Sex Drive & Libido Changes for Trans Women Taking Estrogen
Gender-affirming estrogen hormone therapy is something that can make you feel good in your body. For many trans women, trans feminine people, and nonbinary people, the emotional and physical changes range from subtle to profound and are often life-saving. Yet, when it comes to sex drive, or libido, many AMAB (assigned male at birth) folks who take estrogen experience emotional and physical changes that can be both exciting and also uncomfortable when starting estrogen.
Many AMAB people wonder how their sex drive, sexuality, and sexual expression might change after taking estrogen, and we know there are a lot of myths out there! There aren’t many studies about how estrogen therapy affects transfeminine folks and trans women’s sex drive or libido. But our patients share their lived experiences, which might help inform you as well. And it has shown us that a lot of sex drive has to do with expectations, experience, and feeling at home in your body.
What we know and have learned about estrogen hormone therapy is that sex drive, including sexual desire and orgasm, is nuanced. Libido changes on estrogen are very dependent on the mind-body connection. The mind-body-hormone connection is a sensitive one. All of this is to say that libido is a lot about your state of mind. Everyone is different, and libido can be complex.
What is libido?
Libido is known as sexual desire. It can be baseline interest in or desire for sex. Your sexual appetite or inherent desire is known as libido. Arousal, on the other hand, refers to your physiological response to sexual stimuli. This includes blood flow for erections, blood flow to your clit, getting “turned on,” and hardening of nipples. Arousal can be stimulated through thoughts and sensations.
How estrogen impacts libido
The physiological or physical aspect of sex drive is determined by the way hormones function in the body and how the body reacts to them. Sex drive is based on hormonal interaction and also sensual arousal. Your hormones may play a role in an innate increase/decrease in sex drive, but you can also set the mood to enhance sensations and mindfulness around sexual arousal.
Changes in physiological function and desire are part of switching from a T-based (testosterone-based) system to an E-based (estrogen) system. A different physiology is active now that testosterone is being “shut down.” Some physiological “givens” from pre-estrogen times may not be the same because a different system is at play, in terms of your brain and emotions. For some, the physical changes in libido never happen. For others, sexual function evolves as they affirm who they are.
Physical changes when taking estrogen can cause erectile dysfunction and changes in arousal.
For the physiological (physical) components of your sex drive, it is true that both testosterone blockers (also known as antiandrogens, with spironolactone being a commonly prescribed medication) and estradiol can suppress erectile function and reduce the amount of ejaculate (sperm). For example, spontaneous erection is usually less frequent for some, which can be distressing for some people. Perhaps you used to be horny or have orgasms all the time, and now it is a challenge because everything is different.
As our sex hormones adjust, there can be a variable effect, with waves of changes- similar to puberty changes. For some, this can be an "up and down," and for others can be gradual or feel more sudden. If you experience unwanted changes in erectile function, we can try a medication like sildenafil (viagra) or reduce your hormone medications.
Erectile meds can be used for people who were AMAB and people with penises. So, do these medications work for people who call their anatomy something else? For people who would like to firm up their genital tissue to improve their sexual experience? Potentially, yes to all! The most common side effects include headache, flushing, nasal congestion, light headedness-and of course, erect genital tissue.
Pain with sex
Sometimes, sensations with sex change or sex becomes uncomfortable. If you are having less pleasure with receptive sex, either anal sex or (neo)vaginally, this may be a result of the prostate’s size reduction and may improve with adjusting your medication regimen.
As one trans women writer, Sophie Macdui puts it, “I forgot to get hard, and it hurt.” Yet, her transfem experience is one of many helpful anecdotal stories that shine a light on the nuances of estrogen and sex drive. HRT changed her orgasms, for the better. Yet, it was a process to find sexual pleasure in a new way.
Emotional changes affecting sex
As your body changes, it may affect how you think and feel sexually. Many changes are fun and satisfying. Hormone changes or gender-affirming procedures can be euphoric for many. However, there is often trauma we carry from living in a body that does not match our mind. It is important to understand sometimes this trauma continues to affect us even after hormones or surgery.
What we must do is acknowledge that often, after waiting years for hormones or an affirming surgery, we may carry a history of trauma from living in a body not congruent with our mind. Even after we finally go through the affirmation process, we still can go through issues with body self love and function. You may have gone from being dissatisfied with your body to loving it. It takes time to learn how to love something you have always had challenges with. It is a part of your lived experience that was hurtful to you. It is an opportunity to heal.
Often, libido improves once your body and brain feel more congruent on estradiol. Being relaxed and not tired or stressed, having time, and feeling safe and cared for all contribute to better sex. Our emotions may change, and the type of connections, stimulation, and sex we desire may change
What our patients say
Our clinicians have seen people experience profound changes, in both directions: either a heightened sex drive or a mellowed-out one. Some folks report better sexual experiences on estrogen because they feel happier, more comfortable with their body, and are beginning to enjoy their body more as dysphoria lessens. Touching their breasts or genitals and masturbating may be pleasurable in a new way. Being sexual with someone else and letting them know what feels good can also enhance your sexual pleasure.
Other folks on estrogen say they are missing their sex drive, or miss the ease with which they previously got erections. Others say they don’t want to have sex in the same way, yet feel romantic and enjoy cuddling but don’t desire orgasm or to ejaculate in the same way as pre-estradiol. Some people prefer to not engage with their genitals or sex until after bottom surgery. The difference is as profound as it is individual. It’s about what you feel physically, how your brain responds, and what your heart desires sexually.
Sexual function concerns
It’s normal to have concerns about your sexual function when starting estrogen HRT. Things like attraction, desire, or getting excited about orgasms are all important to a healthy sex life.
A common occurrence is when people on estradiol want to start on a low dose as they don’t want to interrupt their sexual function. Many people find that a low dose increases their enjoyment of nearly everything else in their life and learn a new way to be sexual. If you are concerned about sexual function, you can start low and slow, as we understand folks may want to ease into changes. When working with a good and safe provider, where you’re comfortable talking about your worries and desires, it’s easier to adjust medications and care plans to modify and meet your needs.
People have many goals and concerns when it comes to their sex drive. Many may have a partner where sexual function is important. Other folks may have one where it isn't. There is no one-size-fits-all approach. People/clinicians/care teams at FOLX are not uncomfortable talking about sex. It’s a part of being alive, being human, and a part of sexual and gender development. We want it to work to the best of your ability.
Tips for dealing with changes
If you do experience changes that you don’t want, you can always discuss changing your hormone regimen with your clinician. You can work with your clinician to alter doses, routes, timing, and frequency of estradiol or anti-androgens. Your clinician can also prescribe erectile dysfunction medication. On estrogen GAHT/HRT, we’ve had many folks describe sexual activities involving more choice and thoughtfulness, rather than a "given." A mindfulness approach to sex can help as hormone profiles change on HRT and blockers.
Our sexuality and sexual experiences can be complicated. We hope that you find that GAHT and estrogen supports not just your gender, but your sexuality. We support all aspects of your health at FOLX, to prioritize your utmost well-being, and will always work with you to be partners in your care.
FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include virtual primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health care, preventive care, and fertility consultations. FOLX memberships give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ resources, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-specialized health care that helps you meet your wellness goals. FOLX Health is health care that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!