Sexual Preferences and Partnerships of Transgender Persons Mid- or Post-Transition

A Content and Readability Analysis of Genitourinary and Sexual Health-Related Patient-Reported Outcome Measures in Gender-Affirming Care

OBJECTIVES

To the evaluate the readability and comprehensiveness of genitourinary and sexual health-related patient-reported outcomes (PROMs) used in gender-affirming care.

METHODS

Common PROMs that measure genitourinary and sexual health-related outcomes in gender-affirming care literature were identified from six recent systematic reviews. Readability analysis was completed at the level of individual items and full scale using established readability assessment tool, including Flesch Kincaid Grade Level (FKGL), Gunning Fog Score (GF), Coleman Liau Index (CLI), and Simple Measure of Gobbledygook (SMOG) Index. The concepts measured by the PROMs were evaluated for comprehensiveness.

RESULTS

25 PROMs were included, of which 12 assessed genitourinary outcomes and 13 assessed sexual health outcomes. A total of seven genitourinary domains and eight sexual health domains were identified during concept mapping. Readability analysis showed a median PROM grade level of 9.0 and 9.5 in genitourinary and sexual PROMs, respectively. The Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction v2.0 had the lowest median reading grade level of 5.7, and the Female Sexual Function Index has the highest median reading grade level of 13.9. No single PROM was found to be comprehensive. Multiple PROMs contained double-barreled items or used outdated terminology.

CONCLUSIONS

Most PROMs used in the genital gender-affirming literature failed to meet the readability recommendations for patient-facing material and were culturally unfit for use in transgender and gender-diverse individuals. None of the PROMs were found to be comprehensive for evaluating outcomes of gender-affirming care. Validated gender-affirming care-specific PROMs that are comprehensible, comprehensive, and relevant are urgently needed.

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.

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 orientation in transgender individuals: results from the longitudinal ENIGI study

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.

Fertility Options for the Transgender and Gender Nonbinary Patient

Comprehensive care for transgender and gender nonbinary patients has been a priority established by the World Professional Association for Transgender Health. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition can affect gonadal function, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. In this review, we outline the impacts of gender-affirming treatments on fertility potential and discuss the counseling and the treatment approach for fertility preservation and/or family building in transgender and gender nonbinary individuals.