Sexuality is experienced in multiple ways and with subjective meanings. Some transgender people live sexuality in a positive way, others do not. Some transgender people may, for example, not feel comfortable with their body or experience the fear of rejection due to internalized transphobia. Furthermore, when a person starts a medical gender affirming path, important changes in sexuality may occur. In this case, people tend to report acquiring better self-esteem, with positive implications also in sexuality. However, some hormone therapies (such as antiandrogen) can decrease sexual desire and / or impair sexual functions (for example erections), which may be a cause of sexual distress. On the other hand, testosterone, usually increases sexual desire, an effect described by some people as a destabilizing feeling that has never been dealt with before. However, after the first months of therapy, sexual desire tends to stabilize. The increase in the size of the clitoris, linked to the intake of testosterone, also may improve the pleasure in sexual activity (if contact with the genitals is not a source of discomfort).
Since the experience of sexuality is highly subjective, people must therefore be well informed and aware of the consequences on sexuality before starting a medical gender affirming path. In fact, the same effect can be desired by one person and be a source of distress for another. For example, some transgender people are relieved not to have erections after starting hormone therapy, while for others losing this function can be a problem. Sexuality is often lived as a taboo that arouses shame and embarrassment.
When sexuality is a characterized by anxiety and a sense of inadequacy, it is important to talk about it. The work with a psychologist / sexologist can offer support in increasing self-esteem and in achieving a positive perception of oneself, as well as encouraging the exploration of the body and go over the idea, rooted in our culture, that sexual pleasure is concentrated exclusively in the genitalia. Confronting with people who have experienced similar challenges can be useful too. In conclusion, the importance of an early gender inclusive sexual education strongly emerges. Furthermore, communication between partners and mutual respect in knowing oneself and the other must be facilitated. Sexual education and body awareness are important goals also following gender affirming surgery: the person may in fact need to know the body, how it feels, where the erogenous zones are and learn to share awareness with the partner to achieve better sexual satisfaction.
While surgical procedures on the genital organs result in a permanent loss of fertility, gender affirming hormonal treatment cause variable but likely reversible reductions in reproductive capacity.
Contraception in assigned male at birth transgender people
Although it is likely that oestrogen and antiandrogen therapy may compromise spermatogenesis, it cannot be excluded that, through vaginal penetrative intercourse with an assigned female at birth person, pregnancy is induced. For this reason, if this is not desired, it is recommended to use a condom in case you have vaginal penetrative intercourse. Alternatively, the assigned female at birth partner (with a functioning female reproductive system) can be asked for an alternative method of contraception (such as the contraceptive pill). The use of condoms, unlike the contraceptive methods described above, is also useful in the prevention of sexually transmitted diseases. However, its use can be difficult for a transgender person under gender-affirming hormone therapy, due to the possible reduction of tumescence (incomplete erection).
Contraception in assigned female at birth transgender people
Testosterone often undertaken by assigned female at birth transgender people usually causes cessation of menses in a period ranging from 1 to 12 months from the first administration in most people. However, the lack of menses does not mean the absence of ovulations, which therefore implies that there is still a risk of pregnancy. Rare cases of unwanted pregnancy are reported under masculinizing hormones, for which testosterone treatment cannot be considered a valid and effective contraceptive option, in addition to presenting teratogenic effects on the fetus.
Testosterone does not represent a contraindication to any type of hormonal contraception. However, we have no information on the best contraceptive option in the population under this hormone as well as we do not know if some effects can be maintained, amplified or reduced when contraceptives are taken together with testosterone. Each method has some advantages and some disadvantages, therefore the choice of contraceptive must be discussed with the doctor and personalized based on the preferences and needs of the concerned person.
Below we outline some contraceptive options with the possible advantages and disadvantages of each formulation in assigned female at birth transgender people.
What it is
It is a small stick of a particular type of flexible and thin plastic, 4 cm long and 2 mm in diameter, which contains 68 milligrams of the progestin hormone called etonogestrel (hormone similar to natural progesterone but synthesized in the laboratory). It is inserted under the skin in the inner area of the upper arm (left or right if you are left handed). It remains in place for three years and must be removed at the end of the third year. It is inserted and removed through a small incision, made by the doctor in the clinic. A local anesthetic is administered during insertion and removal to reduce discomfort. Once inserted it is not visible to the naked eye, a feature that makes it extremely discreet.
Intrauterine devices (copper-containing IUD and levonorgestrel-releasing IUD)
What it is
It is a T-shaped device. Depending on the type, it may contain copper or silver or a small amount of the progestin hormone levonorgestrel (hormone similar to natural progesterone, but synthesized in the laboratory). It is inserted into the uterus and can remain in place for 3-5 or 10 years, depending on the type.
Progestin-only oral contraceptive
What it is
Pill containing the progestin hormone called desogestrel or drospirenone (hormones similar to natural progesterone but synthesized in the laboratory) to be taken daily, orally.
Combined oestrogen-progestin oral contraceptives
What it is
Pill containing both oestrogen and progestin hormones (hormones similar to oestrogen and natural progesterone but synthesized in the laboratory), to be taken daily orally.
What it is
It is a ring-shaped device made from a special type of plastic, flexible and thin, with a diameter of 54 mm and a thickness of 4 mm. It should be placed in the vagina and replaced once a month. In contact with the vaginal wall, the ring releases oestrogen and progestin (hormones similar to oestrogen and natural progesterone but synthesized in the laboratory).
Taboos and stereotypes can negatively affect sexuality. This section will give some correct information and dispel false myths.
I am a transgender boy and I am attracted to men, is there something strange in me?
Sexual orientation and gender identity are two distinct and independent dimensions. Like a cisgender person, a transgender person can in fact be attracted to a man, a woman, both or to another transgender person. For this reason, sexual orientation does not interfere with any gender affirming path. In some cases, it may be useful to ask a professional about contraception or about the effects on sexuality linked to a medical gender affirming path.
I am not interested in sex. Do I need to worry?
In a transgender person sexuality may be impaired by the discomfort towards the body and by the fear of not being recognized in one’s gender identity. Therefore, a person may avoid relationships and/or sexuality. Health professionals can provide support to deal better with these challenges. The discomfort towards one's body can subside spontaneously during a gender affirming path, allowing to better live sexuality. However, if sexual distress persists, it may be useful to consult a sexologist with expertise in transgender health for psychological support and / or medications.
How will sexuality change after gender affirming surgery?
Gender affirmining surgery is a choice that only some transgender people will take. In making such a decision, it is certainly important to be aware of the possible consequences of surgery on sexuality. This requires a careful evaluation of the aspects that could improve (for example, better relationship with the body), but also of possible limits, which vary according to the experience of the surgeon and the peculiarities of the individual case. For this reason, it is important that people are carefully informed and have realistic expectations. A transgender person may feel confused regarding anatomical changes. In this case it is important to explore new ways of sexual stimulation and learn about the body. For some couples, sexual therapy can be of further help.
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