This article was updated by Katie Taibl, RN, on 7/6/23. This article has been clinically reviewed by Jacob, RN and Jess, DNP. Jacob also contributed to this article.
Most information around sexually transmitted infections (STIs) and sexually transmitted diseases (STDs) is by default geared towards cisgender people having heterosexual sex. Even when information about protection from STIs includes LGBTQ+ people—such as these recommendations from the Centers for Disease Control and Prevention (CDC)—they usually center on the experiences of cisgender gay men.
If materials about STIs do happen to include transgender people, transgender women are usually centered in these discussions. The point is, there aren't a ton of resources out there on the sexual behaviors and experiences of transgender men, transmasculine people, and other non-binary or genderfluid folks. That’s why we’ve set out to create an STI guide for folks on gender-affirming testosterone GAHT/HRT.
Unfortunately, there is a gap in clinical research, health studies, and medical information for transgender people and nonbinary people who were assigned female at birth (AFAB), especially those who have sex with cisgender men or transgender women. If you’re having sex, thinking about having sex, or just generally want to feel more relaxed and protected in the ways that you are sexually intimate with other people, it’s a good idea to get to know the ways to do it safely, so you are protecting yourself and others.
It’s also important to know the differences between physical changes you might experience on testosterone hormone replacement therapy (HRT) and symptoms of common STIs. This guide is geared toward anyone who is assigned female at birth, or intersex, and identifies as nonbinary or on the trans masculine spectrum.
What are sexually transmitted infections (STIs)?
Sexually transmitted infections are infections that pass from one person to another through sexual contact. The contact can include vaginal, anal, or oral contact as well as other, intimate physical contact such as skin-to-skin contact. There are over 20 types of STIs that a person can contract, but some of the most common include gonorrhea, syphilis, chlamydia, herpes, and human immunodeficiency virus (HIV). Bacterial vaginosis (BV) is not usually labeled as an STI, but we are including it in the conversation as sexual activity can often be the cause of BV.
There is also a misconception that if you were assigned female at birth and primarily have sex with other AFAB bodies, you aren’t at risk for getting sexually transmitted infections. STIs don’t care what body parts you have, what your gender identity is, or whether you identify as straight, bisexual, or gay. And while different types of unprotected sex (sex without barriers or condom use) may result in a higher likelihood of contracting STIs, they can affect anyone and are easily passed from all types of sex. Whether your sexual practices include oral sex, anal sex, or front hole/vaginal sex using any body parts and/or sex toys, it’s important to learn about how to protect against STIs.
Getting an STI can be upsetting, but it’s important to educate yourself, practice self-compassion, and reduce the stigma and shame that can often be attached to contracting sexually transmitted infections. For transgender people and nonbinary people, in particular, feelings of gender dysphoria can be triggered by getting an STI, especially if it focuses our attention on parts of our bodies that we might have complicated feelings around. Staying on top of and empowered in your sexual health and getting tested regularly is the best way to protect against STIs.
What is the difference between an STI and an STD?
There isn’t much of a difference between STI and STD. No matter if people use the term “sexually transmitted infection” or “sexually transmitted disease,” they are talking about infections that get passed from one person to another during sex. STI is the most up-to-date term used by healthcare providers and sexual health educators, as the word “infection” is more accurate and less stigmatizing than the word “disease.”
Furthermore, infections happen when viruses or bacteria enter the body and the immune system mobilizes to fight them off, whereas disease happens when an infection leads to damage and illness in the body. Long story short: most infections never turn into diseases. This is especially true for STIs, as many people are asymptomatic and don’t know when they have one, and they can often be treated or cured before they cause damage.
Are my physical symptoms from an STI or testosterone GAHT/HRT?
You may notice physical changes to your groin area that accompany discomfort. However, it can be easy to miss symptoms of STIs and likewise, mistake common physical changes for symptoms. Bottom growth and front hole irritation are two common physical changes that accompany testosterone GAHT/HRT, for instance.
First off, bottom growth can feel slightly painful, itchy, hot-feeling, and uncomfortable. Especially weeks, months, and years over time, you’ll notice the physical growth down there. Hypersensitive growth can be uncomfortable when brushing against underwear. One study found that the discomfort that some people experienced with bottom growth resolved around six months of treatment.
Second, front hole irritation, or vaginal atrophy, is characterized by the tissues around your front hole becoming thin, easily irritated, and especially sensitive to internal friction (such as different types of penetration during sex) while on testosterone GAHT/HRT. As a result, this area can feel dry, painful, itchy, and/or as if it were burning. In addition to dryness, thinness, and irritation, front hole irritation can also cause urinary incontinence—or an inability to hold in your pee—which can cause urinary urgency, or the need to pee quickly and/or more frequently.
Testosterone can also change the pH and beneficial bacteria that keep everything healthy and balanced. Due to this hormonal change, front holes can be more prone to bacterial vaginosis (BV) and yeast infections. The tissues of the urethra (the urinary pee hole) are also affected and can cause some people on testosterone to be more susceptible to urinary tract infections (UTIs) or bladder infections. While everyone's body reacts differently to this hormonal shift, these changes can start within three to six months of testosterone and reach maximum effect around one to two years.
What are the symptoms of some common STIs?
Some symptoms of STIs look different for different bodies. If you’re having sex (front hole or anal sex), then it’s important to get STI testing regularly and after each new sexual partner as not everyone will show symptoms. Most STIs are treated with a course of antibiotics, so the more quickly they can be treated, the more you can be sure that you haven’t passed anything on to anyone else. Here are what some of the symptoms of common STIs can look like in transgender bodies.
- Gonorrhea— Many AFAB people don’t have any symptoms of gonorrhea, but for those who do, the most common symptoms are often painful urination—some people may experience urinary urgency (the sudden urge to pee) and/or urinary frequency (having to pee very frequently). Symptoms can also include yellowish and possibly bloody front hole discharge or discharge that is thin, watery, and/or green or yellow in color. For those who bleed monthly, it’s possible to have bleeding between cycles with gonorrhea. Abdominal pain isn’t common but can indicate a more serious infection. STI swabs can be used to detect the presence of gonorrhea in your front hole. Gonorrhea can also be present in the throat, which is a location that shows even fewer symptoms if any at all. In the rare case that a person has symptoms of oral gonorrhea, this may present as a sore throat, swollen lymph nodes, or pharyngeal exudates (fluid secreted from the tonsils), usually from a firm and painless sore.
- Syphilis— Syphilis is divided into stages, with the first two stages showing symptoms for the most part. The first sign of a syphilis infection tends to be a chancre, a sore that develops in the same spot where syphilis entered your body. That means that even if a chancre does develop, it could be inside the body and difficult or impossible to see. One of the key symptoms of secondary syphilis is a rash that is most often on the palms of the hands and soles of the feet.
- Chlamydia— Folks who have chlamydia often do not realize that they do because the symptoms tend to be either very mild or not present at all. The symptoms to look out for are yellowish front hole discharge that has a strong smell to it, painful front hole penetration, painful peeing, and peeing more often. Chlamydia tends to affect the cervix most commonly, so folks who have had their cervix removed have a greater likelihood of not having symptoms. This is why it’s super important to get tested regularly!
- Herpes— There are two viruses that cause herpes: HSV-1 and HSV-2. Although HSV-1 tends to be associated with oral herpes (cold sores) and HSV-2 tends to be associated with genital herpes, it’s possible to have either virus affect either location. Genital sores can look a lot different than oral herpes sores, so it’s important to know what to look out for. The primary symptoms of genital herpes have a lot to do with the location of the sore. If a sore is near your urethral opening, you might experience some pain when you pee from urine getting on the sore. Similarly, you might have difficulty peeing if the sore is in or near your urethra. Itching on and around the sore is also a common symptom. Genital herpes sores can look a lot different than oral herpes, sometimes looking like just a small cut or scrape, so it’s important to get checked out if you think you have symptoms of herpes.
- Bacterial vaginosis/BV— Itchy and/or painful in and around your groin area; burning while peeing; strong odor, especially after sex, and front hole/vaginal discharge.
- HIV—Early/acute signs of HIV infection look a lot like the flu. Headaches, fever, rash, fatigue, and swollen lymph nodes are common symptoms seen in folks with an acute HIV infection. PrEP (pre-exposure prophylaxis) is a useful preventative medication that can reduce the transmission of HIV. Despite popular belief, PrEP is not just for gay cisgender men! Learn more about if PrEP might be right for the types of sex you’re having.
- Crabs: Same symptoms regardless of what parts you have. Itching, small spots of blood in underwear, white dots in pubic hair that are hard to remove, low-grade fever sometimes.
- Giardia (from rimming): Common symptoms include diarrhea, abdominal pain/cramps, nausea, vomiting, dehydration, foul-smelling and greasy poop.
- Hep-C: Symptoms are very similar across the board, no matter what parts you have, since the symptoms are liver-related. Symptoms include fatigue, abdominal pain, nausea/vomiting, decreased appetite, yellowing of the eyes, dark urine, and clay-colored stool.
- HPV: Most people have HPV at some point and are asymptomatic. Know you will most likely clear it. However, there are some strains of HPV that can progress to more serious infections, so it’s important to get STI screenings done regularly and talk to your provider about HPV vaccines.
When should you get things checked out?
If you experience any of the symptoms listed above, know that you have been exposed to an STI, or if you just have a feeling that you should get checked out, get tested! Contact your local healthcare provider, health center, or FOLX care team for more information. It’s also important to get tested regularly, even if you don’t have any symptoms.
If you’re new to FOLX and interested in gender-affirming healthcare, learn more about our estrogen and testosterone offerings. If you have additional questions about STI signs or symptoms, you can schedule a virtual primary consult here. If you have additional questions, please reach out to our Member Navigators at the FOLX Help Center. FOLX members with questions about their sexual health are encouraged to contact their clinician.
FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include expert, gender-affirming virtual primary care, gender-affirming hormone therapy including estrogen and testosterone, mental health care, sexual health care, and preventative care. We offer FOLX memberships that give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ referrals, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-friendly healthcare with FOLX. FOLX Health is healthcare that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!