Abigail Shrier and surgeon Marci Bowers falsely claimed trans girls on puberty blockers lack sexual response after vaginoplasty

Last October, anti-trans activist Abigail Shrier was platformed on Bari Weiss’s Substack to discuss – what else? – being silenced. In “Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care”, Shrier opens:

For nearly a decade, the vanguard of the transgender-rights movement — doctors, activists, celebrities and transgender influencers — has defined the boundaries of the new orthodoxy surrounding transgender medical care: What’s true, what’s false, which questions can and cannot be asked.

As a Littman-certified “transgender influencer”, I decided to spend some time asking exactly those questions raised in her article, particularly this ominous claim:

And they never said anything about the distinct possibility that blocking puberty, coupled with cross-sex hormones, could inhibit a normal sex life.

Shrier’s assertion of sexual dysfunction is a fusion of two claims. One questions the outcomes of alternative vaginoplasty techniques necessary for some trans girls who may have very little genital tissue due to early use of puberty blockers. This known issue was broadly misused as a right-wing talking point that began circulating several years ago – long after equally effective surgeries were already in widespread use. The other is an apparently novel claim by Dr. Marci Bowers, a trans woman and vaginoplasty surgeon, that some experience of sexual stimulation or orgasm is necessary before vaginoplasty in order to access any meaningful sexual arousal after surgery. In her telling, early use of puberty blockers at Tanner stages 2 or 3 of a youth’s natal puberty could leave them sexually “naïve” and never motivated to seek out any sexual stimulation or derive enjoyment from this, an issue she says is not being acknowledged by other transition care providers.

But extensive data does exist on these questions. These and other relevant issues have been studied at length in clinical settings, and major transgender care centers have continued to publish their detailed findings in this patient group. What we know about the outcomes of youth who receive these treatments does not at all reflect the claims of Shrier and Bowers. Let’s directly refute the central point.

Quality of alternatives to standard penile inversion vaginoplasty

Shrier and Bowers raise the issue of vaginoplasty, which typically uses the genital tissue to create a clitoris, vulva and vaginal canal, and the options for trans girls on puberty blockers whose genitals have not developed under a male puberty:

Another problem created by puberty blockade — experts prefer “blockade” to “blockage” — was lack of tissue, which Dutch researchers noted back in 2008. At that time, Cohen-Kettenis and other researchers noted that, in natal males, early blockade might lead to “non-normal pubertal phallic growth,” meaning that “the genital tissue available for vaginoplasty might be less than optimal.”

But that hair-raising warning seems to have been lost in the trip across the Atlantic.

Many American gender surgeons augment the tissue for constructing neovaginas with borrowed stomach lining and even a swatch of bowel. Bowers draws the line at the colon. “I never use the colon,” she said. “It’s the last resort. You can get colon cancer. If it’s used sexually, you can get this chronic colitis that has to be treated over time. And it’s just in the discharge and the nasty appearance and it doesn’t smell like vagina.”

Shrier is offering the perspective of one vaginoplasty surgeon on the relative quality of outcomes for different techniques. That perspective is not supported by the findings of other surgical centers that have performed large numbers of these intestinal segment vaginoplasties on cis women, on adult-transitioning trans women, and specifically on young adult trans women who received puberty blockers from Tanner stages 2/3.

Back across the Atlantic, surgeons at that Dutch clinic have collected data on trans women who began transitioning at different developmental stages and have received standard vaginoplasties or intestinal vaginoplasties (van der Sluis et al., 2022). Importantly, these different techniques are not categorically indicated based solely on age of transition, but are bimodally distributed. Supplementary Table 2 examines vaginoplasty techniques among only those trans women who had used puberty blockers, and reveals that among those who began taking puberty blockers at Tanner stage 2 or 3, 71-72% required an intestinal vaginoplasty while the remainder were able to receive a penile inversion vaginoplasty. Conversely, 13% of those who did not receive blockers until stage 5 still required an intestinal vaginoplasty.

Early use of puberty blockers is not a guarantee of needing this alternative surgery, and later use or non-use of blockers is not a guarantee of avoiding it. It also may not be an inferior surgery. Bustos et al. (2021) found in a systematic review of 57 studies of trans vaginoplasty outcomes that intestinal vaginoplasty recipients had similarly high satisfaction and were able to achieve orgasm at the same or greater rates:

For the penile skin inversion technique, patient-reported outcomes showed a satisfaction rate of 87% (78%–94%) for overall satisfaction, 87% (74%–96%) for functional outcomes, and 90% (84%–95%) for aesthetical outcomes. For the intestinal vaginoplasty technique, patient-reported outcomes showed a satisfaction rate of 99% (97%–100%) for overall satisfaction, 86% (75%–95%) for functional outcomes, and 86% (69%–94%) for aesthetic outcomes. Overall, the ability to achieve orgasm was 76% (64%– 86%). In the subgroup analysis, the ability to achieve orgasm was 73% (60%–84%) for the penile skin inversion technique and 95% (88%–99%) for intestinal vaginoplasty.

Bouman et al. (2016), again of the Dutch clinic across the Atlantic, have reported on the results of 31 trans women who underwent intestinal vaginoplasty at a median age of 19, with an average followup time of 2.2 years. 84% had a history of using puberty blockers. These patients also had very good results from intestinal vaginoplasty, comparable to the outcomes of penile inversion vaginoplasty:

In our cohort, a good quality of life after primary total laparoscopic intestinal vaginoplasty was reported. The total score of the SWLS was similar to that in a reference group of 1,700 young healthy Dutch adults. A long-term Dutch follow-up study on psychological outcome after puberty suppression and sex reassignment in a group of 55 transgender men and women reported a total score of 4.73 ± 0.77 on the SHS. The 22 transgender women scored a total score of 27.7 ± 5.0 on the SWLS.

Esthetic outcome and functionality of the neovagina were graded a median value of 8 out of 10. Most women reported satisfaction with the surgical result. These results are similar to those of a Dutch cohort of 49 transgender women after penile inversion vaginoplasty (age = 41.1 ± 12.1 years, follow-up = 4.1 ± 1.0 years) who graded their esthetic outcome and functionality a mean of 7.9 ± 1.5 and 7.7 ± 1.9, respectively.

Bowers also correctly highlights a risk of neovaginal cancer for recipients of intestinal vaginoplasty, but omits that this risk appears to exist regardless of surgical technique, typically appearing as adenocarcinoma in intestinal vaginoplasty and as squamous cell carcinoma in penile inversion vaginoplasty (Fierz, Ghisu, & Fink, 2019). Both are noted to be “a rare condition” that “may develop after a long latency period”, and there is no indication that this disproportionately impacts intestinal vaginoplasty recipients. Bowers also points out the risk of a form of diversion colitis of the neovagina, which does appear as a mild chronic inflammation in most patients (van der Sluis et al., 2016), yet “patients’ subjective experience of symptoms did not correlate with endoscopic findings” – the presence of this mild inflammation did not always translate to clinically significant symptoms.

None of this relevant data on outcomes and risks was mentioned by Bowers or Shrier as they were busily describing young trans women’s genitals as “the discharge and the nasty appearance and it doesn’t smell like vagina”.

Bowers’ unsupported “orgasmically naïve” model

Shrier and Bowers also propose that adolescent trans girls must experience their undesired natal puberty to the point that their genitals are “endow[ed]… with erotic potential” and assert that these girls must experience orgasms before surgery in order to experience any sexual response after surgery:

The problem for kids whose puberty has been blocked early isn’t just a lack of tissue but of sexual development. Puberty not only stimulates growth of sex organs. It also endows them with erotic potential. “If you’ve never had an orgasm pre-surgery, and then your puberty’s blocked, it’s very difficult to achieve that afterwards,” Bowers said. “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.”

Nor is this a problem that can be corrected surgically. Bowers can build a labia, a vaginal canal and a clitoris, and the results look impressive. But, she said, if the kids are “orgasmically naive” because of puberty blockade, “the clitoris down there might as well be a fingertip and brings them no particular joy and, therefore, they’re not able to be responsive as a lover. And so how does that affect their long-term happiness?”

Two days later, Bowers added:

Patients who “are “are able to orgasm pre-surgery, they’re very highly likely to be able to orgasm afterwards.” But “Jazz does not know what an orgasm is and it’s very important when expressing intimacy,” she said. “And although it is not something that’s going to delay surgery, it’s not going to be any easier for her to have an orgasm after surgery.”

Shrier suggests that this alleged issue, which I had indeed never heard of before, is not widely known because according to unnamed doctors, other unnamed doctors are covering it up:

The mainstream media ignored this. And even to the millions who watched the show, it was not clear whether this was a unique feature of Jazz’s transition, or whether this was a predictable risk of early puberty blockade. Several endocrinologists I interviewed for my book told me they believed it was the latter, but no practitioners of gender medicine had ever acknowledged this.

But these claims about presurgical and postsurgical sexual development in early-transitioning trans girls can be evaluated, and they do not line up with reported clinical findings on this group. Across the pond in Amsterdam again, Bungener et al. (2017) studied 60 trans girls and 77 trans boys aged 11-17 who had not yet received any gender-affirming treatment, and found that romantic and sexual experience was less frequent than among their cis peers but still quite common:

As expected, transgender adolescents were sexually less experienced than sameaged adolescents from the general population. However, contrary to our expectations, transgender adolescents in this study were more sexually active than assumed. The majority had fallen in love (77%), and about half of the group engaged in romantic relationships (51%). A somewhat smaller group had some experience in petting while undressed (26%), although only a few reported sexual intercourse (5%).

The authors also noted that even before treatment, these youth were following a developmental trajectory typical of the romantic and sexual experiences of cis youth:

Despite these obstacles, the adolescents participating in this study managed to take the first steps of the common adolescent sexual development trajectory (falling in love and engaging in a romantic relationship). This finding is in contrast to the entire skipping of these stages during puberty, as previously described in a small retrospective study of 12 transgender people. Moreover, our study group seemed to reach their first sexual milestones along the usual sexual trajectory pathway, with an increase in both number and intimacy of experiences with progressing age.

In a later study of 38 trans women and 75 trans men who had received early treatment with puberty blockers followed by HRT and gender-affirming surgery, Bungener et al. (2020) observed that they do find relationships and sexuality more appealing than a joyless, platonic poke of a fingertip:

Transgender young adults value sex (92.7%; n = 92), love (93.7%; n = 104), and relationships (94.6%; n = 105) as moderate to very important, with no significant gender differences.

These early transitioners generally report a satisfying and active sex life:

Young transgender adults report being moderately to very satisfied with the frequency of sex (58.7%; n = 37), how good it feels (73.0%; n = 46), and their sex life in general (66.7%; n = 42). There were no gender differences. The majority of transgender young adults manage to get in touch with a person to whom they are romantically or sexually attracted (73.9% [n = 82]; no gender differences). For most of the group, the last sexual activity happened within the past month (68.8%; n = 44) or year (87.6%; n = 56). Sexual competence and assertiveness in the young adult transgender group was high: the percentage answering “often” or “always” was 82.8% for “feeling at ease during sex” (n = 40) and 66.6% for “I let the other person know what I like” (n = 31).

They had “a strong increase in sexual experiences” after surgery and “became far more sexually active”:

In the current study, we found that young transgender adults reported a strong increase in sexual experiences after completing early GAT, including puberty suppression, affirming hormones, and surgeries. Although the difference between them and their same-aged peers in experience was attenuated, in comparison with the Dutch population, young transgender adults were still less experienced in all types of sexual activities. Between young transmen and transwomen, hardly any differences in sexual experiences were reported. Almost all valued sex as important, and the majority was satisfied with their sex life. After the surgeries, young transgender adults who started early GAT became far more sexually active.

Are these the behaviors of a cohort whose capacity for sexual interest has allegedly never developed? Blasdel et al. (2022) recently found in that in a group of 199 trans women undergoing vaginoplasty, “Postoperative orgasm was not significantly correlated with preoperative orgasm”, while “Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty”. 86% of patients had been able to reach orgasm at a one-year followup. This directly contradicts Bowers’ statement that postoperative orgasm is not possible without experience of preoperative orgasm.

Bouman et al. (2016) also provide an even more granular look at outcomes of sexual response among early-transitioning trans girls who received intestinal vaginoplasty. 100% of respondents reported that sexual arousal was possible after their surgery; 100% reported having sexual feelings after surgery; 84% said orgasm was possible after surgery, with 4% saying it was not and 12% who had not tried. 62.5% said the sensation of orgasm was equal to that before surgery, while 25% reported more sensation after surgery and 12.5% reported less. While Shrier and Bowers highlight the risk of a loss of sensation in this group of trans girls, they’ve failed to mention this is twice as likely to produce a gain of sensation. Shrier is content merely to cite Bowers’ “fear”:

“And my fear about these young children who never experience orgasm prior to undergoing surgery are going to reach adulthood and try to find intimacy and realize they don’t know how to respond sexually.”

That fear is not borne out by the consistent findings that most or all of these adolescent and young adult trans women are capable of sexual sensation, arousal, and orgasm after this alternative vaginoplasty, and most seek out and find a satisfying sex life. But readers of Shrier’s article would come away believing the very opposite is true.

Don’t ignore this

“The mainstream media ignored this.” That is how Abigail Shrier, typical of those with a dependence on being silenced as loudly as possible, frames her total misrepresentation of young trans women’s affirming care and sexual experiences. Abigail Shrier said this treatment “tends to leave patients … sexually dysfunctional” when it does not. As a “transgender influencer”, I hope the mainstream media does not ignore this. I hope they don’t ignore this in the same way I don’t ignore this.

Silenced Abigail insists “Anyone who dared disagree … were inevitably smeared as hateful and accused of harming children”. But it is harmful to children to obstruct their access to necessary and beneficial healthcare on the basis of falsehoods. Promoting the falsehood that affirming treatment for trans youth induces permanent sexual dysfunction is one part of a larger web of similar misrepresentations currently motivating policymakers and parents to bar trans youth from accessing this care entirely. Shrier openly acknowledges this is her goal:

I am personally aware of families who were counseled to put their own children on puberty blockers by some of the best gender clinics in this country—and never told of this risk. Parents have been pressed to put their children on early blockade without full information or, therefore, informed consent. Because Bowers spoke up, they will now know better what’s at stake. Some families may choose a different path based on this information.

But there’s no value in providing actionable information when that information is misleading. That applies to me, Abigail Shrier, Marci Bowers, and everyone else, everywhere. Don’t ignore this.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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