Expert Article
By Dr. John O’Dea
It doesn’t matter where in the world we find ourselves or what religion the locals favor, sexuality is and has been a taboo subject for thousands of years. Celibacy is idealized as if abstinence were a virtue and sexuality itself inherently evil. However, sex is a physical necessity, like food. Nature designed us to seek both obsessively, but we aren’t condemned for eating unless we overdo it. Yet with sex, any degree of activity is considered sinful unless it is procreative. In this context, it shouldn’t be surprising that trans-women are often urged to abstain until the completion of transition. This approach has no basis in logic.
Prudishness goes back a long way, but conveys no evolutionary benefit. It is a trait that is promoted by religion to the extent that it becomes social brainwashing. I grew up in an Ireland noted for its uniquely Jansenistic form of Catholicism & experienced that brainwashing at first hand. We were taught that sexuality should be utilized solely for the purposes of reproduction. Our teachers were clergymen whose celibacy, in retrospect, may have been highly questionable. And of course we’re all familiar with Calvinism and its perverse rejection of the biological drives and urges that nature itself gives us.
Today, the sexuality of the male-to-female trans-woman is even more of a taboo subject than it is for the general population. Little research has been conducted and even less written in regards to the topic because of our social hang-ups about sexuality in general.
The History of the Erection
Prior to the advent of modern medical gender transition based on feminizing hormone therapy and androgen blockade, castration was the only way to feminize the body. Castration can be performed either before puberty or afterwards. The male castrated after puberty is called a scopt. Scopts are capable of sexual function although it usually requires some stimulation to arouse them whereas the intact male is a self-starter. And the scopt is usually more detached and rational about sex than the intact male, who is driven by the tides of his own testosterone. Scopts played prominent roles in the histories of empire, including the Byzantine, the Ottoman and China’s Tang Dynasty. By virtue of their infertility, they were allowed access to the harems of the ruling emperors where they became powerful agents of their discarded queens. Their power derived from the fact they could still function sexually because their adrenal glands produced small amounts of testosterone and other androgens, and that was all it took to keep them sexually functional.
‘Trans-Sexuality’
Sexual function in humans is a complicated subject because of the human mind’s unique ability to override or modify the body’s natural drives. For some, it necessarily means having erections, but there’s a lot more to sexual function than tumescence, particularly in the trans-woman. Transsexuality is more complex because it can involve each sexual partner penetrating or being penetrated, both, or neither. However before we focus on erectile function we should appreciate that human sexuality begins elsewhere in the body. Hormones, by virtue of their powerful influences on the brain and mind, are an important part of what influences, and ultimately defines the feminine identity, as well as both female and feminine sexuality. Let’s face it: most, if not all males have limited insight, if any, into female sexuality. In contrast, the feminized brain of the male-to-female transsexual offers the trans-woman a real window into this mysterious state of mind.
With regards to the genitals of a ‘top’ partner, erectile function is obviously important, but it is pointless unless accompanied by a sexual drive or libido. In addition, the genital skin needs to be sexually sensitive, as do other erogenous zones. For example, nipple sensitivity is greatly increased when one uses effective feminizing hormone therapy, thus creating a brand new source of sexual satisfaction in the trans-woman. All of these interdependent functions must cascade in order to create a pleasurable orgasmic climax. For many young trans-patients, erections continue unabated despite generous feminizing hormone therapy while for others, erectile function can be blunted or lost. Intervention may then be required and can be highly effective.
Any and all of these sexual functions are hormone-sensitive and can be lost, restored, or optimized by an enlightened, experienced medical care provider.
What do we do differently than other providers? For one, at our centers we reduce or eliminate the use of anti-androgens such as spironolactone. Androgen blocking drugs frequently interfere with erectile function and sexual desire while fueling depression. Needless to say, depression can have a lethal impact on all aspects of sexuality.
When the male animal is castrated, testosterone originating from the testicles is obviously lost, but the adrenals are spared and still continue to make androgens. And whereas normal testicular production of hormones fuels the aggressive, impulsive nature of the male psyche, the far lower amounts of androgens produced by the adrenals are more than sufficient to maintain sexual function and to keep depression at bay. However, anti-androgenic drugs indiscriminately block all male hormones, whatever their source, even the adrenals. As a result the trans-patient is pushed into an asexual state of depression by the anti-androgens, but the anti-depressant drugs used to treat this depression fuel further sexual dysfunction instead of reducing it.
Not a ‘Top’?
In contrast to the ‘top’ partner, the knee-jerk reaction of many is to ignore the sexuality of the ‘bottom’ partner. This is not valid. In the receiving patient, tumescence may be desirable, because it makes the partner feel appreciated and wanted and can be stimulated by the partner in other ways. In addition, the prostate gland of the receiving partner requires some hormonal stimulation if it is to generate sexual (prostatic) pleasure. Finally even in the individual who lacks a partner, self-stimulation to orgasm is often a desired and satisfactory source of sexual pleasure, and the firmer the organ, the better the quality of orgasm. What could be more harmless than solo-sexuality?
This brings us to the post-operative patient, the forgotten child of transgender care. She is hormonally no different than the orchiectomy patient, both having lost their testicles. When such individuals are given feminizing hormones, their testosterone levels frequently drop below even the normal female level. Just as with women who’ve had their ovaries removed as part of a hysterectomy, these patients often develop premature heart disease, severe sexual dysfunction including complete loss of sex drive, depression, and even suicidal feelings and behaviors. In these women, hormonal treatment is critically essential. Sadly, though, most postoperative patients do not receive proper care.
Treatment
The trans-woman, whether top or bottom, pre-operative or post-op, can often tolerate highly effective doses of feminizing hormones without loss of sexual function. Indeed, we at our clinic have seen many über-feminized, strikingly attractive trans-women who could still achieve full erections. However, when the need arises, other hormonal therapies and medical treatments can restore sexual function to a desired degree, and we believe that in a free society, treatment should be available for the restoration and maintenance of sexual function in all trans-women, regardless of social attitudes in the community at large.
When sufficiently retained, the quality and nature of sexuality in the trans-woman does have a subtly different nature. Most trans-women describe an experience that is more complex. The climax has been reported to be better, more drawn out, sustained, or even multiple. Moreover, in the ‘bottom’ patient, in addition to penile function we should consider the role of the prostate in sexual pleasure. The hormone-deprived prostate becomes insensitive; therefore, a modest amount of testosterone may be required to maintain its sensitivity as well.
All-in-all, and despite unnecessary mainstream social attitudes against it, transsexuality is a complex phenomenon worthy of our attention. A wide variety of treatments are available that can effectively correct not only erectile dysfunction but also optimize the entire panorama of sexual functions including sexual drive, prostatic pleasure, and genital sensitivity without sacrificing the psychosocial underpinnings of sexuality including one’s feminine personality and appearance.
To achieve balance, all one has to do is visit a physician who is truly an expert in this field of medicine, and I’d like to be yours. If you’re not quite ready for that yet, we also offer an online discussion forum which features group discussion, as well as my answers to many of your questions in our Q&A blog. To begin your journey to wellness and peace of mind, please join us!
Dr. John O’Dea, M.D. – Endocrinology
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