Safer sex and sexual health for trans masculine people

If you’re having sex, you should get to know the ways to do it safely so you’re protecting yourself and others.

As well as making sure you’re happy and comfortable with the sex you’re having, making sex safer looks after you and your partners’ physical health. Using barriers if they’re needed, alongside lube, and getting screened regularly is a way to reduce the risk of HIV and other sexually transmitted infections (STIs).

Discovering your sexuality can be really exciting, and you may be exploring new things, or with new parts of your body. Wherever you are in your transition, and whether you have decided to have surgery or not, you're entitled to have sex that is safe and enjoyable.

STIs can affect anyone and are easily passed on from all types of sex with all types of body parts and sex toys. If you’ve had lower surgery or not, using a barrier such as a condom or dam along with water-based lube is the best way to protect against STIs.

If you’re having sex, then it’s important to test regularly. Have a sexual health screen at least once every year, and more frequently if you change partners or have casual or new partners. STI screening is quick, free, and painless and you can take your own samples from the body parts you use for sex.

Not everyone will show symptoms so it’s important to test regularly and after each new sexual partner. Most STIs are easily treated with a course of antibiotics, and the sooner you know you have one, the more quickly it can be treated, and you can make sure you don’t pass it on to anyone else.

Getting an STI can be upsetting and can trigger feelings of gender dysphoria for some trans and non-binary people, especially as it focuses on parts of our bodies which we may not want to engage with. Keeping in control of your sexual health and using condoms where needed is the best way to protect against STIs.

Condoms can stop STIs from being passed on when used correctly. Use a new condom for each partner and never use the same one for anal and frontal sex.

External condoms can be used on a neo phallus, post phalloplasty or metoidioplasty. They come in a variety of sizes and materials (including latex-allergy free), so you can find one that fits you best. If you’re having sex for more than half an hour, it’s a good idea to change the condom to prevent it breaking.

Some trans people fashion condoms from medical grade gloves to cover their genitals during sex. This is not ideal as the prophylactic can fall off. Dental dams and internal condoms should be used instead.

• External condoms go over a penis, including metoidioplasty, or sex toy. They are the safest option for penises, whether it has always been there, is surgically-constructed or bought in a shop.
• Internal condoms (formerly known as Femidoms) go inside the front hole or anus (remove the top ring for anal sex). This is the safest option for those with a metoidioplasty or enough testosterone-enhanced clitoral growth for penetration.
• When using lube, use only water-based or silicon-based lubes with condoms and not oil-based lubes or lotions, which weaken latex. Avoid silicone-based lubricant with silicone dildos and sex toys as it can degrade the surface.
• Dental dams consist of a sheet of latex used as a barrier in oral-front hole sex and rimming which can prevent the transmission of STIs.

HIV is a virus that can be passed on through sexual contact. It's carried in blood, anal mucus, semen (cum and pre-cum), and vaginal/front hole fluid. HIV can be transmitted if no protection is used and the person with HIV doesn’t have an ‘undetectable viral load’ (when the amount of HIV is so small it can’t be detected in a blood test).

It can take up to six months for a person on HIV treatment to become undetectable and unable to pass it on to others, with or without a condom.

HIV can also be transmitted when an object (e.g. a sex toy) that has body fluids on it is put inside an HIV-negative person during sex.

HIV is not transmitted through sweat, saliva/spit or urine/pee.

HIV prevention pill PrEP is an effective way to prevent HIV transmission. PrEP is taken before and after you have sex.

People of any gender or sexuality can be HIV positive, but there is evidence that globally some trans people, especially trans women, can be at higher risk for HIV. This can partly be attributed to lack of information and access to good sexual health care for trans and non-binary people.

An analysis of several international studies has shown that trans women were 49 times more likely to be HIV positive than any other group. Trans sex workers in particular are at higher risk for HIV. More research is needed about trans men and HIV, though prevalence is estimated to be lower. A recent study shows that HIV prevalence in trans and gender diverse people living in England is much lower than international estimates.

If you’re having receptive or insertive vaginal/front hole or anal sex, using condoms or PrEP will prevent HIV transmission. Regular testing is key, so you can access treatment and protect your partners.

If you’re having sex, it’s a good idea to test for HIV at least once a year, or more often if you change partners or have casual or new partners or have been diagnosed with an STI. It's easier to acquire or pass on HIV if you have another STI.

HIV treatment is highly effective and means you can have a long, healthy life. Testosterone has no known interactions with HIV medications and they can be taken together.

It’s better to know your status and start treatment early to prevent serious illness. Scientific evidence has shown that people living with HIV who are on effective treatment cannot pass the virus on to anyone else.

There are lots of ways to test for HIV, including testing at a sexual health clinic, online postal kits, HIV testing centres and your GP. You can also order self tests online that you can do in your home and get instant results.

If you’ve recently had lower surgery and have unhealed skin, this could make it easier for you to acquire or pass on HIV as bleeding can provide a route into or out of your body. Discuss with your surgeon what kind of activity you can do and how soon.

Taking hormones can also increase the risk of bleeding during penetrative frontal and anal sex. Use plenty of lube and always use a condom, unless you and your partner have tested and know you don’t have any STIs, and regularly check for any tears.

Testosterone can cause vaginal/frontal symptoms such as dryness, pain and bleeding on having sex, and discharge which can be easily mistaken for symptoms of some STIs.

Testosterone (or T) can change vagina/front hole lubrication, so you might find you don’t produce enough. It may be because the natural acidity in the lubrication has changed, making you more vulnerable to infections like cystitis. This seems to be more of an issue during the first few years on testosterone. Make sure you always have enough lube.

Reduced levels of oestrogen affect the thickness of the walls of the front hole, which may result in tiny unnoticed tears happening more easily if you’re having frontal sex. The walls of the rectum can be affected in the same way. Making it even more important to use condoms and lube.

Long-term use of testosterone will change the normal, healthy bacteria inside your front hole/vagina. This can lead to a condition which can make penetrative sex painful and produce unpleasant discharge. This can be treated with oestrogen cream, which does not affect your T levels and few people report any side effects.

It's recommended that if you do not elect to have a hysterectomy then you should have a trans-abdominal ultrasound every two years to ensure no abnormalities are occurring. This will measure the thickness of the uterus.

Being on testosterone will decrease your fertility, and long term use can lead to infertility. Within a few months of starting testosterone, periods usually stop. Over time the reproductive system will go through a process similar to the menopause, which will thin the lining of the uterus and cause the ovaries to shrink.

However, testosterone is not an effective form of contraception and, if you don't want to get pregnant, you should use an effective form of contraception. Consistent condom use will prevent pregnancy but there are other things, such as the coil, implant, injection or pill, which can be safely taken with testosterone and are more effective than condoms at preventing pregnancy.

The desire or wish to have children is not limited to cisgender people or women specifically. Many trans men and non-binary people transition without having surgery that removes reproductive organs or reconstructs genitals.

A physical transition that only involves hormone therapy and/or chest surgery may not necessarily remove the ability to become pregnant. The decision to try to have children can be difficult and will require some special considerations regarding your own personal circumstances.

Becoming pregnant is dependent on a number of factors, including stopping testosterone. Depending on how long you've been taking testosterone, you may need to help your reproductive system by taking oestrogen for a while.

Top surgery may remove your ability to chestfeed an infant.

University of Leeds Trans Pregnancy Project has some useful resources and films for transmasculine people (including trans men and non-binary people) who wish to or become pregnant.

There are a variety of reasons why some trans masculine people might find it challenging to negotiate condom use with their partner. Some of these reasons may include:

• fear of rejection
• internalised transphobia
• not feeling empowered to speak up
• belief that it is masculine not to use condoms
• prioritising social affirmation over protecting your health.

Trans masculine people who have sex with cis men are at a higher risk of HIV and STIs. Some cis gay men might only associate HIV and STI risk with anal sex, so might not think there is a risk with frontal/vaginal penetration. They may also assume that you are unable to become pregnant. This risk is also present with anyone who has a penis, no matter how they identify. Condoms are effective contraception and protect you from STIs and HIV.

Tips on negotiating condom use

• Discuss condoms prior to sexual activity.
• Avoid drugs and alcohol as that will affect your ability to negotiate.
• Make putting on a condom part of play.
• Passing a condom to a partner can be understood to mean you want to be fucked. It also signals that you want to use a condom for this activity.
• Make sure you have condoms with you – take responsibility for your sexual health.
• Make sure you have the right size.
• Practise using them before you have sex.

Anal and frontal/vaginal sex

• Has the highest risk for getting an STI or HIV.
• Use an internal or external condom.
• Use water-based or silicone-based lube.
• Some infections such as herpes, genital warts and syphilis, can be transmitted through regular skin-to-skin contact. A barrier such as a condom, dental dam, or a latex glove reduces risk but only protects the covered area.
• Use a different condom with each partner, and when a penis/sex toy is moved between vagina/front hole and anus.

Oral sex

• Has a low risk but it’s still possible to get or pass on STIs such as herpes, syphilis or gonorrhoea.
• Has a very low risk of HIV transmission.
• Avoid if you have bleeding gums, ulcers, a sore throat or had recent dental work.
• Avoid receiving oral sex until you are fully healed from genital surgery as there is a risk of infection.
• Avoid letting a partner ejaculate in your mouth – you can also use flavoured condoms or dental dams.

Using sex toys

• Clean them thoroughly using warm soapy water before using them with different people to avoid sharing fluids.
• Use a new condom for each new person or when moving from anus to front hole.
• Sex toys can cause tiny unnoticed tears to the skin lining the front hole or the anus so use condoms and lube.

Fingering

• Make sure you don’t have any cuts on your hands or fingers. Keep your nails short and use plenty of lube.
• Clean your hands thoroughly using warm soapy water before fingering a different partner as fluids can transfer on the surface of fingers
• Use a latex glove to cover the finger or avoid fingering more than one person.

Rimming

• Rimming is licking someone’s anus.
• This had an extremely low risk for HIV but it's possible to pick up hepatitis A or bacterial infections such as shigella or gonorrhoea.
• Good personal hygiene can reduce risks slightly.
• Use a barrier like a dental dam to cover the anus.

Frottage

• Frottage involves rubbing genitals together without any penetrative sex.
• Low risk but a chance that skin-contact bacteria or viruses could be transferred (such as herpes, syphilis or genital warts).
• Parasites (such as scabies or crabs) can be passed via skin contact.

Rougher sex

• Use a different condom with each partner, and when a penis/sex toy is moved between vagina/front hole and anus.
• Bondage, fisting or S&M can result in bleeding or tearing of the anus, vagina/ front hole or mouth, providing a route for STIs, HIV and hepatitis.
• Use latex gloves when fisting and don’t share a pot of lube as minute traces of blood can be transferred onto your hands, making it easy to pass on hepatitis C.

Next: Using PrEP and PEP