UCSF

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 is scarce.

Objective

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 1,219 participants ages 18-72 years old using 2019-2021 data from an online, prospective, longitudinal, cohort study of sexual and/or gender minority people in the US (The PRIDE 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 eight Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction (SexFS) domains.

Results

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

Conclusions

Testosterone use among transgender men and gender diverse people was associated with a higher interest in sexual activity and ability to orgasm as well as vaginal pain/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 (e.g., testosterone-associated vaginal atrophy) and psychological factors (e.g., gender affirmation). Given this high burden, there is an urgent need to identify effective and acceptable interventions for this population.