I have a question. Feel free not to answer as well if you don’t want to (since I’m probably going to have bottom surgery in the future) when it comes to STDs do you have an increase or decrease of getting them? I mean, I know bottom surgery isn’t like a get away free card on STDs.
1st thanks for a great question!
Notes on language, I’ll be using:
STBBI or Sexually Transmitted and Blood Borne Infections rather than STI/STD
Also, frontal hole, cervix, colpocleisis (defined below) and colpectomy
The short answer to you question is that no one knows; it’s yet to be studied. I reached out to 2 senior HIV specialists at the CDC with questions and they knew of no protocols or other sources of information around this. If/when someone comes across a study on transmission risk for post-lower surgery trans guys, please let me know so I might amend this entry and give due credit.
The longer answer are a series of educated guesses because it’s a complex question. It depends on what someone has done. Does lower surgery include colpocleisis or not? Does the lower surgery include urethraplasty or not?
Anecdotally, many trans men post-urethraplasty report a higher occurrence of UTI than prior to surgery. This is likely due to the lack of smooth muscle along their urethral extension combined with damage to the final urethral sphincter as part of urethraplasty. So in the space beyond where their natal urethra ends up to the tip of their penis, it’s possible to carry up to approximately a teaspoon’s worth of urine at any given time. Even without sexual activities, that urine is trapped in an environment conducive to UTI.
Your natal urethra is lined by smooth muscle, much like your intestines are as an example of one you might know more about even if you’ve not studied or thought about it before. Smooth muscles activate automatically upon the presence of substance inside a hollow organ, to ensure movement of whatever’s inside the cavity (in this case urine inside the urethra) to move it along.
Milking involves pushing, usually immediately behind or front of the scrotum, to help get the urine in the bottom of the U part of the urethra into the shaft so gravity can lead it out the penis. Some guys also squeeze all along the length of their shaft as part of their milking. The other thing that helps is having stronger bladder muscles so the urine is sent on its way with a stronger flow.
For those whose urethra is made of skin, it’s a lower risk of infection acquisition than if it was mucous membrane, in theory anyway. But studies on those whose urethra are made of mucous membrane assume the presence of personally produced lube, which the vast majority of post-phalloplasty trans guys don’t have or only very little.
For those whose urethra is partially made of buccal mucosa, the tissue is taken from the front third of the mouth, which is not as prone to HIV infection as the buccal mucosa in the back third of the mouth. If others have more to add to this section, please let me know.
People with a prostate and testiscles produce pre-cum, which protects them, and potentially raises risk for their intimate partners. A post-op urethral tip, thus, is lower risk for others, but a 1 way street of potential risk for the post-op guy. How much risk? No one knows. The 2 HIV specialists at the CDC hypothesised it is likely a low risk, but there is a theoretical risk. As such, if a trans guy was to penetrate an intimate partner of unknown HIV status without a barrier or being on PrEP, they recommended taking PEP for peace of mind. The greater concern, if it’s unprotected anal sex, would be in acquiring a UTI as the bacteria in the colon could go into the urethra not protected by pre-cum or smooth muscle. Peeing after unprotected anal sex would flush some of it out but not as thoroughly as it would for someone whose urethra hasn’t been elongated. PrEP provides no protection against UTI. If you’re going to wear a condom to prevent UTI transmission, than PrEP would be redundant.
Besides lowering the risk of acquiring a STBBI, a condom prevents the involuntarily peeing up to a teaspoon’s worth into people.
My educated guess is that their risk revolves around the opening of their urethra as well as the surface of their dick, as their bundle of nerves is covered by mucous membrane. Finger cots or modified vinyl gloves (e.g. cut open along the pinky side to utilise the thumb) may be useful barriers. If others have more to add to this section, please let me know.
Guys who shave their balls risk micro-cuts (that is, small nicks invisible to the eye and not necessarily resulting in blood spilling), which raise transmission risks. This can be lowered by shaving as far in advance as possible (I believe that 45 minutes is the minimum recommended but I can’t find a source for that.) If others have more to add to this section, please let me know.
Colpocleisis involves burning/ablating the lining of the frontal hole. The wound is then left to fuse together over the next few weeks, thus no more frontal hole. It’s fusing it shut without removing the Skene glands, and leaving a maximum amount of erotic nerves as they were. The surgeons prefer it because it causes less blood loss than colpectomy.
Whether the internal part is fused or removed, that removes the risk of acquiring a STBBI there.
Testosterone causes atrophy in the frontal hole tissue. This raises the risk for STBBI as the tissue is more likely to tear from penetrative sex. Some guys use local estrogen (usually topically applied) to increase lube production without impacting their hormone levels.
For anyone having sex, regardless of which genitals they have, wanting to lower their risk of acquiring a STBBI: too much commercial lube is almost enough.
Lube lowers risk by lowering the odds of tissue breakdown from repeated friction. One’s own lube similarly lowers our risk, but increases it for our intimate partners if we have anything (which we may or may not be aware of having.)
Thanks again, anon, for a great question! I hope this provides useful food for thought.