LGBTQ + people are often seen as a cohesive group, but sexual orientation and gender identity are different. Sexual orientation describes who a person prefers to have intimate sex with. Gender identity, on the other hand, describes their perception of themselves as male, female or some other gender. Transgender and other gender different (TGD) people, whose gender identity does not match their registered sex at birth, can have any sexual orientation. (The same is true, of course, for cisgender people, whose gender identity matches their registered sex at birth.)

What is sexual health?

Sexual health is a concept that goes beyond pregnancy and preventing sexually transmitted infections. The World Health Organization describes it as “the opportunity to have pleasurable and safe sexual experiences, free from coercion, discrimination and violence”. This is not assured for many people, especially TGD people, who face higher risks of 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 can affect sexuality and fertility.

Can Gender Affirmation Through Medical or Surgical Means Affect Your Sexuality?

The experience of each TGD person is unique, as are their approaches to gender affirmation. While some people may choose to assert 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 available and desired, can reduce distress and can make life easier in a sometimes hostile world.

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

  • Gender-affirming hormone therapy (GAHT) which includes testosterone has been linked to increased libido. Still, testosterone treatment can cause vaginal atrophy, which can lead to sexual pain or discomfort. For people who are transfeminine, therapies designed to lower testosterone may reduce libido and may also decrease or eliminate spontaneous erections. This may or may not be experienced as a positive change.
  • Gender affirming surgeries also have various benefits and tradeoffs for sexual health. Transmasculine people who have chest surgeries may experience less or no nipple tenderness, but find that their overall sexual function increases – perhaps making a person more comfortable when partners see and touch their breasts. Vaginoplasty restructures the head of the penis into a clitoris and creates a vaginal cavity. In a study of 119 vaginoplasty patients, 90% of transfeminins operated on said they were still able to orgasm, and 75% said their orgasms were either the same or more intense than before. . However, their experience of arousal could be very different.

Different techniques can be used to create a neophallus, a structure that looks and serves as a penis. During a phalloplasty, the clitoris is pushed into the base of the penis, which allows a 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 retains its sensitivity and natural erectile function, but most people do not have sufficient length to engage in sexual penetration. Either way, research suggests that most people are able to have an orgasm after surgery, but metoidioplasty is generally not recommended for patients who want the opportunity to engage in sexual penetration.

If you want to have genital surgery, let your surgeon know about your sexual goals as well as your interest in other aspects of the surgery (like being able to pee).

Gender-affirming hormones and your fertility

If you want to have children who are genetically related to you, it is best to discuss fertility with your doctors before starting treatment with gender-affirming hormones. GAHT generally reduces, but does not eliminate, fertility.

  • People with transmasculins have been shown to be able to produce viable eggs even after years of testosterone treatment, leading to both planned and unplanned pregnancies. Small case studies have reported of transmasculine people who chose to stop testosterone treatment in order to become pregnant and give birth. The frequency with which ovulation occurs in people who take testosterone regularly is not yet fully understood.
  • Transfeminine people can also produce viable sperm after long periods of estrogen. It is not clear how often this happens.

However, if you are making the transition after puberty and want to save the eggs or sperm, it is usually easier to do so before starting hormone therapy, if such a delay is tolerable.

Also, keep in mind that gender-affirming hormones should not be taken for birth control, and everyone should be on the lookout for sexually transmitted infections. In addition, doctors recommend that transmasculine people who still have their uterus and ovaries use a reliable method of birth control if they have sex that could lead to pregnancy, even if the use of testosterone eliminated menstruation. Transfeminine people who can still ejaculate may be able to get someone pregnant and should discuss this possibility with the partners concerned. Talk to your healthcare team about what’s best for you.

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