Sexual Health for Transgender People

Sexual health is a right of all people, regardless of gender identity. Yet, questions surrounding the sexuality of trans people often go unanswered: are different precautions needed? How does prevention work with a changing body? What screenings are necessary?

The starting answer is simple: the fundamental rules of sexual health are the same for everyone. Condom use, regular testing, open communication with partners. There are no “special risks” linked to being transgender. However, there are anatomical and hormonal specificities that are useful to know in order to take complete care of yourself.

This article compiles the scientific evidence and recommendations from major health organizations — CDC, WPATH, UCSF — to provide a practical, up-to-date guide.

Prevention of Sexually Transmitted Infections

The Basics Apply to Everyone

Sexually transmitted infections (STIs) are transmitted through contact with mucous membranes, body fluids, and micro-abrasions of the skin, regardless of the gender of the people involved. The CDC guidelines for transgender and gender diverse persons recommend the same prevention strategies applicable to the general population: correct and consistent condom use, periodic testing, and access to available vaccines (hepatitis A and B, HPV, mpox) [1].

A specific aspect concerns anatomy-based screening. The CDC recommends performing STI tests on all mucosal sites exposed during sexual activity, regardless of the person’s gender [1]. For trans women who have undergone vaginoplasty, screening should include the neovagina. For trans men who have not undergone vaginectomy, cervical testing remains indicated.

Condoms with Different Anatomies

The external (male) condom fits any penis and is effective regardless of whether the person is cis or trans. The internal (female) condom can be used in the vagina, neovagina, or rectum. The choice depends on anatomy and type of intercourse, not on gender.

For people who have undergone vaginoplasty, the internal condom can be used in the neovagina, but it is important to use a sufficient amount of water-based lubricant, as the neovagina does not produce natural lubrication. For trans men taking testosterone, the same recommendation applies: testosterone-induced vaginal atrophy reduces lubrication and thins vaginal walls, making lubricant essential to reduce the risk of micro-abrasions.

Effects of Hormone Therapy on STI Vulnerability

Testosterone therapy in trans men causes changes in vaginal mucosa similar to those of menopause: thinning of the epithelium, reduction of protective lactobacilli, decreased glycogen, and reduced lubrication. A 2022 study documented that these vaginal microbiome changes can increase susceptibility to sexually transmitted infections because epithelial barrier integrity is compromised [8].

This does not mean testosterone makes sex dangerous. It means that lubricant and condom use becomes particularly important to protect a more fragile mucosa. Low-dose topical estrogen treatment applied directly to the vaginal area can counteract atrophy without interfering with testosterone therapy: it is a localized intervention that does not alter systemic hormone levels.

For trans women on estrogen therapy, no specific effects of hormone therapy on STI risk at the rectal or oral level have been documented.

PrEP and Transgender People

Efficacy and Safety

PrEP (pre-exposure prophylaxis for HIV) is effective and safe for transgender people, including those on hormone therapy. This is one of the most frequently asked questions in the trans community, and the research answer is clear.

A systematic review published in 2024 in the British Journal of Clinical Pharmacology analyzed drug interactions between gender-affirming hormone therapy and antiretroviral drugs used for HIV prevention and treatment [2]. The results show that:

• PrEP with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) in trans women may slightly reduce plasma tenofovir concentrations, but intracellular tenofovir diphosphate concentrations — those that determine protective efficacy — are not reduced [2].
• In trans men on testosterone therapy, no significant alterations of tenofovir levels have been detected [2].
• Newer formulations (injectable cabotegravir, tenofovir alafenamide) show no interactions with either feminizing or masculinizing hormone therapy [2].
• PrEP does not alter hormone levels in either trans women or trans men [2].

The authors’ conclusion is straightforward: PrEP is effective and safe in trans people and should be offered to high-risk individuals regardless of gender-affirming hormone therapy use [2].

Doxy-PEP: A New Option

In 2024, the CDC published clinical guidelines on doxycycline post-exposure prophylaxis (doxy-PEP) for bacterial STI prevention [9]. This strategy involves taking 200 mg of doxycycline within 72 hours of unprotected sex. Three large randomized clinical trials demonstrated a reduction in syphilis and chlamydia infections of over 70% and gonococcal infections of approximately 50% [9].

The CDC recommends doxy-PEP for men who have sex with men (MSM) and transgender women with a history of at least one bacterial STI in the preceding 12 months [9]. This is an additional prevention tool, not a substitute for condoms.

Cancer Screenings: What Is Needed Based on Anatomy

Cervix: Trans Men

Trans men who retain their cervix must follow the same cervical cancer screening recommendations as cisgender women [4]. Testosterone does not eliminate the risk of cervical cancer. UCSF Transgender Care guidelines recommend Pap tests starting at age 21, at the same frequency as the general population (every 3 years between ages 21-29; every 5 years with HPV testing between ages 30-65) [4].

A practical problem is that Pap tests in trans men have an inadequate result rate ten times higher than in cisgender women [4]. This is correlated with the duration of testosterone therapy, which alters cell morphology. To obtain reliable results, it is important that the test request explicitly indicates testosterone use and amenorrhea, so that the pathologist can correctly interpret the cells.

A concerning finding: according to a U.S. study, only 64.3% of trans men are up to date with cervical screening, compared to 73.5% of cisgender women [10]. The barriers are multiple: discomfort accessing an exam perceived as “feminine,” lack of training among healthcare workers, and in some cases, lack of awareness of the need for screening.

Prostate: Trans Women

Trans women retain their prostate even after vaginoplasty. Estrogen therapy and possible orchiectomy significantly reduce prostate volume and PSA levels, but do not eliminate cancer risk [5]. A study published in the British Journal of Cancer in 2023 recommends following the same prostate screening guidelines as for cisgender men, with a caveat: since hormone therapy lowers PSA levels, the threshold value may need to be reduced to 1.0 ng/mL instead of the usual 4.0 ng/mL [5].

In trans women who have undergone vaginoplasty, the prostate is located anterior to the neovaginal wall. The digital exam can be performed via the neovaginal or rectal route, depending on the patient’s preference and the physician’s experience [5].

Breast: All Trans People

For trans women, mammographic screening is recommended after at least 5 years of estrogen therapy, regardless of age [6]. Some guidelines suggest waiting until 10 years of therapy before starting screening, given that breast cancer risk in trans women, while present, is lower than in cisgender women but higher than in cisgender men [6][10].

For trans men, recommendations depend on the presence of residual breast tissue. Those who have not undergone mastectomy should follow screening guidelines for cisgender women [10]. After mastectomy, the risk is reduced but does not completely disappear: an individual assessment with one’s doctor remains important.

Contraception

Hormone therapy strongly reduces fertility, but it is not a contraceptive method [3]. This applies to both trans men on testosterone therapy and trans women on estrogen therapy.

Trans men who have vaginal intercourse with partners who produce sperm can become pregnant even while on testosterone therapy, especially in the first months or in case of irregular use. Testosterone suppresses ovulation in most cases, but not in a guaranteed manner. Those wishing to avoid pregnancy should use an additional contraceptive method: condoms (which also protect against STIs), copper or hormonal intrauterine devices (IUDs), or other barrier methods.

For trans women, estrogen therapy drastically reduces sperm production, but residual fertility may persist, especially in the first months of treatment or in case of temporary interruption. If the partner can become pregnant, condoms remain the simplest and most comprehensive method.

Mental Health and Sexual Health

Sexual health is not just about the body: it is also about how one feels in one’s body during intimacy. For many trans people, gender dysphoria can profoundly affect sex life. Body parts may cause discomfort; the terminology used by a partner may feel alienating; physical contact can be complex to negotiate.

These aspects are not “problems” of the trans person: they result from the interaction between a gender experience and a context that often does not recognize it. Open communication with one’s partner is fundamental. Establishing together which words to use to describe one’s body, which types of contact are desired and which are not, is an element of sexual health just as important as condom use.

Psychological support can be helpful in addressing the relationship between dysphoria and sexuality. As documented in the article on mental health of trans people, psychological distress in trans people is related to social context, not to identity itself. A respectful and aware sexual environment is part of that context.

The WPATH Standards of Care version 8 dedicate a specific chapter to sexual health, recognizing that sexual well-being is an essential component of quality of life for trans and gender diverse people [3].

Data in the United States and Europe

A study published in Eurosurveillance in 2024 analyzed the prevalence of HIV and bacterial STIs among 452 transgender and non-binary people in 20 European countries [7]. Results show a self-reported HIV prevalence of 2.8% among transgender people, with recent STI rates of 6.7% for syphilis, 15.6% for gonorrhea, and 19.6% for chlamydia [7].

These data confirm the need for accessible, non-judgmental prevention and screening services, calibrated to the anatomical and behavioral specificities of trans people, without pathologizing gender identity.

Resources in the United States

In the United States, access to sexual health services for trans people is available through several structures.

STI Testing Centers

Many public health departments, community health centers, and Planned Parenthood locations offer free or low-cost STI testing. Key resources include:

• Planned Parenthood clinics nationwide, which offer inclusive STI testing and sexual health services
• UCSF Transgender Care in San Francisco, a leading center for comprehensive trans healthcare
• Fenway Health in Boston, specializing in LGBTQ+ healthcare including STI screening
• Callen-Lorde Community Health Center in New York, offering sliding-scale sexual health services

PrEP in the United States

PrEP is widely available in the United States through primary care providers, sexual health clinics, and community health centers. Many insurance plans cover PrEP at no cost under the Affordable Care Act. For those without insurance, manufacturer assistance programs (such as Gilead’s Advancing Access program) can provide the medication at reduced or no cost. The Ready, Set, PrEP program from the Department of Health and Human Services also provides PrEP at no cost to qualifying individuals.

In Summary

Sexual health for trans people does not require different rules from those that apply to everyone. Condoms, regular testing, vaccinations, and communication with partners are the fundamental tools. What changes are certain specificities related to anatomy and hormone therapy: cervical screening for those who have a cervix, prostate screening for those who have a prostate, attention to lubrication in case of vaginal atrophy, and awareness that hormone therapy is not a contraceptive.

PrEP works and is safe for trans people on hormone therapy [2]. Cancer screenings should be calibrated to present anatomy, not to sex assigned at birth [10]. And sexual health also includes psychological well-being: feeling respected in one’s body and identity is a necessary condition for a healthy sex life [3].

Resources exist, in the United States and internationally. The first step is knowing that you have the right to competent, respectful, evidence-based care.