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Page 4 of 18 Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52

Transgender individuals in the United States report a wide range of sexual orientations, though they are
generally less likely to identify as heterosexual than the general population [12-15] . In the 2015 USTS, 21% of
respondents identified as queer, 18% as pansexual, 16% as gay/lesbian/same-gender-loving, 15% as straight,
[16]
14% as bisexual, and 10% as asexual . Similar distributions were observed in the EU according to the 2019
FRA survey data . Clinicians should also recognize that sexual orientation, attraction, and behavior are not
[17]
static; they may change over time, including during social, medical, and surgical affirmation [15,18,19] . Sexual
histories, when relevant to care, should therefore be reassessed regularly through respectful inquiries about
orientation and behavior.

When discussing sexual orientation in the context of surgical assessments, it is critical not to conflate
orientation with behavior. Where GAS may affect specific aspects of sexual function (e.g., nipple
stimulation, ability to receive or engage in genital penetration), clinicians should ask about patients’ interest
in and/or experience with particular behaviors to provide appropriate counseling on possible sexual effects
and risks .
[20]

SEXUAL HEALTH AND FUNCTION IN TGD INDIVIDUALS
The World Health Organization defines sexual health as including “the possibility of having pleasurable and
safe sexual experiences” . This definition extends beyond reproductive rights and the treatment of
[21]
dysfunction to envision a world where individuals can express their sexuality positively. Achieving sexual
health, in this framework, is more comparable to achieving gender euphoria than merely treating gender
[22]
dysphoria - a positive and affirming goal rather than simply addressing dysfunction .

For some individuals, gender-affirming hormones and surgery improve sexual health by alleviating gender
dysphoria and allowing them to inhabit a body that feels comfortable and sexually affirming. This may
involve both the removal of body parts that are incongruent with self-image and distressing for sexual
interaction (e.g., chest masculinization surgery) and the creation of body parts aligned with one’s sexual
self-image (e.g., vaginoplasty). Recognizing that gender affirmation can foster greater sexual self-confidence
also highlights a fundamental problem with the concept of autogynephilia: it is normal for individuals to
have sexual fantasies involving the body in which they feel most comfortable living [23-25] .

As with cisgender individuals, TGD individuals display diverse sexual orientations and desires, along with
differences in sexual health that may reflect functional concerns as well as experiences of dysphoria and
minority stress [26-28] . A large European study reported that the most common sexual dysfunctions among
trans women were difficulties initiating sexual activity and achieving orgasm, although overall sexual
[29]
function generally improved after genital surgery . A review of the literature similarly found that sexual
health improved after vaginoplasty, though interpretation is complicated by the lack of standardized
outcome measures and the limited number of studies prospectively assessing sexual health prior to
surgery . Prospective research is particularly important for determining how presurgical sexual function
[30]
influences postsurgical outcomes.

Available data suggest that transgender individuals may experience higher rates of sexual dysfunction than
the general population prior to genital surgery, and that surgical interventions often improve - but do not
fully eliminate- these differences. A 2021 systematic review reported that among transmasculine individuals,
hormone therapy generally improved desire and arousal, while surgery had mixed effects on these domains
but typically enhanced sexual activity and satisfaction. For transfeminine individuals, hormones showed
mixed effects on desire, but surgery consistently increased both arousal and desire . Interpretation remains
[31]
challenging due to heterogeneity in study designs and outcome measures, as well as variability in