My first visit to the gynaecologist

Trigger Warning: this post contains frank descriptions of the human anatomy, male and female, and sensation.  Of course, this is also told by a pre- and post- op transsexual who sat uncomfortably in a male body and who is only just discovering the unfolding beauty of her female body, and there are many differences between the natal female body and trans female body, which I attempt to cover.

My main question was given my gynaecologist is a woman whether she would warm the speculum before inserting it.  Those chairs are rather clinical.  I can’t help but think that the entire process was invented by men to make women fear their own bodies.  Surely there is a better way?

I took an Oxy an hour before going. Just in case.  They want me off of it as of a few days unless pain gets too much, but they also don’t want me to wait until the pain is unbearable, as it becomes harder to manage.  The pain is mostly okay, but it does hurt down there if I am not taking anything.

After all, I didn’t know what she would do to me, peak all the way inside? That might be uncomfortable, I thought.

I am getting to know my vagina a bit more every day.  I like gently running my fingers along the very edges of my labia.  Sensation is largely intact, though there are some spots which are slightly numb.  It takes a year for the nerves to recover…but up to 10 years for the complete wiring that began two years ago when my body began taking instructions from oestrogen and my testosterone was relegated to a bit part in my overall makeup.

There have been snippets of this process in other posts, such as this one, where I describe what my skin feels like, or what it feels like down there to touch my skin and recognise that it was no longer the same, or this one about having a sexual release and experiencing it in a totally different way than a male orgasm.  But I’d like to spell it out.  

What Has Happened to Me Down There?

Okay.  Here goes. 

The foetus is female up until a certain point in gestation when it either stays female or becomes masculinized.  A discussion of that process is beyond this post, other than to say that the “trigger” mechanism comes from the child’s genetic profile, but as we know, this communication can be affected by environmental factors which influence the mother in ways which then impact the development of the child.

Here’s what matters: any anatomical component of the male pre-existed in a female form, but when the instructions came to turn the foetus male, these male parts evolved from their female forms.  The clitoris becomes a penis, the ovaries become the testicles, the labia fuse (leaving the raphe as the trace of this fusion), and the vaginal lining instead becomes the tunica vaginalis, which is a tissue which contains the balls in the sac.

My scrotal skin stopped being scrotal skin about 6 months after starting on GAHT (gender affirming hormone therapy).  [I know that the more common term is HRT, or hormone replacement therapy, but this was created for natal women who were experiencing the menopause or other issues.  I therefore make the distinction between HRT and GAHT, also because dosing levels and the cocktail of substances given are so different.]. When I say it stopped being scrotal skin what I mean is the following.  It lost the wrinkled texture that it had.  It became thinner, smoother, and this became really noticeable after so many rounds of electrolysis left it completely smooth.  It also changed colour and became darker.

The raphe line, the line that runs from the tip of the penis right down the centre line all the way to the anus became much darker.  As indicated, this line shows where the two labia fused together in the foetus during the process of conversion from female to male.  And the tunica vaginalis, instead of becoming a vaginal lining, travels with the labia on their journey to becoming a scrotal sac and ends up containing the converted ovaries: the balls.  Kind of miraculous.

What sex change surgery attempts to do is to reverse this process as much as possible.  Progress moves slowly when there is not a lot of access to trans healthcare, but there has been a boom in the time since President Obama made being trans not a pre-excludable condition for insurance.  That has actually been pushed back now in many places, but in some progressive states like NY and CA, the taps have kept running.  And where money can be made by hospitals and doctors, research dollars also flow.

Sadly, Europe is barely a player in this market with the exception of the odd doctor in Germany, Serbia…but even then, the standards are not at the level of where the top US doctors are.  Or the doctors in Thailand, a nation that realised about 50 years ago that surgical tourism could be big business and did the right things from a policy standpoint that quality standards could be adhered to, that patients could come for world-class health care and pay Thai prices.  This is still true, and some of the Thai doctors are still very much amongst the clutch of the world’s best.  I hope that the money keeps flowing, but should the Republicans win control of the White House in the coming election, the erasure of trans people is a stated aim in their platform.  Kind of scary.

Anyway, this flow of money has meant that some big advances have happened in trans healthcare.  I spoke to one of the world’s top doctors who did transgender operations in the 1970’s and 1980’s, who rather uncannily happens to be related, and his description, “gosh, when I was operating we were happy if the person could pee afterwards.  And they were happy with anything.  I was just a plumber.  What they can do now with sensation is nothing short of miraculous.”

And he is right.  The very best surgeons are creating neo-vaginas that gynaecologists struggle to differentiate once they have healed.  Of course, there is no cervix, but until you are well inside, they’ll have no idea.  The puzzled comment, “but you don’t have a cervix?” is not uncommon for the trans girls who have surgery young enough to have not developed too many/any secondary characteristics of the male.  I digress.

The changes to my scrotal skin were effectively turning them into labia.  And they started to feel like labia—and the colour change is consistent with that.  They became much more sensitive to touch.  So, when the doctor slices from a point a wee bit more than 1 cm from my anus, along the perineum, all the way along the raphe line to the tip of my penis, they are creating the opening that will lead to my vagina.  They are gently (as if anything gentle can be done with a razor sharp surgeon’s knife) cutting around the top of the penis leaving it intact with all of the blood vessels, nerve bundle, but removing the erectile tissue.  The head of the penis is resized leaving the most nerve dense part, but the urethra is cut and cut again to the length it needs to be for my new anatomy.  The crown of the penis is “tightened” in much the same way you fashion a ball of dough when baking bread (for those who do such things), and made much smaller, and placed in a fold in the new vaginal opening, with the nerve bundle tucked in just above it…this is why a trans girl experiencing penetrative sex will really get off on feeling the weight of a body on her pubic bone, as this nerve bundle itself produces feelings of pleasure when stimulated.

In a natal woman, this nerve bundle would be inside the full clitoral structure.  I include a picture of a clitoris here for your reference.  Apart from looking like the external male sex organs (it does because they are the same), it gives you a good idea of what is going on.

The clitoris extends deep into the body, but also around the labia, underneath, just inside the vagina, and these two “extensions” are filled with the same nerve bundle I’ve been describing.  In other words, a natal female will experience more pleasure in and around the vaginal opening itself whilst the trans woman will experience more pleasure from contact with the mons.  Same nerves; different places.

A similar story goes with the discarded erectile tissue.  Some doctors leave erectile tissue behind during the operation, in an attempt to mimic the small level of erectile tissue that natal women have which lines the vagina, but this almost always results in something which looks unnatural.  Over time, I am sure that there will advances in this procedure that will bring the two closer together.

A few doctors are innovating with the tunica vaginalis, the tissue that lines the scrotum in a male and is the lining of the vagina in the female.  They do this as an option with the penile inversion technique, which uses scrotal, penile, and skin grafts from the inner thighs (if needed) to create a vaginal opening. 

Most operations of this kind are penile inversion.  People choose the different types of operation for different reasons.  The other two types are peritoneal flap and colon.  The latter, which I have not discussed before, is a last resort when depth is lost because dilation was not done, or for reasons of other complications.  It is also a first choice for someone who does not wish for an abdominal operation.  It has the advantage of being mucosal tissue and allowing from stretch and depth.  There is some scuttlebutt on the idea that the colon tissue which is harvested leads to the smell of faeces coming from the vagina, but others suggest this is perverted fantasy or a lack of hygiene.  Another advantage of using the colon is that there is some level of natural lubrication produced by this tissue, and that it feels a lot like vaginal lining.

One other major advantage I see with the use of colon tissue and which is shared with the peritoneal flap method I had, is that there is no need to use scrotal or penile tissue to create a vaginal canal, meaning that they can be used to create labia, which is what they should be used for if the goal is sensation and the closest approximation to the female.

I have given an overview of the peritoneal flap surgery and how they create a vaginal canal from it.  The self-lubricating qualities of peritoneal flap tissue, a top reason for choosing this method, are already evident to me.  I am always “wet” down there, as if I am aroused.  Since I am a senselessly sexed up human, this makes sense to me, though there is no connection between my brain and my vag in the way that there is for a woman born with one.  Mine doesn’t turn on and off.  At the moment this is 100% okay as I am wearing pads 24/7, or diapers when I sleep or am worried about potential bleeding or other colourful issues.  And supposedly, this level of wetness will diminish over the coming year of healing.  My trans sisters who have this operation really like this “feature” as it is felt that it gives the neo-vaginal some of the self-cleaning properties that a natal vagina has.

I admit to relentless curiosity about my new vagina.  I am sticking my fingers in, feeling it, checking up on it, but also smelling it, wanting to get used to its odours, slightly ammoniac, but clean smelling.  That’s what I want.  Off smells can be an indicator of infection, something I really don’t want now (or ever).  The new neo-vagina is more prone to infections than a natal vagina because the difference in acidity levels.  Over a long period of time these will equalise.

But answer me this.  Just like the human gut, with its micro-biome, the vagina has a micro-biome.  The human get gets fed and populated by what we eat, pre-biotics, pro-biotics, and what we consumed in the womb.  But how does the vagina get its bacterial population?  How does a trans woman’s vaginal micro-biome get constructed.  I did ask my doctor and she said, even after I am healed, I have no business squirting honey or yoghurt up there.  I will have to look into this further.  I am taking daily probiotics, and one of them is a vaginal probiotic, so by some miracle, the little bugs must get there somehow.

Another miracle of life.  In just the same way that happens when women live together and their periods sync up, over time, their vaginal microbiomes align.  And that’s true even if they eat different things.  I can’t get over the idea that there are more nerve connections that are not sensate but are communications channels between the human gut and the brain than any other pathway in the human body.  “Second brain” is not a misnomer.  Really, we should call the gut the “first brain” as it was our primordial brain, what governed us when we emerged from the mists of the past and shifted from creatures of instinct to creatures of the mind.

I don’t know about you, but I love my instinct.  I listen to it, love what it tells me, love that it speaks to me and keeps me out of all kinds of trouble.  But I wonder now even more about the vagina and its microbiome, and another “lining” which is not ostensibly sensate but is filled with communication links to the brain.  Is the vaginal micro-biome a “third brain”, and if so, what is it telling us?  Could this be a part of the mystery of women, that women have a whole additional set of instinctual sensors that centre around the giving of life?

The full kit lies with natal women.  The human body is extraordinary.  That my body already thought my scrotum were labia from the moment that oestrogen took over, and so much that I could actually feel the difference, is quite something.  And what is important in this is that once the body thinks that a tissue somewhere is something, it becomes that something.

So, in the example of penile inversion vaginoplasty, something which I made sound less appealing than the other two operations, the “skin” grafts of scrotal and penile skin (and possibly thigh skin) are stitched together to make the vaginal canal.  It’s a bit like a patchwork quilt, but they are “dead” tissue in that they are grafts and need to find life again by reconnecting to the blood supply.  This operation is much simpler and is far more rehearsed, with hundreds of doctors around the world capable of doing it vs. a handful who are adept at doing the other types (or will have to bring in other specialists).  This means less risk.  Less cost.  Less recovery time.

But also, the miracle of the body is such that over time, though this began as skin tissue, your brain is able to tell it to behave more like mucosal epithelial tissue, so over a period of years it will take on that delicate pink colour that we love in a healthy vagina.  The clutch of doctors who are taking the small piece of tunica vaginalis harvestable from the scrotum are using it to line the very cap, or end of the neo vagina.  What happens next is miraculous.  The brain “knows” to grow that tissue and not the others, and so over a period of years, it gradually “grows” down the vaginal canal and becomes the vaginal canal.  Given that this is original vaginal lining it is a rather beautiful concept.

I was so taken by it I asked my doctor whether they would/could use the tunica vaginalis in my operation as well.  The answer was yes, but with a penile inversion only, or possibly with the colon (as this operation involves harvesting and removing a section out of your colon and then sewing one end closed like a sock, so there is no reason that the end of that sock couldn’t be tunica vaginalis.  The reason it doesn’t make sense with peritoneal flap is that this process involves leaving the tissue connected to the body and the blood supply, so it isn’t a graft.  And the “sock” end in my case is not a sock end at all, as it is still fully attached to where it was always attached inside my lower abdomen, just that the “sock end” is created by my pelvic floor, which it was threaded through.  So, no place for the tunica vaginalis to go.  My doctor also felt that tunica vaginalis is unproven and too fragile.  They had their way.

What is truly special is that over the period of a few years, no matter what type of operation you have, all the seams disappear, and the tissue takes on the healthy pink character of natal vaginal tissue.  Pretty miraculous.

For those of us who have all the scrotal/outer labial tissue and penile/inner labial tissue, here is what happens.  After the doctor has mad that central incision, they make a tall “W” cut whose central point joins the raphe line cut, whose outer edges run up along the inguinal lines, and these flaps can then be crafted into labia by stitching them into place with the characteristic texture and folds.  The opening cuts made allows for the removal of the testes and the inguinal canals, which carried the sperm fluid.

It is rather beautiful.  I can feel it all.  Despite it being swollen, it looks exactly right.

My doctor told me today that they are very happy with my progress, and I am sure my kitty will be on their website advertising what is possible in short order.

One of the wildest things about having a vagina is that I can look all the way inside my body.  And when I talked about how having a vagina is changing my brain, this is a part of it.  The process of dilation involves me lying down, listening to music which relaxes me, opening my legs as far they will go…I have the bottoms of my feet together, and my legs flop all the way open (I can thank the last 18 months of ballet stretches that makes this possible), and I slide a dilator in.  And when it meets resistance or begins to hurt, I concentrate on my breathing, and relax further, feel myself opening up further, and feel everything just falling away.  And this is a feeling I have never experienced, and the opening up that it involves on a physical plane is mirrored by what happens to me on a rational level, but more so on a spiritual level.

It is unbelievable.  So beautiful.  I am so happy I did this.  I said I was prepared to face any cost, prepared to spend the rest of my life incontinent or unable to experience any kind of sexual pleasure, and I meant it. Fortunately, that will not be the case.  What kind of discrimination I may face just serves to cement my feelings of solidarity with the sisterhood, which is why it meant so much to me to do this in the first place.

Bliss.  Surrender.  Grace.