Safer sex and sexual health for trans feminine people

If you’re having sex, you should get to know the ways to do it safely so you’re protecting yourself and others.

As well as making sure you’re happy and comfortable with the sex you’re having, making sex safer looks after you and your partners’ physical health. Using barriers if they’re needed, alongside lube, and getting screened regularly is a way to reduce the risk of HIV and other sexually transmitted infections (STIs).

Discovering your sexuality can be really exciting, and you may be exploring new things or new parts of your body. Wherever you are in your transition, and whether you have decided to have surgery or not, you're entitled to have sex that is safe and enjoyable.

STIs can affect anyone and are easily passed on from all types of sex with all types of body parts and sex toys. Using a barrier such as a condom or dam along with water-based lube is the best way to protect against STIs.

If you’re having sex, then it’s important to test regularly. Have a sexual health screen at least once every year, and more frequently if you change partners or have casual or new partners. STI screening is quick, free, and painless and you can take your own samples from the body parts you use for sex.

Not everyone will show symptoms so it’s important to test regularly and after each new sexual partner. Most STIs are easily treated with a course of antibiotics, and the sooner you know you have one, the more quickly it can be treated, and you can make sure you don’t pass it on to anyone else.

Whether you’ve had lower surgery or not, the best way to protect yourself and your partner against STIs is to use a condom. Use a new condom with each partner and never use the same one for anal and vaginal sex.

They come in a variety of sizes and materials (including latex-allergy free). If you’re having sex for more than half an hour, it’s a good idea to change the condom to prevent it breaking.

• External condoms go over a penis or sex toy.
• Internal condoms (formerly known as Femidoms) go inside the vagina or anus (remove the top ring for anal sex). Not all trans women/AMAB non-binary people who’ve had lower surgery can use internal condoms – it will depend upon the depth of your vagina.
• When using lube, use only water-based or silicon-based lubes with condoms and not oil-based lubes or lotions, which weaken latex. Avoid silicone-based lubricant with silicone dildos and sex toys as it can degrade the surface.
• Dental dams consist of a sheet of latex used as a barrier in oral-vaginal sex and rimming which can prevent the transmission of STIs.

HIV is a virus that can be passed on through sexual contact. It's carried in blood, anal mucus, semen (cum and pre-cum), and vaginal/front hole fluid. HIV can be transmitted if no protection is used and the person with HIV doesn’t have an ‘undetectable viral load’ (when the amount of HIV is so small it can’t be detected in a blood test).

It can take up to six months for a person on HIV treatment to become undetectable and unable to pass it on to others, with or without a condom.

HIV can also be transmitted when an object (e.g. a sex toy) that has body fluids on it is put inside an HIV-negative person during sex.

HIV is not transmitted through sweat, saliva/spit or urine/pee.

HIV prevention pill PrEP is an effective way to prevent HIV transmission. PrEP is taken before and after you have sex.

People of any gender or sexuality can be HIV positive, but there is evidence that globally some trans people, especially trans women, can be at higher risk of HIV. This can partly be attributed to lack of information and access to good sexual health care for trans and non-binary people.

An analysis of several international studies has shown that trans women were 49 times more likely to be HIV positive than any other group. Trans sex workers in particular are at higher risk for HIV. A recent study shows that HIV prevalence in trans and gender diverse people living in England is much lower than international estimates.

If you’re having receptive or insertive vaginal/frontal or anal sex, using condoms or PrEP will prevent HIV transmission. Regular testing is key, so you can access treatment and protect your partners.

If you’re having sex, it’s a good idea to test for HIV at least once a year, or more often if you change partners or have casual or new partners or have been diagnosed with an STI. It's easier to acquire or pass on HIV if you have another STI.

HIV treatment is highly effective and means you can have a long, healthy life. Most HIV medication is safe to take with hormone therapy. Your HIV doctor will help you choose the treatment that is best for you.

It’s better to know your status and start treatment early to prevent serious illness. Scientific evidence has shown that people living with HIV who are on effective treatment cannot pass the virus on to anyone else.

There are lots of ways to test for HIV, including testing at a sexual health clinic, online postal kits, HIV testing centres and your GP. You can also order self tests online that you can do in your home and get instant results.

Trans women and trans feminine people, like anyone, come in different shapes and sizes – you might not have had surgery or take hormones, or you might have surgery or just take hormones.

Is the risk of STIs different depending on the type of surgery I had?

If you’ve recently had lower surgery and have unhealed skin, this could make it easier for you to acquire or pass on HIV as bleeding can provide a route into or out of your body. Discuss with your surgeon what kind of activity you can do and how soon.

If your vagina was made from part of your colon (known as a colovaginoplasty) it may be easier to get some STIs. The vaginal lining will be a mucus membrane and some STIs can easily penetrate it. Always use a condom unless you and your partner have tested and know you don’t have any STIs.

A vagina created from penile and scrotal skin is less vulnerable to STIs. However, if there are any cuts or abrasions this could be a way for STIs or HIV to enter your body.

Use lots of lube as depending on the type of surgery you've had, your vagina may not naturally lubricate. Plenty of water-based lube helps prevent tearing and makes sex more comfortable.

Dilators help stretch vaginal skin post-surgery but can cause bleeding, so unless you and your partner have tested and know you don’t have any STIs use a condom if you have sex afterwards.

After lower surgery, your anus, as well as your vagina, might be delicate while your genital area recovers.

Before surgery, treat any warts on your penis or they can continue to grow inside your vagina.

Contraception

If you haven’t had an orchidectomy or vasectomy, you should use contraception for insertive vaginal/frontal sex with a partner who is not using contraception and is at risk of pregnancy.

Estradiol therapy and hormonal therapy (such as gonadotrophin-releasing hormone [GnRH] analogues, finasteride or cyproterone acetate) don't provide adequate contraceptive protection.

Anal and vaginal/frontal sex

• Has the highest risk for getting an STI or HIV.
• Use an internal or external condom.
• Use water-based or silicone-based lube.
• Infections such as herpes, genital warts and syphilis can be transmitted through regular skin-to-skin contact. A barrier such as a condom, dental dam or latex glove reduces risk but only protects the covered area.
• Use a different condom with each partner, and when a penis/sex toy is moved between vagina/front hole and anus.

Oral sex

• Has a low risk but it’s still possible to get or pass on STIs such as herpes, syphilis or gonorrhoea.
• Has a very low risk of HIV transmission.
• Avoid if you have bleeding gums, ulcers, a sore throat or had recent dental work.
• Avoid receiving oral sex until you are fully healed from genital surgery as there is a risk of infection.
• Avoid letting a partner ejaculate in your mouth – you can also use flavoured condoms or dental dams.

Fingering

• Make sure you don’t have any cuts on your hands or fingers. Keep your nails short and use plenty of lube.
• Clean your hands thoroughly using warm soapy water before fingering a different partner as fluids can transfer on the surface of fingers.
• Use a latex glove to cover the finger or avoid fingering more than one person.

Rimming

• Rimming is licking someone’s anus.
• This had an extremely low risk for HIV but it's possible to pick up hepatitis A or bacterial infections such as shigella or gonorrhoea.
• Good personal hygiene can reduce risks slightly.
• Use a barrier like a dental dam to cover the anus.

Frottage

• Frottage involves rubbing genitals together without any penetrative sex.
• Low risk but a chance of transferring skin-contact bacteria or viruses (such as herpes, syphilis or genital warts).
• Parasites (such as scabies or crabs) can be passed via skin contact.

Rougher sex

• Use a different condom with each partner, and when a penis/sex toy is moved between vagina/front hole and anus.
• Bondage, fisting or S&M can result in bleeding or tearing of the anus, vagina/front hole or mouth, providing a route for STIs, HIV and hepatitis.
• Use latex gloves when fisting and don’t share a pot of lube as minute traces of blood can be transferred onto your hands, making it easy to pass on hepatitis C.

Next: Using PrEP and PEP