Lower gender-affirming surgery for trans women will mean they need to wait until the surgical site heals before having sex. Using lubricant and taking additional steps to protect against contracting sexually transmitted infections (STIs) can also help during the healing process.

Three options for lower gender-affirming surgery for transgender women include:

  • Orchidectomy: This involves the removal of the testes. It can be a stand-alone procedure or occur during a vaginoplasty.
  • Vaginoplasty: This involves removing the penis, testicles, and scrotum and creating a vaginal canal and labia. The surgeon will also create a clitoris using a portion of the glans penis.
  • Vulvoplasty: This creates a vulva, including the mons pubis, labia, clitoris, and urethral opening. People may opt for this surgery if they are uninterested in receptive vaginal sex or do not wish to maintain the dilation and aftercare regime necessary after vaginoplasty. People may also refer to this option as a minimal depth vaginoplasty.

This article discusses how long recovery can take and when people can have sex after gender-affirming surgery.

It also looks at what to expect during sex after surgery and tips for hygiene, contraception, and protection from infections.

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According to Johns Hopkins Medicine, people can have receptive intercourse or take part in any sexual activity 12 weeks after a vaginoplasty. Sexual activity before this may lead to delayed wound healing and complications.

After an orchidectomy, it may take 1–2 days for people to become fully mobile again. They may be able to return to work a few days to a week after surgery.

Full recovery from an orchidectomy may take 2–8 weeks. For a few weeks following surgery, people will not be able to carry out certain activities such as driving or heavy lifting. The area of surgery will need to fully heal before people can have sex.

A healthcare professional can advise people when it is safe for them to have sex after gender-affirming surgery.

Following surgery, it can take time for people to recover and start to experience orgasms.

When people undergo a vulvoplasty, the surgeon forms a clitoris from the head of the penis. This means most people will still be able to experience orgasms through clitoral stimulation.

Johns Hopkins Medicine states that people may experience clitoral sensation after a vaginoplasty, although it can vary for each individual. Nerve regeneration may begin around 3 weeks following surgery, but in some cases, it may take a year or more to regain sensation.

People may experience a shooting or tingling sensation as the nerves regenerate, which should decrease over time.

In a 2017 study, 84 participants had rectosigmoid vaginoplasty. A post-surgery interview found that 79 of the participants had had sexual intercourse, and 72 had experienced orgasm.

Some reported infrequent symptoms, such as pain after sex and vaginal spotting, but these improved within 6 months.

A 2016 study of 22 people who had undergone a vaginoplasty and clitoroplasty found that 86% of participants could experience orgasm after surgery.

In addition, research from 2017 involving 28 transgender women found that pressure and vibration provided the best results for genital sensitivity after gender-affirming surgery.

Transgender women may experience a decrease in sex drive after gender-affirming surgery.

According to a 2020 article, people can stop taking anti-testosterone medication and may experience a decreased sex drive following an orchidectomy.

Hormone replacement therapy may help maintain a regular sex drive.

Vaginal depth after a vaginoplasty can vary for each person and depend on the amount of skin in the genital area before surgery.

An average vaginal depth after a vaginoplasty is 4–6 inches. For comparison, the average depth of a cisgender female’s vagina measures from 3.5 to 5 inches.

In people who have a rectosigmoid vaginoplasty or colovaginoplasty, the vagina may have more depth.

The University of California, San Francisco Medical Centre notes that the most common vaginoplasty technique uses the penile inversion procedure. This does not create a vaginal mucosa. As a result, the vagina will not self-lubricate, and a person will need to use lubricants to undergo dilation or have penetrative sex.

Another vaginoplasty technique uses the colon or small bowel to line the vagina, which will result in a self-lubricating vagina. However, it is a far less common procedure that may lead to serious and possibly life threatening complications.

When using lubrication, people should use a water or silicone-based lube with latex condoms, as oil-based lubricants can damage latex.

After a vaginoplasty, people need to use a vaginal dilator to stretch the vaginal canal and keep it open. Following surgery, people may need to dilate twice each day for a minimum of 15 minutes. This helps prevent loss of vaginal depth and width.

A healthcare professional will provide instructions on how to safely and correctly use a dilator. Although people may experience some discomfort when they begin dilating, they should not experience any severe pain.

If people experience pain when dilating, they will need to stop and readjust the dilator and body position. People will also need to use lubrication during dilation.

An orchidectomy can cause testosterone levels to drop. A sudden drop in testosterone may lead to mood swings or low energy following surgery.

To help prevent this, people may want to discuss mild testosterone replacement options with a healthcare professional to allow a more gradual reduction in testosterone.

People may need to use plenty of lubricant to make sex feel more comfortable and prevent any tears. They may also find the rest of the genital area, including the anus, is more tender following surgery.

According to the Terrence Higgins Trust, surgery can increase the risk of contracting STIs, as any unhealed skin can allow infections to pass more easily into the body.

If people have had a vaginoplasty that uses part of the colon, a mucus membrane will line the vagina, making it easier for STIs to pass through.

If people have had a vaginoplasty that uses penile and scrotal skin, the vagina is less susceptible to STIs, but any unhealed skin can still be a risk factor.

Dilation of the vagina can also cause bleeding, so it is important to use a condom for any sex following dilation.

Using a condom during sex can help protect from STIs. People can use an external condom over a penis or sex toy and an internal condom inside a vagina. An internal condom may not suit everyone, as using an internal condom will depend on vaginal depth.

People can also use a dental dam during oral-vaginal sex. Regular testing can help to prevent passing on or contracting STIs from a sexual partner.

If people have not had an orchidectomy or vasectomy, they will need to use contraception for any penetrative sex with a partner who is able to get pregnant and is not using contraception.

If people are taking estrogen or other hormone therapy, these will not provide enough contraceptive protection, so they will need to use other contraceptive methods.

Learn more about sexual health for transgender women here.

After a vaginoplasty, it is important to keep the genital area clean and free of infection.

People will need to keep the outside of the vagina dry. It may be useful to place an absorbent pad between the labia to soak up any excess moisture.

Once the genital area is allowed to get wet, people should use soap and water to gently wash the area. It is important to avoid scrubbing or allowing shower spray to reach the surgical site.

Johns Hopkins Medicine states that people will need to douche using a non-fragranced vaginal douche, beginning 8 days after surgery. Depending on how much vaginal discharge people have, douching may be required 1–2 times each week. More frequent douching may be necessary if there is a large amount of discharge.

Following an orchidectomy, people may experience some mild discomfort, bruising, and swelling around the area of surgery. Some bleeding may occur, although this is rare. People may need to apply topical antibiotics to prevent infection.

People will need to speak with a healthcare professional to check when they can bathe the area of surgery following an orchidectomy.

It can take time to heal, recover, and adjust to sex and intimacy after gender-affirming surgery.

If people are experiencing any physical or emotional issues regarding surgery, they can speak with a doctor, a mental health professional, or a sex therapist.