Trans, gender non-conforming and non-binary individuals’ perspectives on experienced sexuality during medical transition

Abstract

How gender-affirming treatments (GAT) influence the experienced sexuality of transgender, gender non-conforming, and non-binary (TGNB) individuals remains understudied. The aim of this research was to discern factors contributing to a satisfying sexual experience for TGNB individuals, explore the influence of GAT on this process, and identify potential areas for improvement in transition-related care. We conducted interviews with 21 participants at various stages of GAT. Participants identified as (trans)men (12), (trans)women (7), transgender (1), and genderqueer/gender non-conforming/non-binary (1). Thematic analysis was conducted and involved multiple researchers. Three themes emerged from the data: (i) the role sexuality plays in understanding and affirming one’s gender, (ii) satisfaction with one’s physical sexual function, (iii) positive communication about sex and its subsequent influence on relationships. Many participants associated satisfaction with physical sexual function with positive sexual experiences, often describing GAT-induced changes in sexual arousal, drive, and orgasm as gender-affirming. Emotional connection and affirmation from sexual partners also contributed to positive experiences. The ability to (re-)define what sex meant individually increased satisfaction levels. Moreover, understanding and affirming one’s gender identity were closely related to a satisfactory sex life. This study offers valuable insights for healthcare providers working with TGNB individuals during GAT, particularly concerning their sexuality.

Introduction

Experienced sexuality refers to an individual’s encounters, feelings, attitudes, and behaviors related to their sexual identity, desires, interactions and overall sexual well-being (WHO, 2006a). It encompasses a range of dimensions including, but not limited to sexual orientation, preferences, practices, and emotions, which in turn reflect the unique and multifaceted nature of an individual’s sexual experiences and expressions (WHO, 2006a). In both sex research and health care there has been a shift in focus from disease and dysfunction to experiential dimensions ─ i.e., sexual satisfaction, sexual self-efficacy, sexual self-esteem and sexual pleasure (also called sex-positive approach) (Doorduin & van Berlo, 2014; Ford et al., 2019; Klooster, Knutson, & Matsuno, 2023; Laan, Klein, Werner, van Lunsen, & Janssen, 2021). Researchers have found that positive sexual experiences not only have a beneficial impact on an individual’s sexual health, but also contribute to improvements in mental and physical well-being (Anderson, 2013; Marinelli et al., 2023; Nikkelen & Kreukels, 2018).

In recent years, transgender, gender non-conforming and non-binary (TGNB) specific health care and research has evolved, offering greater insight into the multifaceted realm of gender identity, medical interventions (i.e., hormone replacement therapy (HRT), surgeries, etc.), and the effect that both can have on one’s well-being (Baker et al., 2021; Bradford, Rider, & Spencer, 2021; Hughto, Gunn, Rood, & Pantalone, 2020; Lelutiu-Weinberger, English, & Sandanapitchai, 2020; Scheim, Perez-Brumer, & Bauer, 2020). Research regarding sexual function within TGNB populations has often times been narrowly defined and focused primarily on the individual’s capacity for orgasm and/or engagement in penetrative sexual activities, which more often than not had been used as an indicator of post-gender-affirming treatment (GAT) function and success (Al-Tamimi et al., 2019; Bradford et al., 2021; Schardein & Nikolavsky, 2021; Tirapegui, Acar, & Kocjancic, 2020; van de Grift, Pigot, Kreukels, Bouman, & Mullender, 2019; Veerman et al., 2020). However, a noticeable and ongoing shift is taking place, reflecting an increasingly recognized necessity for more extensive research into TGNB experiences, including sexuality. In recent years, research regarding the sexual experiences of TGNB individuals during and following medical transition have focused on various themes, including: body image and satisfaction, function and satisfaction (i.e. physical, sexual, etc.), communication and intimacy, relationship dynamics, identity and sexual orientation, mental health and well-being, access to care, and resiliency/coping strategies (Anzani, Lindley, Prunas, & Galupo, 2021; Goldbach, Lindley, Anzani, & Galupo, 2023; Lindley, Anzani, & Galupo, 2022; Lindley, Nagoshi, Nagoshi, Hess, & Boscia, 2021; Nieder, Eyssel, & Köhler, 2020; Oorthuys, Ross, Kreukels, Mullender, & van de Grift, 2023; Ross, Jahouh, Mullender, Kreukels, & van de Grift, 2023; Siboni, Prunas, & Anzani, 2023; Skorzewska et al., 2021). In addition to the aforementioned, it is important to acknowledge that while questions of GAT and sexual pleasure may be relatively new within scholarly contexts, trans and gender diverse individuals have been writing about GAT and sexuality in community-produced literature for decades (i.e., Lou Sullivan, Kate Bornstein, Leslie Feinberg, Alok Vaid-Menon, Kai Cheng Thom, Aiden Dowling).

Within the context of scholarly research regarding gender-affirming treatment, some key findings on TGNB sexuality have been described. Preceding GAT, TGNB individuals frequently grapple with adverse sexual attitudes, often stemming from feelings of gender incongruence or dysphoria (Bartolucci et al., 2015; Doorduin & van Berlo, 2014; Shuster, 2021), or unfulfilled desire for GAT (Murad et al., 2010; Nikkelen & Kreukels, 2018; Staples, Bird, Gregg, & George, 2020). One of the coping mechanisms individuals reported using in order to enhance their experienced sexual satisfaction included fantasizing about having the physical appearance and genital function matching one’s experienced gender identity (Doorduin & van Berlo, 2014). With regards to the post-GAT experienced sexuality of trans women, divergent findings have emerged, encompassing an increase in the frequency of sexual activities and satisfaction with orgasms (Hess et al., 2018; Zavlin et al., 2018), alongside a reduction in sexual desire (Murad et al., 2010). Findings for trans masculine individuals appear more aligned, with an increase of sexual desire, arousal and frequency of sex and masturbation after hormonal GAT (Klein & Gorzalka, 2009; Murad et al., 2010; Wierckx et al., 2014). Overall, TGNB individuals report a general improvement in sexual well-being (Staples et al., 2020; Weigert, Frison, Sessiecq, Al Mutairi, & Casoli, 2013), sexual satisfaction (De Cuypere et al., 2005; Klein & Gorzalka, 2009; Lindley, Anzani et al., 2021) and sexual function (Murad et al., 2010) after GAT, with a positive contribution of improved genital satisfaction (De Cuypere et al., 2005; van de Grift et al., 2019). Often times, TGNB individual’s sexual development is intertwined with the process of both social and medical transition (Doorduin & van Berlo, 2014; Staples et al., 2020).

While the earlier research has shown that different dimensions of TGNB individuals’ sexual functioning may improve after GAT, there remains little research regarding if/how GAT influences experienced sexuality (Bungener, de Vries, Popma, & Steensma, 2020; Garz et al., 2021; Özer, de Kruif, Gijs, Kreukels, & Mullender, 2023; Özer, Poor Toulabi, Gijs, Kreukels, & Mullender, 2023). HRT and surgical interventions can lead to physical changes that may influence how individuals experience and express their sexuality. HRT, for example, can affect aspects such as sexual desire/arousal, genital sensitivity, and other sexual functions (Costantino et al., 2013; Garz et al., 2021; Kuper, Stewart, Preston, Lau, & Lopez, 2020). Also, gender-affirming surgeries may alter the physical appearance of genitalia, potentially impacting an individual’s body image and comfort during sexual activity (De Cuypere et al., 2005; Weyers et al., 2009). Recommendation has been made in prior research to address the relationship between positive aspects of sexuality and medical transition (Engelmann, Nicklisch, & Nieder, 2022; Özer, de Kruif, et al., 2023). Given the aforementioned, the present study aimed to qualitatively explore what is associated with experienced sexuality in TGNB individuals going through (medical) transition from a sex-positive approach and how this topic should be addressed best within current health care.

Materials and methods

Study procedure

Data collection was part of a larger qualitative study aiming to develop a patient-reported outcome measure (PROM) based on the experienced of TGNB individuals (Klassen et al., 2018). The study involved collecting qualitative data on various aspects of individuals’ healthcare experiences which enabled both primary and secondary analyses (Oorthuys et al., 2023; Ross, Jahouh, et al., 2023; Ross, Wesseling, Mullender, Kreukels, & van de Grift, 2023). The study was conducted according to the Helsinki criteria and received ethical approval from the Amsterdam UMC (location VUmc) institutional review board (no.2017.617).

Study setting

The study was conducted at the Amsterdam UMC (location VUmc). At this center, the team includes various departments and medical professions, based on the requested care. The team consists of healthcare providers from fields such as psychology, psychiatry, endocrinology, gynecology, and plastic surgery. Additionally, urology, dermatology, ear, nose, and throat (ENT), speech therapy, surgery, and facial surgery are also involved based on individual treatment wishes.

Access to the facilities was granted upon referral by a general practitioner. Generally, individuals began with consultations with a psychologist, where they discussed their experiences of gender incongruence, their needs, and the available options for gender-affirming interventions. The diagnostic procedure typically lasted 6–8 months with monthly visits. The process concluded with a multidisciplinary team evaluating the individual’s eligibility for gender-affirming care. Hormonal treatment follows the diagnostic phase for those who desire to undergo medical transition. If individuals had already started hormone treatment somewhere else, treatment would be continued with potential adjustments. During gender-affirming hormone treatment, individuals had appointments every 3 months with an endocrinologist and a psychologist. On average, most individuals will have had at least 12 months of hormone replacement therapy before qualifying for gender-affirming surgeries.

Participants and recruitment

Eligible individuals were aged 16 years or older, had received a diagnosis of “gender dysphoria”, had initiated or completed the process for gender-affirming procedures in the Netherlands, were fluent in Dutch or English, and able to provide informed consent. For the purpose of this study, only data collected in the Netherlands were included. Candidates were approached to participate via the research team, clinicians from the Amsterdam UMC (location VUmc), peer support groups and social media. Purposeful sampling was employed to ensure a diverse range of participants in terms of age, gender, and healthcare history. Recruitment took place over a three-month period (August 2018 to October 2018). Participation was voluntary, and it was emphasized that participants’ involvement would not influence their future care. Each participant received a EUR 50 gift card as a token of appreciation, which they were informed about after their participation in the research.

Data collection

After providing written and verbal informed consent, interviews were conducted at a location of participant’s preference. The in-person, one-on-one interviews were conducted by the first author (M.R.), a non-binary-identifying psychologist and trained interviewer with previous experience in qualitative research. The majority of the interviews took place at the participants’ homes and had an average duration of 85 min, ranging from 55 min to 156 min.

The interviews followed a semi-structured format following the development of the PROM domains (Klassen et al., 2018), of which sexuality was one. It consisted of 48 pilot tested questions, which covered different themes of quality of life, of which six were specific to this topic of sexuality. It allowed participants to elaborate on their experiences within these themes and allowed the interviewer to ask further questions whenever necessary. An overview of the sexuality-related questions and the other PROM domains can be found in Table 1. Sampling and interviewing took place until the point of saturation was reached for the primary study objectives.

Table 1. GENDER-Q interview guide.

Covered areas of quality of life

Questions asked regarding sexual quality of life

Experience of care Treatments and recovery Appearance Voice Psychological Body image Social Physical Additional questions Sexual

How important is your sexual life and well-being to you? How do you feel about your body sexually? Probe: positive (confident, attractive, normal) and negatives (self-conscious, uncomfortable, unattractive, abnormal) and clothed/unclothed. Can you tell me about any problems or concerns with the sexual life related to your gender identity? In what ways has gender-affirming treatment changed your genitalia? Probe: appearance, function. Has your sexual life changed with any gender-affirming treatment and how? Probe: frequency, quality, drive, arousal. Which gender-affirming treatments have helped the most in terms of your sexual life?

The participants had the freedom to pause or terminate the interview at any point and were also able to withdraw from the study during or after the completion of the interview. All participants completed the interview in a single session, and no participant chose to withdraw or provide comments or corrections on the interview transcripts.

Data extraction and analysis

All interviews were audio-recorded and transcribed verbatim. Subsequently, for use in the larger project, the transcripts were translated into English and anonymized by removing personal identifiers (Klassen et al., 2018). For the purpose of this study, the data were subjected to line-by-line coding using interpretative codes by a coding team consisting of two researchers (M.R. and P.R.). All codes were cross-verified by a third member of the research team (T.G.). Quotes specifically related to sexuality and/or sex were extracted from the data and imported into a Microsoft Excel spreadsheet for further analysis.

Thematic data analysis was conducted on the extracted codes using the method described by Braun and Clark (Braun & Clarke, 2014). Initially, a set of codes was generated through axial coding to identify potential themes and subthemes. The coders reviewed and discussed all the identified themes until a consensus was reached. The remaining codes were then utilized to internally validate and refine the themes and subthemes. Similar to the first set of potential themes, the final set of themes, definitions, and possible biases were extensively discussed among the authors until a consensus was achieved. Finally, all findings were thoroughly reviewed, and illustrative quotes were selected to represent each theme.

Reflexivity statements

The team consisted of members with diverse backgrounds, including those who identify as non-binary/queer (M.R.), cisgender/gay (T.G), and cisgender/heterosexual (P.R., M.M). All researchers possessed at least one university level degree (M.R., P.R., T.G., M.M) and two of the researchers possessed doctorates (T.G., M.M). Regarding relationship status, three of the team members had partners and/or are married (M.R., T.G., M.M.). As a non-binary individual, M.R. has not undergone any medical GAT. This diversity enriched the team with a combination of personal experiences, such as insights from the LGBTQAI + community, and valuable professional expertise gained from their roles as researchers and clinicians. Additionally, the research team actively engaged in personal and group reflection to identify and address potential gaps and biases in their work, ensuring a rigorous and comprehensive analysis.

Results

A total of 57 TGNB individuals were invited to take part in this study; 21 responded and consented to participate (response rate = 37%). The reasons for not responding to the invitation were not recorded. Amongst these 21 individuals 12 self-identified as (trans) men, 7 as (trans) women, 1 as transgender and 1 as genderqueer/gender non-conforming (GNC)/non-binary. Of the 21 participants, 20 participants had started hormone replacement therapy (HRT) and 14 participants had undergone gender-affirming surgical procedures. Participant demographics are presented in Table 2. A total of 628 codes regarding sexuality/sex were extracted from the 21 interviews. Three overarching themes that related to experienced sexuality in TGNB individuals emerged from the coded data: (i) the role sexuality plays in understanding and/or affirming one’s gender, (ii) satisfaction with one’s physical sexual function, (iii) positively communicating about sex and its subsequent influence on relationships.

Table 2. Participants demographics.

Characteristic	Value (%)/[range]
Birth assigned sex
Male	8 (38)
Female	13 (62)
Gender self-identification
Man	12 (57)
Woman	7 (33)
Other	2 (10)
Age
Median	36 [18-62]
16-19	1 (5)
20-30	9 (43)
31-40	2 (10)
41-70	9 (43)
Education level*
Low (ISCED 1, 2)	2 (10)
Middle (ISCED 3-5)	4 (19)
High (ISCED 6, 7)	15 (71)
Relationship status
Single	15 (71)
With partner/married	6 (29)
Gender affirming treatment received
No treatment:	1
Only HRT:	6
HRT + Top surgery (e.g. mastectomy):	3
HRT + Top surgery + hysterectomy:	1
HRT + Top surgery + hysterectomy + bilateral salpingo-oophorectomy:	1
HRT + Top surgery + hysterectomy + bilateral salpingo-oophorectomy + colpectomy:	2
HRT + Top surgery + hysterectomy + bilateral salpingo-oophorectomy + colpectomy + genital surgery:	2
HRT + Top surgery + hysterectomy + bilateral salpingo-oophorectomy + genital surgery:	1
HRT + orchidectomy:	1
HRT + orchidectomy + vaginoplasty:	1
HRT + orchidectomy + vaginoplasty + Facial feminization surgery + breast augmentation + glottoplasty:	1
HRT + orchidectomy + vaginoplasty + chondrolaryngoplasty:	1

*ISCED, International Standard Classification of Education; HRT, Hormone Replacement Therapy.

Theme 1: The role sexuality plays in understanding and/or affirming one’s gender

To many of the participants, sexuality was a way to discover (more about) their own gender identity, to experiment, and to receive gender affirmation.

Understanding one’s gender

Before fully realizing/understanding one’s gender identity, participants expressed feelings that their physical sexual arousal did not feel ‘right’ without fully understanding why. One participant expressed how sexuality was a tool for him in the journey of discovering not only his sexual, but also his gender, identity.

“I had my first orgasm when I was 21 or something. And that only happened because I had very recently; like that week…started thinking more about just gay couples…and that is the only reason why it happened. Because I was fantasizing about that and the first time that I did it, it happened almost immediately that I was able to orgasm. And that is also when it clicked for me. I was like oh my god, I am not a-sexual. I do like it. I just feel like because then it made sense when I realized I was transgender because then there was no female role. So I didn’t feel like I had to be anything, I just…there were only those roles.” (participant 09, age 26, man, HRT, mastectomy).

Another participant described that sexual activity in itself was unfulfilling before the realization of their gender identity: “When it [sex] happened, I was again not happy. It didn’t make sense why sex wasn’t fulfilling” (participant 16, woman, age 56, HRT, vaginoplasty, intestinal vaginoplasty). Some participants described that sexual activity provided them with their first insights into realizing their gender incongruence: “Having sex made me realize really quickly that I didn’t like my body” (participant 8, man, age 27, HRT, chest surgery mastectomy, hysterectomy, bilateral salpingo-oophorectomy, colpectomy).

Multiple participants described that their gender-related distress pertained often to the sexual roles that were expected of them by their partner(s). One participant described feeling as though the masculine sexual role, prior to transitioning, was one that never suited her. Similarly, another participant described that during sex she realized she wanted to be penetrated instead of being the one who penetrated. Developing comfortable sexual roles were associated with increased levels of satisfaction in the experienced sexuality by many of the participants.

In understanding the relationship between sexual activity and realizing/understanding one’s gender identity, one participant described that when looking back at her life, prior to understanding her gender identity, her method of masturbation already suggested a more feminine-typical gender role.

“Yeah, masturbation, I do that sometimes. And how do I do that? That’s a little crazy. I didn’t find out until later. So apparently I do it in a really weird way. I’ve learned, if most guys satisfy themselves, they jerk off of course, but I’ve never done that. Maybe out of nature or something, I don’t know. But I’ve always just, I think it’s really weird to talk about this, but yeah. The thing is, if you’ve got the penis, you’ve got the head. I’m just gonna massage or caress or something. And then at some point I’m just gonna come. So I don’t really do that pulling, just a little caressing, with my hand over it. I don’t really know how a woman does that, because of course, I’ve never experienced that myself.” (participant 02, age 28, woman, HRT)

In retrospect, participants described that their sexual preferences and approaches may have assisted them in discovering their gender identity.

Prior to realizing their gender identity, some participants described how they had struggled with exploring and defining their sexual identity. Participants expressed feeling that their sexual identity was not suitable nor making sense at the time.

“More than 10 years ago I still identified myself as a lesbian because I mainly like women, and I’m also a woman. But at the beginning of my twenties I was dating someone who identified as a woman, but masculine or… And yes, I also dated non-binary people. Actually I didn’t only do it with women and actually I’m not a lesbian and I could date trans people anyway. I could date all kinds of people except maybe still men. So then I thought that doesn’t really feel logical than to do it that way so then I started to use queer and then I started to think more about my own gender and then I actually thought I don’t feel like a woman either so it’s only logical.”(participant 17, age 27, GNC/non-binary, still unsure if would like to have HRT)

Through the discovery of their sexual identity, participants described that it became clear that their gender identity was underlying their feelings of discomfort and not knowing. Looking back, some participants described how understanding their sexual orientation was often difficult to distinguish from understanding their gender identity. Overall, developing a clear and affirmative understanding of both one’s gender and sexual identity were described as being supportive of the individual’s experienced sexuality.

Theme 2: Satisfaction with one’s physical sexual function

The participants’ satisfaction with their physical sexual function, whether or not in relation to GAT, was found to be a factor contributing toward a satisfying sexual experience. These functions included sexual desire, physical arousal and function (i.e., vaginal lubrication and erection), ability to orgasm and masturbation.

Sexual desire

Feelings of sexual desire, and subsequent motivation to have sex, differed among participants and was reported to be strongly influenced by hormone replacement therapy (HRT). Multiple trans feminine participants indicated that the sexual desire before starting HRT was somewhat difficult to handle.

“My testosterone was in the way. I always felt such a nasty kind of aggression and a sex drive that I actually really didn’t want. The continual desire to have sex and to be constantly only thinking about sex.” (participant 15, age 61, woman, hormone replacement therapy (HRT), breast augmentation, facial feminization surgery (FFS), chondrolarygoplasty, vaginoplasty, glottoplasty).

Most participants described that they experienced an overwhelming level of sexual desire, which did not match one’s gender identity. As a result, the sexual desire that individuals experienced was often described as unpleasant. Following the introduction of HRT, in some trans feminine participants a decline in desire was experienced which resulted in a decreased sexual interest. Most trans feminine participants stated that this decrease in sexual desire was experienced as comfortable, more in line with their identity, and ultimately contributed positively to their overall experienced sexuality.

“Now I can have sex, not come, and still find it very amazing” (participant 8, age 56, woman, HRT, vaginoplasty).

On the contrary, trans masculine participants generally reported an increase in sexual desire after starting HRT. Albeit somewhat new and surprising, many argued that this increase was welcomed, but described it as something they had had to get used to.

“My sex drive shot through the roof on testosterone, I thought about sex constantly.” (participant 7, age 37, man, HRT, mastectomy, hysterectomy, colpectomy, bilateral salpingo-oophorectomy)

Throughout the cohort, HRT-induced changes in sexual desire contributed positively to the experienced sexuality of individuals as long as the changes were experienced as being congruent with one’s gender.

Physical arousal and function

Many participants reported that physical arousal, prior to GAT, was not always a pleasurable or wanted experience.

“I didn’t always like getting wet. It can be practical, but that was it for me. I always felt uncomfortable about it because it wasn’t right.” (participant 08, age 22, man, HRT, mastectomy, hysterectomy, bilateral salpingo-oophorectomy).

“With sex, of course I didn’t want to do anything with my genitals. So, I just avoided it.”(participant 15, age 46, woman, HRT)

Trans masculine perspective

Repeatedly, trans masculine participants described how, prior to HRT, vaginal lubrication resulting from arousal, was a trigger for gender dysphoria:

“When I get aroused it’s annoying, all that shit comes out. It’s coming out of the wrong hole” (participant 6, age 60, man, HRT, mastectomy, hysterectomy, bilateral salpingo-oophorectomy, metoidioplasty with urethral lengthening, phalloplasty with urethral lengthening, erectile prosthetic, testicle implants).

After starting HRT, some trans masculine participants experienced a change in the nature and intensity of physical arousal. Some described that the increase in testosterone added a bit of a “rugged edge” to the levels of arousal. In general, this change was experienced as gender-affirming and described as having a positive influence on most of the participants’ experienced sexuality. Additionally, multiple trans masculine participants reported positively about the growth of their clitoral tissue after starting HRT, saying that it got bigger, more sensitive and made the sex more enjoyable.

Furthermore, most trans masculine participants described the positive effect of chest surgery on their experienced gender congruency, and subsequently, their sexual physical function: “Top surgery has helped so much for getting a better sex life” (participant 5, age 26, man, HRT, mastecotomy). Participants who underwent metoidioplasty described that the sensitivity of their penis contributed positively to their satisfaction with sexual function, despite the relatively smaller size of their penis which provided limited capability for penetrative sex.

Trans feminine perspective

Trans feminine participants explained how HRT frequently led to a desired decrease in physical arousal and decrease of unwanted erections:

“I would find it annoying if it became erect, it [hormones] stopped me from getting erections” (participant 10, age 58, woman, HRT).

While HRT has been described as having a satisfactory influence on physical sexual function, the impact of gender-affirming surgery (GAS) was also reported as significant. Trans feminine participants described how the function of the neo-vagina after vaginoplasty improved their experienced sexuality. Specifically, participants mentioned that having sufficient genital sensation and the ability to receive penetrative sex contributed positively to the experienced physical sexual function:

“Sexually my vagina works well.” (participant 3, age 52, woman, HRT, vaginoplasty, chondrolaryngoplasty).

Ability to orgasm

Some participants described they experienced an increased self-awareness during sexual activities that made reaching an orgasm more difficult. Participants described these feelings as being present before their transition and appearing largely unaffected by GAT alone. One participant described,

“I would like to be able to have sex without feeling uncomfortable due to not knowing what to do with myself.” (participant 15, age 41, man, HRT, mastectomy, hysterectomy, bilateral salpingo-oophorectomy, colpectomy, metoidioplasty)

With that being said, some trans masculine participants experienced an improved ability to reach an orgasm, as well as an increase in the intensity of orgasming, post HRT.

“I can remember, when I had a vagina, that you could climax multiple times but it would be less explosive. Now it’s like an explosion; it’s just once and then it’s done. That definitely changed.” (participant 06, age 60, man, HRT, mastectomy, hysterectomy, bilateral salpingo-oophorectomy, genital surgery)

Additionally, a few trans feminine participants reported being able to reach an orgasm after GAS by masturbating on their own, but having difficulty to relax enough during partnered sexual activity in order to orgasm. In general, participants described the ability to orgasm as positively contributing to their overall experienced sexuality.

Masturbation

Some participants described having an ambivalent relationship with masturbation prior to beginning GAT. Participants described feeling triggered by the touching of their genitalia and, as a result, experienced heightened feelings of gender incongruence and gender dysphoria.

Upon the initiation of HRT, participants’ experiences with masturbation changed. Some trans masculine participants described needing to release “pressure”,

“Since I started hormones, I had to get used to the fact that I had painful erections. Then I thought, I have to unload every few minutes to release that pressure” (participant 05, age 40, man, HRT, mastectomy)

One trans feminine participant described: “The different experience with masturbation also helps with the feeling of being a woman. That it is affirming, that also made it a nicer experience” (participant 13, age 23, woman, HRT, puberty inhibitors). For some participants post-GAT, masturbation became an affirmative act,

“I had to regularly masturbate, just because it was necessary. Otherwise everything would just get worse, but since the hormones that is all gone. First it was just emptying my head because it was a physical thing. And now it isn’t just a physical thing…it is also just, my whole body actually, that is involved with it, and also my head saying…I am. It has become a very different experience, a much more complete experience for me.”(participant 14, age 56, woman, HRT, vaginoplasty).

Theme 3: Positively communicating about sex and its subsequent influence on relationships

In our analysis, participants highlighted the ways affirmative sexual relationships and positive communication around sexuality can influence levels of sexual satisfaction.

Positive communication

Several participants described that the medical transition aided them in being more readily able to communicate their sexual preferences, as well as, becoming more comfortable during sexual experiences with partner(s). One participant mentioned that in the beginning of his relationships he had trouble describing his sexual preferences to his partners. After starting GAT, he described being able to talk more freely to his partners and felt more satisfied in his sexual experiences:

“My partners, they know not to touch me with their fingers or anything and if they are doing things with their hands, they just…on top of my underwear just how I do it. I have gotten more comfortable about them touching me and so on. But they don’t do anything like that because they know it just feels weird for me” (participant 5, age 26, man, HRT, mastectomy).

Another participant shared a similar experience, emphasizing the enhancing effect that positive communication has on supporting pleasurable sex and minimizing gender dysphoria during sexual activities.

“Sometimes I do have, for example, that if they caress my breasts, then I don’t want to be touched, but then it’s not uncomfortable because then I can just say that. So I don’t really feel uncomfortable with him. I just try to communicate about what I do and don’t want and what I do and don’t like. And also in the relationship of gender to this. Well, I’m having a bad day in that area in this area or something you want because you make it feel good in that respect. Yeah, I think it is very important to be able to talk about this with your partner.” (participant 17, age 27, non-binary/GNC, still unsure if would like to have HRT).

In general, participants demonstrated that improved communication regarding one’s sexual preferences resulted in higher levels of sexual comfort, pleasure and subsequently satisfying sexual experiences.

Affirmative sexual relationships

The majority of the participants described how the emotional connection to their sexual partners strongly mediated their sexual experiences.

“I do like sex, but I think it’s more the intimacy that I like when I’m with someone. Someone who finds me attractive and accepts me as I am.” (participant 02, age 28, woman, HRT)

Emotional closeness supported the levels of sexual comfort and bodily confidence individuals described experiencing. And through the development of by stronger emotional connections, which in turn contributed positively to satisfactorily sexual experiences, participants described that a safe environment to engage in sex was created.

Relationships that were emotionally and sexually affirming made many evaluate their sexuality differently. For example, more attention was paid to the shared experience and meeting all partners’ preferences, which often resulted in more positive sexual experiences.

“Fortunately, my partner isn’t someone who necessarily insists on that either. Also not the other way around either. It is not important. An orgasm is not something important. Being together and how you deal with each other is much more important than coming.” (participant 03, age 53, woman, HRT, vaginoplasty, chondrolaryngoplasty)

“I like it when someone satisfies me in my own way, that doesn’t necessarily has to be satisfied down there.”(participant 02, age 28, woman, HRT)

Some participants still experienced gender dysphoria during sexual contact and described this as one of the main challenges sexually. They described using coping mechanisms where they would shift the focus from sexual aspects that were uncomfortable (i.e., touching of the genitalia), to other aspects that were comfortable (e.g., such as being close with- and to one another). One participant explained that other sexual experiences outside of sex itself (e.g., kissing sensually) had given her sexual satisfaction prior to starting HRT.

“Just being able to kiss sensually in different places, that sort of thing. That was always just enough for me.” (participant 02, age 28, woman, HRT)

In general, after starting GAT, most participants described that less attention was paid to the importance of sexual function, such as reaching an orgasm, and more to affirmative partner connection: “Now I can have sex, not come and still find it amazing. I cannot come and still fall asleep peacefully afterwards” (participant 16, woman, age 56, HRT, vaginoplasty, intestinal vaginoplasty). Altogether, the strengthening of sexual relationships and communication within said relationship(s) added positively to sexual satisfaction.

Discussion

Through in-depth interviews we explored what factors affect the positive subjective sexual experiences of a group of TGNB individuals undergoing, or having undergone, gender affirming treatment. The specific effects of very specific gender-affirming treatments have not been discussed, but rather the experiences of people that positively contribute to their sexual life. Our research emphasizes shared experiences among transgender individuals, irrespective of their gender identity. Similar to experiences of cis individuals, subjective evaluation of sexuality depended on both personal and relational aspects. We discerned three main themes and several subthemes which involved factors that affected positive sexual experiences. In these three themes, gender affirmation in relation to sexuality was a common denominator. This finding enables a more experiential sex-positive approach to sexuality research in TGNB healthcare.

From the narratives it became apparent that sexual development, understanding one’s own gender identity, transitioning, and sexual experiences are often interwoven. It has been proposed that physical sex characteristics may be understood as an expression of gender, as opposed to gender being dependent on biological sex (Dozier, 2005). In line with this, the individuals in this study described their gender as decisive, where experienced sexual function, sexual roles and sexual behavior that, according to them, matched their gender were perceived as positive. Overall, gender affirmation experienced in a physical, psychological and social-relational sexual context contributed to positive sexuality. This was generally observed, regardless of transition status, sexual preferences and gender identity of the participants.

In some participants, they were still exploring their gender identity as they started to get sexually involved. In general, most individuals find themselves within an environment that is still heavily dominated by a heteronormative narrative, and thus, exploring one’s own gender identity was more of a challenge for some. They explained that sexual experiences played an important role in discovering and understanding their gender identity(e.g., through non-heterosexual identities, participants were able to experience non-binary and/or cross-gender (sexual) roles). Experiencing ‘fitting’ (i.e., congruent and affirmative) sexual feelings, roles and behaviors promoted awareness of one’s gender and which direction one’s transition would take. Empirical studies have repeatedly observed that especially non-heterosexual sexual identities generally account for less normative and narrow gender roles (Kowalski & Scheitle, 2020). Such sexual relationships and identities may provide a safe space for individuals to experience not only how to better understand, but also affirm, one’s gender.

Similar to findings within cis individuals (Dundon & Rellini, 2010; Özer, de Kruif, et al., 2023; Staples et al., 2020), satisfaction with one’s physical sexual function was found to contribute as one of the factors to positive sexual experiences. Through medical transition, individuals experienced changes in various physical sexual functions. Overall, individuals described that these physical changes felt appropriate and made sense with regard to their gender, and through this, physical gender affirmation was described as contributing to sexual satisfaction. This is consistent with previous literature, in which positive effects of gender affirming treatments on various aspects of sexuality are reported (Bartolucci et al., 2015; Becker et al., 2018; Davis & Meier, 2014; Engelmann et al., 2022; van de Grift, Elaut, Cerwenka, Cohen-Kettenis, & Kreukels, 2018; van de Grift et al., 2017; Wierckx et al., 2014). A more gender-congruent sexual function was affirmed through both improved self-esteem and gender congruence, as well as through more gender-affirmative interactions with sexual partners.

It is important to emphasize that it appeared to be not the physical function per se that matters, but how this function is perceived by the individual. For example, either an increase or a decrease in arousal were experienced as positive effects of hormone treatment by the participants. The importance of researching the subjective experiences of sexual function in TGNB individuals was already noted by scholars, and within the field of sexology it is essential to inquire whether an individual experiences distress or not (Doorduin & van Berlo, 2014; Hendrickx, Gijs, & Enzlin, 2013; Kerckhof et al., 2019). For example, when considering an individual with low sexual desire who does not experience distress (perhaps because it aligns with their gender identity), this would not be classified as sexual dysfunction. This approach ensures that health care providers do not pathologize cases of reduced sexual function unnecessarily and fosters a sex-positive perspective. However, most medical literature in which gender affirming treatments are evaluated only assesses objectified sexual functions by itself (e.g. ability to orgasm, or to have penetrative sex) (Holmberg, Arver, & Dhejne, 2019). It remains however unclear how these outcomes should be valued; while clinicians or even peers may label something as dysfunctional, the individual concerned may experience it very differently. A noticeable example was described in the study of Schilt and Windsor in which a trans masculine participant “imagined his nonsurgical (prosthetic) penis as even more functional and masculine than a “natural” penis” (Schilt & Windsor, 2014). Clearly, function acquires meaning only through the experiences of the individual concerned. Clinicians ought to support TGNB healthcare seekers in weighing their treatment objectives with regard to sexual functioning, and to choose the desired treatment approach accordingly.

With regard to positively evaluated sexual experiences, participants frequently discussed the importance of relational dimensions. The emotional relationship with sexual partners was experienced to be vital. Emotional bonding supported sexual confidence and mediated positive sexual experiences. This is in line with research among cis individuals describing how sexual relationships are often the result of the partner-attachment quality within relationships, and how sexual satisfaction can evolve with the increasing levels of emotional connection (Meltzer et al., 2017). Affirmative gender roles, but also consideration of a partner with body parts dysphoria, enhanced positive experiences in our sample. Similar findings were described previously (Lindley, Anzani et al., 2021; Martin, 2020). In the context of non-normative bodies and non-heteronormative partners, positive communication about sex was described as an important enabler for positive sexual experiences. Being able to communicate about sex, sexual roles, desires and preferences often enhanced overall sexual satisfaction. Several participants felt more comfortable communicating about sexuality after medical affirming treatment, which made them feel more confident with their body and being less distressed by body-induced dysphoria.

Positive sexual communication is not only vital for fostering healthier relationships, but also intersects with broader discussions surrounding GAT and sex-positive research. These conversations, in turn, highlight the significance of community-based literature and discussions in ensuring inclusivity, respect, and empowerment within the realm of sexuality and gender. Scholarly research regarding sexuality from a sex-positive lens involves a progressive alignment with the perspectives and experiences that TGNB individuals have been expressing in their community-based writings and discussions for decades. Given the growing global anti-trans activism, integrating scholarly literature into these discussions is crucial. Scholarly work offers empirical evidence and theoretical support, which in turn strengthens community insights, reduces stigma, promotes education, body positivity, and encourages exploration of desires and identities. The following synergy between community voices and scholarly work would ensure that research and therapeutic practices in GAT and sex-positive research are not only respectful but also truly inclusive and effective. Transgender activists and scholars (i.e., Jamison Green, Julia Serano) have played vital roles in promoting community-based approaches that prioritize the lived experiences and needs of TGNB individuals, ultimately leading to more informed and compassionate care.

Clinical implications

This study provides healthcare providers with valuable information on working with TGNB individuals during their medical transition in regard to their sexuality. It could be valuable to focus also on how sexual functions are experienced, rather than only focusing on the objective sexual functions. By helping to understand which sexual functions are, or could be, experienced as affirmative to TGNB individuals, the healthcare provider can aid in shared decision making for possible future GAT. Also, by creating space for partners of GAT-seeking TGNB individuals, clinicians can help facilitating affirming-, and sexual experience enhancing communication. Participants’ preferences for receiving sexual information and care during medical transition were not a focus of this study. Future research is needed to explore how information about sexuality after GAT can support the decision-making process about GAT. Recommendations on guidance of sexual health within TGNB healthcare have been made (Coleman et al., 2022), and this study provides examples into how some of these recommendations could be put into practice.

Strengths and limitations

A strength of this study was the open, in-depth and sex-positive approach. Although this study was limited by a relatively small sample size and heterogeneity of experiences, it helps to understand what factors can contribute to positive sexual experiences in a subpopulation of TGNB individuals, i.e., the TGNB individuals who desire gender affirming treatment. Further limitations included context-specific factors (e.g., the sex-positive culture in which the participants lived) that may reduce generalizability and reporting bias due to the study’s sensitive topic. Additionally, data saturation was achieved for the primary study objectives, and because this study was a secondary analysis recruitment was not specifically based on saturation of this particular topic.

Conclusion

It is important to note that the impact of GAT on experienced sexuality varies widely among TGNB individuals. Gender-affirming treatments are generally experienced as sexually pleasant if it enables individuals to experience sexually affirming physical function. Individuals that report having supportive sexual partners and good-quality communication further experience the positive effects of gender-affirming treatments on experienced sexuality. Sex-positive and experiential-oriented healthcare predominantly centers on the subjective experience of individuals in terms of affirmation, rather than exclusively evaluating changes in sexual functionality (i.e., heteronormative) and drawing conclusions regarding the efficacy of GAT. Given the growing global anti-trans activism, integrating scholarly literature and community-based literature and discussions is crucial. Experienced sexuality should play a much more important role in the decision making process about GAT and in guidance both during and after GAT.

Acknowledgements

The authors would like to thank all the participants for their cooperation, as well as Anne Klassen, Manraj Kaur and Shelby Deibert for their study support in the development of the GENDER-Q.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was funded by ZonMW as part of the project “Personalized care for individuals experiencing gender dysphoria” (project ID: 606360098510).