The assessment of sexual wellbeing in treatment-seeking transgender individuals: a systematic review of the medical literature

Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery?

INTRODUCTION

For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used.

OBJECTIVE

This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population.

METHODS

Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX.

RESULTS

Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors.

CONCLUSION

Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

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.

Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review

INTRODUCTION

The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention.

OBJECTIVE

Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries.

METHOD

We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy.

RESULTS

We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes.

CONCLUSION

There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;XX:XXX-XXX.