Missing Evidence

Why We Still Don’t Know What Surgery Does to Puberty-Blocked Boys

By Corinna Cohn, author of “What I Wish I'd Known About Sex Change Surgery When I Was 19,” published in the Washington Post, April 11, 2022.

Photo by Rona Lao on Unsplash

I had sex reassignment surgery when I was 19. Over thirty years later, I still live with the permanent consequences of that decision. People often ask why I chose it—but the better question is:

What evidence justified offering it to me in the first place?

That question is more urgent now than ever. Vaginoplasty is being offered to minors, particularly to boys who’ve been blocked at the start of puberty. Yet we have no reliable outcome data for this group. Strip away the affirming language, and much of this practice rests on assumptions, not evidence.

These are life-altering decisions made during a period when most people, teens and adults alike, have no clear picture of what a functional sex life entails. The evidence base—especially for puberty-blocked youth—is thin to nonexistent.

What the Best Available Research Doesn’t Tell Us

Let’s begin with the largest systematic review to date: a 2021 paper published in Andrology by Kloer et al. This review examined 140 studies involving 6,953 patients who had undergone vaginoplasty. These were transgender women, typically adults, using a variety of surgical techniques.

The findings showed that the ability to achieve orgasm varied widely, ranging from 17.4% to 100%, with a median of around 80%. General sexual satisfaction also spanned a broad range, from 64% to 98%, with a median of 81%. The most frequently reported disruption to sexual function was dyspareunia, or pain with penetration.

This may seem promising at a glance. But once you dive deeper, concerns emerge. Most of these studies are retrospective, observational, and poorly standardized. The term "orgasm" is often self-reported without clear definitions—whether it was with a partner or not, whether it was pleasurable, or merely a reflex, remains unclear. There is no meaningful data for puberty-blocked youth, who now represent a growing share of surgical candidates. The authors themselves admit that the outcomes can’t be meaningfully compared across clinics, let alone used to predict results for individuals—especially not teens who experienced a truncated or missing male puberty.

From Personal Experience to Broader Pattern

When I had vaginoplasty at 19, I believed I was taking a step toward authenticity, adulthood, and intimacy. I wasn't sexually experienced and had no real conception of what functional adult sex entailed. Like many young patients today, I thought surgery would resolve my distress and enable me to experience a "normal" life.

But the reality, in my case, was far more complex. I developed painful complications related to residual erectile tissue, which made intercourse difficult and sometimes impossible. I later learned that this kind of outcome isn't rare—but patients aren't always told that.

The bigger issue isn’t my personal story. It's that many surgical candidates are in a similar position: young, inexperienced, and emotionally vulnerable. They may report feeling satisfied postoperatively, but these metrics often fail to capture the real-world challenges of partnered intimacy, physical dysfunction, and emotional disconnection that can result.

Surveys frequently ask questions like whether someone can orgasm or if they are sexually active, but they don’t probe deeper into whether their sexual relationships are fulfilling, whether they feel connected to others, or whether they experience mutual pleasure beyond mere sensation.

This matters because sexual desire is not just about physical sensation. It plays a key role in our capacity to form and sustain romantic bonds. According to recent psychological research, sexual desire functions as a mechanism that encourages investment in one’s partner, motivating affectionate behavior, sacrifices, and emotional responsiveness—all of which are essential to maintaining a relationship over time.

When sexual function is compromised—not only the ability to orgasm but the capacity for pleasure and shared intimacy—it can undermine a person's ability to engage in and sustain these deeper relationships. The consequences go beyond the bedroom. They touch on one's potential for connection, commitment, and love.

The research tends to rely on surface-level self-reports that obscure more nuanced or negative outcomes. This leaves a distorted picture of success—one that fails to prepare young people for the reality they may face.

These are not rare exceptions. They are part of a broader pattern that needs acknowledgment and further study.

How Do Puberty Blockers Affect Outcomes?

The vast majority of studies in the Andrology review looked at adults who underwent surgery after experiencing male puberty. That’s a crucial distinction. Going through puberty gives surgeons more to work with: penile and scrotal tissue, nerve development, and some baseline sexual function.

But what happens when boys are blocked at Tanner stage 2, the very onset of puberty? According to leaked internal discussions from WPATH (World Professional Association for Transgender Health), even high-ranking surgeons have privately admitted concerns. Dr. Marci Bowers, WPATH's current president and a surgeon himself, was quoted as saying that, to date, he is unaware of an individual claiming the ability to orgasm when they were blocked at Tanner 2.

Let that sink in. The president of the organization setting global standards for gender-affirming care is acknowledging that we have no known cases of puberty-blocked individuals achieving orgasm post-surgery.

The reason is that their sexual anatomy never developed. This includes not just size and tissue availability but also the neurological wiring necessary for adult function.

Surgeons working with puberty-blocked patients must rely on alternative grafts like intestinal segments or peritoneal flaps. These techniques are more complex, carry higher risks of prolapse, chronic discharge, and stenosis, and offer no guarantee of sensation or function.

And yet, these procedures are being offered to minors in the name of gender affirmation.

Sex, Love, and What Gets Left Out

There is an enormous blind spot in this field: partnered sexual function. Most of the research, and much of the counseling, focuses on body image, dysphoria reduction, or general satisfaction. But what about love? What about sex as an adult?

The question isn’t just whether someone can experience arousal. It’s whether they can share physical intimacy with another human being in a satisfying way. If a neovagina causes pain, doesn’t accommodate penetration, or lacks sensation, how do you build a romantic life around that?

And this isn't just about physical mechanics. A growing body of psychological research suggests that sexual desire serves as a motivational system for long-term bonding. It encourages people to invest emotionally in their partners—to show affection, sacrifice, and commitment. In the absence of that desire, these relational investments can weaken or disappear.

For those who lose sexual function through early medical intervention, the stakes are high. Not because they’ll never experience orgasm, but because they may struggle to build and maintain the very relationships that give life meaning. That’s a reality that deserves serious attention.

Fertility and the Myth of "Pause"

Puberty blockers are often described as a reversible “pause button.” That’s misleading. If a boy starts blockers before sperm development and proceeds to surgery, he will be irreversibly sterile.

While experimental techniques like testicular tissue preservation exist, they are still research-stage—not widely available or proven to work. True fertility preservation requires allowing puberty to proceed to the point of sperm maturation. But in many clinical settings, puberty itself is treated as something to prevent, not protect.

A 2020 review in the Journal of Adolescent Health by Lai et al emphasized that while the biological risks of infertility are acknowledged, the emotional weight, including the loss of future parenthood and the grief that can surface decades later, is poorly understood. Even providers admit that talking to a 14-year-old about fertility is often like “talking to a blank wall.”

This is more than a consent issue. It’s a question of timing. Most kids who say they don’t want children at 14 can’t imagine how they’ll feel at 34. And once the blockers start, and surgery follows, that door quietly closes behind them.

Complications: Not Just a Risk, But a Likelihood

When families hear the word "surgery," many imagine a single procedure followed by healing. But in the case of vaginoplasty, even under ideal circumstances, the road forward often involves medical complications—some of them lifelong.

The most common problems are structural, such as narrowing of the canal (stenosis), pain with penetration, urinary issues, and the need for constant dilation to maintain depth. More serious outcomes include permanent numbness, tissue necrosis, and fistulas that create unintended pathways to the rectum or urethra. These complications can arise even when the surgeon is highly skilled.

The Andrology systematic review, while aiming to offer a comprehensive snapshot, shows just how widespread these issues are. Many patients in the literature—often categorized as "satisfied"—still report difficulties with intercourse, chronic discharge, or additional surgeries. The catch is that satisfaction scores don't capture whether these patients are living in bodies that feel functional, or just survivable.

For young people considering this surgery, and for their families, it's important to understand that these are not rare outcomes. They are part of the expected risk profile. And because minors are often entering surgery with less tissue due to puberty blockers, their complication rates may be even higher—though, notably, no long-term study has yet told us for sure.

Weak Evidence, Strong Claims

Despite how definitive the messaging often sounds, the body of evidence surrounding vaginoplasty—especially for adolescents—is shaky at best.

The Andrology review attempted to synthesize results across 140 studies involving nearly 7,000 patients. But the review itself had to acknowledge the limitations: no GRADE scoring system was used to evaluate the quality of evidence. Most included studies were cross-sectional, lacked standardized outcome measures, and relied on unvalidated, self-reported satisfaction surveys.

The review pooled studies with significant variation in surgical technique, patient demographics, and follow-up duration. In short, we are dealing with a fragmented landscape: many anecdotes, few certainties.

Even more glaring is what's missing. There is virtually no research on outcomes for puberty-blocked teens—precisely the population now being targeted for early surgical intervention. What should concern any parent is that clinicians are moving forward with these procedures based on adult data that doesn’t apply, and under pressure to “affirm” rather than to assess cautiously.

The bottom line is that what looks like solid science from a distance crumbles under closer inspection. And teenagers, who often lack the experience to question expert authority, are being asked to make irreversible decisions under the illusion of medical certainty.

Despite the life-altering nature of these procedures, the quality of evidence remains poor. There are no randomized controlled trials, few long-term studies, inconsistent outcome measures, and a heavy reliance on self-report and convenience sampling. Even the *Andrology* review, though following PRISMA guidelines, did not use GRADE scoring or risk-of-bias tools. Its findings are suggestive, not definitive. And for teens, especially those who haven’t gone through puberty, the data simply isn’t there.

And yet we continue to make bold claims about the benefits of early surgery.

To Parents, Providers, and Young People

These surgeries are permanent and irreversible. Even in ideal conditions, they introduce lifelong medical burdens and carry risks that are poorly understood—because the research simply hasn’t been done.

And it likely won’t be.

For youth—especially puberty-blocked boys—there are no high-quality, long-term studies showing that sex reassignment surgery results in bodies capable of adult sexual function, intimacy, or fertility. What little evidence exists is drawn from adults who went through natural puberty, who had more tissue to work with, and whose anatomy developed along typical male lines. That data doesn’t apply to the younger patients now being funneled into early interventions.

But the medical model proceeds anyway, often under pressure to affirm rather than assess. Those of us who underwent surgery as teens, or before reaching sexual maturity, are now living with the outcomes. Some are silent, some are struggling, and some are just beginning to question what was done to them under the guise of compassion.

This isn’t a story about regret. It’s a story about uncertainty, irreversibility, and a profession that’s willing to gamble on children’s futures without the evidence to justify it.

Desire is not function. Satisfaction is not pleasure. And none of this is guaranteed.