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.

Subcutaneous implant
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.

Advantages: 

• it does not contain oestrogens, commonly considered the female hormones that most counteract the masculinizing effect of testosterone
• can remain in place for three years, without needing to remember it anymore
• it is the most effective method of contraception for the prevention of pregnancy
• the modest androgenic effect of the hormone contained in the device can act in synergy with testosterone therapy or in any case does not counteract it
• no involvement of the genital system for positioning

Disadvantages: 

• insertion procedure requires administration of local anesthesia
• possible persistent and irregular genital bleeding, probably limited in case of concomitant use of testosterone

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.

Advantages: 

• it does not contain oestrogen, commonly considered the female hormones that most counteract the masculinizing effect of testosterone
• once positioned inside the uterus it can remain in place for 3/5 or even up to 10 years, without needing to remember it anymore
• it is among the most effective methods of contraception for the prevention of pregnancy
• the intrauterine device containing progestin has an action mainly on the uterus, however a minimum amount of hormone can go into the circulation. This has an androgenic effect and can act in synergy with testosterone therapy or in any case does not counteract it

Disadvantages: 

• the placement of these devices requires a gynecological procedure
• possible bleeding and pain upon insertion and post-insertion
• the copper-containing intrauterine device can cause an increase in menstrual flow

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.

Advantages: 

• it does not contain oestrogen, commonly considered the female hormones that most counteract the masculinizing effect of testosterone
• taken orally
• minimal androgenic effect of desogestrel which can therefore act in synergy with testosterone therapy or in any case does not counteract it
• no gynecological procedure is required

Disadvantages: 

• needs daily intake
• the control of genital blood loss achieved with this method could be suboptimal, even if we have no information on concomitant intake with testosterone
• possible reduction of efficacy in case of gastrointestinal disorders (diarrhea) or concomitant intake of some drugs

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.

Advantages: 

• it is taken orally
• offers good control of genital bleeding, especially when taken without interruption
• no gynecological procedure is required

Disadvantages: 

• it contains oestrogen which can interfere with the masculinizing effect of testosterone
• needs daily intake
• albeit modest, it causes an increase in thromboembolic risk
• possible breast tenderness
• possible reduction of efficacy in case of gastrointestinal disorders (diarrhea) or concomitant intake of some drugs

Vaginal ring
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).

Advantages: 

• offers good control of genital bleeding
• remains in place for 3 weeks

Disadvantages: 

• it contains oestrogen which can interfere with the masculinizing effect of testosterone.
• insertion and removal from the vagina
• albeit modest, it causes an increase in thromboembolic risk
• possible breast tenderness
• possible reduction of efficacy in case of concomitant intake of some drugs.

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.

Blair KL, Hoskin RA. Transgender exclusion from the world of dating: Patterns of acceptance and rejection of hypothetical trans dating partners as a function of sexual and gender identity. Journal of Social and Personal Relationships. 2018; 1-22.
Bungener SL, Steensma TD, Cohen-Kettenis PT, et al. Sexual and Romantic Experiences of Transgender Youth Before Gender-Affirmative Treatment. Pediatrics. 2017; 139(3).
Cerwenka S, Nieder TO, Briken P, et al. Intimate Partnerships and Sexual Health in Gender-Dysphoric Individuals Before the Start of Medical Treatment. International Journal of Sexual Health. 2014; 26(1): 52-65.
Chianura L, De Santis K, Mirabelli A. "Profilo dell'utenza: analisi dei dati". In (a cura di) Chianura L, Ravenna AR, Ruggeri V. Esistenze possibili. Clinica, ricerca e percorsi di vita nei disturbi dell'identità di genere. Edizioni Universitarie Romane, Roma, 2007.

Coleman E, Radix AE, Bouman W,  et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022; Sep 6;23(Suppl 1):S1-S259.

Costantino A, Cerpolini S, Alvisi S, et al. A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. Journal of Sex & Marital Therapy. 2013; 39(4): 321-35.

Defreyne J, Elaut E, Kreukels B, et al. Sexual Desire Changes in Transgender Individuals Upon Initiation of Hormone Treatment: Results From the Longitudinal European Network for the Investigation of Gender Incongruence. Journal of Sex Medicine. 2020; 17(4): 812-25.

Fisher AD, Castellini G, Ristori J, et al. Cross-sex hormone treatment and psychobiological changes in transsexual persons: two-year follow-up data. Journal of Clinical Endocrinology & Metabolism. 2016; 101(11): 4260-69.

Galupo MP, Mitchell RC, Davis KS. Sexual minority self-identification: Multiple identities and complexity. Psychology of Sexual Orientation and Gender Diversity. 2015; 2(4): 355–64.

Galupo MP, Henise SB, Mercer NL. “The labels don’t work very well”: Transgender individuals’ conceptualizations of sexual orientation and sexual identity. International Journal of Transgenderism. 2016; 17: 93–104.

Guidelines for the primary and gender-affirming care of transgender and gender non binary people; 2nd ed. Deutsch MB. Center of Excellence for Transgender Health, Department of Family and Community Medicine, University of California San Francisco. 2016. Disponibile al link: https://transcare.ucsf.edu/sites/transcare.ucsf.edu/files/Transgender-PGACG-6-17-16.pdf.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017; 102(11):3869-903.

Krempasky C, Harris M, Abern L, Grimstad F. Contraception across the transmasculine spectrum. Am J Obstet Gynecol. 2020;222(2):134-143.

Lev AI, Sennott S. Understanding gender nonconformity and transgender identity: A sex-positive approach. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives. 2012; 321–36. Routledge/Taylor & Francis Group.

Light AD, Obedin-Maliver J, Sevelius JM, et al. Transgender men who experienced pregnancy after female-to-male gender transitioning. Obstet Gynecol. 2014;124(6):1120–7.

Mizock L, Mueser KT. Employment, mental health, internalized stigma, and coping with transphobia among transgender individuals. Psychology of Sexual Orientation and Gender Diversity. 2014; 1(2): 146–58.

Platt LF, Bolland KS. Trans* Partner Relationships: A Qualitative Exploration. Journal of GLBT Family Studies. 2017; 13(2): 163-85.

Pulice-Farrow L, Brown TD, Paz Galupo M. (2017). Transgender Microaggressions in the Context of Romantic Relationships. Psychology of Sexual Orientation and Gender Diversity. 2017; 4(3): 362-73.

Ravenna AR, Delle Grotti F, Lubrano Lavadera G. "Aspetti sociali e relazionali della realtà transessuale". In (a cura di) Ruggeri V, Ravenna AR. Transessualismo e identità di genere. Edizioni Universitarie Romane, Roma, 1999.

van de Grift TC, Cohen-Kettenis PT, Elaut E, et al. (2016). A network analysis of body satisfaction of people with gender dysphoria. Body Image. 2016; 17: 184-90.

van Dijk D, Dekker MJHJ, Conemans EB, et al. Explorative prospective evaluation of short-term subjective effects of hormonal treatment in trans people—results from the European Network for the Investigation of Gender Incongruence. Journal of Sex Medicine. 2019; 16(8): 1297-09.

van Trotsenburg MAA. (2009). Gynecological aspects of transgender healthcare. International Journal of Transgenderism. 2009; 11(4): 238-46.

Wierckx K, Elaut E, Van Hoorde B, et al. (2014). Sexual desire in trans persons: associations with sex reassignment treatment. Journal of Sex Medicine. 2014; 11(1): 107-18.