What trans women over 50 should know about their sexual health

What sexual health changes should trans women and transfemmes over 50 expect?

Trans women, transfeminine people, and gender diverse folks’ sexual health after 50 looks a little different than for their cis counterparts. While cis women struggle with the symptoms of menopause and cis men deal with hormone-driven sexual health changes because of significant drops in testosterone levels, those changes won’t be issues for anyone on stable hormone therapy. “This is because estrogen therapy keeps their testosterone suppressed and hormone levels steady rather than declining with age,” says OB/GYN Dr. David Ghozland, who is the founder of Intimate Health Center, with over 15 years of clinical experience specializing in pelvic reconstruction surgery like vaginoplasty and labiaplasty.

“That doesn’t mean they’re exempted from the tax of time,” he says. “Skin, vaginal, and neovaginal tissue, and blood vessels will all lose collagen and elasticity over time. But overall, honestly, this is an area of research that’s still very understudied. We really don’t know how much long-term GAHT [gender-affirming hormone therapy] affects the sexual health of trans women over 50.”

Many trans women are on estradiol hormone therapy, and while it’s an important part of gender-affirming care and helps keep hormone levels stable, it can also negatively impact your sexual health. “Estradiol reduces libido or sex drive,” says Dr. Michelle Forcier, a clinician for the LGBTQ+ telehealth company FOLX Health. “Estradiol can result in changes in erectile function and sometimes sexual dysfunction. Sexual arousal changes. It can be harder to get hard or climax. Ejaculation changes as well.”

And if you “don’t use or have a penis,” there are changes in rectal tissue that you should be aware of, Forcier tells Out. Not only does rectal tissue “become more lax or loose with age,” but the gastrointestinal tract also has hormone receptors that change the internal anal sphincter muscles as well as the lining of the rectum, which can “change colorectal cancer risks and drug absorption.”

According to Forcier, it’s also important to remember that while everyone faces physical and psychological changes as they age, your experience will be unique to you. “There really is no one single experience for trans women/transfemmes after 50 years of age,” she says. “People, their bodies, and their genders are too diverse for there not to be a rainbow of changes and lived experiences.”

What can trans women and transfemmes do to improve their sex lives after 50?

Pelvic floor exercises aren't just for people who have given birth; most people would probably benefit from doing them. Trans women and transfemme people can improve sexual function and decrease pain during sex by doing pelvic floor exercises, whether or not you’ve had any gender-affirming surgeries.

“Lower sexual satisfaction after pelvic surgery is a significant and well-documented issue, one that transgender women can improve with pelvic floor physical therapy,” Ghozland says. “It's proven to ease dilation, reduce pain, and lower long-term pelvic floor dysfunction after vaginoplasty even decades after surgery. In fact, even those who haven’t undergone gender-affirming surgeries can benefit from it too, as long-term estrogen therapy can also result in pelvic issues. “

Lasara Firefox Allen, founder of the Gender-Affirming Menopause Care certification course, and author of Gender Queer Menopause, says that no matter what you have going on below the belt, genital health is important. But for people who have sought surgical transition and had a vaginoplasty, there are additional steps you can take to help you tap into your own pleasure and ease any pain or discomfort, including asking your doctor about genitally applied estrogen. “If you have a neovagina, make sure you are doing your maintenance work,” Allen says. “Are you using your dilators? Are you doing self-massage? Are you using estrogen cream or suppositories on your vaginal tissues? Moisturizers? Lube?”

But if things just aren’t working, and you're not interested or enjoying sex, it’s also OK to take a step back. “Ask yourself, ‘How important is sex to me, now?’ And answer honestly,” Allen recommends. “If sex is not ranking at the top of the list, that’s OK! Don’t force it. That will just cause further dissociation and discomfort. Give yourself room to feel into what is true for you.”

Pelvic floor exercises, hormone treatments, and taking care of your genitals will help you have better sex as you get older. But Jericho Feng, a trans therapist who has provided LGBTQ-affirming therapy for the past 12 years, says that your mental health and the way you feel about your body are also crucial. “One of the best aphrodisiacs is gender euphoria,” he says. “In the U.S., not enough is highlighted about the sexual benefits of gender euphoria — which is a result of gender affirming care. When trans people honor their physical and emotional needs, they create space for joy, and with joy comes sexual liberation.”

What can you do to prevent your sexual health from declining?

Meeting with your health care provider to ensure you’re still on the right hormonal treatment as you age, and taking care of your overall physical wellness, are both important steps to take to stop your sexual health from declining as you age.

“While they don’t undergo the same menopausal journey as those AFAB, with aging comes increased vulnerabilities, most notably in their cardiovascular health, bones and tissues, and overall metabolic health,” Ghozland says. “Because of this, their providers may advise to change their hormone dosing, or switch up to transdermal delivery rather than oral — oral estradiol is associated with increased blood clots.”

It’s also a good idea to check in with a provider about your breast cancer risk. As a trans woman or transfemme person, you may think you don’t have to worry about breast cancer. But although your risk is much lower than it is for cisgender women, you are not immune. “ Long-term hormonal therapy also increases the risk of breast cancer in trans women, significantly higher than cisgender men, although it remains substantially lower than the risk for cisgender women,” he says.

You can also help keep your sex life from taking a nosedive as you speed past middle age by talking to your doctor about prescription sexual aids. Don’t let shame or awkwardness keep you from having a fulfilling sex life, Ghozland says. “It also doesn't have to be embarrassing to reach for sexual aids like sildenafil or arousal creams,” he recommends. “For trans women who haven't had surgery and want to retain erectile function, sildenafil can genuinely help, but please do it with a doctor's guidance.”

Taking care of your overall health will also aid in protecting your sexual health for years to come and help you have a fantastic sex life in the here and now too. According to Forcier, getting enough sleep, reducing your stress, and lowering your blood pressure, blood sugar levels, and cholesterol will all help with “overall cardiovascular stamina” and sexual function.

Forcier also says transgender and gender diverse people “have a leg up on their cis aging peers” because they have more control over hormone levels, which can help protect you from having your sexual health fall apart as the years slip by. “Gender hormones that come from a pill, patch, or injection are not subject to aging effects that both ovaries and testes are subject to,” she says. “There can be more control over hormone levels as people age in their transgender and gender diverse identities. And that is lovely for our patients to know, and act on if important to them.”

9 tips for having better sex after 50

1. Expand your definition of sex

Now that you’re over 50, you may be stuck in your ways, but it’s important to open your mind to a more expansive definition of sex as your body changes. “And sex doesn't always have to be penetrative. Many trans women have reported more satisfaction in other erogenous zones like nipples, legs, or back after starting hormone therapy, so deliberately exploring those areas can help too,” Ghozland says.

2. Don’t stop communicating

It can be hard to share intimate details with a new partner or hookup, and in long-term relationships, open communication can often become difficult or ignored, but it can be the key to a healthy sex life. “Communication with their partner goes a long way,” Ghozland says. “Research on gender-affirming care consistently ties open communication and positive body image to better sexual satisfaction after transition. Be open to them on what feels good and what doesn’t, focus on pleasure over performance."

3. Don’t forget the importance of lube

Lube is always a good idea, but as we age and natural lubrication wanes and our skin gets more prone to micro-tears, it’s a must-have. “Lube is not optional,” Ghozland says. “I cannot stress this enough, even if you think you have enough, squeeze that bottle again and add more.”

4. Add in sex toys

Don’t just rely on the same old sex toys you’ve always had. Branch out and try new things that may be better suited to your aging body. “Explore sex toys designed specifically for trans bodies,” Ghozland says. “Depending on where you’re from, it may be hard to find and would definitely include a lot of trial and error. But for an aging body, vibration does really go a long way.”

5. Ask about medication

If you are diagnosed with Hypoactive Sexual Desire Disorder, where your libido tanks and you have a persistent lack of sexual desire, consider adjusting the amount or type of hormones you are taking or try out a sexual dysfunction medication. "You may want to talk to your doctor about Addyi, Viagra, or Cialis," Allen says. "If you don’t like the results or side effects, you can always go off. But give it enough time to know whether they may work, if it’s bearable for you."

6. Work on your relationship

If you want to increase sexual desire and improve your sexual health, work on problems in your relationship and any trauma you haven’t dealt with. “Having dynamic, safe, healthy, loving relationships can also improve both desire and function,” Forcier says. “Working on and resolving prior relationship or sexual trauma can result in a healthier sexual self.”

7. Don’t judge your aging body

Many people are quick to judge their own bodies against what they were capable of at 20. But you’re not a kid anymore, and things are different now. Accept the changes and embrace how amazing your new sex life can be past middle age. “But, like any changing aging body, sexual needs as well as sexual function may change,” Forcier says. “What turns you on at 50 may be very different than what worked at 20! As we age, peni take longer to get hard, and don't always get as hard as before. Orgasm and ejaculation might change. Rectal tissue may become more lax or loose with age.”

8. Work toward gender euphoria

It’s never too late to have your gender affirmed and strive to feel gender euphoria, both of which will increase your confidence and improve your sex life. “Affirming one’s gender can happen at any stage or age, and can involve social transitions, such as having sexual partners use an affirming name for you, as well as medical transitions, like beginning HRT,” Feng says.

9. Accept that your preferences may change

Feng has noticed that many of his trans patients’ sexual preferences change as they age. Learn to accept that you may be attracted to people you previously weren’t and may want different things in bed now. “She may also experience pleasure in different ways, whether that’s using toys to change sensations, trying different positions to get more comfortable physically, or needing different foreplay to get into the mood,” Feng says.

Sources cited:

Dr. David Ghozland is a board-certified OB/GYN and the founder of Intimate Health Center.

Dr. Michelle Forcier is a clinician for the LGBTQ+ telehealth company FOLX Health.

Lasara Firefox Allen is the founder of the Gender-Affirming Menopause Care certification course and author of Gender Queer Menopause.

Jericho Feng is a gay, trans, Asian therapist who provides LGBTQ-affirming therapy.