By Emma McGowan

Pain during sex is, unfortunately, really common for people with vaginas and vulvas, whether they’re cisgender women or they are transgender or non-binary people who were assigned female at birth (AFAB). And while vaginal pain in cisgender women is understudied, vaginal or frontal hole opening pain in transgender men or trans masculine people taking testosterone is even less so.

When Elliot, 36, an AFAB non-binary agender person, started taking testosterone three years ago, their sexual desire increased “to the point of distraction.” They found that they were especially turned on in the early afternoon, while they were still at work, with the accompanying increase in vaginal lubrication. It was… awkward, to say the least.

“I also started to get significant clitoral growth, which was super sensitive and changed a lot about how my body responded to different types of stimulation,” Elliot tells The Pelvic People. “My experience has been that clitoral growth was almost immediate, with most of the growth happening quickly, and then incremental over time after the first year.”

Needless to say, sex also changed a lot for Elliot. Notably, they now need more warm-up and foreplay than they’d previously needed and they can’t handle intense clitoral stimulation anymore. 

“I now prefer air pulse toys — my go-to is the Satisfyer Pro 2 because the head has a larger opening — and a slower build to more intense bullet vibrations,” Elliot says. “I am also much more interested in anal stimulation than I was before. With a partner, I still enjoy mixing sensations (e.g. penetration with clitoral stimulation), but need to work up to penetration first. Pre-T, I was almost always able to jump right to penetration without much warm-up.”

Elliot has also experienced some new types of pain with sex since they started taking T, especially around vaginal dryness now that the initial flood of natural vaginal lubrication has ended. But while everyone’s experience taking T will be different and individual, there are some fairly common experiences when it comes to pain and sex. Let’s take a look.

Testosterone 101

Before we dive into the sex stuff, we’re going to do a quick review of what testosterone is and does. If you’re taking T, you probably already have a decent idea about a lot of this. However, not everyone has trans-informed health care providers, so we want to make sure we cover the basics.

Testosterone is one of three main reproductive hormones (the other two are estrogen and progesterone) in humans of all genders. It’s responsible for the development of testes and penises.

Traditionally called the “male sex hormone,” it’s used for “masculinization” — i.e. the development of secondary sex characteristics that are associated with cisgender men — in transgender men and other trans masculine people. People taking gender-affirming testosterone go through what’s often called a “second puberty:” lower voice, increase in facial and body hair, acne, and a change in fat distribution throughout the body. They’ll also, like Elliot, often experience an increase in sexual desire, an enlarged clitoris, and increased vaginal dryness.

Potential causes of painful sex for trans masculine people taking testosterone and what to do about them

Because testosterone is a sex hormone, it naturally affects your sexual organs. The vagina or frontal hole opening is very responsive to estrogen, which is the hormone that creates secondary sex characteristics like breasts and wider hips. When you start taking testosterone, the estrogen in your body decreases and that can lead to discomfort and even pain in the vagina, vulva, or front hole opening. Here’s how those changes could potentially cause pain during sex.

Vaginal atrophy

Vaginal atrophy is the super not scary term used to describe what happens to the vagina and vulva when estrogen decreases, usually either due to menopause or because a person is taking gender-affirming testosterone. The lower amounts of estrogen lead to vaginal or front hole opening dryness, thinning of the vaginal and vulvar/front hole opening skin, and inflammation. 

The biggest issue when it comes to the main symptoms of vaginal atrophy is that there’s likely to be more friction during sex. Think about any time you’ve had penetration without proper lubrication. It was dry. It rubbed. It “felt like sandpaper.” Not great! Add on top of that the increased likelihood of skin tears, and what used to be a lot of fun is all of sudden decidedly not. 

Luckily, there’s a super accessible solution for this problem: Lube it up!

“There is no such thing as too much lube!” Elliot says. “I keep a high quality lube on hand (my favorite is Sliquid H2O or Sliquid Sassy) to make things slipperier when needed. More foreplay and easing into things like penetration are also easy to manage.”

Vaginal atrophy can also lead to urinary issues, like an increase in urinary tract infections, as well as an increase in bacterial vaginosis, both of which make sex really uncomfortable. If that’s an issue for you, you’ll need to go to the doctor for antibiotics to ease the infection. They might also recommend localized estrogen, either in the form of a cream or a ring inside the vagina or front hole, which is extremely low dose and shouldn’t affect your gender-affirming testosterone treatments.

Clitoral overstimulation

Because the external clitoris tends to grow and elongate during gender-affirming testosterone treatment, it also tends to get a lot more sensitive. Think about it: It has all of those same nerves that it always had, but there’s more surface area to access them. It also might get too big to be covered by the clitoral hood, leaving it further exposed and stimulated. 

For Elliot, dealing with increased sensitivity — and subsequent soreness — has meant experimenting with new toys and different sex acts.

“I have found that just changing it up and doing something else for a while gives my body enough of a break before returning to clitoral stimulation,” Elliot says. “Since I won’t climax without clitoral involvement, it’s important to stop and change pace as soon as I feel a bit of soreness coming on.”

Pain with orgasm

Some transgender men and trans masculine people taking T report deep pelvic pain during orgasm and cramping after intercourse. This is an especially under-researched area and it seems that most of the information out there about this kind of pain is anecdotal. 

Some people choose to have a hysterectomy with this kind of pain, but that’s not the only solution — or even necessarily the best one, if the issue isn’t with your uterus. If you’re experiencing this kind of pain during sex, your best first move is to go to your doctor and figure out the most likely cause.

Advocating for trans-informed health care

Doctors often aren’t trained in trans care, which means you’ll likely have to do a lot of advocating for yourself at the doctor’s office. It might seem a little scary at first, but if you come informed and feeling empowered, you’ll feel so much better about your appointments.

Your first move can be seeing if there is a trans-informed health care provider in your area. You’ll likely have better luck if you live in a big city or, at the very least, a city with a university medical program. Do some googling; check out Folx Health or this provider directory; ask your trans friends who their doctors are; and see if there’s a provider who’s better than the others that you can go to.

Then, do what you’re doing now — research! Read articles. Find Facebook groups. Talk to your friends. There is a lot of community knowledge out there about medical transition and you’ll likely find that your peers are your best resource.

Oftentimes your best bet for receiving great trans-informed care is, unfortunately, to trans-inform your providers. Health care providers have very little time with patients, so it can help to come armed with information about what you’re dealing with, as well as potential solutions that other trans folks have used. You should also lean on the side of oversharing, because your provider can’t treat an issue that they don’t know about. 

Sex shouldn’t hurt (unless it’s on purpose), regardless of your anatomy or the hormones in your body. And while taking T can lead to its own set of potential pain with sex, they’re all solvable. You’ve got this.