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Long-Term Assessment of the Physical, Mental, and Sexual Health Among Transsexual Women
Abstract
Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking.
To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS.
Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited.
Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored.
Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals.
Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.
... The evaluation of sexual function in trans women, through generic questionnaires (e.g., the Female Sexual Function Index), has shown suboptimal valuations in terms of low levels of lubrication, dyspareunia, and arousal [15]. As far as we know, there is currently only one specific questionnaire for the population of transgender women, the operated Male to Female Sexual Function Index (oMtFSFI). ...
... The phrase "en las pasadas 4 semanas" [in the past 4 weeks] is replaced by "en las últimas 4 semanas" [in the last 4 weeks] 1, 2, 3, 5, 6,7,8,9,11,12,13,14,15,16,17, and 18 Verbena, 24 years old, in a relationship, heterosexual "…as the questions started with, 'en las 4 semanas pasadas' I think it's easier to say 'en las últimas 4 semanas'…" ...
... The phrase "cuán a menudo" is replaced by "con qué frecuencia" [both are equivalent to how often] 1, 2, 3, 5, 6,7,8,9,11,12,13,14,15,16,17, and 18 Violeta, 24 years old, single, heterosexual Violeta: "…I mean, 'cuán a menudo', the phrasing is a bit weird there…" ...
Transgender and gender-diverse people often experience discrimination or even outright exclusion when undergoing medical attention. It has been shown that gender-affirming treatments improve quality of life in transgender patients, and genital-affirming surgery (GAS) is increasingly spreading worldwide. Sexual function after male-to-female GAS has long been evaluated by using tools designed for assigned female at birth (AFAB), resulting in suboptimal assessments. Currently, the operated Male to Female Sexual Function Index (oMtFSFI) is the only validated questionnaire to assess the sexual function of operated transgender women. The current study was aimed at performing cross-cultural adaptation and to test the face validity of the Chilean version of the oMtFSFI.
We carried out an observational descriptive study. The questionnaire was translated into Spanish, adapted, and face validated in five phases with eight participants. The study was approved by the Universidad del Desarrollo Scientific Ethics Committee.
According to participants, the questionnaire was shown to both pertinently and exhaustively evaluate the sexual function of post-feminizing genitoplasty transgender women. The questionnaire was well understood by the participants, except for a difficulty in understanding certain terms. Some participants criticized the perspective of the instrument in terms of the assumption of having a partner or having penetrative intercourse via the neovagina. The amendments to the Italian version of the questionnaire were discussed until an agreement on adaptation considering the patient´s perspective was reached. The present preliminary data support the face validity of the Chilean version of the oMtFSFI in the assessment of sexual function in operated transgender women.
This adapted questionnaire could be a valuable tool for clinicians and researchers.
... Multiple studies have compared sexual arousal levels of trans women post-operatively with sexual arousal in cisgender women. In these studies, 90-100% of trans women reported experiencing sexual arousal post-operatively, but when level of sexual arousal was assessed using the Female Sexual Function Index (FSFI), sexual arousal scores were overall lower in trans women than in their cisgender counterparts [35][36][37]. The FSFI is a validated 19 question tool that measures sexual function in cisgender women, assessing desire, arousal, lubrication, orgasm, satisfaction, and pain [38]. ...
... While lubrication is not directly associated with neovaginal function, it can be more prevalent in certain vaginoplasty types. FSFI scores assessing lubrication for cisgender women and trans women were obtained with subgroup analyses differentiating between penile inversion vaginoplasties and intestinal vaginoplasties [35][36][37]. Lubrication scores out of 6 were on average 5.7 for cisgender women, 2.8 for trans women who received a penile inversion and 4.0 for trans women who received an intestinal vagina. One study was also done to investigate the association of lubrication with arousal in trans women and demonstrated a 64.3% ...
... Due to the unique anatomy of trans women post-operatively, it must be noted that orgasms can occur at multiple locations including the clitoris and prostate via masturbation or vaginal penetration, for example. There is variability in the rates of orgasm post-operatively with studies citing percentages between 40-100% [35][36][37]. These studies used the FSFI to assess orgasmic scores and demonstrated ranges of 2.82 to 4.0 out of 6 in comparison to cisgender women without sexual dysfunction who scored an average of 5.1. ...
Purpose of Review
Sexual function and satisfaction in the transgender community is a nascent field with a paucity of data due to the fast paced nature of improving upon surgical technique and variety of patient experiences. The authors aim to review the current literature for areas of success as well as areas of improvement in order to better the sexual health of the transgender community.
Recent Findings
Gender dysphoria is a feeling of distress experienced by those whose gender assigned at birth is not in line with their gender identity. While social transition to the desired gender can suffice for some, medical and surgical interventions are often sought out to achieve gender euphoria, the decrease or absence of gender dysphoria. Often, issues with sexual function and satisfaction can trigger gender dysphoria, especially prior to social, medical, or surgical transition.
Summary
Surgical genital gender affirmation has been the most studied in terms of sexual function and improvement of gender dysphoria. Surgical complications, hormonal changes, and other organic causes of sexual dysfunction can still interfere with one’s overall sexual satisfaction. A validated measure of sexual function for trans men and trans women is needed to better assess outcomes.
... Regret is broadly defined as a negative, cognitive-based emotion involving counterfactual inference and feelings of personal agency or self-blame (Zeelenberg & Pieters, 2007). Studies evaluating regret following medical transition have used non-standardized definitions, and methods to ascertain regret have been heterogeneous Dhejne et al., 2014;Lawrence, 2003;Narayan et al., 2021;Pfäfflin, 1993;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). Likewise, definitions of detransition vary across studies, but most include discontinuing medications, having surgery to reverse the effects of transition, or both (Exposito-Campos, 2021;Littman, 2021;Vandenbussche, 2022). ...
... Historical data suggest that regret following gender transition in adulthood is rare Dhejne et al., 2014;Lawrence, 2003;Pfäfflin, 1993;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). However, studies reporting low rates of regret are generally from an era when hormonal therapy and surgery were only undertaken under strict protocol. ...
... However, studies reporting low rates of regret are generally from an era when hormonal therapy and surgery were only undertaken under strict protocol. Regret was ascertained by a variety of methods, including retrospective review of medical charts for documentation of regret, or unvalidated questionnaires and semi-structured interviews, which are susceptible to non-response bias Lawrence, 2003;Rehman et al., 1999;van de Grift et al., 2018;Weyers et al., 2009;Wiepjes et al., 2018). Other researchers have used a very narrow definition of regret, such as application to have birth sex reinstated as legal sex (Dhejne et al., 2014). ...
Gender transition is undertaken to improve the well-being of people suffering from gender dysphoria. However, some have argued that the evidence supporting medical interventions for gender transition (e.g., hormonal therapies and surgery) is weak and inconclusive, and an increasing number of people have come forward recently to share their experiences of transition regret and detransition. In this essay, I discuss emerging clinical and research issues related to transition regret and detransition with the aim of arming clinicians with the latest information so they can support patients navigating the challenges of regret and detransition. I begin by describing recent changes in the epidemiology of gender dysphoria, conceptualization of transgender identification, and models of care. I then discuss the potential impact of these changes on regret and detransition; the prevalence of desistance, regret, and detransition; reasons for detransition; and medical and mental healthcare needs of detransitioners. Although recent data have shed light on a complex range of experiences that lead people to detransition, research remains very much in its infancy. Little is known about the medical and mental healthcare needs of these patients, and there is currently no guidance on best practices for clinicians involved in their care. Moreover, the term detransition can hold a wide array of possible meanings for transgender-identifying people, detransitioners, and researchers, leading to inconsistences in its usage. Moving forward, minimizing harm will require conducting robust research, challenging fundamental assumptions, scrutinizing of practice patterns, and embracing debate.
... 12 Three studies with a total of 130 TGW reported an increase in the FSFI (The Female Sexual Function Index) subscale for sexual desire after GAS. [29][30][31][32] On the contrary, Wierckx and colleagues found that 69.7% of 214 TGW reported a decrease in sexual desire after GAS. 12 And a study by van der Sluis and colleagues reported comparable sexual desire scores (FSFI) in 24 TGW underwent intestinal vaginoplasty technique. 33 Type of GAS had different effects on sexual desire. ...
... 7 Being sexually active related to higher sexual desire scores. 30,32 To compare with cisgender women, 4 studies that include 145 TGW reported a lower sexual desire score in nonclinical TGW with neovagina than cisgender women without sexual problem using FSFI score [30][31][32] or the Brief Index of Sexual Functioning for Women (BISF-W) score. 34 ...
... Difficulties in sexual arousal were assessed in 8 studies among 599 TGW 6,17,[30][31][32][33][34][35] (Table 8). GAHT demonstrated no impact on arousal difficulties in a study by Kerckhof and colleagues. ...
Transgender people may choose to affirm their gender identity with gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS). The effects of GAHT and GAS on sexual health in transgender people have not been well elucidated. This systematic review aimed to appraise the current scientific literature regarding sexual desire, arousal, orgasm, pain, and satisfaction in transmen and transwomen before, during, and after gender transition. Overall, sexual dysfunction is common in both transmen and transwomen. GAHT and GAS may help to improve sexual satisfaction. More studies that focus on sexual health in the transgender population are urgently needed.
... The World Health Organization considers sexual satisfaction/health an important determinant of quality of life (WHOQOL Group, 1994), indicating the importance of research on sexuality in transgender individuals. Although some studies indicate that sexual dysfunctions occur in a relatively large proportion of the transgender population (Kerckhof et al., 2019;Weyers et al., 2009), it was found that gender affirming treatment has a positive influence (Constantino et al., 2013). However, most of the research on sexuality in this population has typically applied a rather medical/functional approach, by focusing on neo-vaginal depth (Hess et al., 2018), frequency of masturbation and orgasm (Wierckx et al., 2011), and sexual functioning (Weyers et al., 2009). ...
... Although some studies indicate that sexual dysfunctions occur in a relatively large proportion of the transgender population (Kerckhof et al., 2019;Weyers et al., 2009), it was found that gender affirming treatment has a positive influence (Constantino et al., 2013). However, most of the research on sexuality in this population has typically applied a rather medical/functional approach, by focusing on neo-vaginal depth (Hess et al., 2018), frequency of masturbation and orgasm (Wierckx et al., 2011), and sexual functioning (Weyers et al., 2009). Such a functional approach tends to ignore the biopsychosocial nature of sexual responses, which are determined by a myriad of biological, psychological, relational and sociocultural factors. ...
... In both transgender groups, fear of sexual contacts was frequently reported, which fits with the current finding that transgender individuals report more sexual anxiety as part of their self-concept. Another study investigating sexual function in transgender women who had undergone gender affirming surgery also found that this group shows elevated rates of sexual dysfunctions (Weyers et al., 2009), such as problems with arousal. This coincides with our finding of lower scores on sexual attitudes -arousal in the transgender sample. ...
Sexual responding in transgender people has typically been investigated from a medical and functional perspective. Aligning with the biopsychosocial model, it is however equally important to consider psychological aspects of sexuality in this population. We propose that the Sexual Self-Concept (SSC) theory offers a valuable framework to understand (sexual) wellbeing in transgender people, while Self-Concept Discrepancy (SCD) theory could offer an explanation of the mechanisms underlying negative SSCs related to gender dysphoria. We investigated differences in SSC (consisting of sexual esteem, sexual attitudes, and sexual self-efficacy) in 197 binary transgender and 205 cisgender individuals using an online survey and explored the mediating role of actual/ideal self-discrepancies in explaining the relation between gender dysphoria and SSC. Transgender and cisgender individuals differed significantly in seven out of eight components related to sexual esteem and sexual attitudes. Actual/ideal self-discrepancies mediated the relationship between gender dysphoria and the SSC in transgender individuals for the sexual esteem components related to body perception, conduct, and attractiveness, as well as for sexual anxiety. We found no relation between gender dysphoria and the other SSC components in this group. We conclude that SSC discrepancies could be a valuable treatment target to improve transgender individuals' sexual esteem and sexual attitudes.
... Une majorité des femmes trans ne regrette pas ce choix, même si la satisfaction obtenue quant aux résultats en est limitée. Pour Weyers et al. [27], la perception de leur état de santé par les femmes trans interrogées est meilleure après l'opération et 96 % d'entre elles affirment ne pas regretter celle-ci. Il n'y aurait aucune différence significative entre la santé perç ue des femmes trans ayant bénéficié d'une telle opération et les femmes cisgenres de la population générale. ...
... Les expériences sexuelles postopératoires sont fondamentales en vue d'une meilleure réappropriation, une érotisation du corps qui dépend en majorité du bon fonctionnement d'un néovagin [26]. En ce qui concerne l'apparence, l'étude menée par Weyers et al. [27] met en évidence une corrélation positive entre une satisfaction sexuelle globale et la perception que les autres ont de leur apparence féminine (notamment des modifications corporelles apportées par les traitements). Les femmes trans hétérosexuelles ont un niveau de fonctionnement sexuel (évalué à l'aide du Female Sexual Function Index dans lequel sont examinés le désir sexuel, l'excitation, la lubrification, l'orgasme, et la satisfaction sexuelle) [33] similaire à celui des femmes cisgenres sans aucune plainte exprimée, contrairement aux femmes trans homosexuelles (les termes hétérosexuelles et homosexuelles sont repris de l'article). ...
... L'autre moitié a changé de partenaire après l'opération. Weyers et al. [27] ajoutent à cette analyse le biais de l'orientation sexuelle. Selon ces chercheurs, les femmes trans strictement hétérosexuelles et homosexuelles ont autant de probabilité d'être en relation avec un partenaire stable, alors que celles qui sont bisexuelles sont moins fréquemment engagées dans une relation amoureuse plus stable. ...
Résumé
Objectifs
Comprendre la place et les évolutions des prises en charge médicales et psychologiques de la vie sexuelle des femmes trans, dans le cadre des parcours de transition/affirmation de genre.
Méthode
Une revue narrative de la littérature médicale, psychiatrique et psychologique. Après sélection, 19 articles ont été retenus et analysés de façon inductive à l’aide de la théorie ancrée et des méthodes classiques d’analyse de contenu thématique.
Résultats
La majorité des articles recensés et analysés font le constat d’une relative absence de recherches sur le thème de la vie sexuelle. Les traitements chirurgicaux de réassignation sexuelle augmentent significativement la qualité de la vie sexuelle des femmes trans sauf dans le cadre de la pose d’un « néovagin ». Les changements d’orientation sexuelle ne sont pas toujours liés aux éléments du traitement entrepris par les personnes mais apparaissent liés à d’autres facteurs psychosociaux.
Discussion
Les catégories d’orientation sexuelle sont fluides autant que les pratiques sexuelles et le genre. Elles évoluent selon le moment de vie des personnes interrogées dans une parole singulière.
Conclusions
Après avoir longtemps été considérée comme un élément central du diagnostic de « transsexualisme », la question de la sexualité et notamment de l’orientation sexuelle des personnes apparaît actuellement peu prise en compte dans les parcours de soin. Cette absence est critiquée fortement par les auteurs des principales revues de la littérature déjà publiées. On suggère une meilleure prise en compte de la vie sexuelle comme élément clinique de l’histoire singulière des femmes trans. On observe par ailleurs que la pratique des opérations chirurgicales sur les organes génitaux n’occupe pas la place centrale qu’elle occupait encore récemment et que la question de la sexualité se pose indépendamment des modifications anatomiques génitales.
... 53 FSFI was the most commonly used validated questionnaire (17 studies). [31][32][33]35,36,39,41,[46][47][48][49][52][53][54][55][56]73 ...
... and are concerning for bias to this effect, as shown inWeyers et al. (2009) in which FSFI scores are considerably higher in the heterosexual cohort when compared to the members of the LGBTQ+communities.56 Vedovo et al. (2020) published a recent, somewhat validated questionnaire for TGD patients after vaginoplasty that is adapted from the FSFI.53 ...
... and are concerning for bias to this effect, as shown inWeyers et al. (2009) in which FSFI scores are considerably higher in the heterosexual cohort when compared to the members of the LGBTQ+communities.56 Vedovo et al. (2020) published a recent, somewhat validated questionnaire for TGD patients after vaginoplasty that is adapted from the FSFI.53 ...
Background:
Vaginoplasty is a gender affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.
Objectives:
To investigate sexual health after gender-affirming vaginoplasty for TGD patients. Data Sources MEDLINE/PubMed, Embase, Scopus and PsycINFO databases were searched, unrestricted by dates or study design.
Methods:
We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences or aids.
Results:
Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4 - 100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 - 28.6). 64 - 98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.
Conclusions:
The heterogenous methods of measuring sexual outcomes reflects the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires and inclusive metrics.
... Among transgender individuals, satisfaction with primary sex characteristics is particularly low before GAT compared to other body parts (Becker et al., 2016;van de Grift, Cohen-Kettenis, Elaut, et al., 2016) and seems to be particularly related to sexual satisfaction (de Cuypere et al., 2005;Weyers et al., 2009). Moreover, sexual satisfaction and positive perception of primary sex characteristics were positively correlated in a small sample of transmen and women after genderaffirming surgery (GAS) (de Cuypere et al., 2005). ...
... Improvement of satisfaction with body characteristics not modified by GAT has been shown as well (van de Grift et al., 2017). In addition, transwomen with higher sexual functioning report more satisfaction with their appearance after GAS (Weyers et al., 2009). These findings are in line with research in the general population indicating that individuals with better body image show better sexual well-being (Gillen & Markey, 2019) and that a better body image may be associated with stronger sexual desire (Dosch, Ghisletta & van der Linden, 2016). ...
... Whereas body image has been discussed to be of central importance for sexual satisfaction and functioning, the present study did not confirm indirect effects of body image (measured via the dimension of attractiveness and self-confidence) on the associations between GAHT/GAS and sexual desire. The reason for this result may be that previous research focused more on sexual functioning (Weyers et al., 2009) and sexual excitement (de Cuypere et al., 2005), whereas the present study focused on sexual desire as an outcome. It is important to mention that these bio-psychological constructs are overlapping but not to be equitable. ...
It has been posited that gender-affirming treatment (GAT) can have an influence on body image and sexual desire in trans people. This study aims to examine associations between GAT and sexual desire as well as whether body image mediates the influences of gender-affirming hormone therapy (GAHT) or gender-affirming surgery (GAS) on sexual desire. A total of 210 individuals diagnosed with gender dysphoria (n = 105 of each gender) were assessed via self-assessment questionnaires in a cross-sectional study. Associations between GAT and sexual desire were investigated via multivariate analyses of variance. Mediation analyses were conducted to clarify associations between GAHT/GAS, body image, and sexual desire. GAHT was associated with increased sexual desire only in transmen. GAS had no significant effect on sexual desire in transmen and transwomen. Body image did not mediate the influence of GAHT or GAS on sexual desire in both groups. GAHT and GAS had significant direct effects on body image in both genders, whereas body image showed no significant direct effect on sexual desire. The results indicate that effects of GAT on sexual desire seem to be attributable to other factors than body image, such as the hormonal influence of testosterone in transmen.
... Previous research in adult transgender men (TM) as well as transgender women (TW) showed a highly heterogeneous distribution of sexual orientation/sexual identity [1][2][3][4][5][6][7][8][9][10][11][12][13][14], with changed preferences after gender-affirming surgery [2,5,6], after initiating gender-affirming hormonal therapy (HT) [5], and-in general-over the course of life [1]. The results on the causality of gender-affirming treatment-and the use of testosterone in particular-remain mixed [1,3,4]. ...
... Previous research in adult transgender men (TM) as well as transgender women (TW) showed a highly heterogeneous distribution of sexual orientation/sexual identity [1][2][3][4][5][6][7][8][9][10][11][12][13][14], with changed preferences after gender-affirming surgery [2,5,6], after initiating gender-affirming hormonal therapy (HT) [5], and-in general-over the course of life [1]. The results on the causality of gender-affirming treatment-and the use of testosterone in particular-remain mixed [1,3,4]. ...
... Previous studies are not always consistent in how these sexual identity labels are classified: relative to birth-assigned sex or to gender identity [3]. In addition, many recent papers on sexual orientation in cohorts of transgender people have methodological shortcomings due to their cross-sectional [3,4,11,12,[14][15][16][17] or retrospective design [1,2,7,8,13]. ...
Transgender people and their next-of-kin may request information on sexual orientation and preferred partners during hormonal affirming process. Although previous research on sexual orientation in transgender people is extensive, this literature may already be outdated and/or the methodology of studies assessing sexual orientation may fall short. This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Gender role and preferred partner in sexual fantasies, sexual orientation and gender of current sexual partner were assessed at baseline (initiation of HT) and every follow-up visit. Data from 469 transgender women (TW) and 433 transgender men (TM) were analyzed cross-sectionally and prospectively. At baseline, more than half reported having no partner (35% of TW, 47% of TM). After 12 months, more than half reported having a partner (59% of TW, 56% of TM), with no changes between one and three years of HT. The majority of TM preferred a female partner, TW preferred male and female partners. The sexual identity of their partner matched their sexual orientation in >80%. Sexual orientation did not change over time. We did not observe associations with serum levels of sex steroids or gender-affirming surgery (chest or genital surgery). Sexual orientation did not change during hormonal transition and was not associated with sex steroids or surgery. Also, preferences matched the partner’s sexual identity. We do not assume that changing serum levels of sex steroids is directly associated with changes in partner choice. The number of people with a current partner increased, possibly due to the indirect effects of gender-affirming care.
... The health-disease balance is influenced by multiple economic, cultural, social, environmental and genetic/ biological factors. 19 However, the multiplicity of determinants has not always been taken into account in the development of health-related policies. Therefore, a broad understanding of these determinants enables the development of appropriate interventions at different levels to minimise their impact on health outcomes. ...
... Therefore, a broad understanding of these determinants enables the development of appropriate interventions at different levels to minimise their impact on health outcomes. [19][20][21] It should be emphasised that the term 'SDOHs has received considerable attention as a foundational concept in the field of population and public health. 22 23 The WHO defines SDOH as the conditions or circumstances in which people are born, grow, live, work and age, 24 shaped by political, social and economic forces. ...
Introduction There is an urgent need for knowledge about the transgender population to inform the development of clinical protocols and training of health professionals on the unique issues affecting this population. Discussing transgender quality of life (QoL) through the lens of social determinants of health (SDOHs) would enable gender-specific health interventions. Here, we aimed to review the evidence on the QoL of transgender people from an SDOH perspective.
Methods and analysis A scoping review (ScR) protocol following the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews statement and guided by the Joanna Briggs Institute was used. MEDLINE/PubMed, Cochrane Library, Embase, PsycINFO, Web of Science, Scopus and registry sites such as ClinicalTrials.gov and WHO ICTRP will be searched. Additional sources to be searched include ProQuest Dissertations/Theses Global, British Library, Google Scholar and Preprints for Health Sciences-medRXiv. Two independent researchers will carry out the selection, data charting and data synthesis. No date restriction will be applied in this ScR. The search will be restricted to articles published in English, Spanish and Portuguese. The results will be presented in tables, narrative summaries and graphs and will be graded on the type of data presented and the results. The search strategy will be updated in April 2023. The expected completion date of this ScR is July 2023.
Ethics and dissemination This ScR protocol does not require ethical approval. Dissemination plans include peer-reviewed publications, conference presentations to be shared with experts in the field, and advisory groups to inform discussions on future research. It is hoped that our findings will be of interest to practitioners, researchers, stakeholders, public and private managers, and the general population concerned with this emerging public health issue.
Trial registration number osf.io/9ukz6.
... (e.g., nonreassigned trans men, reassigned trans women, and nonbinary people) than the DSM-5 edition, despite the underreported prevalence of GPPPD among individuals who do not identify as cisgender women (Abern, Maguire, Cook, & Carugno, 2022;Kerckhof et al., 2019;Paviani et al., 2022;Peixoto & Nobre, 2015b;Weyers et al., 2009). Although the authors of this manuscript understand that some people experiencing GPPPD symptoms may identify differently than with the gender and pronouns used in this piece, we decided to use gender-specific language when citing studies in the referenced publications that only included cisgender women and girls. ...
... Anxiety experiences, pain-fear cycle, and negative cognitions about the vagina and vaginal penetration could also be present beyond these populations, possibly modulating their penetration behavior. Sexual pain in trans men and trans women populations has been previously reported (Abern et al., 2022;Weyers et al., 2009). Some studies also suggest that the prevalence of vaginismus among cisgender, lesbian, and bisexual women could be as high as in cisgender, heterosexual women (Paviani et al., 2022;Peixoto and Nobre 2015b). ...
Vaginal penetration skills and behavior are considered different aspects of vaginal penetration. Nevertheless, these terms are used interchangeably in most genito-pelvic pain/penetration disorder (GPPPD) intervention studies, possibly impacting the assessment and selection of intervention outcomes. This is the first theoretical essay on the relevance of nonsexual vaginal penetration skills in understanding and treating GPPPD symptoms, mainly for patients with vaginismus complaints. We aim to provide avenues for further empirical research and new perspectives for assessing, preventing, and treating GPPPD symptoms. We highlight the conceptual boundaries, overlaps, and commonalities between vaginal penetration skills and vaginal penetration behavior and the implications for measuring and selecting GPPPD treatment outcomes. We then briefly explain vaginal penetration skills as a self-learning process and review the impact of fear, anxiety, and cognitive factors on GPPPD symptoms. We also outline the role of the nonsexual genital self-exploration skills in later penetration behavior and offer implications for a new GPPPD patient-centered treatment approach.
... Sexual activity varied gravely as 21-100% at 1-132 post-operative months during assessment ( Figure S6A Sexual function was assessed most often with the Female Sexual Function Index (FSFI). 16,17,76,78,80,81,84,25,47,[62][63][64]70,72,73 Dyspareunia was also reported by 5-point, 60 4-point, 59 3-point 68 and 2-point 17,25,70,72,73,76,79,83,43,44,48,55,58,61,64,66 self-made questionnaires and present after all but the Wharton-Sheares-George-technique ( Figure S6C/D). ...
... 17 Penile-inversion-vaginoplasty reported normalQoL 99 and partnered patients scored higher on vitality, social functioning and mental health. 63 Skin flap-GAS reported minimal depression by decreased sexual satisfaction. 62 Penoscrotal-vaginoplasty improved personality, lifestyle and self-esteem, 71,100 body and femineity satisfaction 100 and overall QoL 49,69,77 with low post-operative depression 71,100 and anxiety. ...
BACKGROUND: About 8,800-34,200 Gender Dysphoria (GD)- and 39,000-650,800 Mayer-Rokitansky-Küster-Hauser (MRKH)-patients undergo vaginoplasty annually. Various procedures are available, but comparisons are lacking. OBJECTIVES: To highlight information gaps, weaknesses and strengths of vaginoplasty techniques, to aid well-informed decision making by patients and healthcare professionals. SEARCH STRATEGY: A systematic search in Medline, EMBASE, Web of Science and Scopus until October 6, 2022, by PICO method and PROSPERO registration. SELECTION CRITERIA: Original retrospective studies on complete neovaginal creation in adult GD- and MRKH-patients and discussing anatomy, Quality of Life (QoL), satisfaction, sexual function, complications or complaints. DATA COLLECTION AND ANALYSIS: The 95% confidence intervals were calculated with DerSimonian and Laird random-effects. Methodological quality and potential bias were assessed. MAIN RESULTS: In total, 35 GD- and 16 MRKH-studies were eligible. Vagina length was 11.6 and 9.5 cm, respectively. In GD-patients, Hemorrhage (6%), prolapse (1%), gastrointestinal complications (1%), revisions (26%), pain (6%), regret (1%), fecal- (11%) and urinary issues (17%) were reported. Necrosis, stenosis, dyspareunia and revisions decreased, while duration increased with higher graft quantity. Intestinal-vaginoplasty reported 100% sensation. MRKH-patients reported more necrosis (17%) [McIndoe] and average satisfaction with sexual function (91%) and vaginal discharge (32%). They were more sexually active (86%) and had 100% anatomical satisfaction. Only Intestinal-vaginoplasty reported overall dissatisfaction. CONCLUSIONS: For GD- and MRKH-patients, multiple safe vaginoplasty techniques demonstrated acceptable outcomes, with significantly improved QoL and self-image. However, standardized validation tools are needed for well-informed decision-making. Direct technique comparisons per patient-cohort and exploration of tissue-engineering methods are critical for future surgical advancements.
... 79,87,90,95,98,99,101,102,117,118,120,126 Subjective arousal and desire were similarly experienced by a majority (79,1%) of postsurgical women. 79,90,108,123,135,142 Twenty-four studies discussed whether participants could attain orgasm. 79,87,88,90,91,95,96,[98][99][100][101]104,[106][107][108][109]113,120,121,123,125,126,128,134 A majority (about 70%) could achieve orgasm, 79,87,88,90,91,95,98−101,104,106 −109,113,117,120,121,123,125,126,128,134,143 whereas less than 10% could not or had not, 79,88,90,95,99,100,107,109,120,125,143 10% had not tried 79,90,99,125 , and another 10% chose 'not applicable.' 107 Five studies applied the Female Sexual Function Index (FSFI) and reported a mean orgasm domain score ranging between 2.82 −3.9 (scores CIS women without sexual problems 5.1 SD1.1). ...
... 100,120 Whether GAS brings about a change in sexual activities remains unclear, this data and associations between presurgical and postsurgical sexual a 142 ctivity were not provided. 92,96,107,109,128,147 Overall sexual satisfaction or satisfaction with sex life (77%), 79,84,90,92,94,107,108,113,119,135,142,143 satisfaction during sex, 80,120,123 and satisfaction with orgasmic function was present in a majority of postsurgical individuals. 87,91 Some studies reported on sexual dysfunction, where sexual wellbeing was mostly defined as a lack of sexual dysfunction. ...
Introduction
Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.
Aim
To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.
Methods
The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.
Main Outcomes Measure
The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.
Results
The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.
Conclusion
The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Müjde Özer, Sahaand Poor Toulabi, Alessandra D. Fisher, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2021;XX:XXXXXX.
... Almost all studies conducted non-validated questionnaires to assess regret due to the lack of standardized questionnaires available in this topic. 15,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Most of the questions evaluating regret used options such as, "yes," "sometimes," "no" or "all the time," "sometimes," "never," or "most certainly," "very likely," "maybe," "rather not," or "definitely not." 14,18,19,23,[27][28][29][30][31][32][33][34][35][36][37][38] Other studies used semi-structured interviews. ...
... 15,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Most of the questions evaluating regret used options such as, "yes," "sometimes," "no" or "all the time," "sometimes," "never," or "most certainly," "very likely," "maybe," "rather not," or "definitely not." 14,18,19,23,[27][28][29][30][31][32][33][34][35][36][37][38] Other studies used semi-structured interviews. 34,37,[39][40][41][42][43] However, in both circumstances, some studies provided further specific information on reasons for regret. ...
Background:
There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.
Methods:
A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.
Results:
A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.
Conclusions:
Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.
... Alternative techniques, such as peritoneal flaps, not only present increased complexity and higher costs compared to established techniques, they are also less extensively supported by evidence [5,6]. Given that surgery has shown to improve the quality of life and sexual health for transgender patients [7,8], it is crucial to continually evaluate common techniques to ensure a standardized approach that minimizes complications and maximizes patient satisfaction. The objective of this study was to assess the wound healing after gender affirming surgery, specifically focusing on the neovaginal cavity and it's lining with full thickness skin grafts (FTGs) from the scrotum. ...
In 1956, Dr. Georges Burou independently developed the anteriorly pedicled penile skin inversion vaginoplasty, a technique that would later become the gold standard
... Vaginoplasty, penectomy and phalloplasty can fall under genital interventions whereas rhinoplasty, jaw restructuring and brow lift could be exemplified as facial interventions (Weissler et al. 2018, Levy et al. 2019, Sayegh et al. 2019). It has been reported that after sex reassignment surgeries performed on individuals with gender dysphoria, individuals' physical, sexual and mental satisfaction increase (Weyers et al. 2009, Wierckx et al. 2011. When focusing on the physical, sexual and mental levels, individuals with gender dysphoria stated that their sexual life satisfaction (Sigurjónsson et al. 2016, van de Grift et al. 2019) and their quality of life increased (Paudrier et al. 2019) after their surgery. ...
Gender dysphoria refers to a feeling of awkwardness or discomfort in an anatomically compatible gender role and a desire to have a body of the opposite sex, as well as the negative emotion associated with marked incompatibility between the sex they have and their experienced or expressed gender. It is known that sex reassignment surgeries cause critical changes in the lives of individuals with gender dysphoria. For this reason, it is thought that it is important to follow up individuals before and after surgery. In this systematic review study, it is aimed to examine the effect of sex reassignment surgery for individuals with gender dysphoria on body and sexual satisfaction and quality of life. The framework of the research question was created on the basis of PICOS steps. PubMed, PsycARTICLES and ULAKBİM databases were used in the literature review. The review is based on studies that measure body and sexual satisfaction and quality of life before and after sex reassignment surgery. The study was created using the preferred reporting elements for the PRISMA Statement checklist. The publication year range of the articles evaluated within the framework of inclusion and exclusion criteria among the total articles reached is 2014-2022. The studies were examined in two separate groups: studies on body and sexual satisfaction and studies on quality of life. After examining the articles, it was concluded that sex reassignment surgery increases the body and sexual satisfaction of individuals as well as enhancing the quality of life.
... Analyzing the oMtFSFI scales, the lowest score was reached in the Sexual Pain Item in both groups. This finding is in accordance with other studies on transgender women who seem to suffer from specific difficulties, especially concerning lubrication and pain [14,15]. Painful sexual intercourse could be related to scarce lubrication and low neovagina compliance [16]. ...
Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.
... 2,4 GD is influenced by instinct and identity, with the most severe form of sexual identity disorder being trans-sexualism. 5 Despite more focus on transgender health research, some basic epidemiological and clinical issues have as of yet been resolved. 6 For example, in the case of this disorder or transsexual population prevalence, the reported estimates are strongly influenced by psychological differences and various definitions of transgender. ...
Gender dysphoria (GD) phenomenon is affected by a person’s instinct and identity. The aim of this present review study was to examine the causes, symptoms and treatment of GD. Various factors can be involved in the development of GD. And this disorder causes unpleasant physical, psychological and social complications for the individual. Therefore, therapeutic methods; such as, counseling, hormone therapy and transgender surgery can increase the mental health and quality of life for these individuals. The cause of GD can be attributed to a variety of biological, hormonal, psychological, social, family, and childhood abuse factors that are characterized by symptoms; such as, biological sex dissatisfaction, the desire to be the opposite sex, feelings and reactions of the opposite sex. These individuals are interested in transgender surgery with pharmaceutical surgical and other therapeutic methods to improve their quality of life.
... This nding is in accordance with other studies on transgender women who seem to suffer from speci c di culties, especially concerning lubrication and pain. (14,15) Painful sexual intercourse could be related to scarce lubrication and low neovagina compliance.(16) As the neovagina is not mucosa-coated and therefore endogenous secretions are reduced, the problem of lubrication is well known and foreseeable in these patients who should resort to arti cial lubrication. ...
Natal women with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in magnetic resonance imaging (MRI) measurements of neoclitoris volume and distance between the neoclitoris and the neo-vagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone gender affirming surgery (GAS), using two different techniques, the pubic neoclitoris technique (PNT) and the neourethroclitoroplasty according to Petrović (NCP), and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 oMtFs were operated with PNT and 11 with NCP. The PNT group presented a neo-clitoris mean volume of 1.04 cc vs 1.31 cc of the other group (p = 0.55). The mean distance between neo-clitoris and neovagina was 4.20 cm in the PNT group and 2.55 in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous used PNT (FSFI 25.8 vs 18.6 p = 0.08; oMtFSFI 23.36 vs 27.18 p > 0.20). According to pelvic MRI measurements, this study suggests a correlation between neoclitoris location and operated male to female sexual satisfaction.
... Ondanks de globaal positieve effecten van genderbevestigende interventies op seksueel functioneren, blijkt een grote variabiliteit in de individuele ervaringen (Klein & Gorzalka, 2009). Sommige trans vrouwen rapporteren moeilijkheden bij opwinding, lubricatie en pijn (Weyers et al., 2009). Trans mannen die preoperatief reeds problemen ervaren met seksueel functioneren, hebben een grotere kans om ook na chirurgie minder tevreden te zijn (Garcia, Christopher, De Luca, Spilotros, & Ralph, 2014). ...
Samenvatting Hoewel transgender personen steeds zichtbaarder worden in onze maatschappij en in de zorgverlening, blijkt er bitter weinig onderzoek uitgevoerd naar hun seksualiteitsbeleving. Oudere, vaak kleinschalige studies hebben het seksueel functioneren na een medische transitie vaak verengd tot het al dan niet kunnen beleven van een orgasme. Het doel van de huidige studie is om de prevalentie van een breed spectrum aan seksuele functiestoornissen en disfuncties (met last) in kaart te brengen bij een multicenter cohorte van transgender personen tijdens/na hun transitie. De pre-valentie wordt eveneens gerapporteerd naargelang de verschillende mogelijke medische trajecten die deelnemers (hebben) doorlopen. 518 transgender personen (307 die zich vooral vrouwelijk, 211 die zich vooral mannelijk identificeren) hebben een online follow-up vragenlijst ingevuld in het kader van het European Network for the Investigation of Gender Incon-gruence Initiative (ENIGI). Alle participanten hadden hun eerste afspraak vier à zes jaar voor het onderzoek in een genderteam in Gent, Amsterdam of Hamburg. Zowel trans vrouwen als trans mannen ervaren het vaakst 'last van problemen bij het initiëren van seks' (26% en 32%) en 'last van problemen met het bereiken van een orgasme' (29% en 15%). Trans vrouwen ervaren na vaginoplas-tiek minder vaak opwindingsproblemen, seksuele aversie en een laag seksueel verlangen, in vergelijking met trans vrouwen die enkel hormonale therapie innemen. Vergeleken met trans mannen die geen medische stappen zetten, ervaren trans mannen na een falloplastiek minder vaak problemen met seksuele aversie maar vaker pijn na het vrijen. Seksuele disfuncties bij transgender personen vier tot zes jaar na hun eerste contact met transgenderzorg zijn frequent. Medische stappen kunnen helpen en zelfs essentieel zijn voor de ontwikkeling van een gezonde seksualiteit. Toch blijkt een significante groep van transgender personen (nog) last te hebben van seksuele disfuncties na genitale chirurgie. Seksuologische nazorg in deze groep verdient dus zeker aandacht.
Introduction:
Gender-affirmation surgeries are a rapidly growing set of procedures in the field of plastic surgery. This study is novel in that a thorough analysis has not been performed quantifying, identifying, and recognizing the reasons and factors associated with regret in a largely US population.
Methods:
A systematic review of several databases was conducted. After compiling the articles, we extracted study characteristics. From the data set, weighted proportions were generated and analyzed.
Results:
A total of 24 articles were included in this study, with a population size of 3662 patients. A total of 3673 procedures were conducted in the United States, 514 in European nations, 97 in Asian nations, which included only Thailand, and 19 in South American nations, which included only Brazil. The pooled prevalence of regret was 1.94%. The prevalence of transfeminine regret was 4.0% while the prevalence of transmasculine regret was 0.8%.
Conclusions:
Both transfeminine and transmasculine patients had significantly lower rates of regret in the United States when compared with the rest of the world. Our study largely excluded facial gender-affirming surgeries as most of its articles did not fall into our inclusion search criteria. To our knowledge, this is the most recent review performed on the topic of regret among gender-affirming surgery patients with an emphasis on a US cohort. This analysis can help shed light on better ways to enhance patient selection and surgical experience.
Introduction:
Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.
Aims:
Our aim was to evaluate transgender women's sexual function and lubrication after vaginoplasty by penile skin inversion.
Methods:
We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.
Results:
The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.
Conclusion:
This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion's GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.
Background:
Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.
Aims:
This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.
Method:
Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.
Results:
After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.
Conclusions:
Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.
Sexuality changes associated with the medical transition in transgender women are not well known; the few studies present discrepancies in labeling their sexual orientation and controlling surgery conditions. This study aimed to evaluate the self-reported sexual response to audiovisual sexual stimulation protocol in androsexual transgender women on hormone replacement therapy. This study also evaluated their sexual functioning to support the empirical protocol. Participated androsexual transgender women with (n = 16) and without hormone therapy (n = 15) in a non-sex reassignment surgery condition. Androsexual cisgender men (n = 25) and women (n = 24) also were included as contrast groups. All participants were assessed with the Short Form of the Changes in Sexual Functioning Questionnaire; then watched video clips with neutral and sexual content and informed their sexual responses through two self-report scales adapted from the Film Scale. The results showed trans women with hormone therapy, compared to trans women without treatment, experienced a less selective sexual response to sexual stimuli. Also, they registered the lowest scores for every sexual functioning except for pleasure. In conclusion, transgender women on hormone therapy without sex reassignment surgery showed fluidity in their self-reported sexual response and reduced sexual functioning.
Introduction
Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining.
Objectives
The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV.
Methods
We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum.
Results
We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented.
Conclusions
None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.
IMPORTANCE Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.
OBJECTIVE To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.
EVIDENCE REVIEW In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).
FINDINGS In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.
CONCLUSIONS AND RELEVANCE In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.
This comprehensive and authoritative book is written by over seventy of the foremost experts working with the care of transgender and gender expansive patients for gynecologists and those working in neighboring disciplines. Among medical specialists, understanding of the complex reality and medical needs of transgender and gender diverse individuals is still limited. This book offers the opportunity to understand transgynecology in a way that is inclusive and up-to-date, with insights into liaison with specialties such as urology, dermatology, sexuology, physiotherapy amongst others. By contextualising transgender/gender diverse medicine before covering specific issues such as imaging, benign disorders, fertility maintenance, medico-legal concerns and uterine transplantation, this book is truly unique. Aimed at gynecologists, obstetricians, general practitioners, counsellors and all those who work with transgender, non-binary, or gender diverse patients, this book prepares the reader for the prerequisites and subtleties of transgynecology.
This comprehensive and authoritative book is written by over seventy of the foremost experts working with the care of transgender and gender expansive patients for gynecologists and those working in neighboring disciplines. Among medical specialists, understanding of the complex reality and medical needs of transgender and gender diverse individuals is still limited. This book offers the opportunity to understand transgynecology in a way that is inclusive and up-to-date, with insights into liaison with specialties such as urology, dermatology, sexuology, physiotherapy amongst others. By contextualising transgender/gender diverse medicine before covering specific issues such as imaging, benign disorders, fertility maintenance, medico-legal concerns and uterine transplantation, this book is truly unique. Aimed at gynecologists, obstetricians, general practitioners, counsellors and all those who work with transgender, non-binary, or gender diverse patients, this book prepares the reader for the prerequisites and subtleties of transgynecology.
Everyone has sexual rights and is entitled to enjoy sex, regardless of gender identity or expression. It is therefore encouraging to witness a recent growth in research on sexuality in transgender individuals. We provide a short overview of extant research on sex and relationships in this population and argue that current research has mostly been conducted from a medical and functional approach; there is a strong focus on negative experiences and prevention; and there is a lack of data regarding psychological and socio-relational variables. Furthermore, many studies have been conducted in a cis- and hetero-normative setting and have methodological shortcomings such as applying questionnaires that have not been validated in a transgender population. We encourage researchers to expand their focus to positive variables such as sexual pleasure and (in accordance with the biopsychosocial model) investigate subjective experiences and relationship variables when studying sexuality in transgender individuals.
Background
Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions.
Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS.
Results
After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. “Attainment of orgasm”, “Neovaginal stenosis”, and “Neovaginal depth/length” were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general.
Discussion
The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.
Introduction: With the increase in the prevalence of gender dysphoria, and the increase in people's desire to sex reassignment strategies, the increasing effects of these therapies on quality of life are mainly observed. Understanding these effects enable the treatment community to empowers, transgender people to improve their quality of life. Methods: This study is a narrative review study that searches using these keywords: Quality of life (QOL)-Gender reassignment surgery (GRS)-Sex reassignment surgery (SRS)-Male to female (MTF) In databases: Science Direct, PubMed, Scopus, Google Scholar, Magiran, SID Done without time limit. Results: In this study, based on the mentioned keywords, 50 articles were obtained. After implementing inclusion and exclusion criteria, 13 articles remained. Based on the findings, some studies indicate that in long-term studies after surgery, the quality of life of transgender people is the same as ordinary people, and in some areas, the quality of life is lower than ordinary people. Conclusions: Findings of the studies in this study, based on the surgical technique used, the time of examination of transgender people after surgery and the control group is variable. In general, the results indicate an increase in the quality of life of transgender people in the areas of interpersonal and social relationships and a decrease in the physical area despite patients' satisfaction with surgery. The results of changes in the field of psychology are variable and need further investigation in this area.
Background
The term transgender (TRANS) may be used for people whose gender identity differs from the one assigned at birth. A large part of this population segment faces social (lack of social support, discrimination, rejection, transphobia) and psychological (anxiety, depression) challenges. These factors, in turn, may negatively impact the quality of life (QoL) of these individuals. In this context, the aim of this study is to identify the factors associated with QoL of TRANS people.Methods
Cross-sectional study with non-probability sample, conducted with TRANS and cisgender (CIS) adults living in a southeastern Brazilian state. The research questionnaire was accessed electronically and comprised sociodemographic, health, and QoL information. QoL was assessed through the Short-Form 6 dimensions (SF-6D) instrument. Multivariable linear regression analysis (forward method) was applied to determine the influence of independent variables on QoL (outcome variable). All variables that presented p < 0.10 in the bivariate analyses were included. The analyses were carried out in the Statistical Package for the Social Sciences (SPSS)® software, version 22.0, with a significance level of 5%.ResultsThe sample included 65 TRANS individuals and 78 CIS individuals. The CIS group showed a predominance of people with higher education (p = 0.002) and higher income (p = 0.000) when compared with the TRANS sample. TRANS participants had worse QoL score (p = 0.014) and the same was observed when QoL was assessed by all dimensions (p ≤ 0.05). In addition, the place of residence and the report of recent prejudice remained associated with QoL even after adjusting for age, gender identity, occupation, and follow-up by a health professional (p < 0.05).Conclusion
The TRANS population showed worse QoL when compared with the CIS population. Moreover, living in the state’s capital and having suffered episodes of prejudice were the factors remain statistically associated with the QoL among TRANS individuals.
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8.
Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.
Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings.
Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health.
Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
Background: The term transgender (TRANS) may be used for people whose gender identity differs from the one assigned at birth. A large part of this population segment faces social (lack of social support, discrimination, rejection, transphobia) and psychological (anxiety, depression) challenges. These factors, in turn, may negatively impact the quality of life (QoL) of these individuals. The aim of this study is to identify factors that influence the quality of life of transgender people when compared with cisgender people (CIS).
Methods: Cross-sectional case-control study with non-probability sample, conducted with transgender and cisgender adults living in a southeastern Brazilian state. The research questionnaire was accessed electronically and comprised sociodemographic, health, and QoL information. QoL was assessed through the Short-Form 6 dimensions (SF-6D) instrument. Multivariate logistic regression was used to verify the participation of the independent variables in QoL. Odds ratio (OR) values and their respective confidence intervals (CI) were estimated. The analyses were carried out in the SPSS® software, version 22.0, with a significance level of 5%.
Results: The sample included 65 transgender and 78 cisgender individuals. The cisgender group showed a predominance of people with higher education (p=0.002) and higher income (p=0.000) when compared with the transgender group. Transgender participants had worse QoL score (p=0.014) and the same was observed when QoL was assessed by dimension (p≤0.05). In addition, having an income between 1 to 3 minimum wages (MW) reduced by 94.6% (OR=0.054, CI=0.004 – 0.707, p=0.026) the chances of having better QoL, when compared with those with income higher than 3 MW. Living in the state’s capital reduced the chances of having better QoL by 96.2% (OR=0.038, CI=0.004 - 0.387, p=0.006) when compared with those living in the countryside.
Conclusion: The transgender population showed worse QoL when compared with the cisgender population, with income and place of residence being the factors that influenced this indicator.
Background:
Following gender-affirming penile inversion vaginoplasty or vulvoplasty, patients may seek vulvar revision procedures for a variety of common aesthetic and functional concerns. These indications for revision and accompanying techniques are not well-described in the literature.
Methods:
Patients who underwent vulvar revision surgery at the authors' institution were identified, and patient demographics, surgical indications, operative details, and complications were described. Common complaints requiring external genital revision were sorted into four categories: clitoral, labial, introital, and urethral.
Results:
Thirty-five patients with a history of vaginoplasty underwent vulvar revision between May of 2017 and December of 2019. The mean age at surgical correction was 38.9 years. Ten patients (28.6 percent) had undergone prior secondary procedures (range, 1 to 3). Mean follow-up after revision surgery was 10.7 ± 8.7 months (range, 0 to 30.6 months). The majority of patients underwent concurrent revisions in multiple "categories". Labial aesthetic concerns were most common (n = 27, 77.1 percent), followed by clitoral (n = 20, 57.1 percent), urologic (n = 17, 48.6 percent), and introital complaints (n = 12, 34.3 percent). Twelve patients (34.3 percent) had canal stenosis requiring concurrent robot-assisted canal revision with peritoneal flaps. Complications included labial abscess (n = 1) and deep vein thrombosis (n = 1). Three patients (8.6 percent) underwent subsequent external genital revisions. Management approaches and surgical techniques for each of these common revision categories are provided.
Conclusion:
As more individuals seek vaginoplasty and vulvoplasty, surgeons must be prepared to address a range of common aesthetic and functional complaints requiring vulvar revision.
Clinical question/level of evidence:
Therapeutic, IV.
Purpose of review
Analyze the utilization of patient-centered outcomes research (PCOR) methods in the literature containing patient-reported outcome measures (PROMs) for gender affirming surgery (GAS).
Recent findings
Multiple recent systematic reviews have demonstrated that the majority of PROMs used to assess GAS are either ad hoc measures never intended for validation or are neither specific to nor validated for the population or intervention being studied. This review builds on prior works with inclusion of articles related to facial and vocal GAS and presentation of PCOR recommendations and best practices based on review findings.
Summary
A systematic review of records in PubMed and Scopus using search terms related to GAS and PROMs yielded 652 total articles of which 158 were included in the final analysis. Just over half of included articles utilized validated PROMs, though only 38% of those articles utilized a PROM that had been validated in the TGNB population. Thirteen (8.2%) studies detailed the involvement of patients in PROM development as subjects, and only 4 (2.5%) utilized PCOR methods that engaged TGNB individuals as research stakeholders. Utilization of PCOR methods in research evaluating outcomes of GAS is exceedingly rare despite increasing use of PROMs over time. To collect data that are both accurate and meaningful to the TGNB population, PCOR methods must be adopted within this field.
Background: While the importance of sexual pleasure for physical and mental health becomes increasingly evident, research on sexual pleasure in transgender persons is lacking. Recently, the first version of the Amsterdam Sexual Pleasure Index (ASPI Vol. 0.1) was validated in cisgender persons. This questionnaire aims to assess the tendency to experience sexual pleasure independent of gender, sexual orientation or anatomy.
Aim: The aims of this study were threefold. First, to perform exploratory scale validation analyses of the ASPI in transgender persons. Secondly, to compare transgender sexual pleasure scores to reference data in cisgender persons. Finally, to identify factors that are associated with sexual pleasure.
Methods: In a follow-up study conducted within the European Network for the Investigation of Gender Incongruence (ENIGI), online questionnaires were distributed to persons who had a first clinical contact at gender clinics in Amsterdam, Ghent or Hamburg four to six years earlier. Internal consistency of the ASPI was assessed by calculating McDonald’s omega (ωt). ASPI scores were compared to scores from the cisgender population using a one sample t-test, and linear regressions were conducted to study associations with clinical characteristics, psychological wellbeing, body satisfaction and self-reported happiness.
Results: In total, 325 persons filled out the ASPI. The ASPI showed excellent internal consistency (ωt, all: 0.97; transfeminine: 0.97, transmasculine: 0.97). Compared to data from cisgender persons, transgender participants had significantly lower total ASPI scores (i.e., lower sexual pleasure; transgender vs. cisgender, mean(SD): 4.13(0.94) vs. 4.71(0.61)). Lower age, current happiness and genital body satisfaction were associated with a higher tendency to experience sexual pleasure.
Conclusion & discussion: The ASPI can be used to assess the tendency to experience sexual pleasure and associated factors in transgender persons. Future studies are needed to understand interplaying biopsychosocial factors that promote sexual pleasure and hence transgender sexual health and wellbeing.
Introduction:
Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Sexual health post-vaginoplasty is an important aspect of quality of life that can have a significant impact on overall well-being.
Objectives:
The objective of this review is to provide a summary of the literature on the sexual outcomes of transgender females post-vaginoplasty and identify treatment strategies for those experiencing sexual dysfunction.
Methods:
A literature review was conducted with a focus on sexual health outcomes in transgender females post-vaginoplasty as well as treatment options for sexual dysfunction.
Results:
Penile inversion vaginoplasty with or without free skin grafts or local tissue flaps and intestinal vaginoplasty are the options available to patients interested in transfeminine genital reconstructive surgery with a neovagina. Sexual satisfaction post-vaginoplasty is high regardless of the vaginoplasty technique, however up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance. Hormone treatment, pelvic floor physical therapy, sex therapy, and sex surrogacy are treatment options for patients with sexual dysfunctions.
Conclusion:
Patient reported outcome measures appropriately validated for this patient population are necessary to better understand sexual function outcomes, sexual dysfunction and treatment options for post-vaginoplasty patients. Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.
Background:
To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited.
Methods:
A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion.
Results:
Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low.
Conclusions:
Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.
Background
Few studies have investigated how physical, mental and sexual function are associated with each other in operated transgender women (oTW).
Aim
To provide information on the physical, mental and sexual health of oTW in comparison with a group of cisgender women (cisW).
Methods
An age-matched control study was carried out, recruiting 125 oTW in 7 national referral centers and 80 volunteer women. Beck Depression Inventory Primary Care (BDI-PC), General Health Survey (SF-36), Female Sexual Function Index (FSFI) and operated Male to Female Sexual Function Index (oMtFSI) questionnaires were web-based administered. Data included: age, area of origin, educational level, sexual orientation, years since surgery and hormone therapy.
Outcomes
T-test was applied to inspect mean score differences between oTW and cisW, in mental, sexual and physical health; simple correlations and multiple regression analysis revealed how mental, sexual and physical health were concurrently associated in the two groups
Results
Response rate 60% (52% oTW, 71% cisW). oTW mean age 38.5 years (SD = 9.3), cisW 37.7 years (SD = 11.5). Both cisW and oTW reported average values in the range of mental, physical and sexual health. Statistical comparisons revealed no significant group differences in mental and physical health. oTW who referred a worse sexual function also reported worse overall mental well-being and higher levels of depressive symptoms. FSFI scores were negatively associated with years since surgery, but not with age. Multiple regression analysis showed that FSFI Pain accounted for a significant unique variance proportion of risk of depression in oTW. FSFI Sexual Pain was the strongest estimator of inter-individual differences in BDI-PC among oTW (P < .01).
Clinical Implications
No significant differences in the levels of depressive symptoms, physical and mental well- being were found in oTW and cis-W. The relation between depressive symptoms and sexual function in oTW is stronger than in cisW, and sexual pain substantially predicts risk of depression in oTW.
Strengths & Limitations
The evaluation of outcomes using validated questionnaires and the relatively large sample size. The convenience control group reported mental, physical and sexual health levels within the range of Italian normative data. Since this is a cross-sectional study, we must be careful in drawing conclusions from our results.
Conclusions
Sexual pain and lubrication difficulties are the main causes of worse sexual function in oTW, highlighting the importance of perioperative counseling to make surgical expectations realistic and to educate to a proper neovagina management.
Vedovo F, Di Blas L, Aretusi F, et al. Physical, Mental and Sexual Health Among Transgender Women. A comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network. J Sex Med Rev 2021;xx:xxx–xxx.
Despite the population of transgender individuals in the United States doubling from 2011 to 2016, this population is one of the most understudied in counseling and related disciplines. Of the available research, the associations between gender congruence, defined as an individual’s body matching their gender identity, and well-being have been examined, particularly demonstrating positive associations between gender congruence and overall life satisfaction. However, a dearth of research remains on the possible associations between gender congruence and indices of relationship well-being—particularly sexual satisfaction—and possible moderating effects of the internal negative feelings regarding one’s identity (internalized transphobia). To address these gaps in the literature, this study gathered self-report data from 165 binary transgender men. While there was not an effect of gender congruence on sexual satisfaction, internalized transphobia was found to moderate this association; individuals who reported high internalized transphobia and high gender congruence reported the highest sexual satisfaction. Results of this study highlight the existing literature on the negative associations between internalized transphobia and well-being for transgender individuals. Implications for counselors are discussed, including advocacy efforts and implementation of techniques to facilitate growth and resilience to help transgender clients navigate the negative effects of internalized transphobia.
Introduction
Feminizing gender-affirming surgery (GAS) has been an increasingly used procedure in the United States and worldwide for transgender women with gender dysphoria. Studies on patient-reported quality of life outcomes in those undergoing GAS remain limited.
Objective
To provide recent insights from the literature on sexual metrics in the evaluation of the transgender women.
Methods
We queried PubMed to identify studies assessing sexual function metrics in those undergoing feminizing GAS.
Results
There is no single validated method to establish preoperative and postoperative sexual function. Assessment currently remains institutionally dependent. Evaluation can involve questionnaires including but not limited to the International Index of Erectile Function, the Female Sexual Function Index, and the Male to Female Sexual Function Index.
Conclusion
In this literature review, we discuss considerations for the evaluation of sexual function for patients considering feminizing GAS with vaginoplasty. Although we describe some of the major tools currently used in evaluating sexual function in this patient population, a need for a validated method remains.
Syed JS, Honig S. Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index. Sex Med Rev 2020;XX:XXX–XXX.
Although mastectomy could lead to a decrease in sexual performance among patients, only a handful of studies focused on the psychological and sexual behavioral aspects after the surgery. Research on post-mastectomy sexuality has focused mainly on female subjects but barely on lesbian, gay, bisexual, transgender, queer (LGBTQ), and male patients. This narrative review aimed to explore the importance of sexuality after mastectomy from a LGBTQ perspective. Each sexual minority group has been addressed individually. In general, sexual and gender minority breast cancer (BC) patients undergoing bilateral mastectomy expect a complex treatment plan in terms of physical and emotional outcomes. Bilateral mastectomy or top surgery for masculinization reasons was reported to be the most popular procedure among transmen, which resulted in a significant improvement in the quality of life. Heterosexual and lesbian female patients are willing to undergo mastectomy after repeated lumpectomies or to avoid radiation, despite potential post-operative somatic and quality-of-life complications. Transwomen would seek gender-affirming surgery to improve physical satisfaction and psychological well-being. There is not enough evidence for non-oncological reasons and consequences of mastectomy in gay men and cisgender heterosexual men. Establishing the awareness of the sexuality impact of mastectomy will allow the implementation of tailored perioperative psychological care.
Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment. Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.
To establish the benefit of sex reassignment surgery (SRS) for persons with a
gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. From 107 Dutch- speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and
were personally interviewed by researchers, who had not been involved in the subjects’ initial assessment or treatment. On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. Noneof them showed any regrets about the SRS. A homosexual orientation, a younger age when applying
for SRS, and an attractive physical appearance were positive prognostic factors.
Conclusion. — While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.
The purpose of this study was to examine body image and relationship satisfaction in male and female college students. A total of 101 males and 187 females, primarily Caucasian and middle class, completed a questionnaire designed to measure satisfaction with specific body parts, overall body characteristics, and relationship status. These variables were examined in light of gender and body size differences. Results indicated that women, especially those under or above average weight, were more dissatisfied with their appearance than were men, whereas men were more dissatisfied with their relationships and sex lives than were women. In addition, those body parts with which each gender was most dissatisfied were consistent with the body parts emphasized through ideal images. These results are discussed in relation to gender role dynamics and societal pressures.
This paper explores the relationship between marital status and mortality for both men and women. It is shown that, controlling for age, the married have lower mortality rates than the single, the widowed, or the divorced and that the differences between the married and unmarried statuses are much greater for men than for women. It is argued that these relationships can, at least in part, be attributed to the characteristics of the marital statuses in our society, for: (1) precisely the same pattern is found in studies of psychlogical wellbeing and mental illness; (2) the evidence from specific types of mortality indicates that this pattern is characteristic primarily of types of mortality in which one's psychological state may greatly affect one's life chances; (3) a role explanation can account for the way the pattern varies with changes in age; and (4) it appears that the alternative explanation, namely, that the relationship are due to selective process, does not account for most of the variation in r...
This article presents the development of a brief, self-report measure of female sexual function. Initial face validity testing of questionnaire items, identified by an expert panel, was followed by a study aimed at further refining the questionnaire. It was administered to 131 normal controls and 128 age-matched subjects with female sexual arousal disorder (FSAD) at five research centers. Based on clinical interpretations of a principal components analysis, a 6-domain structure was identified, which included desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. Overall test-retest reliability coefficients were high for each of the individual domains (r = 0.79 to 0.86) and a high degree of internal consistency was observed (Cronbach's alpha values of 0.82 and higher) Good construct validity was demonstrated by highly significant mean difference scores between the FSAD and control groups for each of the domains (p < or = 0.001). Additionally, divergent validity with a scale of marital satisfaction was observed. These results support the reliability and psychometric (as well as clinical) validity of the Female Sexual Function Index (FSFI) in the assessment of key dimensions of female sexual function in clinical and nonclinical samples. Our findings also suggest important gender differences in the patterning of female sexual function in comparison with similar questionnaire studies in males.
The Female Sexual Functioning Index (FSFI; Rosen et al., 2000) is a self-report measure of sexual functioning that has been validated on a clinically diagnosed sample of women with female sexual arousal disorder. The present investigation extended the validation of the FSFI to include women with a primary clinical diagnosis of female orgasmic disorder (FOD; n = 71) or hypoactive sexual desire disorder (HSDD; n = 44). Internal consistency and divergent validity of the FSFI were within the acceptable range for these populations of women. Significant differences between women with FOD and controls and between women with HSDD and controls were noted for each of the FSFI domain and total scores.
The Female Sexual Function Index (FSFI) is a brief multidimensional scale for assessing sexual function in women. The scale has received initial psychometric evaluation, including studies of reliability, convergent validity, and discriminant validity (Meston, 2003; Rosen et al., 2000). The present study was designed to crossvalidate the FSFI in several samples of women with mixed sexual dysfunctions (N = 568) and to develop diagnostic cut-off scores for potential classification of women's sexual dysfunction. Some of these samples were drawn from our previous validation studies (N = 414), and some were added for purposes of the present study (N = 154). The combined data set consisted of multiple samples of women with sexual dysfunction diagnoses (N = 307), including female sexual arousal disorder (FSAD), hypoactive sexual desire disorder (HSDD), female sexual orgasm disorder (FSOD), dyspareunia/vaginismus (pain), and multiple sexual dysfunctions, in addition to a large sample of nondysfunctional controls (n = 261). We conducted analyses on the individual and combined samples, including replicating the original factor structure using principal components analysis with varimax rotation. We assessed Cronbach's alpha (internal reliability) and interdomain correlations and tested discriminant validity by means of a MANOVA (multivariate analysis of variance; dysfunction diagnosis x FSFI domain), with Bonferroni-corrected post hoc comparisons. We developed diagnostic cut off scores by means of standard receiver operating characteristics-curves and the CART (Classification and Regression Trees) procedure. Principal components analysis replicated the original five-factor structure, including desire/arousal, lubrication, orgasm, pain, and satisfaction. We found the internal reliability for the total FSFI and six domain scores to be good to excellent, with Cronbach alpha's >0.9 for the combined sample and above 0.8 for the sexually dysfunctional and nondysfunctional samples, independently. Discriminant validity testing confirmed the ability of both total and domain scores to differentiate between functional and nondysfunctional women. On the basis of sensitivity and specificity analyses and the CART procedure, we found an FSFI total score of 26.55 to be the optimal cut score for differentiating women with and without sexual dysfunction. On the basis of this cut-off we found 70.7% of women with sexual dysfunction and 88.1% of the sexually functional women in the cross-validation sample to be correctly classified. Addition of the lubrication score in the model resulted in slightly improved specificity (from .707 to .772) at a slight cost of sensitivity (from .881 to .854) for identifying women without sexual dysfunction. We discuss the results in terms of potential strengths and weaknesses of the FSFI, as well in terms of further clinical and research implications.
A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male) post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome. Relatively few and minor morbidities were observed in our group of patients, and they were mostly reversible with appropriate treatment. A trend toward more general health problems in male-to-females was seen, possibly explained by older age and smoking habits. Although all male-to-females, treated with estrogens continuously, had total testosterone levels within the normal female range because of estrogen effects on sex hormone binding globulin, only 32.1% reached normal free testosterone levels. After SRS, the transsexual person's expectations were met at an emotional and social level, but less so at the physical and sexual level even though a large number of transsexuals (80%) reported improvement of their sexuality. The female-to-males masturbated significantly more frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement, and more easily reaching orgasm was seen in the female-to-male group. The majority of participants reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported the secretion of a vaginal fluid during sexual excitation, originating from the Cowper's glands, left in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more realized (compared to those without), but pain during intercourse was more often reported.
The aim of the present study was to investigate the psychometric properties of the Female Sexual Function Index (FSFI; Rosen et al., 2000) and the Female Sexual Distress Scale (FSDS; Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002) within a Dutch population of approximately 350 women with and without sexual complaints. The main conclusions of this study are that the multidimensional structure of the FSFI and the unidimensional structure of the FSDS are fairly well replicated in a Dutch sample. The amount of variance explained by confirmatory and exploratory factor analyses was good. Internal consistency and stability of the FSFI and its subscales and the FSDS are satisfactory to good, and the subscales are reasonably stable across demographic variables. The discriminant validity and the ability of the scales to predict the presence or absence of sexual complaints was excellent. The convergent and divergent construct validity of the FSFI and the FSDS was good. These results support the reliability and psychometric validity of the FSFI and the FSDS in the assessment of dimensions of female sexual functioning and sexual distress in clinical and nonclinical samples.
An unknown proportion of transsexual women (defined as post-operative male-to-female transsexuals on oestrogen replacement) experience hypoactive sexual desire disorder (HSDD). It has been suggested that the absence of ovarian androgen production together with oestrogen treatment-related increase in sex hormone-binding globulin (SHBG) levels could be leading to HSDD, due to low levels of biologically available testosterone. This study wishes to document the HSDD prevalence among transsexual women and the possible association to androgen levels.
Cross-sectional study.
Transsexual women (n=62) and a control group of ovulating women (n=30) participated in this study. Questionnaires measuring sexual desire (sexual desire inventory) and relationship and sexual satisfaction (Maudsley Marital Questionnaire) were completed. Serum levels of total testosterone, LH and SHBG were measured in blood samples obtained at random in transsexual women and in the early follicular phase in ovulating women.
The transsexual group had lower levels of total and calculated free testosterone (both P<0.001) than the ovulating women. HSDD was reported in 34% of the transsexual and 23% of the ovulating women (P=0.30). Both groups reported similar levels of sexual desire (P=0.97). For transsexual women, no significant correlation was found between sexual desire and total (P=0.64) or free testosterone (P=0.82). In ovulating women, these correlations were significant (P=0.006, resp. P=0.003).
HSDD is reported in one-third of transsexual women. This prevalence is not substantially different from controls, despite markedly lower (free) testosterone levels, which argues against a major role of testosterone in this specific group.
Blanchard's (J Nerv Ment Dis 177:616-623, 1989) theory of autogynephilia suggests that male-to-female transsexuals can be categorized into different types based on their sexuality. Little previous research has compared the sexuality of male-to-female transsexuals to biological females. The present study examined 15 aspects of sexuality among a non-clinical sample of 234 transsexuals and 127 biological females, using either an online or a paper questionnaire. The results showed that, overall, transsexuals tended to place more importance on partner's physical attractiveness and reported higher scores on Blanchard's Core Autogynephilia Scale than biological females. In addition, transsexuals classified as autogynephilic scored significantly higher on Attraction to Feminine Males, Core Autogynephilia, Autogynephilic Interpersonal Fantasy, Fetishism, Preference for Younger Partners, Interest in Uncommitted Sex, Importance of Partner Physical Attractiveness, and Attraction to Transgender Fiction than other transsexuals and biological females. In accordance with Blanchard's theory, autogynephilia measures were positively correlated to Sexual Attraction to Females among transsexuals. In contrast to Blanchard's theory, however, those transsexuals classified as autogynephilic scored higher on average on Sexual Attraction to Males than those classified as non-autogynephilic, and no transsexuals classified as autogynephilic reported asexuality.
syn. “categorized” VAS → see Likert scale, visual Analogue cale.
syn. linear analogue self assessment (LASA); scale with finite boundaries at 0 and 100 mm (end of the scale) for the conventional
10 cm line presentation; in general such scales are more reliable and sensitive but also more difficult to explain to patients
than e.g. a Numerical Pain Scale (NPS, discontinuous 0 to 10 data collection between the same boundaries) ordinal scales;
an “anchored” or “categorized” VAS has the addition of one or more intermediate marks positioned along the line with reference
terms assigned to each mark to help subjects to identify the locations between the ends of the scale; → see also scale, quality of life scale.
Although the greater longevity of married people as compared with unmarried persons has been demonstrated repeatedly, there have been very few studies of a comparative nature. We use log-linear rate models to analyze marital-status-specific death rates for a large number of developed countries. The results indicate that divorced persons, especially divorced men, have the highest death rates among the unmarried groups of the respective genders; the excess mortality of unmarried persons relative to the married has been generally increasing over the past two to three decades; and divorced and widowed persons in their twenties and thirties have particularly high risks of dying, relative to married persons of the same age. In addition, the analysis suggests that a selection process is operating with regard to single and divorced persons: the smaller the proportion of persons who never marry or who are divorced, the higher the resulting death rates.
The primary objectives of this research were to translate, validate, and generate normative data on the SF-36 Health Survey for use among Dutch-speaking residents of the Netherlands. Translation of the SF-36 into Dutch followed the stepwise, iterative procedures developed by the IQOLA Project. Following extensive pilot testing, the SF-36 was administered to: (1) a random sample of adult residents of Amsterdam (n = 4172); (2) a random, nationwide sample of adults (n = 1742); (3) a sample of migraine sufferers (n = 423); and (4) a sample of cancer patients undergoing active anti-neoplastic treatment (n = 485). Data quality across the four studies was consistently high. The rates of missing data ranged from 1% to 5% at the item level, and from 1.2% to 2.6% at the scale level. Multitrait scaling analysis confirmed the hypothesized scale structure of the SF-36 and associated scale scoring in all four samples. Cronbach's alpha coefficients surpassed the 0.70 criterion for group comparisons in all but one case (the Social Functioning scale in the cancer sample), with a mean alpha coefficient across all scales and samples of 0.84. Known-group comparisons yielded consistent support for the validity of the SF-36. In the two community samples, statistically significant differences in SF-36 mean scale scores were observed as a function of age, gender, and the prevalence of chronic health conditions. In the migraine and cancer samples, mean SF-36 scale scores varied significantly as a function of various indicators of disease severity. The SF-36 profiles for the two community samples were highly similar. The cancer sample yielded the lowest SF-36 scores, with the migraine sample holding an intermediate position. On-going studies will generate data on the responsiveness of the SF-36 to within-group changes in health over time. Efforts are underway to translate and validate the questionnaire for use among ethnic minority groups in the Netherlands.
Simulations are of particular advantage in research studies where large samples are necessary to achieve statistical power and the information must be collected under uniform conditions in order to aid interpretation. In the study reported below, simulation was achieved through the use of medical photography accompanied by case studies of the same patients. All information was collected on the same day. The purpose of the study was to determine the validity of the three pressure ulcer risk assessment scales most commonly used in clinical nursing practice in the UK. Each clinical nurse assessed the same four patients using three risk assessment scales and a visual analogue scale designed to capture their own clinical judgement. External validity was assessed by a panel of tissue viability experts who provided independent ratings. Data were obtained from 236 clinical nurses, yielding 941 risk assessments. Experience with this approach to data collection suggests that it requires careful planning. This should include measures to ensure that the simulated information is valid and that all data collectors have been adequately trained and are able to motivate the nurses participating in the study. Providing consideration is given to these issues, the use of simulation can help to collect data that would be difficult to obtain by more conventional means. It is also important to recognize that clinical decisions are de-contextualized in simulations because they are reduced to verbal and visual summaries. The decision to use simulations should thus be taken only if this is acknowledged.
This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.
The Belgian medical world has acknowledged the diagnosis of transsexualism and accepted Sex Reassignment Surgery (SRS) as one of the steps in the treatment of choice since 1985. This prevalence and demographic study analyses data on all Belgian individuals who have undergone SRS since that year.
All (188) plastic surgeons as well as all gender teams (Antwerp, Bruges, Ghent, and Liège) in Belgium were sent demographic questionnaires to be completed for each of their transsexual patients.
The results show an overall prevalence of 1:12,900 for male-to-female and 1:33,800 for female-to-male transsexuals in Belgium. In Wallonia (the French-speaking region of Belgium) the prevalence is significantly lower than in Flanders (the Dutch-speaking region) and in Brussels (the bilingual capital region). In the total Belgian population the male/female sex ratio is 2.43:1, again with a substantial difference between Wallonia on the one hand and Flanders on the other.
While in Flanders and in Brussels the prevalence is comparable to that in other Western European countries, in Wallonia it is markedly lower. Transsexualism in Wallonia appears to be socially less acceptable: persons suffering from gender dysphoria in that part of Belgium encounter more problems accessing gender clinics and receiving treatment.
Tactile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery. Since November 1993 until April 2003, a total of 105 phalloplasties with the radial forearm free flap and 127 vaginoclitoridoplasties with the inverted penoscrotal skin flap and the dorsal glans pedicled flap have been performed at Ghent University Hospital. The specific surgical tricks used to preserve genital and tactile sensitivity are presented. In phalloplasty, the dorsal hood of the clitoris is incorporated into the neoscrotum; the clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft; and the medial and lateral antebrachial nerves are coapted to the inguinal nerve and to one of the 2 dorsal nerves of the clitoris. In vaginoplasty, the clitoris is reconstructed from a part of the glans penis inclusive of a part of the corona, the inner side of the prepuce is used to reconstruct the labia minora, and the penile shaft is inverted to line the vaginal cavity.
A long-term sensitivity evaluation (performed by the Semmes-Weinstein monofilament and the Vibration tests) of 27 reconstructed phalli and 30 clitorises has been performed.
The average pressure and vibratory thresholds values for the phallus tip were, respectively, 11.1 g/mm and 3 microm. These values have been compared with the ones of the forearm (donor site). The average pressure and vibratory thresholds values for the clitoris were, respectively, 11.1 g/mm and 0.5 microm. These values have been compared with the ones of the normal male glans, taken from the literature. We also asked the examined patients if they experienced orgasm after surgery, during any sexual practice (ie, we considered only patients who attempted to have orgasm): all female-to-male and 85% of the male-to-female patients reported orgasm.
With our techniques, the reconstructed genitalia obtain tactile and erogenous sensitivity. To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential. To obtain orgasm after a vaginoplasty, the reconstruction of the clitoris from the neurovascular pedicled glans flap is essential.
The objectives of this descriptive study were (1) to characterize sexual functioning of lesbian women, (2) to validate the use of a modified version of the Female Sexual Function Index (FSFI) with lesbians, and (3) to evaluate correlates of sexual functioning in lesbians.
The current study was a cross-sectional examination of correlates of sexual functioning in lesbian women. Participants were 350 self-identified lesbians, aged > or = 18 (mean age 35.5 +/- 11.4 years), who completed an anonymous, Internet-based survey. The survey instrument included measures of sociodemographics, sexual functioning, psychological symptoms, and relationship characteristics.
Adequate reliability was demonstrated for all domains of the FSFI, as well as for the total score. Reliability coefficients were comparable to those obtained with the normative sample of heterosexual women. In univariate analyses, age, psychological symptoms, and relationship characteristics were related to many dimensions of sexual functioning in lesbians. Older age was associated with less desire for sexual activity, greater difficulty with lubrication during sexual activity, and lower scores for overall sexual functioning. Psychological symptoms were associated with decreased arousal, pleasure (i.e., orgasm), satisfaction, overall sexual functioning, and increased difficulty with lubrication during sexual activity. Higher relationship satisfaction was associated with increased arousal during sexual activity, less difficulty with lubrication during sexual activity, greater pleasure/orgasm, greater sexual satisfaction, and better overall sexual functioning. Psychological symptoms and relationship characteristics were consistently associated with aspects of sexual functioning in multivariate models.
Age, psychological symptoms, and relationship characteristics were related to some but not all indices of female sexual functioning. Findings provide a solid empirical basis upon which to explore other determinants of sexual functioning in lesbians.
There are men in the Western world who are voluntarily castrated and are not male-to-female transsexuals.
We surveyed members of this group to understand their responses to androgen deprivation (AD) and how their experiences matched their expectations of AD.
We posted a questionnaire on the Eunuch Archive (http://www.eunuch.org) that received responses from 92 voluntarily orchiectomized males who identified as eunuchs. Data from this questionnaire were supplemented with interviews with 19 of the eunuchs.
Participants completed questionnaire items regarding: (i) the side effects they expected and experienced; (ii) their current physical and psychological condition; (iii) their level of regret; (iv) what they appreciated most about their castrated status; and (v) who performed their orchiectomies.
The most appreciated aspect of castration was the sense of control over sexual urges and appetite (52%). The major side effects experienced were loss of libido (66%), hot flashes (63%), and genital shrinkage (55%). The population had high self-rated sociability, and mental and physical health. Although there was an insignificant reduction in depression after castration, the overall level of self-reported obsessive-compulsive disorders decreased significantly (P < 0.01). Twenty-two percent of the population reported a change in sexual orientation. Many respondents (60%) took supplemental hormone treatments to counteract the side effects of AD. The use of both supplemental testosterone and high-dose estrogen correlated with a significant increase in self-reported sexual desire and activity above the agonadal level (P < 0.001). The majority of the castrations (53%) were not performed by medical professionals.
The medical community needs to be aware of men at risk of unsafe castrations in order to provide them with more information on the side effects of AD and access to safe orchiectomies.
The principal goal of surgical techniques for male to female gender reassignment is to provide aesthetic and functional external female genitalia.
To present a new surgical technique which permits a safer and faster construction of the neoclitoris and the configuration of a natural-looking mons veneris.
The neoclitoris sensitivity was reported by the patients themselves and checked during the follow-up medical examination. In order to define the degree of the patients' satisfaction with the mons veneris appearance, we used a simple questionnaire.
From April 2004 to February 2007, 26 patients underwent male to female sex reassignment surgery. The new technique was applied in the last 15 cases. A strip of albuginea, with the penile dorsal neurovascular bundle and a little portion of glans, was prepared, bended on itself, and fixed in the suprapubic area in order to create the mons veneris and the neoclitoris.
This technique was easy to perform, permitting the safe preservation of the penile dorsal neurovascular bundle and a reduction in the operation time of 30-45 minutes. No major complications occurred in this series. Neoclitoris trophism and sensitivity were preserved in all patients. At follow-up, ranging from 3 to 20 months, the genital appearance was satisfactory, and the neoclitoris was pleasantly sensitive after a short period of hypersensitivity. Moreover, seven patients reported some form of climax during intercourse. The technical outcome was successful in all cases. The patients' satisfaction was extremely high for the neoclitoris sensitivity (present in all patients) and high in 11 out of 15 for the appearance of the mons veneris.
The neoclitoris and mons veneris configuration with a strip of albuginea is a new, safe, and time-saving surgical procedure. The cosmetic appearance and function of transsexual female external genitalia appears to be improved by using this technique.
Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment.
To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia.
Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively.
Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated.
Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10% do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision.
Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.
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