Can transsexuals have orgasm after sex reassignment surgery?

September 8, 2000

Dear Cecil:

After the operation, do transsexuals experience normal sexual function, including orgasm? If not, what's the point?

What's your idea of "normal"? Having studied the medical journals and spoken with Stanley Biber, one of the leading surgeons specializing in this line of work, I can tell you the following:

(1) Some studies say that 80 to 100 percent of male-to-female transsexuals experience orgasm after sex reassignment surgery (this term is preferred to "sex change operation" nowadays). Dr. Biber claims a 95 percent orgasm rate in patients age 18 to 35, which is higher than the rate for biological women. Typically the researchers take the respondents' word for it, though. One suspects a certain amount of wishful thinking.

(2) One might suppose that sexual responsiveness would depend on the surgical technique used, but if there's a consensus on the best way, you can't tell from the medical literature. The procedure used by Dr. Biber is called penile inversion: removing most of the penis's innards and turning the skin inside out, like a sock, to create a vaginal pouch. The glans (tip) of the penis winds up at the bottom (far end) of the vagina. A clitoris can be created from the corpora spongiosa, the erectile tissue that causes the penis to stiffen during arousal. Advantage: simplicity. If it worked as a penis, it'll work as a vagina, right? In addition, sensitive tissue at both ends of the vagina doubles one's opportunities for pleasure. Disadvantage, according to the journals: the resultant vagina often atrophies (too shallow, too narrow, etc). Biber says he's had good success, though.

(3) Other surgical techniques include the sigmoid neovagina, made from a chunk of the large intestine (which supposedly won't shrink, a common complication), and sensate pedicled neoclitoroplasty, in which the glans, with nerves and blood vessels intact, is whittled down and reinstalled at the vaginal opening as a substitute clitoris. The remainder of the penile skin and the skin of the scrotum are used to fashion the vagina.

(4) A long-term failure rate of 50 percent has been reported for M-to-F transsexual surgery, failure being defined as a blocked or otherwise nonfunctional vagina. Some of the unsuccessful cases date from many years ago, when surgical techniques were less sophisticated and patients were not screened. Biber says his long-term success rate is higher, but typically short-term failure rates run in the neighborhood of 20 percent--a high percentage, it seems to me, for cosmetic surgery on a physiologically normal organ.

(5) You get the impression that, at least in the early days, the big thing with transsexuals was not feeling good but looking good. Some surgeons felt their transsexual patients were hyposexual--low sex drive. Dr. Biber and more recent journal articles dispute this. However, in a 1990 study of 14 transsexuals interviewed an average of 1.8 years after surgery, only one said orgasm was very important for sexual satisfaction, six said it was somewhat important, and three said it was not at all important (remaining four not known). When asked about potential for orgasm, two said usually, six said seldom, and two said never. Draw your own conclusions.

(6) The preceding applies to M-to-F surgery. F-to-M surgery is less common, more expensive, and, according to the literature, less successful, from both functional and aesthetic points of view. Since 1969, Dr. Biber has performed about 4,000 M-to-F operations but only about 400 to 500 F-to-M ones. He says, however, that with advances in technique in recent years the ratio has shifted to roughly 50-50. Answer to obvious question number one: no, you can't get an erection in the usual sense, but you can be provided with a prosthesis to permit intercourse. Answer to obvious question number two: some F-to-M patients claim to have orgasms, Dr. Biber says, but he has done no formal research.

(7) One wants to have an open mind, but when looking at pictures of M-to-F sex reassignment surgery in progress, one's first thought is: no way would I ever do this.

(8) So are one's second, third, and fourth thoughts. Not to make light of the situation, but what's so bad about being male? At least you get to pee standing up.

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