Sexual health and gender-affirming care

LGBTQ+ people are often considered a cohesive group, but sexual orientation and gender identity are different. Sexual orientation describes who a person prefers to be sexually intimate with. Gender identity, on the other hand, describes their sense of themselves as male, female, or another gender. Transgender and other gender diverse (TGD) people, whose gender identity is not aligned with their recorded sex at birth, can have any sexual orientation. (The same is true, of course, with cisgender people, whose gender identity aligns with their recorded sex at birth.)

What is sexual health?

Sexual health is a concept that goes beyond pregnancy and sexually transmitted infection prevention. The World Health Organization describes it as “the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence.” This is not assured for many people, particularly TGD people, who face higher risks for discrimination and interpersonal violence, including within their intimate relationships.

This blog post discusses two aspects of sexual health: how certain types of gender-affirming care may affect sexuality and fertility.

Can gender affirmation through medical or surgical means affect your sexuality?

The lived experience of every TGD person is unique, as are their approaches to gender affirmation. While some people may choose to affirm their gender only socially, or not at all, others use a variety of medical and surgical procedures to do so. Some research shows that gender-affirming care, when accessible and desired, may reduce distress and can make it easier to live in a sometimes hostile world.

People are more likely to enjoy intimacy with others when they are happier and feel comfortable in their own skin. Those who choose to pursue gender-affirming care may find it affects their sexuality in both positive and negative ways. The examples below speak to both possibilities, although it’s best to discuss the range of options available to you with a doctor who provides gender-affirming care, if you’re wondering about your own situation.

• Gender-affirming hormone therapy (GAHT) that includes testosterone has been associated with an increase in sex drive. Yet testosterone therapy may cause vaginal atrophy, which has the potential to lead to sexual pain or discomfort. For transfeminine individuals, therapies designed to reduce testosterone may lower sex drive, and may also decrease or eliminate spontaneous erections. This may or may not be experienced as a positive change.
• Gender-affirming surgical procedures also have various benefits and tradeoffs for sexual health. Transmasculine people who have chest surgeries may experience less or no nipple sensitivity, but find their overall sexual function increases — possibly through making a person more comfortable having partners see and touch their chests. Vaginoplasty restructures the head of the penis into a clitoris and creates a vaginal cavity. In one study of 119 vaginoplasty patients, 90% of transfeminine people who had the surgery reported that they were still able to have an orgasm, and 75% said their orgasms were either the same or more intense than before. However, their experience of arousal could be quite different.

Different techniques can be used to create a neophallus, a structure that resembles and serves as a penis. During a phalloplasty, the clitoris is embedded in the base of the penis, which allows for sexual sensation. Many surgeons also attach one of the clitoral nerves to the flap. With metoidioplasty, the hormonally enlarged clitoris used as the body of the penis maintains its sensitivity and natural erectile function, but most people do not have sufficient length to engage in sexual penetration. In both cases, research suggests most people are capable of orgasm after surgery, but metoidioplasty is not generally recommended for patients who desire the ability to engage in sexual penetration.

If you wish to have genital surgery, tell your surgeon about your sexual goals as well as your interest in other aspects of surgery (such as being able to stand to pee).

Gender-affirming hormones and your fertility

If you are interested in having children who are genetically linked to you, it’s best to discuss fertility with your doctors before starting treatment with gender-affirming hormones. GAHT generally reduces, but does not eliminate, fertility.

• Transmasculine people have been shown to be able to produce viable eggs even after years on testosterone treatment, leading to planned or unplanned pregnancies. Small case studies have reported on transmasculine people who chose to stop testosterone treatment in order to become pregnant and give birth. How often ovulation occurs in people taking testosterone consistently isn’t well understood yet.
• Transfeminine people may also still make viable sperm after long periods on estrogen. How often this happens is unclear.

However, if you transition after puberty and wish to preserve eggs or sperm, it is usually easiest to do this prior to starting hormone treatment, if such a delay is tolerable.

Also keep in mind that gender-affirming hormones should not be counted on as birth control, and everyone should be mindful of sexually transmitted infections. Additionally, doctors recommend that transmasculine individuals who still have their uterus and ovaries use a reliable method of birth control if they have sex in ways that could cause pregnancy, even if testosterone use has eliminated menstruation. Transfeminine individuals who can still ejaculate may be able to get someone pregnant, and should discuss that possibility with relevant partners. Talk to your medical team about what is best for you.