Written by: Mel McGovern (they/them).
Edited by: Miles Llewellyn (they/them).
I have a complicated relationship with my genitals, but I also want to experience pleasure and eliminate painful pelvic symptoms. However, navigating my vaginal and vulvar pain, often publicized as a “women’s issue,” while being transgender is extremely frustrating and dehumanzing. In addition to the pain felt in my pelvis, there’s the pain of constantly battling to obtain the care one needs through the flawed medical systems and the repeated misgendering in waiting rooms, medical offices, intake forms, online resources and support groups.
In an attempt to advocate for greater inclusivity, I requested an American vulvodynia (i.e. pain in the vulvar area) organization make their language inclusive to trans people and was met with a response similar to, “not enough time and not enough resources.” Spaces intended for aid, care, and healing instead become spaces of retraumatization and loss of hope. While trying to receive care, the process needlessly diverts precious energy towards the auxiliary work of advocating for respect. I have created this writing in part for anyone seeking resources about transgender pelvic pain and also to touch on the connection between my journey with chronic pelvic pain (CPP) and Hypermobility Spectrum Disorders (HSD). While it isn’t possible for me to be exhaustive in this pursuit, I do try to consider many aspects of this complex issue.
My experience receiving care for CPP as a transgender person has been incredibly difficult and began nearly two decades ago. I’m located in the US and there have been the barriers of health insurance and financial accessibility, as well as the issue of finding a trans-competent pelvic pain practitioner. Trans competency means more than just acknowledging that trans people exist; it looks like using the correct pronouns and preferred terminology for body parts, as well as the ongoing education about trans experiences and needs.
Many trans people needing pelvic care have experienced emotional, verbal or sexual abuse in their lifetime and, on top of this, may have experienced trauma directly from the medical system. With each additional type of minority group a person is a part of, the access to comprehensive pelvic health care grows more out of reach. Trans people of colour navigate the intersecting oppressions of both racism and transphobia within pelvic health spaces that are designed for upper-class, cisgender, white women. People of colour experience more instances of having their generalized pain ignored by clinicians and, furthermore, experience more pregnancy-related deaths (1, 2).
I am white and located in a predominantly white, low-income and rather sparsely populated area. There are difficulties I face being disabled, poor, far from a metropolis, and having personally experienced emotional, physical and sexual trauma. One of the simplest ways a pelvic floor specialist can make a transgender person feel more at ease is to ask, “Is there a way you would like me to refer to you and/or your parts/genitals?”. With this language agreed upon upfront, a patient can feel like more of a collaborator and confusion from euphemisms can hopefully be avoided (3). For the ease of the reader and because it is my way of speaking, I’ll be abbreviating transgender to trans and I offer definitions here for commonly used words in the trans lexicon:
AFAB: Assigned Female at Birth.
AMAB: Assigned Male at Birth.
Non-binary: A person whose gender identity is neither exclusively male or female.4
MtF: Male-to-Female
FtM: Female-to-Male
Transmasculine/Transmasc: Anyone that is AFAB and identifies with masculinity. This could be someone that is transgender, non-binary, demiboy, multigender, gender fluid, and more.5
Transfeminine/Transfemme: Anyone that is AMAB and identifies with femininity. This could be someone that is a transgender woman, non-binary, multigender, gender fluid, or other identities.6
Chest: An often preferred term to describe breast tissue for transmasc people.
Clit: A natal clitoris or a transfemme penis.
Clit/Outie/Strapless/Girldick: Various terms AMAB transfemme people may prefer for their parts.7
Dick: Can be a term preferred by transmasc people to refer to their parts. Some transfemme people also use the term dick.
Front hole: An often preferred term for the vagina by transmasc people. *I have heard the word “anterior” used as well.3
Metoidioplasty: A surgery to free a dick enlarged due to testosterone from the ligaments in the labia to let it hang lower.
Phalloplasty: A surgery to form a larger dick (with implant for creating an erection) using skin grafted from the arm, back, or thigh.
Orchiectomy: The surgical removal of testes.
Vaginoplasty: A surgery to form all vaginal structures.8
While it may seem it goes without saying, anyone with natal or surgically created genitals, whether internal or external, can experience chronic pelvic pain (CPP). Additionally, intersex people with variability/differences of sex development (VSD/DSD) can experience pelvic pain and may or may not seek Gender Affirming Surgeries (GAS). They also may or may not identify as trans or gender nonconforming (TGNC). Unfortunately, most of the research and conversation happening around pelvic pain completely misses, ignores or silences the existence of TGNC pelvic care needs.
The recent growing visibility of trans people in the media has not necessarily meant that trans people are being thought of by those in healthcare and medical research.
There is some CPP research mentioning TGNC people, but it mostly focuses on the changes of hormone replacement therapy (HRT) or surgery as the progenitor of CPP. Though trans specific information is important, there is little to no mention of the potential pre-existing/co-existing causes for pelvic pain that individuals with CPP may experience such as bladder dysfunction, irritable bowel syndrome, interstitial cystitis, endometriosis and other musculoskeletal dysfunctions (10, 19). (Note: though many trans people will give birth, I have not offered any information regarding pelvic pain pre or postpartum.)
My experience with CPP began in early childhood, well before I began testosterone (T). Long had tight, denim pants or a hard, wooden seat been making my crotch hurt! To my memory, I have always experienced front hole pain. I recall being 12 and the sharp, localized pain I felt when I started to menstruate and tried to use a tampon. I thought this was normal. Then, when I was 19 I sought advice from an OB-GYN. I then learned what I was experiencing was considered a sexual dysfunction. This made me feel like I had failed somehow. Failed at being a woman, a lover and someone with a vagina. My original cis male OB-GYN recommended me to a specialist, whom I saw a few times and she introduced me to internal trigger point release and dilator use. I was moving halfway across the US at that time and, after settling in Colorado, paid to see a helpful pelvic floor specialist that taught me how to do trigger point release on myself and relax specific, nuanced muscles in the pelvis. I wondered for a long time if it would ever get better, but in the last few years, despite not being able to find a trans-friendly pelvic floor therapist in my current area, I have made progress with the pain I feel in and around my vulva. Some of this progress can be attributed to T and some of this progress is from behavioral and physical therapy.
For a quick, synthesized understanding of the effects of T on AFABs, common changes include: increased hair growth, including growth of hair on genitals, abdomen, chest, and back; potential front hole dryness and atrophy; dick growth; increased muscle mass; increased sex drive; oilier skin and acne; menstrual cycle becomes irregular or ceases; voice deepens as vocal cords lengthen and thicken; and potential changes to pain, sensation, mood, range of emotions, interests, and how one interacts and relates with others. Fat distribution changes in the body and the layer of fat under the skin becomes thinner (8, 9).
My experience has been that some of my CPP actually got better nearly immediately upon starting testosterone, while my overall pain has remained, intensified, receded and continues to fluctuate. For instance, as my dick/clitoris grew, I no longer experienced pain when my foreskin/clitoral hood was pulled back, exposing the head. It wasn’t nearly as sensitive to the touch. My hypothesis is that it is due to the nerve endings being spread out over more surface area. This is dissimilar to the phenomenon that my orgasms have become (and other transmasculine people’s orgasms often become) more centrally localized at the pelvis, rather than more spread out and a full-body experience (9). With my menstrual cycle mostly stopping within the first month of T, I no longer experienced the monthly increased low back, tailbone and vulvar pain. Now, two years into HRT, I occasionally get a phantom “period cramp” and, while writing this, I actually experienced the first bleeding from my uterus since starting T. My clinician and I deduced this was triggered by deep penetration and decreasing my dose from 0.3 mL/week to 0.25mL. Also, occasionally after orgasm I will feel uterine cramping that feels period-like, which is common for other transmasc folx and cisgender women, especially those who are perimenopausal. Some people will need and choose to have a hysterectomy to aid with this pain if it is persistent (11, 12). This isn’t always mentioned, but I also experienced that my labia majora became more scrotum-like and, thus, I needed more room in undergarments to be comfortable.
A number of factors can also increase pressure created on the pelvis. For instance, chest binding and dysphoria can posturally cause transmasc people to hunch forward and conceal the chest, resulting in thoracic kyphosis. Depression and anxiety can also cause a postural protection of the chest and heart, as well as rounding of the shoulders. This exaggerated curvature of the upper spine imbalances the downward distribution of weight, causing irregular holding patterns in the pelvis, hips, and low back. These irregular holding patterns can cause pain through weakness, underuse and/or overuse, additionally causing lactic acid to build up. This lactic acid can cause soreness (3). Regarding posture, I have personally felt this rounding of the shoulders and closing off of my chest and have worked over decades to encourage length in my spine and openness in my chest. With the aid of yoga, physical therapy and checking in throughout my day with my habitual muscle gripping and unnecessary muscle recruiting, I’ve seen my overall posture improve from what it was over a decade ago.
One way I have learned new alignment is by standing against the corner of a wall with feet hip width apart and close up to the corner. Then, make points of contact with the wall at 1. the back of the head, 2. shoulder blades, 3. tailbone and 4. heels (see diagram). Stand up tall, breathe and gently engage the lower abs. Next, move away from the wall and around the room while maintaining that posture. This can also be practiced seated with a stool if standing is not a possibility. At first, I felt foolish, like l was puffing up my chest, but when I looked in the mirror I was shocked that I just appeared to be standing up straight. My head was no longer projecting too far forward. This upright posture then allows me to more fully feel and engage my abdominal muscles, thus relaxing my low back and pelvic floor. Testosterone has also pleasantly changed the breadth and flatness of my chest more than I anticipated, which makes me feel more comfortable standing upright. These moments of musculoskeletal alignment are directly related to the gender euphoria I feel.
Furthermore, I cannot overstate the importance of safety and downregulating a heightened nervous system, aka the fight-flight-freeze-fawn response, for people experiencing pain, especially people regularly coming up against oppression, adversity and harassment. Clinical research suggests there is a link between experiences of helplessness and depression with chronic pain. States of helplessness (e.g. marginalization, lack of access to resources, racism, shaming, etc.) lead to remaining in a heightened stress response and elevated cortisol levels, which are linked to depression and chronic pain (13). A deep breathing component when approaching pelvic floor therapies can be incredibly helpful for de-escalating these bodily alarm systems and has helped me time and time again when my mind needs to reassess the pain signals it is receiving. I use this method as a part of making my weekly T injections more painless as well. Combining techniques such as movement, myofascial release, trigger point release and (front hole) dilation with breath has been incredibly powerful for me. I’ve also experienced how deep, diaphragmatic breathing triggers the parasympathetic nervous system, thereby lowering the body’s stress response (14).
Dilators are commonly used by people with internal genitals that are experiencing CPP or to maintain the canal openings after vaginoplasty, and are also practiced in conjunction with breathwork and mindfulness. A tip I suggest is to regularly and very patiently insert a dilator or finger in the shower or lying down, using a water based lubricant. For me, this is not only for possible pleasure, but a necessity in protecting against atrophy and maintaining ease during pelvic exams. Now, I even occasionally enjoy a small dual-density silicone dildo when masturbating. As a transmasc person, I know that it is not always desirable to insert something in the anterior. It’s never been something that I’ve desired, but working in a slow, safe way over time can be helpful. This is only possible for me through simultaneous deep, focused breathing — sending the breath in every direction of the lungs and expanding the diaphragm. I feel that my lungs are so expansive that they gently massage my muscles from the inside, all the way down to the hammock-like muscles of my pelvic floor. This is methodical work that has taken me years, but I cannot speak enough to the importance of using breath to relax the pelvic muscles. For me, this physical therapy and self-massage ultimately relaxed holding patterns in my vagina, levator ani muscles (pelvic hammock), perineum (taint) and glutes. Through kind, gentle massage to one’s pelvic tissue, you’re creating a chance to retrain the nociceptors (pain receptors) throughout that region.
In Standard of Care: Pelvic Floor Considerations in the Transgender/Gender Nonconforming Patient, Harvard’s Brigham and Women’s Hospital describes specific techniques for transfeminine folks practicing dilation post-operatively, as well as irrigation methods for neovagina post-op cleansing. This resource also describes practical advice to anyone using dilators — practices like positive self-talk, using pillows to support your knees, using a water based lubricant and breathing (10).
For people undergoing bottom GAS, short and long term pain are potential risks. Also, for vaginoplasty, immediate risks include bleeding, infection, skin or clitoral necrosis, suture line dehiscence (wound separation), urinary retention or vaginal prolapse. If they appear, fistulas from the rectum, urethra or bladder usually present early on. Scarring is likely with GAS and can require scar tissue mobilization and desensitization (with surgeon approval after healing). For phalloplasty and metoidioplasty, risks include infection, bleeding, damage to surrounding tissues, risk of transplanted tissue loss, urethral complications, wound breakdown, pelvic bleeding or pain, bladder or rectal injury, lack of sensation, prolonged need for fluid collection from the surgical site to prevent accumulation under the skin post-op, or need for further revisions beyond the multi-surgery process of bottom surgery (10, 15). All measures should be taken to ensure no one is continually existing in a state of pain after these procedures. Instead, one should be able to heal and celebrate these big steps. The reality is that, globally, what little findings are available, show that these systems of care are not sufficiently in place. While there is much to be celebrated with the progress of GAS in recent years, there are many factors not always considered in its comprehensive pain management.
Tucking, common for transfeminine people (and drag queens), is the practice of making external genitalia appear smooth in tight fitting clothing by moving the testes into the inguinal canal and pulling the shaft and scrotal skin in between the legs and buttocks towards the anus (16, 17). Research is lacking regarding tucking, an unfortunately common issue in trans health and wellness, but safer tucking practices include tucking for less time and, if using tape instead of a gaff (tucking garment), removing the tape slowly (18). However, complications can occur, for instance, infections, pain and/or swelling associated with the testicles, scrotum, and prostate (16). According to Barry Zevin, MD, author of Testicular and scrotal pain and related complaints, “Ready access to transgender surgeries when medically necessary, including orchiectomy and vaginoplasty for the treatment of gender dysphoria, may also minimize this condition [pain] (17).”
Again, research surrounding transgender health and wellness is pervasively lacking, including data for patient reported outcomes after GAS (10, 20). A study published in 2021 conducted by the European Network to Investigate Gender Incongruences (ENIGI), found that out of 260 transgender people (122 transmasc, 119 transfem, 16 other, 3 missing), 127 (48%) reported complications after surgeries. Some of these complications included prolonged pain. Transfeminine people with neovaginas will require lifetime dilation and our healthcare should reflect that by offering lifelong (preferably free) support. This study concluded that transgender people needed “health care providers to include more emphasis on guidance during surgical recovery, postoperative psychological support, and physiotherapy for the pelvic floor (20, p. 1920)”. Additionally, their study reinforced another European study conducted in 2017 that suggested a correlation between postoperative satisfaction and preoperative psychological factors and life satisfaction. This is to say, trans people experience more satisfaction (hypothetically less pain) post-GAS when they have access to resources like mental health care and social support systems preoperatively (21). Health and wellness practitioners around the world recognize a connection between mental and physical state. It is easy then to draw the conclusion that there is a ghastly undermet need for trans CPP healthcare and the interconnection of mind and body, which can be further complexified by hormone therapies and factors outside one’s control (e.g. trauma).
Another phenomenon of trans health and pain management, one that really hasn’t even begun to be explored, is the seemingly common occurrence of being transgender, Autistic (neurodivergent et al.) and having a type of Hypermobility Spectrum Disorder (HSD) like Ehlers-Danlos Syndrome (EDS), which I mentioned at the beginning is something I personally deal with. This may seem like a weird, unrelated correlation, but if you run in these circles online or in person, you start to notice a curious number of folks sharing these same overlaps! (22)
In fact, I came to discover that I could even be neurodivergent/Autistic or that my lifelong struggle with chronic pain could be related to HSD/EDS only after seeing people online start to talk openly about their experiences, many of them trans, and making direct connections to similarities in my life (23). In fact, the private, queer EDS Facebook group that I’m a member of started a trans group as a space for our specific dialogue. The only published medical paper I have found that recognizes the relationships between being trans and EDS was published in August 2019 from a university in Japan, but I have chosen not to use it as a resource in this writing because the language and point of view is problematic – treating the trans identity as a psychological symptom, amongst other things.
However, it is interesting to look at a different (still problematic) 2021 patient survey from EhlersDanlosNews.com. According to Vanda Pinto, PhD at EhlersDanlosNews.com, women (cis) with EDS/HSD reported being 6 times more likely to experience vulvodynia and dyspareunia (painful intercourse) than in the general population (24). EDS/HSD affects the collagen of the entire body; we have soft skin and are more prone to easy cuts, skin splitting open and bruising. From personal experience, this could contribute to being more at risk for CPP issues, including injury, STIs, IBS, and interstitial cystitis.The writing from Dr. Pinto, however, is unfortunately biased because it completely fails to acknowledge that trans people exist. It is valid to hypothesize, however, that if people with EDS/HSD are more likely to suffer from vulvodynia and trans people are more likely to suffer from EDS/HSD, then trans people are likely at a far greater risk for vulvodynia, dyspareunia and other forms of CPP.
If, like me, you are a trans person dealing with pain, I would like to leave you with the reminder that our tissues can heal and what we feel today will be different tomorrow.
Although there are many factors associated with pain perception, through methods such as tissue pacing and graded exposure (think dilator technique) we can negotiate and work with our pain overtime, making strides toward living our lives to the fullest (25).
I also hope readers take away that if trans pelvic pain knowledge were Madonna’s discography, we’ve only just released the self-titled debut album! Not only do we need more data and research, we need to create spaces that allow trans people to move deeper into wellbeing. We need research that throws out cisgender as the default and, instead, writings that use trans and queer inclusive language to better understand the human experience, wellness and relieve suffering. We need STEM scholarships for TGNC, Black, Indigenous, and people of colour to lead the way in scientific understanding. Many of the studies referenced in this writing focus primarily on Western, white, higher-educated and affluent populations.
If given the time, fatigued, under/overutilized tissues can heal when given the opportunity and environment. An individual needs to be able to rest and have sufficient resources to do so. One needs to feel like they are going to receive well-versed, welcoming and expedient medical attention, as well as be heard. Healthcare teams and facilities can do the work of prioritizing thorough CPP management by paying people of colour, trans people, disabled people, sex workers, and other marginalized individuals to write, speak, teach, learn and lead.
All too commonly, it is a privilege and not a human right to experience pleasure and euphoria over pain. For me, this euphoria has been, at times, surprising and also subtle. There’s the euphoria of looking at myself in the mirror and feeling joyous at the sight of the person I now see in the reflection. I also experience the happiness that has come with a slightly deeper voice, a different sex drive, bottom growth, and muscle definition seemingly happening without effort. Euphoria sneaks up on me in other ways, such as every time I hear someone I’ve newly met gender me correctly. Because I use they/them pronouns, it is very rare that I hear the correct pronouns and it still brings me elation everytime I overhear nurses using my correct pronouns in the hallway when they may or may not know I’m listening. Living with chronic pain, my periods of euphoria are experienced as indeterminate waves of time in which my body is not receiving the alarm signal of <pain!>. Rather than a flickering flame trapped inside a malfunctioning body that is coming up against hostility, I’m free to exist and truly be myself in blissful totality.
If you would like to seek more information regarding chronic pelvic pain and other topics discussed here, such as GAS, HSD/EDS, language used around gender and more, please see the included references.
Other Resources:
1. Vaginoplasty Information [Internet]. Oregon USA: OHSU Dept. of Urology Transgender Health Program; [updated 2020 December]. Available from: https://www.ohsu.edu/sites/default/files/2020-12/Vaginoplasty-Information-Guide-Dec-9-2020.pdf
2. Dy GW, Nolan IT, Hotaling J, Myers JB. Review Article: Patient reported outcome measures and quality of life assessment in genital gender confirming surgery [Internet]. USA: Translational Andrology And Urology; 2019 June;8(3):228-240. Available from: https://tau.amegroups.com/article/view/25962/23880 DOI 10.21037/tau.2019.05.04
3. Boris JR, McClain ZB, Bernadzikowski T. Clinical Course of Transgender Adolescents with Complicated Postural Orthostatic Tachycardia Syndrome (POTS) Undergoing Hormonal Therapy in Gender Transition: A Case Series [Internet]. Transgender Health; 2019 December; 4(1):331-334. Available from: https://www.liebertpub.com/doi/full/10.1089/trgh.2019.0041 DOI 10.1089/trgh.2019.0041
References:
1. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi, M. The Report of the 2015 U.S. Transgender Survey [Internet]. Washington, DC USA: National Center for Transgender Equality. 2016 December. Available from: Reports https://www.ustranssurvey.org/reports
2. Racial and Ethnic Disparities Continue in Pregnancy-Related Deaths [Internet]. USA: Centers for Disease Control and Prevention; 2019 [updated 2019 September 6]. Available from: https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-disparities-pregnancy-deaths.html
3. Body Connect Health & Wellness (US). Pelvic Floor PT & The Transgender Experience [Internet]. Washington, DC USA: Body Connect Health & Wellness; c2016 . Available from: https://bodyconnecthw.com/pelvic-floor-pt-the-transgender-experience/eisman, Y. (2017).
4. Queer Undefined: a Crowdsourced LGBTQ+ Dictionary [Internet]. Meaning of nonbinary; [about 3 screens]. Available from: https://www.queerundefined.com/search/nonbinary
5. Queer Undefined: a Crowdsourced LGBTQ+ Dictionary [Internet]. Meaning of transmasculine; [about 1 screen]. Available from: https://www.queerundefined.com/search/transmasculine
6. Queer Undefined: a Crowdsourced LGBTQ+ Dictionary [Internet]. Meaning of transfeminine; [about .5 screen]. Available from: https://www.queerundefined.com/search/transfeminine
7. Valens AN. Trans/Sex: From ‘girldick’ to ‘clit, what trans women call their genitalia: one term doesn’t fit all [Internet]. Austin (TX) USA: The Daily Dot; 2018 December 26 [updated 2021 May 20]. Available from: https://www.dailydot.com/irl/trans-sex-genitalia-girldick/
8. Palmisano BI. Safer Sex for Trans Bodies [Internet]. Washington, DC USA: Whitman Walker Health & Human Rights Campaign Foundation. Available from: https://www.hrc.org/resources/safer-sex-for-trans-bodies
9. Deutsch MA. Information on Testosterone Hormone Therapy [Internet]. San Francisco (CA) USA: University of California, San Francisco; 2020 July. Available from: https://transcare.ucsf.edu/article/information-testosterone-hormone-therapy
10. Standard of Care: Pelvic Floor Considerations in the Transgender/Gender Nonconforming Patient [Internet]. Boston (MA) USA: The Brigham and Women’s Hospital, Inc., Department of Rehabilitation Services; 2020. Available from: https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/pelvic-floor-considerations-in-the-transgender-and-gender-noncomforming-patient.pdf
11. Grimstad FW, Boskey E, Grey M. New-Onset Abdominopelvic Pain After Initiation of Testosterone Therapy Among Trans-Masculine Persons: A Community-Based Exploratory Survey. LGBT Health [Internet]. 2020 July;7(5):248-253. Available from: https://pubmed.ncbi.nlm.nih.gov/32552294/ DOI: 10.1089/lgbt.2019.0258
12. Vardaraj AW, Orgasms Are Excruciating for Me – & I’m Not Alone [Internet]. SheKnows, Penske Media Corporation; 2017 December 1. Available from: https://www.sheknows.com/health-and-wellness/articles/1137174/painful-orgasms/
13. Müller MJ. Helplessness and perceived pain intensity: relations to cortisol concentrations after electrocutaneous stimulation in healthy young men. Biopsychosoc Med [Internet]. 2011 June 30;5:8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3141369/ DOI:10.1186/1751-0759-5-8 *only cismen
14. Diaphragmatic Breathing: Practicing deep breathing can help when feeling tense or in pain [Internet]. FL USA: John Hopkin’s All Children Hospital. Available from: https://www.hopkinsallchildrens.org/Services/Anesthesiology/Pain-Management/Complementary-Pain-Therapies/Diaphragmatic-Breathing
15. Deutsch MA. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People [Internet]. San Francisco (CA) USA: University of California, San Francisco; 2016 June 17. Available from: https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf
16. Matsui De Roo JE. Addressing tucking in transgender and gender variant patients [Internet]. Vancouver (BC) CAN: BC Centre for Disease Control; 2016 October 20. Available from: https://smartsexresource.com/health-providers/blog/201610/addressing-tucking-transgender-and-gender-variant-patients
17. Zevin BA. Testicular and scrotal pain and related complaints [Internet]. San Francisco (CA) USA: University of California, San Francisco; 2016 June Available from: https://transcare.ucsf.edu/guidelines/testicular-pain
18. Things to Know About Tucking [Internet]. British Columbia CAN: Trans Care BC: Provincial Health Services Authority. Available from: http://www.phsa.ca/transcarebc/Documents/HealthProf/Tucking-Handout.pdf
19. Interstitial Cystitis (Chronic Pelvic Pain Syndrome) [Internet]. San Francisco (CA) USA: University of California, San Francisco. Available from: https://urology.ucsf.edu/patient-care/adult-non-cancer/female-urology/interstitial-cystitis *this source only uses the language “females” and “women”
20. de Brouwer IJ, Elaut EL, Becker-Hebly IN, Heylens GU, Nieder TO, van de Grift TC, et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. The Journal of Sexual Medicine [Internet]. 2021 September 20;18(11):1921-1932. Available from: https://www.sciencedirect.com/science/article/pii/S1743609521006317 DOI https://doi.org/10.1016/j.jsxm.2021.08.005
21. van de Grift TI, Elaut EL, Cerwenka SU, Cohen-Kettenis PE, Kreukels BA. Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow Up Study [Internet]. Europe: Journal of Sex & Marital Therapy; 2017 June 12;44(2):138-148. Available from: https://www.tandfonline.com/doi/pdf/10.1080/0092623X.2017.1326190?src=getftr& DOI: 10.1080/0092623X.2017.1326190
22. Powers WI. There is a statistically anomalous amount of Ehler’s Danlos Syndrome / Hypermobility Spectrum Disorder in my MTF community. I literally can’t ignore it anymore [Internet]. Michigan USA: Reddit; 2021 April 07 [updated 2021 Nov]. Available from: https://www.reddit.com/r/DrWillPowers/comments/mmbg3t/there_is_a_statistically_anomalous_amount_of/
23. Ansuini AA. The Overlap Between Autism, Transness, and EDS [Web streaming video]. YouTube; 2018 August 10. Available from: https://www.youtube.com/watch?v=gciRLth3Pn8
24. Pinto VA. High Rates of Vulvodynia Likely in Women With EDS/HSD: Survey [Internet]. Ehlers-Danlos News; 2021 November 29 [cited 2021 December 18]. Available from: https://ehlersdanlosnews.com/2021/11/29/high-rates-of-vulvodynia-likely-in-women-with-eds-hsd-survey/?cn-reloaded=1
25. Butler DA, Moseley LO. Explain Pain. 2nd ed. Adelaide AU. Noigroup Publications; 2013. Page 114 p.
