Sexual Inactivity Among Transfeminine Persons: A Canadian Respondent-Driven Sampling Survey

Using focus groups to inform a peer health navigator service for people who are transgender and gender diverse in Saskatchewan, Canada

BACKGROUND

This study investigated healthcare access and quality for people who are transgender and gender-diverse (PTGD) in Saskatchewan (SK), Canada, to inform a larger project that was piloting two peer health navigators for PTGD.

METHODS

Two online focus groups were held. Nineteen participants were recruited to represent a broad range in age, gender and location in SK. Transcripts of the focus groups were analyzed using a thematic approach.

RESULTS

The core theme that was identified was participants' desire for culturally safe healthcare. This core theme had two component themes: (1) systemic healthcare factors and (2) individual healthcare provider (HCP) factors. The healthcare system primarily acted as a barrier to culturally safe healthcare. HCPs could be either barriers or facilitators of culturally safe care; however, negative experiences outweighed positive ones.

CONCLUSIONS

PTGD in SK face discrimination, with delays and barriers to care at all levels of the healthcare system. Peer health navigators can address some of these discrepancies; however, greater support is required for PTGD to be able to access culturally safe healthcare.

PATIENT OR PUBLIC CONTRIBUTION

People with lived experience/PTGD were involved in all stages of this project. They were included on the team as community researchers and co-developed the research project, conducted the focus groups, participated in the analyses and are co-authors. As well, both navigators and all the participants in the focus groups were also PTGD.

HIV prevalence among a retrospective clinical cohort of transgender women in Canada: Results of the Montreal-Toronto Trans study, collected 2018-2019

BACKGROUND

HIV prevalence data among transgender (trans) people are not routinely collected in national estimates, including Canada, contributing to gender-based inequities. We examined HIV prevalence and associated factors among trans women in clinical care in two large Canadian cities.

METHODS

Retrospective chart data of trans women aged 16+ were collected from six family medicine and/or HIV clinics in Montreal and Toronto, Canada, 2018-2019. Multinomial logistic regression was used to analyze factors associated with documented HIV positive or missing HIV status relative to documented HIV negative status.

RESULTS

Among 1,059 patients, 7.5% were HIV positive, 54.4% HIV negative, and 38.1% missing HIV data. Findings showed lower odds of being HIV positive for those <30 years or 30-50 years (vs. >50 years); higher odds were seen for those: of Black race/ethnicity (vs. white), landed immigrant or refugee (vs. Canadian citizen), receiving social assistance (vs. not), and whom ever having used recreational drugs.

CONCLUSIONS

Albeit high, the prevalence of HIV was lower than expected based on global estimates. Missing HIV status data suggest gaps in testing. Findings highlight socioeconomic and clinical realities among trans women in Canada and inform future HIV prevention and support.

Heterosexual Men's Visual Attention to Nude Images Depicting Cisgender Males, Cisgender Females, and Gynandromorphs

Gynandromorphophilia refers to sexual attraction and arousal to feminine males, who may or may not have breasts, and who retain their penises. Previous research has suggested that some capacity for gynandromorphophilia may characterize males who are gynephilic (i.e., sexually attracted and aroused to adult females). This study examined Canadian cisgender gynephilic men's (n = 65) visual attention and subjective ratings of sexual arousal when presented with nude images of feminine males with, and without breasts, masculine males, and feminine females. Visual attention was assessed using an infrared eye-tracker. Subjective arousal to feminine females was highest, followed by subjective arousal to feminine males with breasts, feminine males without breasts, and masculine males. However, subjective arousal to feminine males without breasts and to masculine males did not differ significantly. The patterning of visual attention to images of females was unique, in that participants were equally likely to attend first to the face, chest or genitals. These areas also elicited relatively greater fixation durations and counts. Although participants fixated onto the chests of feminine males with breasts for longer durations than those of masculine males, most of the differences between feminine males, with and without breasts, were non-significant. These results suggest that female sex-based traits play a more primary role in gynephilic men's sexual arousal than feminine gender-based traits.

Feminizing hormone therapy in a Canadian cohort of transgender women with and without HIV

BACKGROUND

Potential bidirectional drug-drug interactions between feminizing hormone therapy (FHT) and antiretroviral therapy (ART) are of concern for trans women with HIV and their healthcare providers. This study aimed to characterize patterns of FHT and ART among trans women with HIV and to compare serum hormone levels to trans women without HIV.

METHODS

Charts of trans women were reviewed at seven HIV primary care or endocrinology clinics in Toronto and Montreal from 2018 to 2019. ART regimens, FHT use, serum estradiol, and serum testosterone levels were compared on the basis of HIV status (positive, negative, missing/unknown).

RESULTS

Of 1495 trans women, there were 86 trans women with HIV, of whom 79 (91.8%) were on ART. ART regimens were most commonly integrase inhibitor-based (67.4%), many boosted with ritonavir or cobicistat (45.3%). Fewer (71.8%) trans women with HIV were prescribed FHT, compared to those without HIV (88.4%) and those with missing/unknown status (90.2%, p < 0.001). Among trans women on FHT with recorded serum estradiol (n = 1153), there was no statistical difference in serum estradiol between those with HIV (median: 203 pmol/L, IQR: 95.5, 417.5) and those with negative (200 mol/L [113, 407]) or missing/unknown HIV status (227 pmol/L [127.5, 384.5) (p = 0.633). Serum testosterone concentrations were also similar between groups.

CONCLUSIONS

In this cohort, trans women with HIV were prescribed FHT less often than trans women with negative or unknown HIV status. There was no difference in serum estradiol or testosterone levels of trans women on FHT regardless of HIV status, providing reassurance regarding potential drug-drug interactions between FHT and ART.

Heterosexual men's pupillary responses to stimuli depicting cisgender males, cisgender females, and gynandromorphs

Gynandromorphophilia is the sexual attraction and arousal to feminine individuals assigned male at birth, who may or may not have breasts, and who retain their penises. Previous research has suggested that some capacity for gynandromorphophilia may characterize all males who are gynephilic (i.e., sexually attracted and aroused to adult cisgender females). This study examined Canadian cisgender gynephilic men's (n = 65) pupillary responses and subjective ratings of sexual arousal when presented with nude images of cisgender males, cisgender females, and gynandromorphs with, and without, breasts. Subjective arousal to cisgender females was highest, followed by subjective arousal to gynandromorphs with breasts, gynandromorphs without breasts and cisgender males. However, subjective arousal to gynandromorphs without breasts and to cisgender males did not differ significantly. Participants' pupils dilated more to images of cisgender females than to all other stimulus categories. Participants' pupils dilated more to gynandromorphs with breasts than to cisgender males, but pupillary response to gynandromorphs without breasts and cisgender males did not differ significantly. If the capacity for gynandromorphophilic attraction is a cross-culturally invariant aspect of male gynephilia, then these data suggest that this capacity may only extend to gynandromorphs with breasts and not gynandromorphs without breasts.

Men's Sexual Interest in Feminine Trans Individuals across Cultures

Feminine trans individuals (i.e., individuals who were assigned male at birth but who have a feminine gender presentation and identity) are present in many cultures. In some cultures, these individuals identify as (trans) women. Many of these individuals undergo medical treatments to feminize their bodies (e.g., breast augmentation), but most do not undergo vaginoplasties and therefore have penises. In many non-Western cultures, feminine trans individuals identify as a non-binary gender (i.e., neither man, nor woman). Many of these individuals do not surgically augment their bodies. Across cultures, some men express sexual interest in feminine trans individuals. Are manifestations of sexual interest in feminine trans individuals consistent across Western and non-Western cultural settings? Our review suggests that, across cultures, most of these men are also sexually attracted to cisgender individuals. Many are sexually attracted to cisgender women or to cisgender members of both sexes. A small subset is sexually attracted to cisgender men. Men who are sexually interested in feminine trans individuals commonly report being primarily insertive during anal sex. Additionally, they tend to report that their sexual interest in these individuals is motivated by attraction to femininity or to the combination female- and male-typical characteristics.

Sexual Function of Transgender Women After Gender Affirming Surgery: A Mini Review

BACKGROUND

A transgender person has a gender identity opposite to the sex assigned at birth. Transgender individuals may have altered sexual function (SF) due to psychosocial factors related to body image distortion, shame, and dissatisfaction with genital appearance, and these conditions can increase the risk of sexual dysfunction. This study aimed to characterize the SF of trans-women after gender affirming surgery.

METHODS

We reviewed the Pubmed database for studies published between January 2008 to December 2021.

RESULTS

17 studies were included, 4 were cross-sectional studies, 1 prospective study, 4 prospective cohort studies, five retrospective studies. The instruments used to evaluate the SF were Female Sexual Index (FSFI), semi-structured questionnaires, patients' opinion, Sexual Desire Inventory (SDI), Maudsley Marital Questionnaire-S, WHOQOL-100. The results of our review indicate there is weak evidence that gender affirming surgery improves the SF of trans-women.

CONCLUSION

We thus recommend that future studies use questionnaires that are validated for the assessment of the SF of trans-women to better determine the impact of genital surgery in this population. This article is protected by copyright. All rights reserved.

Resisting Trans Medicalization: Body Satisfaction and Social Contextual Factors as Predictors of Sexual Experiences among Trans Feminine and Nonbinary Individuals

Past research has constructed a medicalized model of trans women's sexuality, where trans women are believed to be hyposexual and distressed by their bodies pre-transition, and are cured of their sexual dysfunction as a result of gender affirmative medical procedures. The current study engaged a community sample (N = 169) of trans feminine and nonbinary individuals assigned male at birth (TFNB) to investigate predictors of sexual experiences after addressing methodological biases of prior studies, including body satisfaction (using a modified Body Image Scale) and social contextual factors. Hierarchical regressions were conducted to test the hypothesis that after accounting for demographic variables and social contextual aspects (i.e., body satisfaction, social dysphoria, and fetishization), medical transition (i.e., hormone therapy) would not significantly predict five outcomes of sexual experience (i.e., receptive penetration, insertive penetration, importance of sex, sexual pleasure, and sexual intimacy). Across all models, medical transition was not a significant predictor of sexual experiences; however, sexual orientation, age, body satisfaction, and experiences of fetishization were frequent predictors. Results suggest that the sexual experiences of TFNB individuals do not align with the medicalized model and that demographic and contextual factors play an important role in the sexual outcomes for this population.

Reproductive health risks and clinician practices with gender diverse adolescents and young adults

BACKGROUND

Reproductive health counseling is essential for adolescents and young adults (AYAs). Transgender and gender diverse (TGD) AYAs would benefit from tailored counseling given concerns about iatrogenic infertility and sexual dysfunction, and high rates of interpersonal violence, unplanned pregnancies and sexually transmitted infections, yet there are multiple obstacles to providing this care at the patient/family and clinician levels.

OBJECTIVES

This narrative review summarizes the literature on reproductive health considerations for TGD AYAs, current practices, and clinician barriers and facilitators to providing culturally sensitive reproductive care for TGD AYAs. Specific areas of focus include reproductive health goals, risks, and access barriers; clinician knowledge practices and challenges; and strategies for improving counseling practices.

MATERIALS AND METHODS

PubMed, Google Scholar, Medline, Web of Science, and PsycInfo databases were searched using the following terms: transgender, non-binary, gender expansive, gender non-conforming, reproductive health, sexual health, fertility, family planning/building, contraception, sexual dysfunction; gender-affirming hormones/surgery, clinician, physician or provider knowledge and attitudes; counseling.

RESULTS

Many TGD AYAs desire biological children and improved sexual experiences. TGD AYAs may experience infertility and sexual dysfunction associated with transition; have disproportionate HIV/STI risk; experience high rates of interpersonal/sexual violence and trauma; and encounter barriers to accessing competent medical care. Clinicians lack knowledge about reproductive health needs of TGD AYAs; inconsistently discuss family building options; perceive counseling challenges; and desire more training in this area.

DISCUSSION

Enriched communication training for medical/mental health clinicians is necessary to provide a skilled workforce for TGD AYAs. Web-based reproductive health training with other populations (eg oncology) demonstrates efficacy for improving communication skills and confidence in counseling, CONCLUSION: This review highlights barriers to adequate reproductive care encountered by TGD AYAs, exacerbated in underserved minority youth. Dedicated training for providers, and programs increasing access are important goals for improving care. The need for additional research is also emphasized.

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

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.

Associations between Childhood Sexual Abuse and Sexual Well-being in Adulthood: A Systematic Literature Review

Child sexual abuse (CSA) tends to occur in close relationships and involves sexual acts and betrayal. Thus, it is thought to affect sexual well-being in adulthood more so than any other form of childhood trauma. Research conducted over the last decade resulted in an impressive diversity of evidence reporting that CSA may be related to greater sexual dysfunction and lower sexual satisfaction as an adult, but also to higher levels of sexual compulsivity and sexual risk behaviors. Some studies also found no significant association between CSA and adult sexual well-being. Faced with these mixed results, understanding how CSA may affect sexual well-being in adulthood remains challenging for clinicians and researchers. The aim of this comprehensive literature review was to synthesize the empirical studies published in the last five years documenting the associations between CSA and several indicators of sexual well-being in adults excluding risky sexual behaviors. The literature search yielded 18 eligible studies which mainly examined five domains of sexual outcomes of CSA: sexual function, sexual satisfaction, sex-related cognitions, sexual behaviors and affective components of sexuality. Findings suggest that CSA is not unanimously related to all domains of sexual well-being, but rather, that associations are largely a function of the presence of other comorbidities or nature of the sample. Moreover, men are still significantly underrepresented in reviewed studies. Implications of the findings will be discussed in light of their relevance for clinicians and for researchers about gaps in current literature need to be filled.

Sexual Satisfaction in Trans Masculine and Nonbinary Individuals: A Qualitative Investigation

The present study investigated the ways trans masculine and nonbinary individuals describe aspects of their sexual satisfaction. Sexual satisfaction refers to an individual's subjective evaluation of their sexual experiences, and is influenced by relational, contextual, and personal experiences. Prior research with sexual satisfaction among trans individuals utilized quantitative measures, restricting the ability for respondents to describe trans-related aspects. Further, the pervasive focus on the effects of medical transition on binary trans individuals' experiences in prior research limits our understanding of those who do not desire a medical transition or live outside of the gender binary. Participants represented a community sample of 358 trans masculine and nonbinary individuals who responded to the question: "In what ways are you satisfied with your sex life?" Thematic analysis revealed eight overarching themes that represented two categories: universal and trans-related. Discussion focuses on the ways in which clinicians and researchers can utilize the current findings to improve the sexual satisfaction of trans masculine and nonbinary individuals.

Canadian undergraduate men's visual attention to cisgender women, cisgender men, and feminine trans individuals

Some heterosexual men express sexual interest in feminine trans individuals with penises. It is possible that this interest arises from a tendency for heterosexual men to be sexually responsive to gender in addition to sex. We compared the self-reported sexual attraction and visual attention patterns of Canadian undergraduate heterosexual men (N = 51) and gay men (N = 20) to nude images of feminine trans individuals with penises, cisgender men, and cisgender women. Heterosexual men were most attracted to cisgender women and fixated on them the longest. However, they were more attracted to feminine trans individuals with penises than to cisgender men. They also biased their attention to feminine trans individuals with penises over cisgender men. This pattern was unique to heterosexual men. Gay men were most attracted to cisgender men and allocated the most visual attention to them. They responded to feminine trans individuals and cisgender women in a relatively similar manner. As such, heterosexual men appear to be responsive to sex and gender, which may account for sexual interest in feminine trans individuals among some heterosexual men.