Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction

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.

"Society Isn't Designed for Us to Win": Trauma and Sexual Healthcare Experiences Among Transgender Women in the Southeastern United States

Transgender women (TGW) are disproportionately affected by sexually transmitted infections (STIs). Experienced trauma threatens TGW's commitment to sexual healthcare. Trauma-informed approaches to sexual healthcare can improve engagement. This study aimed to characterize the trauma experienced by TGW in the Southeastern US, especially related to sexual health. TGW completed in-depth individual interviews guided by the Modified Social Ecological Model (MSEM) and Minority Stress framework. Interviews explored the nature of trauma, sexual health, and their intersection in TGW's lives, and a thematic analysis was performed. Between August 2022 and January 2023, 13 TGW enrolled (69% Black, 31% White). Mental illness was common (77%). Five participants (38%) were HIV+, and seven (54%) reported lifetime STI history. Themes reflected societal (barriers to healthcare, anti-transgender legislation), community (misgendering/deadnaming), network (limited support), and individual (dysphoria, sex work, fear for physical safety, stigma, mental health conditions, race) stressors. The physical/sexual violence and resilience themes pervaded all stressor levels. Medical mistrust was exacerbated by past traumatic experiences within sexual healthcare settings. Resilience and transgender representation in healthcare settings were protective. Various experienced traumas and their cumulative effects were pervasive in the daily lives of TGW. Development of targeted interventions to improve sexual health engagement of TGW must optimize personal strengths and provide holistic support.

Pharmacotherapy of Hypoactive Sexual Desire Disorder in Premenopausal Women

OBJECTIVE

This review aims to provide an overview of pharmacologic management for hypoactive sexual desire disorder (HSDD) in premenopausal women, with a focus on available agents.

DATA SOURCES

Through a literature search on PubMed, Google Scholar, and ClinicalTrials.gov from 1999 to 2024, studies were selected using the following MeSH search terms: hypoactive sexual desire disorder, premenopause, pharmacologic management, flibanserin, bremelanotide, buspirone, bupropion, and testosterone, excluding those involving postmenopausal women or other sexual disorders. Product monographs were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies or those conducted in humans were considered.

DATA SYNTHESIS

Hypoactive sexual desire disorder, characterized by a lack of motivation for sexual activity, predominantly affects women aged 45 years and older. Treatment involves a multimodal approach, including nonpharmacologic interventions such as psychotherapy and lifestyle adjustments, alongside pharmacologic options. Although bupropion and buspirone may be considered off-label treatments, flibanserin and bremelanotide are the sole medications approved by the Food and Drug Administration for generalized acquired HSDD in premenopausal women. However, caution is advised due to their limited efficacy, potential adverse effects, and transparency issues in reporting.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Hypoactive sexual desire disorder, while not life-threatening, significantly impacts well-being and relationships. Pharmacotherapy, including options like flibanserin and bremelanotide, is essential within a multidisciplinary approach. Validated tools and objective measures inform tailored premenopausal HSDD care plans and aid in striking a balance between potential risks and adverse effects while maximizing meaningful clinical benefits, including for transgender individuals.

CONCLUSIONS

Clinicians must discern important distinctions between flibanserin, bremelanotide, and other agents when managing premenopausal HSDD. Further research with the most suitable clinical endpoints and consideration of patient factors are crucial before widespread adoption of flibanserin and bremelanotide. Pharmacists are encouraged to embrace this opportunity to provide premenopausal HSDD care in ambulatory and community practice settings.

Preventive and Sexual Health in LGBTQ+ Older Adults

Sexual health is an important but often overlooked health concern of LGBTQ + older adults. Multiple factors influence sexual health including intersecting identities; adverse life events; coping mechanisms; and psychological, social, and physical health domains. Thus, the use of a culturally competent and comprehensive person-centered approach to sexual health is warranted. In this review, we discuss approaches to engaging LGBTQ + older adults to ensure they are able to achieve their sexual health priorities and prevent new human immunodeficiency virus infections. We also discuss doxycycline postexposure prophylaxis to prevent other sexually transmitted infections and the impact of chemsex.

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.

Trans, gender non-conforming and non-binary individuals' perspectives on experienced sexuality during medical transition

How gender-affirming treatments (GAT) influence the experienced sexuality of transgender, gender non-conforming, and non-binary (TGNB) individuals remains understudied. The aim of this research was to discern factors contributing to a satisfying sexual experience for TGNB individuals, explore the influence of GAT on this process, and identify potential areas for improvement in transition-related care. We conducted interviews with 21 participants at various stages of GAT. Participants identified as (trans)men (12), (trans)women (7), transgender (1), and genderqueer/gender non-conforming/non-binary (1). Thematic analysis was conducted and involved multiple researchers. Three themes emerged from the data: (i) the role sexuality plays in understanding and affirming one's gender, (ii) satisfaction with one's physical sexual function, (iii) positive communication about sex and its subsequent influence on relationships. Many participants associated satisfaction with physical sexual function with positive sexual experiences, often describing GAT-induced changes in sexual arousal, drive, and orgasm as gender-affirming. Emotional connection and affirmation from sexual partners also contributed to positive experiences. The ability to (re-)define what sex meant individually increased satisfaction levels. Moreover, understanding and affirming one's gender identity were closely related to a satisfactory sex life. This study offers valuable insights for healthcare providers working with TGNB individuals during GAT, particularly concerning their sexuality.

Does Genital Self-image Correspond with Sexual Health before and after Vaginoplasty?

Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty.

Methods

A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction.

Results

A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort.

Conclusions

Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.