Experiences and evidence of transfeminine people’s challenges with chronic, recurrent neovaginal malodor: a cross-sectional qualitative study

Background Penile inversion vaginoplasty, which uses penile and scrotal skin to surgically create a neovagina, is a medically necessary gender-affirming surgery for some transfeminine individuals. Much like cisgender women, roughly a third of transfeminine individuals who have undergone vaginoplasty report having experienced bothersome neovaginal malodor in the past 30 days. However, sources of neovaginal malodor remain unclear. This study sought to collect data on odour quality and characterize the experiences of transfeminine individuals with neovaginal malodor. Methods Participants (n = 20) completed a cross-sectional questionnaire answering semi-structured interview questions on malodor experiences, exacerbating factors, and attempted reduction methods. Participants were mailed scent test kits containing samples of known malodorous compounds, and rated sample resemblance to their own malodor on a Likert scale. Results were evaluated by Spearman’s correlation. Participant comments were analysed using a thematic analysis and organized into key themes. Results Twenty-nine different scents were reported by 20 participants. Sixteen participants completed semi-structured interview questions, providing sixty-four total comments. Three key themes were identified: (i) odor and malodor diversity, ii) lifestyle and physiological factors, and iii) preventative hygienic practices. Participants often described both nonbothersome, desirable neovaginal odor, as well as unpleasant and undesirable neovaginal malodors. Scent test results revealed three malodor typologies, characterized by i) trimethylamine, ii) isovaleric acid, and iii) a diverse combination of the polyamines spermine, cadaverine, putrescine, as well as acetic acid. Participants engaged in diverse malodor management strategies, which were differentially effective. Conclusions The identification of three unique malodour typologies and varying success of treatments and hygienic practices in reducing neovaginal malodour suggests that different microbial communities may underlie each odour type. Further, the diversity of malodor reduction methods and douching substances reported highlight the lack of standard care guidelines for neovaginal malodor, demonstrating the need for further research aimed to develop evidence-based treatments.