By Allison Danish, MPH

Painful sex is common for people with vaginas. The limited research we have on cis women confirms this is true, and recent studies demonstrate that painful sex may be even more common in trans women and trans feminine people who have had gender affirmation bottom surgery. But why can sex hurt post-bottom surgery and what can you do about it? We talked to Dr. Gladys Ng, a board certified urologist with a special focus on genitourinary reconstruction to help answer these questions.

As a reminder before we dive in: bottom surgery is not a necessary part of transitioning for everyone—neither is top surgery nor hormone therapy, laser hair removal, or facial reconstruction surgery. Any and all medical or aesthetic interventions you decide to pursue are entirely up to you and what feels right for your body and gender expression.

What is bottom surgery?

If you’ve had bottom surgery, you definitely know what it is. But here’s a little recap for everyone else!

Bottom surgery for people assigned male at birth is kinda what it sounds like. It means surgically going from a penis and scrotum to a vagina and vulva (or somewhere in between). Dr. Ng says, “The kind of bottom surgery people undergo depends on what they want and what affirms them. Some people just want to take off the testicles and scrotum, others want to do a cosmetic vulvoplasty and no vaginal canal, but most commonly patients come in for a vaginoplasty.” 

Vaginoplasties as gender-affirming care have been around since the early 1900s, first described (as far as we know) in German publications in the 1920s. One of the most famous and earliest documented trans women to undergo a vaginoplasty was the artist Lili Elbe—you probably know her from the book/movie The Danish Girl. 

This is a wee bit graphic, so skip ahead if you’re squeamish: In the modern-day United States, docs almost always use the penile inversion method. Again, that’s what it sounds like: the penis is, more or less, flipped around. The skin of the penis becomes the vaginal canal (sometimes the scrotum or, very rarely, intestine is used to achieve a longer canal); the urethra is shortened and gets its own new, designated hole; the scrotal skin becomes the labia majora; and portions of the tip of the penis become the clitoris. Ta dah!

What’s the healing process like?

Healing after bottom surgery is a long process, but your surgeon will make sure you know what to expect so you’re not blindsided. Dr. Ng says, “It’s quite extensive because it’s a difficult area to heal.” Basically: genitals don’t get a lot of air and don’t see the light of day all that much, peeing and pooping happens nearby, and you can’t just put your crotch in a cast (although, Crotch Cast would be an excellent band name). Naturally, given all that, it takes a few months.

If you’ve had a vaginoplasty, you’ll also know the healing process isn’t a passive one. There’s vaginal dilation involved to maintain the length and width of the vaginal canal. Dr. Ng says, “Dilating is a life-long process. It begins 5 days after surgery, and has to be done about 3 times a day for the first few months, then 2-3 times a week afterwards.” 

For the first 2-3 months, she recommends that patients focus on “healing, getting dilation down, and taking it easy. It takes about 6 months for things to really come together.” 

Why can sex be painful after bottom surgery?

Dr. Ng says there are a few main reasons why sex might be painful:

1. Vaginal stenosis

After bottom surgery, the vagina might be too short or narrow to accommodate what’s going inside. This narrowing or decrease in length is called vaginal stenosis. This is mostly a risk if someone hasn’t kept up with dilating or if there’s a buildup of scar tissue.

2. Pelvic floor muscle dysfunction

While the surgery itself may sometimes be a cause of pelvic floor muscle dysfunction, a lot of people have muscle dysfunction pre-surgery. This may not have been a super apparent before surgery, but becomes more noticeable after beginning dilator therapy and/or having vaginal intercourse. One study looking at whether pelvic floor physical therapy pre- and post-surgery is effective for trans women found that 42% of the participants had pelvic floor muscle dysfunction prior to surgery.

As for during the vaginoplasty, pelvic floor muscles (namely the levator ani muscles) are typically separated to make room for and widen the vaginal canal. This might lead to some pelvic floor muscle tightness and tenderness, which could mean pain during penetrative sex. 

3. Irritated bowels

The rectum (or as I like to call it, the poop storage chamber) is really close to the vagina! When something is inserted into the vagina, nearby organs and structures are jostled and squished around a bit. If your bowels or rectum are feeling grumpy, or you’re constipated, you might feel some pressure or pain during penetrative sex. 

4. Not enough lube

Because neovaginas don’t self-lubricate it’s really important to use lube. Inserting anything dry (or without a sufficient amount of lube) will probably cause some discomfort. 

What should you do if sex is painful after bottom surgery?

1. Use lube

Like we discussed above, lube is 100% necessary. If you’ve had bottom surgery, Dr. Ng recommends using water-based lubricants. 

2. Stick to your dilators

Dilating can feel like a chore—but it’s critical for maintaining the integrity of the vaginal canal post-bottom surgery. Try out Pelvic Gym’s Dilator Buddy program if you need a little additional support!

If it feels like there isn’t enough depth or your partner’s going too deep during sex—don’t hesitate to speak to your doc about your concerns (and, shameless self-plug, Ohnut might be a helpful tool for limiting depth).

3. Pelvic floor physical therapy

Some recent evidence suggests pelvic floor muscle and bowel dysfunction may be common in trans women/transfeminine people pre-bottom surgery, and pelvic floor physical therapy can be really helpful pre- and post-op. Check out this directory for finding a pelvic PT near you.

4. Botox for pelvic floor muscles

That’s right, Botox! And not because your pelvic floor is wrinkly. Botulinum toxin (the active ingredient in Botox) keeps muscles from contracting—so if the pelvic floor is tight or overactive, your doctor might recommend a few injections. 

5. Go see your doctor

When in doubt—go see your doc! As Dr. Ng says, they can help you figure out where the pain is coming from, and what the best course of action might be. Our bodies are remarkable and complex—hence (frustratingly sometimes), there's often no one-size-fits-all solution for painful sex.

If you’ve had bottom surgery (or are considering it) and you’re experiencing painful sex—you’re not alone and there’s a lot you can do about it!