Does Affirmative Treatment Impair Sexual Response in Trans Youth?

Source: Steven Pisano, via Wikimedia Commons.

Use of puberty-blocking medications and cross-sex hormone treatments for children and adolescents who experience gender dysphoria is a complex modern medical controversy. Over the past decade, clinics have seen an explosion in the number of young people seeking such treatment. At the same time, there has been a complex debate over whether these medical interventions are safe, appropriate, and effective. That controversy is far too broad to be covered here, but I will briefly explore one aspect of it, as related to these youth’s ability to experience sexual pleasure.

Abigail Shrier is a journalist and author of a controversial 2020 book, Irreversible Damage: The Transgender Craze Seducing Our Daughters. She recently interviewed two doctors (both trans themselves) who provide treatment to trans youth. One, Marci Bowers, is the surgeon who treated reality TV star Jazz Jennings, whose life and transition are chronicled in the show I Am Jazz. Describing her treatment of Jennings, Bowers states,“If you’ve never had an orgasm pre-surgery, and then your puberty's blocked, it's very difficult to achieve that afterwards. I consider that a big problem, actually. It's kind of an overlooked problem that in our ‘informed consent’ of children undergoing puberty blockers, we’ve in some respects overlooked that a little bit .... if they’re not able to be responsive as a lover ... how does that affect their long-term happiness?” In her show, Jennings described that she had never had an orgasm.

For a sexual clinician, the concept of orgasmic naiveté and the experience of sexual pleasure and health raise fascinating questions. Unfortunately, it turns out there is relatively little data or research to explore these issues in trans youth.

Trans persons appear to report generally lower levels of sexual health, according to several studies, though it should be noted that the field of trans medicine is advancing quickly. Trans men appear more likely to report orgasms and sexual arousal post-transition compared to trans women, though it is unknown whether this is related to the fact that most trans men do not go through "bottom surgery" and retain their clitoris and vagina. In addition, trans women historically demonstrate higher levels of discomfort with their genitals and sexual arousal, compared to trans men. Trans women are much more likely to report sexual arousal without orgasm, and lower levels of sexual desire in general. Studies with trans women in particular find a wide variance in ability to experience orgasm post vaginoplasty surgery, ranging from 17-100% across 140 different studies. However, these studies are focused mostly on adults who transitioned in adulthood. At this time, there do not appear to be any studies which examine sexual health or orgasmic experience in trans individuals who initiated affirmative treatment prior to adulthood or the onset of puberty.

There are few studies examining orgasmic capacity and development in children and adolescents, for the obvious reason that such studies would run clear ethical risks. Whether orgasms are even possible pre-puberty is it itself somewhat unclear in research, with some sexual health texts asserting that orgasms prior to puberty in males are qualitatively and quantitatively distinct from post-pubertal orgasms. It appears, based on the limited literature, that pre-pubertal females may have more capacity for orgasms. However, most studies report that both males and females report first orgasms after age 13, coinciding with the onset of puberty. In youth assigned male at birth, it appears that 1.5 years after the onset of puberty is most reliably associated with ability to ejaculate (recognizing that orgasm, ejaculation and sexual pleasure are separate, often conflated concepts).

Abby Stein and Jazz Jennings at the Philadelphia Trans Health Conference

Source: Image by Ovrim, via Wikimedia Commons.

It is somewhat surprising to discover that the physiology and neurology of orgasms are still little understood. It appears that orgasms involve both a psychological and physiological interaction, involving neurons in one’s spine. Researcher Adam Saffron described this dynamic interaction as “rhythmic entrainment” involving a sexual trance which triggers psychological and physiological oscillations. By email, he agrees that in this model, “there’s plenty of room for learning to impact orgasmic propensities.”

Certainly many people, often females, don’t experience orgasm until later in life, and are often uncertain as to whether they have experienced orgasm, until they actually do. So, there likely is some interaction in both creating and recognizing the rhythmic physical and psychological oscillations which precede and signal an orgasm. But, there’s always a first orgasm, which occurs without prior experience. Ray Blanchard, who has researched gender dysphoria for decades, suggested to me via Twitter recently, “That’s like saying you can’t sneeze unless you know what a sneeze feels like.”

Kevin McKenna is a researcher at Northwestern University, in neuroscience and urology. He recently published a paper “What is the trigger for sexual climax?” describing how lumbar spinothalamic (LSt) cells are innervated by genital stimulation and generate sexual climax. McKenna argues that these same neural mechanisms underlie climax in human males and females, as well as rats. By email, McKenna suggested that his research views orgasm as independent from hormones, though long-term castration or ovariectomy can lead to genitals being atrophied, such that orgasm is less readily apparent (both to self or an observer), “though the neural responses remain.” McKenna indicated that in rats, sexual climax is possible prior to puberty, and that the LSt neuronal cells are both present, and sexually dimorphic (present at different levels in males and females) at birth. He reported that current research hasn't looked very much at what role puberty has on the development or function of LSt cells.

It seems quite possible that the reduced physical genital development that results from puberty suppression could inhibit the phenomenological experience and behaviors associated with sexual climax. In other words, while youth who undergo trans-affirmative treatment may have less genital tissue with which to experience sexual stimulation, their bodies and brains are likely capable of sexual climax though they may feel the experience less intensely due to reduced genital tissue. It is possible that individuals assigned as male and female at birth may experience these effects differently, as seems evident in research with people who experience transition as adults. Finally, it seems likely that learning plays a role in this process, though contrary to Bowers, it seems unlikely that it is the only factor involved. However, it seems quite important that future research examine the sexual health experiences of individuals who initiate trans affirmative treatment prior to adulthood.

Addendum/Update: In 2023, researchers published a study of 37 transwomen and orgasm functioning. 76% were able to achieve orgasm post affirmative surgery. There were no differences between those individuals who underwent puberty suppression or not. While these data do suggest there is a significant risk - 1 in 4 were unable to orgasm - the risk certainly doesn't appear to be as universal as has been suggested.