The Neglected Science of Neovaginas

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Getting to the bottom of the trans woman neovaginal microbiome.

THE MICROBIOME IS HAVING A MOMENT. These days, those various compartments of microbes in our guts, mouths, and other bodily crevices are being touted as the answer to the mysteries of many human quirks and ailments, from gut health to mental health. Laboratories worldwide are exploring those colossal communities of bacteria, fungi, and viruses—trillions of them—that live on and in our bodies. We depend on our microbiomes to function: They control our immune systems, fight our pathogens, and keep us going. 

But, as is often the case in science, the more we learn about the human microbiome, the more we realize we don’t yet have all the answers.

One hole in our knowledge involves the impact of microbial changes of our sex organs. And it seems that one organ in particular is missing out on the billions of dollars currently being spent on research of the human microbiome: the trans woman neovagina. 

The construction of vaginas in transgender women undergoing gender confirmation surgeries has been evolving in medicine for nearly 100 years. Also called sex reassignment surgery, the first known procedure took place in Germany in 1931. In 1952, the first U.S. trans woman to undergo vaginoplasty jump-started a medical field that today sees thousands of such surgeries performed every year. Vaginoplasty is just one of a suite of surgeries trans people choose to undergo during gender transition, but a person’s genitalia is not indicative of their gender, and it is not necessary to undergo surgery to identify as a trans or non-binary person.

Still, despite thousands of procedures performed every year in the United States, it’s nearly impossible to answer the question: How does the microbiome of trans neovaginas work, and how does this unique human organ function?

“Half of transgender people report having to teach their own medical providers about appropriate health care for transgender people.”

Some self-lubricate, some don’t. Some use only penile and scrotal tissue, while others also use tissue borrowed from the colon. Some often have vaginal odor, some never do. Some are prone to infection, some aren’t. But unlike the vaginas of cis women, which also differ widely but have a plethora of research studies directed at them, the vaginas of trans women are often a mystery to those women themselves—and to the medical establishment. There have only been three studies as of mid-2021 that looked specifically at the microbial makeup of neovaginas. 

“There is a paucity of information out there regarding neovaginas. Most of it is conjecture or speculation,” Connecticut-based journalist Dawn Ennis tells Ennis, who underwent gender confirmation surgery in 2018, says the process of managing her gynecological care can be excruciating because of conflicting advice from doctors, surprising complications and infections, and a lack of local specialists. 

A photograph of Dawn Ennis.
Dawn Ennis

Trans health care in general has been an absurdly under-researched field, and our lack of understanding of trans-specific health issues contributes to sky-high death rates within the queer and trans communities, which include millions of Americans. According to Funders for LGBTQ Issues, an NGO that tracks philanthropy and research for trans and LGBTQ+ communities, “Half of transgender people report having to teach their own medical providers about appropriate health care for transgender people.” However, the percentage of trans women seeking what is colloquially known as “bottom surgery” has increased rapidly, according to a study in the journal Translational Andrology and Urology. Researchers found that nearly 13 percent of trans women reported undergoing bottom surgery, and between 45 to 54 percent of trans women said they desire vaginoplasty in the future. Between 2019 and 2020, genital gender confirmation surgery increased 11 percent for trans women, according to the American Society for Plastic Surgeons, which reported 1,231 surgeries in 2020, compared with 1,108 in 2019. 

But the research on neovaginal flora just isn’t keeping up with demand

Melody Maia Monet, a 50-year-old trans woman in Orlando, Florida, tries to fill this information gap about trans women’s vaginas on YouTube, where she shares information about her neovagina with other trans women, like Ennis, who may feel as lost as Monet often does in her quest to find information about her body. 

Monet says medical professionals seem to know as little about the function of neovaginas as the women themselves, and even rank-and-file gynecologists can seem bewildered by questions that should be routine. Monet mentioned having friends whose new vaginas have inexplicably prolapsed (a condition that also affects cis women, where a vagina slips out of position), who have had bacterial infections that went untreated, and who have questions about their bodies with nowhere to go—in addition to facing discrimination when seeking treatment. 

“It has been endlessly frustrating,” Monet says. 

“How can we prevent and treat problems for trans women if we have no idea what we’re dealing with?”

Grace Aldrovandi, an infectious disease specialist at UCLA, agrees that more research is needed about the function of the neovaginal microbiome. While investigating a study about preventing HIV transmission in trans people, Aldrovandi began one of the handful of initiatives looking into neovaginas. Her study enrolled five trans women and a group of 32 cis women as a control, and her team found a wide spectrum of difference between the trans neovaginas and cis vaginas. 

“[The] neovagina is something that’s not well-studied at all, and even our paper is a relatively modest contribution,” says Aldrovandi, who is hoping to do more studies on trans health in the near future. “Generally speaking, when we do these studies, we want hundreds and thousands of people, [in order] to see robust differences.”

A photograph of Melody Maia Monet.
Melody Maia Monet

A forthcoming project in France aims to significantly add to the existing literature and get us a step closer to the research that’s needed to understand the neovaginal microbiome. The majority-trans research team of the Transbiome project say they hope to get at least 50 trans women to participate and provide samples from throughout Europe, which would be the largest study of neovaginal microbial diversity. (A 2009 study, the first of its kind, had 50 participants.)

According to a fundraising site about the open-source project, participants will be mailed a sample collection kit for self-swabbing, along with a return envelope and postage, and a short survey about participants’ surgery details. Transbiome aims to have samples that cover a range of surgical methods, post-operative care, and timeframes, which could lead to advancing knowledge about the ways difference in care impacts the microbial communities in neovaginas. All the anonymized data will be hosted on a platform run by Open Humans. 

“I’m really excited that we managed to build a study on that scale from the ‘grassroots’ and with a team that’s majority trans and speaks to the power that such efforts can have,” Transbiome research coordinator Bastian Tzovaras said to by email.

Tzovaras, who is also the Director of Research of the Open Humans Foundation and works on managing aspects of the Open Humans platform, says there is still a lot more work that needs to be done in this arena. The fact that the largest study in the field is a crowdfunded grassroots effort illustrates how neglected this topic is in traditional academic circles, he says.

“There’s a whole list of topics that the trans community would be interested in, but that seems to be highly underrepresented in the scientific literature so far,” Tzovaras says. “I hope that Transbiome can act as a catalyst for more research in the future and will help spark interest in other labs to work on relevant topics.”

“Transgender health is neglected,” reads a video on the team’s website. “How can we prevent and treat problems for trans women if we have no idea what we’re dealing with?” And in a recent article in Physiology News magazine, the Transbiome team wrote that from the start, they envisioned Transbiome to be done “by the community, for the community—allowing trans women to help and contribute to building the science.”

Ennis, who half-jokingly offered to fly to France to participate in the study said she understood why a majority trans research team was undertaking the project. “My feeling is that it falls to those of us who have the ability and vested interest [as trans people] to conduct this research. Because if not us, who?”

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