Sexual health for transgender women: A guide

Maintaining good sexual health and using protection can help people stay healthy and enjoy their sex lives while protecting themselves and others from risks.
Sexual health and using protection during sexual activity apply to people of all gender identities and can help protect against infections and unplanned pregnancies.
This article looks at sexual health for transgender women, transfeminine people, or non-binary people assigned male at birth (AMAB).
Transfeminine is a term that refers to those who were AMAB but identify with femininity or feminine identity.
Protection during sexual activity
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Sexually transmitted infections (STIs) can pass between any person of any gender identity and through any type of sex.
It is important that people test at least once a year for STIs to get any necessary treatment and prevent passing an STI on to a sexual partner.
at least once a year
Using barrier methods, such as condoms and dams, each time people have sex is the best way to protect against STIs. This is regardless of whether people have had bottom surgery or not. “Bottom” surgery refers to alterations to the genital region, also known as gender-affirming surgery.
Examples of barrier methods include:
External condoms: These go over a penis or sex toy. If people are having sex for more than half an hour, it is best to use a new condom. People will also need to use a new condom if they are alternating between anal and vaginal sex.
half an hour
Internal condoms: Internal condoms go inside the vagina or the anus. Some transgender women who have had bottom surgery may not be able to use an internal condom, as it depends on the depth of the vagina.
Dental dams: A dental dam is a layer of latex that people can use in oral-vaginal sex and rimming. The dam acts as a barrier to protect against STIs.
Those who have undergone bottom surgery may find it beneficial to use a lubricant. This is because the vagina might not lubricate naturally, according to the Gender Identity Research and Education Society.
Gender Identity Research and Education Society
People can use a water-based or silicone-based lubricant when using a condom. People should avoid using oil-based lubricants, as they can weaken latex condoms.
weaken
It is also best to avoid silicone-based lubricants with silicone dildos and sex toys, as the lube may damage the surface.
damage
Surgery and sex
The Terrence Higgins Trust notes that having bottom surgery can affect the chance of contracting an STI. If people have any unhealed skin due to bottom surgery, it may increase the chance of infections passing into their bodies.
Terrence Higgins Trust
Before undergoing bottom surgery, it is important for people to tell a healthcare professional if any warts are on their penis. The warts will require treatment before the surgery, otherwise they can continue to grow inside the vagina.
If people have had a colovaginoplasty — where surgeons use part of the colon to form the vagina — it may increase the likelihood of some STIs passing through the vaginal lining.
If penile and scrotal skin forms the vagina, there is less chance of STIs entering the skin, although any cuts or tears could allow infections to enter the body.
People may need to allow time for the genital area to recover after surgery. People can discuss any precautions they may need to take with their surgeon and when it is safe to resume sexual activities.
People can try the following tips after undergoing bottom surgery:
Using a lubricant: People can use plenty of water-based lube to help prevent any tears from forming and make sex feel more comfortable.
Using a dilator: Using a dilator may help stretch vaginal skin after surgery, but this may also cause bleeding and increase the chances of an STI passing into the body.
Using a condom: If people do not know if they or their partner has an STI, using a condom each time during sex can help protect them from STIs.
Contraception
If people have not had an orchidectomy or vasectomy, they will still need to use contraception to avoid any risk of pregnancy during vaginal sex with any partner who is not using contraception and has a risk of pregnancy.
orchidectomy
vasectomy
contraception
If people are taking hormones, they will not provide sufficient contraceptive protection.
This includes:
includes
estradiol
gonadotrophin-releasing hormone (GnRH)
analogues
finasteride
cyproterone acetate (not available in the US)
HIV in the transfeminine communities
According to research from the Centers for Disease Control and Prevention (CDC), transgender women are at high risk of HIV. In a survey of seven major cities in the United States, 4 in 10 transgender women have HIV.
Centers for Disease Control and Prevention (CDC)
The survey also found ethnic and racial disparities, with HIV affecting 62% of Black transgender women and 35% of Hispanic and Latina transgender women, compared with 17% of white transgender women.
The reason for these high HIV rates may include:
racism and discrimination affecting transgender women, which impacts access to healthcare, employment, and housing
transphobia as a barrier to HIV treatment and care
lack of knowledge from healthcare providers of transgender issues
HIV stigma
an unmet need for medical gender affirmation
HIV testing is important so that people know their HIV status. Sexually active transgender women may want to test for HIV at least once a year or more frequently if they change sexual partners or have an STI.
once a year
People can access HIV testing at a sexual health clinic or order an HIV self-test online. People can search for HIV test services through the CDC search tool.
CDC search tool
Learn more about HIV among transgender women here.
Learn more about HIV among transgender women here.
If people test positive for HIV, they can take medication called antiretroviral therapy, which is highly effective at controlling HIV. It is important for individuals to begin HIV treatment as soon as possible and take medication daily as a healthcare professional prescribes.
HIV-positive people taking HIV medication can live long, healthy lives. HIV medication lowers the viral load of HIV, meaning it can reach an undetectable load. When taken correctly, this means people cannot pass the virus onto others.
cannot
Most HIV treatment is safe for people to take alongside hormone therapy.
safe
Some antiretroviral medicines may interact with gender-affirming hormones. A healthcare professional can monitor hormone levels to ensure both drugs are working effectively and safely.
may interact
Using PrEP
Pre-exposure prophylaxis (PrEP) is a medication HIV-negative that people can take before sex to prevent them from contracting HIV. The Food and Drug Administration (FDA) has approved two anti-HIV drugs for PrEP: Truvada and Descovy.
Truvada
Descovy
PrEP is safe for people of all gender identities.
safe
Transgender women may choose to take PrEP if they:
feel at risk of HIV exposure
do not use condoms with a partner of unknown HIV status
either they or a sexual partner has recently had gonorrhea or syphilis
gonorrhea
syphilis
want to have sex without condoms with an HIV-positive partner
are a sex worker
inject drugs and share needles or any drug equipment with others
According to PleasePrEPMe, it is safe to take hormones alongside PrEP. Truvada does not reduce hormone levels. Although healthcare professionals do not think that Descovy reduces hormone levels, more research is necessary.
PleasePrEPMe
PrEP will also not cause fat redistribution in the face or body.
not
People can take PrEP daily, or on-demand dosing, which individuals take before and after having sex.
People will need to take daily dosing 7 days before having sex for it to be effective against HIV.
7 days
Daily dosing is best for people who are taking gender-affirming hormones and those engaging in vaginal sex.
People will need to take on-demand dosing before and after sex:
1 tablet 2–24 hours before sex
1 tablet 24 hours after sex
1 further tablet 48 hours after sex
On-demand dosing may be suitable for people who are not taking gender-affirming hormones and are only having anal sex.
People can stop taking daily PrEP 7 days after the last time they had sex. People can stop taking on-demand PrEP two days after the last time they had sex without a condom.
7 days
If people have hepatitis B and want to stop taking PrEP, they will first need to talk to their healthcare provider.
hepatitis B
People can talk with their healthcare provider about getting PrEP or at a sexual health clinic. People can also search for a local PrEP provider here.
here
A person can also find out more about financial help for getting PrEP here.
here
Using PEP
Post-exposure prophylaxis (PEP) is medication people can take if they think they have had exposure to HIV. PEP works to prevent an HIV infection after the virus enters the body.
People will need to take PEP within 72 hours of exposure, although it is best to take it within 24 hours. People can go to a sexual health clinic or the emergency department to access PEP and inform a healthcare provider of any hormones or medications they are taking.
72 hours
Transgender friendly services
A person can search for transgender-friendly healthcare providers and clinics in their state or city through the CDC resource page.
CDC resource page
Summary
Transgender women, transfeminine people, or non-binary people assigned male at birth (AMAB) can use barrier methods to help prevent unplanned pregnancies and prevent the transmission of STIs. Barrier methods include condoms and dental dams.
Using barrier methods every time people have sex and regularly testing for STIs and HIV can help to maintain good sexual health for people of all gender identities.
People can access care and treatment from sexual health clinics or online resources. Highly effective treatments are available to protect people and control STIs and HIV.