OPS Spotlight - Can it really be said that blocked puberty does not affect adult sexuality? A critical reading of a new Dutch study

By Magali Pignard

In April 2025, a study by van der Meulen et al., published in the Journal of Sexual Medicine, was presented as reassuring: according to its authors, blocking puberty in transgender adolescents would have no negative effect on their sexual life in adulthood. However, a careful reading of the protocol and results invites a more cautious and nuanced interpretation.

Presentation of the Study

Researchers from the Amsterdam Gender Dysphoria Expertise Center interviewed 70 transgender adults who began puberty suppression between 1998 and 2011, followed by hormone treatment and, for some, surgery. The goal was to assess, more than a decade after treatment began, sexual satisfaction and the prevalence of sexual dysfunction.

Here are the results:

• 52% of birth-registered females and 40% of birth-registered males reported satisfaction with their sex life.

• 58% of birth-registered females and 50% of birth-registered males reported at least one sexual dysfunction. The study states that distressing dysfunctions were more frequent than non-distressing ones, but gives no precise breakdown for each group.

• The authors report that the rates of dysfunction and sexual satisfaction were similar whether puberty suppression began early (Tanner stages 2–3) or later (Tanner 4–5).

An Unacknowledged Institutional Loyalty Bias

All authors of the study are affiliated with the Dutch center that designed, implemented, and promoted the Dutch Protocol for over two decades. In other words, they are now evaluating the long-term outcomes of a protocol they themselves helped develop and advocate. This situation creates a bias of institutional loyalty: even unconsciously, researchers may be tempted to frame hypotheses, select indicators, or interpret results in a way that confirms the validity of their past work. This kind of bias doesn’t necessarily imply dishonesty, but it may affect the neutrality of the analysis.

However, this risk is neither acknowledged nor discussed in the article, even though it is a crucial issue when a study is conducted by the very individuals or team who designed and implemented the protocol being assessed. In such cases, an independent analysis or external perspective would have been preferable to ensure greater impartiality.

A Small Sample and Uncorrected Biases

With only 70 participants, including just 20 birth-registered males, the study relies on too small a sample to draw strong or representative conclusions. Such a limited sample increases the risk that results may reflect chance or idiosyncrasies of the group rather than generalizable patterns. The study relies exclusively on self-administered online questionnaires completed more than ten years after treatment. Memories may be imprecise and subjective, and the results are hard to compare to other studies without standardized instruments.

Optimistically Framed Results

Several aspects of how the authors interpret and present their findings fall under what the scientific literature calls “spin”: a presentation strategy that, according to Chiu et al. (2017), consists of “distorting the interpretation of results and misleading readers to make conclusions appear more favorable than they really are.”

• Although 56% of participants reported at least one distressing sexual dysfunction, the authors write that “the majority do not experience significant sexual problems.”

• They claim that sexual satisfaction is comparable to that of the general population, citing a 49% satisfaction rate in their cohort versus 47% in a general population sample. However, they provide no information about the instruments, context, or methodological biases of the comparison group.

• They conclude that the treatment has no negative impact, despite their protocol allowing no causal inference.

An Ignored Biological Improbability

In cases where puberty suppression begins at early stages (Tanner 2–3), before any sexual maturation, the genital organs of birth-registered boys do not develop. Without exposure to testosterone, neither penile development nor the neurological pathways for sexual pleasure are formed. Taking estrogen during adolescence followed by genital surgery (vaginoplasty) does not recreate the sensory structures of a biological vagina.

This issue is not merely theoretical. It has been acknowledged internally by the current WPATH president, Marci Bowers, herself a surgeon specialized in vaginoplasty. In a January 2022 exchange, she stated:

“I don’t know of any individual who has been able to have an orgasm who was blocked at Tanner stage 2 (around age 11–12). That number needs to be documented, and the long-term sexual health of these individuals needs to be tracked.”

(WPATH Files, p. 118/241, internal forum, January 31, 2022)

This empirical observation aligns with broader concerns in the scientific community and makes the complete lack of discussion in the Dutch study about the biological prerequisites for orgasmic response in early-blocked birth-registered males all the more surprising.

The authors seem to assume—without stating it—that subjective self-reporting is sufficient evidence of sexual functioning, regardless of any clinical or objective analysis. This assumption, with significant implications, deserved explicit discussion.

A Flawed Comparison with the General Population

The authors claim that sexual satisfaction in their cohort (49%) is comparable to that of the general population, citing a 47% rate (ref. 33) and 55% and 45% for sexually active men and women (ref. 47). However, these comparisons are methodologically invalid:

• Source [33] (Skevington et al., 2004) does not provide a 47% rate of sexual satisfaction but rather an overall quality of life score in 23 countries through an aggregate score, without details by sex or sexual activity.

• Source [47] (Flynn et al., 2016) does not state any percentage of sexual satisfaction, but reports standardized average scores (50.7 for men, 49.1 for women), obtained using a completely different instrument (PROMIS v2.0).

Thus, the Dutch authors compare non-equivalent figures derived from different methodologies, scales, and populations, without any statistical analysis. The 47% figure appears to be extrapolated without clear justification, rendering the comparison scientifically unfounded.

A Structural Imbalance in the Sampl

Birth-registered females make up 71% of the sample. However, testosterone (administered to birth-registered females) is known to increase sexual desire, whereas birth-registered males receive estrogen, which may decrease libido, and undergo more extensive surgery on less developed structures. This imbalance could obscure significant differences in sexual satisfaction or functioning. A more balanced sample might have revealed more contrasting results.

If one simulated a sample with 50% birth-registered males and females, the overall rate of distressing sexual dysfunction would rise to 54%. This high figure still does not support a conclusion of harmlessness for the medical protocol.

Unrepresentative Recruitment

The study recruited 145 former patients from the center. Only 70 responded (48%). No information is provided on the profile or reasons for non-participation among the others. It is plausible that those who had negative experiences with their transition, developed sexual or psychological complications, or came to question their medical journey declined to participate or were unreachable. This silence represents a major selection bias.

The reported results may therefore primarily reflect the experiences of patients still in contact with the medical team and likely to feel continuity with their path. In contrast, individuals who may have experienced their transition more negatively—regret, complications, or detachment—are likely underrepresented, or entirely absent. Yet their experiences are essential for a balanced evaluation of the benefits and risks of such a medical protocol. Their probable underrepresentation limits the generalizability of the study’s conclusions.

Undiscussed Limitations

The authors acknowledge certain technical limitations (sample size, recall bias) but fail to discuss:

• selection bias,

• lack of a control group,

• institutional bias,

• validity of comparisons with the general population,

• or the absence of data on negative trajectories.

These omissions are significant and skew the overall interpretation of the study in an unjustifiably optimistic direction.

Conclusion

This study is a first attempt to document adult sexuality after puberty suppression. But due to major structural biases (participant selection, lack of a control group, retrospective self-reporting, overrepresentation of certain profiles), it does not allow us to conclude that the protocol has no harmful effects on sexual function. Caution remains warranted. Any optimistic generalization of its results is, at present, scientifically unfounded.