Sexual health and gender-affirming care – Harvard Health Blog

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 be sexually intimate 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 is not aligned with their registered sex at birth, can have any sexual orientation. (The same is true, of course, with cisgender people, whose gender identity matches their registered sex at birth.)

What is sexual health?

Sexual health is a concept that goes beyond preventing pregnancy and 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 guaranteed for many people, especially TGD people, who face higher risks of discrimination and interpersonal violence, including in 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?

Each TGD person’s lived experience 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 make life easier in a sometimes hostile world.

People are more likely to enjoy intimacy with others when they are happier and 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 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 about your own situation. .

  • Gender affirming hormonal therapy (GAHT) which includes testosterone has been linked to increased libido. Still, testosterone therapy 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. It may or may not be experienced as a positive change.
  • Gender affirming surgeries also have various benefits and compromises for sexual health. Transmasculine people who have chest surgeries may experience less or no nipple sensitivity, but find that their overall sexual function increases – perhaps making a person more comfortable having partners who 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 transfeminine people who had the surgery said they were still able to have an orgasm, and 75% said their orgasms were 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 integrated at 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 enlarged hormonal 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. Either way, research suggests that most people are able to orgasm after surgery, but metoidioplasty is generally not recommended for patients who wish to have the ability to engage in sexual penetration.

If you want to have genital surgery, talk to your surgeon 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 doctor 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 either planned or 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 of ovulation in people taking testosterone is not yet fully understood.
  • Transfeminin people can also produce viable sperm after long periods of estrogen. It is unclear how often this happens.

However, if you are making the transition after puberty and want to save 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 aware of sexually transmitted infections. Additionally, doctors recommend that transmasculine people who still have their uterus and ovaries to use a reliable method of contraception if they are having sex in a way that could lead to pregnancy, even if the use of testosterone has caused it to fail. eliminated menstruation. Transfeminine people who can still ejaculate may be able to get pregnant and should discuss this possibility with relevant partners. Talk to your healthcare team about what’s best for you.

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Jothi Venkat

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