Transgender Men's Sexual Wellness: Exploring Sexuality, Surgeries, and Related Issues
In the realm of sexual health, transgender men who undergo long-term testosterone therapy experience a variety of effects, some of which are reversible, while others are permanent.
Sexual Characteristics
An increased libido is a common side effect of testosterone therapy. Physically, transgender men may experience deepening of the voice, increased facial and body hair, and clitoral enlargement, all of which are generally irreversible. Acne and changes in sweat/body odor are typical, especially in the first years of therapy.
Reproductive System
Testosterone therapy suppresses the ovarian cycle and menstruation by inhibiting ovulation and the uterine cycle, leading to amenorrhea. This suppression also causes atrophy of the vagina and uterus. Ovaries may develop polycystic ovary syndrome (PCOS)-like morphology, including increased ovarian cysts, follicular atresia, stromal overgrowth, and partial replacement of ovarian tissue with collagen. The uterine (fallopian) tubes may become closed or partially closed, potentially impacting egg movement. However, the number of available egg cells might not significantly decline.
Despite these effects on fertility, testosterone is not a reliable contraceptive, and pregnancy can still occur even if menstruation has stopped. Unintended pregnancies have been reported in trans men on testosterone. Because of potential fertility impacts, fertility preservation discussion is recommended prior to initiating hormone therapy.
Breast tissue undergoes atrophy but some capacity for lactation may remain if chestfeeding, although elevated testosterone suppresses lactation and is generally not recommended during breastfeeding.
Other Long-term Systemic Effects
Testosterone may affect cardiovascular parameters such as QT interval shortening. It modulates immune cell populations, with observed changes in B and T cell subsets, reflecting immune impacts that require further study for long-term health.
Protecting Against Sexually Transmitted Infections (STIs)
Sexual activity carries the risk of transmitting and contracting STIs. Using oil-based lubricant with latex condoms can weaken them. The recommended approach is to use barrier methods such as condoms and dams, used with water-based lubricant, to protect against STIs.
Cervical Screening
Those with a cervix should get regular cervical screening in line with current guidelines. Clinics may offer an option for people to self-collect swabs for testing.
HIV and PrEP
Getting HIV testing at least once a year is crucial for knowing one's HIV status and allowing for prompt treatment if positive. Pre-exposure prophylaxis (PrEP) is a medication people take before exposure to HIV to prevent contracting HIV. It is safe for transgender men to take PrEP and use gender-affirming hormones alongside daily PrEP, use contraception, including hormonal birth control, become pregnant, and chestfeed.
Fertility and Contraception
Testosterone decreases fertility but is not effective as a contraceptive. Contraceptives such as coils, implants, injections, or the pill are effective and safe methods to use alongside testosterone. Internal condoms made from nitrile are suitable to use with an oil-based lubricant.
Other Considerations
Long-term use of testosterone can affect healthy bacteria inside the front hole/vagina, which may cause unusual discharge and make penetrative sex feel painful. There is a risk of cervical cancer for any person with a cervix. For those still able to become pregnant but who do not wish to do so, it is important to use contraception, such as condoms.
For those who have had bottom surgery, unhealed skin could increase the risk of STIs entering the body. Those who have undergone top surgery may require additional support, such as an at-chest supplementer, if they wish to chestfeed a baby. Getting an ultrasound of the abdomen every two years can check for any abnormalities in the uterus for those who have not had a hysterectomy.
In summary, the long-term use of testosterone in transgender men leads to reversible and irreversible changes in sexual characteristics, suppresses ovarian and uterine function, potentially compromises fertility though does not guarantee infertility, and alters reproductive anatomy and function without requiring surgery. Fertility preservation and contraceptive counseling are important parts of care before starting therapy.
- Transgender men undergoing long-term testosterone therapy may encounter mental health challenges due to the alteration in their sexual characteristics. (mental-health)
- The increased libido resulting from testosterone therapy can lead to personal growth and self-discovery in the realm of sexual health and education. (personal-growth, sexual-health, education-and-self-development)
- Science continues to explore the long-term health effects of testosterone therapy on the immune system, particularly changes in B and T cell subsets. (science, health)
- Men with a cervix require regular health-and-wellness checks, including cervical screenings and HIV testing, and may benefit from learning about PrEP for HIV prevention. (health-and-wellness, HIV, PrEP)
- Those undergoing bottom surgery should be mindful of potential risks, such as unhealed skin increasing the chance of STIs entering the body. (surgery, STIs)
- Among other considerations, transgender men should discuss fertility preservation options with healthcare providers before initiating hormone therapy, as testosterone decreases fertility but is not an effective contraceptive, and internal condoms can be used with oil-based lubricant. (fertility, hormone-therapy, contraception, lubricant)
