For full show notes and transcripts, please go to www.queerhealthpod.com.

For full show notes and transcripts, please go to www.queerhealthpod.com.

For full show notes and transcripts, please go to www.queerhealthpod.com.

Our usual vocabulary round-up:

This episode is going to talk about queer women - but more specifically specifically on folks with vaginas having sex with other folks who have vaginas. Our subject matter is deliberately focused. Because we’re discussing sexually transmitted infections (STIs) and the things that can cause them, we have to be precise (and consistent) about what parts are being used during sex, and what’s happening to them. So in other words, we’re focusing on folks with vaginas because it allows us to be scientifically accurate about the risk of transmission and infection. But this is by no means a reflection of who is included within the community of queer women! For more on that subject, check our previous podcast episode.

Who’s STI and what’s she doing at this party? “STI” stands for “sexually transmitted infection” and is the cooler, hipper, Gen Z cousin to the millennial term “STDs” or “sexually transmitted diseases” The term “STI” has become favored within the medical community because: There’s stigma associated with the word “disease” Because things like gonorrhea and syphilis often have no symptoms. And so “infection” is a better word to reflect that fact

Why are we doing an episode on STIs for queer women with vaginas?

Queer women are often excluded or ignored within conversations/teaching about sexual health and STI risk

Why isn’t this more prominently discussed and understood? Queer women’s sex is ~varied~ (in terms of what anatomy is involved or what’s in what hole, if any). This makes it challenging to ascribe a standard amount of “risk,” since that risk could vary drastically between two queer women. The scientific literature on this subject isn’t doing us any favors, either. Papers that look at queer women’s STI risk use a variety of labels to define queer women, and it’s hard to find consistency or specificity. Lastly, there’s a widespread conception out ~in the ether~ that queer women have negligible (meaning, close to zero) risk of getting/giving STIs. So, some folks believe the subject isn’t worth spending time on.

The bottom line(s)

For folks with vaginas, the risk of STIs isn’t zero One study suggested that rates of chlamydia between queer women with vaginas are comparable to the rates in the general population Moreover, queer women with vaginas are susceptible to the same infections that other folks are at risk for, such as: Herpes Hepatitis A Trichomoniasis

Note: HIV is unlikely to spread by using fingers or toys, but queer folks with vaginas may still be at risk for HIV if they are having condomless sex with partners with penises, sharing needles, or participating in sexual or erotic blood play.

So while folks with vaginas who exclusively have sex with other folks with vaginas do have lower STI risks, there’s number of factors consider: Number of partners (since multiple partners provides more opportunities to introduce new bacteria) Whether there are penises present Whether toys or fingers are being inserted How and where folks put their mouths or tongues. Fewer things being inserted likely means lower risk of transmission, but it’s definitely not a zero-risk situation.

This is why, at the end of the day, we always recommend having an individualized conversation with your healthcare provider about your sexual practices.

BV: the STI that isn’t an STI

BV stands for “bacterial vaginosis”. It happens when the normal (read: healthy!) bacterial environment of the vagina gets thrown off balance, and can cause symptoms like changes in discharge, changes in odor, or itchiness.

It is more common in queer folks with vaginas by a factor of 2, which is thought to be related to: Whether a partner has BV already Oral sex (which can bring extra-vaginal bacteria to the vagina) Menses

What to do? None of us recommends going out of the way to prevent BV, but cleaning any toys you share with other partners is a great thing to do in general and will likely help reduce the risk of getting BV. If you know you have BV but don’t have symptoms (and aren't pregnant), Dr. Garment does not recommend treatment. If you do require treatment - either because of symptoms or because you are pregnant - then a short course of antibiotics usually solves the problem for most.

HPV - the sexually transmitted…virus?

What is HPV? HPV stands for “human papilloma virus” which is a virus that causes the overwhelming majority of cervical cancers. Mostly, HPV can be cleared by your immune system. The problem comes if (for whatever reason) your body isn't able to get rid of that infection. In these cases, HPV hangs around for too long and over years, it can start to cause changes in the cells of your cervix which, over time, can lead to cervical cancer.

What does this have to do with queer women, again? HPV can be transmitted in all sorts of ways – from a penis to vagina, from a mouth to any kind of genitals, from a mouth to a rectum. It can also be on toys, it can be on fingers. Said otherwise: queer women can get HPV from sex! In fact, when you look at HPV rates in, women who have sex with women, compared with women who identify as heterosexual, the rates are not so dissimilar in terms of the rate of HPV.

HPV prevention On a day-to-day basis, cleaning toys between use can help reduce the risk of transmission (if you're sharing your toy with more than one partner). You can check out if you're eligible for the Gardasil vaccine, which reduces the risk of getting HPV in the first place. Lastly, the cornerstone of all STI prevention is testing. In the case of HPV, it's going to be testing for the changes that it causes to your cervix via a pap smear.

Cleaning toys: a brief ode to the top rack of the dishwasher

Toys made of silicone or metal can be run through the top rack of the dishwasher.

Anything with a motor can be washed down with antibacterial soap.

Toys made of porous materials (eg, hard plastic) are difficult to clean fully. In these cases, barrier protection (eg, a condom) can limit transmission.

Dental dam…to the rescue?

Things dental dams are: Made of polyurethane Meant to be placed over par the vagina or anus while engaging in oral sex to reduce the fluids that are being transmitted between partners (and therefore reduce the number of potential STIs)

Things dental dams aren’t: Attractively named Used very often

Things dental dams may or may not be: Effective It’s hard to find data on this, TBH How protective they are (or aren’t) may be more a product of how consistently or correctly folks are using them An all-encompassing form of protection After all, queer women have many kinds of sex where barrier protection with a stretchy piece of latex won’t be helpful! At the end of the day, this is (as always) about knowing the risk of your individual sexual practice

What’s in a (queer woman’s) name – we mean, identity label?

Some terms that are typically used to describe the community of queer women:

WSW, or Women who have Sex with Women: a medicalzied term that focuses on behaviors, not people

A public health term that focuses on behaviors (e.g., sexual acts) rather than identity

Not a term most (if any) would use to describe their sexual identity

Implies cisgender women having sex with cisgender women (which is not inclusive of the entire queer women’s community!)

Lesbian, bisexual, and pansexual women

Not medicalized. These are identity terms, not terms that focus on behavior

Notably, these terms aren’t all-inclusive, and don’t capture everyone in the community

Ultimately, there is no perfect label neatly who the episode is “for”

Focusing on behavior (“WSW”) erases identities and stigmatizes behaviors

Focusing on identities (lesbian, bi, pan) can exclude folks

Lastly, other elements of identity (e.g. race, ability) often factor into gender expression and sexuality in ways that are complex, numerous and expansive

Besides, language is fickle and changes with time!

Mythbusting queer women’s sex

Scissoring: is a thing, though over-represented within the straight conceptions of queer sex.

It hurts Jessica’s back, and (based on anecdotal evidence) doesn’t seem like a common sexual act

In contrast, tribadism is more common face-to-face body position where genitals are rubbed together

Penetrative sex

Is not off the menu for queer women, should they want to incorporate it into their sex lives

Very much an individual preference (the overall theme of this episode!)

Topping and bottoming

Some folks may find more satisfaction in giving sexual pleasure (tops), others in receiving (bottoms)

But these dynamics are…well…dynamic, and can vary with time or sexual partners

User beware: often we retrofit stereotypes (e.g. tops and bottoms) onto how folks find pleasure

Orgasms

Not a necessary component of a sexual experience

Do not need to happen for pleasure to also happen

Death to “Bed Death”

Lesbian bed death

A sexist, pathologizing and inaccurate trope in which two women in a long-term relationship will eventually stop having sex altogether.

May be rooted in a different context within queer history - one where queer women felt pressure to stay together in order to subjugate their own desires for the wellbeing of their larger community.

So, what’s actually going on?

Dips or lulls in one’s sex life can be normal, though many folks might feel they “should” be having more regular sex due to external societal standards and pressures.

Your mind and body have a relationship! Stress (capitalism, homophobia, emotional disconnect with your sexual partners) can take away from sex drive, which - let’s just say it again - is totally normal.

All that being said, some challenges with sex may be medical in nature (for instance, vaginal dryness) - in which case

Centering pleasure, joy and ecstasy

Get specific

Kink - an umbrella term that includes (but isn’t limited to) BDSM fetish, voyeurism, exhibitionism – provides a model for how folks can use language to communicate what they want (or don’t want) to their sexual partners

“Brakes” and “accelerators” can be useful vocab to identify things that push pleasure forward or slow it down (but do not negatively impact)

You’ve got resources

Healthcare providers - particularly within primary care specialties like OB/GYN, internal medicine and family medicine - can be a great first-line option for those who are open to it

That being said, we acknowledge that not all folks will be comfortable or able to talk to their providers about their sexual satisfaction. Other professionals - such as pelvic physical therapists, psychologists, or social workers - may be better fits.

It can be tough to have these conversations, but the payoff may be worthwhile

As always, some definitions up front.

Non-binary is a space that lives somewhere outside of male and female, or occupies both genders in varying degrees simultaneously. 

For most folks, non binary falls under the identity umbrella of transgender, but as always, this is not universal.

Some sibling terms: gender queer or gender nonconforming

Why discuss non-binary care on its own?

We know that non-binary communities have a unique set of healthcare disparities and health care experiences.

We also know that non-binary individuals have different health outcomes, healthcare needs, and healthcare experiences when examed separately from the binary transgender umbrella. 

Gender is a social construct. This matters to medicine because it impacts how we see non binary individuals and impacts their ability to navigate health care spaces

Non-pharmaceutical gender affirming steps

Stuffing: often rolled socks or a phallic shaped object in one's pants to present the image of a fuller package

Tucking - people with penises to tuck their testes into their groin and often tape their phallus to create a flatter appearance in their crotch 

Check out some health tips at Callen Lorde’s Safer Tucking pamphlet

Binding - Wearing a special garment, cloth or other material to flatten chest tissue or contour one’s body

Some tips, consolidated from Callen Lorde’s Safer Binding pamphlet:

Max out your daily binder wearing around 8 to 12 hours a day

Avoid duct tape and ace bandages as these can cut into skin

Use undershirts or body powder to minimize the effects of sweating, like rashes and chafing

Hormones (specifically microdosing)

On the “micro” in microdosing: 

It implies a binary as the “standard” size. We don’t love that implication, but it’s the word we heard from the community. 

Other similar words we like more: “low dose”. 

Our (improved) slogan: same hormones, different dosing

Misconceptions: 

You can control the changes you going to get with a smaller dose

The effect size will be smaller (i.e. proportional to the dose)

Small doses mean non-permanent effects

General approach from a provider standpoint:

Go slowly and monitor effects

Expect a time frame of months to years to fully realize any changes

Constantly re-assess

Informed consent and microdosing. 

The lack of studies on microdosing makes this difficult. Know that taking hormones at these doses leaves some of the risks and benefits that are known at other doses up in the air. 

What to know about testosterone hormone therapy: here.

What to know about estrogen hormone therapy: here.

Surgery, briefly.

It’s a la carte. 

Any gender affirming surgery can be part of someone’s non binary affirming care.

Something we don’t love: to get a surgery approved by insurance, non-binary folks often have to resort to the binary - for example, someone may have to state they claim a male gender identity in order to receive the coverage for top surgery

Primary care for a non binary individual

Good gender-affirming care is grounded in good primary care! 

Regardless of someone’s need for medically regulated medications (hormones) or procedure (surgeries) high quality primary care will include discussion of anatomy, gender identity, and sexual orientation. 

For non binary folks, the binary expectations of a clinical space can be a barrier. From the paperwork to the social understanding of binary gender that health care workers bring with them to the clinical space - the reality of anticipated or experienced stigma is real. 

Providers who are skilled in LGB health or transgender health may have shortcomings when it comes to understanding the goals and lived experience of non binary health care consumers. 

Heads up

This episode is best listened to (or read) after our other one about the intersex community.

Content warning – some of the discussion around surgeries is considered violent given their non-consensual nature

What makes a surgery medically necessary?

A “rule of thumb” definition is: will not intervening cause the loss of life or limb

 Some gonadectomies – or the removal (-ectomy) of the gonads (anatomical precursors to the ovaries or testes) – have been justified to avoid the tissue becoming cancerous.

But, a 2016 consensus paper on DSD care said there is “poor evidence” to support that

Definitions:

Hypospadias: when opening of where urine comes out is not at the very tip of the penis.

Congenital Adrenal Hyperplasia: where a missing enzyme creates more testosterone and the clitoris is often enlarged

There are others, but these are two of the main variations that folks who have experienced non-consensual surgeries have.

The past, the present:

1950s-1990s, John Money: a child’s gender identity would follow the anatomy of its genitalia, so if you change the genitalia you resolve any ambiguity

Most current surgeons who perform these reject the reasoning presented in the historical paradigm, and they know that genital appearance doesn’t dictate gender identity

Now: many variations in genitals are defined as pathologic due to cultural definitions and expectations that people will want to have heterosexual penetrative sex.

Example: a penis that can’t penetrate isn’t a penis

Example: a clitoris that is too big….is too big

One current common justification for surgery is that it can alleviate the emotional distress from someone’s variation

An ethicist’s takedown of surgeries performed on intersex minors

Surgery done for a variation that isn’t life or limb threatening and done to improve psychosocial (meaning emotional, stigma-based, psychological) suffering is NOT ethical. 

Don’t forget: there ARE surgeries performed on infants with DSD variations that are medically necessary – these ethical concerns don’t apply to those

Parental stress is not a medical emergency, and parental stress does not define medical necessity (as per 2016 consensus paper, a landmark paper in intersex policy). 

 Four ethical reasons that infant and child DSD surgeries are a no-no:

o   High potential for harm from invasive surgeries, especially on fertility and sexual pleasure

o   Surgeries of this nature are not routine procedures, like a vaccine; rather, they are closer to a procedure affecting fundamental rights like sterilization. So, there is an inconsistent absence of legal oversight

o   There is almost no outcome data that supports the justification of psychosocial alleviation for these surgeries

o   Ongoing justification for surgery: ease parental distress and promote bonding with children. Two issues: 1) not an agreed-upon conclusion, and 2) still isn’t an ethically sound reason to subject an infant or child to a highly invasive surgery

o   The big concern is: was this surgery justified by psychosocial reasons?

Surgeries: making medical care more complicated

After surgery, many folks need follow-up medical are

Having your gonads removed during surgery means you will have to hormones that would have otherwise been made in your gonads

Some folks may need follow-up procedures on the body parts that were part of the original surgery

Why does this suck?

First off, we’re talking about American health care, so needing life-long insurance (to see doctors for the consequences a surgery performed before you even knew what the term “insurance” meant) makes things hard.

Folks age out of pediatric practices, or move, or folks retire – so continuity of care is also quite challenging

Dr. Gregorio pointed out that there are only a handful of academic centers that can manage folks with surgical complications at the standard of care that they warrant.

Overview:

What is gender affirming surgery?

> A range of surgeries that includes the removal or addition of breast or chest tissue, creating a vagina and labia, creating penile tissue, or creating a penis. A gender affirming hysterectomy is also possible. Don’t forget facial surgeries!

> The most common ones are chest and facial surgeries, but given the difficulty in accessing genital surgeries we talk about those a little more here

Pre-surgery:

1. First up: information gather

> Online forums are great! But buyers beware...bias. It's still an online review forum, so now that its biased in who chooses to participate in online forums or share pictures there

> Surgeon’s website, realizing that they only choose the best photos, are also a good place

> Look for folks with similar bodies and skin colors to hear their stories

3. Find a good primary care doctor 

> Primary care providers will help navigate any possible changes in hormones post-op and be there to set you up with any resources for possible post-op stress or depression

> In addition: surgery stresses your body! A PCP can find ways to get your medical care in a good place before surgery to make the recovery process as smooth as possible

> E.g. having your blood pressure, cholesterol, and/or diabetes optimized

> Also, quitting smoking. Many surgeons will do a lab test to see if someone is smoking. Called cotinine testing, it's a breakdown product of nicotine and tells the health care provider if someone recently smoked nicotine. 

> FYI: there is some data that says folks who had access to primary care prior to beginning or completing puberty, including hormone blockers, are less likely to get surgery because the tissues they want surgically modified never developed

> For example, someone who took hormone blockers never developed breast tissue so never gets breast tissue removed surgically 

4. Find a surgeon

- Where to look?

>> For some folks, the internet is a great starting point

>> Others will be able to receive referrals from PCPs

- Some things to look for regardless of where you find your surgeon:

>> Make sure they are board certified

>> Someone with experience providing these procedures to trans individuals.

>> Do they take your insurance? 

5. Hair removal! If this is relevant to the surgery being planned.

- Get a head start - it often requires upwards of 10 sessions and takes about a year

- Look for folks who have experience in clients with your level of melanin

- What kind of hair removal? Laser hair removal or electrolysis (more about this in our full show notes on our website).

6. Getting mental health providers to provide a letter for your insurance clearance

- Let’s start out by saying: this is a controversial barrier to care that is often seen as a transphobic and discriminatory gate-keeping measure (almost no other surgery requires this step) ...but, if someone is making you see a mental health provider know that surgery is stressful and there are real resources a mental health provider can offer

- Heads up: this can take a while. And double heads up: if you are having bottom surgery you will almost certainly need TWO different mental health provider letters

7. Submit your mental health letters to your surgeon, who submits them to insurance. Cue the hours of hold music.

Post-surgery

- Set expectations

>> Post-op depression is common! It's not unusual that with big changes and the physical stress to experience changes in mood in unexpected ways

>> There is a healing process. It can take months, depending on which surgery you have

>> Your physical comfort and activity level will take time to return to baseline

- Seek out caregivers before hand to help you afterwards

- Dilation (this is relevant only to vaginoplasty)

>> Dilation is done to maintain depth and width in a newly constructed vagina

>> Expect to dilate weekly throughout your lifetime in order to have receptive vaginal intercourse 

>> To that point - not everyone will share a goal of keeping an open vaginal canal. If that’s the case for you, we encourage you to check in with your healthcare provider about what this means re:dilation

- Pelvic floor physical therapy 

>> Helps with healing, pain, urinary issues, dilation - a win!

>> Ask your surgeon for someone who has worked with people who have had your surgery before you, and who will be affirming!

- Sexual satisfaction

>> Is totally defined by the person experiencing it, and different folks will have different goals for their own sexual satisfaction

>> Lubrication may or may not happen, and may or may not be enough to make penetrative sex comfortable

>> Orgasming - can take time, practice, and getting to know your new body. Again - ask your surgeon honest questions!

>> If you use the body part for sex, get it tested for STIs

- Hormones may change - it really depends on the surgery, so talk to your provider

Some final context:

To quote our community voice: having surgery is not everyone’s end goal. Everyone’s journey with any gender affirming medical care is their own!