Sexual health outcomes following gender affirming metoidioplasty: a systematic review

Abstract

Introduction: Numerous studies have evaluated urologic and aesthetic outcomes of genital gender affirming surgery. However, minimal data exist on sexual function of transmasculine individuals after genital gender affirming surgery, and studies often aggregate outcomes from different techniques. This paper aims to systematically review the literature on sexual health outcomes following metoidioplasty surgery.

Objectives: To synthesize and analyze the literature on sexual health following metoidioplasty, to identify areas of further investigation, and to improve shared decision making and sexual outcomes following metoidioplasty.

Methods: Studies were systematically identified using PubMed, Embase, and Web of Science from database origins through July 30, 2025, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Included sexual health outcomes were desire/arousal, sensation, orgasm, masturbation, erection, penetrative capacity, sexual activity, and sexual satisfaction. Studies were screened independently by two authors and reviewed by four authors for eligibility. Disagreements were decided between three authors, including a sexual health expert and a gender affirming surgeon. Quality assessment was done using the Newcastle-Ottawa Scale.

Results: Twenty-three papers met inclusion criteria. All studies used ad-hoc questionnaires, and the majority did not primarily assess sexual health. Arousal/desire, preservation of erogenous sensation, and masturbation received high ratings (85+%). Erectile function scores were high (94+%), despite one outlier study (20%). Orgasm outcomes were mixed (66%-100%). Ability for penetrative intercourse was generally low (0%-24%), with one outlier study (70%). Overall sexual satisfaction was moderate-high (53%-88%).

Conclusions: Metoidioplasty appears to have largely satisfactory sexual health outcomes if penetrative sex is not a priority. Potential areas of further research include phallus lengthening protocols, PDE5 inhibitors (eg, Viagra), intracavernosal injections, and insertion of penile prostheses. Future studies are needed that include larger populations, are transparent regarding selection criteria and baseline anatomy, use standardized outcome measures, and investigate these complex outcomes from a person-centered, holistic approach.

Keywords: arousal; erection; gender affirming care; masturbation; metoidioplasty; orgasm; penetration; satisfaction; sensation; sexual health.