Sexual Health (Phalloplasty)

Welcome to your customized sexual health guide! This guide is for anyone who was assigned female at birth (AFAB) and has had phalloplasty, including people who’ve had penile and/or testicular implants. It applies whether or not you had vaginectomy as part of your surgery (surgeons in Canada usually require vaginectomy as part of phalloplasty but some international surgeons do not).

This guide is also for intersex people, if you were born with a vagina and/or ovaries. Whether you’re a trans man, non-binary, or any other gender, we’ve got all the info you need for a healthy, happy sex life.

Safer Sex

Safer sex can mean different things to different people. In this guide, we use safer sex to mean ways to reduce the risk of sexually transmitted infections (STIs) and HIV. Anyone can get or transmit an STI, no matter what kind of sex or how many partners you have. Here are a few ways to make sex safer while still keeping it fun!

Condoms 

Condoms are thin, tube-shaped pieces of latex that make a barrier between people’s genitals during sex. This stops bodily fluids or bacteria transferring from one person to another. They help prevent pregnancy, most STIs and HIV.

Condoms either go over the penis (external condoms) or inside the front hole/vagina or anus (internal condoms). External ones are a lot more common. You can also put them on sex toys, if you’re sharing them. You can use condoms on all kinds of penises, including after phalloplasty. 

Using an external condom

You can use external condoms for oral, anal or vaginal sex. Condoms protect people against HIV and STIs, whether you’re giving or receiving.

First, check the expiry date on the condom packet (yes, condoms expire!) and make sure it’s intact with no rips or tears. Open the packet with your hands, not teeth - this helps avoid damaging the condom itself. 

Next, make sure the unrolled condom is the right way up. Then pinch the tip with one hand to squeeze out any air and then, at the same time, roll the ring all the way down the shaft with your other hand. To take a condom off a penis, the wearer should move away from their partner’s body and remove it while they’re still hard. This helps avoid any fluid spilling out, if the person produces sperm.

Don’t reuse condoms. If it breaks, falls off or you want to go again, just grab a new one! It helps to keep a few around. You should also use a new condom every time you:

• Switch partners

• Switch between anal (back) and vaginal (front) sex

• Share toys (e.g. dildos)

Finding the right condom

Condoms are usually made of latex, but can also be made of polyurethane and polyisoprene. These are useful if you or your partner are allergic to latex. Avoid lambskin condoms - these have small holes in them, so they don’t prevent STIs and HIV.

Condoms come in all different sizes. They even come in flavours (but these should be used for oral sex only). If your partner is wearing an external condom, it should fit snugly. If it’s too tight or painful then try a bigger size, and if it’s loose then try a smaller one. 

Lube

If you’re on testosterone (T) and you didn’t have vaginectomy, you may find that your front hole (vagina) self-lubricates less than it used to. Whether you’re using toys, fingers or a penis, lube can make sex easier and a lot more enjoyable. It can also prevent tears or abrasions, which raise the risk of STI transmission. If you’re also using toys in your back hole or having anal sex, then lube is a must!

Lube can be water-based, silicone-based or oil-based, but the type that’s best for you will depend on what you’re using it for. For example: 

• Water-based lube works well with all toys and condoms. It leaves less stains compared to silicone or oil-based lube, but it can dry out faster (so you need to reapply). You can get flavoured water-based lubes for oral sex, but these shouldn’t be used for vaginal (front) or anal (back) sex.

• Silicone-based lube works well with condoms and toy materials like glass or metal. It should not be used with silicone toys, as it can degrade them.

• Oil-based lube or other oil products (like coconut oil) should not be used with condoms. It can degrade them, which makes them ineffective and raises risk for STIs. It can also be harder to clean off toys. 

PrEP

PrEP stands for Pre-Exposure Prophylaxis, and is a medication that prevents HIV. You might benefit from PrEP if:

• Your sex partners were assigned male at birth (AMAB) and they have sex with AMAB people

• Your sex partners are from countries with high HIV rates

• You inject drugs

If taken as prescribed, PrEP reduces HIV risk by 99% for vaginal (front) or anal (back) sex. It also reduces the risk of HIV when sharing equipment to inject drugs, but we don’t know by how much. Most people take PrEP as a single daily pill.

If you’re on PrEP, it means you don’t need condoms to prevent HIV during sex. PrEP doesn’t work against STIs, though. To prevent STIs you can use condoms. If you are on PrEP, you’ll also be required to get STI testing every three months.

You can get PrEP from most sexual health clinics that serve LGBTQ2S+ people. You can also get it from family doctors, if they’re informed about LGBTQ2S+ health. If you are a Foria patient you can get PrEP from your clinician; another option is our sibling service Freddie, a virtual PrEP clinic. Visit www.gofreddie.com for more information.

Depending on where you live, public health plans may cover part or all of the cost of PrEP. It’s also usually covered by private insurance, like if you have benefits through your employer. Freddie also offers financial assistance, so 90% of patients pay $0.

HIV Treatment

If you’re living with HIV, starting treatment as soon as possible and taking it as prescribed has huge benefits for your health. In fact, modern HIV treatment is so effective that someone diagnosed today can live just as long as someone who doesn’t have HIV. 

One of the main benefits of HIV treatment is that it stops HIV transmission through sex. Effective treatment can lower the amount of virus in someone’s blood so much that it wouldn’t be picked up by most types of HIV test. This is called “undetectable”. When someone is undetectable and taking treatment as prescribed, their HIV is untransmittable (known as “U=U”). 

U=U means that you can’t pass HIV to someone else through sex. It’s not just a low or very low risk – it’s zero risk. This can help ease any anxiety you or your partners may have, so you can focus on having fun!

STI Testing

STIs often don’t have symptoms, so the only way to know your STI status is to get tested. STI testing can be daunting, especially if you’ve faced transphobia or other types of discrimination in healthcare before. We’re here to demystify the process. 

This section will tell you what tests to get and how often to get them. These will vary based on the kind of sex you’re having. If your healthcare provider doesn’t offer you the tests you need, you can ask for them. 

What tests to get

A full routine STI test checks for syphilis, HIV, gonorrhea and chlamydia. Some parts of this test are standard for everyone:

• To check for syphilis and HIV, you’ll get blood taken from your arm. This is then sent to a laboratory to be tested. Some clinics will have rapid HIV tests, which use a few drops of blood from your finger and can give you results in minutes.

• To check for gonorrhea and chlamydia in your genitals, you’ll need to give a urine sample or do a vaginal swab (if you didn’t have vaginectomy). 

Whether you do a vaginal swab or a urine sample will vary depending on your clinic’s protocol and your individual situation. Depending on your sex life, you may also need to do some additional swabs. These are:

• A throat swab, if you’ve performed oral sex on someone with a penis.

• A rectal swab, if you’ve had receptive anal sex (bottomed) for someone with a penis or shared sex toys (e.g. butt plugs or dildos).

You may also be screened for hepatitis C periodically, depending on your risk factors. 

How often to test

If you’re starting a new monogamous relationship, then you can test after you’ve been monogamous for three months. Some people might test sooner, but if so then it’s recommended to re-test at three months. This is because of the time it takes for an STI to be detected on a test, known as the “window period”. Window periods range from one to two weeks (for chlamydia) to three months (for syphilis). Testing after three months means you are outside the window period for all STIs and HIV. Afterwards, you don’t need to test again unless you open up your relationship.

It’s recommended that everyone should test at least once per year if you have new partners. If your partners have a penis they were born with and you use condoms, then test every three to six months. If you don’t always use condoms, then test every three months. This includes if you don’t always use condoms for oral sex.

If you are on PrEP, then you’ll be enrolled in testing every three months.

Where to test

You can get STI testing and treatment at sexual health clinics, public health clinics, primary care clinics (e.g. family doctors and nurse practitioners), walk-in clinics, and some community health centres. Sexual health clinics are often the best equipped to serve trans, non-binary and gender-diverse people. To find a service near you visit Where to?.

STI Symptoms

STIs happen sometimes! Luckily, they can often be easily treated. Because there is a stigma around STIs, if you have symptoms these may bring up feelings of shame or guilt. Stigma towards LGBTQ2S+ people and our sex lives can make these feelings more intense. This is a normal reaction, but there’s no need to feel shame!

There are a few symptoms to look out for – if you notice any, avoid sex until you’ve managed to see a healthcare provider. These are:

• Blisters, sores or firm bumps in your genital or anal area

• Pain when peeing*

• Pelvic pain*

• New or different discharge from your genitals (this can be yellow, white or green)

• Itching in the pubic area*

• Unusual vaginal bleeding*

• Pain, bleeding or discharge from your anus

• A rash

Some changes, like pimples in your pubic area, are usually harmless.

STI Treatment

STIs can happen to anyone, no matter how many partners you have. Just like how going to a bar or using public transit carries a risk for colds or flu, sex carries a risk for STIs. What’s important is getting treatment as soon as you can to make sure that you stay healthy.

If you have symptoms, make an appointment with your sexual health clinic or visit them during walk-in hours. Most clinics can diagnose and treat you right away. For example, if you have genital or rectal discharge they may take a urine sample, swab your front hole (vagina) if you haven’t had vaginectomy and/or swab your rectum and test these on site. They may order some additional tests to confirm your diagnosis, and will get in touch when those results come back.

If you’ve had treatment, you’ll also need to avoid sex for a short period while the medication is working. Your healthcare provider can advise you on this.

If you test positive for an STI, you should notify your recent partners so they can get tested and treated if needed. However, this may not be safe for everyone. If you don’t feel comfortable contacting them directly, you can visit www.tellyourpartner.org. This is a free, anonymous service based in the U.S. that also works in Canada. It will send a text to your partner on your behalf. Note that if your partner is only having sex with you, they will know who the message is coming from.

Vaccines

Some STIs and blood-borne infections can be prevented with vaccines. These are:

Hepatitis A & B

These viruses affect your liver, and vaccines are recommended if your sex partners have a penis they were born with and they have sex with AMAB people, or if you inject drugs. They are usually covered in Canada for trans and non-binary people who fall into these groups. Your clinician or sexual health centre can check your immunity when they do blood tests, and should offer vaccines if you need them.

Human Papillomavirus (HPV)

This virus can cause genital warts and some types of cancer (throat, anal, cervical and penile). The HPV vaccine can protect you against the most common strains that are linked to cancers and warts, but it can’t cure any strains that you already have. However, if you have a healthy immune system your body may clear the virus naturally. 

In Canada, the HPV vaccine is offered for free to all AFAB children in elementary school since 2007/8. If you didn’t receive it as a child then it may still be covered for you under the public system, but this can vary by location. If you have extended health benefits through a private insurance plan, this may also cover the vaccine.

Contraception

If your sex partners produce sperm and you haven’t had hysterectomy or vaginectomy, then you’ll need to use contraception if you’d like to prevent pregnancy. This applies even if you are on T or if your partner’s on estrogen and/or androgen blockers. This is because both types of hormones can reduce fertility, but they aren’t effective contraceptives. There are many options for contraception including condoms, IUDs and birth control pills.

Emergency contraception

The emergency contraceptive pill is also known as the morning after pill. It’s a medication you can take after sex to prevent pregnancy if your contraceptive fails or you weren’t using any. You can get the progestin pill (Plan B and generic versions) without a prescription from a pharmacy, doctor or sexual health clinic. It needs to be taken within 72 hours (three days). You can get the ulipristal pill (Ella and generic versions) by prescription from a doctor or nurse practitioner. It needs to be taken within 120 hours (five days). With both pills, the sooner you take them the more effective they are.

It is safe to take the morning after pill while you are on T, and the risk of it interacting with your hormone therapy is low. The progestin pill is less effective for people with a higher body weight, so make sure to read the label – you may need to take a higher dose.

Another emergency contraceptive is the copper IUD, which is extremely effective. This does not contain any hormones. There are no weight restrictions for it, and it can be inserted within seven days after sex. Once it is inserted, the copper IUD lasts for 5-10 years. You can get it from your doctor and at some sexual health or community health clinics.

Pregnancy

It’s possible to get pregnant while you’re on T. However, hormone therapy is not safe while pregnant and you may not be able to continue a pregnancy that began while you were on it. If you learn that you’re pregnant, make an appointment with your hormone clinician as soon as you can to discuss your options. 

Pap tests

Pap tests are tests that screen for cervical cancer. During a pap test, your clinician takes a swab from your cervix to check for cells that could develop into cancer. Regular pap tests are recommended for everyone with a cervix, including people who’ve had a hysterectomy that left the cervix intact. If you had vaginectomy or hysterectomy that removed your cervix, then you do not need pap tests.

Pap tests are recommended whether you are on T or not. It’s a good idea to tell the person doing your tests if you’re on T and they don’t know your medical history. This is so they can keep you more comfortable during the test (e.g. using lube) and make sure your results are processed correctly.

Vaginal atrophy

If you haven’t had vaginectomy and you’re on T, this hormone can have effects on your front hole known as vaginal atrophy. This is where vaginal tissues become thinner and drier. You may need to use lube for vaginal (front) sex when you didn’t before, and you might notice some symptoms like itching, bleeding and pain during sex. Vaginal atrophy can also raise your risk for UTIs.

Treatments

Vaginal atrophy can be easily treated with topical products that you apply directly to the front hole. These include:

• Vaginal moisturizers (e.g. Repagyn, Replens) – non-medicated lotions that improve moisture levels in the vagina

• Estrogen cream – topical creams applied to the vaginal tissue that improve symptoms by raising estrogen levels in vaginal tissue

• Estrogen tablets – small tablets that are inserted into the vagina and release estrogen into the vaginal tissue

Hormonal treatments can improve symptoms because vaginal tissue needs estrogen for optimal health. These are safe to take with T because they only release estrogen locally and it doesn’t travel throughout your body. The risk of estrogen medications interacting with gender-affirming hormone therapy is low.

After surgery

After you’ve had phalloplasty, your surgeon will give you an after-care plan to guide you through recovery. You will have to avoid sex (including masturbation and anal sex) until you’ve healed. This healing process will vary depending on what surgical stage you are at and what elements you included (e.g. phalloplasty, urethral construction or erectile implant). 

Each clinic will have their own recommendations, so it’s a good idea to stay in touch with them and follow their instructions closely. They can also help if you’re having complications through the healing process. Once you have fully healed from surgery (usually around the one year mark), you can talk to your primary care clinician if you have any issues. In some cases, they may refer you to a specialist.

This content has been reviewed by Foria’s Medical Director, Dr. Kate Greenaway and our community advisory team.

by Foria Clinical Team

Feb 2, 2024・ minute read

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