Overview

Sexual function is one of the least discussed outcomes of medical transition, yet it is among the most personal. Cross-sex hormones act directly on the genitals, the pelvic organs and the brain systems that govern desire. Genital surgeries remove or reconstruct the organs through which sexual sensation is experienced. Puberty blockers given early can mean that sexual maturation never happens at all.

This page summarises what is known about these effects, where the evidence is weak, and what detransitioners and trans people describe. It is educational, not medical advice: anyone experiencing sexual or pelvic symptoms after hormones or surgery should speak to a clinician, ideally one familiar with detransition (see the support directory).

How sex hormones shape sexual function

Sex hormones (testosterone and estradiol) are not just "gender" hormones; they maintain the tissues used in sex. In females, estrogen keeps the vaginal lining thick, elastic and lubricated; in males, testosterone drives libido, erectile function, sperm production and the prostate and seminal glands that produce ejaculate. Replacing one with the other does not simply swap one sexuality for another. It creates a hormonal state neither body is built for — closer to menopause in a female's genital tissue, and closer to medical castration in a male.

The same logic explains why some effects are partly reversible and others are not. Tissue that depends on ongoing hormone exposure (vaginal lining, testicular function, libido) often recovers to some degree after stopping. Structural growth (clitoral enlargement) or organs that are surgically removed or never developed do not.

Testosterone in females

The page on testosterone in females covers the full range of effects. The sexual effects fall into four groups.

Increased libido

Testosterone usually raises sex drive, sometimes dramatically. In a large US survey, current testosterone use was associated with greater interest in sex and ability to orgasm (Tordoff et al. 2023). Several detransitioned women describe this heightened drive as one of the things they found hardest to lose — and also as something that felt compulsive at the time.

Clitoral enlargement

Clitoral enlargement ("bottom growth") is a permanent effect of testosterone. It is often presented as a desired change, but accounts on /r/detrans describe two opposite complications: hypersensitivity, where the enlarged tissue sits outside its protective hood and is painfully sensitive to friction, and loss of sensation.

I do wish that doctors would warn their patients that taking T could permanently affect their sex life (having to protect exposed clit during sex) because I had no idea that I couldn't handle direct stimulation until after it had grown beyond the protective hood. —Sonderosity, detrans female

Bottom growth complications come in a lot of varieties. Some people here have painful oversensitivity. I'm in the group of people who lost sensitivity. Sex is ruined for me. I was on T a short time (under six months) and I've been off for two years. —tmipersonalproblem, detrans female

Commenters also describe how distress about the changed anatomy leads some women to consider surgical clitoral reduction, and how other detransitioned women urge caution because further surgery risks more nerve damage.

Vaginal atrophy and painful sex

Because testosterone suppresses ovarian estrogen, the vaginal lining can become thin, dry and fragile — vaginal atrophy, the same process seen after menopause. In the Tordoff survey, 64.6% of transmasculine participants reported genital pain or discomfort during sexual activity in the previous 30 days, most commonly in the vagina (Tordoff et al. 2023). The authors note that dyspareunia (painful sex) in this population appears markedly higher than in women generally, and that its causes are probably both physiological and psychological.

Atrophy is not only a problem for those who have penetrative sex. A trans man who later detransitioned explains the reasoning many make — and why it fails:

Since I don't want the receptive role in sex, I thought the health of my vaginal tissue didn't matter. I was wrong. Atrophy can be painful regardless. —Takeshold, detrans female

Pelvic pain

Pelvic pain on testosterone is common and poorly understood. In an Australian survey of 486 people using testosterone, 72.2% reported pelvic pain after starting it, most often described as cramping (Zwickl et al. 2023). Some detransitioned women describe pain severe enough that they were offered a hysterectomy as the solution:

I was on a low-to-medium dose of (gel) testosterone for 7 months and began to experience debilitating atrophy half a year in, so much so that I was offered a hysterectomy at 19. —Ferali, detrans female

A minority report chronic conditions such as vulvodynia (chronic burning genital pain) that they attribute to testosterone. Whether testosterone caused these, unmasked them or coincided with them cannot be established from individual accounts — which is precisely why better research is needed.

Trans perspectives

On r/ftm, vaginal atrophy is widely acknowledged as a common side effect, and the standard advice is low-dose topical estrogen, which many trans men report works well:

those tissues actually need a little estrogen to function so things can get pretty painful if you don't supplement the little we make while on T. —mxguppy, trans man (FTM)

This is worth noting: for some, the problem is manageable. But it also illustrates a recurring theme — a treatment whose side effects require further treatment, often for life, which several detransitioners say they were not told about in advance.

Estrogen and testosterone blockers in males

The page on estrogen and testosterone blockers in males covers these drugs in full. In effect they suppress male sexual function much as androgen-suppressing treatment does: estrogens have historically been used to lower testosterone in prostate cancer (Wierckx et al. 2014).

Libido, erections and orgasm

In a Belgian study, 62.4% of trans women reported a decrease in sexual desire after hormonal and surgical treatment, and around 73% rarely or never experienced spontaneous or responsive desire (Wierckx et al. 2014). Erections become weaker or absent, ejaculate volume falls sharply, and orgasms are commonly described as changed — slower, less intense, or harder to reach.

when I was on E my sex drive was WAY lower, my penis felt limp and useless, my prostate basically shut down making orgasms faint and very little pleasure. —Ok_Trifle5336, detrans male

Testicular atrophy

Without testosterone stimulation the testes shrink and stop producing sperm. This links sexual function closely to fertility. Long-term use can lead to persistent atrophy; orchiectomy makes it permanent and means lifelong dependence on external hormones.

Different interpretations

Not every male experiences reduced libido as a loss. Some detransitioned men describe relief:

My sex drive pretty much disappeared and I'm not a very sex-driven person so it felt very empowering for me to not feel controlled by it. —kornly, detrans male

Trans women frequently describe the change in positive terms — a slower, "whole-body" or longer-lasting orgasm, or a calmer relationship with sex. Others on r/MtF describe a year or more with no libido, or difficulty reaching orgasm at all. These reports are sincere, but they raise a question that comes up repeatedly in detransitioner discussions: whether a drop in sexual drive is being welcomed because it relieves distress about male sexuality itself. For some detransitioned men, that distress — including internalised homophobia or shame about being male — later turned out to be part of why they transitioned. Others contest the "multiple orgasms" narrative directly:

if i was having multiple orgasms in a night, it was out of desperation because they were a nearly pleasureless disappointment. —bradx220, detrans male

Puberty blockers followed by cross-sex hormones

The most serious concerns arise when puberty blockers are started in early puberty (Tanner stage 2) and followed directly by cross-sex hormones. The child's genitals never mature, and they may never experience adult sexual arousal or orgasm under their own hormones.

The Marci Bowers remark

Marci Bowers, a prominent gender surgeon and a former president of WPATH (the World Professional Association for Transgender Health), raised this as a "red flag" during a recorded online panel hosted by Duke University. According to reporting on the recording, she said:

every single child … or adolescent, who is truly blocked … has never experienced orgasm. I mean, it's really about zero. — Marci Bowers, as quoted by the Daily Citizen and Jennifer Block

In a 2023 interview with journalist Jennifer Block, Bowers said that answers to these questions about young patients' future sexual lives were still "unfolding" because the treatment had only been in use since the late 2000s (Block 2026). She has nevertheless continued to describe blockers as beneficial for some patients (Fox News 2023). Her remark was an observation from clinical practice, not a study. It matters because it came from a senior figure in the field rather than a critic.

What the research shows

The only study to compare early and late puberty suppression on this question followed 37 transfeminine patients from the Amsterdam clinic (van der Meulen et al. 2025). Before surgery, only 19% of the early-suppressed group had ever experienced orgasm, compared with 58% of the late group. After vaginoplasty, 78% of all participants reported being able to reach orgasm, with no significant difference between groups. 52% reported sexual difficulties such as pain.

This is the main evidence against Bowers' "about zero," and it should be taken seriously. It has clear limits: a small sample (16 in the early group), a self-developed questionnaire, short follow-up (around 1.5 years after surgery), and a measure of whether orgasm is possible rather than how often or how satisfying it is. It also confirms the most worrying part of Bowers' observation: most early-blocked participants had never had an orgasm before having their genitals surgically removed.

Insufficient tissue for surgery

Blocking male puberty early also means there is often too little penile and scrotal tissue for standard vaginoplasty. In the Amsterdam cohort, the early-suppressed group mainly received intestinal vaginoplasty, a more invasive procedure using a section of bowel. A critical review of the original Dutch protocol (the Dutch model of blockers, then hormones, then surgery for adolescents) notes that one patient in the founding study died because puberty suppression required this riskier operation (Biggs 2022).

When I was 18 and started the process to get a vaginoplasty, I was told that I simply didn't have the anatomy needed to create a neovagina because my puberty was stopped… I also have never and will NEVER achieve orgasm. —Crafty-Damage2808, detrans male

Genital surgery outcomes

Genital surgery is irreversible, and its sexual outcomes vary widely by technique, surgeon and complications. Most published studies are observational, small, rely on custom questionnaires, and lose many patients to follow-up.

Vaginoplasty

Even surgeons' own data show that a substantial minority of patients cannot reach orgasm after vaginoplasty. The neovagina (the surgically constructed vagina) has no natural lubrication (with penile inversion) and must be dilated for life to prevent closure. Some regretful patients describe a sense of disconnection rather than outright failure:

my surgery was done 3.5 years ago and fully healed. I took care of myself… I'm just not connecting to my genitals. I barley touch myself there and the orgasms are weak and strange. —throwawayac101010, self-questioning

Satisfied trans women often report the opposite. One MTF commenter recounted her surgeon's rule of thumb:

My surgeon's general statement was that "if you could orgasm before, you'll likely be able to orgasm after". That is, of course, dependent on not having complications that would affect that outcome. —MaybeAlice1, trans woman (MTF)

That rule of thumb carries an implication for adolescents who were blocked early: by definition, many of them could not orgasm before.

Phalloplasty

Phalloplasty involves multiple operations and has high complication rates, particularly involving the urethra. In a 2025 systematic review, roughly half of patients reported being able to orgasm after the two most common techniques. The authors noted that the lack of pre-surgery data makes it impossible to say whether sexual health improved or worsened (Zack et al. 2025).

Hysterectomy

Some detransitioned women report that orgasm changed after hysterectomy. Commenters speculate that removal of the cervix and uterus, which contract during orgasm, may play a role, though this has not been studied in this population:

I had an ovary-sparing hysterectomy as well, and noticed the same. I had read it is mainly the removal of the cervix that causes a reduction in sensation because that is the area capable of spasming. —ViscountVixen, detrans female

After stopping hormones: what recovers and what persists

Recovery is highly variable, and there are almost no clinical studies of it. What follows is drawn from detransitioner accounts and should be read as the range of experiences described, not as typical outcomes. See testosterone cessation and estrogen cessation for broader detail.

Females after testosterone

Stopping testosterone often brings a sudden drop in libido, as the body goes from high androgen levels back to female levels — and the ovaries may take time to resume normal function. Some describe this as a learning process:

We want sex less often and we build the our desire differently. It doesn't come to us, and we have to go to it… It was important for me to learn patience and value sensuality again. —Takeshold, detrans female

Others report lasting problems. One woman more than two years off testosterone listed "sexual dysfunction" and vaginal atrophy that "never repaired itself" among her ongoing issues (inspireddelusion, detrans female). Another described the opposite trajectory: orgasms felt worse on testosterone, and after two years off she felt she was "returning to the way it was" (BaggyKill, medically detrans female).

Males after estrogen and blockers

Many detransitioned men report that erections and libido returned within one to four months of stopping:

i was on hormones from 17-20 and i regained function/size within 4 months. —loveincautionn, detrans male

But a smaller number describe persistent dysfunction, sometimes after short exposure:

the sexual side effects of estrogen have never gone away, still have ED and testicular atrophy almost 5 years after stopping, its a big block in the way for me experiencing a lot of life when it comes to relationships etc. —MythicalDawn, detrans male

It is not possible to say from these accounts how common persistent dysfunction is, or how much is due to hormones as opposed to depression, anxiety or other factors that some commenters also raise. What they do show is that recovery is not guaranteed.

The informed-consent problem

Sexual function makes the informed-consent critique especially sharp. Informed consent requires understanding what is being given up. An adolescent who has never experienced adult sexual desire or orgasm is being asked to trade away something they have no way of valuing — often alongside their fertility, another loss that tends to matter more with age.

It's like they forget children will hopefully become adults one day… while they simultaneously rob those same children of their ability to explore one of the most important, intimate, and ubiquitous adult experiences. —GriffinQueenOfHeaven, detrans female

Gorin argues that justifying paediatric transition by appeal to a young patient's "embodiment goals" misunderstands the role of autonomy in medicine. A patient's wish for a body modification, he argues, does not justify risky interventions without evidence of health benefit (Gorin 2024). Sexual function is a clear example: the "goal" is set before the young person knows what they stand to lose.

Several further problems compound this:

• Unknown outcomes. A 2025 systematic review rated the evidence on sexual dysfunction after cross-sex hormones in young people as low to very low certainty (Miroshnychenko et al. 2025). Clinicians cannot give accurate odds when the data do not exist.
• Side effects learned afterwards. Many commenters say genital side effects such as atrophy, clitoral hypersensitivity or persistent erectile dysfunction were never mentioned to them, or were described as rare. In a survey of 100 detransitioners, 49% cited concerns about medical complications as a reason for detransitioning, and 55% felt they had not been adequately evaluated before transition (Littman 2021).
• Dysphoria distorts the trade-off. People who feel disgust toward their own genitals may see losing their function as a benefit at the time. That view can change when dysphoria resolves — as it does for many detransitioners and desisters (see desistance).

Sarah Jorgensen argues that detransitioners should be recognised as survivors of iatrogenic harm — harm caused by medical treatment — and given the specialised care they need (Jorgensen 2023). For many, that care includes sexual medicine, pelvic floor therapy and endocrinology, which few clinics offer to detransitioners.

Psychological dimensions

Sexual function after transition is not only a matter of tissue and hormones. Several themes recur in detransitioner accounts:

• Transition as an escape from sexuality. Some women describe being drawn to testosterone partly to escape the vulnerability of female sexuality or past sexual trauma; some men describe estrogen as a relief from a sex drive they experienced as shameful. When the hormones are removed, the underlying feelings often return and need to be worked through directly.
• Comparison and grief. Women coming off testosterone often compare their libido to the heightened state they had on it, rather than to their pre-transition baseline. Some describe being relieved to feel less driven by sexual urges, while others grieve the loss.
• Disconnection. Several commenters who had surgery describe an emotional disconnection from their genitals, distinct from physical numbness.
• Relationships. Detransitioners on both sides describe fear of dating because of changed anatomy or function. That fear can feed into wider isolation (see healing and recovery).

Rebuilding a sexual life after detransition often involves patience, medical help with hormones or atrophy, and therapy that addresses why sexuality felt intolerable in the first place. Some detransitioners have found gender-exploratory therapy and detrans peer groups helpful for this.

Limitations of the evidence

• Most studies of sexual function after transition are small, cross-sectional or retrospective, use non-validated questionnaires, and have high loss to follow-up — the people with the worst outcomes, including detransitioners, are often the least likely to be counted.
• Almost no studies follow sexual function after people stop hormones.
• Studies often measure ability to orgasm, not its frequency, quality or satisfaction, and rarely compare with pre-treatment function.
• Detransitioner and trans community accounts are self-selected. They show the range of experiences but not how common each outcome is.

Browse the study archive and detransition videos for more, or see the wider detransition overview.

References

• Biggs, M. (2022). The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence. Journal of Sex & Marital Therapy. source.
• Block, J. (2026). Some kids' gender is "hardwired," said WPATH's Marci Bowers. The FTC is calling it fraud. Unpopular Science. source.
• Daily Citizen. Leading Trans Docs Admit Experimenting on Children. source.
• Fox News (2023). WPATH's president, Dr. Marci Bowers, switches course on puberty blockers. source.
• Gorin, M. (2024). The Aims of Medicine in Pediatric Gender Care: Against the Autonomy-Based View. study page, source.
• Jorgensen, S. C. J. (2023). Iatrogenic Harm in Gender Medicine. Journal of Sex & Marital Therapy. study page, source.
• Kloer, C., Parker, A., Blasdel, G., Kaplan, S., Zhao, L., & Bluebond-Langner, R. (2021). Sexual health after vaginoplasty: A systematic review. Andrology. source.
• Littman, L. (2021). Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Archives of Sexual Behavior. study page, source.
• Miroshnychenko, A., et al. (2025). Gender affirming hormone therapy for individuals with gender dysphoria aged <26 years: a systematic review and meta-analysis. Archives of Disease in Childhood. study page, source.
• Post-surgical outcomes in transgender women: a prospective analysis of sexual function and health-related quality of life (2025). source.
• Tordoff, D. M., Lunn, M. R., Chen, B., et al. (2023). Testosterone use and sexual function among transgender men and gender diverse people assigned female at birth. American Journal of Obstetrics & Gynecology, 229(6). source.
• van der Meulen, I. S., Bungener, S. L., van der Miesen, A. I. R., et al. (2025). Timing of puberty suppression in transgender adolescents and sexual functioning after vaginoplasty. Journal of Sexual Medicine, 22(1). source.
• Wierckx, K., Elaut, E., Van Hoorde, B., et al. (2014). Sexual desire in trans persons: associations with sex reassignment treatment. Journal of Sexual Medicine, 11(1), 107–118. source.
• Zack, J., Goldstein, B., Okamuro, K., Lewis, P., Anger, J., & Uloko, M. (2025). Sexual health outcomes following gender-affirming phalloplasty: a systematic review. Journal of Sexual Medicine, 22(9), 1700–1706. source.
• Zwickl, S., Burchill, L., Wong, A. F. Q., et al. (2023). Pelvic Pain in Transgender People Using Testosterone Therapy. LGBT Health. source.