Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review

International Journal of Impotence Research (2023)Cite this article

Subjects

Abstract

Sexual health is pivotal to the overall health and well-being of individuals. To date, transgender persons’ sexual function results to be poorly investigated. Gender affirming medical and/or surgical treatments (GAMSTs) in transgender assigned female at birth (t-AFAB) can have an impact on overall quality of life and subsequently on sexual life. Before GAMSTs, literature shows a low sexual wellbeing of t-AFAB due to a complex interaction of organic and psychological factors. During gender affirming hormone therapy, testosterone treatments induce virilization that results in a better sexual satisfaction, in particular for sexual desire, arousal and orgasm. The majority of the available literature reports an increased sexual quality of life among t-AFAB after gender affirming surgery. Nevertheless, the different surgical techniques, the possible post-operative complications and sexual pain can negatively influence sexual function. Thus, this narrative review aims to summarize the available data about modifications on sexual health status in t-AFAB before and after GAMSTs. In transgender population, dealing with the evaluation of sexual life and satisfaction represents a relevant topic with a view to promote and sustain not only sexual wellbeing but especially general quality of life.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Stephenson KR. Sexual functioning. In: Michalos AC, editor. Encyclopedia of Quality of Life Research. The Netherlands: Springer Dodrecht; 2014. pp. 5899–902.

  2. Basson R, Berman J, Burnett A, Derogatis L, Ferguson D, Fourcroy J, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888–93.

    Article  CAS  PubMed  Google Scholar 

  3. Basson R. Human sex-response cycles. J Sex Marital Ther. 2011;27:33–43. https://doi.org/10.1080/00926230152035831.

    Article  Google Scholar 

  4. The sexual desire disorders: Dysfunctional regulation of sexual motivation. - PsycNET. https://psycnet.apa.org/record/1995-98610-000. Accessed 22 Oct 2022.

  5. Kaplan HS. Hypoactive sexual desire. J Sex Marital Ther. 1977;3:3–9.

    Article  CAS  PubMed  Google Scholar 

  6. Sexual health. https://www.who.int/health-topics/sexual-health#tab=tab_1. Accessed 24 Jan 2023.

  7. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23:S1–S259.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. ICD-11 for mortality and morbidity statistics. https://icd.who.int/browse11/l-m/en. Accessed 22 Oct 2022.

  9. Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103:943–51.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51:53–69.

    Article  PubMed  Google Scholar 

  11. Reisner SL, White JM, Mayer KH, Mimiaga MJ. Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center. AIDS Care. 2014;26:857–64.

    Article  PubMed  Google Scholar 

  12. Kerckhof ME, Kreukels BPC, Nieder TO, Becker-Hébly I, van de Grift TC, Staphorsius AS, et al. Prevalence of sexual dysfunctions in transgender persons: results from the ENIGI follow-up study. J Sex Med. 2019;16:2018–29.

    Article  PubMed  Google Scholar 

  13. Catelan RF, Saadeh A, Lobato MIR, Gagliotti DAM, Nardi HC, Costa AB. Depression, self-esteem, and resilience and its relationship with psychological features of sexuality among transgender men and women from Brazil. Arch Sex Behav. 2022;51:1993–2002.

    Article  PubMed  Google Scholar 

  14. Mattawanon N, Charoenkwan K, Tangpricha V. Sexual dysfunction in transgender people: a systematic review. Urol Clin North Am. 2021;48:437–60.

    Article  PubMed  Google Scholar 

  15. Vedovo F, Di Blas L, Perin C, Pavan N, Zatta M, Bucci S, et al. Operated male-to-female sexual function index: validity of the first questionnaire developed to assess sexual function after male-to-female gender affirming surgery. J Urol. 2020;204:115–20.

    Article  PubMed  Google Scholar 

  16. Becker I, Nieder TO, Cerwenka S, Briken P, Kreukels BPC, Cohen-Kettenis PT, et al. Body image in young gender dysphoric adults: a european multi-center study. Arch Sex Behav. 2016;45:559–74.

    Article  PubMed  Google Scholar 

  17. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med. 2015;12:180–8.

    Article  PubMed  Google Scholar 

  18. Cerwenka S, Nieder TO, Cohen-Kettenis P, De Cuypere G, Haraldsen IRH, Kreukels BPC, et al. Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study. J Sex Marital Ther. 2014;40:457–71.

    Article  PubMed  Google Scholar 

  19. Kim GW, Kim SK, Jeong GW. Neural activation-based sexual orientation and its correlation with free testosterone level in postoperative female-to-male transsexuals: preliminary study with 3.0-T fMRI. Surg Radiol Anat. 2016;38:245–52.

    Article  PubMed  Google Scholar 

  20. Kim GW, Jeong GW. Neural mechanisms underlying sexual arousal in connection with sexual hormone levels: a comparative study of the postoperative male-to-female transsexuals and premenopausal and menopausal women. Neuroreport. 2014;25:699–706.

    Article  Google Scholar 

  21. Sturüp GK. Male transsexuals: a long-term follow-up after sex reassignment operations. Acta Psychiatr Scand. 1976;53:51–63.

    Article  PubMed  Google Scholar 

  22. Elaut E, Bogaert V, De Cuypere G, Weyers S, Gijs L, Kaufman J-M, et al. Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: an exploration in male-to-female transsexuals. J Endocrinol Invest. 2010;33:37–41.

    Article  CAS  PubMed  Google Scholar 

  23. Kraemer B, Hobi S, Rufer M, Hepp U, Büchi S, Schnyder U. [Partner relationship and sexuality of female-to-male transsexuals]. Psychother Psychosom Med Psychol. 2010;60:25–30.

    Article  PubMed  Google Scholar 

  24. Selvaggi G, Monstrey S, Ceulemans P, T’Sjoen G, De Cuypere G, Hoebeke P. Genital sensitivity after sex reassignment surgery in transsexual patients. Ann Plast Surg. 2007;58:427–33.

    Article  CAS  PubMed  Google Scholar 

  25. Beckwith N, Reisner SL, Zaslow S, Mayer KH, Keuroghlian AS. Factors associated with gender-affirming surgery and age of hormone therapy initiation among transgender adults. Transgend Health. 2017;2:156–64.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8:3379–88.

    Article  PubMed  Google Scholar 

  27. Costantino A, Cerpolini S, Alvisi S, Morselli PG, Venturoli S, Meriggiola MC. A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery. J Sex Marital Ther. 2013;39:321–35.

    Article  PubMed  Google Scholar 

  28. de Cuypere G, Elaut E, Heylens G, van Maele G, Selvaggi G, T’Sjoen G, et al. Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery. Sexologies. 2006;15:126–33.

    Article  Google Scholar 

  29. Nikkelen SWC, Kreukels BPC. Sexual experiences in transgender people: the role of desire for gender-confirming interventions, psychological well-being, and body satisfaction. J Sex Marital Ther. 2018;44:370–81.

    Article  PubMed  Google Scholar 

  30. Wierckx K, Van Caenegem E, Schreiner T, Haraldsen I, Fisher A, Toye K, et al. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. J Sex Med. 2014;11:1999–2011.

    Article  CAS  PubMed  Google Scholar 

  31. Asscheman H, Giltay EJ, Megens JAJ, De Ronde W, Van Trotsenburg MAA, Gooren LJG. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol. 2011;164:635–42.

    Article  CAS  PubMed  Google Scholar 

  32. Giltay EJ, Gooren LJG. Effects of sex steroid deprivation/administration on hair growth and skin sebum production in transsexual males and females. J Clin Endocrinol Metab. 2000;85:2913–21.

    Article  CAS  PubMed  Google Scholar 

  33. Wierckx K, Van de Peer F, Verhaeghe E, Dedecker D, Van Caenegem E, Toye K, et al. Short- and long-term clinical skin effects of testosterone treatment in trans men. J Sex Med. 2014;11:222–9.

    Article  CAS  PubMed  Google Scholar 

  34. Fisher AD, Castellini G, Ristori J, Casale H, Cassioli E, Sensi C, et al. Cross-sex hormone treatment and psychobiological changes in transsexual persons: two-year follow-up data. J Clin Endocrinol Metab. 2016;101:4260–9.

    Article  CAS  PubMed  Google Scholar 

  35. Davey RA, Grossmann M. Androgen receptor structure, function and biology: from bench to bedside. Clin Biochem Rev. 2016;37:3.

    PubMed  PubMed Central  Google Scholar 

  36. Pfaus JG. Reviews: pathways of sexual desire. J Sex Med. 2009;6:1506–33.

    Article  CAS  PubMed  Google Scholar 

  37. Christensen LW, Clemens LG. Intrahypothalamic implants of testosterone or estradiol and resumption of masculine sexual behavior in long-term castrated male rats. Endocrinology. 1974;95:984–90.

    Article  CAS  PubMed  Google Scholar 

  38. Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinology. 2012;37:662–70.

    Article  PubMed  Google Scholar 

  39. Keo-Meier CL, Herman LI, Reisner SL, Pardo ST, Sharp C, Babcock JC. Testosterone treatment and MMPI-2 improvement in transgender men: a prospective controlled study. J Consult Clin Psychol. 2015;83:143–56.

    Article  PubMed  Google Scholar 

  40. Fuss J, Claro L, Ising M, Biedermann SV, Wiedemann K, Stalla GK, et al. Does sex hormone treatment reverse the sex-dependent stress regulation? A longitudinal study on hypothalamus-pituitary-adrenal (HPA) axis activity in transgender individuals. Psychoneuroendocrinology. 2019;104:228–37.

    Article  CAS  PubMed  Google Scholar 

  41. Colizzi M, Costa R, Todarello O. Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: results from a longitudinal study. Psychoneuroendocrinology. 2014;39:65–73.

    Article  CAS  PubMed  Google Scholar 

  42. Ristori J, Cocchetti C, Castellini G, Pierdominici M, Cipriani A, Testi D, et al. Hormonal treatment effect on sexual distress in transgender persons: 2-year follow-up data. J Sex Med. 2020;17:142–51.

    Article  CAS  PubMed  Google Scholar 

  43. Parish SJ, Simon JA, Davis SR, Giraldi A, Goldstein I, Goldstein SW, et al. International society for the study of women’s sexual health clinical practice guideline for the use of systemic testosterone for hypoactive sexual desire disorder in women. J Sex Med. 2021;18:849–67.

    Article  CAS  PubMed  Google Scholar 

  44. Davis SR, Burger HG. The rationale for physiological testosterone replacement in women. Baillieres Clin Endocrinol Metab. 1998;12:391–405.

    Article  CAS  PubMed  Google Scholar 

  45. Garz M, Schröder J, Nieder T, Becker I, Biedermann S, Hildebrandt T, et al. Body image and sexual desire in the context of gender affirming therapy: results of a cross-sectional multi-centered transgender study. J Sex Marital Ther. 2021;47:435–45.

    Article  PubMed  Google Scholar 

  46. Matthys I, Defreyne J, Elaut E, Fisher AD, Kreukels BPC, Staphorsius A, et al. Positive and negative affect changes during gender-affirming hormonal treatment: results from the European Network for the Investigation of Gender Incongruence (ENIGI). J Clin Med. 2021;10:1–13.

    Article  Google Scholar 

  47. Wierckx K, Elaut E, Van Caenegem E, Van De Peer F, Dedecker D, Van Houdenhove E, et al. Sexual desire in female-to-male transsexual persons: exploration of the role of testosterone administration. Eur J Endocrinol. 2011;165:331–7.

    Article  CAS  PubMed  Google Scholar 

  48. van Dijk D, Dekker MJHJ, Conemans EB, Wiepjes CM, de Goeij EGM, Overbeek KA, et al. Explorative prospective evaluation of short-term subjective effects of hormonal treatment in trans people-results from the European Network for the Investigation of Gender Incongruence. J Sex Med. 2019;16:1297–309.

    Article  PubMed  Google Scholar 

  49. Santoro N, Worsley R, Miller KK, Parish SJ, Davis SR. Role of estrogens and estrogen-like compounds in female sexual function and dysfunction. J Sex Med. 2016;13:305–16.

    Article  PubMed  Google Scholar 

  50. Corona G, Isidori AM, Aversa A, Burnett AL, Maggi M. Endocrinologic control of men’s sexual desire and arousal/erection. J Sex Med. 2016;13:317–37.

    Article  PubMed  Google Scholar 

  51. Somboonporn W, Davis S, Seif MW, Bell R. Testosterone for peri- and postmenopausal women. Cochrane Database Syst Rev. 2005. https://doi.org/10.1002/14651858.CD004509.PUB2.

  52. Bancroft J. The endocrinology of sexual arousal. J Endocrinol. 2005;186:411–27.

    Article  CAS  PubMed  Google Scholar 

  53. Corona G, Rastrelli G, Morgentaler A, Sforza A, Mannucci E, Maggi M. Meta-analysis of results of testosterone therapy on sexual function based on international index of erectile function scores. Eur Urol. 2017;72:1000–11.

    Article  CAS  PubMed  Google Scholar 

  54. Zaliznyak M, Lauzon M, Stelmar J, Yuan N, Smith SM, Garcia MM. A proposed inventory to assess changes in orgasm function of transgender patients following gender affirming treatments: pilot study. Sex Med. 2022;10. https://doi.org/10.1016/J.ESXM.2022.100510.

  55. Rastrelli G, Corona G, Maggi M. Testosterone and sexual function in men. Maturitas. 2018;112:46–52.

    Article  CAS  PubMed  Google Scholar 

  56. Smith YLS, Van Goozen SHM, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35:89–99.

    Article  PubMed  Google Scholar 

  57. Li VY, Demzik A, Snyder L, Ogunleye AA, Wang A, Figler BD. Genital gender affirming surgery. Am Surg. 2022;88:2817–22.

    Article  PubMed  Google Scholar 

  58. Jun MS, Crane CN, Santucci RA. What urologists need to know about female-to-male genital confirmation surgery (phalloplasty and metoidioplasty): techniques, complications, and how to deal with them. Minerva Urol Nefrol. 2020;72:38–48.

    Article  PubMed  Google Scholar 

  59. Falcone M, Preto M, Blecher G, Timpano M, Gontero P. Total phallic construction techniques in transgender men: an updated narrative review. Transl Androl Urol. 2021;10:2583–95.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124:510–8.

    Article  CAS  PubMed  Google Scholar 

  61. Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: a systematic review. Turk J Urol. 2017;43:229–36.

    Article  PubMed  PubMed Central  Google Scholar 

  62. van de Grift TC, Pigot GLS, Boudhan S, Elfering L, Kreukels BPC, Gijs LACL, et al. A longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen. J Sex Med. 2017;14:1621–8.

    Article  PubMed  Google Scholar 

  63. Defreyne J, Elaut E, Kreukels B, Fisher AD, Castellini G, Staphorsius A, et al. Sexual desire changes in transgender individuals upon initiation of hormone treatment: results from the longitudinal european network for the investigation of gender incongruence. J Sex Med. 2020;17:812–25.

    Article  CAS  PubMed  Google Scholar 

  64. Falcone M, Timpano M, Oderda M, Cocci A, Morelli G, Preto M, et al. Suprapubic pedicled phalloplasty in transgender men: a multicentric retrospective cohort analysis. Int J Impot Res. 2020;33:808–14.

    Article  PubMed  Google Scholar 

  65. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, et al. Sexual desire in trans persons: associations with sex reassignment treatment. J Sex Med. 2014;11:107–18.

    Article  PubMed  Google Scholar 

  66. Smith YLS, Van Goozen SHM, Cohen-Kettenis PT. Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 2001;40:472–81.

    Article  CAS  PubMed  Google Scholar 

  67. De Cuypere G, T’Sjoen G, Beerten R, Selvaggi G, De Sutter P, Hoebeke P, et al. Sexual and physical health after sex reassignment surgery. Arch Sex Behav. 2005;34:679–90.

    Article  PubMed  Google Scholar 

  68. Garcia MM, Christopher NA, De Luca F, Spilotros M, Ralph DJ. Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience. Transl Androl Urol. 2014;3:156–62.

    PubMed  PubMed Central  Google Scholar 

  69. McNichols CHL, O’Brien-Coon D, Fischer B. Patient-reported satisfaction and quality of life after trans male gender affirming surgery. Int J Transgend Health. 2020;21:410–7.

    Article  PubMed  PubMed Central  Google Scholar 

  70. Campbell JD, Chan EP, Pierdominico AD, Karakus S, Trock B, Brock GB, et al. Chronic pain associated with penile prostheses may persist despite revision or explantation. Can Urol Assoc J. 2022;16. https://doi.org/10.5489/CUAJ.7391.

  71. Littman L. Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: a survey of 100 detransitioners. Arch Sex Behav. 2021;50:3353–69.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Endocrinology, Diabetes, and Metabolism, Department of Medical Sciences, University of Turin, 10126, Turin, Italy

    Lorenzo Marinelli, Serena Cagnina, Andreina Bichiri, Domiziana Magistri, Chiara Crespi & Giovanna Motta

Authors
  1. Lorenzo Marinelli
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Serena Cagnina
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andreina Bichiri
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Domiziana Magistri
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Chiara Crespi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Giovanna Motta
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

LM and GM conceived and designed the review. LM, SC, AB and DM wrote the original draft of the manuscript. CC and GM conducted a critical revision of the paper and supervised the entire work. All authors approved the final version of the article.

Corresponding authors

Correspondence to Lorenzo Marinelli or Giovanna Motta.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Marinelli, L., Cagnina, S., Bichiri, A. et al. Sexual function of transgender assigned female at birth seeking gender affirming care: a narrative review. Int J Impot Res (2023). https://doi.org/10.1038/s41443-023-00711-7

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41443-023-00711-7

Search

Advanced search

Quick links