‘Sex’ means different things to different people. Many people think about sex as only revolving around the penetration of the vagina with a penis. But there are many other forms of sex that can be enjoyable. If you choose to have genital surgery, this will change your genitals and, consequently, the way you experience sex.

If you are experiencing significant gender dysphoria, this may affect your sex drive. You may have little or no desire for sex. It is difficult to say whether your sex drive will change as a result of surgery. We do know, however, that reduced genital gender dysphoria can lead to an improvement in your sex life. It is important to take this into account when making a decision. Are you unsure how genital surgery might change your sexual activity? Or do you have specific questions about sex before or after genital surgery? If so, we recommend that you book a consultation with a sexologist from your gender team.

If possible, it’s a good idea to explore what feels good for you sexually. Take plenty of time to explore this and discuss it with any partner(s) you may have. If you can explore this before genital surgery, it will help you after genital surgery.

For example, ask yourself the following questions:

After genital surgery, you are likely to experience your sex life differently than you did before the operation. After surgery, you will have new genitals. Not everything works in the same way as cisgender genitals do. For example, nerves need to heal after the operation, which means you will gradually regain sensation. Your experience of your genitals can also change following internal (gynaecological) surgery.

Every change requires you to rediscover your experience of your genitals and your sensuality. Making your genitals feel ‘your own’ and learning to use them pleasurably is important following genital surgery. It is often easier to reach orgasm when you masturbate than when you have sex with someone else. After genital surgery, it is important that you continue to explore what feels enjoyable for you sexually, both on your own and together with your any partner(s) you may have.

Don’t underestimate how long it takes to rediscover your sexuality after genital surgery. Over the years, you’ll develop more confidence around your genitals, so take plenty of time for this. The more comfortable you feel in your own body, the greater the sexual pleasure you’re likely to experience.

An internal gynaecological operation, such as a hysterectomy or a colpectomy, can affect your sex life. For example, you may experience less gender dysphoria, or your orgasms may feel different. Complications from surgery such as pain may also affect your sexual functioning for some time after the operation. How might this affect your sex life?

After an internal operation, the appearance of your genitals will not change. Try to consider how the appearance of your genitals affects your sex life, and what it means to you if the appearance of your vulva does not (yet) change.

Some trans men and gender-diverse people wish to retain their vaginal cavity for penetration. A colpectomy (removal of the vagina) is not suitable in this case, as penetration would no longer be possible.

A metoidioplasty is a major genital reconstruction procedure followed by a long recovery process. Once your penis has healed, you can have sex if you wish. After a metoidioplasty, there are many ways you can have sex, but you will almost never be able to penetrate using your penis. However, you can often penetrate a partner using external prostheses. Before the operation, consider how important it is to you to be able to penetrate. Would you also be satisfied with having sex in other ways?

Most people can experience sexual arousal and orgasms following a metoidioplasty, both on their own and with a partner. However, it can take months for the nerves from the former clitoris to regrow. You will therefore not know immediately after the operation what sensation the penis will have.

Almost everyone regains sensation in the penis within two years of a metoidioplasty, and for many people this is a pleasurable sensation. Another advantage of metoidioplasty is that the skin moves slightly when you touch or stroke the penis. The penis also swells a little when you are aroused. Stimulating the head of the penis feels pleasurable for many people. An orgasm following a metoidioplasty usually feels similar to an orgasm before the operation. Do you place great value on how you currently experience orgasm? Do you consider the possibility of penetration to be less important? If so, a metoidioplasty is a better fit for your sexual preferences than a phalloplasty. Following a metoidioplasty, you will not ejaculate semen during orgasm.

Once the penis has healed sufficiently following phalloplasty, you can have sex if you wish. ‘Having sex’ is not the same as penetration. Sexual arousal and sexual activity following phalloplasty will be different from what you are used to before.

After phalloplasty, the former clitoris is ‘buried’ beneath the skin. You will have to discover for yourself what feels good, as it will be more difficult to stimulate the former clitoris. Stimulation leading to an orgasm often centres around the former clitoris, somewhere between the base of the penis and the scrotum.

It can take a long time for the nerves to regrow, sometimes as long as 1 to 2 years. So, it is only after 2 years that you will know how much, if any, sensation you have in the penis. Sometimes the penis remains numb, and sometimes it feels, when touched, much like the skin on your arm or side. This does not automatically result in a sensual sensation. However, some people do experience a sensual sensation when the penis is touched. Following phalloplasty, the penis is generally much less sensitive than after metoidioplasty.

If you wish to retain your vaginal cavity so that you can be penetrated, it is important to know that it is not always sufficiently accessible after a phalloplasty. Is the vaginal cavity important to you? For example, because it gives you sexual pleasure or because you wish to give birth to a child. If so, discuss your options with the surgeon and the gynaecologist.

Following a phalloplasty, you are usually unable to penetrate another person. However, you may sometimes be able to penetrate another person using an aid. Some of these aids are worn on or around your body; we call these external prostheses. You can read more about the different prostheses here. With external prostheses, you will need to explore for yourself to see which one might work for you and which feels comfortable to use during sex.

There are also internal penile prostheses, which are inserted into your penis during an operation. Internal penile prostheses do not last forever. It needs to be replaced after several years, or sooner if complications arise. In 70% of cases, an issue with the prosthesis requiring replacement occurs within 3 years. After each reinsertion, you will need another recovery period and will develop new scar tissue. Furthermore, erection prostheses can only be replaced a few times; after that, no further prostheses can be fitted. Some people also experience pain at the site where the prosthesis is attached to the body. These factors can affect your sex life and arousal.

With a metoidioplasty or phalloplasty, you can opt for a urethral lengthening. This choice also has implications for your sex life. Many people who have had a urethral lengthening require several operations before they can urinate from the head of the penis, whilst standing. After each operation, there is a recovery period and the possibility of new scar tissue forming. Recovery from some complications is relatively quick, but for others (dribbling, a narrowed urethra) it can take months to years, or full recovery may not be possible. Factors such as recovery, the appearance of the penis due to scarring, and other complications may ultimately also affect your sex life. So, try to consider in advance what any potential complications following a urethral lengthening might mean for you and how this might affect how you feel about, and engage with, sex.

If you wish to have a urethral lengthening, you must have previously undergone a colpectomy, and therefore also a hysterectomy. Some trans men and gender-diverse people wish to retain the vaginal cavity after genital surgery for various reasons. If this is something you wish to do, a urethral lengthening is less suitable due to the mandatory colpectomy. You are advised to discuss the options with your surgeon.