Sex and Sexual Agreement Negotiation Among Trans Women and Trans Men Partnered with Cis Men

Abstract

Though trans individuals have some of the highest rates of HIV in the U.S., little is known about how trans couples navigate these risks within committed relationships. Thirty-nine couples, composed of one trans partner and one cis male partner, were asked about their relationship agreements, including sexual negotiations, in semi-structured, qualitative interviews. Couples reported definitions of monogamy and non-monogamy that were inconsistent with previous literature, each ranging as if on a continuum. While agreements varied, most non-monogamous couples reported a focus on safe sex practices and HIV risk mitigation, specifically highlighting negotiations around fluid exchange or fluid bonding. Changes in sexual desire arose for many couples, often due to hormonal changes during gender-affirming measures. Most couples navigated these shifts successfully, by changing their relationship agreement or sexual practices. Changing sexual behavior included addressing motivations for sex that were unrelated to one’s own sexual pleasure; this motivation is called “maintenance sex”. Alarmingly, nearly half of the couples interviewed reported discrepant agreements, which is associated with higher sexual risk. With an apparent ambiguity in defining agreements, it is imperative to trans communities’ sexual health that relationship agreements are explicitly communicated to partners and healthcare providers.

In recent years, there has been an increase in research conducted on the health and identities of trans individuals. We use the term “trans” to describe individuals who transition from the sex assigned to them at birth to another gender, and the word “cis” to describe individuals who feel that the sex assigned to them at birth matches their gender identity. At 14%, trans women in the United States have one of the highest estimated prevalence rates of HIV (Becasen et al., 2019). Researchers have identified several important factors that contribute to trans women’s uniquely high prevalence rates. These known risk factors include experiences of stigma and discrimination, commercial sex work, drug use, economic hardship, complicated power and gender dynamics with sexual partners, and mental health issues (Marshall, 2020). The most recent estimates of HIV prevalence among trans men are significantly lower than trans women’s rates, at 3.2% (Becasen et al., 2019). Despite lower prevalence rates, studies report trans men engaging in considerable unprotected anal and vaginal sex, sex work, drug use, and having high STI rates, all known risk factors for HIV (McFarland et al., 2017; Reisner et al., 2010; Sevelius et al., 2009). In addition to gender and these other factors, race remains an important variable when examining HIV prevalence rates, with African American/Black trans women and Hispanic trans women considerably more vulnerable than their white counterparts (Becasen et al., 2019).

Recent research on HIV risk among men who have sex with men (MSM) have found that sexual risk taking for those in committed relationships can depend on a variety of relationship factors. For example, positive relationship factors, such as satisfaction, trust, and commitment, are associated with less sexual risk with outside partners (Hoff et al., 2016). Agreement types also play an important role in sexual risk (Hosking, 2014). Agreements about whether sex with partners outside of the relationship is permitted are ubiquitous among MSM. MSM couples who have agreements where sex with outside partners is permitted (e.g., non-monogamous agreements) must negotiate the parameters of acceptable behaviors. For example, some MSM couples allow sex with outside partners only if a condom is used, while others do not allow anal sex at all with outside partners. Some MSM partnerships allow outside sex only when a partner is traveling, and others may allow it anytime but have parameters about who the outside partner is and where the outside sexual encounter occurs (Hoff & Beougher, 2009). Some MSM couples prefer to have sex with outside partners together at sex parties or in three-way sexual encounters. MSM couples who have agreements where sex with outside partners is not permitted (e.g., monogamous agreements) may have fewer parameters to negotiate, but may be more vulnerable to broken agreements that could put the couple at risk for HIV (Essack et al., 2020). Within MSM studies, couples who have the same understanding of what their agreement is report greater relationship satisfaction and less HIV risk (James et al., 2020; Mitchell & Konda, 2020).

Less is known about agreements among trans couples. One recent study of trans women partnered with cis men found that although most couples had an agreement, an impressive 45% were discrepant, meaning each partner had a different understanding of what the agreement was, while 40% were monogamous, and 13% were non-monogamous (Gamarel et al., 2014). It is unknown if the high percentage of discrepant agreements impacts relationship satisfaction and HIV risk in the same way as it does for MSM couples. Another study of trans women with cis male partners found an important association between couples having an agreement, either explicit or implicit, and acceptability of couples’ HIV counseling and testing (Reisner et al., 2019). This finding suggests that relationship agreements could be an important piece in supporting couples in their HIV prevention efforts.

However, a recent review article reported a strong need to expand sexual agreement research beyond MSM (Rios-Spicer et al., 2019). We are aware of only one study that addressed sexual health needs of cis men in committed relationships with trans partners, which concluded that these men are understudied and may have unique vulnerabilities around HIV risk (Poteat et al., 2020). Thus, it is not clear whether sexual agreements have similar benefits for trans/cis couples as have been found for MSM couples.

The present study explores factors associated with negotiating sexual agreements among trans women and trans men in committed relationships with cis men. The goal of the analysis is to identify factors unique to trans/cis couples that could potentially support or hinder sexual health.

Method

Participants

Trans women with cis male partners and trans men with cis male partners were recruited from the San Francisco Bay Area over a 12-month period from May 2016 through May 2017. Active (i.e., outreach by field research staff) and passive (i.e., postcards and fliers left in community venues, and posted on social media) recruitment strategies were conducted in community settings. Recruitment material instructed those interested in participating to call a toll-free number for more information. Callers were screened over the phone and partners were screened individually for eligibility. Eligibility criteria required that at the time of screening, participants identify as a trans man or trans woman currently in a primary relationship of three months or more with a cis male partner. “Relationship” was defined as, “being committed to your partner over anyone else and that you have had sex together”. All participants were asked their current gender identity and the gender they were assigned at birth to confirm trans and cis identities. Eligibility also included participants be at least 18 years old, have knowledge of their own and their partner’s HIV serostatus, and agree to be interviewed in English. Couples were eligible to participate only after both partners were screened and found to have met the eligibility criteria.

In total, 39 couples were eligible and went on to participate in the semi-structured interviews. For some couples, though, there was a several week delay between time of screening and the scheduled interview. In one case, a participant identified as cis at screening and as gender queer at the interview. The data collected at screening was used to determine eligibility. Data collected at the interview is what is presented in Tables 1 and 2. Thus, the minor discrepancies between eligibility criteria at screening and the interview date (e.g., trans identity and knowledge of HIV status) could be due to the time delay between screening and the interview. In order to honor our participants’ confidentiality, all names quoted in the Results section are pseudonyms.

Table 1.

Individual Level Demographics (n = 78)

	N	%
Gender
Trans Woman	22	28
Trans Man	17	22
Cis Man	38	49
Genderqueer	1	1
Race/Ethnicity
African-American/Black	20	26
Asian-American/Asian	5	6
European-American/White	39	50
Latina/Latino/Latinx	5	6
Native American	2	3
Mixed	7	9
HIV Status
HIV-Positive	15	19
HIV-Negative	61	78
Unknown	2	3
Age
18–24	12	15
25–31	23	30
32–38	17	22
39–45	7	9
46–52	8	10
53–59	7	9
60–66	4	5
Education
No high school degree	2	3
High School (or equivalent)	15	19
Some College	28	36
Associate Degree	4	5
Bachelor’s Degree	20	26
Post Bachelor’s Degree	8	10
Unknown	1	1
Income
Under $10,000	29	37
$10,000– $29,999	30	39
$30,000– $49,999	10	13
$50,000– $69,999	1	1
$70,000– $89,999	4	5
$110,000+	3	4
Unknown	1	1

Table 2.

Couple Level Characteristics (n = 39)

	N	%
Couple Gender
Trans women with cis male partner	22	56
Trans men with cis male partner	16	41
Trans men with genderqueer partner	1	3
HIV Status
Seroconcordant HIV-negative	28	71
Seroconcordant HIV-positive	5	13
Serodiscordant	5	13
Unknown	1	3
Agreement Type
Monogamous	22	56
Non-monogamous	13	34
No sexual agreement	4	10
Couple Race
African-American/Black – African-American/Black	6	15
African-American/Black – European-American/White	4	10
African-American/Black – Latina/Latino/Latinx	1	3
African-American/Black – Mixed	3	8
Asian-American/Asian – European-American/White	3	8
Asian-American/Asian – Latina/Latino/Latinx	2	5
Latina/Latino/Latinx – European-American/White	2	5
Native-American – Native-American	1	3
European-American/White – European-American/White	14	35
Mixed – Mixed	2	5
Mixed – European-American/White	1	3
Average Relationship Length			4.3 years

Procedure

After a research staff member screened both partners and determined the couple was eligible, they were scheduled for a 90-minute semi-structured interview. Partners were interviewed separately to allow for the candid discussion of their relationship, agreements, and any reported agreement breaks. Interviews examined the following topics: identity, relationship history, attraction, experiences of discrimination, decision-making, sexual behavior, agreements, sexual health, and relationship satisfaction. Three interviewers were trained to guide the participants through the interview by posing questions in an open-ended, conversational tone, to probe for clarity when and where necessary, and to allow emergent topics to arise. The training stressed the intent of each question in the guide, so interviewers were not required to ask them in a particular order, giving the interviews a natural flow and participants the freedom to discuss other issues they felt were salient. Each partner was paid $50 for participating at the end of each interview. All interviews were audio tape recorded using digital recorders and transcribed verbatim by an outside transcriptionist. Transcribed interviews were reviewed by the person who conducted the interview. The research staff member who conducted the interview was responsible for reviewing the accompanying transcript for accuracy (e.g., mistakes, misspellings, and omissions). Once the interviews were completed, transcribed, and reviewed, they were grouped by couple and reviewed by two research staff for preliminary data analysis guided by grounded theory (Strauss & Corbin, 1997). One research staff served as primary reader, conducting the preliminary analysis of the transcripts to allow for salient themes to emerge at the individual level and the couple level. The primary reader prepared detailed notes and the second staff member provided feedback on the lead reviewer’s notes. Throughout the process, different research staff members took the lead in analyzing transcripts. In the preliminary analysis, readers summarized each partner’s transcript, identified main areas of interest, and then created a new document that summarized both partners as a couple and identified main areas of interest for the couple. Members of the study team (the Principal Investigator, the Project Director, and two interviewers) discussed summaries at weekly meetings, at which point additions and corrections to the summaries could be made and any discrepancies between the two readers could be resolved. Themes that emerged from the summaries were used to identify and develop codes. Emergent codes were developed by research staff members and fell into the following categories: gender, relationship quality, agreements about sex with partners outside the relationship, sexual behavior, discrimination, family relationships, and sexual health. Only the categories concerning sexual agreements and sexual behaviors with outside partners were utilized for the present analysis. Once codes were identified, research staff members applied them to selected sections of the transcripts to verify code definition and application consistency among team members. When agreement was found among research staff, which in some cases required revising the definition of certain codes, the transcripts were coded. The coding process began by having two research staff members (coders) code the same transcript independently of one another. Afterwards, they met to compare their coded transcripts for discrepancies. This process was repeated until both coders demonstrated sufficiently consistent coding techniques (approximately the first 16 transcripts coded i.e., 8 couples). All subsequent interviews were coded by one coder only, rather than both simultaneously (Frieze, 2008). Further analysis using Dedoose (2021) was conducted by searching for specific codes and pairings of codes.

Study Team

The study team was diverse in terms of sexual and gender minority statuses. The team received consultation from an Advisory Board comprised of trans individuals several times to develop the recruitment strategies, the interview guide, and study procedures. The five core staff included sexual and gender minorities, including trans and cis identities. The three authors, all cis women, analyzed the data with the intention of data fidelity and limited bias. However, the analysis was conducted through a cis woman’s lens and may have over- or under-represented some of the dynamics at play.

Results

The sample consisted of 22 trans women, 17 trans men, who were all partnered with cis men, and one genderqueer person partnered with a trans man. At the individual level, 50% of the sample identified as European-American/White, 26% identified as African American/Black, 6% identified as Asian American/Asian, 6% identified as Latinx, 3% as Native American and 9% identified as Mixed. While 3% of the participants had unknown HIV status at the time of their interviews, 19% were HIV positive and 78% were HIV negative. The average age of participants was 36 years old, and the majority (36%) had some college education (see Table 1. Individual Level Characteristics).

At the couple level, 56% of participants were trans women partnered with cis male partners, 41% were trans men partnered with cis male partners, and one couple (3%) was a trans man partnered with a genderqueer partner. Most couples (47%) were mixed race couples. Thirty-five percent of couples were exclusively European-American/White participants, 15% of couples were exclusively African-American/Black, and 3% was exclusively Native-American. The sample included 13% who were seroconcordant HIV-positive, 71% were seroconcordant HIV-negative, and 13% were HIV discordant. The average relationship length was 4.3 years (see Table 2. Couple Level Characteristics).

The following results are divided into three sections that will report on the types of sexual agreements, negotiating agreements, and negotiating sex for trans-cis couples. Findings reveal that trans couples fall under three categories of sexual agreements: monogamous, non-monogamous, and no agreement. Negotiating sexual agreements is included to account for flexibility in relationship agreements that reflects couples’ own parameters. The final subheading, negotiating sex, is based on changing sexual desire, body concerns, and maintenance sex that trans and cis partners reported.

Sexual Agreements

Monogamous Agreements

Most couples reported that they had an agreement about whether or not sex with outside partners was allowed. We found that there were two main types of sexual agreements: monogamous and non-monogamous. We define monogamous couples as those that do not allow sex with outside partners. In this type of sexual agreement, the partners in the couple are each other’s only sexual partner.

• Q: “Okay cool. So how did you come to that agreement that there was going to be no sex outside the partnership? Was there a conversation?”

• A: “I think we did have a conversation like that before. But it was pretty much like if we’re going to be in a relationship, it’s just going to be us two and like really, it’s just going to be us together and that’s it. And there’s no need to go and have sex anywhere else. Yeah, I guess I’m old fashioned, but like definitely, like I spend my relationship with this one person and only have sex with one person and yeah, I’m all about just one person basically, you know I don’t know if that makes sense, but yeah.” (Trans woman)

• Q: “So at this point in your lives are you having sex outside of the relationship?”

• A: “I’m glad you asked that question, because I knew that was going to be the next question. (Laughs) No. Know why? I don’t like cheating. Not where we are now. It brings up bad feelings. And people talk too much.” (Cis man)

Some couples use the term “monogamous” loosely, depending on the needs of each partner. For example, while those in monogamous relationships do not have outside sexual partners, their agreement allows chatting or flirting with other people. One trans man mentions that his partner talks to people online, but this behavior is acceptable because it is online, purely for play, and occurred before their relationship began.

“We’re monogamous basically, although he has like online like chat buddies and stuff which I know about and it’s totally fine, like as long as there is no like physical contact I don’t care.” (Trans man)

Another couple reported that even though they had a monogamous agreement, he and his partner allow sex outside the relationship, saying, “we’re primary partners in that we’re in a monogamous relationship and that we have casual sex with other people but we’re not dating other people” (Trans man). In this excerpt, the emotional connection within the relationship is prioritized and considered the primary factor to their monogamy, so sexual encounters with outside partners are allowed, so long as neither develop an emotional connection. This couple defines monogamy in emotional terms, rather than sexual.

In other instances of self-reported monogamous agreements, sex with others is permitted because one partner is not able to fulfill the other’s sexual desires, specifically due to differences in desired body parts during sex. In this situation, the couple still considers their relationship to be monogamous, but body-specific sexual preferences are accommodated. One trans woman, who has not undergone any gender-affirming surgery, allows her partner to have vaginal sex with cis women as long as he lets her know beforehand.

“But I said, if you ever was to go out and you was to ever find you some P-U-S-S-Y, excuse my language, because saying the word is just nasty. Just come to me, talk to me because you’ve been having ass A-S-S for so long. I know you like women. I know you attracted to women, so just let me know. And you never know girl, sometimes I might want to watch. But make sure you’re satisfied because of the fact that I don’t want to deprive you of that.” (Trans woman)

In this example, the trans partner acknowledges her partner’s sexual preferences and modifies their sexual agreement based on that factor. This trans participant also mentions that though she gives her partner the option, he has not had sex with other people. Regardless, she wants to give her partner choices that can satisfy his sexual desires so that they can maintain a monogamous relationship otherwise. Overall, couples defined their own version of monogamy, reflecting the specific and complex needs of their own relationship.

Non-Monogamous Agreements

The second type of sexual agreement is non-monogamous, in which couples allow sex with outside partners. Some non-monogamous agreements were specific about what kinds of sexual acts, partners, and situations were considered acceptable to the couple,

“You know we can have penetrative sex, you can cum inside me if you want. It’s not a big deal. Sometimes I think it’s hot. But outside of my primary partner I will be using condoms with everybody. Even though I’m on PrEP also… And we have an agreement that if I’m going to be playing at [a sex club] there will always be a condom involved, which is my preference” (Trans man)

Others have non-monogamous agreements that emphasize sexual health management and practicing safe sex,

• Q: “Do you have a specific agreement or expectations or understanding about sex with outside partners?”

• A: “Yes. It should be protected and if for some reason it’s not we have let each other know. And do whatever is necessary, get tested or whatever.”

• Q: “And how did you come to make this agreement?”

• A: “(Sighs) Well, you know first it made sense, yeah, just being educated. Or just knowing risks of having unprotected sex. And then just knowing that you don’t want to pass something onto them. Yeah.” (Trans woman)

  “[Our agreement is] whatever we did that we’d be safe because we’re both like really paranoid and don’t want to catch STDs or give an STD to the other” (Cis man)

In the quotes above, both partners of a non-monogamous couple emphasize that their agreement centers sexual health. Both partners highlight specific prevention tactics, like education, communication, HIV testing, and wearing condoms with outside sexual partners, as a major part of their relationship agreement.

Couples with No Agreements

The final kind of sexual agreement emerged from couples who had no agreement whatsoever. Four couples reported that they did not discuss a sexual agreement with their partner, nor did they find a need to create one because trust and communication had been established.

“Yeah. I mean we don’t – we don’t have like – we never really developed an explicit agreement. It’s definitely not that we conceal things from each other. We’ll like talk, yeah, we’ll talk about other people if they come up. And I guess like it just feels like we keep open communication. And so at this point we haven’t really developed like an agreement like that.” (Cis man)

As this quote suggests, couples who reported no agreement at all may have implicit agreements that have simply remained unspoken.

Negotiating Agreements

There were a handful of couples with a sexual agreement that was dynamic and allowed for flexibility and changes. Couples who experienced breaks in their agreements because of cheating, not wearing a condom, or not communicating with their partner about outside sexual encounters were able to re-negotiate their agreements to better fit their altering needs. One couple initially had a non-monogamous agreement that allowed each partner to have casual sex with more than one partner. As this couple decided non-monogamy was not as satisfying as an emotionally close, monogamous relationship, the couple changed their agreement.

“I would like to be open, but not really. Like sometimes I miss the casual sex but… I feel like we make love and it’s this intense emotional experience along with a sexual experience and with like casual sex it’s really not that” (Trans woman)

Some couples have a sexual agreement that fluctuates to accommodate the needs of one partner. Several couples with different levels of sexual desire noted that they would be open to renegotiating their agreement to reflect the changing needs of their relationship. For example, one trans woman once had a high sex drive, but after an orchiectomy, the surgical removal of the testicles, found her sex drive significantly lower. As a result, her partner’s higher level of sexual desire did not match her newly lowered sexual drive. In a situation like this, the couple talks about the problem and ways that they can solve it.

“But we would have sort of more general conversations about levels of sex drive and what that means in our relationship. And yeah, we just process it like anything else. We would sort of talk about it, talk about what it means for me to have a higher sex drive and for her not. And if there are solutions to that or if there are ways that we can deal with it that alleviate any stress from either of our parts. So yeah, sort of like a combined attempt to find a solution I think that’s sort of like what always happened.” (Cis man)

Other couples have a working agreement that is motivated by an open-minded attitude towards making their sexual relationship better. In this type of agreement, there is less focus on broken agreements because these moments are instead highlighted as indicators of what works or doesn’t work in their relationship. These couples view broken agreements as a chance to reassess their existing agreements and make changes.

• Q: “And has your agreement always been this way in your relationship with Jason?

• A: Things change. Everything always changes. Like there will be some agreement broken and we try to talk about fixing it. All right, if that don’t work let’s try new things. So like things always change. But the one thing so far that’s solid is we’re fluid-bonded.” (Trans man)

This participant acknowledges that he and his partner will adjust their sexual agreement to better fit the needs of their relationship as it grows and changes over time, demonstrating the dynamic nature of their relationship.

Negotiating Sex

Sexual Desire

When negotiating sex, participants highlighted how differences in sexual desire accounted for tension within romantic relationships. A third of couples spoke of mismatched libidos, with most attributing the discrepancy to new changes in hormones or fluctuating sexual desire. Many participants noted that when their sex was reduced in frequency due to hormonal changes, body dysphoria, or different sex drives than their partners, there was more frustration and dissatisfaction within the relationship.

“I think that I would like to have the higher sex drive. So in that sense I’m like not satisfied. But like it’s not that I’m like, I really want to have sex and he won’t have sex with me. It’s like I want to want to have sex with him and I can’t get there like um, chemically” (Trans woman)

Some participants remarked upon the ways that gender affirming measures influenced more than their hormones and sex drive, influencing their sexuality as a whole, “My body is changing as a result of testosterone and so things don’t feel the same. I don’t want the same things and so my sexuality is kind of changing” (Trans man). Though most trans men noticed that an increase in testosterone heightened their sexual desire, some trans men noted that hormonal changes led to dips in desire.

“Right now my hormones have shifted and I wonder if my hormones are impacting my sex drive so it’s decreased recently.” (Trans man)

“I was on a higher dose of testosterone when I was on injectable and then I really didn’t want to be a human pincushion anymore so I switched to the gel. And the gel is a high enough dose to keep all my organs like turned off and my body happy and healthy. But a lot lower than it was on injectable so one of the things is sex drive, is just like [makes dropping noise].” (Trans man)

Conversely, most trans women noticed a drop in their sex drive after gender affirming measures. Several respondents specifically noted an orchiectomy as influencing their sex drive and, more broadly, their sexual identity.

“My hormones, because I do take hormones, has my body just wacky. And for me personally since I’ve had my orchiectomy I am not very aroused.” (Trans woman)

“After I got an orchiectomy my sex drive was like significantly lower. And so I’m like not– I’m not like a super sexual person.” (Trans woman)

Though trans men and trans women found that hormonal changes significantly affected their bodies and desire, both increasing and decreasing their sex drive, most trans men found testosterone to increase sex drive, while most trans women had lower sex drives due to gender affirming measures. Often, though, trans participants just needed to find the right hormonal balance to have satisfying sexual desire and arousal, which can mean experimenting with doses and methods.

“No, I mean since I’ve been on testosterone vaginal penetration has been less pleasurable for me, or at least I’ve had to mess around with my dose… The dose that I was on, which was like half a cc once a week gave me vaginal atrophy really quickly and then vaginal penetration became really painful and unpleasant, even with a ton of lube. Lubrication didn’t seem to be the issue, it was just like the tissue gets thinner and a lot more sensitive, kind of like post-menopause. And I like being able to have penetrative sex. So I just experimented with reducing my dose like to the point where that was no longer a problem” (Trans man)

Navigating Bodies

Most trans participants avoided certain sexual positions because they led to body dysphoria and, often, a subsequent loss in sexual arousal. Almost all trans women reported heightened bodily dysphoria at seeing or feeling their penis during sex. As such, most of the trans women interviewed did not like to receive oral sex and chose to never penetrate their partner, considering this a non-feminine or unwomanly sexual act. One participant, when asked if she ever penetrated her partner said simply, “I’m a girl,” (Trans woman) indicating that receptive vaginal penetration was incongruent with her gender identity.

“But like when he goes down on me and anyone goes down on me like no one can make me cum because it just feels uncomfortable because it’s not the part that I want or feel that I’m supposed to have and that’s probably why it feels uncomfortable for me” (Trans woman)

On the other hand, trans men felt less dysphoric about having sex that included receptive vaginal penetration. With the exceptions of one participant who was practicing abstinence and another who was undergoing the months-long process of bottom surgery, every trans man noted participating in penetrative vaginal sex with their partner(s). Despite feeling comfortable with vaginally penetrative sex, trans men were mindful of the language used for their genitals. While some were comfortable with “vagina,” most respondents preferred “front hole” or “other hole,” if “vagina” felt dysphoric or, as one participant remarked, “too feminine” (Trans man).

Maintenance Sex

Several respondents reported that they were motivated to have sex with their partner at times when they were not experiencing sexual desire. Motivations for maintenance sex when not feeling desire fell into both positive and negative narratives. Some trans participants noted they were motivated to engage in negative maintenance sex, which is sex stemming from feelings of fear and distrust. Most often, this fear was around cis partners breaking monogamous agreements by cheating, especially if the trans partner was experiencing a dip in desire and it had been a while since their last sexual encounter.

“I worry sometimes because I can’t give him what he wants. Is he going to go outside our relationship?” (Trans woman)

Other participants had positive maintenance sex, in which individuals would have sex just to provide pleasure and satisfaction to their partners, despite not feeling aroused themselves. For these participants, there was no fear or concern about the repercussions of longer sexual breaks.

• Q: “You didn’t necessarily orgasm in that circumstance that you talked to me about. Is that something that usually happens?”

• A: “Well I mean like I still feel like I had some type of orgasm doing that. I just didn’t like actually have to cum to do that.” (Trans woman)

• Q: “What were your expectations in that circumstance?”

• A: “Mostly to please him. Yeah, during that time uh, yeah I was just mostly depressed anyway so I was like finishing myself elsewhere. (Laughs) So it was mostly just to make him feel loved and supported because we are both kind of barreling into this.” (Cis man)

  These instances of positive maintenance sex are usually characterized by feelings of intimacy with one’s partner, though seldom result in having an orgasm or feeling sexually aroused themselves. Moreover, positive maintenance sex has less to do with sex or sexuality and more to do with maintaining a happy and satisfying relationship. Maintenance sex, whether positive or negative, functions to preserve closeness in a sexual relationship by focusing on one partner’s sexual needs.

Fluid-Bonding in Non-Monogamous Agreements

One defining characteristic within couples’ sexual agreements is their choice in exchanging sexual fluids, which literature and participants sometimes call fluid-bonding (Kosenko, 2011). Non-monogamous couples who considered themselves fluid-bonded allowed the exchange of fluids during sex with their primary partner but were required to wear condoms with outside sex partners.

“Yeah, with Jason we say like we’re good with being fluid bonded just between us two. But with other people I wear a condom” (Trans man).

Some non-monogamous couples spoke of fluid-bonding as a distinguishing factor between the main partner and outside sexual partners. As demonstrated in the quotes below, individuals in non-monogamous couples used language of closeness and intimacy when discussing their choice to be fluid-bonded exclusively with their primary partners.

“But typically [during sex] we’re like face-to-face and you know looking at each other and kissing and it’s just very intense and intimate and they really like when I cum in them and they can sort of feel it pulsing. And I mean we’re fluid-bonded, which adds quite another layer of intimacy to it.” (Cis man)

“We started off having sex in the beginning of our relationship with condoms because we’re not mutually exclusive with each other. Once we sort of figured out that we were at least going to be primary partners, I don’t know if you’ve heard the term fluid-bonding or Chi is the specific term for it…” (Cis man)

Fluid-Bonding in Monogamous Couples

Unlike non-monogamous couples, monogamous couples make decisions about fluid-bonding not because of intimacy or sexual risk due to additional partners, but because of discordant HIV statuses or for birth control. They do not mention elements of intimacy or closeness in their decisions around fluid-bonding in the same way that non-monogamous couples do.

“I really do honestly make him put on two condoms…because if one breaks I don’t want to share fluids…even though I’m undetectable at this moment I’m still HIV positive. And you are negative, and if you cannot get satisfied with two condoms on that’s on you.” (Trans woman)

“By him being on the level of testosterone that he is on it would be very challenging for him to get pregnant because of the hormones that he’s taking.I don’t cum inside of him so that’s how we sort of play it safe. We do our best to not share fluids and to not – like I always pull out and I don’t ever cum inside of him. So just on the off chance that just to make sure [he doesn’t get pregnant] even though it would be very unlikely based on the hormones that he takes.” (Cis man)

In monogamous agreements, decisions about fluid-bonding are not concerned with defining intimacy in the relationship, as they are in non-monogamous agreements, and are rather decisions about family planning and sexual health.

Discussion

Previous research has highlighted the importance of identifying sexual risk factors that are unique to specific populations (Sevelius, 2013; Sullivan et al., 2009; Operario et al., 2017). Given the trans community’s high rate of HIV, it is imperative that trans couples’ sexual risk factors are prioritized. In committed relationships agreements about whether sex with outside partners is permitted, motivations for agreements, negotiating agreements, and maintaining agreements have been found to be critical in promoting sexual health within MSM couples (Hoff et al., 2016; Essack et al., 2020; Mitchell & Konda, 2020; James et al., 2020; Hosking, 2014). The present findings demonstrate that trans men and trans women partnered with cis men similarly have sexual and relationship dynamics that are important to understand to support trans couples’ relationships and sexual health.

Although most of the couples reported having an agreement, some reported definitions of monogamy and non-monogamy that were inconsistent with previous literature on agreements (Hoff & Beougher, 2009; Mitchell & Konda, 2020). For example, some couples reported that their monogamous agreements, typically defined as restricting sex with partners outside of the relationship, allowed sex with outside partners if the primary couples’ emotional relationship remained primary. Similarly, some couples felt it was important to allow outside sex if one partner could not fulfill the other’s sexual desires, especially due to desired body parts that a partner may not have. With the understanding that the couples’ relationship was prioritized, sex to fulfill a partner’s sexual desires was permitted. This flexibility within agreements seems to accommodate the sexual and emotional needs of the couple; however, providers should make sure they fully understand what a person means when they label their agreement monogamous given its conventional meaning and the divergence from it seen in this study.

Non-monogamous agreements were varied in their specific rules and boundaries, as would be expected given the literature on non-monogamous relationships among MSM (Hoff & Beougher, 2009; Mitchell, 2014). Importantly, most agreements between non-monogamous trans-cis couples emphasized safe sexual practices, including informed HIV and STI prevention tactics. Fluid-bonding emerged as a factor for many non-monogamous couples. While these couples allowed sex with outside partners, fluid exchange was reserved for primary partners. This rule allowed for a level of intimacy and exclusivity within the primary relationship, while sexual desires for outside partners could still be fulfilled. Monogamous couples in this study, however, made fluid-bonding a choice about family planning or sexual health. It is important to note that there is some debate within literature on MSM couples about whether fluid-bonding is a method of practicing safer sex or if it is still engaging in risky sexual practice (Mitchell, 2013); however, there is evidence that these agreements are mostly honored and upheld and that they help to sustain safe sex practices in outside partnerships, as well as intimacy in long-term relationships with primary partners (Crawford et al., 2001; Kippax et al., 1997). This study found that fluid-bonding was used as a tool to emphasize intimacy within non-monogamous couples, potentially reinforcing agreements that already spotlighted safe sex with external partners.

A few couples reported that they did not have an agreement and instead talked about the trust they had established in their relationship. It was difficult to discern if the trust they referred to was a substitute for an agreement, or if they had an implicit agreement of monogamy that had not been verbally formalized. It was more troubling that almost half of the couples reported discrepant agreements. Because previous research demonstrates that discrepant agreements and the absence of an agreement can be associated with sexual risk, it is important for future interventions to encourage clearly articulated agreements within couples (Mitchell, 2014; Hoff, 2010). As demonstrated in this study, definitions of monogamy and non-monogamy can be capacious and complex, a finding that may account for the discrepancies in agreement type. With this considerable ambiguity, it is important that healthcare providers encourage trans communities to explicitly communicate their relationship agreement with their partners and with other healthcare providers, as well. It is crucial to recognize the different types of sexual agreements among trans couples so that they may receive the best care for their sexual health.

Overall, couples seemed to negotiate and navigate changes in sexual desire and subsequent agreements successfully. One of the primary factors in desire changes was hormone use for both trans men and trans women. In general, trans men found their sexual desire increased due to testosterone use and trans women found their sexual desire declined due to estrogen and other feminizing hormones. But, trans participants emphasized the importance of finding a balance with their hormone levels that minimized changes in desire and potential differences in sexual satisfaction within the couple. Generally, couples communicated openly about sexual differences that did surface and worked collaboratively to find satisfactory solutions for both partners. Sometimes this included an outside sex partner, a temporary reduction in sex together, or unwanted but consensual sex (maintenance sex) to satisfy the sexual needs of their partner. Specific sex acts were an important factor influencing sexual desire. Some trans women reported experiencing gender dysphoria and had trouble maintaining arousal if they felt their penis during sex or if their partner wanted to perform oral sex on them. Trans men reported that although they engaged in vaginal sex, they conscientiously referred to their genitals with terminology that felt less feminine and more gender affirming. It is important for providers to be aware of these unique sexual needs so that they can encourage ongoing negotiation to support sexual satisfaction as it changes over time.

The present study offers novel information about agreements and sexual negotiation among trans men and trans women partnered with cis men. However, there are several limitations that should be noted. The design of the study was structured so that all participants were self-selected, which may have produced a sample of couples who felt that their relationships were healthy and had few problems. Moreover, the study was a cross-sectional, semi-structured interview of participants living in the San Francisco Bay Area. Given this, the data are limited to the scope of topics set at the start of the study and the regional sample may not be representative of trans men and trans women partnered with cis men and therefore is not generalizable. While the study team was diverse in terms of gender identities and were advised by a trans community advisory board, the authors are cis women and conducted the analysis through a cis lens that may have inadvertently omitted some nuanced relationship dynamics unique to trans/cis couples.

The present study examined the complexity of sexual agreements and sexual negotiation among trans men and trans women partnered with cis men. Although there is some literature examining the health of trans individuals, it is limited to: gender transitions (Marshall et al., 2020), gender affirmation strategies (Glynn et al., 2016), medical procedures (Coleman, et al., 2012), and legal issues (Persson, 2009). Less is known about the complexities of relationship formation and sexual negotiation and agreements. Unique sexual needs were identified for both cis and trans partners and, in general, couples negotiated these needs to ensure sexual and relationship satisfaction for both members of the couple. It is important to understand these needs and desires so that providers can support couples’ negotiations and help them maintain their agreements and sexual health over time.