ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"

Sexual health in transgender and gender diverse people

PURPOSE OF REVIEW

Sexual health and sexual function are critical to the wellbeing of cisgender, transgender, and gender diverse populations. To date, there has been only limited patient-focused evaluation of sexual function in transgender and gender diverse patients at several stages in their gender-affirming medical care. There remains a need to better understand the impact of gender affirming medical and surgical therapy on sexual health, and to develop evidence-based treatments to address sexual dysfunction when present.

RECENT FINDINGS

The impact of gender-affirming hormone therapy on sexual health is complex and evolves over time on treatment. Despite high incidences of complications, major genital gender-affirming surgeries such as vulvovaginoplasty and penile implant placement after phalloplasty yield high patient satisfaction. While treatments to preserve or restore erections and to improve vaginal lubrication have been trialed based upon literature in cisgender populations, there remains minimal evidence to guide medical treatment of sexual dysfunction ranging from erectile dysfunction to dyspareunia.

SUMMARY

There is a continued need for ongoing efforts to develop patient-reported outcome measures and rigorous investigation of sexual health preservation and restoration treatments in transgender and gender diverse populations.

The Effect of Obesity on Vaginoplasty Outcomes

BACKGROUND

Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques.

METHODS

A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected.

RESULTS

A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001).

CONCLUSIONS

Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

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.