Category: Sexual function
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94% of females taking testosterone experience pelvic floor dysfunction.
In a study1 of 68 women taking testosterone, 94.1% had some form of pelvic floor dysfunction. 86.7% had urinary symptoms. Other problems included storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%.)
- da Silva LMB, Freire SND, Moretti E, Barbosa L. Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study. International Urogynecology Journal. 2024 May;35(5):1077-1084. doi: 10.1007/s00192-024-05779-3. Epub 2024 Apr 25. PMID: 38662108. ↩︎
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Quality Of Life scores start to decline around one year after “gender-affirming” surgery. After five years, these scores are below pre-surgery levels.
A systematic review and meta-analysis1 of studies on the Quality Of Life (QoL) of transgender patients showed that in every domain, these patients tended to have poor QoL compared to the general population. Some patients showed an increase in QoL in some domains, but this peaked after about a year. After five years, these scores were below pre-transition levels.
- Nobili, A., Glazebrook, C. & Arcelus, J. Quality of life of treatment-seeking transgender adults: A systematic review and meta-analysis. Rev Endocr Metab Disord 19, 199–220 (2018). https://doi.org/10.1007/s11154-018-9459-y ↩︎
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Genital surgery is associated with high rates of pelvic floor and sexual dysfunction.
A 2025 systematic review and meta-analysis1 examined 25 studies on pelvic floor outcomes after genital “gender-affirming” surgery. The findings show a high prevalence of complications among both male and female patients:
Type of Dysfunction Males (vaginoplasty) Females (hysterectomy & phalloplasty) Pelvic organ prolapse 1–7.5% 3.8% Urinary incontinence up to 15% up to 50% Urinary irritative symptoms up to 20% up to 37% Sexual dysfunction 25–75% 54% - Dominoni, M., Scatigno, A. L., Pasquali, M. F., Bergante, C., Gariboldi, F., & Gardella, B. (2025). Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis. The Journal of Sexual Medicine, 22(1), 184-195. [Link] ↩︎
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Long term testosterone use potentially compromises fertility and negatively affects ovarian follicle health
One study in 2023 found that long-term testosterone exposure, as seen in transgender men undergoing gender-affirming therapy, could potentially compromise fertility by negatively affecting ovarian follicle growth, health, and DNA integrity.
In 2023, a study by Bailie et al1. explored the effects of long-term testosterone exposure on ovarian follicles in transgender men receiving gender-affirming endocrine therapy. The research indicated that testosterone was linked with decreased follicle growth activation, poor follicle health, and increased DNA damage, suggesting possible impacts on fertility. Further, these negative effects were intensified following six days of in vitro culture. These findings may have crucial implications for reproductive health and fertility considerations among transgender men receiving testosterone as part of their gender-affirming therapy.
- Bailie, E., Maidarti, M., Hawthorn, R., Jack, S., Watson, N., Telfer, E. E., & Anderson, R. A. (2023). The ovaries of transgender men indicate effects of high dose testosterone on the primordial and early growing follicle pool. Reproduction and Fertility, 4(2). [Link] ↩︎
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Young transgender people are at elevated risk of contracting HIV and other STDs
Transgender adolescents and young adults, particularly trans females, are at a disproportionately high risk of contracting human immunodeficiency virus1 and other sexually transmitted diseases2.
- Poteat, T., Scheim, A., Xavier, J., Reisner, S. & Baral, S. (2016). Global Epidemiology of HIV Infection and Related Syndemics Affecting Transgender People. Journal of Acquired Immune Deficiency Syndromes 72 (Suppl 3). [Link] ↩︎
- Reisner, S.L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D. & Mimiaga, M.J. (2015). Mental Health of Transgender Youth in Care at an Adolescent Urban Community Health Center: A Matched Retrospective Cohort Study. Journal of Adolescent Health 56 (3): 274-279. [Link] ↩︎
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Vaginoplasty can result in fistula, stenosis, necrosis, prolapse and even death
Male-to-female genital surgery (vaginoplasty) is associated with significant long-term complications: there is a 2% risk of fistula, 14% risk of stenosis (abnormal narrowing), 1% risk of necrosis (tissue death) and 4% risk of prolapse1.
One systematic review2 found an overall complication rate of 32.5%.
A Dutch study3 of 55 (out of an original 70) adolescents treated with puberty blockers, cross sex hormones, and genital surgery, showed that among 22 male-to-female patients who underwent vaginoplasty, one adolescent died as a result of necrotizing fasciitis after the surgery.
- Manrique, O., Adabi, K., Martinez-Jorge, J., Ciudad, P., Nicoli, F. and Kiranantawat, K. (2018). Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty—Where We Are Today. Annals of Plastic Surgery 80 (6): 684-691. [Link] ↩︎
- Dreher, P.C., Edwards, D., Hager, S., Dennis, M., Belkoff, A., Mora, J., Tarry, S. & Rumer, K.L. (2018). Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management. Clin Anat. 31 (2):191-199. [Link] ↩︎
- de Vries, A., McGuire, T., Steensma, E., Wagenaar, T., Doreleijers, P. & Cohen-Kettenis, P. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. [Link] ↩︎
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Feminizing hormones reduce sexual function in males
Feminizing hormonal treatments lead to a lessening drive, erectile dysfunction, and shrinking of testes and penis1, significantly compromising sexual function.
A Belgian doctoral thesis study2 found that 69.7% of transwomen reported a decrease in sexual desire — while the opposite effect is found in transmen.
- Levine, S. (2018). Informed Consent for Transgendered Patients. Journal Of Sex & Marital Therapy, 45(3), 218-229. [Link] ↩︎
- Elaut, E. (2014). Biopsychosocial factors in the sexual desire of contraception‐using couples and trans persons. Doctoral thesis, University of Ghent. [Link] ↩︎
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Genital surgeries tend to reduce the capacity for orgasm in males, and may do so in females
One study showed that around 30% of male-to-female genital surgeries result in the inability to orgasm1.
Figures on female-to-male transitioners are less clear. However, a clinical follow-up study2 of 38 transmen – 29 of whom had received phalloplasty, and 9 metoidioplasty – found that reported loss of orgasmic capacity was more marginally common than reported gain of orgasmic capacity.
The negative intrapsychic and interpersonal consequences of anorgasmia (the inability to climax) is well-documented, and applies equally to transgender individuals3.
- Manrique, O., Adabi, K., Martinez-Jorge, J., Ciudad, P., Nicoli, F. and Kiranantawat, K. (2018). Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty—Where We Are Today. Annals of Plastic Surgery 80 (6): 684-691. [Link] ↩︎
- van de Grift, T., Pigot, G., Kreukels, B., Bouman, M., & Mullender, M. (2019). Transmen’s Experienced Sexuality and Genital Gender-Affirming Surgery: Findings From a Clinical Follow-Up Study. Journal Of Sex & Marital Therapy 45 (3): 201-205. [Link] ↩︎
- Levine, S. (2018). Informed Consent for Transgendered Patients. Journal Of Sex & Marital Therapy, 45(3), 218-229. [Link] ↩︎
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Long-term testosterone use in natal females can cause vaginal atrophy, which makes sex painful
A study1 of 16 female-to-male transgender individuals concluded that long-term testosterone administration leads to vaginal atrophy (Baldassarre et al., 2013). The study noted that:
Vaginal samples from FtM showed a loss of normal architecture of the epithelium, intermediate and superficial layers were completely lost, and glycogen content was depleted.
Vaginal atrophy, characterized by thinning of vaginal walls and poor lubrication of vaginal tissues, leads to tearing, micro abrasions, bleeding, and painful intercourse.
- Baldassarre, M., Giannone, F., Foschini, M., Battaglia, C., Busacchi, P., Venturoli, S., & Meriggiola, M. (2013). Effects of long-term high dose testosterone administration on vaginal epithelium structure and estrogen receptor-α and -β expression of young women. International Journal Of Impotence Research, 25 (5): 172-177. [Link] ↩︎
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Female-to-male genital reconstruction surgery has a high negative outcome rate, including urethral compromise and worsened mental health
The results of a 2021 international survey1 of 129 female-to-male patients who underwent genital reconstruction surgery support anecdotal reports that complication rates following genital reconstruction are higher than are commonly reported in the surgical literature.
Complication rates, including urethral compromise, and worsened mental health outcomes remain high for gender affirming penile reconstruction. In total, the 129 patients reported 281 complications requiring 142 revisions.
Another paper2 found a 70% complication rate in one type of female-to-male genital reconstruction surgery.
Even with the “radial forearm free flap” method of creating a synthetic penis — “considered by many as the gold standard for phalloplasty”3 — there are high rates of complications, with up to 64% urethroplasty related complications4.
- Robinson, I.S., Blasdel, G., Cohen, O., Zhao, L.C. & Bluebond-Langner, R. (2021). Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 18 (4): 800-811. [Link] ↩︎
- Bettocchi, C., Ralph, D.J. & Pryor, J.P. (2005). Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 95:120–4. [Link] ↩︎
- Rashid, M. & Tamimy, M. S. (2013). Phalloplasty: The dream and the reality. Indian J Plast Surg 46 (2): 283-293. [Link] ↩︎
- Fang, R.H., Lin, J.T. & Ma S. (1994). Phalloplasty for female transsexuals with sensate free forearm flap. Microsurgery 15: 349–52. [Link] ↩︎