For individuals assigned male at birth undergoing gender transition, maintaining erectile function whilst pursuing feminisation goals is a valid and achievable priority. Feminising hormone therapy—typically involving oestrogen and anti-androgens—commonly affects erectile function through reduced testosterone levels, but the degree and timeline of changes vary considerably between individuals. Understanding how hormone therapy influences sexual function, alongside evidence-based strategies to preserve erectile capacity, enables informed decision-making throughout your transition journey. This article explores the physiological mechanisms involved, practical approaches to maintaining function, available medical treatments in the UK, and when to seek specialist support from your healthcare team.

Understanding Erectile Function During Gender Transition

Erectile function is a complex physiological process involving hormones, blood vessels, nerves, and psychological factors. For individuals assigned male at birth who are undergoing gender transition, understanding how various aspects of transition may affect erectile function is an important consideration for informed decision-making.

Testosterone plays a central role in maintaining erectile function through several mechanisms. It supports the production of nitric oxide in penile tissue, which is essential for vasodilation and blood flow. Testosterone also influences libido (sexual desire) and helps maintain the structural integrity of erectile tissue. When testosterone levels decrease—whether through hormone therapy or surgical intervention—these mechanisms may be affected to varying degrees.

It is important to recognise that experiences vary considerably between individuals. Some people undergoing feminising hormone therapy report changes in erectile function within weeks, whilst others maintain function for longer periods. Factors influencing this variability include dosage of medications, individual physiology, age, baseline vascular health, and psychological factors such as gender dysphoria and body comfort.

Erectile dysfunction can also be a marker of cardiovascular disease in the general population. If you experience new erectile difficulties, particularly alongside cardiovascular risk factors (such as high blood pressure, diabetes, or smoking), discuss this with your GP to ensure appropriate cardiovascular risk assessment.

Gender-affirming care should be personalised to align with each individual's goals and priorities. For some people, changes in erectile function may be welcomed as part of their transition journey, whilst others may wish to preserve this aspect of sexual function. Both goals are equally valid. Open communication with healthcare providers about sexual health goals allows for tailored treatment approaches that respect individual needs and values. Understanding the physiological basis of erectile function provides a foundation for making informed choices throughout the transition process.

Hormone Therapy and Sexual Function: What to Expect

Feminising hormone therapy typically involves oestrogen (oestradiol) and anti-androgens such as cyproterone acetate or GnRH analogues (including goserelin, leuprorelin, or triptorelin), which work together to reduce testosterone levels and promote physical feminisation. These medications fundamentally alter the hormonal environment that supports erectile function, leading to predictable changes over time.

Oestrogen combined with androgen suppression lowers testosterone, which commonly reduces spontaneous erections and libido. The degree of change varies by dose, route of administration, and individual factors. Anti-androgens have a direct impact: cyproterone acetate blocks androgen receptors and suppresses testosterone production, whilst GnRH analogues suppress testosterone at the pituitary level. Both approaches significantly reduce circulating testosterone, which typically results in decreased frequency and firmness of erections, reduced libido, and changes in orgasmic experience.

Important safety note on cyproterone acetate: The MHRA has issued a safety update regarding cyproterone acetate and the risk of meningioma (a usually benign brain tumour). The risk is dose- and duration-dependent. Cyproterone acetate should be used at the lowest effective dose for the shortest necessary duration, and it is contraindicated in people with current or past meningioma. Your prescriber will discuss this risk and monitor you appropriately.

The timeline of changes varies individually and evidence is limited in transfeminine populations. Many people notice reduced spontaneous erections (particularly morning erections) within the first 1–3 months of hormone therapy. Erectile function during sexual activity may be maintained longer, especially with adequate stimulation. By 6–12 months, most individuals on full-dose feminising hormones experience substantial changes in erectile capacity, though some function often remains. These timelines should be considered approximate and individual.

Testicular atrophy (reduction in size) commonly occurs with prolonged hormone therapy, typically becoming noticeable after 3–6 months. This is a normal response to reduced testosterone production. Some individuals also report changes in ejaculatory volume, orgasmic sensation, and refractory period (time needed between orgasms).

Fertility is significantly impaired by hormone therapy, and the degree and reversibility of impairment are unpredictable. Individuals should discuss fertility preservation options—such as sperm banking—before commencing treatment if future fertility is a consideration. Do not assume fertility will return if hormone therapy is stopped.

Strategies to Maintain Erectile Function While Transitioning

For individuals who wish to preserve erectile function during gender transition, several strategies can be considered in consultation with healthcare providers. These approaches recognise that sexual health goals are valid and can be integrated into gender-affirming care plans.

Regular erectile tissue use may help maintain function. Erectile tissue requires oxygenated blood flow to maintain health. Regular erections—whether through sexual activity, masturbation, or other means—promote blood flow and may help preserve tissue elasticity and function. This principle is sometimes described as "use it or lose it" and is extrapolated from penile rehabilitation literature in other clinical contexts. However, there is limited formal research specifically in transgender populations to establish definitive protocols. Some specialists suggest attempting erections several times weekly, but this should be discussed with your clinician as individual advice.

Adjusting hormone regimens can be discussed with your endocrinologist or gender specialist. Some individuals use lower doses of anti-androgens or oestrogen, which may slow changes in erectile function whilst still achieving feminisation goals. Others use oestrogen monotherapy (oestrogen alone without anti-androgens), which can suppress testosterone through feedback mechanisms whilst potentially having less impact on erectile function, though this approach may not achieve complete testosterone suppression in all individuals. Do not adjust your hormone doses yourself; any changes should be made collaboratively with your prescribing clinician, with regular blood tests to ensure hormone levels remain within agreed safe and effective ranges.

Phosphodiesterase-5 (PDE5) inhibitors such as sildenafil, tadalafil, or vardenafil can be used alongside hormone therapy. These medications are licensed for erectile dysfunction and work by enhancing erectile response through increased blood flow to penile tissue. They do not counteract hormonal effects but can enhance the erectile response to sexual stimulation. Response to PDE5 inhibitors may vary and can be reduced at very low testosterone levels.

Your GP can assess suitability and prescribe these medications where appropriate. Generic sildenafil is generally prescribable in NHS primary care. Sildenafil 50 mg (Viagra Connect) is also available from pharmacies following a safety assessment. Tadalafil can be used either on-demand before sexual activity or as a daily low-dose medication; daily use for erectile tissue health is not a licensed indication but is sometimes discussed off-label with specialist guidance.

Important safety information for PDE5 inhibitors:

• They are contraindicated (must not be used) with nitrates (e.g., glyceryl trinitrate for angina), nicorandil, or riociguat, and must not be used with recreational nitrate drugs ("poppers")—the combination can cause dangerous drops in blood pressure.

• Use with caution if you take alpha-blockers (for prostate or blood pressure).

• Discuss any heart conditions or medications with your prescriber before use.

Lifestyle factors supporting vascular health also support erectile function. These include regular physical activity, maintaining a healthy weight, not smoking, limiting alcohol consumption, and managing conditions such as diabetes and high blood pressure. Good cardiovascular health directly translates to better erectile function regardless of hormone status.

Medical Support and Treatment Options Available in the UK

The NHS provides gender identity services through specialist Gender Identity Clinics (GICs), though waiting times can be substantial. Private gender services are also available across the UK. Discussing sexual health goals should be a routine part of gender-affirming care, and healthcare professionals should create space for these conversations without judgement.

Hormone therapy adjustments can be made collaboratively with your prescribing clinician. This might involve modifying anti-androgen doses, changing medication types, or adjusting oestrogen levels. Some individuals work with their healthcare team to find a balance between feminisation goals and sexual function preservation. Regular monitoring through blood tests helps ensure hormone levels remain within safe and effective ranges.

PDE5 inhibitors are the first-line medical treatment for erectile dysfunction in the general population and are often helpful for individuals on feminising hormones, though response varies and may be reduced at low testosterone levels. Your GP can assess suitability, check for contraindications (such as use of nitrates, nicorandil, or riociguat, and certain heart conditions), and prescribe where appropriate. Local formulary choices may apply. Sildenafil 50 mg is also available from pharmacies (as Viagra Connect) following a safety assessment by the pharmacist.

Vacuum erection devices (VEDs) are non-pharmacological options that use negative pressure to draw blood into the penis, creating an erection that can be maintained with a constriction ring. These devices may be available on NHS prescription for erectile dysfunction, though commissioning varies locally. Your GP or specialist can advise on suitability and access.

Psychological support is an important component of sexual health during transition. Gender identity clinics, sexual health services, and organisations such as CliniQ (a sexual health service for trans people) provide specialist support. Psychosexual therapy can help individuals navigate changes in sexual function, body image, and intimate relationships. Many people find that as gender dysphoria decreases through transition, overall sexual satisfaction improves even if specific aspects of sexual function change.

Specialist sexual health services with experience in transgender healthcare can provide tailored advice. Some NHS sexual health clinics have specialists with expertise in this area. You can find your local NHS sexual health clinic via the NHS website. Organisations such as the Gender Identity Research and Education Society (GIRES) and the LGBT Foundation can provide information about accessing appropriate services.

When to Seek Specialist Advice from Your Healthcare Team

Proactive communication with healthcare providers ensures that concerns are addressed promptly and that treatment plans remain aligned with your goals. You should contact your GP or gender specialist if you experience sudden or unexpected changes in erectile function that concern you, particularly if these occur before starting hormone therapy or seem disproportionate to your medication regimen. New erectile dysfunction, especially if you have cardiovascular risk factors or symptoms, warrants GP assessment for cardiovascular risk.

Seek medical advice if you develop:

• Painful erections or curvature of the penis (which might indicate Peyronie's disease)

• Erections lasting more than 4 hours (priapism)—this is a medical emergency requiring immediate attendance at A&E do not delay

• Urinary symptoms such as difficulty passing urine, pain, or blood in urine

• Testicular pain or swelling beyond expected atrophy

• Any new testicular lump or swelling—this requires urgent GP review, as suspected testicular cancer is referred via a 2-week wait pathway under NICE guidance (NG12)

Before starting hormone therapy, discuss your sexual health priorities with your prescribing clinician. This conversation should cover your goals regarding erectile function, fertility preservation options (such as sperm banking), and how different hormone regimens might affect sexual function. There is no "wrong" priority—your healthcare team should support your individual goals.

Regular monitoring is essential during hormone therapy. Attend scheduled blood test appointments to ensure hormone levels are appropriate and safe. If you feel your current regimen is not meeting your needs—whether regarding feminisation, side effects, or sexual function—request a review appointment. Adjustments can often be made to better align treatment with your goals.

If you are considering PDE5 inhibitors or other treatments for erectile function, discuss this with your GP or gender specialist. They can assess suitability, check for contraindications (including use of nitrates, nicorandil, riociguat, and caution with alpha-blockers), and provide appropriate prescriptions. Do not obtain these medications from unregulated sources, as counterfeit products pose serious health risks.

If you experience side effects from any medication, you can report these via the MHRA Yellow Card scheme at yellowcard.mhra.gov.uk. This helps improve the safety monitoring of medicines.

Finally, if sexual function changes are affecting your mental health or relationships, seek support from psychological services. Your gender clinic, GP, or organisations such as the LGBT Foundation can provide appropriate referrals. Sexual health is an integral part of overall wellbeing, and concerns in this area deserve professional attention and support.

Frequently Asked Questions