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Jamie L Finegan, Maja Marinkovic, Kyle Okamuro, Ron S Newfield, Jennifer T Anger, Experience with gender affirming hormones and puberty blockers (gonadotropin releasing hormone agonist): a qualitative analysis of sexual function, The Journal of Sexual Medicine, 2025;, qdaf061, https://doi.org/10.1093/jsxmed/qdaf061
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Abstract
Gender-affirming medical therapy (GAMT), including puberty blockers (PB) and gender-affirming hormone therapy (GAHT), is part of the transition for many transgender and nonbinary (TGNB) individuals; however, there have been few studies investigating sexual function and desire during GAMT, and no reports on individuals who received PB.
We aimed to qualitatively evaluate the sexual experience of TGNB individuals during GAMT and identify significant and consistent themes that arose from our analysis.
We performed an Institutional Review Board-approved two-institutional study. Our study group (n = 63) included individuals who had received or were receiving puberty blockers (GnRHa) and/or GAHT (estrogen or testosterone) at the time of enrollment.
The enrolled subjects were interviewed using an open-ended topic-based guide, and qualitative analysis was performed by hand coding the interview transcripts using Constructivist Grounded Theory qualitative methods until thematic saturation was reached.
A total of 63 TGNB subjects (33 transgender women, 20 transgender men, 10 non-binary, or another gender identity), aged 18-25 years, were interviewed about the effect of GAMT on their sexual function and desire. Our analysis uncovered several themes that were consistent among subjects from different subgroups. Half the participants reported feeling no regrets regarding GAMT therapy, and the other half reported that they wished they had started GAMT sooner. Two notable themes were identified: many subjects reported “less dysphoria” as a positive change in sexual desire, and others reported more enjoyable sexual experiences since being on GAMT. The subgroup of subjects with a history of GnRHa use did not differ in their experiences and responses from the subgroup on GAHT alone, which indicated no negative effect of GnRHa on sexual function.
Our results illuminate the need for providers to discuss the potential impacts of GAMT on sexual function and desire with transgender and nonbinary patients.
An important strength of this study is the open-ended interview design. This design allowed subjects to speak freely and openly about their experience. One limitation is a relatively small sample size, particularly of the puberty blocker (GnRHa) subgroup. A more robust sample is needed to further investigate the effect of GAMT on sexual function and desire in TGNB individuals, specifically those receiving GnRHa.
Themes were similar for all subjects; however, the most prominent theme among our subjects was that the positive changes in sexual function and desire outweighed any negative changes.
Introduction
As part of their medical transition, some transgender and nonbinary (TGNB) individuals receive puberty blockers like a gonadotropin-releasing hormone agonist (GnRHa) as the first step before they start gender-affirming hormone therapy (GAHT) in the form of testosterone or estrogen (via various preparations and routes of administration such as intramuscular or subcutaneous injections, oral/sublingual, and transdermal). The use of these gender-affirming medical therapies (GAMT) is outlined in several practice guidelines.1,2 In addition to estrogen, transfeminine individuals often take spironolactone (anti-androgen) to help lower testosterone effect and levels.
GAMT may impact sexual function and desire, however, there have been some studies investigating these outcomes with GAHT (estrogen, testosterone) and there are few if any studies of sexual functioning in young adults either during or after pubertal blockers. The European Society for Sexual Medicine released a position statement in 2020 about the clinical consensus on transgender healthcare regarding sexual function and satisfaction.3 While the position statement addresses that there is an influence of GAMT on sexual function and satisfaction, it does not address specifics of the effect on sexual function and highlights the lack of literature on sexual satisfaction during or following GAMT. Additionally, the World Professional Association for Transgender Health (WPATH) released an updated version of their Standards of Care for the Health of Transgender and Gender Diverse People in 2022, which highlighted the importance of sexual health on the well-being of TGNB individuals and advocated for sexual health care to be included in TGNB-related care.1
Despite the known importance of sexual function to overall health, medical professionals do not regularly discuss sexual health with patients due to patient or provider discomfort, lack of time, and non-inclusive questionnaires.4 To date, studies investigating sexual function and desire have focused on quantitative measures of sexual function and desire or surgical outcomes following gender-affirming surgeries, but other factors even without GAMT, such as body satisfaction, seem to be impactful. 5–7 It is known that hormones play a crucial role in sexual function and desire, thus learning about the impact of these gender-affirming hormone therapies on sexual function is of great importance. In studies conducted among cisgender women, hypogonadal cisgender men, and transgender men, exogenous testosterone has been shown to improve sexual desire, arousal, and sexual satisfaction.2,7,8 Similarly in studies conducted on transgender men (TGM), testosterone use was associated with an increased interest in sexual activity and a higher ability to orgasm.9 Alternatively, estrogen and antiandrogen therapy in transgender women may reduce sexual desire and cause fewer erections.10,11 Despite an increase in research on knowledge of short- and long-term effects of GAMT, there remains a need to better understand how GAMT affects sexual function and desire in TGNB individuals.
Materials and methods
Following Institutional Review Board (IRB) approval, eligible subjects were recruited in person or by telephone from two academic institutions, including a pediatric-based gender clinic and an academic medical center caring only for adult patients. Eligible subjects included young adults aged 18-25 with gender dysphoria who previously or currently are receiving GAMT (GnRHa and/or GAHT). All enrolled subjects spoke English. All participants provided verbal informed consent following a discussion of study goals, procedures, and risks and were given an opportunity to ask questions. Very few (7/100) approached patients declined to participate, but those who did had concerns about privacy and the protection of their information. Subjects participated in a phone call with the female study coordinator, which included a collection of demographics and a semi-structured interview. De-identified demographic data such as age, sex assigned at birth, gender identity, type of GAMT, date of puberty blockers and GAHT started, gender-affirming surgical history, and incidence of depression and anti-depressant use were collected in REDCap, an encrypted database. The study coordinator conducted phone interviews from her private office, securing full confidentiality. Subjects had no information about the study coordinator before the interview, except that she managed the project and had experience conducting research interviews. The interviewer and interviewees had no established association/relationship prior to the study’s commencement. There were no subsequent/repeat interviews carried out.
Sexual function and desire outcomes were assessed through a semi-structured interview using an open-ended topic-based guide (Appendix A), which included questions about the subject’s experience with gender-affirming medical therapy (both GnRHa and GAHT), if they experienced any changes in sexual function and desire since beginning GAMT, and how they perceived these changes (positive, negative, or neutral). Interviews were guided by questions from the interviewer but allowed subjects to speak freely and openly about their experience. The interviewer took notes during the phone call, and the interviews were audio recorded and transcribed verbatim by the study coordinator. Transcripts were hand-coded using Constructivist Grounded Theory qualitative methods, as described by Charmaz and were not returned to subjects for comment and/or correction.12 Two bachelor’s degree level researchers, one cisgender homosexual male and one cisgender heterosexual female, conducted coding procedures by reading through each deidentified transcript without preconceived thematic expectations, making note of the themes line-by-line, then identifying the repeating main ideas throughout each transcript. Once the main ideas throughout each interview had been compiled, common themes or categories were identified between them and incorporated into a table. Theme tables from each researcher were compared, and common themes were retained in a final thematic table. A third researcher (a cisgender heterosexual female medical doctor) performed a final review of each transcript and the compiled themes to assess for consistency and ensure any additional notable themes were not missed. Relevant and representative quotes that exemplified each theme were then incorporated into the final table.
To reduce bias and ensure the reliability of the data, more than one study personnel conducted the coding and theme identification was performed by following the Constructivist Grounded Theory qualitative method for coding the transcripts. Participants were recruited and enrolled until thematic saturation was achieved, indicating enough data had been collected to draw consistent conclusions. Thematic saturation was determined to have been reached when no new themes were arising throughout the coding process. Study subjects received a $20 gift card compensation for their time.
Positionality statement
The authors bring diverse perspectives shaped by their backgrounds in clinical medicine, research, and lived experiences. The team includes cisgender, straight, and gay individuals with academic training ranging from BA and BS to MD levels. While none identify as transgender, the authors acknowledge the potential for implicit biases and have approached this work with that in mind. They have prioritized the voices and experiences of transgender individuals throughout the research process to ensure a respectful and accurate representation of the community.
Results
A total of 63 young adults between the ages of 18 and 25 were enrolled and interviewed. Their mean age was 22 (+/-2.2) years, and 39 (62%) were assigned male at birth (AMAB) while 24 (38%) were assigned female at birth (AFAB). Of those subjects, 20 identified as transgender men (TGM), 33 as transgender women (TGW), and 10 as non-binary (NB) or another gender identity (agender, transmasculine nonbinary, or transfeminine nonbinary). Of the latter 10 subjects, six were AFAB, and four were AMAB. The average age at which subjects started any gender-affirming medical therapy was 17.7 years, ranging from 9 to 24 years. Thirteen subjects had a history of GnRHa use. The average starting age for GnRHa was 13 (range of 9-17), and the average starting age for GAHT was 19 (range of 15-24). Most of our subjects reported experiencing symptoms of depression (68%) at the time of the interview, with 37% receiving antidepressants (Table 1). This information was considered in our analysis of the effects of hormone therapy on sexual function and desire, and follow-up questions were asked to assess how subjects viewed their depressive symptoms as contributing to any possible sexual dysfunction.
| Mean (SD) or n (%) . | n = 63 . |
|---|---|
| Age (years), range | 22 (2.2), 18-25 |
| Sex assigned at birth | |
| Male | 39 (62%) |
| Female | 24 (38%) |
| Gender identity | |
| Transgender man | 20 (53%) |
| Transgender woman | 33 (52%) |
| Non-binary | 3 (5%) |
| Othera | 7 (11%) |
| Age of starting GAMT (GnRHa and or GAHT) | 17.7 (3) |
| Treatment | |
| Estrogen (tablets) | 40 (63%) |
| Testosterone (injection) | 24 (38%) |
| Spironolactone | 33 (52%) |
| GnRH agonist | 13 (21%) |
| Gender affirming surgery | |
| None | 33 (52%) |
| Male chest reconstruction | 19 (30%) |
| Breast augmentation | 2 (3%) |
| Hysterectomy | 1 (0.15%) |
| Oophorectomy | 0 |
| Vaginoplasty | 4 (6%) |
| Phalloplasty | 1 (0.15%) |
| Metoidioplasty | 1 (0.15%) |
| Scrotoplasty | 0 |
| Orchiectomy | 5 (8%) |
| Facial feminizing | 1 (0.15%) |
| Facial masculinizing | 1 (0.15%) |
| Depression-self reported (current) | |
| Yes | 43 (68%) |
| No | 20 (32%) |
| Antidepressants (current) | |
| Yes | 23 (37%) |
| No | 40 (63%) |
| Mean (SD) or n (%) . | n = 63 . |
|---|---|
| Age (years), range | 22 (2.2), 18-25 |
| Sex assigned at birth | |
| Male | 39 (62%) |
| Female | 24 (38%) |
| Gender identity | |
| Transgender man | 20 (53%) |
| Transgender woman | 33 (52%) |
| Non-binary | 3 (5%) |
| Othera | 7 (11%) |
| Age of starting GAMT (GnRHa and or GAHT) | 17.7 (3) |
| Treatment | |
| Estrogen (tablets) | 40 (63%) |
| Testosterone (injection) | 24 (38%) |
| Spironolactone | 33 (52%) |
| GnRH agonist | 13 (21%) |
| Gender affirming surgery | |
| None | 33 (52%) |
| Male chest reconstruction | 19 (30%) |
| Breast augmentation | 2 (3%) |
| Hysterectomy | 1 (0.15%) |
| Oophorectomy | 0 |
| Vaginoplasty | 4 (6%) |
| Phalloplasty | 1 (0.15%) |
| Metoidioplasty | 1 (0.15%) |
| Scrotoplasty | 0 |
| Orchiectomy | 5 (8%) |
| Facial feminizing | 1 (0.15%) |
| Facial masculinizing | 1 (0.15%) |
| Depression-self reported (current) | |
| Yes | 43 (68%) |
| No | 20 (32%) |
| Antidepressants (current) | |
| Yes | 23 (37%) |
| No | 40 (63%) |
Abbreviations: GAMT = gender-affirming medical therapy; GnRHa = gonadotropin-releasing hormone agonist; GAHT = gender affirming hormone therapy.
Other gender identities included agender, transmasculine nonbinary, or transfeminine nonbinary.
| Mean (SD) or n (%) . | n = 63 . |
|---|---|
| Age (years), range | 22 (2.2), 18-25 |
| Sex assigned at birth | |
| Male | 39 (62%) |
| Female | 24 (38%) |
| Gender identity | |
| Transgender man | 20 (53%) |
| Transgender woman | 33 (52%) |
| Non-binary | 3 (5%) |
| Othera | 7 (11%) |
| Age of starting GAMT (GnRHa and or GAHT) | 17.7 (3) |
| Treatment | |
| Estrogen (tablets) | 40 (63%) |
| Testosterone (injection) | 24 (38%) |
| Spironolactone | 33 (52%) |
| GnRH agonist | 13 (21%) |
| Gender affirming surgery | |
| None | 33 (52%) |
| Male chest reconstruction | 19 (30%) |
| Breast augmentation | 2 (3%) |
| Hysterectomy | 1 (0.15%) |
| Oophorectomy | 0 |
| Vaginoplasty | 4 (6%) |
| Phalloplasty | 1 (0.15%) |
| Metoidioplasty | 1 (0.15%) |
| Scrotoplasty | 0 |
| Orchiectomy | 5 (8%) |
| Facial feminizing | 1 (0.15%) |
| Facial masculinizing | 1 (0.15%) |
| Depression-self reported (current) | |
| Yes | 43 (68%) |
| No | 20 (32%) |
| Antidepressants (current) | |
| Yes | 23 (37%) |
| No | 40 (63%) |
| Mean (SD) or n (%) . | n = 63 . |
|---|---|
| Age (years), range | 22 (2.2), 18-25 |
| Sex assigned at birth | |
| Male | 39 (62%) |
| Female | 24 (38%) |
| Gender identity | |
| Transgender man | 20 (53%) |
| Transgender woman | 33 (52%) |
| Non-binary | 3 (5%) |
| Othera | 7 (11%) |
| Age of starting GAMT (GnRHa and or GAHT) | 17.7 (3) |
| Treatment | |
| Estrogen (tablets) | 40 (63%) |
| Testosterone (injection) | 24 (38%) |
| Spironolactone | 33 (52%) |
| GnRH agonist | 13 (21%) |
| Gender affirming surgery | |
| None | 33 (52%) |
| Male chest reconstruction | 19 (30%) |
| Breast augmentation | 2 (3%) |
| Hysterectomy | 1 (0.15%) |
| Oophorectomy | 0 |
| Vaginoplasty | 4 (6%) |
| Phalloplasty | 1 (0.15%) |
| Metoidioplasty | 1 (0.15%) |
| Scrotoplasty | 0 |
| Orchiectomy | 5 (8%) |
| Facial feminizing | 1 (0.15%) |
| Facial masculinizing | 1 (0.15%) |
| Depression-self reported (current) | |
| Yes | 43 (68%) |
| No | 20 (32%) |
| Antidepressants (current) | |
| Yes | 23 (37%) |
| No | 40 (63%) |
Abbreviations: GAMT = gender-affirming medical therapy; GnRHa = gonadotropin-releasing hormone agonist; GAHT = gender affirming hormone therapy.
Other gender identities included agender, transmasculine nonbinary, or transfeminine nonbinary.
From our analysis of the interviews, we identified several themes that were consistent among our study subjects (Table 2). These themes described various effects of gender-affirming medical therapy on sexual function and desire and revealed common perceptions of these effects by our subjects. Importantly, responses from the subgroup of young adults who received or were still receiving GnRHa were similar to those who have not received puberty blockers.
| Themes . | Representative Quote . |
|---|---|
| Transfeminine: Erectile dysfunction met with a neutral or positive attitude | “I have less erections in public which is a huge bonus” (TGW) “No more morning or spontaneous erections which has been positive” (TGW) |
| Transfeminine: Reduced sexual desire was not a negative change | “Overall, my sex drive has been on a decreasing trajectory, but I feel a more emotional connection during sex now whereas before it was only physical attraction” (TGW) “My sex drive plummeted after starting hormones. Now I am less often aroused randomly, and more when I want to be” (TGW) “My sex drive has decreased, but now it is less of a compelling force and more like a want” (NB TF) |
| Transfeminine: Increased difficulty with reaching orgasm was a minor inconvenience amidst overpowering benefits | “It takes longer for me to orgasm and when I do the orgasms are shorter” (TGW) “Sometimes it is almost impossible to reach orgasm, but I don’t really mind” (TGW) |
| Transmasculine: Bottom growth reduces gender dysphoria and increases sexual pleasure | “My bottom growth functions as a small penis and I am able to penetrate in some positions” (TGM) “I have gained 3 cm in bottom growth and my orgasms feel much fuller and better now” (TGM) “I have more bottom growth which has reduced my dysphoria when masturbating” (NB TM) |
| Transfeminine, Transmasculine: Having less gender dysphoria increased sexual enjoyment | “My sexual desire has kind of always been the same, but I feel more like myself now” (TGM) “I am more open with my body now, so I have been experimenting [with sexual experiences]” (TGW) “I was deeply disgusted by sex prior to hormones, but now I am more sexually confident” (NB TF) |
| Transfeminine, Transmasculine: Increased libido makes engaging in sexual activity more fun and exciting | “Sex is on my mind all the time and I am now thrilled and enamored by sexual experiences” (TGW) “Hormones have had a big impact on my sex drive. I used to view sex as a bad thing but now I see it as a good thing” (TGM) |
| Themes . | Representative Quote . |
|---|---|
| Transfeminine: Erectile dysfunction met with a neutral or positive attitude | “I have less erections in public which is a huge bonus” (TGW) “No more morning or spontaneous erections which has been positive” (TGW) |
| Transfeminine: Reduced sexual desire was not a negative change | “Overall, my sex drive has been on a decreasing trajectory, but I feel a more emotional connection during sex now whereas before it was only physical attraction” (TGW) “My sex drive plummeted after starting hormones. Now I am less often aroused randomly, and more when I want to be” (TGW) “My sex drive has decreased, but now it is less of a compelling force and more like a want” (NB TF) |
| Transfeminine: Increased difficulty with reaching orgasm was a minor inconvenience amidst overpowering benefits | “It takes longer for me to orgasm and when I do the orgasms are shorter” (TGW) “Sometimes it is almost impossible to reach orgasm, but I don’t really mind” (TGW) |
| Transmasculine: Bottom growth reduces gender dysphoria and increases sexual pleasure | “My bottom growth functions as a small penis and I am able to penetrate in some positions” (TGM) “I have gained 3 cm in bottom growth and my orgasms feel much fuller and better now” (TGM) “I have more bottom growth which has reduced my dysphoria when masturbating” (NB TM) |
| Transfeminine, Transmasculine: Having less gender dysphoria increased sexual enjoyment | “My sexual desire has kind of always been the same, but I feel more like myself now” (TGM) “I am more open with my body now, so I have been experimenting [with sexual experiences]” (TGW) “I was deeply disgusted by sex prior to hormones, but now I am more sexually confident” (NB TF) |
| Transfeminine, Transmasculine: Increased libido makes engaging in sexual activity more fun and exciting | “Sex is on my mind all the time and I am now thrilled and enamored by sexual experiences” (TGW) “Hormones have had a big impact on my sex drive. I used to view sex as a bad thing but now I see it as a good thing” (TGM) |
Abbreviations: TGW = Transgender woman; TGM = Transgender man; NB=Non-binary, TF = Transfeminine; TM = Transmasculine.
| Themes . | Representative Quote . |
|---|---|
| Transfeminine: Erectile dysfunction met with a neutral or positive attitude | “I have less erections in public which is a huge bonus” (TGW) “No more morning or spontaneous erections which has been positive” (TGW) |
| Transfeminine: Reduced sexual desire was not a negative change | “Overall, my sex drive has been on a decreasing trajectory, but I feel a more emotional connection during sex now whereas before it was only physical attraction” (TGW) “My sex drive plummeted after starting hormones. Now I am less often aroused randomly, and more when I want to be” (TGW) “My sex drive has decreased, but now it is less of a compelling force and more like a want” (NB TF) |
| Transfeminine: Increased difficulty with reaching orgasm was a minor inconvenience amidst overpowering benefits | “It takes longer for me to orgasm and when I do the orgasms are shorter” (TGW) “Sometimes it is almost impossible to reach orgasm, but I don’t really mind” (TGW) |
| Transmasculine: Bottom growth reduces gender dysphoria and increases sexual pleasure | “My bottom growth functions as a small penis and I am able to penetrate in some positions” (TGM) “I have gained 3 cm in bottom growth and my orgasms feel much fuller and better now” (TGM) “I have more bottom growth which has reduced my dysphoria when masturbating” (NB TM) |
| Transfeminine, Transmasculine: Having less gender dysphoria increased sexual enjoyment | “My sexual desire has kind of always been the same, but I feel more like myself now” (TGM) “I am more open with my body now, so I have been experimenting [with sexual experiences]” (TGW) “I was deeply disgusted by sex prior to hormones, but now I am more sexually confident” (NB TF) |
| Transfeminine, Transmasculine: Increased libido makes engaging in sexual activity more fun and exciting | “Sex is on my mind all the time and I am now thrilled and enamored by sexual experiences” (TGW) “Hormones have had a big impact on my sex drive. I used to view sex as a bad thing but now I see it as a good thing” (TGM) |
| Themes . | Representative Quote . |
|---|---|
| Transfeminine: Erectile dysfunction met with a neutral or positive attitude | “I have less erections in public which is a huge bonus” (TGW) “No more morning or spontaneous erections which has been positive” (TGW) |
| Transfeminine: Reduced sexual desire was not a negative change | “Overall, my sex drive has been on a decreasing trajectory, but I feel a more emotional connection during sex now whereas before it was only physical attraction” (TGW) “My sex drive plummeted after starting hormones. Now I am less often aroused randomly, and more when I want to be” (TGW) “My sex drive has decreased, but now it is less of a compelling force and more like a want” (NB TF) |
| Transfeminine: Increased difficulty with reaching orgasm was a minor inconvenience amidst overpowering benefits | “It takes longer for me to orgasm and when I do the orgasms are shorter” (TGW) “Sometimes it is almost impossible to reach orgasm, but I don’t really mind” (TGW) |
| Transmasculine: Bottom growth reduces gender dysphoria and increases sexual pleasure | “My bottom growth functions as a small penis and I am able to penetrate in some positions” (TGM) “I have gained 3 cm in bottom growth and my orgasms feel much fuller and better now” (TGM) “I have more bottom growth which has reduced my dysphoria when masturbating” (NB TM) |
| Transfeminine, Transmasculine: Having less gender dysphoria increased sexual enjoyment | “My sexual desire has kind of always been the same, but I feel more like myself now” (TGM) “I am more open with my body now, so I have been experimenting [with sexual experiences]” (TGW) “I was deeply disgusted by sex prior to hormones, but now I am more sexually confident” (NB TF) |
| Transfeminine, Transmasculine: Increased libido makes engaging in sexual activity more fun and exciting | “Sex is on my mind all the time and I am now thrilled and enamored by sexual experiences” (TGW) “Hormones have had a big impact on my sex drive. I used to view sex as a bad thing but now I see it as a good thing” (TGM) |
Abbreviations: TGW = Transgender woman; TGM = Transgender man; NB=Non-binary, TF = Transfeminine; TM = Transmasculine.
Decrease in erections
The first theme described how erectile dysfunction, or a reduction in erections, was a welcomed effect of GAHT among transgender women and transfeminine individuals that decreased their gender dysphoria and improved their emotional well-being. One study participant shared, “I’ve only had positive changes, like I still get aroused, but it doesn’t get very erect and honestly that’s been such a good thing for me.” (TGW) This experience was reported by a majority (78%) of the participants who were assigned male at birth. Another participant explained, “I can’t really use it, I mean like the blood flows there and stuff, but it feels a lot different and if I wanted to use it I probably couldn’t use it for penetration. But I don’t like the idea of doing that anyway.” (TGW) Very few (2) of our TGW subjects were interested in using their penis for penetration during sex, so this experience with less erections was a notable positive change.
Decrease in sexual desire (libido)
Another theme we uncovered was that the majority of subjects who experienced a reduction in sexual desire since starting gender-affirming medical therapy identified this as a positive or neutral change. Reduction in sexual desire was noted in 43% of our subjects, 3/20 TGM (15%), 20/33 TGW (61%), and 4/10 NB/Other (40%). During an interview a subject explained, “My libido is definitely a lot lower. It’s not like gone but it is less than it was before, and I would consider that a neutral change... well maybe more positive than neutral” (TGW). Comparing the reduced desire between TGM and TGF, it is statistically significant (Chi-Square P < 0.005, alpha = 0.05). Around 58% of participants AMAB experienced decreased libido, compared to 16% participants AFAB. For some (31%) participants, this reduction was a relief, and for other participants (38%), it was seen as neither positive nor negative.
While some subjects did experience a lower libido and less desire to engage in sexual activities, they explained that the sexual experiences they began engaging in were more meaningful and fulfilling to them. One participant shared, “I feel like I can almost control my desire. Like before, my physical desire took over from what I actually wanted, but now anytime I have sexual desire it’s because that’s what I want” (NB). Other subjects shared a similar experience – sexual desire was overpowering before starting GAHT, but since their transition they feel more in control of when they become aroused. This was reported as a relief for many.
Increase in sexual enjoyment
An additional theme that arose was that the improvement in gender dysphoria from GAMT resulted in an increase in sexual enjoyment and willingness to explore sexual experiences. Most of our TGM participants (18/20) experienced an overall increase in sexual desire and bottom growth. A participant shared, “Hormones made me more open and receptive to sexual acts. I was a lot more reserved and not as enthusiastic about sexual intimacy before. I wasn’t asexual or anything it was just a lot less pronounced than it is now” (NB). Since starting GAMT, non-binary individuals in this study found more confidence to engage in masturbation and sex with others. Additionally, per our TGW subjects, the sexual experiences they engaged in prior to starting GAMT were more about meeting a physical need rather than forming emotional connections or exploring the changes in their body. Another subject shared, “sex is just like a more joyful experience in a lot of ways, and I like having partners a lot more now, and it just feels so much more like the way that it should be, and it’s helping me to get closer to the person that I want to be” (TGW). Since starting GAHT, many study subjects reported forming more emotional connections through sexual experiences, which has improved not only their sexual life, but their emotional well-being as well.
Regrets
When asked about regrets related to gender-affirming medical care, no study subjects reported any regret. Additionally, half of the subjects in our population voluntarily expressed that they wished they had started GAMT sooner. One participant emphasized, “I wish I had started sooner, but I’m still young so I’m glad it’s all happening now rather than later” (TGM). Reasons for not starting GAMT sooner included lack of knowledge about gender-affirming medical care options, fear about coming out to family members or friends, worry about the side effects and risks of hormone therapy, and not feeling ready to take that step forward in their transition.
Discussion
Overall, we found themes to be similar among study subjects with no significant differences regarding sex assigned and birth (though more subjects AMAB reported decrease in libido, compared to AFAB), GnRHa use, and surgical history. In our study population, the effects of GAMT on sexual function and desire were perceived as positive or neutral rather than negative.
There is a concern that puberty blockers may affect sexual functioning in TGNB individuals. A novel finding from our study is that there was no difference in themes regarding sexual function and desire among subjects who received puberty blockers (GnRHa) compared to those who did not. To our knowledge, this has not been previously addressed or reported in the literature.
Another novel finding from our study was regarding sexual experiences of NB individuals. Previous research highlighted the lack of assessment tools for sexual function in non-binary individuals, and the factors that contribute to their satisfying sexual experience, however, there is limited research on the specific effects of GAMT on their sexual functioning and desire. We found no difference in themes from non-binary individuals compared to TGW or TGM regarding sexual functioning or sexual desire after starting GAMT.13,14 The differences are instead between the type of GAMT received (estrogen or vs. testosterone) and assigned sex at birth. Our study contributes to the growing body of knowledge on the effects of GAMT on the sexual experiences of non-binary individuals.
TGW who experienced erectile dysfunction related to gender-affirming medical therapy viewed this outcome as a positive effect and expressed that it decreased their gender dysphoria, including “bottom” dysphoria, and did not negatively impact their sexual experiences. This is likely because those experiencing dysphoria were typically not engaging in penetrative sexual activities, and thus were not affected by erectile dysfunction. Many of our TGW subjects emphasized that a reduction of morning erections improved their emotional well-being by eliminating an immediate reminder of their gender dysphoria upon waking. Additionally, some TGW emphasized the improvement that a reduction of “random erections” had on their well-being. This is consistent with previous research from Santos et al., who found that a decrease in spontaneous erections was rated one of the most satisfactory changes experienced by TGW since starting feminizing therapy.15
Our TGM participants experienced an overall increase in sexual desire and bottom growth that made engaging in sexual activities more pleasurable due to reduced “bottom” dysphoria and enhanced sensitivity. Additionally, while a few of our non-binary subjects experienced a reduction in sexual desire since starting GAMT, they did not view this as a negative effect, and they found more confidence to engage sexual activity.
For many subjects, starting gender-affirming medical therapy quickly contributed to a reduction in gender dysphoria, which resulted in an increased feeling of comfort in their body. This increased comfort translated to an interest in expanding their sexual experiences. Many subjects expressed feeling more open with their sexual partners and are willing to explore more and discover their preferences. These findings are in line with previous studies; Nikkelen et al., showed that enjoyment of sex is positively correlated to body satisfaction in TGNB individuals and Mattawanon et al., showed that GAHT and GAS may help to improve the sexual satisfaction of these individuals.16,17 Study subjects reported increased sexual satisfaction, which translated to subjective improvements to emotional and mental health, and a positive effect on self-image.
The subjects who experienced a reduction in sexual desire were primarily TGW receiving estrogen, which may be due to the decrease in their testosterone levels. A study by Kerckhof et al. showed that 69% of the TGW reported at least one sexual dysfunction, such as difficulty reaching orgasm.18 This finding relates to the first theme noted in our study—reduced erections, and comparatively, this reduction in sexual desire became a positive and welcomed change in our subjects. Without the regular need to relieve sexual arousal, TGW subjects experienced a sense of relief.
An important strength of this study is the open-ended interview design. This design allowed subjects to speak freely and openly about their experience. This was invaluable to capture the authentic experience they have had with GAMT and its effect on their sexual function and desire. There are some limitations to our study. Subjects were recruited from two institutions within the same city. This may have led to a less diverse patient population, making results less generalizable to a wider TGNB population. Another limitation is a relatively small sample size, particularly of the puberty blocker (GnRHa) subgroup. A more robust sample is needed to further investigate the effect of GAMT on sexual function and desire in TGNB individuals, specifically those receiving GnRHa. With this topic becoming increasingly debated in the United States and globally, more research is needed to assess the potential effects of GAHT on sexual function and desire. Additionally, there may be bias of the researchers due to varying perspectives, experiences, and positionality that may shape the interpretation of findings, despite efforts to maintain objectivity and center the voices of transgender individuals.
Although further studies with more subjects and a wider age range are needed, in our study population of young TGNB adults, most participants reported experiencing positive changes related to use of GAMT (both pubertal blockers and GAHT), and were open to sharing their experience with the researchers. We recommend that clinicians, when reviewing GAMT effects, should discuss possible changes in sexual health and incorporate more sexual counseling to help TGNB people improve their sexual experiences.
Acknowledgments
We would like to express our sincere gratitude to the patients who participated in this study, without whom this research would not have been possible.
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Author contributions
J.L.F.: Conceptualization-lead, Data curation-lead, Formal analysis-lead, Investigation-lead, Methodology-lead, Project administration-lead, Writing – original draft-lead. M.M.: Conceptualization-supporting, Data curation-supporting, Writing – review & editing-equal. K.O.: Conceptualization-supporting, Methodology-equal, Writing – review & editing-equal. R.S.N.: Conceptualization-supporting, Methodology-supporting, Writing – review & editing-equal. J.T.A.: Conceptualization-equal, Methodology-equal, Supervision-lead, Writing – review & editing-equal.
Funding
None declared.
Conflicts of interest
None declared.
Appendix A: topic-based guide
Puberty Blockers
How old were you when you started Puberty Blockers?
Have you stopped Puberty Blockers?
Can you describe the process of your experience with Puberty Blockers? (starting, taking, stopping)
What were your sexual preferences at the time that you started Puberty Blockers?
Did you have any sexual experiences prior to starting Puberty Blockers?
What are your sexual preferences now?
Did you experience any positive changes in the following while being on Puberty Blockers:
Sexual function (orgasm, ejaculation, vaginal lubrication, erection)?
Sexual desire (thoughts, emotions, frequency of engagement with yourself or others)?
Did you experience any negative changes in the following while being on Puberty Blockers:
Sexual function (orgasm, ejaculation, vaginal lubrication, erection)
Sexual desire (thoughts, emotions, frequency of engagement with yourself or others)?
What do you wish you would have known about Puberty Blockers before starting them? (specifically about sexual function and desire)
Are you satisfied with your experience on Puberty Blockers?
Do you have any regrets related to Puberty Blockers?
Gender Affirming Hormone Therapy
How old were you when you started GAHT?
Have you stopped GAHT?
Can you describe the process of your experience with GAHT? (starting, taking, stopping)
What were your sexual preferences at the time that you started GAHT?
Did you have any sexual experiences prior to starting GAHT?
What are your sexual preferences now?
Did you experience any positive changes in the following while being on GAHT:
Sexual function (orgasm, ejaculation, vaginal lubrication, erection)
Sexual desire (thoughts, emotions, frequency of engagement with yourself or others)?
Did you experience any negative changes in the following while being on GAHT:
Sexual function (orgasm, ejaculation, vaginal lubrication, erection)
Sexual desire (thoughts, emotions, frequency of engagement with yourself or others)?
What do you wish you would have known about GAHT before starting them? (specifically about sexual function and desire)
Are you satisfied with your experience on GAHT?
Do you have any regrets related to GAHT?
