Most trans persons desire a sexual life as much as cisgender people, but some trans persons have a complicated relationship with their bodies. As a result, sexuality often remains a delicate issue, both during counselling and in their private life. Transitioning and gender-affirming treatment for those who need it, can have a positive influence on sexual experiences although others may still struggle. As the way of understanding trans identities and bodies changes and becomes more positive and socially accepted, it is assumed that more and more trans people have a good or better relationship with their bodies.
Also avoid assumptions about the sexual orientation of the trans person. Trans persons may also identify as heterosexual, gay/lesbian or bisexual and their sexual partners may be cisgender or trans. As such, discussions of safe(r) sex, contraception, and fertility should always begin with questions about the trans person’s practices and needs.
Effect of gender-affirming treatment
Both hormone treatment and gender-affirming operations influence the sexual experience.
Hormone treatment has a particular effect on sexual desire and sexual arousal: the use of testosterone is associated with an increase in sexual desire and arousal (Elaut et al., 2011), while blocking testosterone and oestrogen intake is often associated with a decrease in sexual desire and erections becoming less easy or impossible to attain (Elaut et al., 2008). The orgasmic feeling can also change under the influence of hormones (De Cuypere et al., 2005). The use of testosterone causes the clitoris to grow and become more sensitive, but the vagina will sometimes also become less lubricated and the tissue more fragile. This can cause irritation with sexual contact. Hormone therapy also has an effect on the fertility of trans persons.
Gender-affirming surgeries generally have a positive effect on the sexual experience of trans persons, when satisfaction with the body is increased. Gender-affirming surgeries can improve body satisfaction and ease gender dysphoria, but the surgery itself can also be associated with sexual sequelae associated with physical constraints of the new genitals or postsurgical pain, psychological difficulties with accepting the new body, or social aspects of having changed gender (Holmberg, Arver & Dhejne, 2019). Potential sexual problems trans people encounter may occur in all phases of surgical treatment, therefore collaboration with a sexologist with knowledge and experience with trans people is recommended (T’Sjoen et al, 2020).
It is important to keep in mind the diversity and possibilities sexual practices offer for both trans and cis persons. While some people may have a more traditional understanding of sex, such as prioritizing genitals and penetration, many others may see sex within a wide range of possibilities regarding erogenous parts of the body and the practices they encompass.
Many studies in this area focus on sexual functioning: the capacity to achieve an orgasm or to have penetrative sex. From these studies it is known that most trans persons can achieve orgasms after surgery, via masturbation or through sexual contact (De Cuypere et al., 2005; Holmberg et al, 2019). Penetration is usually not possible after a metoidioplasty. For this, the use of a strap-on dildo or penis prosthesis can be possible. Trans people who have a phalloplasty can penetrate, provided that an erection prosthesis is placed during an additional operation. The most sensitive place for trans people with a phalloplasty, however, is not at the tip of the penis but at the bottom of the shaft, where the clitoris used to be. Trans people who underwent vaginoplasty may have vaginal penetrative sex, but usually do not get wet enough with sexual arousal. The use of lubricant is therefore recommended. The most sensitive place for trans people with a vaginoplasty is their clitoris.
Sexual pleasure after gender affirming treatment remains highly under examined in trans people. Even if sexual function is impaired, most trans people report that they are more satisfied with their sexual life postoperatively (De Cuypere et al, 2005; Nobili et al, 2018; Wierckx et al, 2011).
Fertility
After cessation of testosterone therapy, many trans and non-binary people are able to become pregnant. Long-term impacts of testosterone therapy (10 years or more) on fertility are not yet widely documented, but studies of trans and non-binary conception and pregnancy do indicate that an adequate period of testosterone cessation can potentially lead to resumed fertility. It is important also to note that testosterone is not an effective contraceptive, and it is possible for trans and non-binary people on testosterone therapy to conceive through intercourse if they are not using appropriate protection.
A trans woman or nonbinary person who has a penis and has not had testes removal can get a person with a uterus and ovaries pregnant, including cisgender women, some trans men, and some nonbinary people. Contraception therefore remains important to prevent pregnancy. Health practitioners may refer trans persons seeking fertility treatments to the gender wellbeing clinic for information and support. You can find additional information on fertility here.
HIV & STI’s
Research on the prevalence of HIV and other sexually transmitted diseases (STDs) in trans persons is limited. Although international (mainly American) studies indicate very high prevalence rates for transgender persons, HIV prevalence rates for transgender persons in Europe are scarce (Van Schuylenbergh, Motmans & Coene, 2017). A recent English study calculated a HIV prevalence rate of 0.46-4.78 per 1000 for transgender and genderdiverse people, based on HIV surveillance data (Kirwan et al., 2021). American research indicates that the prevalence of HIV among trans women who have sex with cis men would be much higher than within the general population (Operario, Soma & Underhill; 2008; Herbst et al., 2008). A meta-analysis of 88 studies estimated an overall HIV prevalence rate of 9.2% – 14.1% for transgender women and 3.2% for transgender men (Becasen et al., 2019). 31% report engagement in sex work. Furthermore, this study calculated a self-reported history of sexually transmitted disease (STD) diagnosis rate of 21.5%. HIV prevalence estimates still seem to be much higher than within the general population, however several researchers have been critical towards the samples used in current HIV research in transgender persons.
For all trans people, exposure to HIV depends heavily on their sexual partner(s). Trans people who have penetrative or oral sex with partners assigned male at birth are at higher risk than trans people who have non-penetrative sex or use prostheses for penetration. There is limited exposure for trans men and nonbinary people assigned female at birth who have sex only with others assigned female at birth. However, there is very little research on the exposure or risk of trans men or nonbinary people, regardless of their birth assignment. Trans men who have sex with men (TMSM) are additionally systematically excluded from HIV prevention and treatment clinical trials, so risk information must be extrapolated from information on cisgender men and women and trans women, which leads to clear gaps in understanding. Regardless of whether or not surgery has been performed, it remains important to prevent STD infection through the use of contraceptives such as condoms, although this can sometimes be a problem for trans persons. See the following section for further discussion.
Safe sex
Information about safe sex is almost always focused on cisgender people. There are, however, a number of trans-specific aspects that are generally not included in relational and sexual education programs. For example, a penis after metoidioplasty is usually too small to use a standard condom. An alternative is special small condoms or bands, although these are generally more difficult to obtain and more expensive. For trans men and nonbinary people assigned female at birth without genital surgery or who choose to maintain the vaginal opening, a female condom or internal condom, is recommended for penetration, or if their sex partner is a cisgender male, he can use a condom. An additional consequence of testosterone can be vaginal dryness or atrophy, which can make use of condoms uncomfortable or lead to increased risk of tearing during penetrative vaginal intercourse when using condoms.
In addition to condoms to protect against STDs, trans women and nonbinary people who have had a vaginoplasty should also use water or silicone-based lubricants, since the vagina becomes less or not moist with sexual arousal. After vaginoplasty, it is recommended to be careful with anal sex, as the tissue between the new vagina and the rectum is thin. During intercourse it is best to use a condom and extra lubricant. Fisting, or the practice of penetration with the whole hand in a closed fist, of the vagina after vaginoplasty is also discouraged, since the vagina is less elastic than that of many cisgender women.
Sexual behaviour is rarely discussed within our current society: active, dominant behaviour (penetration) is attributed to men while passive behaviour to women. This can lead to confusion, avoidance or ambivalence around sexuality for trans persons. This is also true regarding contraceptives: the use of condoms is generally considered to be something male, and trans men may find it unpleasant to use an internal condom or dental dam. It is sometimes easier for trans people to discuss safer sex by separating body characteristics and sexual behaviour from gender when giving information about safe sex: emphasise which contraceptive can be used in the presence of specific genitals or internal organs or in performing a certain sexual act, without applying it to men or women. In addition, not all trans persons have the same sex characteristics: some are still working on their transition process, others do not consider certain steps in the transition necessary, and still others are unable to access procedures that they want because of medical or financial barriers. Therefore, avoid assumptions with regard to the anatomy of trans persons.
References:
- Becasen JS, Denard CL, Mullins MM, Higa DH, Sipe TA. Estimating the prevalence of HIV and sexual behaviors among the US transgender population: a systematic review and meta-analysis, 2006–2017. American journal of public health. 2019;109: e1-e8.
- De Cuypere, G., T’Sjoen, G., Beerten, R., Selvaggi, G. De Sutter, P., Hoebeke, P., Monstrey, S. & Vansteenwegen, A. (2005). Sexual and Physical Health After Sex Reassignment Surgery. Archives of Sexual Behavior , 34, 6, 679-690.
- Elaut, E. & Wierckx, K. (2013). Sexuality. In G. T’Sjoen, M. Van Trotsenburg & L. Gijs (Eds.), Transgender care . (pp. 199-204). Leuven / The Hague: ACCO
- Elaut, E., De Cuypere, G., De Sutter, G., Gijs, L., Van Trotsenburg, M., Heylens, G., Kaufman, JM, Rubens, R. & T’Sjoen, G. (2008 ). Hypoactive sexual desire in transsexual women: prevalence and association with testosterone levels. European Journal of Endocrinology , 158, 393-399.
- Elaut, E., Wierckx, K., Van Caenegem, E., Van de Peer, F., Dedecker, D., Van Houdenhove, E. & T’Sjoen, G. (2011). Sexual desire in female-to-male transsexual persons: exploration of the role of testosterone administration. European Journal of Endocrinology , 165, 331-337.
- Herbst, JH, ED Jacobs, TJ Finlayson, USA McKleroy, MS Neumann, and N. Crepaz. (2008). Estimating HIV Prevalence and Risk Behaviors of Transgender Persons in the United States: A Systematic Review. A ids Behavior , 12: 1-17.
- Kirwan, P., Hibbert, M., Kall, M., Nambiar, K., Ross, M., Croxford, S., Nash, S., Webb, L., Wolton, A. and Delpech, V. (2021), HIV prevalence and HIV clinical outcomes of transgender and gender‐diverse people in England. HIV Med, 22: 131-139. https://doi.org/10.1111/hiv.12987
- Operario, D., T. Soma, and K. Underhill. (2008). Sex Work and HIV Status among Transgender Women: Systematic Review and Meta-Analysis. Journal of Acquired Immune Deficiency Syndrome 48, 1.
- Van Schuylenbergh, J., Motmans, J. & Coene, G. (2017, in review). TGNC persons and sexual risk: a critical review of 10 years of research in a feminist intersectional perspective. Critical Social Policy.