Sexual health outcomes following gender-affirming phalloplasty: a systematic review.

Background: Sexual function is a crucial factor in achieving optimal sexual health and is typically assessed by one's ability to achieve desire, arousal and orgasm. The majority of genital gender-affirming surgery literature has focused on urologic or esthetic outcomes, with less emphasis on sexual function.

Aim: We sought to systematically review studies assessing sexual health outcomes of phalloplasty in the transmasculine population to elucidate our current understanding of the range of sexual health outcomes studied and to identify knowledge gaps.

Methods: Studies on sexual function in transmasculine patients were systematically identified using PubMed, Embase, and Web of Science searches from database origins through February 29, 2024 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

Results: Eighteen articles met the criteria for inclusion. Arousal/desire outcomes ranged from 5.4% of patients with difficulty with arousal to 77% of patients with reduced arousal to half the time or less. Studies varied widely in assessment, but the majority reported ratings of erogenous sensation to be between 53% and 100%. The ability to orgasm ranged from 50%-93% during masturbation, 58%-75% during intercourse with a partner, and 29%-100% when asked generally. The ability to engage in penetrative intercourse ranged between 19% and 100%, and often included people who had not received penile implants. The absence of pre-surgical data limits our ability to assess whether the reported post-operative outcomes reflect an improvement in sexual health.

Conclusion: This review revealed differences in sexual function based on phalloplasty technique. Specifically, the largest post-op increase in desire was after radial forearm free flap (RFFF). Roughly half of patients who underwent phalloplasty with either RFFF or suprapubic pedicle reported the ability to achieve orgasm. Most patients reported penetrative ability with a penile implant, though patients did endorse penetration without an implant. Future studies are needed with outcome measures that have been validated within the transmasculine population and with more granular information regarding ancillary procedures, donor sites, and type of nerve coaptation.