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Presented by Papillon Center

Will I be able to Orgasm? Yes.

Orgasm is a reflex that builds much like a sneeze. We know that orgasm is a complicated event that depends on many factors in order to occur. One of these factors is an intact erotic neural pathway. The classic clitoral/penile orgasm relies on the dorsal nerves of the clitoris/penis to relay feelings of erotic touch to the brain by way of the pudendal nerve and spinal cord. There is a second system originating at the G-spot/prostate that travels to the brain via the hypogastric plexus. The G-spot/prostate pathway is often underutilized by post-op transwomen. The penile inversion technique with dorsal nerve preservation keeps both of those systems in tact; however, the orgasm reflex is not that simple.

This is not a debate about which surgeon saves the dorsal nerves; we all do (meaning the US/Canadian WPATH surgeons who specialize in vaginoplasty). It is more of a debate about understanding the very real effects that hormones, self-esteem and surgery can have on your libido as it compares to the vigorous male libido.

Orgasm Triad: Anatomy, hormones, psyche

Anatomy: Trans women are justifiably concerned with the post-operative rate of orgasm but often unjustifiably place praise/blame on the surgeon. Understand that orgasm may be influenced by many factors in addition to anatomy. As a general rule, patients who orgasm easily in the weeks prior to surgery can expect post-op orgasm as the healing process unfolds. Understanding of the complex situation of transition is key to understanding how to have a happy sex life following GCS. The female clitoris contains thousands more nerve endings than the male counterpart (glans penis); therefore, the clitoris is more sensitive to touch. However, higher testosterone levels can lower the threshold for orgasm. It is important to note that erotic touch and orgasm are different "things". Remember, the orgasm is like a sneeze. One either reaches climax or they donít; yet one can experience different intensities of erotic sensation from touch, erectile fullness and lubrication. For these reasons, comparing male and female orgasm is a bit of a conundrum. During clitoroplasty, the glans is trimmed to 10-20% of its original size, thus limiting the nerve endings further. The brain uses feedback from the body to let it know to prepare for orgasm. One important feedback input is the erotic sensation of the glans/clitoris (now limited to 10-20%). Another important feedback is the sense of erection that the brain has grown accustom to over the years. This input is also significantly limited by the removal of 80-90% of erectile tissue in addition to a lack of testosterone, which I will discuss later. All of this sounds disparaging, but the human body is an amazing organism and is able to adapt to change. It is known that trans women, who underwent surgery in the days before dorsal nerve sparing, are able to orgasm by way of the pudendal nerve stumps that are present in the mons area. This type of orgasm feels very different from what the person was used to in their past because those erotic touch sensations and feeling of erection are largely lost. Therefore, it takes persistence to make the "sneeze" happen.

Hormones: The more we learn about hormones; the more we realize we are just beginning to understand their function. In my practice of Gender Confirmation Surgery(GCS) as well as contra-hormone therapy (CHT), I take a detailed sexual history of my patients as they pass through pre-CHT, CHT, post-op and beyond. What I observe pre-CHT is that there seems to be two main groups of people: Those that report a healthy libido and ability to orgasm and those that report the opposite. It is important to note that surgery will not cure a low libido or inability to orgasm if these issues were present prior to surgery.