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Page 14 of 20 Kant et al. Plast Aesthet Res. 2026;13:4

SEXUALITY AFTER GENITAL SURGERY
A common concern in the weeks, months, and years after genital reconstructive surgery is how the patient’s
body now works in the context of their sexual interactions. This can be a difficult conversation to initiate,
due to both the general embarrassment many feel regarding sexual topics and the fact that individuals often
forget that learning to navigate their natal anatomy - both alone and with others - is a gradual process. For
individuals who were never comfortable enough in their bodies to engage in masturbation or partnered sex,
this can be even more difficult, as they may lack the context to start figuring out what they want or with
whom they want it [54,96-101] .

For many people, masturbation is a critical tool for learning about their own bodies after surgery. They can
learn what feels good to them and what does not, which in turn allows them to communicate this
information to a partner. They can also learn some of the idiosyncrasies of their anatomy, which may be
related to angles of penetration or types of lubricant that work better or worse for certain types of sexual
behavior. It is important to normalize that these types of exploration are not unique to individuals who have
undergone genital affirmation surgery, and that most people will need to experiment with what works best
for them sexually every time they have a new sexual partner or try a new sexual activity.

Post-surgical care requirements may enhance some individuals’ sexuality. For example, a partner may engage
in dilation with them as part of sex play. However, for others, the medicalization of their genitalia can make
engaging with it sexually more difficult. They may want to set clear boundaries between care and sex.
Furthermore, some romantic partners find challenges in the caretaking role that may negatively impact
relationship satisfaction [102,103] . Figuring this out will be different for every person, and couples therapy or sex
therapy may be indicated in some situations.

BEHAVIORAL HEALTH SUPPORT IN THE LONG TERM
Genital affirmation surgery represents a major milestone in a person’s life - one that, for many, has been not
just a long-term goal but also perceived as the final step in their gender journey. While for most, achieving
this goal is a uniformly positive experience, no longer having a goal to strive for can be disorienting. After
spending years, or even decades, reaching the point of having surgery, it is not uncommon for individuals to
experience the uncomfortable dialectic of feeling happy about their gender affirmation while also feeling
uncertain or empty about what comes next. This phenomenon of impact bias in affective forecasting is not
unique to this situation [104,105] , and behavioral health providers often have substantial experience addressing
these concerns in other milestone contexts (e.g., graduating from a degree program, getting married), even if
they have not previously addressed them in the context of gender-affirming care. Behavioral health providers
can help normalize these feelings and support individuals through these difficult periods.

Depending on their life stage, individuals may also require additional support related to their genital
affirmation surgery throughout their lives. Those who enter new romantic or sexual relationships may
sometimes struggle with questions of disclosure, including whether and when to inform a prospective
partner about their gender history and journey [106,107] . Similar questions may arise in other contexts,
particularly in situations where transgender individuals become legally vulnerable, such as under recent U.S.
presidential administration rulings that have led to loss of access to identification documents associated with
their affirmed sex [108,109] . Aging may also raise new questions and influence care choices - for example, if an
individual loses interest in sex and considers stopping vaginal dilation (which could lead to loss of depth) or
has an erectile device removed without replacement. While it is not the role of behavioral health providers to
offer medical advice in these situations, they can provide support to individuals who need a safe space to
consider their options.