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Billings et al. Plast Aesthet Res. 2025;12:27 https://dx.doi.org/10.20517/2347-9264.2025.52 Page 5 of 18

dysfunction estimates in both TGD and general populations [32,33] .

It is also important to recognize that TGD populations may have higher rates of certain chronic diseases
(e.g., diabetes, obesity) and behavioral risk factors (e.g., trauma, smoking) that can affect sexual health and
function [34-36] . A multidisciplinary approach is therefore valuable during the perioperative process, involving
collaboration between surgeons, social workers, behavioral health professionals, and patients’ primary care,
mental health, and specialty providers [4,37-39] .

EFFECTS OF GENDER-AFFIRMING HORMONAL THERAPY ON SEXUAL FUNCTION
Most individuals who undergo GAS first receive gender-affirming hormone therapy (GAHT). GAHT is
often, though not always, a prerequisite for surgery. Its positive effects are well documented, including
improved quality of life (QOL) and reduced depression, anxiety, and suicide risk, and are supported by a
growing body of literature and consensus guidelines [3,4,40-46] . Hormone therapy can also influence sexual
health and future surgical planning.

Masculinizing hormone therapy typically involves the use of exogenous testosterone in various
formulations. Sexual effects - many of which are desirable for some or all patients - include amenorrhea,
vaginal atrophy, clitoral enlargement, and increased spontaneous arousal [3,4,47-49] . Vaginal atrophy and clitoral
enlargement may become apparent soon after initiation, with peak effects observed after 1-2 years of
[49]
therapy . Large-scale survey studies also report an association between testosterone use and pelvic pain,
particularly with sexual penetration, likely secondary to atrophic changes . For patients with persistent or
[50]
distressing symptoms related to vaginal atrophy, topical estrogen and/or vaginal moisturizers can be used
without significant systemic absorption .
[51]
Feminizing hormone therapy involves the use of estrogens, often combined with an antiandrogen such as
spironolactone or cyproterone acetate (the latter not commonly prescribed in the United States). Some
individuals may also receive, or request, adjunctive progesterone. Common sexual effects of estrogen
include reduced spontaneous arousal, decreased erectile function, lower semen volume, and testicular
atrophy [3,4,49,52] . Patients should be counseled about these potential effects. While some may find them
desirable, others may experience them as distressing; in such cases, adjuvant medications or dose
adjustments may help . Antiandrogens generally carry sexual effects similar to those of estrogen.
[4]

Earlier guidelines recommended perioperative cessation of GAHT for both testosterone and estrogen.
However, more recent studies have found no increased risk of venous thromboembolism (VTE) or other
surgical complications when hormones are continued [53-56] . Moreover, perioperative cessation carries risks of
mood disturbance related to hypogonadism. Accordingly, current international guidelines advise against
stopping hormones in the perioperative setting . Nevertheless, consensus is lacking, and existing standards
[4]
of care do not provide a specific recommendation on perioperative hormone use . Surgeons should
[4]
therefore employ shared decision making with each patient to determine the most appropriate approach.

Gonadotrophin release hormone agonists (GnRHas, or puberty blockers) are prescribed to TGD children at
Tanner Stage II to pause the development of secondary sex characteristics, allowing more time for identity
[3,4]
exploration and planning for future interventions (e.g., hormone therapy) . Importantly, recent studies
indicate no evidence of negative impacts of pubertal suppression on long-term sexual health, function, or
well-being, while highlighting multiple positive outcomes in these domains [57,58] . It is highly unlikely that a
patient would still be on GnRHa therapy at the time of surgery, except potentially as an adjuvant to estrogen
therapy as an alternative to other antiandrogens.