Erectile dysfunction is consistently counted among the most common sexual disorders. It’s also a topic close to my heart (and other organs) because I experience it. Trans women are frequently left out of conversations about erectile dysfunction even though many of us feel it very keenly. That’s the limp noodle topic on my mind today: Trans women, erectile dysfunction, and what we can do to deal with it.
The what and who
Most medical resources describe erectile dysfunction as an inability to achieve or maintain an erection (ED) that is satisfactory for sexual activity. That’s an adequate summary for the majority of sufferers. But I come from a critical health psychology background, so I want to tease out some nuances.
For one, the standard medical understanding of ED is based on the needs and experiences of cisgender men. Yes, cis men make up the majority of sufferers, but aren’t all of them. I’m living, breathing evidence of the exception. Since ED is characterized as a men’s health issue, there’s an implication in its medical definition that the natural state of anyone with a penis is to want erectile function. Therefore, lack of erectile function is disordered or undesirable.
Trans people who happen to have penises and don’t want penile function throw a wrench into that presumption. Trans women with genital dysphoria often fondly remember how joyful it is to lose penile function after starting hormone replacement therapy. That state of existence is praiseworthy in the pursuit of individuality and happiness, but it’s also not all of us. My sex life all but died when I started hormones because my preferred way to have sex was no longer available.
That’s why a mainstream medical characterization of ED as the loss of penile function alone is inadequate. In my mind, it only warrants the ‘dysfunction’ or ‘disorder’ label if it’s actually negatively impacting a person. There are lots of people who’d be elated to have erectile ‘dysfunction’. Likewise, there are plenty of trans women who want to retain erectile function.
The reasons we may want erectile function are diverse, too. Some of us realize we’re trans in a context that discourages transition and have to uphold a masculine sexual script until opportunity comes up. Some of us just like having a penis and would prefer it worked in a certain way — that’s affirming. Some want to retain penile function while transitioning. Trans sex workers may need penile function to perform their proverbial part. Even trans women who are pursuing gender confirmation surgery may wish to retain penile function for a while. Not all trans women undergo gender confirmation surgery either. At any given time, most trans women don’t. It’s extremely difficult to establish why we haven’t. There can be an abundance of interest, but financial or interpersonal barriers might prevent it.
But I have to take a page from one of my favorite subreddit: /r/abrathatfits. Their motto is that everyone who wants a bra deserves one that fits. My aim is similar. I think that every girl who wants an erection should have one.
Deflating our way to happier lives
After I got on estrogen, one of my only downer moments was realizing my penis no longer worked the way I wanted. The addition of that new health condition is only a slight speck compared to the happiness I got out of transitioning, but I deserve better, dammit. Even though all the trans women in my life had genital dysphoria, I knew I wasn’t the only one.
I caught up with Dr. Anastacia Tomson (general practitioner, queer activist) recently to get a sense of what experiences she’s seen among trans women who have ED. Her answer was brief, but pointed: “This will be different for everyone, but they can be profound – I’ve seen patients experience frustration, disappointment, sadness, shame, distress, and even anger.”
Many of those listed emotions appeared in my transition. Disappointment at having to give up parts of my sex life. Frustration at not being able to ‘get it up’ for the camera when I’m doing sex work. Sadness about losing something as a side effect of an otherwise wonderful journey.
Not much anger, though. The only time I was pissed off was when I got a tadalafil prescription to treat my ED. The instructions said that the 10mg dose was standard, so I took it as indicated. Well, I forgot that the 10mg dose was tested extensively on cisgender men. Men who have much higher muscle and body mass than me. Oh sure, 10mg ‘resolved’ my erectile dysfunction. It also gave me a pounding headache and blurred vision so bad I couldn’t have sex until the pill started wearing off the next day. Since there aren’t enough clinical trials to establish the norms and safe dosages of ED pills for trans women, I (unintentionally) took one for the team. Have a laugh at my expense. It’s what I do.
In cis men, there are numerous drivers for ED: Cardiovascular conditions, substance use, anxiety, and medication, to name a few. Trans women bring new physiological and emotional dimensions to ED risk. Unsurprisingly, a high dose of estrogen does not encourage penile and testicular function. The opposite, actually. For some trans women, this leads to the desirable loss of erections, reduced sperm count, and penile atrophy.
Even so, a heightened chance of experiencing ED is no guarantee. In Dr. Tomson’s words, “Erectile function is a complex interaction of multiple systems – nerves, blood vessels, glands, hormones – each of which needs to function harmoniously with the others in order to achieve and maintain erection. Transition can interfere with any of these, potentially – but most often it’s through the effect on hormones (less T, more E) that we see this play out.”
ED is not yet fully understood in cis men, especially when we bring complex causes like conditions of the nervous system or vascular interference from COVID. I’m a bit saddened to report that in terms of medical consensus, trans women have very little to go on if we want to retain penile function.
There’s also a very complex psychological dynamic between trans women and erectile dysfunction. Gender transition alters how we perceive our sexual selves, too. Sex isn’t just about bumping body parts into each other. It’s an emotional and cultural experience. From Contrapoints’ use of the word mouthfeel for the feminine penis to my past sex partners who didn’t want their penis perceived or touched, we have an array of value judgements about penises.
Gender transition is just that: a time of flux applied to every part of our being. Trans women routinely find our preferred bedroom roles changing with everything else. People who start their journey satisfied with erectile function may lose interest as genital dysphoria sets in. Many trans women love their flaccid penises and treat them like an oversized clitoris. On the other side of the fence, trans men may find the same joy in seeing a clitoris grow on testosterone and become more penis-like.
I guess what I’m saying is that it’s complicated. Trans people are vibrant and complex people in our own ways, and our engagement with genital function is one facet of that. But what if you just want it to be hard?
A path paved with pills and health providers
Until the scientific community catches up to our sex lives, we’ll do what we’ve always done: find supportive healthcare professionals who are happy to tailor existing standards of care to our needs.
Estrogen and testosterone hormone replacement were not developed for gender transition. They’re indicated for cis people, and trans people have always gotten our prescriptions off-label. Puberty blockers? Also developed for, and tested on, cisgender people. Spironolactone remains a common prescription in trans women’s pockets but was likewise developed for treating heart conditions.
Erectile dysfunction is pretty much the same story. It’s very treatable through lifestyle changes and medication. If your ED happened due to estrogen, that’s probably a physiological cause. There are reliable and safe medications for that. Just don’t be a fool and take a dose too large for your body to handle like I did.
This is another area where affirming healthcare professionals matter. A good doctor will understand exactly why you want your body to work a certain way and help you pursue those goals safely. A bad one? Dr. Tomson knows of, “some medical professionals [who ]believe that sacrificing erectile function is a necessary part of transition, and that a “real” trans woman would be okay with that.” For those of us looking, she adds that, “It’s hard to find the right healthcare provider, but if you have one who is safe and competent, I’d hope you’d be able to discuss this without shame.”
Besides doctors and leafy greens, erectile dysfunction — especially if it erodes your self-esteem — shouldn’t be a lonesome road. Mental distress prefers isolated prey. If ED is something you stress over, it’s well-worth talking to your partner or an online community about it. We assert ourselves as women with our whole selves. That girl card isn’t revoked due to the absence or presence of an organ, and it’s everyone’s right to have it work (or gone) the way they want.
