ArticleThe journal of sexual medicine2026
Genital atrophy in transmasculine individuals using testosterone: symptom experiences, treatment preferences, and barriers to care.
Article in The journal of sexual medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundTestosterone gender-affirming hormone therapy frequently results in genital atrophy among transmasculine individuals. Low-dose topical genital estrogen is currently recommended for transmasculine individuals experiencing dyspareunia and vaginitis, but its effectiveness has not been assessed among those using testosterone. The objective of this study was to describe the lived experience of genital atrophy and the acceptability of available treatments in this population.
methodsWe conducted in-depth one-on-one interviews with 28 transmasculine adults using testosterone, recruited through PRIDEnet, an established national LGBTQIA+ community-engagement network. Participants were asked questions related to their lived experiences of genital atrophy, including symptom recognition, experiences seeking care, and treatment preferences using a structured interview guide. Transcribed interviews were analyzed using qualitative thematic analysis and content analysis.
resultsNearly all participants (93%) had heard of genital atrophy and 64% had ever experienced it in their lifetimes (46% in the past year). Symptoms ranged from transient dryness and discomfort during penetrative sex to chronic pain affecting walking, sitting, urination, and daily functioning. Most participants (79%) had heard of topical genital estrogen; 43% had ever used it, and most reported symptomatic relief. Cream was the most commonly prescribed but least preferred formulation due to messiness, dysphoria associated with genital contact, and interference with sexual activity; suppository tablets and the genital ring were most preferred. Concerns about systemic estrogen absorption and interference with testosterone were pervasive. Participants encountered significant treatment barriers including providers who lacked knowledge of genital atrophy in transmasculine patients, minimized or dismissed symptoms, or refused to prescribe topical genital estrogen. Insurance denials, formulation restrictions, and negative pharmacy interactions represented additional barriers.
conclusionThe provider knowledge gaps and systemic barriers documented in this study underscore that improving genitourinary health outcomes for transmasculine individuals will require concurrent advances in medical education, insurance policy, and clinical evidence. Clinicians should proactively counsel transmasculine patients about genital atrophy at testosterone initiation and discuss all available treatment formulations with explicit attention to gender dysphoria, systemic absorption concerns, and insurance constraints. Provider education on the genitourinary effects of testosterone and the diagnosis and treatment of genital atrophy must improve across clinical training programs. Clinical trials evaluating the efficacy, systemic absorption, and acceptability of all available treatment options - including topical estrogen formulations, dehydroepiandrosterone, and ospemifene - among transmasculine individuals using testosterone are urgently needed.
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