How To Maintain Your Penis' Function On Feminizing HRT

Trans Science!

Content Warning: This article is a frank and extended discussion of penile health. It uses medical terminology throughout, but it nevertheless addresses genital health and function. Please leave now if you are under 18, and be mindful of any dysphorias you may have before continuing.

Foreword: I am not a medical doctor. It is crucial that you talk to your own medical care team—especially a urologist—to safely monitor your health in this respect. As with anything to do with human biology, major deviations from typical responses are not only normal, but expected.

Somewhere on the order of one in five trans women—never mind nonbinary transfeminine people, of whom little study on this subject has been completed—do not experience bottom dysphoria, and wish to continue to use and enjoy their natal genitals in transition in more or less the same way they always have. Others who do experience bottom dysphoria are often concerned about penile atrophy while they’re on feminizing HRT. This is most typically the case when they want to maintain what they have to keep their options open for eventual bottom surgery, because several techniques, such as penile inversion vaginoplasty, rely on parts of the penis to construct a neovagina, and atrophy in the penis before surgery limits surgical options and vaginal depth.

As such, “how do I keep my penis from atrophying?” is probably the single most frequent medical question I see new-in-transition transfems asking the community at large, and answers are often riddled with misinformation.

This guide exists to dispel common myths and to give concrete, practical guidelines, based in science, for how to maintain penile function and size indefinitely while on feminizing HRT.

The Bottom Line Up Front

To keep your penis from atrophying, you will need to use it regularly. Full erection. Three times a week, for at least ten minutes a session.

That’s it.

If you like, you can accomplish this through regular sexual activity, though no actual interaction with the penis is necessary. I am aware of cases where transfems with bad bottom dysphoria have accomplished this by taking a Viagra at bedtime, so they’re asleep when their maintenance erections occur.

While you’re on this regimen, watch for pain inside the penis. This is most commonly a sign of creeping atrophy, and an indication that you may need to use your penis more frequently or for longer. If you experience pain and it doesn’t go away within a week or two, make an appointment with a urologist to check for other possible causes.

This regimen is based on a review of the medical literature (which is direly lacking for transfems. I’ve had to adapt research on cis men with similarly reduced testosterone to develop this) and an interview with a bottom surgeon who has worked with transfems who wish to retain penile function. Unfortunately—and I cannot stress this emphatically enough—there is no meaningful research on penile health in the transfeminine population. Until such a time as that research appears, this is the best we have.

How to Get An Erection Suitable For Penetrative Sex on HRT

Since most transfems lose at least some erectile function while taking feminizing HRT, a little help is often needed to restore the functionality of their penises. For the overwhelming majority, 2.5mg daily Cialis (or its generic form, tadalafil) or Viagra (or its generic, sildenafil) will restore full penile function. The main differences are as follows:

• Tadalafil is a daily pill which will restore spontaneous erectile function in response to stimuli. It most closely mimics natal erectile function, and some transfems even report that it restores nocturnal erections.

• Sildenafil is a pill taken as needed, and which produces an erection on demand.

Generally speaking, the transfeminine community seems to prefer tadalafil over sildenafil but, again, every body is different. One advantage of tadalafil is that if the 2.5mg daily dose is not enough to produce a suitable erection, it can be increased to 5mg daily, which almost always is.

In the rare cases that tadalafil and sildenafil are not enough to restore penile function, a low-dose topical testosterone cream can be formulated to remain local (that is, to only affect the places it’s put), and which can be applied to the penis to supplement the oral drugs. However, this is best done in partnership with a urologist who has experience with transfeminine patients, as there are occasionally other causes of this loss of function which ought to be investigated.

The surgeon I interviewed had never had a patient who wanted an erection and hadn’t been able to get it back through the use of these drugs. Again, every body is different, but chances are this should work well for you.

Common Myths About Penis Atrophy

By far the most common myth about penile atrophy on HRT is that it is directly caused by taking estrogen. It is not. There is currently no known relationship between erectile function and estrogen. Rather, it is the loss of testosterone which typically causes penile atrophy, through the loss of erections.

The second most common myth is that loss of functionality is inevitable on feminizing HRT—that, given enough time, every penis will atrophy. This is false. Many, many transfeminine people have reported continued size and functionality many, many years into feminizing HRT (the most high-profile and explicit discussion of which is probably Carta Monir’s Napkin).

The third most common myth is that loss of erectile function is consistent between individuals. This, obviously, is nonsense. As with all biology, there is a huge amount of variation from person to person; some transfeminine people will continue to be able to maintain erections suitable for penetrative sex regardless of how low their testosterone levels fall. The reasons for this are unknown. Most transfeminine people will lose some peak erectile firmness, however, and some will lose all ability to get and maintain an erection unaided.

Why do Penises Atrophy on HRT?

To understand what’s happening, we need to remember how erections work in the first place.

The process is actually pretty simple. Sphincters in large veins in the penis iris closed, preventing blood from leaving. The penis is full of capillaries housed in highly elastic fleshy tissue, so when this blood is retained, those capillaries and that elastic tissue stretch and fill, as does the penile sheath itself, producing an erection. As odd as it sounds, it’s basically the same thing as filling up a water balloon.

Atrophy occurs when the penis loses the ability to do these things—and elasticity is typically the first thing to go. The actual structural change is called fibrosis, or the formation of miniscule scar tissue within the penis as small structures which no longer need to be elastic lose the ability to be elastic. This is somewhat similar to Peyronie’s Disease, but on a micro scale, rather than a macro scale. First, the penis’ blood-retaining structures—those capillaries and elastic structures—begin to scar over at the microscopic level, which makes erections painful. Eventually, if this process continues, the venous sphincters that cause an erection to happen in the first place will over time lose the ability to close off.

So, to prevent atrophy, those tissues need regular use. As with any structure of the body, it’s use it or lose it.

Cis men don’t need to pay attention to this because testosterone, among its many other functions, causes something called nocturnal erections (you might know them by another name), and while their function is not well-understood, it seems one of the more critical parts is to exercise the elastic structures within the penis—in essence, it’s a natural, biological response to prevent penile atrophy. Unfortunately, when a transfeminine person starts HRT, testosterone blockade will usually, but not always, end nocturnal erections.

Fortunately, medical science has looked into this problem for cis men who survive one of a variety of conditions—hormone sensitive prostate or testicular cancer, for instance—and it seems that any intervention which causes regular, full, firm, and sustained erections is effective at preventing penile atrophy.

It’s important to note, however, that this process is slow, and occurs over months and months of consistent disuse. Even with total disuse, many transfems report that it takes a year or more for penile atrophy to complete.

What Do I Do If Atrophy Has Already Occurred?

I cannot stress this enough: see a urologist immediately.

Research on transfeminine penile health is essentially nonexistent, so there’s a lot we don’t know. However, to the best of my knowledge, once penile atrophy has progressed to the point that an erection is not possible even with the help of drugs, it is not possible to regain any erectile function—in other words, once fibrosis and atrophy of the penis is complete, there just aren’t many structures elastic enough to take the actions necessary to have an erection.

However, if you can still get an erection, even if it’s painful, there are very likely treatment options available. They may be as simple as increased use of your penis until early scarification is reversed, and they may be more complex or involved interventions.

But again, see a urologist immediately. It’s possible to cause more damage if you’re not careful, depending on what’s going on and how far the atrophy has progressed.