Episode 46: “So, What’s In Your Pants?” (Genitals, Part I)
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More Bad News:
- “Arizona lawmakers vote to restrict trans athletes, surgeries” (AP News, 24 March 2022)
- Embryonic development
- “Leydig cells: formation, function, and regulation” (Biology of Reproduction, 2018)
- “Histology, Leydig Cells”
- “Development of the human female reproductive tract” (Differentiation, 2019)
- “Development of the Human Penis and Clitoris” (Differentiation, 2019)
- “‘Genetic Evidence Equating SRY and the Testis-Determining Factor’ (1990), by Phillippe Berta et al.” (Embryo Project Encyclopedia at ASU, 2014)
- “Sex-determining Region Y in Mammals” (Embryo Project Encyclopedia at ASU, 2013)
- “Twenty-five years since the discovery of the human sex determining gene” (Murdoch Children’s Research Institute, 2015)
- “Observe the meiotic reproduction of a diploid cell into four haploid gametes” (Encyclopedia Britannica, video)
- “Intersex for allies” (Intersex Human Rights Australia)
- “Androgen Insensitivity Syndrome (AIS)” (ISNA)
- “Partial Androgen Insensitivity Syndrome (PAIS)” (ISNA)
- Y chromosome / SRY gene translocation
- “Does having a Y chromosome make someone a man?” (ISNA)
- “Identification of new susceptibility regions for X;Y translocations in patients with testicular disorder of sex development” (Sexual Development, 2011)
- “Case report of whole genome sequencing in the XY female: identification of a novel SRY mutation and revision of a misdiagnosis of androgen insensitivity syndrome” (BMC Endocrine Disorders, 2016)
- History of vaginoplasty
- “[History of vaginal reconstruction]” (Ginekol Pol, 2004)
- Dora Richter, first documented recipient of gender-affirming vaginoplasty
- “Remembering Dora Richter, One of the First Women to Receive Gender-Affirming Surgery” (them, 2022)
- “On This Day | 6 May 1933: Dorchen Richter Killed In Hirschfeld Institute Attack” (Berlin Guides Association)
- Hirschfeld Institute
- “On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca” (Annals of Plastic Surgery, 2007)
- “A Historical Review of Gender-Affirming Medicine: Focus on Genital Reconstruction Surgery” (The Journal of Sexual Medicine, 2017)
- Contemporary vaginoplasty
- “How Vaginoplasty Works [PENILE INVERSION METHOD] | MTF/NONBINARY” (Leo Mateus, YouTube)
- “Anatomy before and after penile inversion” (Mayo Clinic)
- “Vaginoplasty procedures, complications and aftercare” (UCSF Transgender Care)
- “Different Types of Vaginoplasty” (VeryWell Health)
- Get vaccinated against HPV
- “FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old” (FDA News Release, 2018)
- “HPV and Cancer” (National Institutes of Health)
Selected Reading on Trans History:
- How Sex Changed: A History of Transsexuality in the United States by Joanne Meyerowitz ***CIS AUTHOR AND PUBLISHED IN 2004 SO PROCEED WITH CAUTION
- Transgender History by Susan Stryker (2008)
- Black on Both Sides: A Racial History of Trans Identity by C. Riley Snorton (2017)
- Lou Sullivan: Daring to Be a Man Among Men by Brice D. Smith (2017)
Hello and welcome to Assigned Scientist at Bachelor’s. I’m Charles and I’m an entomologist.
And I’m Tessa and I’m an astrobiologist.
Today it’s just the two of us. And we are going to begin a two part journey into the subject that has been the focal point of cis nosiness…
And anxiety since time immemorial: the genitals. Tessa, you’ve been very public, relatively public about the state of yours.
I am. Yes, yes.
Going so far as to say that Arizona State bought them for you.
Yes, I have on record thanked ASU for having a vagina.
I will say… not to begin the episode on a real downer note. But [cat meows loudly] Alan, put it better than I ever could, just existential terror every moment of every day.
But putting that aside, today, we wanted to talk a little bit about genitals. It’s hard for me to know how much other people know because I know a lot. Do you know what I mean? Like…
What is clear, is that a lot of people either are, honestly or willfully, ignorant and misinformed about what actually goes on, given the rhetoric around access to gender affirming care, wild stuff out there. So yeah, do you have any sort of opening thoughts before we just kind of…?
Yeah, first off, I’m going to preface this episode that we are probably going to be veering into TMI territory, so if you’re someone who’s close to me, like say, my brother, and don’t want to hear about the intricate details of my genitalia, and how they got…
Get out of here.
…to that configuration, you may want to just skip this one.
But with all that said, yeah, it is intensely frustrating the degree to which people cis people in particular obsess over the genitals of trans people, regardless of what configuration they’re in, but also how little information they understand about them.
And the sheer number of misconceptions involving them.
Perfectly said. So the thing that I wanted to begin with is talking a little bit about what mechanisms at what stages of life determine sexual characteristics.
Our story begins at about six weeks of embryological development, where gonads and genitals are present in sort of a preliminary form, but they are undifferentiated – i.e. there is no way to meaningfully sex the embryo at that point, other than doing a karyotype and even a karyotype, which is, you know, seeing all of the chromosomes that are present.
If you did a karyotype at about six weeks, you would be able to tell the chromosomes that are present but you would not be able to predict the sexual phenotype of the eventual child faultlessly, because variations in development and how these different developmental pathways are followed lead to a variety of naturally occurring variations in human phenotypes, which is how we get for instance, people who are intersex with genital quote unquote, abnormalities, which obviously is pathologizing language, but that’s how it appears in a lot of the medical literature, which is perhaps another conversation that we can have about pathologizing natural human diversity, but not in this moment.
In this moment, we are at six weeks of embryo logical development where gonads and genitals are present, but undifferentiated. They can go in either of the two majors sort of templated pathways towards what we recognize as a stereotypically male genital setup or of stereotypically female one.
And as we talked about in our episode on hormones, the thing that is responsible for which kind of sexual differentiation happens, in the broadest terms, is the Y chromosome, and specifically the SRY gene that is present on the Y chromosome, the presence of that SRY gene is what leads to differentiation along the quote unquote male pathway and the absence of that gene leads to development along the quote unquote female pathway.
So basically starting out you have Mullerian and Wolffian ducts that develop and if you have the SRY gene present, there is a protein that is produced called the “testis determining factor.” Actually, we didn’t know that the testis determining factor was linked to the SRY gene until the 1990s. Isn’t that wild?
Yeah, I mean, it’s kind of amazing, like how late breaking a lot of this stuff was,
Honestly, it’s just wild how so much of what’s kind of taken for granted now is in fact, very, very recent information.
So you start out with these two different kinds of ducts, essentially, the Wolffian ducts differentiate into things that are still kind of duct-y. So in people who have the SRY gene who are undergoing androgenizing, it differentiates into the epididymis, the vas deferens and the seminal vesicle.
Right, so the SRY gene, then leads to the development of these two different kinds of cells – Leydig and Sertoli. I don’t know if I’m saying those appropriately. They’re both named after guys, so you know, who knows?
But so Leydig cells are responsible for developing androgens – so the the class of hormones that testosterone belongs to – and they are present in the testes and then those androgens encourage development of the Wolffian ducts into the epididymis, the vas deferens, and the seminal vesicles.
And vas deferens should be familiar to peoplem at least in the back of their minds, because that’s where we get to vasectomy.
So it leads to the differentiation into Leydig cells, which then produce androgens, as well as into the Sertoli cells which produce something called Mullerian inhibiting factor, which basically inhibits the formation of Mullerian ducts and the Mullerian ducts are specific here, because in individuals who are not undergoing this androgenizing influence, the Mullerian duct differentiates into fallopian tubes, the uterus and the upper part of the vagina.
With their sertoli cells, they produce the Mullerian inhibiting factor, and then that prevents the further development of the Mullerian ducts into the fallopian tubes, the uterus and the upper part of the vagina.
So in the androgenizing part of all of this individuals have two things kind of going on: they have the Leydig cells, which are producing antigens, which are encouraging development of certain features. And then they have the sertoli cells which are producing the MIF which is preventing the development of the Mullerian ducts into what we recognize as parts of the quote unquote, female reproductive system.
And then in individuals who do not have the androgenizing hormones, they go through ovary development. The Mullerian duct differentiates into the fallopian tubes, the uterus and the upper part of the vagina, and then around eight 9-10 weeks oogenesis is also happening.
Because, spermatogenesis, i.e the creation of sperm, happens more or less throughout life – as long as the testicle is up and kickin, it is producing sperm. Versus if you are born with ovaries typically… I don’t know about exceptions to this but the the only universal in biology is that there are no universals – basically, you are born with all of the ova that you’re ever going to have.
So the takeaway is kind of, (a) wild stuff is going on in there all the time.
And then also, (b), a lot of… going back to kind of one of the things that we said during the hormone episode is that, nothing that people who undergo medical transition are going through is alien to their body. We all went through a point of embryonic development where things could have gone any which way…
And for some people they did, and for other people they didn’t. We all have androgenizing hormones, we all have that point of undifferentiated genitalia and gonads, where it’s all the same stuff in there, and then it either develops along one pathway or develops along another pathway, or there are a couple of relatively well known intersex quote unquote conditions, which result from various quote unquote abnormalities, either chromosomally or just developmentally.
So one example is androgen insensitivity syndrome, where you can have an individual who is XY, but they also have a gene that codes for partial or total androgen insensitivity, meaning that they have the SRY gene, they have the gene that tells their developing embryo to produce testes, but they also are unable to respond to those androgenizing hormones.
And this results in kind of a spectrum of what might be called feminizing effects on the developing embryo. So for instance, the fetal testes produce some Mullerian inhibiting hormone and testosterone but it can’t really respond to the testosterone. So the fetal Mullerian ducts do regress, so they don’t have a uterus or fallopian tubes, usually a cervix, potentially upper part of the vagina, but the visible genitals externally would read to people as more typically female. So there are testes present, but they are also present like external vulva.
Yeah, their testes are internal. And furthermore, and this ties in a little bit to the discussion we had on hormones since the body can’t respond to testostone, it just accumulates and eventually another enzyme called aromatase starts converting it into estrogen.
Everybody has aromatase, it’s what keeps our hormone levels from getting too out of whack, since our body can’t respond to testosterone at all, pretty much all the gets converted to estrogen and so throughout the rest of their lives, they develop phenotypically normally as cis women would.
Right, exactly. And then also, there are individuals who are XX, who develop phenotypically male, quote, unquote, because one thing that is interesting, that I have learned recently is that the SRY gene is on the short part of the Y chromosome, and it is near the pseudo autosomal regions that cross over during the creation of gametes – which all of that is just to say that there is a crossover event between chromosomes that happens during meiosis…
And the result is the SRY gene gets stuck onto an X chromosome and you end up with people who are chromosomally XX but phenotypically male, it’s a technical, the medical term part is de la Chapelle syndrome, incidentally.
There you go. And so you can have these instances where somebody is XX, but underwent, like, the development that you would expect from a Y chromosome, because they had that portion of the Y chromosome, the SRY gene that kicked off the whole process.
And I I do want to be very careful because a lot of the time both cis and trans people will sort of weaponize intersex people as a gotcha card, like you can’t be transphobic because what about intersex people, basically, people love to trot out various kinds of intersex conditions as like a, you can’t say this about whatever because intersex people exist, but then they don’t meaningfully include intersex people overall.
And I, I want to be very clear, I want to be very clear that this is not my intention. And I it’s not your intention, Tessa, but rather to include this of – humans, and other mammals, and the whole world, is full of irreducible complexity, and the simplified version of biology that people use and then weaponize as a cudgel to beat trans and intersex people over the head with is not accurate to the diversity of the world. It is a simplification for the purpose of making concepts easier for beginners to learn.
But once you’ve learned those basics, then you can expand to the full diversity of human experience. The reality of it is, you can crow about specific chromosomes all day long, as long as you want, but that doesn’t stop the fact that all kinds of variations of development can happen and do happen, and there’s nothing wrong with those people.
And you can’t just make these very basic statements about well, male people are this and they have this and female people are this and they have this, because that’s never going to be universally accurate.
You can have XY individuals who go along what people would consider a typical female development, and you can have XX individuals who go along what people would consider a typical male development. And that’s life, baby.
The final thing that I really want to get to is sort of the takeaway point, which is that, because we all began with exactly the same stuff that then different genes, and subsequently different hormones, led to differential development of, there is a lot of overlap, ultimately, in the experience… listen, we’re all just humans at the end of the day, and all genitals came from the same stuff.
And that’s part of why gender affirming genital reconstruction surgery is possible as much as it is. I think we’ll kind of get more into the implications of that in our next episode, but a lot of it is – what medically transitioning can teach the world is many things but among them is, things that you think are very, very different are in fact, not so much.
Yeah, and honestly, if people stop and think about this, it’s not really that surprising. The homologies, the similarities, between different portions of reproductive anatomy are pretty obvious. The penis and the clitoris – very similar structures to each other. Testicles and ovaries, scrotum and labia, etc, etc. And that’s because they all come from the same base tissue. It’s just in a slightly different configuration.
That’s sort of a primer on human sex differentiation during embryological development, and now let’s go back another 60 years to the beginning of the 20th century.
A lot of the procedures that many people primarily associate with people who are undergoing medical transition, for example, vaginoplasty…
And maybe as a note on terms for people who are not familiar with them, “-plasty” is generally the creation of something, and “-ectomy” is the removal of something. So we can talk about vaginoplasty, which is the surgical construction of a vagina, as well as orchiectomy, which is the removal of testicles, and we will talk about them.
So going back to the beginning of the 20th century, I tried to look into this… one thing that kind of gets brought up is that we think of these things as being associated with trans people, we think of vaginoplasty in people undergoing genital reconstruction surgery in a gender affirming way, we think of puberty blockers being given to trans children when they’re like 11 years old to prevent unwanted pubescent changes.
But both of these things, and many other things, were in fact, created first, to serve cispeople. So the origins of vaginoplasty are in the late 19th century for cis women who experienced congenital or traumatic sort of abnormalities or destruction to the vagina.
And so the origin of those surgeries was not to serve trans people, they were to serve cis people, and then trans people came along and were like, Hey, wait a minute. And I tried to find more information about the specific historical origins of vaginoplasty for cis women, but the primary thing I could find was a review article in Polish. And unfortunately, polish is not among the languages that I can read.
But the first documented gender affirming vaginoplasty that most people seem to reference is not in fact Lili Elbe, who is perhaps better known and who was insultingly portrayed by Eddie Redmayne.
But a woman called Dora Richter. So Dora Rector was born in 1891, and she underwent the first documented trans vaginoplasty in 1931, at the Magnus Hirschfeld Institute in Berlin. And this is going to be kind of a sad interjection because another thing that I don’t think a lot of people know is that Magnus Hirschfeld is a really important historical figure in the modern history of trans people going back over the past century, where his sexual Institute in Berlin was a very important center of sexological studies in what we would now group together as queer and trans people.
But another thing was happening in the 1930s in Germany, which was not so positive.
And so Dora Richter underwent surgery, and it was not the method that is most common now and became most common later.
It was pretty primitive by comparison, yeah.
Yeah. So it was not the penile inversion technique, it was like skin grafting. From one article, “Dora’s surgery was a rudimentary two part affair, a penectomy” – removal of the penis performed by one doctor, “followed by the construction of a new vagina” by another.
So it was not sort of the relatively sophisticated procedure that is present now. But it was more sophisticated than no procedure. But unfortunately, she got the surgery in 1931. And then in 1933, Nazi Storm Troopers raided the Institute for Sexual Science, Magnus Hirschfeld Institute, and killed the bunch of people, a, and also led to a massive book burning. So a lot of the progress that was being made for trans and queer, and people in that area, was literally arson’d out of existence.
And actually, the famous pictures people have seen of Nazi book burnings are from that specific event.
Bad. It’s not good. It’s very sad. And so Dora… the sources that I found are a little bit unclear about whether she died in that raid, or she died shortly thereafter. But we do know that she did die very soon around that time, and then a bunch of worse stuff happened.
So… not a lot of progress, unsurprisingly, was made in this area until we got to the 1950s, where the origin of these surgeries was largely in Western Europe. And so there were cases of, for instance, Americans traveling to Western Europe.
The most high profile example of these was, of course, Christine Jorgensen, who became a sensation because of the novelty of… “Ex-GI Becomes Blonde Beauty,” I think is the classic headline. And so Christine Jorgensen went to Western Europe and she had, again a series of things to happen. I think she had an orchiectomy, a penectomy, and then a vaginoplasty.
The penile inversion technique, which is sort of the dominant technique since the mid century was not really happening yet. But the 50s and 60s saw a proliferation of the procedures that were done, as well as an increase in the sophistication and quality of results, including the development of the penile inversion technique.
They were pretty much limited to Western Europe for the period of the 1950s, and then in the 1960s, the first surgical clinics available in the United States started popping up but it was still highly, highly restricted. According to a review article that I found, “Johns Hopkins University in Baltimore, Maryland announced the opening of the first gender identity clinic to offer GAS in the United States” – in like the 1960s – “in its first two to three years of operation, the clinic received nearly 2000 applications for surgery mostly from MTF patients. Inundated with desperate requests, JHU staff exhibited a strong preference for candidates who were the most likely to, quote, pass as the opposite sex and behave in accordance with traditional gender norms. Ultimately, they turned quote, almost all of them down performing on only 24 patients.”
I think there are a couple of things here that I would like to highlight. First of all, bad ratio, bad job. And then secondarily, this gets to something that I don’t… I don’t know how much people know this. But part of the reason we are seeing such a dramatic increase of people medically transitioning is because for most of the time, in the 20th century, when these things were available, the gatekeeping was so intense, that only 1% of the applicants to this clinic were allowed to go through the procedure. Like the first one, one of the biggest ones, and they were only doing it for 1% of the people who applied.
And not just because of like, lack of availability of qualified surgeons, but because of, as stated, a strong preference for candidates who were the most likely to pass. The gatekeeping against gender affirming medical care for decades was unbelievably restrictive, to the point where like, literally, if they thought that you would be an ugly version of your identified gender, you were not allowed access to medical transition.
It was all based around maximizing the comfort of the non transgender population.
Right. It was not about serving the people who were looking for these treatments, it was about creating only the most acceptable trans people who would then effectively live as cis individuals. Like it was not uncommon… and it’s also a point of clarification really, is that the history of different demographics of trans people are very different in a lot of ways where like, if you were a middle class white person, your experience as a trans woman was likely to be extremely different from, for example, a poor black woman, like Marsha P. Johnson.
And so it was, it was very, very common for people demographically, who could just sort of slide into cis anonymity to leave their whole lives behind, like to transition and cut contact and move. And it’s the reason people are seeing so many more trans people now than they ever used to is because a, they started actually letting more people access medical transition. And then, b, increasingly it is not a requirement that you just abandon your life and go stealth forever, like trans people have been around…
Like, even if you restrict transness to just the medical advances in the early 20th century around hormones and surgery, like even if you restrict transness as a modern phenomenon to a century ago, even during that period, trans people have been around that whole time they’ve been going on hormone replacement therapy, and they’ve been getting surgery, and they’ve been transitioning legally, medically and socially. The reason that so many people never heard about them until now, is because there was literally no way for trans people to make themselves known, other than the very rare exceptions, like Christine Jorgensen.
And I would argue Christine Jorgensen only got away with it because she was such at the forefront, at least in the US that that sort of culture of gatekeeping and stigma really hadn’t had a chance to develop.
Yeah, I mean, it’s interesting. If you look into trans history of the past 50, 60 years, there are a lot of examples of people just being really legally confused by it. Trans people, because there was no like, before enough trans people existed to put demands on like various legal systems, there was like no pathway to change the sex on your birth certificate or whatever, right? So there are a lot of examples of trans people just kind of finding loopholes and slipping through the cracks, because nobody really knows what to do with them, because they fundamentally are unfamiliar with trans people. And with trans in general. Anyway, I’m just really steamed up about it.
Yeah, yeah. I mean, like, I would not have survived… I was actually just reading about this earlier today, where like, there are interviews of people who went through the Canadian system like an 80s-90s. And they were aggressively gatekeeping people to the point where like, someone had to change their jobs from being a aircraft mechanic to becoming a registered nurse, because the doctors thought that being an aircraft mechanic was too masculine. Another one had to change the way she spelled her name because it was deemed too masculine. It was ridiculous. I mean, based on that, I probably would have not made it through a lot of those gate standards.
Beyond that, neither of us would have been allowed to transition for a long time, because we’re both gay.
Yeah, that too.
Like gay trans people, as in trans people who were transitioning so that they would then live as a gay individual, word literally – they were just flatly not allowed access to medical transition, until shockingly recently. Shockingly. Steamed, steamed up about it.
So, okay, but basically, before the 1950s vaginoplasties were largely done using skin grafts from the back, butt or thigh, which are still very popular locations for skin grafts. But then in the 1950s, the penile inversion technique was developed. And since then, has been the primary method used. There are a couple of different options like bowels use, where you take a portion of the intestinal tract and you use that, but those tend to be secondary, if not last resort options.
The sigmoid colon technique has largely fallen out of favor, you know, hurt because of its we’ve gotten better ways of developing grafts for those who do need added depth. Also, because a major part of it was like, Oh, well, it’ll increase lubrication, because it’s a chunk a colon. And while that’s true, it doesn’t really ever stop discharging, which is not great. And also, colon tissue is not as resilient as skin tissue. So there’s issues with that as well. So yeah, I literally, I don’t think I’ve ever known anyone who’s actually undergone that technique, I’ve just heard about it.
Yeah, well, that leads us beautifully into talking about what is actually happening surgically, with the genitals of people who in medical literature are referred to as MTF.
So, okay, so the surgical procedures that are happening.
They put you under and then what happened?
Okay, so there are actually two different I guess, sub varieties of the inversion approach. Well, one is technically not invert, penile inversion specifically. So… but the the penile inversion is the most common one, we’ll talk about the other one in a bit, which is basically that, yeah, they put you under.
First they remove the testicles, if that hasn’t already been done in an earlier procedure, and then they remove the skin of the penis, and just kind of hold on to it basically construct a cylinder out of it. And then short version is, they use the head of the penis to construct a new clitoris from, as well as a clitoral hood. And then from the scrotum, they construct the labia, both majora and menorah.
And then finally, they use the skin of the penis that I just mentioned, as well as some of the urethral lining from the former penis to construct the vagina. And basically, because you know, evolution and biology are very conservative, everyone, regardless of what genitals they do end up with, has basically sort of an empty space in their pelvic floor where you could stick a vagina, which is convenient.
And they basically just put that constructed cylinder, the new vagina into that area and stitch it in, and then everything heals up over time afterwards, and then you have a functioning new vagina. The advantages of this technique are that if you do it right, you preserve all the nerve endings. So you know, you’re still orgasmic. I know I definitely am. Um… [Charles laughs] Hey, I told you all this was gonna be TMI.
[still laughing] We don’t have this kind of friendship. [fake seriously] But we do have this kind of podcast.
We do. We do. Charles, you knew what you’re getting into when you asked about this topic and, um, it’s, you know, very elegant. The way my surgeon referred to it was, it’s basically using sort of the embryonic development process we talked about earlier as a guide, reconfiguring the existing genitals into the same configuration they would have had had, you know, I gone down the other, I guess phenotypically female development path.
Two roads diverged in a uterus.
And then later, you tracked back to the fork and you went, I want to go that way, actually.
Yeah, exactly, exactly. There is one variant technique, which is mostly done in Thailand, where instead of using the penile skin to build the vagina, they use the scrotal skin and then they use the penis to build the labia, the skin of the penis to build the labia majora and minora, but it’s still the same basic concept. And there’s also a lot of crossover between those techniques… like I know for a fact that to be perfectly blunt, some of the skin on what is now my labia came originally from the penile shaft because a birthmark got moved there.
[amused] Oh my god.
So, you know…
What environment… that’s great environmental storytelling.
You’re welcome. But anyhow, yes, that’s the gist of it.
So why is this the most common technique versus…
Again, I think it’s just because it’s very elegant and very simple. You don’t actually have to separate a lot of skin tissue, you just have to move it around, which means nerves are more likely to be preserved and it’s also like… in terms of, I guess, the amount of material being moved around is relatively conservative. You’re not making a whole lot of massive changes to what’s already there in order to make it work.
Well, what happens to the cavernous tissue… did they just toss it out in the bio waste?
Yeah, I think the the like tissue that’s part of like becoming erect, as part of the penile shaft is, I think discarded. I think the Thai technique preserves it somehow. I don’t know what they use it for, though.
I think I saw in one of the documents talking about early like 1950s 1960s procedures, there was some preservation of it as going basically along the labia. I think my guess would be because the internal like clitoral structure also goes that way.
Oh, that would make sense. Yeah, but that’s, that’s just a guess.
So I have seen on TikTok that some people have to get electrolysis. Did you ever do electrolysis?
Oh, yeah, I did. It’s not required. But it does help basically because otherwise you can end up having hairs growing in your vagina which is you know, again, it won’t kill you but a aesthetically some people are not fans of that.
Hm, well also potentially you could get ingrown hairs, I guess.
Yeah, theoretically. Like the surgeons are supposed to, for lack of a better term, scrape the hair follicles out of the penile skin before they plant it into the new vagina but like that’s not as surefire as electrolysis.
Hmm. Just as a, as a primer, or a review for anybody who doesn’t know basically, you’re taking a needle that has a laser and you’re putting it in the follicle.
No, it’s not lasers different. Okay, with electrolysis, you’re just putting an electrified needle into the hair follicle and basically zapping it.
What’s the laser? Is there a laser one?
Laser, zaps it just through using the heat of the laser pulse.
Okay. [pause] They both sound terrible.
Laser’s not too bad, because it’s over quick. It’s like, you know, getting snapped by a rubber band electrolysis. If possible, I’d definitely recommend definitely some sort of numbing or analgesic. Because yeah, it’s about as pleasant as it sounds.
Okay. So a common talking point of people who think that this is gross and weird, is that you were basically taking a healthy organ and making what they refer to – I wouldn’t – they refer to as just an open wound.
Yep. That is a common talking point. And I really hate it partially because it’s gross. But also because if you actually sat down and thought about it for even just a minute, you’d realize it has to be false. Because if it were literally an open wound, first off, good luck finding any surgeon who would be willing to perform that, but also, secondly, you would hear about trans women periodically, either, you know, hemorrhaging and bleeding out, or getting sepsis and dropping dead. And those aren’t things that happen.
The other part of it is that they assume it’s an open wound because of the need for dilation. And this is a also very common misconception. And the idea is that well, it’s like a piercing, it’s a wound.
Well, let’s, let’s back up for the positive but uninformed, what is dilation and why is it necessary?
Okay, so dilation is the practice of basically inserting something into the neovagina, usually like a hard cylindrical object.
They basically look like poorly designed dildos.
Yeah, yeah, they are not like, basically dildos designed by someone who was just not very interested in sex. You know, and I mean, like, we were talking about how these techniques were originally developed for cis people – dilators were actually originally developed for cis women with vaginismus, and only later got applied to trans women recovering from GRS.
But in that case, in the case of trans women dilation is done early on in the recovery from surgery to essentially make sure that you don’t get scar tissue forming where it shouldn’t be, and to basically make sure that the vaginal canal that you’ve constructed stays open, it doesn’t like collapse upon itself as tissue heals, at least initially.
After the first month or two, the primary purpose of it is actually in fact to retrain the pelvic floor muscles to accommodate the fact that there’s a vagina there now, because they’re never had to deal with that before that I think is like, what leads to a lot of common misconceptions is that people are like, Oh, you need to keep doing this or otherwise it’ll heal shut, it will not heal shut.
Like I said, the neovagina is made out of a combination of mucosal tissue from the penile urethra and skin of the penis – like it will not heal shut any more than your nostrils are in danger of healing shut, skin doesn’t heal shut to skin like that. Otherwise, we’d have to worry about our fingers healing shut to each other too.
The primary purpose of dilation, like I said, is to retrain the pelvic floor muscles, and again, early on, prevent the formation of surgical adhesions or scar tissues in places where you don’t want them. And it’s because of this trans women generally have to dilate less and less over time both because you know, after a certain point, scar tissue is not an issue because you’ve done healing. And also because the pelvic floor muscles have adapted to having a vaginal canal there. I know trans women who had surgery like years, sometimes decades ago, and some of them just kind of stopped dilating after a while because they realized they didn’t need to anymore.
Well, and as I’ve seen some saucier commenters note, dilation can count as anything.
So if you’re having a rolicking good time out there…
Exactly. There’s that to the idea that, you know, neovaginas are these open wounds, or that you know, they’re festering or bleeding or whatever is completely wrong. And like I said, if you actually just thought, stopped and thought about it for even a minute, you’d realize it would have to be because it, nothing would make sense otherwise.
Well, kind of a related negative talking point is that the neovagina has to be gross, or weird, because unlike sort of a naturally occurring vagina, it’s not self lubricating. And it’s not self cleaning.
Yeah, so this is also kind of, well, there’s a little bit more truth to this, it does not self clean the same way sis vaginas do. But I mean, just because of the nature of the structure, and where it’s oriented on your body, things that you know, will tend to get shed, same way it is, and sis people with vaginas, it’s not quite as active and self cleaning, but it’s not going to like turn into this foul, you know, waste dump, if you don’t do everyday or whatever, it will usually take care of itself.
It’s not connected, like there’s not another organ that is producing stuff that has to get flushed out.
And the other thing is about self lubrication. Now, this is something where your mileage can vary considerably because I have heard of trans women who do not lubricate. However, and this is going back to the original. The earlier discussion about homogeneous structures is that most surgeons nowadays, make a point to preserve the cowper’s gland which is homologous to the bartolan’s gland, and people who went down that sort of stereotypically female development, the pathway we discussed earlier, and that can provide some degree of lubrication. It’s also the same gland that’s involved in producing pre ejaculate, I believe. So, you know, again, in my case, I do self lubricate.
You know, it’s never really been a problem for me, there is some debate about the micro flora that are present in Neo vaginas compared to vaginas of people who are assigned female at birth. I’ve read some really horrible store studies that have said, Oh, we did, you know, metagenomic analysis and found that it was mostly like fecal bacteria, or you know, stuff like that or staph.
On the other hand, I read another study that use completely different method and said no, actually mostly found lacto bacteria, the same sort of type you find in the vaginas of AFAB people. So this is one of the cases where there simply isn’t a whole lot of information available because no one’s really done studies on the micro flora a post op transwomen. But regardless, whatever negative stuff you may have heard about it, or about neovaginas is probably wrong.
I mean, I think that’s probably true for most people, but most of the stuff I’ve heard about neovaginas is directly from people who have them.
So I think I’m on the right track.
Oh, and then another thing occurred to me and I really don’t know the answer to this. Do you go to a gynecologist?
I happened in the past. Yeah. Like, at one point I thought I had BV it turned out to be a yeast infection. And yeah, I went to the campus Women’s Health Center. I don’t go as regularly because I’m obviously for example, at a lot less risk for cervical cancer, cervical cancer. Theoretically, trans women can get a form of cancer from HPV, but it’s much rarer.
Well, I mean, I mean, literally, HPV is one of the leading causes of penile cancer.
Yes, exactly. And theoretically, the vaginal lining that’s constructed from penile tissue can be susceptible to cancer from HPV.
I really care about people protecting themselves against unnecessary HPV transmission, go get Gardasil nine, it’s approved for people up to like 50 years old now. Get out there.
But yeah, you know, for other concerns, I have been to a gynecologist before because, like, they’re the people who are gonna have the best idea of what’s going on down there. I have seen transphobes in the past, like, accused trans women of doing this, like stealing resources from quote, unquote, real women, and that they should go to proctologist instead, which, yeah, you know, not, I’m sure anyone’s gonna know about like, BV, it’s gonna be…
It’s a different structure, yeah.
…since that makes sense.
I will… cause I can also imagine a very bad faith reading of like, it being a weird of it being an extension of the weird pervert fantasy that they think trans women are living in of like, I’m going to get the surgery done. And then I’m going to get off on going to the gynecologist or whatever.
Yeah, since you know, going to the gynecologist is such a…
Everybody loves it. It’s famously very erotic and very comfortable.
[laughing] Yeah, exactly. [both laugh] Yeah, yeah. On that note, speaking of like, medical concerns, most surgeons nowadays also preserve the prostate, or at least part of the prostate and basically repurpose it as the g spot, so theoretically…
Do they move it around?
I’m not sure. I will note that again, not to get into too much detail, mine is located in a slightly different place than it has been on most cis women I’ve known so I don’t know if they actually move it or if they just kind of, like it stays where it is.
This is going to secretly be the backdoor most controversial statement of this episode, a definitive affirmation of the existence of the G spot.
Oh, yeah. 100%.
So I think another thing kind of maybe to end on is this idea that you’re basically taking something that works and is healthy, presumably, and then making it into something that is going to come with a bunch of unnecessary risks? So are there a lot of long term risks medic, like, assuming neutrality on the value of genital reconstruction, but literally, like medical health risks?
Long term? Not so far as I know, I’ve never heard of any long term risks associated with GRS. If anything, you know, because the removal of the testes, I’m at less risk, comparatively speaking, since I no longer have to worry about testicular cancer. And I mean, theoretically, I could still be affected by prostate cancer, but with my hormone balance being what it is, it’s much less likely.
I mean, as we as we noted, in the hormone episode, that puberty blockers were developed for sis men at risk of like prostate cancer.
You’re helping your long term health. Fantastic. Well, I love that you’re so open. And yeah, I don’t have anything else to conclude from that. Great job. And thank you, Arizona State.
Yeah, thank you ASU for the vagina. I made my quibbles with you, but that actually did significantly improve my quality of life.
Great job. Oh, well, a final thing that we I wasn’t because here’s the thing. We know, as in you, and I know, and also probably most of the people listening to this know that when you go on hormone replacement therapy as part of medical transition, it affects your genitals.
I looked, I was not able to find like research talking about the effects.
I mean, there were a couple of just observational kind of studies of like, this is what people had happened to them, but nothing about like, the mechanisms or… could you just to touch on that?
So this is diving much more thing, anecdotal realm, because people’s experiences vary tremendously. But the major changes in sort of like if your pre op or non op and going on a feminizing hormone treatment, is that major changes that the scent of everything down there changes, which isn’t too surprising, because hormones in general will alter your body odor overall. So that changes the texture and firmness of the skin changes, which again isn’t too surprising because that happens elsewhere in your body as well. Generally speaking, there’s sometimes a reduction in penile size. I don’t know if that’s due to hormones specifically or just because they’re getting fewer erections.
And anecdotally, I have heard some people like reporting getting essentially wetness, so almost like a weird form of, you know, their vagina is trying to self lubricate, except they don’t have a vagina at that time. Like on scroll or penile skin. I have no idea how accurate that is. It wasn’t something I recall experiencing. The but yeah, that is something I have heard. And biology is weird, so who knows?
Who knows? Well, fantastic. That’s an episode of a podcast.
If you want to find me online, I am on Twitter @cockroacharles.
And I’m on Twitter @spacermase, or you can go to my website tessafisher.com
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