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Male-to-female gender changes and sexual functioning

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Maya asks:

Can people who have sex changes (male to female) get erections? And if so, do erections and intercourse feel the same as it would for someone who was born male and still identifies as male?

CJ replies:

To answer your question, I find myself wanting to give a little bit of background information and talk about the language I’m going to use, just so we’re all on the same page and you can best understand where I’m coming from! Hopefully you can bear with me for a minute while we talk about that, and then I can better answer your important questions.

It sounds like what you asking about in your question has to do with people who are transgender, or, more specifically, transgender women (people who were assigned male at birth, and now identify as female). When I talk about transgender, or “trans”, I define that as someone who was assigned one sex or gender at birth, but identifies in some other way now. That could mean that you were born female and now you identify as male (some people would use the term FTM, or female-to-male, to describe that) or that you were assigned male at birth and now identify as female (also sometimes noted as MTF, or male-to-female). But being FTM or MTF are not the only categories of transgender. I believe that there are an infinite number of possible gender identities out there in the world, and not everyone will come to either identify as male or female.

The idea that there are two and only two genders—male and female—and that everyone fits neatly into one of those categories is called the idea of a “gender binary”. At least in our culture, the gender binary is a pretty commonly accepted truth. If you think about it, that’s one of the first questions that people want to know if someone is pregnant: is it a boy or a girl? In many cases, the answer to that question will dictate whether the baby shower theme is in pink or blue. Just think, all of this gender determinism before the kid is even born! Many people are invested in this (artificially simple) way of thinking about gender, but I don’t really buy it.

I believe that gender is fluid. The ways in which we come to identify ourselves in life depend on a whole host of factors, and I don’t think that much of anything is carved into stone. Our gender identities, meaning the way we think and feel about ourselves internally as men, women, or something else all together, are one of those pieces of identity that can sometimes change as we grow and move through life. Some people may go through life and realize along the way that they don’t feel at home in the gender they’ve been assigned. Others may have persistently felt that throughout life. Questioning your gender, or trying on different hats when it comes to gender does not automatically make you trans, but some people will decide that the conflicts they feel about their gender are sufficiently strong and disturbing to their lives and well-being that they need to make some changes.

For some trans folks, simply identifying as such, and asking others to respect that identity, allows them enough comfort and emotional relief that they do not choose to pursue any other intervention to change their genders. So when, in your question, you asked about a “sex change”, I just want to put it out there that there is no single procedure or intervention that constitutes a “sex change”, and not every person who is transitioning (moving from one gender to another) will want—let alone have access to—any given type of care.

So not knowing precisely what you mean from your question, I will try to answer broadly and I’m hoping I’ll hit at what you meant!

Someone who is MTF may decide that she (it’s always respectful to refer to someone using the pronouns they prefer, and for someone who identifies as female that is often female pronouns, such as she or her) would like to take hormones to help alter her body. Obtaining hormones from a medical provider is often a step that people take because hormone treatments can help make the physical body look more like how that person feels internally. For instance, someone who is MTF may receive hormone treatments of both estrogen and some type of androgen (testosterone) blocker, and both of those will help feminize their bodies.

There are different ways to go about administering hormones to someone who is transgender, and that is definitely an important topic to discuss with your doctor. It can be, at times, difficult to find a doctor who is sensitive to and knowledgeable about transgender issues, but working with a doctor is the safest way to help assure that you are receiving the right treatments and also taking care of your overall health. Some major cities have health centers that are particularly geared towards lesbian, gay, bisexual, and/or transgender people, and those health centers are often good places to find medical providers who have experience working with trans folks and cross-gender hormone administration. If you do not live locally to such a health center, some internet research for local transgender support groups may help you also locate referrals to which doctors have worked with trans folks, and who other people see.

As I mentioned above, if someone is transitioning from male to female they may receive estrogen, an androgen blocker, or both. Estrogens and androgen blockers work in different ways, and have some different effects in terms of sexual functioning (see, I told you I would get to the actual questions at hand!).

Androgen blockers, such as spironolactone, work to lower the body’s level of androgens, particularly testosterone. Testosterone is largely responsible for what we see as “male” secondary sex characteristics, including facial and body hair and low voices. Testosterone, as a sex hormone, also impacts sex drive and libido, and is a part of the systems and reactions that allow for a penis to become erect, and to ejaculate. Androgen blockers alone generally do not feminize a person who is taking them, but they will lower the person’s testosterone level, which, for some transwomen, makes a huge emotional difference.

Depending on the dosing and how your body reacts, generally within the first 1-3 months of taking an androgen blocker—even in the absence of estrogen administration—transwomen will start to notice fewer of what we call “spontaneous erections” (think waking up with an erection), and also may start to have more difficulty getting an erection even when aroused. Some transwomen who take androgen blockers will lose the ability to gain an erection completely. Aside from impacting ability to have an erection, androgen blockers will generally also decrease one’s sex drive, decrease production of sperm and ejaculatory fluid, and eventually can start to slow facial and body hair growth. Some people also believe that androgen blockers contribute in a small way to the possibility of breast growth in transgender women.

While androgen blockers will not do a lot of physical feminizing by themselves, adding estrogen to that hormone treatment will result in further feminization. This can include: redistribution of body fat into a more typically female pattern, softening skin, decrease of muscle mass and increase of body fat, nipple and breast growth, slowing of body hair growth, and slowed or stopped male pattern baldness. When looking at sexual effects of estrogen, adding that hormone to the treatment of someone who is transitioning from male to female can often result in further decreased production of sperm and ejaculatory fluid (up to and including sterility in some people), decreased testicle size, further decrease in sex drive, fewer spontaneous erections and loss of ability to achieve erection even when aroused. For those women who are still able to achieve erection even with hormone treatments, many find that their erections are more difficult to achieve, not as stiff, or do not last as long as they did prior to hormone treatment.

So that is a little bit about hormone treatments for transwomen and how they impact the ability to get an erection. The most concise answer is, ultimately, “it depends”. It depends on the person and on the treatments they are being given.

Some transwomen will also have various genital surgeries to help their bodies more accurately reflect their inner conception of themselves and their gender. Surgery is often what people mean when they talk about “sex change”, but it’s important to note that not everyone even wants surgery, and certainly even those who want it cannot always afford it. Sex reassignment surgery (sometimes called SRS, or GRS for gender reassignment surgery) is expensive, and even if you have insurance, insurance often does not cover it.

There are many types of surgery that a transwoman could have, not all of which have anything to do with genitals. Some people may have or want facial feminization surgery. Some people may have or want a tracheal shave, which can lessen the appearance of an Adam’s apple. Some people may have or want breast augmentation to supplement the growth that they had from hormone treatments. And some people may have or want genital surgery.

Different types of genital surgery, from orchiectomy (removal of the testicles), to vaginoplasty (creation of a vagina), labiaplasty (creation of labia), and clitoroplasty (creation of a clitoris) both utilize and leave intact different parts of the person’s original anatomy, and have varying impacts on someone’s sexual functioning. Removal of the testicles but leaving the penis intact would render a person unable to achieve an erection. Construction of a vagina, vulva, and clitoris would, in most cases, use the penis to create the new genitalia, so “erection” would probably not be the term someone would use to describe arousal from her new vagina, vulva, and clitoris (though certainly the clitoris is capable of a sort of erection of its own).

So while this starts to answer your question with regard to mechanics and erection potential, it does not really get into the all-important emotional and psychological piece. I think that any time our bodies and our minds are not quite in alignment that there can be an emotional toll. This is in no way to say that all transgender people have emotional problems, but I just want to recognize that our bodies, our gender, and our sexuality can be confusing even when everything lines up. Having the added challenge of feeling uncomfortable with one’s physical sex can add some complications.

As I mentioned earlier, there are many ways to be transgender. Not all MTFs will abhor their penises, and not all of them will be disturbed by erections, or necessarily want erections to stop. Some people will strongly feel that their penises need to go, or that they are very uncomfortable with the ways in which they function. Others may not feel that strong dysphoria about their genitalia, and neither scenario makes someone “more” transgender than another person. There is such diversity, even within people who identify as MTF.

Logically, the way one feels about one’s genitals can impact the way one feels about relating with oneself or someone else sexually.

In your question I am not sure whether you are asking whether an erection and intercourse will feel the same to the person who is transitioning, or to that person’s partner. I will try to touch on both of those scenarios.

Even if a transwoman is not on hormones and has not had any surgery, sex may potentially feel complicated. Hormones and physical makeup notwithstanding, the brain is the largest sex organ that any person has. This becomes important because, for some trans people, the ways in which they choose to think about their body parts—no matter what is physically there—can make a huge difference in how comfortable they feel in sexual situations. While it may seem like a weird conversation to have with someone—only because most of us don’t have a lot of practice talking about this—even a short conversation about what someone calls their body parts or how they want them referred to can help some trans people feel more comfortable or respected. Even if a transwoman has something that looks like a penis, she might think of it as her clit, and want her partner to also call it that, or to touch it as if it were a clitoris.

People, of course, also have different definitions of what “sex” means. Some trans people—heck, this goes for all people—have particular activities they enjoy or dislike, or have particular body parts or spaces that are enjoyable to use or are off limits. Honestly, sex is whatever the people having it decide to make of it, so it’s sort of difficult to give a blanket answer to whether one kind of sex under one set of circumstances would be different than another. My inclination is to say that there are a lot of factors that influence the way sex feels or is experienced, and someone’s gender identity, hormone status, or surgical status could totally impact that.

If you are having sex with someone who is transitioning, or has transitioned, from male to female, it’s probably going to be a bit different than having sex with a cisgender male (meaning someone who was assigned male at birth and still identifies as such). First of all, their body parts could potentially be different. Second of all, even if the body parts look the same, they might work a bit differently. Finally, the person does not identify as male and so that may impact the way she sees herself sexually or wants to interact sexually. The possibilities are really limitless.

And so this leaves us with one important message: we need to talk about this stuff because there is no way of knowing for sure how someone feels or what they want. Positive and healthy sexual interactions usually require good communication, and for all partners to feel understood and respected. Particularly if we might feel uncomfortable in some way with our bodies, sexual or intimate encounters could present challenges if we do not feel safe or able to talk openly with our potential partners about what we like and how we conceptualize our own selves.

For those who may be considering hormone treatment or some kind of surgery to help bring their bodies into alignment with their gender, it’s also important to open up conversations with your doctor about sex and sexuality. We know that sex and sexuality are important parts of who we are as human beings, and so we have the right to talk about this with our providers and also learn, to the best of our doctors’ knowledge, the potential risks and benefits of choosing any one treatment over another. Regardless of our gender identity, we all have the right to a fulfilling and healthy life as a sexual being, whatever that may look like to the individual.

Here are some more resources to learn more about gender, hormones, and transgender care:

written 12 Jan 2009 . updated 22 Jan 2014

Information on this site is provided for educational purposes. It is not meant to and cannot substitute for advice or care provided by an in-person medical professional. The information contained herein is not meant to be used to diagnose or treat a health problem or disease, or for prescribing any medication. You should always consult your own healthcare provider if you have a health problem or medical condition.