Thailand has a new 'vaginal examination' guideline for obstetricians to use to care for the health of 'transgender' people.

It has become a hot topic in both the medical and social circles in Europe. Earlier this February, an obstetrician and gynecologist in France had his license suspended for 1 month and was put on probation for 5 months because in 2023, he refused to treat a transgender patient, citing that he did not have enough expertise to examine a newly created vagina (Neo Vagina) for a transgender woman.

This incident has sparked debate in French society. Those who support the LGBTQ+ community say that this is discrimination by doctors and that it will only increase inequality in society. Meanwhile, those who support the doctor’s reasoning may be sufficient because they may not have enough expertise to examine a transgender woman who has undergone a sex reassignment surgery through a medical procedure.

This situation is likely to occur in many other countries, including Thailand, but it may not be as intense. In February of last year, the Royal College of Obstetricians and Gynecologists of Thailand issued “Guidelines for Examining a Newly Created Vagina” for obstetricians and gynecologists in Thailand to use as guidelines for taking care of transgender patients’ health.

The main reason for creating these guidelines for examining a newly created vagina is The Royal College of Obstetricians and Gynecologists stated that this is because the reconstructed vagina will have some differences in examination due to the surgical method and the tissue used to create the new vagina. However, overall, the examination guidelines are similar to those for a normal vaginal examination.

The key points of the examination guidelines for a reconstructed vagina are divided into 6 steps, covering preparation and post-examination, as follows:

1. Preparation and consent

Provide privacy and comfort. Examine in a private place and explain the procedures to the patient.
Explain the reasons for the examination and obtain consent before beginning the examination. Be careful and considerate of the patient's feelings.
A medical history is taken, review the surgical history (e.g., the method of gender reassignment surgery used—penile flip, peritoneal septum, sigmoid colon), as well as post-operative complications and current symptoms (e.g., vaginal discharge, bleeding, pain).

2. Visual examination

Examine the perineum. Examine the external appearance of the reconstructed vagina, including the labia majora, labia majora, clitoris (if created), and perineum.
Observe for complications and look for signs of infection. Granulation tissue, fistulas, stenosis, or skin irritation
Scar tissue Look for hypertrophic scars or keloids

3. Speculum examination, if necessary

Use lubricant and comfort. Use an adequately lubricated speculum, and consider a smaller size if the patient is uncomfortable or distressed.
Insertion: Gently insert the speculum, observing the depth (which may vary depending on the surgical procedure). A vagina created from the skin of the penis or scrotum may be shallower than a vagina created from intestinal tissue.
Internal examination: Inspect the vaginal wall for granulation tissue, open sores, or abnormal vaginal discharge.

4. Rectal and vaginal examination (bimanual examination)

In many cases, a bimanual examination may not be possible if the newly created vagina is shallow or the cervix is ​​absent. However, the vaginal wall can be palpated for tenderness, lumps, or other abnormalities.

5. Additional Considerations

Pap smears are generally not required unless the reconstructed vagina uses tissue that is at risk for HPV (e.g., the lining of the intestine) or the cervix is ​​preserved.

Using a dilator: Ask the patient if they have used a dilator, as frequent use can lead to a narrowing of the vagina (neovaginal stenosis).

6. After the exam

Explain the results of the exam. Discuss the results in detail and gently, and discuss treatment or follow-up if necessary.
Continuation of care: If necessary, referral to a specialist (e.g., a urologist or pelvic floor specialist).

However, the Royal College of Gynecologists’ guidelines also address common complications after gender reassignment surgery, including: neovaginal stenosis of the reconstructed vagina; granulation tissue, which often appears as red, fragile tissue that is prone to bleeding; fistulas or abnormal connections between the vagina and other organs; and infections, such as abnormal vaginal discharge, unpleasant odor, or irritation.

CR.thecoverage