Maintaining good sexual health and using protection can help people stay healthy and enjoy their sex lives while protecting themselves and others from risks.

Sexual health and the use of protection during sexual activity apply to people of all gender identities and can help protect against infection and unplanned pregnancy.

This article examines the sexual health of transgender women, transfeminine people, or non-binary male birth attendants (AMABs).

Transfeminine is a term that refers to those who were AMAB but identify with femininity or feminine identity.

Sexually transmitted infections (STIs) can be transmitted between anyone of any gender identity and through any type of sex.

It is important that people test for STIs at least once a year to get the treatment they need and to avoid passing an STI to a sexual partner.

Using barrier methods, such as condoms and dams, whenever people have sex, is the best way to protect yourself against STIs. This regardless of whether people have had buttock surgery or not. “Bottom” surgery refers to changes in the genital area, also known as gender affirming surgery.

Examples of barrier methods are:

  • External condoms: These go on a penis or a sex toy. If people have sex for more than half an hour, it is better to use a new condom. People will also need to use a new condom if they switch between anal and vaginal sex.
  • Internal condoms: Internal condoms go inside the vagina or anus. Some transgender women who have had buttock surgery may not be able to use an internal condom, as it depends on the depth of the vagina.
  • Dental dams: A dental dam is a layer of latex that people can use during oral sex and rimming. The dam acts as a protective barrier against STIs.

Use a lubricant

Those who have had buttock surgery may find it beneficial to use a lubricant. This is because the vagina might not lubricate naturally, according to the Gender Identity Research and Education Society.

People can use a water-based or silicone-based lubricant when using a condom. People should avoid using oil-based lubricants because they can weaken latex condoms.

Silicone-based lubricants are also best avoided with silicone dildos and sex toys, as the lubricant can damage the surface.

The Terrence Higgins Trust notes that lower surgery can affect the risk of getting an STI. If people have unhealed skin from lower surgery, it can increase the risk of infections passing through their body.

Before having buttock surgery, it is important for people to tell a healthcare professional if there are warts on their penis. Warts will require treatment before surgery, otherwise they may continue to grow inside the vagina.

If people have had colovaginoplasty – where surgeons use part of the colon to form the vagina – it can increase the likelihood that some STIs will pass through the vaginal lining.

If the skin of the penis and scrotum forms the vagina, there is less chance of STIs getting into the skin, although any cut or tear can allow infections to enter the body.

People may need to allow the genital area time to recover after surgery. People can discuss precautions with their surgeon and when it is safe to resume sexual activity.

People can try the following tips after having lower surgery:

  • Use of a lubricant: People can use a lot of water-based lubricant to prevent tear formation and make sex more comfortable.
  • Using a dilator: Using a dilator can help stretch the skin of the vagina after surgery, but it can also cause bleeding and increase the chances of transmitting an STI in the body.
  • Using a condom: If people do not know whether they or their partner has an STI, using a condom every time they have sex can protect them from STIs.

If people have not had an orchiectomy or vasectomy, they will still need to use contraception to avoid any risk of pregnancy when having vaginal sex with a partner who is not using contraception and who is at risk of pregnancy.

If people take hormones, they will not provide sufficient contraceptive protection.

This includes:

  • estradiol
  • gonadotropin releasing hormone (GnRH)
  • analogues
  • finasteride
  • cyproterone acetate

According to research by the Centers for Disease Control and Prevention (CDC), transgender women are at high risk of contracting HIV. In a survey conducted in seven major cities in the United States, 4 in 10 transgender women are HIV positive.

The survey also found ethnic and racial disparities, with HIV affecting 62% of black transgender women and 35% of Hispanic and Latin transgender women, compared to 17% of white transgender women.

The reason for these high levels of HIV can include:

  • racism and discrimination affecting transgender women, which impact access to health care, employment and housing
  • transphobia as a barrier to HIV treatment and care
  • lack of knowledge of health care providers on transgender issues
  • HIV stigma
  • an unmet need for medical gender affirmation

HIV testing is important so that people know their HIV status. Sexually active transgender women may want to be tested for HIV at least once a year or more frequently if they change sex partners or have an STI.

People can access HIV testing at a sexual health clinic or order an HIV self-test online. People can seek HIV testing services through the CDC Search Tool.

Learn more about HIV in transgender women here.

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If people test positive for HIV, they can take a medicine called antiretroviral therapy, which is very effective in controlling HIV. It is important that people start HIV treatment as soon as possible and take their medicines daily as prescribed by a healthcare professional.

People with HIV who take HIV medicines can live long and healthy lives. Anti-HIV drugs lower the viral load of HIV, which means it can reach an undetectable load. When taken correctly, it means that people cannot pass the virus on to others.

Hormones and HIV treatment

Most anti-HIV drugs can be safely taken at the same time as hormone therapy.

Some antiretroviral drugs can interact with gender-affirming hormones. A healthcare professional can monitor hormone levels to make sure both drugs are working effectively and safely.

Pre-exposure prophylaxis (PrEP) is an HIV negative medicine that people can take before sex to prevent them from getting HIV. The Food and Drug Administration (FDA) has approved two anti-HIV drugs for PrEP: Truvada and Descovy.

PrEP is safe for people of all gender identities.

Transgender women may choose to take PrEP if they:

  • feeling at risk of exposure to HIV
  • do not use condoms with a partner whose HIV status is unknown
  • either themselves or a sexual partner has recently had gonorrhea or syphilis
  • want to have condomless sex with an HIV-positive partner
  • are a sex worker
  • injecting drugs and sharing needles or any drug equipment with others

Can a person take hormones and PrEP?

According to PleasePrEPMe, it is safe to take hormones in addition to PrEP. Truvada does not reduce hormone levels. Although healthcare professionals don’t believe Descovy reduces hormone levels, more research is needed.

PrEP will also not cause fat redistribution on the face or body.

How to take

People can take PrEP daily, or on demand, which people take before and after sex.

People will need to take a daily dose 7 days before having sex for it to be effective against HIV.

The daily dosage is best for people who take gender-affirming hormones and those who have vaginal sex.

People will need to take doses on demand before and after sex:

  • 1 tablet 2 to 24 hours before intercourse
  • 1 tablet 24 hours after intercourse
  • 1 additional tablet 48 hours after intercourse

Dosing on demand may be suitable for people who are not taking gender-affirming hormones and only have anal sex.

People can stop taking PrEP every day 7 days after their last intercourse. People can stop taking PrEP on demand two days after their last sex without a condom.

If people with hepatitis B want to stop taking PrEP, they will need to talk to their health care provider first.

Where to get PrEP

People can talk to their health care provider about PrEP or at a sexual health clinic. People can also search for a local PrEP provider here.

A person can also read more about financial assistance to get PrEP here.

Post-exposure prophylaxis (PEP) is a medicine that people can take if they think they have been exposed to HIV. PEP works to prevent infection with HIV once the virus enters the body.

People should take PEP within 72 hours of exposure, although it is best to take it within 24 hours. People can go to a sexual health clinic or emergency room to access PEP and tell a healthcare professional about any hormones or medications they are taking.

A person can search for trans-friendly health care providers and clinics in their state or city through the CDC Resource Page.

Transgender women, transfeminine people, or non-binary male birth attendants (AMABs) can use barrier methods to help prevent unplanned pregnancies and prevent transmission of STIs. Barrier methods include condoms and dental dams.

Using barrier methods every time you have sex and regularly screening for STIs and HIV can help maintain good sexual health for people of all gender identities.

People can access care and treatment from sexual health clinics or online resources. Very effective treatments are available to protect people and control STIs and HIV.