Sexual Dysfunction Is Common In Trans People Who Have Had Gender-Transition Surgery
The first-ever systematic review and meta-analysis of pelvic floor dysfunctions among transgender people who have had genital gender-transition surgery found that rates varied widely between studies.
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Among transgender people who have had genital-transition surgery, pelvic floor dysfunctions are common. This includes sexual dysfunction, including pain during intercourse and difficulty or an inability to experience orgasm, as well as urinary irritation and incontinence, among other problems.
These findings come from the first-ever systematic literature review—the gold standard of scientific evidence—and meta-analysis of pelvic floor dysfunctions in this population.
However, the review’s authors found that the quality of the related scientific evidence was low, meaning the findings of the analyzed studies had a high risk of bias. In general, the rates of pelvic floor dysfunctions varied widely between studies. Also, the number of studies was limited. Consequently, the Italian investigators who authored the new paper, which was published Nov. 14 in The Journal of Sexual Medicine, said that their findings should be interpreted with caution.
“Pelvic floor dysfunction in transgender individuals is a growing concern,” the authors wrote.
They also emphasized: “Adequate information for each surgical procedure, explicit postoperative instructions, continuity of care, communication with healthcare providers, and recommendation for tailored perioperative pelvic floor physiotherapy are necessary for a better surgical result.”
What About Minors?
The paper offered no insights on pelvic floor dysfunction among, in particular, people who underwent genital gender-transition surgery as minors.
Vaginoplasties—the creation of a vagina among natal males who identify as female—are very rare in people under the age of 18 in the United States. However, some leaders in the pediatric gender medicine field do recommend that trans girls receive such a surgery before leaving their parents’ home for college, putting them at about age 17.
The only age restriction that the World Professional Association for Transgender Heath puts on gender-transition treatment and surgery is for phalloplasty—the creation of a penis in trans males (natal females) using tissue from the thigh or forearm—which WPATH does not advise for those under age 18.
At Least 14,000 U.S. Minors Have Received Gender-Transition Treatment or Surgeries In 5 Years, With Docs Billing $120 million
What Went Into The New Literature Review?
The new systematic literature review examined 25 papers published between 2001 and 2023 and included 17 of those papers in their meta-analysis. The studies needed to concern people who had received genital gender-transition surgery and to include findings about pelvic floor dysfunction; urogenital symptoms; sexual dysfunction; or the effects of pelvic floor physical therapy.
Six of the studies included trans men and 23 included trans women. This imbalance is likely a reflection of the fact that older populations of transgender people are predominantly trans females (natal males). The new generation of young people who identify as trans is predominantly trans masculine (natal females).
From their review of the literature, the authors found: “Several studies report a notable improvement in quality of life, particularly regarding mental health, in patients who have undergone GAS [gender-affirming surgery]. Many patients who underwent vaginoplasty reported a complete resolution of gender dysphoria, and reduced anxiety and depression, which also lead to an overall reduction in suicide rates.”
Outcomes In Trans Women (natal males)
Among trans women who received a vaginoplasty:
Pelvic organ prolapse: According to Johns Hopkins, this is “descent of the uterus, vagina, bladder and/or rectum resulting in a ‘bulging’ sensation within the vagina.” (Obviously, a trans female would not have a uterus.) 1% to 7.5% experienced this complication. Six studies found rates ranging between 1% and 4% and another found a rate of 7.5%.
Urinary incontinence: Up to 15% experienced urinary incontinence, or the inability to control the bladder. This finding derived from 12 papers including 1,412 patients. in particular, studies reported rates of 5%, 8% and 15%.
Urinary irritation: The range of rates spanned 2.6% to 20%.
Sexual dysfunctions: Between 25% and 75% experienced sexual dysfunctions, including pain during intercourse and an inability to or difficulty having an orgasm. But a few papers found lower rates: 14%, 1%, and 18%. These dysfunctions, the analysis, found, “may be related to lubrication issues, inadequate arousal, or pelvic floor dysfunction.” However, the analysis also found that 63% of trans women report significant improvement in sexual functioning after surgery. One study found: “Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire.”
Outcomes In Trans Men (natal females)
Fewer than 5% of trans men undergo genital transition surgeries in the United States, the analysis found.
Among trans men who received a hysterectomy (the removal of the uterus) and a phalloplasty:
3.8% experienced pelvic organ prolapse.
Up to 50% experienced urinary incontinence.
Up to 37% experienced urinary irritation. The range was 4% to 37%.
54% experienced sexual dysfunction. In particular, among sexually active trans men, 54% had at least one sexual dysfunction. The most common were fear and difficulty in initiating and seeking sexual contact, with 32% of participants reporting this. Additionally, 15% of such individuals experienced difficulty in achieving orgasm. That study also found: “Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often.”
Working with a pelvic floor physical therapist, the analysis found, “seems to reduce” trans men’s “risk of experiencing postoperative pelvic floor symptoms.”
What Causes These Dysfunctions?
According to the study authors: “Various factors may contribute to its increasing prevalence” of pelvic floor dysfunctions among people who have undergone genital gender-transition surgeries, “including comorbidities, socioeconomic status, and hormonal therapy, all of which can affect pelvic floor muscle mass, connective and adipose [body fat] tissue organization, and pelvic organ support systems. Genital GAS may as well affect muscle tone, flexibility, and overall muscular function.”
Conclusions
The study authors concluded:
As the field of transgender healthcare evolves, understanding the impact of gender-affirming surgeries on the pelvic floor becomes increasingly crucial.
Currently,we lack sufficient and reliable data regarding the overall prognoses following genital GAS and its effects on pelvic floor functionality, which often affect the quality of life of these patients.
Furthermore, there are significant gaps in the literature about female-to-male surgery, despite the stronger data sup-porting gender-affirming surgery performed on males.
The study’s findings suggest that adequate information for each procedure,clear postoperative instructions,continuity of care, communication with healthcare providers, and tailored recommendations for perioperative pelvic floor physiother-apy are necessary for positive results. Gynecologists play a central role in the perioperative and routine care of transgen-der patients, both transfeminine and transmasculine.
Through continued research and multidisciplinary collabo-ration, we can ensure that the gender affirmation transition process encompasses comprehensive health and well-being.
I am an independent journalist, specializing in science and health care coverage. I contribute to The New York Times, The Guardian, NBC News and The New York Sun. I have also written for the Washington Post, The Atlantic and The Nation. Follow me on Twitter: @benryanwriter and Bluesky: @benryanwriter.bsky.social. Visit my website: benryan.net
I have suffered many complications from the vaginal birth of one of my daughters, which left me with many of these same complications. I have had multiple surgeries, , have an implanted nuerostimulator, and am thankful to live in a time with better medical care so that I have a good quality of life now. But honestly, I’m not the same as I was before the damage. It’s mind blowing to me that our medical system is out here currently disabling people in order to achieve solely a cosmetic result that’s a very poor copy of the original . The FTM phalloplasty surgeries especially have sky high complications . All of this takes up limited health care resources such as uro-gynecologists, OB-GYN’s, pelvic floor therapists. Theres a shortage of these specialists as is, and now there’s another population of people vying for them for cosmetic purposes only. It’s infuriating.
Not surprising at all that women can't ejaculate after "gender affirmative care," given that women don't have testicles, penises or any other male equipment to ejaculate with.