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of pelvic floor therapy in alleviating these symptoms. Attendance at pelvic floor PT both pre- and
postoperatively was significantly associated with lower rates of pelvic floor dysfunction compared to
postoperative therapy alone. Moreover, postoperative PT led to significant improvements in pelvic floor
dysfunction among patients who screened positive for symptoms prior to surgery. Therefore, it is important
to screen patients for preoperative pelvic floor dysfunction and counsel them on the associated risks.
Surgeons should consider referring patients to pelvic floor PT if preoperative symptoms are present or if
symptoms develop/worsen postoperatively.

Behavioral health providers also play an important role in supporting the sexual health and function of
individuals undergoing GAS throughout the perioperative period. As part of a multidisciplinary team, they
are often involved in assessing patients’ psychosocial readiness for surgery, addressing both practical
concerns (e.g., housing, postoperative support) and mental health (e.g., PTSD that may affect the ability to
dilate after vaginoplasty). They may also assist with writing the letters of support required for insurance
coverage [37,143,144] . Additionally, they may work with patients in the preoperative period to develop coping
strategies and other skills to enhance readiness for surgery. After the procedure, they continue to provide
mental health support and counseling on various psychosocial concerns, including sexual health.
Transgender-informed sex therapists can be especially helpful for individuals experiencing sexual health
concerns or dysfunction in the postoperative period, including helping patients navigate how to have a
fulfilling sexual life in the context of surgical complications [79,145] .

CONCLUSION
GAS is a critical aspect of care for many TGD individuals, significantly influencing sexual health,
psychosocial functioning, and overall QOL. The existing literature supports the numerous benefits of GAS
(including improved body image/self-esteem, increased sexual function and satisfaction, and reduced
gender dysphoria). However, it also highlights the need for appropriate, comprehensive preoperative
counseling, which should include discussion about sexual health goals and anticipated outcomes.

This study is limited by its narrative structure rather than being a systematic review, and it is further
constrained by the absence of systematically collected sexual outcome data for TGD individuals undergoing
GAS . Despite significant advances in surgical techniques and increased research focus on TGD
[102]
populations, a major limitation remains the lack of validated, population-specific outcome measures to
assess the impact of GAC on TGD patients’ health, particularly sexual health. While no measures currently
exist that have been well validated or specifically developed for TGD populations, such tools are in
development. For example, the GENDER-Q, a patient-reported outcome measure specifically for GAC
outcomes, published its initial validation study in April 2025 . Incorporating validated measures like the
[146]
GENDER-Q into future research and clinical practice will improve the quality and comparability of
outcome data and ensure that patient voices are meaningfully integrated into care.

As the demand for GAS continues to grow, physicians and researchers must focus on outcomes that matter
most to patients. These include not only the technical success of surgical procedures but also long-term
sexual well-being, relational intimacy, and psychosocial flourishing. Such goals are highly individual and
require intentional assessment to determine whether they are realistic and aligned with the surgical plan.
Sexual health should not be viewed as a peripheral concern - it is a central dimension of human health and
dignity. Therefore, it must be: (1) treated as a core outcome in both research and clinical care; (2) integrated
into our broader understanding of QOL; and (3) supported with the same rigor and empathy applied to
other domains of health. To achieve this, improved training is needed across both undergraduate and
graduate medical curricula to enhance provider competency and comfort in engaging in affirming,