Sexual health outcomes following gender affirming metoidioplasty: a systematic review.

Twenty-three papers met inclusion criteria for sexual health outcomes following metoidioplasty, and all studies used ad-hoc questionnaires rather than standardized validated instruments.

• Studies were identified using PubMed, Embase, and Web of Science from database origins through July 30, 2025
• Searches were conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement
• All 23 included studies used ad-hoc questionnaires
• The majority of included studies did not primarily assess sexual health as their main outcome
• Quality assessment was performed using the Newcastle-Ottawa Scale
• Studies were screened independently by two authors and reviewed by four authors for eligibility, with disagreements decided by three authors including a sexual health expert and a gender affirming surgeon

Arousal/desire, preservation of erogenous sensation, and masturbation outcomes received high satisfaction ratings following metoidioplasty.

• Arousal/desire, sensation, and masturbation outcomes all received ratings of 85% or higher
• These outcomes were among the most consistently positive findings across included studies
• Sensation preservation specifically refers to preservation of erogenous sensation following the surgical procedure

Erectile function scores following metoidioplasty were generally high, with one notable outlier study reporting substantially lower results.

• Erectile function scores were high at 94% or greater across most studies
• One outlier study reported erectile function at only 20%
• The wide range between the outlier and majority of studies suggests variability in how erectile function was defined or assessed across studies

Orgasm outcomes following metoidioplasty were mixed across included studies.

• Orgasm outcomes ranged from 66% to 100% across included studies
• This wide range indicates significant variability in reported orgasm outcomes
• The inconsistency may reflect differences in assessment methodology, patient populations, or surgical techniques across studies

Ability for penetrative intercourse following metoidioplasty was generally low across studies, with one outlier study reporting substantially higher rates.

• Ability for penetrative intercourse ranged from 0% to 24% across the majority of included studies
• One outlier study reported penetrative capacity at 70%
• The low penetrative capacity across most studies reflects the anatomical limitations of metoidioplasty compared to phalloplasty
• This finding is a central consideration for shared decision-making between patients and surgeons

Overall sexual satisfaction following metoidioplasty was moderate to high across included studies.

• Overall sexual satisfaction ranged from 53% to 88% across included studies
• This range suggests that despite limitations in penetrative capacity, a majority of patients reported satisfaction with sexual outcomes
• Sexual satisfaction was identified as a key outcome metric included in the systematic review alongside desire/arousal, sensation, orgasm, masturbation, erection, penetrative capacity, and sexual activity

Potential areas for further research to improve sexual outcomes after metoidioplasty include phallus lengthening protocols, PDE5 inhibitors, intracavernosal injections, and insertion of penile prostheses.

• PDE5 inhibitors such as Viagra were specifically named as a potential avenue for investigation
• Intracavernosal injections were identified as another potential intervention to study
• Penile prosthesis insertion was noted as a potential option for improving penetrative capacity
• Phallus lengthening protocols were identified as a research priority
• These potential interventions were framed in the context of addressing the low penetrative capacity outcomes observed in the review

Future research on sexual health outcomes following metoidioplasty requires larger populations, transparency regarding selection criteria and baseline anatomy, standardized outcome measures, and a person-centered holistic approach.

• The absence of standardized validated questionnaires across all 23 studies was identified as a major limitation of the current evidence base
• Lack of transparency in selection criteria and baseline anatomy reporting was noted as a gap in existing literature
• A person-centered, holistic approach was specifically recommended for future investigations
• The review noted that studies often aggregate outcomes from different surgical techniques, complicating interpretation of results
• Minimal data exist on sexual function of transmasculine individuals after genital gender affirming surgery more broadly