Anatomy of trans women

“What genitals does a trans woman have?” It is a question many people ask themselves but few dare to voice openly. Often the curiosity stems from ignorance, not malice. The problem is that in the absence of clear answers, the space is filled by stereotypes, pornography, and misinformation. This article answers with data: what happens to a trans woman’s body before, during, and after medical transition, with particular attention to genital anatomy.

Necessary premise: not all trans women follow the same pathway. Some do not undertake any medical transition. Others take hormones. Others undergo surgical procedures. Every combination is legitimate, and none makes a person more or less of a woman. Here we describe what happens from an anatomical and physiological perspective for those who follow a medical pathway, according to the available scientific literature.

Starting anatomy

Trans women who have not yet started any medical treatment have typically male genital anatomy: penis, scrotum, and testicles. This anatomical fact does not define their identity, but it is the starting point from which to understand subsequent changes.

Male genitals are composed of tissues that, from an embryological standpoint, derive from the same structures as female genitals. The glans of the penis is the embryological counterpart of the clitoris: both derive from the genital tubercle and share the same innervation and density of sensory receptors. The labioscrotal folds, which in males form the scrotum, in females form the labia majora. This homology is the foundation of vaginoplasty surgical techniques: nothing is “created” from scratch, but rather tissues that have a female anatomical counterpart are reorganized.

What changes with hormone therapy

Estrogen therapy (estrogens combined with anti-androgens) produces significant changes in genital anatomy. According to the Endocrine Society guidelines (Hembree et al., 2017) and the WPATH Standards of Care version 8 (2022), the main effects on the genitals are as follows [2][1].

Reduction of testicular volume

Anti-androgens and estrogens suppress testosterone production by the testicles. This leads to progressive testicular atrophy: the testicles decrease in size, often significantly [3]. A study by Schneider et al. (2017) documented that hormone therapy causes histological changes in testicular tissues, including hyalinization of seminiferous tubules, thickening of the basement membrane, and impairment of spermatogenesis [4]. The volume reduction is visible within the first 3-6 months of therapy and continues over time.

Changes to the penis

The penis tends to decrease in size, both in length and circumference, especially in the flaccid state. The skin becomes thinner and softer due to the effect of estrogens. Spontaneous erections decrease drastically or disappear entirely, although erectile capacity can be maintained with direct stimulation [11][12]. These changes begin within the first 1-3 months and stabilize within 1-2 years.

Changes to skin and tissues

The skin of the genital area becomes thinner, softer, and with less body hair [3]. Sebum production decreases. The skin texture progressively approaches that typical of female skin. These changes are also relevant in view of possible surgical intervention, as the quality of the skin tissue influences the results of vaginoplasty.

Sensation and sexual function

An often overlooked aspect: hormone therapy does not eliminate genital sensation. In fact, many trans women report a qualitative change in the perception of pleasure [12]. Sensation can become more diffuse and less localized compared to the typically male pattern. Libido tends to decrease, at least initially, and then stabilize at levels that vary from person to person. The ability to reach orgasm is generally preserved, although the modalities may change.

What does not change with hormones alone

Hormone therapy does not modify the bony structure of the pelvis, does not remove the testicles, and does not create a vagina. The genitals remain anatomically male in their basic structure, even though profoundly modified in terms of size, texture, functionality, and sensation. For a structural anatomical change, surgery is necessary.

Vaginoplasty

Vaginoplasty is the surgical procedure used to create a neovagina, a neoclitoris, and the external vulvar structures (labia majora and minora, clitoral hood, urethral meatus). Several techniques exist, each with specific advantages and limitations.

Penile inversion

The most widely used technique worldwide is penile inversion vaginoplasty. Penile skin is used to line the neovaginal canal, while the glans is reduced and repositioned as the neoclitoris, preserving the neurovascular bundle to maintain sensation. The scrotum is used to create the labia majora, and urethral tissue may be used for the labia minora.

The systematic review by Hontscharuk et al. (2021), published in Andrology, analyzed the results of this technique [5]. The complication rate varies from 20% to 70% depending on the studies and the definition of “complication,” but most are minor and manageable: tissue granulation, narrowing of the vaginal introitus, urinary infections. Serious complications requiring surgical revision are much less frequent.

A 2021 meta-analysis (Dreher et al.) confirmed that overall patient satisfaction after penile inversion vaginoplasty is high, with rates varying from 80% to 100% depending on the studies [10].

Peritoneal vaginoplasty

A more recent technique uses the peritoneum (the membrane lining the abdominal cavity) to create the vaginal canal, generally with laparoscopic or robotic assistance. The theoretical advantage is that the peritoneum is a moist and flexible tissue that could offer better lubrication compared to penile skin.

However, a review published in Sexual Medicine Reviews in 2023 (Bordas et al.) clarified that no vaginoplasty technique produces lubrication comparable to that of the natal vagina [9]. The lubrication reported by patients with the peritoneal technique is real but limited, and in clinical practice most trans women, regardless of the technique, use lubricants during sexual intercourse.

The peritoneal technique has the advantage of not depending on the amount of penile skin available, making it a good option for trans women who began puberty blockers before complete genital development. Long-term data are still limited compared to penile inversion.

Other techniques

Sigmoid colon vaginoplasty (less commonly practiced due to greater invasiveness) and various hybrid techniques also exist. The choice of technique depends on the patient’s anatomy, the availability of tissues, the surgeon’s experience, and individual preferences.

What the result looks like

One of the most common questions concerns the aesthetic appearance. The results of modern vaginoplasty have improved significantly in recent decades. The external appearance of the surgically created vulva, including labia majora, labia minora, clitoral hood, and vaginal introitus, can be aesthetically very similar to that of a natal vulva. The natural variability of female anatomy is broad, and surgical results fall within this variability [10].

That said, it is important to have realistic expectations. Every procedure produces different results, and the healing process takes time: the final appearance stabilizes over the course of 6-12 months. Post-operative swelling, initial scarring, and temporary asymmetry are normal. Surgical touch-ups (revisions) are common and do not indicate a failed procedure.

“Before and after” photos available online are not representative of the real variability of results, and often show only the best cases. An open dialogue with the surgeon about expectations is essential.

Sensation and orgasmic capacity

This is one of the aspects on which research offers reassuring data. Modern surgical techniques preserve the neurovascular bundle of the glans during the creation of the neoclitoris, maintaining erogenous sensation.

A study by Sigurjonsson et al. (2016), published in The Journal of Sexual Medicine, evaluated genital sensation in 22 trans women after vaginoplasty: 86% reported the ability to reach orgasm [6]. An earlier study by Lowenberg et al. (2007) had found that sensitivity to pressure and vibration was preserved in the neoclitoris, with sensory thresholds comparable to those of the natal clitoris [7].

More recent data confirm these results. A 2025 study published in The Journal of Sexual Medicine (Buncamper et al.) found that 82% of patients reported orgasms after vaginoplasty, and that clitoral stimulation was the primary method for achieving sexual arousal, exactly as it is for many cisgender women [8].

Sensation is not identical to pre-operative sensation: it changes in quality and localization. Some women describe orgasms that differ from those experienced before surgery, often more diffuse. Full recovery of sensation can take 6 to 18 months after surgery.

Penetration and sexual intercourse

The neovagina allows penetrative sexual intercourse. The average depth after surgery generally varies between 10 and 15 cm, depending on the technique and amount of tissue available [5]. Regular dilation in the months following surgery is essential to maintain the depth and width of the neovaginal canal.

The dilation program is intensive in the first weeks (multiple times a day) and gradually reduces over time. Many trans women continue to dilate periodically even long-term, as part of their maintenance routine. Dilation is not painful if done correctly, but requires consistency and discipline.

Lubrication during intercourse is in most cases necessary with the use of external lubricants, regardless of the surgical technique [9]. Some women report minimal mucus production, but this is not sufficient for penetration without lubricant in the vast majority of cases.

Not everyone chooses surgery

It is essential to restate this point: genital surgery is a choice, not an obligation. Many trans women live full and satisfying lives without vaginoplasty. The reasons are multiple and all legitimate:

• Absence of genital dysphoria: not all trans women experience distress about their genitals. Gender dysphoria manifests differently from person to person.
• Surgical risks: like any major surgery, vaginoplasty carries risks (infections, complications, need for revisions) [10]. Some people prefer to avoid them.
• Cost and accessibility: where public health coverage is absent or waiting lists are long (in Italy, wait times often exceed 2-3 years through the NHS), effective access to surgery is limited.
• Personal choice: some trans women simply do not desire this procedure. Their identity is no less valid.

According to WPATH SOC-8 data (2022), the percentage of trans women who undergo vaginoplasty varies widely across different countries and contexts [1]. Surgery is not a criterion of authenticity. In Italy, since 2015 the Supreme Court has established that legal gender recognition does not require surgical interventions.

Respect, consent, and the limits of curiosity

Knowing how trans women’s anatomy works is legitimate. Asking a specific trans woman what genitals she has is not. Anyone’s genitals, cis or trans, are private information. Curiosity does not justify intrusion.

If you are reading this article because you are in a relationship with a trans woman, or are thinking of being in one: what matters is the dialogue with the person, not generic information. Every body is different, every experience is individual. Ask with respect, listen, and remember that intimacy is built on trust, not on curiosity satisfied in advance.

If you are a trans woman looking for information for yourself: this article is a starting point, not a medical guide. Every decision about your body is yours to make, with the support of competent professionals. There is no right or wrong pathway: there is yours.

The scientific picture

The genital anatomy of trans women is a medical fact, not a topic for scandal or political debate. Science clearly describes what happens to the body with hormone therapy, what surgical options are available, and what results to expect. The data show that current techniques produce significant functional and aesthetic results, with high satisfaction rates and the capacity to experience sexual pleasure preserved in the vast majority of cases [6][8][10].

The variability is enormous: between trans women who have had no treatment and trans women who have completed vaginoplasty, there is an entire spectrum of possible anatomies. All are women’s anatomies. Understanding this reality is the first step toward an honest, respectful, and fact-based dialogue. For further insight into the topic of medical transition as a whole, we refer to the article on hormone therapy. For an overview of surgical options, consult the article on gender-affirming surgery.