Sexual Function, Gender Congruence, and Well-Being Before Vaginoplasty: A Mixed-Methods Pilot Study of Trans Women on Gender-Affirming Hormone Therapy

For many transgender women, the journey toward aligning their physical bodies with their internal sense of self involves a long period of medical transition. A central part of this process is gender-affirming hormone therapy, a treatment that gradually changes the body's chemistry, leading to shifts in skin texture, fat distribution, and, significantly, sexual desire and function. While these hormonal changes are well-documented, the time leading up to genital surgery remains a complex and often misunderstood chapter. During this waiting period, individuals navigate a shifting landscape of bodily feelings, relationship dynamics, and the deep, personal question of whether surgery is the necessary next step. Understanding how these internal feelings connect to the desire for surgery is crucial for doctors and counselors, yet it has been difficult to map because standard medical questionnaires often fail to capture the specific, private nature of intimacy for people in this stage of transition.

A new pilot study from researchers at the University Hospital of Zurich and the Zurich University of Applied Sciences seeks to illuminate this hidden territory. The team focused on thirty German-speaking transgender women who were currently undergoing hormone therapy but had not yet undergone vaginoplasty, the surgical creation of a vagina. The researchers wanted to know if a person's general feeling of gender alignment predicted how well they functioned sexually, and whether their sexual experiences or their overall mental well-being were the primary drivers behind their wish to have surgery. To get a clear picture, the study did not rely on numbers alone. Instead, it combined standard medical surveys with a careful analysis of the participants' own written stories about their bodies and relationships, creating a mixed approach that looked for patterns in both the data and the personal narratives.

The study began by asking participants to fill out several established forms. One measured their overall sense of gender congruence, or how well they felt their identity matched their body and social life. Another measured sexual function, specifically looking at desire, arousal, orgasm, and satisfaction, while carefully removing questions about vaginal lubrication or pain that would not apply before surgery. They also reported on their mood and general well-being. Crucially, the researchers added a layer of human interpretation. They asked participants to write freely about their sexual experiences and then had a team of analysts read these texts to identify specific themes. This process created a "narrative index," a way of measuring how much a person's specific feelings about intimacy stood out in their own words, separate from their general scores on the standard forms.

When the researchers first looked at the raw numbers, the connection between a person's general sense of gender alignment and their sexual function was surprisingly weak. A high score on a general survey did not automatically mean a person felt good during intimate moments. The data suggested that a person could feel very aligned with their gender in their daily life—feeling comfortable in their clothes, at work, or with friends—while still experiencing specific, sharp feelings of disconnect during sexual encounters. However, when the researchers added the insights from the written narratives into their analysis, the picture became much clearer. The stories participants told about their intimate lives explained a significant portion of the variation in their sexual function scores. This finding suggests that to truly understand a person's sexual health during this phase, clinicians must look beyond general surveys and listen specifically to how people describe their intimate experiences.

The study also investigated what drives the desire for surgery. A common assumption might be that people want surgery because they are struggling with depression or because their sexual life is failing. The data, however, pointed in a different direction. The researchers found that while a person's general well-being and coping resources were strongly linked to their mood—those with better support systems reported fewer depressive symptoms—these factors did not predict whether someone wanted surgery. A person could be doing very well emotionally and still have a strong, persistent wish for surgery. Conversely, someone struggling with mood issues might not necessarily want surgery if their specific bodily feelings during intimacy were not the source of their distress. The desire for surgery appeared to be driven by a specific type of intimacy-related feeling, rather than a general need to fix unhappiness or a lack of coping skills.

In the detailed analysis of the written stories, a pattern emerged that the researchers describe as a "dysphoria-salience" effect. As participants' general sense of gender alignment improved through hormone therapy, their sexual situations sometimes became more contrast-rich. In other words, as the rest of their life felt more right, the specific parts of their body that did not yet match their identity became more noticeable and disruptive during intimate moments. This does not mean that hormone therapy makes sexuality worse; rather, it suggests that as the body and mind become more aligned overall, the remaining mismatches stand out more sharply in the quiet, focused context of intimacy. This specific feeling of incongruence during closeness was positively associated with the wish for surgery, suggesting that the motivation for the procedure is often rooted in these precise, intimate moments rather than a general sense of being unwell.

The researchers were careful to frame these findings as a pilot study, meaning the results are a starting point for further investigation rather than a final, definitive answer. The group of thirty participants was small, and the study was conducted in a specific cultural and linguistic context, so the results cannot be used to estimate how many transgender women worldwide feel this way. However, the study offers a valuable new way of thinking about pre-surgical counseling. It suggests that doctors and therapists should not assume that a patient who is doing well emotionally is "ready" for surgery, nor should they assume that a patient struggling with depression needs surgery to feel better. Instead, the focus should be on the specific, private world of intimacy. By asking directly about what happens during sexual moments and listening to the stories people tell about those moments, providers can better support patients in navigating their unique paths.

Ultimately, the study proposes a two-track approach to care. One track addresses the general well-being and mental health of the individual, ensuring they have the support and resources to manage stress and depression. The other track focuses specifically on the intimate, body-related feelings that drive the desire for surgery. These two tracks are related but distinct; improving a person's mood or coping skills does not automatically resolve the specific anatomical feelings that lead to a wish for surgery, and treating those feelings does not require a person to be in a state of crisis. By separating these concerns, healthcare providers can offer more precise support, validating the diverse and often complex sexual journeys of transgender women while respecting the autonomy of their decisions to pursue surgery. The findings invite a shift from asking broad questions about happiness to asking specific, meaningful questions about the body and the intimate self.