitorises are formed from the most sensitive area of the penis. Therefore, we might expect trans women to have orgasms most easily from masturbation of the clitoris; the study by Imbimbo et al. that compares different sexual activities supports this hypothesis.

It also makes sense that when we look at orgasms from all sexual activities, we find more trans women are able to orgasm than when we look at just clitoral orgasms; some trans women may be having G-spot orgasms involving their prostate gland.

Interestingly, Imbimbo et al. found that it was easier for trans women to have orgasms from anal sex than vaginal sex (65% of the women often had orgasm from anal sex, 35% seldom or never did; 42% of the women always or often had orgasm from vaginal sex and 58% seldom or never did). Furthermore, more of the trans women were having anal sex than vaginal sex (54% versus 43%). Perhaps they had more experience with anal sex before surgery or perhaps anal sex worked better for some women.

Studies that simply ask about orgasm without talking about what type of orgasm or sexual activity is involved do not give enough information about what is happening. Future studies that include this information would make it easier to compare the results and to improve outcomes.

Comparing the Studies

It is difficult to compare the results of the studies. The studies are of surgery at different clinics around the world; the work is being done by different surgeons and may involve variations in technique. Some of the surgeries are more recent than others as well.

In addition, the studies use different methodologies to collect data and they do not ask the same questions. Some are focused on clitoral orgasms, others talk about orgasm during intercourse, some studies talk about masturbation, and some are vague about what they mean by orgasm.

As is common in follow-up studies, almost all of the studies had a significant drop-out rate; not everyone who had the surgery participated in the study. This could create a bias in either direction – people who regret the surgery might be too depressed to respond to the clinic or people who were dissatisfied might be more motivated to participate in the study.

The method of the study could also introduce biases; people may be more likely to tell the truth in an anonymous survey than in an interview. On the other hand, interviews may allow for follow-up questions and clarifications.

With only 10 studies that are so different it is impossible to come to any definitive conclusions about orgasm after GRS. I like to believe that Goddard et al.’s numbers of anorgasmic women are so high because some of them were sexually inactive or because their study included women 9-96 months after surgery. It could also be something to do with their surgical technique. After all Perovic’s et al.’s study also included women 0.25-6 years after surgery and some of them may have been sexually inactive, but their numbers were much better.

I suspect that the reason all of Giraldo et al.’s patients were orgasmic is that their sample size is so small, but again, it could be that they have a superior technique.

It might be that Buncamper et al. had better numbers than most of the studies because their patients had surgery more recently with improved techniques, but it might also be because their study was smaller.

With so few studies, I could find no clear pattern based on when people had surgery, how data was collected, or follow-up time after surgery. For further information on the studies, see this appendix.

What is clear is that we need more research on patients who are not able to orgasm after surgery. Are some people more at risk than others? Does the surgical technique make a difference? What role does aftercare play?

Is being non-orgasmic just a possible complication of the surgery? If so, how common is it?

And most important, what can be done to enable all trans women to be able to orgasm after surgery?

 

 

 

*I did not find data on orgasm after intestinal vaginoplasty. According to this 2014 review of studies, most studies of intestinal vaginoplasty did not look at sexual function; for those that did the review reports a score for sexuality rather than information on orgasms.

** I have excluded studies published before 1994 and studies where all of the surgeries were performed before 1994. The studies by Imbimbo et al. and Selvaggi et al. may include some participants who had surgery before 1994.

*** The exact number of the participants is unclear because this study is one of a pair using the same participants. The other study by de Cuypere et al. did in-depth interviews with 32 trans women while this one focused on testing the sensitivity of the genitals for 30 trans women. Unfortunately, the de Cuypere study reports data in terms of how many women “Never-sometimes” had orgasm so their data is not comparable to other studies. (They found that 34% of the women never-sometimes had orgasm during masturbation and 50% never-sometimes had orgasm during sexual intercourse.)

**** Goddard also reports that despite problems, “no patient elected to have their clitoris removed.” Is the man mad?

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Ability of an orally administered lactobacilli preparation to improve the quality of the neovaginal microflora in male to female transsexual women – Review and a possible health benefit

This is a very cool study that found that trans women could improve the microflora in their neovaginas by taking lactobacilli orally.

Trans women might need to keep taking the lactobacilli pills to maintain the good microflora in their neovaginas.

Why would you want to do this?

Well in addition to other benefits, mostly for digestion, lactobacilli can help to treat bacterial infections in the vagina and it may help prevent urinary tract infections.

According to the authors of the study, many trans women don’t have enough lactobacilli in their neovagina.

“The microflora of male to female transsexual women is a complex symbiosis of aerobic and anaerobic species with a very limited number of lactobacilli. It has substantial similarity to the abnormal vaginal microflora characteristic of bacterial vaginosis (BV) [1,2]. Weyers et al. reported that, although transsexual women show serum oestradiol levels comparable to those of postmenopausal women taking oestrogen replacement therapy, their neovaginal environment does not support the growth of lactobacilli [1]. In one study [1], only one of thirty transsexual women had neovaginal colonisation with lactobacilli. Another study of transsexual women, the same authors [2] found a neovaginal lactobacilli colonisation rate of 4%.”

In this study, the authors found a higher rate of neovaginal lactobacilli colonisation, however, everyone who took the lactobacilli improved their scores.

The study was a good, randomized test of whether or not the lactobacilli worked, using 60 trans women split into two groups (one taking the lactobacilli, one not).

The bottom line – Post-op trans women should talk to their doctors about whether they should take lactobacilli.

Their discussion of their results:

“The results of this prospective randomised controlled study show that oral administration of L. crispatus, L. rhamnosus, L. jensenii and L. gasseri significantly improved the neovaginal microflora and reduced the Nugent score in a group of transsexual women. Also, the microflora was significantly enriched with lactobacilli after oral supplementation compared to placebo. The combination of Lactobacillus spp. used in this study is the only one published as the physiologic mixture of female vaginal lactobacilli microflora [15]. We used an innovative probiotic lactobacilli composition containing four of the most common lactobacilli isolated from the microflora of healthy women’s vaginas [15] for treatment of 7 days’ duration. Weyers et al. reported that colonisation of the neovagina of transsexual women with lactobacilli is minimal [1,2]. According to Nugent, an intermediate vaginal microflora is defined by a reduction and BV by an absence of lactobacilli with the presence of Gram negative bacteria in both cases [14]. The small number of publications on the standard neovaginal microflora and the near lack of evidence of lactic acid bacteria in the transsexual genital tract area are a challenge for investigations in this population. While transsexual women have normal female anatomy, there is no uterus and no connection of the neovagina to the pelvic cavity, which is why the risk of pelvic inflammatory disease is low. We were therefore able to include all transsexual women without clinical signs of infection, including those with asymptomatic BV. To our knowledge, this is the first study to allow a direct assessment of the comparative effect of oral probiotic lactobacilli and placebo on BV.

The gastrointestinal tract plays an important role as a reservoir for the vaginal colonisation by Lactobacillusspp. [4], [5] and [6]. Both vaginal and oral applications of lactobacilli have been shown to improve the vaginal microflora of both pre- and post-menopausal women [3], [9], [10] and [11]. The results of this study indicate that oral lactobacilli have a similar effect on the neovaginal flora of transsexual women. Descriptive analyses of the difference in Nugent score showed a reduction of −0.18 in the intervention group and an increase of +0.92 in the control group.

We found a significant improvement in the Nugent score in 48.5% of women in the intervention group, compared with only 14.8% in the control group. Lactobacilli concentrations assessed by culture and real-time PCR were 5–6 times higher in the intervention than in the control group, with these differences being statistically significant.

The sample size calculation in this study was based on neovaginal lactobacilli colonization rates of up to 4% reported in the literature [1] and [2]. In the present study, however, 30% of the women in both the intervention and control groups had a normal lactobacillus microflora (Nugent score ≤3). This was an unexpected finding contrasting with the current literature [1] and [2]. Because oral lactobacillus supplementation cannot be expected to change a neovaginal microflora dominated by lactobacilli, this unexpectedly high proportion of women with a normal lactobacillus flora may have led to an underestimation of the treatment effect. We therefore carried out a subgroup analysis including only women with a baseline Nugent score above 4, corresponding to either an intermediate microflora or BV. Even then, after 7 days of treatment with oral lactobacilli, we found an improvement in the Nugent score in the intervention group and no change in the control group. The results of this subgroup analysis are comparable with the results of one of our earlier studies on the effect of lactobacilli on postmenopausal women, which showed an improvement in Nugent scores [11]. In contrast to the previous study with a lactobacilli treatment duration of 14 days, however, the improvement in the current was already seen after 7 days of oral lactobacilli. The renewed increase of the Nugent score two weeks after the end of oral therapy indicates that extended oral probiotic therapy may be necessary to maintain a lactobacilli-dominated microbiota.

This study had several limitations. With a specific study group of male to female transsexual women and very limited number of patients visiting our clinic we could observe only a small sample size in our study. The therapy duration was limited to 7 days: we assume that longer treatment with probiotics could obtain a better outcome. Microbiology analyses of CFU’s and c/ml were presented only for presumptive lactobacilli. In the next step we will include other bacteria with similar colony characteristics, such as Gardnerella vaginalis and Atopobium vaginae to present more detailed data. This study is first to observe male to female transsexual women using probiotics and we are aware of our initial oversights.

In summary, this first study on the effect of oral probiotics on the neovaginal microflora of transsexual women found that oral administration of lactobacilli resulted in a significant improvement in the Nugent score and a change of the neovaginal microflora. These observations are consistent with previous results obtained in pre- and post-menopausal women. The increase of the Nugent score two weeks after the end of oral therapy provides a possible need for extended oral probiotic therapy for maintenance of a lactobacilli-dominated microbiota. In addition, this study shows that even asymptomatic BV may be improved to a normal microflora by 7 days of oral supplementation of lactobacilli.”

Original Aritcle:

Ability of an orally administered lactobacilli preparation to improve the quality of the neovaginal microflora in male to female transsexual women by Ulrike KaufmannKonrad J. DomigChristina I. LippitschManuel Kraler, Julian Marschalek, Wolfgang Kneifel, Herbert Kiss, Ljubomir Petricevic in European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 172, January 2014, Pages 102–105.