Summary

Testosterone thins vaginal tissue, which can make sex painful. This study used the US PRIDE online study to compare sex lives in 602 people born female who were currently on testosterone and 516 who had never taken it. Pain during sex was strikingly common in both groups: 65% of sexually active people had genital pain or discomfort in the past month, 67% of testosterone users and 63% of non-users. Testosterone users reported more interest in sex and easier orgasm, and slightly more vaginal pain, but no greater satisfaction with their sex lives. The group also reported very high rates of past sexual abuse (78%), depression (81%) and PTSD (40%). Because it is a one-time survey of volunteers, it shows links only, not causes. But it records a large and little-noticed problem of painful sex.

Key findings

• El estudio examinó a 1.219 hombres trans y personas no binarias nacidas mujer del PRIDE Study: 602 que tomaban testosterona en ese momento, 516 que nunca la habían tomado y 76 que la habían dejado.
• De 1.091 personas sexualmente activas, el 65 % tuvo dolor o molestia genital durante el sexo en el último mes, con más frecuencia en la vagina (52 %), luego alrededor del clítoris (29 %) y los labios (25 %).
• El dolor genital durante el sexo era común con o sin testosterona: alrededor del 67 % de los usuarios actuales y el 63 % de quienes nunca la usaron.
• El uso actual de testosterona se asoció con claramente más interés por el sexo, un orgasmo algo más fácil y algo más de dolor vaginal durante el sexo.
• El uso de testosterona no se asoció con mayor satisfacción con la vida sexual, lubricación, dolor alrededor de los labios ni placer del orgasmo.
• Las personas informaron de tasas muy altas a lo largo de la vida de abuso sexual (78 %), agresión sexual (50 %), diagnóstico de depresión (81 %) y diagnóstico de TEPT (40 %).
• Los autores piden un mejor acceso a tratamientos como el estrógeno vaginal, que menos del 5 % de los hombres trans refiere haber usado alguna vez.

Abstract

BACKGROUND: Testosterone use among transgender people likely impacts their experience of sexual function and vulvovaginal pain via several complex pathways. Testosterone use is associated with decreased estrogen in the vagina and atrophic vaginal tissue, which may be associated with decreased vaginal lubrication and/or discomfort during sexual activity. At the same time, increased gender affirmation through testosterone use may be associated with improved sexual function. However, data on pelvic and vulvovaginal pain among transgender men and nonbinary people assigned female at birth are scarce.

OBJECTIVE: This study aimed to assess the association between testosterone and sexual function with a focus on symptoms that are commonly associated with vaginal atrophy.

STUDY DESIGN: We conducted a cross-sectional analysis of 1219 participants aged 18 to 72 years using data collected from 2019 to 2021 from an online, prospective, longitudinal cohort study of sexual and/or gender minority people in the United States (The Population Research in Identity and Disparities for Equality Study). Our analysis included adult transgender men and gender diverse participants assigned female at birth who were categorized as never, current, and former testosterone users. Sexual function was measured across 8 Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction domains.

RESULTS: Overall, 516 (42.3%) participants had never used testosterone, and 602 (49.4%) currently used testosterone. The median duration of use was 37.7 months (range, 7 days to >27 years). Most participants (64.6%) reported genital pain or discomfort during sexual activity in the past 30 days, most commonly in the vagina or frontal genital opening (52.2%), followed by around the clitoris (29.1%) and labia (24.5%). Current testosterone use was associated with a greater interest in sexual activity (β=6.32; 95% confidence interval, 4.91-7.74), higher ability to orgasm (β=1.50; 95% confidence interval, 0.19-2.81), and more vaginal pain or discomfort during sexual activity (β=1.80; 95% confidence interval, 0.61-3.00). No associations were observed between current testosterone use and satisfaction with sex life, lubrication, labial pain or discomfort, or orgasm pleasure.

CONCLUSION: Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.

Conclusion

Testosterone use among transgender men and gender diverse people was associated with an increased interest in sexual activity and the ability to orgasm, as well as with vaginal pain or discomfort during sexual activity. Notably, the available evidence demonstrates that >60% of transgender men experience vulvovaginal pain during sexual activity. The causes of pelvic and vulvovaginal pain are poorly understood but are likely multifactorial and include physiological (eg, testosterone-associated vaginal atrophy) and psychological factors (eg, gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.