For many trans women and transfeminine people, oestrogen is an essential part of feminising hormone treatment. However, feminising hormone treatment with oestrogen can cause changes in penile anatomy and physiology, including penile atrophy (shrinkage of erectile tissue in the penis) and erectile dysfunction (decreased capacity for penile erection). For people who engage in sexual activity involving penile stimulation, these effects can be extremely distressing.
Mechanisms
Feminising hormone treatment causes the changes in penile anatomy and physiology in the following ways.
- Antiandrogens and oestrogen in feminising hormone treatment suppress testosterone production, which decreases the frequency of penile erections. This is known as erectile dysfunction.
- Due to the widespread physiological effects of oestrogen, feminising hormone treatment can change the sensations from the penis, which can make penile stimulation uncomfortable.
- Over time, the loss of erections can result in shrinkage of the erectile tissue in the penis, as the smooth muscles in the penis are no longer being stretched regularly. This is known as penile atrophy.
Treatment
Penile atrophy
Penile atrophy can be counteracted by engaging in regular sexual activity or masturbation that stimulates penile erection. Stimulating penile erection at least two to three times a week can help to keep the erectile tissue stretchy and flexible.
In order to reduce irritation, sexual activity or masturbation can be aided with the use of a lubricant.
Erectile dysfunction
While feminising hormone treatment decreases the frequency of spontaneous erections, most people maintain the capacity to achieve erections in response to sexual desire and stimulation. However, if erectile dysfunction is a problem, then there are potential ways it can be overcome.
- By decreasing the dose of the antiandrogen, so that testosterone production is only partially suppressed;
- By using a low dose of testosterone gel.
References
Chiang, H. S., Cho, S. L., Lin, Y. C., and Hwuang, T. I. S. (2009). “Testosterone gel monotherapy improves sexual function of hypogonadal men mainly through restoring erection: evaluation by IIEF score”. Urology, 73: 762-766.
Srilatha, B., and Adaikan, P. G. (2004). “Estrogen and phytoestrogen predispose to erectile dysfunction: do ER-alpha and ER-beta in the cavernosum play a role?” Urology, 63: 382-386.
Zuniga, K. B., Margolin, E. J., De Fazio, A., Ackerman, A., and Stahl, P. J. (2019). “The association between elevated serum oestradiol levels and clinically significant erectile dysfunction in men presenting for andrological evaluation”. Andrologia, 51: e13345.