LGBTQ + people are often viewed as a cohesive group, but sexual orientation and gender identity are different. Sexual orientation describes who a person wants to be sexually intimate with. Gender identity, on the other hand, describes how they see themselves as male, female or a different gender. Transgender and other gender specific persons (TGD) whose gender identity at birth does not match their recorded gender can orientate themselves sexually. (The same applies, of course, to cisgender people whose gender identity corresponds to the gender recorded 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 pleasant and safe sexual experiences that are free from coercion, discrimination and violence”. For many people, especially for VHS people, who are exposed to a higher risk of discrimination and interpersonal violence, even within their intimate relationships, this is not guaranteed.
This blog post discusses two aspects of sexual health: How certain types of gender-affirming care can affect sexuality and fertility.
Can confirmation of sex by medical or surgical means affect your sexuality?
Each VHS person’s lived experience is unique, as are their approaches to gender confirmation. While some people choose to only socially confirm their gender 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, can alleviate hardship and make life easier in a world that is sometimes hostile.
People are more likely to enjoy intimacy with others when they are happier and comfortable with themselves. Those who choose to choose gender-affirming care may find that it affects their sexuality both positively and negatively. The following examples speak for both options, although it is best to discuss the options available with a doctor who provides gender-affirming care if you are wondering about your own situation.
- Sex-affirming hormone therapy (GAHT), which contains testosterone, has been linked to increases in sex drive. However, testosterone therapy can cause vaginal atrophy, which can lead to sexual pain or discomfort. In transfeminine individuals, therapies to reduce testosterone can lower the sex drive and also reduce or eliminate spontaneous erections. This may or may not be perceived as a positive change.
- Sex-affirming surgery also have various sexual health benefits and tradeoffs. Transmasculine people who have had breast surgery may have less or no nipple sensitivity, but find that their overall sexual function increases – possibly by making a person more comfortable having partners see and touch their breast. Vaginoplasty converts the head of the penis into a clitoris and creates a vaginal cavity. In a study of 119 vaginoplasty patients, 90% of transfeminin patients said they could still orgasm, and 75% said their orgasms were either the same or more intense than before. However, your experience of arousal might be very different.
Various techniques can be used to create a neophalus, a structure that resembles the penis and serves as the penis. During a phalloplasty, the clitoris is embedded in the base of the penis, allowing a sexual sensation. Many surgeons also attach one of the clitoral nerves to the flap. In metoidioplasty, the hormonally enlarged clitoris, which is used as the body of the penis, maintains its sensitivity and natural erectile function, but most people are not long enough to be sexually penetrated. In both cases, research suggests that most people will be able to orgasm after surgery. However, metoidioplasty is generally not recommended for patients who want the ability to have sexual penetration.
If you are about to have genital surgery, let your surgeon know about your sexual goals, as well as your interest in other aspects of the surgery (such as being able to pee).
Sex-affirming hormones and your fertility
If you are interested in children who are genetically linked to you, it is best to discuss fertility with your doctors before starting sex-affirming hormone treatment. GAHT generally decreases fertility, but does not eliminate it.
- It has been shown that transmasculine people can produce viable eggs even after years of testosterone treatment, resulting in planned or unplanned pregnancies. Small case studies have reported transmasculine people who chose to discontinue testosterone treatment in order to conceive and give birth. Exactly how often ovulation occurs in people who take testosterone regularly is not yet known.
- Transfeminins can still produce viable sperm even after long periods of estrogen. How often this happens is unclear.
However, if you are going over post puberty and want to receive eggs or sperm, it is usually easiest to do so before starting hormone treatment, if such a delay is tolerable.
Also, keep in mind that sex-affirming hormones shouldn’t be considered a birth control and that everyone should watch out for sexually transmitted infections. In addition, doctors recommend that transmasculine people who still have the uterus and ovaries use reliable contraception if they are having sex in a way that could cause pregnancy, even after testosterone use clears menstruation. Transfeminine individuals who can still ejaculate have the potential to make someone pregnant and should discuss this possibility with relevant partners. Talk to your medical team about what’s best for you.