Happiness After Gender-Affirming Surgery May Not Depend on Sexual Function, Survey Finds

For transgender women who undergo gender-affirming genital surgery, the most important measure of success may not be what happens in the bedroom. A new survey-based study of 41 transgender adults who had undergone vulvovaginoplasty or vulvoplasty at a single academic center found that the overwhelming majority reported being happier after surgery and felt positively about their genitals, regardless of whether they had recently been sexually active or were satisfied with their sexual function. The findings, published in BMC Plastic and Reconstructive Surgery, add a striking psychosocial dimension to a surgical field that has long been evaluated primarily through the lens of sexual function scores borrowed from cisgender women’s health.

The research team, led by Ermina Lee and Jules L. Madzia of the University of Cincinnati College of Medicine together with clinicians at Boston Medical Center’s GenderCare Center, set out to characterize patient-reported outcomes after gender-affirming vulvovaginoplasty, a procedure that constructs a neovaginal complex through urethroplasty, clitoroplasty, and labiaplasty. The most common surgical technique is penile inversion, in which the neuromuscular bundles of the glans are retained for clitoral reconstruction. Some patients, however, do not desire a neovagina or face elevated surgical risk, and for them vulvoplasty offers genital remodeling without the creation of a vaginal opening. Surgical management of gender incongruence is highly patient-centered, requiring shared decision-making among patients, mental health providers, and surgeons to balance individual goals for aesthetics and function.

Between August 2019 and May 2022, the researchers contacted 157 patients who had undergone surgery between September 2016 and March 2022 at their institution, where a single team of co-surgeons from urology and plastic surgery performed all procedures. Forty-one patients, or 26.1 percent, completed the electronic consent and post-surgery survey. The participants had a mean age of 45.8 years, and the median time since surgery was 167.5 days, placing most respondents in the relatively early post-operative period when self-exploration of gender identity, sexuality, and sexual function with new anatomy is still evolving. Thirty-two participants had undergone vulvovaginoplasty with creation of a vaginal opening, while nine had vulvoplasty with a zero-depth neovagina. All patients received pelvic floor physical therapy at six weeks post-operatively, including dilation coaching and counseling on sexual exploration with their new anatomy.

The survey instrument was built from adapted versions of two established questionnaires: the Female Genital Self-Image Scale, a seven-item measure of genital satisfaction, and the Female Sexual Function Index, a nineteen-item inventory considered the gold standard for assessing sexual function in heterosexual cisgender women. Because neither tool has been validated for transgender patients assigned male at birth, the researchers selected items with input from patients and gender-affirming care providers, retaining six FGSIS items and nine FSFI items rated on Likert scales. Gender congruence was assessed with seven items relating the experience of gender to quality of life over the prior two weeks, including questions about whether participants had stopped themselves from participating in activities or behaving in certain ways because of gender. Statistical analyses were performed in R, using chi-squared tests for categorical variables and t-tests for continuous variables, with significance set at p less than 0.05.

The results on gender congruence were striking. Although nearly half of participants, 47 percent, reported thinking about gender very often or often, 61 percent said they were seldom or never troubled by issues relating to gender, and 85 percent said they never felt uncertain or confused about their sense of gender. Eighty percent reported being seldom or never stopped from participating in everyday life because of their gender, and 85.3 percent said they rarely or never avoided social situations due to their sense of identity. Perhaps most tellingly, 97.6 percent of participants reported confidence in their ability to lead a satisfied life with their gender identity, a figure that speaks to the central goal of the surgery: aligning the body with the experienced self.

Genital self-image told a similarly positive story. In response to the statement that they felt positively about their genitals, 82.9 percent of participants agreed or strongly agreed, and 76 percent were satisfied with the appearance of their genitals. Most also reported comfort with intimacy and clinical care: 82.9 percent said they would feel comfortable having a sexual partner look at their genitals, and 95 percent said they would feel comfortable having a doctor examine them. Overall, 85.4 percent agreed that their genitals worked the way they were supposed to. These ratings were comparable to those previously reported for cisgender women on adapted versions of the same instruments, suggesting that the surgery can produce self-image outcomes on par with those in the populations for which the measures were originally designed.

Sexual function, by contrast, presented a more complicated picture. Among the 22 participants who had engaged in sexual activity in the past four weeks, only 40.9 percent were satisfied with their ability to reach orgasm, and of those who attempted orgasm, 87 percent reported that it ranged from slightly difficult to impossible. Overall satisfaction with sexual life was low, with 47.5 percent of all participants expressing dissatisfaction and only 32.5 percent expressing satisfaction. Most participants reported feeling sexual desire or interest infrequently, with 47.5 percent experiencing sexual interest only a few times in the past four weeks and 12.5 percent never. Yet here was the study’s most consequential finding: none of these sexual function measures predicted overall surgical satisfaction. Chi-squared tests found no significant association between agreement with the statement that they would have the operation again and procedure type, age, days since surgery, satisfaction with sexual life, satisfaction with genitals, or recent sexual activity.

The dissociation between sexual outcomes and overall well-being was consistent across subgroups. Among sexually active participants, 83.3 percent felt positively about their genitals and 95.8 percent were happier after surgery than before. Among those who had not been recently sexually active, 82.4 percent felt positively about their genitals and 94.1 percent were happier after surgery. In total, 95.1 percent of participants agreed or strongly agreed that they were overall happier after the operation, and 92.5 percent said they would choose to undergo it again. The authors point to prior research supporting this pattern: a study by Buncamper and colleagues found that patient-perceived neovaginal functionality and appearance remained high, averaging eight out of ten, more than four years after surgery, even though over half of that cohort met criteria for sexual dysfunction on the FSFI.

Why does sexual function fail to track with satisfaction? The researchers argue that sexual function is shaped by a fluid web of biological and psychosocial factors, including age, mood, desire, the subjective importance of sex, changes in genital sensation, relationships, sexual preference, and pre-existing pelvic floor dysfunction, which is prevalent among pre-operative patients but can be mitigated with pelvic floor physical therapy. The timing of the survey may also have mattered, with a median of roughly six months since surgery for the full sample and a gap between sexually active and inactive respondents. More fundamentally, the team criticizes the cis-heteronormative assumptions embedded in the FSFI, which conflates gender identity with sexuality and cannot capture how sexuality changes after vulvovaginoplasty. FSFI scores are known to be higher in heterosexual individuals than in LGBTQIA+ individuals, and heterosexual transgender women score higher than homosexual transgender women even when relationship status is equivalent, suggesting the instrument inadequately captures the intersectional experience of gender-affirming surgery.

The study’s limitations are real: a small sample from a single institution, survey tools validated only for cisgender women, no baseline pre-surgical data, and a median follow-up of 5.5 months when sexual outcomes are still evolving. Yet the authors frame the work as pilot data for a new generation of community-specific patient-reported outcome measures, such as the GENDER-Q, now undergoing field testing for transgender and gender-diverse individuals. Their conclusion is provocative and likely to reshape perioperative counseling: measures that weigh sexual function as the primary indicator of surgical success may not fully capture the broader psychosocial benefits of improved gender congruence. For many patients, the ability to move through daily life without gender-related distress, to feel at home in one’s own body, and to lead a satisfied life appears to be the outcome that matters most, and it is one that, according to this survey, gender-affirming surgery delivers at remarkably high rates.

Subject of Research: Patient-reported outcomes of gender-affirming vulvovaginoplasty in transgender adults

Article Title: Post gender-affirming vulvovaginoplasty survey of transgender adults

Article References: Lee, E., Madzia, J. L., Klein, P., Martin, M., Gomes, L., Navarra, M., Oates, R., Slama, J., & Streed, C. G., Jr. (2026). Post gender-affirming vulvovaginoplasty survey of transgender adults. BMC Plastic and Reconstructive Surgery, 2(1), Article 5. https://doi.org/10.1186/s44452-026-00018-8

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00018-8

Keywords: gender-affirming surgery, vulvovaginoplasty, vulvoplasty, transgender health, patient-reported outcomes, genital self-image, sexual function, gender congruence, penile inversion, pelvic floor physical therapy, GENDER-Q, quality of life