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Abstract Objective Liver transplantation can reduce anxiety and depression and increase the sexual health of end-stage liver disease patients. In this study, we aimed to investigate the difference in sexual health in two groups of liver transplant candidates and recipients, and how anxiety and depression predict sexual functioning. Methods A cross-sectional study performed from March 2022 to May 2023. 750 patients in two groups of liver transplant candidates and recipients (250 and 500 respectively) were included in the study. The hospital Anxiety and Depression Scale was used for measuring anxiety and depression in both groups. The International Index of Erectile Function Questionnaire and Female Sexual Function Index, respectively used for assessing the sexual function of male and female participants. Data were analysed by SPSS 23. Results A total of 164 participants completed the study (115 men, 49 women). Compared with pre-transplant participants, post-transplant participants had lower depressive symptoms in both sexes, while anxiety did not differ significantly. In men, HADS-Depression medians were 6.50 (IQR 3.00–11.25) vs. 4.00 (2.00–8.50) (p = 0.044); in women, 8.00 (7.00–9.00) vs. 7.00 (6.00–8.00) (p = 0.009). Sexual function scores were higher in the post-transplant group. Among men, IIEF-15 total was 45.0 (20.0–59.0) vs. 36.0 (15.5–55.5) (p = 0.033), with higher erectile function (18.0 [8.0–24.0] vs. 14.0 [6.0–21.5], p = 0.048) and desire (6.0 [5.0–8.0] vs. 6.0 [3.0–7.0], p = 0.031); intercourse satisfaction and overall satisfaction were numerically higher (p = 0.055 and p = 0.051), and orgasmic function did not differ (p = 0.126). Among women, FSFI total was 27.4 (22.5–29.85) vs. 23.2 (6.7–25.7) (p = 0.014), with higher desire (p = 0.039), arousal (p = 0.016), lubrication (p = 0.038), orgasm (p = 0.043), and satisfaction (p = 0.007); pain did not differ (p = 0.134). In adjusted models with transplant status as the outcome, higher sexual function scores were associated with post-transplant status: IIEF-15 OR per point 1.020 (95% CI 1.002–1.038, p = 0.031) in men and FSFI OR per point 1.089 (95% CI 1.031–1.151, p = 0.002) in women. Conclusions The status of sexual function, anxiety and depression in the group of liver transplant recipients was better than that of transplant candidates. Depression and anxiety are related to sexual dysfunction, and the sexual health of liver transplant patients can be improved by reducing anxiety and depression.