Transmen's Experienced Sexuality and Genital Gender-Affirming Surgery: Findings From a Clinical Follow-Up Study

Functional outcomes after supra-pubic phalloplasty

BACKGROUND

A thorough evaluation of the functional outcomes resulting from supra-pubic phalloplasty (SPP) assessing different aspects of the phalloplasty technique has not been reported.

PURPOSE OF THE STUDY

To report the outcomes on sexuality, urinary function, satisfaction, and regrets following SPP performed at our centre.

SUBJECTS STUDIED

All consecutive patients who underwent the three-step technique of pre-expanded SPP between 2007 and 2018 and who had at least one year of follow-up.

METHODS

Questionnaires were sent to analyse several domains of penile reconstruction: sexuality, urinary function, perceived sensitivity, and satisfaction. Sexuality was evaluated using the Self-Esteem And Relationship (SEAR) questionnaire. Urinary function was analysed based on the urethral stricture surgery patient-reported outcome measures (USS-PROM) questionnaire.

MAIN FINDINGS

A total of 77 patients were included, 92.2% were transmen, and 33 (42.9%) responded to the questionnaire. Urethral lengthening (UL) was performed in 28 (36.4%) procedures, and erectile prosthesis was implanted in 42 patients (54.5%). The mean length of the neophallus was 15.3 cm (standard deviation [SD] 2.6), and the mean girth was 11.8 cm (SD 2.1). The mean total SEAR score (/100) was 73.8 (SD 26.7). The mean six-item lower urinary tract symptom score (/24) was 8.4 (SD 4.6). The standing position was the usual voiding position reported by 11 patients (73.3%).

CONCLUSION

Pre-expanded SPP is a robust technique that can achieve substantial flap dimensions, leading to high satisfaction with neophallus appearance and the choice of the phalloplasty technique. Overall, sexual outcomes are mostly favourable. UL is feasible and effective in terms of voiding in a standing position.

Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine

BACKGROUND

Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited.

AIM

To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth.

METHODS

There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model.

OUTCOMES

We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW).

RESULTS

TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models.

CLINICAL IMPLICATIONS

When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions.

CONCLUSION

Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

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.

Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional

SUMMARY

Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

Associations between Genital Self-Image and Individuals' Own and Perceived Partner Sexual Satisfaction

Negative genital self-image is linked with lower sexual satisfaction, but no research has examined its association with perceptions of partners' sexual satisfaction. In two studies (N = 475, N = 234), we examined links between genital self-image and own and individuals' perceived partner sexual satisfaction. In the second study, we tested whether a mindfulness intervention moderated these associations. In both studies, more negative genital self-image was significantly associated with individuals' lower own and perceived partner sexual satisfaction concurrently and over a two-week period. Mindfulness intervention exposure did not moderate associations. Findings support negative genital self-image as a risk factor for sexual dissatisfaction.

Ethical considerations regarding penis transplantation surgery in transgender men-an empirical ethics study

Background

The ongoing quest to surgically create the (nearly) ideal neophallus in transgender men has led to the continuous development of transgender medicine and the proposed introduction of penis transplantation. However, both technical and ethical issues arise when developing this treatment.

Aim

We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations.

Methods

Three semistructured focus groups, consisting of different stakeholders, were organized to participate in discussions of ethical considerations retrieved from the ethics literature of transplantation and transgender medicine. Analysis of the results was performed according to empirical ethics.

Outcomes

Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men.

Results

Nineteen people participated in this qualitative study. The main domains that emerged included arguments in favor of and arguments against penile transplantation. Although the participants expressed positive attitudes toward developing this care, with acknowledgement of the current limitations stakeholders of all groups were reluctant to endorse the introduction of penile transplantation for transgender men at this point.

Clinical Implications

Under the present circumstances, all groups expressed both a wide variety of ethical considerations as well as a tendency to prefer developing alternative treatment options or improving the results of currently available treatments in relation to penile transplantation for transgender men.

Strengths and Limitations

This study was the first (empirical) study to focus on this topic and included a diversity of stakeholder perspectives. Limitations included the hypothetical nature of the discussion as well as the clinical setting in which the topic has been studied.

Conclusion

Introducing penile transplantation for transgender men, under the current circumstances, comes with a wide range of ethical considerations, which deal with personal identity, autonomy, medical risks, risk for transgender support and donor willingness, and issues regarding equality. Despite the present hesitancy to use penile transplantation, should the technical side of this treatment option develop, further research in the ethical field of penile transplantation for transgender men is recommended.

Sexual Wellbeing according to Transgender Individuals

Objective

Sexual wellbeing is an important aspect of quality-of-life. In transgender individuals who seek gender affirming treatment, various aspects of sexuality have been assessed. However, not much is known on how transgender individuals themselves perceive sexual wellbeing. This study aims to explore the perception of sexual wellbeing in transgender-individuals (an emic-perspective).

Methods

To explore sexual wellbeing from an emic perspective, qualitative interviews with transgender individuals were conducted, recorded and transcribed verbatim. Inductive coding and thematic analysis were used to assess topics and themes pertaining to sexual wellbeing.

Results

Based on interviews wih15 participants (19-74 years) with diverse self-identified genders, four main themes, relating to sexual wellbeing were derived: (1) given description of sexual wellbeing, (2) conditions for sexual wellbeing, (3) factors affecting sexual wellbeing, and (4) experienced sexual wellbeing.

Conclusion

Positive experiences, feeling comfortable with body/self, intimacy, acceptation and communication with partner appeared helpful to overcome hurdles and experience sexual wellbeing.

Donor and Recipient Nerve Axon Counts in Gender-affirming Radial Forearm Phalloplasty: Informing Choice of Nerve Coaptations

A key component of success of a nerve transfer is the innervation density, which is directly affected by the donor nerve axonal density and donor-to-recipient (D:R) axon ratio. Optimal D:R axon ratio for a nerve transfer is quoted at 0.7:1 or greater. In phalloplasty surgery, there are currently minimal data available to help inform selection of donor and recipient nerves, including unavailability of axon counts.

Methods

Five transmasculine people who underwent gender-affirming radial forearm phalloplasty had nerve specimens processed with histomorphometric evaluation to determine axon counts and approximate donor-to-recipient axon ratios.

Results

Mean axon counts for recipient nerves were 6957 ± 1098 [the lateral antebrachial (LABC)], 1866 ± 590 [medial antebrachial (MABC)], and 1712 ± 121 [posterior antebrachial cutaneous (PABC)]. Mean axon counts for donor nerves were 2301 ± 551 [ilioinguinal (IL)] and 5140 ± 218 [dorsal nerve of the clitoris (DNC)]. D:R axon ratios using mean axon counts were DNC:LABC 0.739 (0.61-1.03), DNC:MABC 2.754 (1.83-5.91), DNC:PABC 3.002 (2.71-3.53), IL:LABC 0.331 (0.24-0.46), IL:MABC 1.233 (0.86-1.17), and IL:PABC 1.344 (0.85-1.82).

Conclusions

The DNC is the more powerful donor nerve with greater than two times the axon count of the IL. The IL nerve may be under-powered to re-innervate the LABC based on an axon ratio consistently less than 0.7:1. All other mean D:R are more than 0.7:1. DNC axon counts may be excessive for re-innervation of the MABC or PABC alone with D:R of more than 2.5:1, potentially increasing risk of neuroma formation at the coaptation site.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

Masculinizing and defeminizing gender-affirming surgery

Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.

Sexuality and fertility desire in a large cohort of individuals with 46, XY differences in sex development

OBJECTIVE

To analyze aspects of sexual life and fertility desire among 46, XY DSD people, including those who changed their gender.

METHODS

It is a cross-sectional study including 127 adults (> 16 years of age) with 46, XY DSD (83 females; 44 males) from a Single Brazilian Tertiary-Care Medical Center.

RESULTS

Sexual fantasies and masturbation were more frequent in 46, XY DSD males, whereas orgasm and sexual life satisfaction were similar in both genders. More 46, XY DSD men than women had a long-term romantic relationship. 46, XY DSD women with prenatal androgen exposure reported more fear of being romantically rejected. External genitalia appearance at birth did not impact the sexuality of 46, XY DSD women after surgical genital treatment had been completed. Overall, the sexual life was similar between 46, XY men assigned as males and those who changed to the male gender. Regarding sexual orientation, most self-reported as heterosexual (91% and 92% of women and men, respectively). The desire for fertility had a similar prevalence in both genders, but more women than men considered infertility a barrier to a long-term romantic relationship. Twelve individuals (7 males) had children; 10 out of 12 have adopted children.

CONCLUSION

Fertility desire was shared among 46, XY DSD people, regardless of gender. Prenatal androgen exposure reduced the desire for motherhood in 46, XY women. 46, XY DSD people who changed from female to male gender presented similar sexual parameters as those assigned as males. Among females, virilized genitalia at birth did not affect sexuality once the surgical treatment is completed.

Components of Good Sex in Young Urban Trans People Assigned Female at Birth: A Qualitative Interview Study

BACKGROUND

Prevalence of sexual dissatisfaction and dysfunction is high in trans people, as reflected in lower sexual pleasure scores compared to cis people.

AIM

The aim of this study is to explore components of good sex and sexual pleasure in young, urban trans people assigned female at birth (AFAB).

METHODS

16 semi-structured interviews were conducted with young urban AFAB trans people. The interviews were analysed using qualitative content analysis.

OUTCOMES

Main outcomes were providing participants components of good sex and sexual pleasure.

RESULTS

Regarding components of good sex, the participants of this study described various influences on their ability to relax as well as strategies to increase relaxation during sex. Next to general influences on relaxation, the ability to relax was influenced by the way their partners interacted with them and thus how accepted they felt in their identities and feeling safe. Further, transition and coming-out status, physical and sexual function changes due to hormone therapy and gender affirming surgeries, specific sexual techniques and aids, social constructs and the circumstances in which sex took place were important. Strategies to increase relaxation included using aids such as penis prostheses, preferring certain sexual practices, that is, being more dominant or on eye-level, reducing visual aspects, drinking alcohol, and deconstructing gender and sexual norms.

CLINICAL IMPLICATIONS

When working with trans clients, inhibitors of relaxation should be assessed and addressed, which could include working on clients believes about trans sexuality, gendered sexual scripts or various techniques to reduce body dysphoria, if present, during sexual practices.

STRENGTHS & LIMITATIONS

Following a non-clinical community sampling with no treatment-related dependency between researchers and participants, the sample provides an open access to the participating trans people's sexuality. However, the sample is small, selective, and it includes only able-bodied trans people from Christian religious backgrounds.

CONCLUSION

Next to sexual problems and dysfunctions, future research on the relationship between medical transition and sexuality should additionally address positive aspects of sexuality, such as sexual pleasure and sexual satisfaction, and its possible function as a resource pre, during and post transition. Engelmann AJ, Nicklisch S, Nieder TO. Components of Good Sex in Young Urban Trans People Assigned Female at Birth: A Qualitative Interview Study. J Sex Med 2022;19:1687-1706.

Long-term Outcomes After Gender-Affirming Surgery: 40-Year Follow-up Study

BACKGROUND

Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes.

METHODS

Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared.

RESULTS

Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria.

CONCLUSION

Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.

Dual Innervation in Anterolateral Thigh (ALT) Phalloplasty: Consider the Femoral Perforating Nerves

Sensation following anterolateral thigh (ALT) phalloplasty is traditionally viewed as inferior to sensation following radial forearm phalloplasty, potentially due to fewer nerve coaptations performed. Neural anatomy of the ALT is well described, with branches of the femoral nerve innervating the medial flap. The purpose of this article is to draw attention to these nerves as a potential source of additional coaptation in ALT phalloplasty allowing for dual flap innervation.

Methods

A PRISMA literature review was conducted to assess nerve coaptations used in ALT phalloplasty. Anatomic location and territory of the nerves of the thigh in ALT phalloplasty cases are reviewed.

Results

Seventeen articles discuss ALT phalloplasty innervation, and 16 mention the use of only one nerve coaptation with the lateral femoral cutaneous nerve. In our experience performing ALT phalloplasty, perforating branch(es) of the femoral nerve are the first nerve(s) encountered on the medial border of the ALT flap lying on the fascia over the sartorius. With a flap design where the urethra is based laterally, the femoral perforating nerves can innervate a significant portion of the phallic shaft (medial flap), where sensation is most desired.

Conclusions

It is common practice to perform only one nerve coaptation in ALT phalloplasty with the lateral femoral cutaneous nerve. However, perforating branches of the femoral nerve consistently innervate medial skin of the ALT. The authors propose that the femoral perforating nerves, when present, can be used as additional nerves for coaptation in ALT phalloplasty to allow for dual innervation.

Familiar Infections in Novel Anatomy: Patient Reports of Sexually Transmitted Infections After Gender-Affirming Penile Reconstruction

BACKGROUND

Sexually transmitted infections (STIs) after penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations have not previously been described, despite known risk factors in the population. After T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines.

METHODS

A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups.

RESULTS

A total of 128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups from January to May 2020. Seven respondents (5.5%) self-reported 1 or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (P = 0.002). Sexually transmitted infections were correlated with reporting sex with cisgender men (P = 0.001), transgender men (P = 0.009), and transgender women (P = 0.012). Of health care access variables, only receiving health care at a community health center was correlated with STI history (P = 0.003).

CONCLUSIONS

This exploratory survey indicates that STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of postreconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of health care provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm after gender-affirming penile reconstruction.

Depression, Self-Esteem, and Resilience and its Relationship with Psychological Features of Sexuality among Transgender Men and Women from Brazil

This cross-sectional study investigated whether depression, self-esteem, and resilience (mental health indicators) are associated with some psychological features of sexuality (sexual fear, sexual anxiety, sexual dissatisfaction, and sexual body image worries) in a sample of 462 transgender men and women from Brazil. Pearson's correlations were performed between all continuous variables in the study. Those that were significantly associated with the psychological features of sexuality in previous analyses were tested as independent variables in multiple linear regression models. Sexual fear, sexual anxiety, sexual dissatisfaction, and sexual body image worries were negatively related to self-esteem and resilience, while positively related to depression. Higher levels of depression were associated with sexual fear, while higher levels of depression and lower self-esteem were associated with sexual anxiety. In addition, higher levels of depression and lower levels of resilience were associated with sexual dissatisfaction. Depression and resilience were associated with the composite score of sexual dissatisfaction and sexual anxiety. Our results suggest that negative mental health indicators may impair the sexual life of transgender individuals. Clinical interventions should be developed and tested to address the psychological features of sexuality.

Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review

Background

Many transgender women and men undergo gender-affirming surgeries. Existing work shows that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive quality of life outcomes. Less work, however, examines these outcomes in the longer-term.

Aims

To conduct a systematic literature review into the longer-term (i.e., ≥ 1 year) surgical satisfaction and quality of outcomes following various forms of gender-affirming surgery in transgender populations. Specifically, we aim to examine research on such outcomes at least one-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries.

Methods

Studies were identified through Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. We considered all studies published until October 2021. Two reviewers extracted data from suitable studies using Covidence. Both reviewers also independently assessed the identified studies' risk of bias and strength of evidence.

Results

Seventy-nine low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggest that most transgender patients are satisfied with surgical outcomes when assessed at least one-year post-surgery. Low quality research also indicates that transgender women and men typically report positive psychological and sexual wellbeing post-surgery, and similar wellbeing outcomes as those who have not had surgery.

Discussion

To the best of our knowledge, this literature review is the first to critically summarize and evaluate all published studies on the longer-term quality of life outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. While the results suggest promising surgical satisfaction and quality of life outcomes following surgery, many studies only draw on small samples, and most studies do not allow for causal conclusions. Further, few studies have compared surgical outcomes between transgender women and men. We conclude by offering concrete suggestions for future research.

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

Sexual-wellbeing is recognized as an important aspect of quality-of-life. Yet, no overview exists of which aspects of sexual-wellbeing have been assessed in trans individuals seeking or undergoing medical treatment, nor is it clear what tools are used to evaluate the effect of medical treatment on sexual-wellbeing. First, to identify which topics pertaining to sexual-wellbeing have been assessed in transgender individuals in a medical context. Second, to determine which tools have been used for measuring aspects of sexual-wellbeing. A conceptual framework of sexual-wellbeing, was used as reference. A literature search (in PubMed, Embase, Cochrane Library) was performed up to March 10th, 2020. Studies that assessed aspects of sexual-wellbeing in transgender individuals' medical context were included in this review. Specific sexual topics addressed in each study were extracted by two independent reviewers. Thematic analysis was performed to identify sexual themes. Additionally, tools used to measure topics related to sexuality in transgender individuals were identified. In 172 papers, a total of 178 topics related to sexual-wellbeing were identified. Ten overarching themes were identified; sexuality, enacted sexual script, sexual activities, sexual relations, sexual response cycle, genital function, sexual function, sexual pleasure, sexual satisfaction, and quality-of-sex-life. Functional aspects of sexuality are assessed most frequently. A variety of methods was used to evaluate aspects related to sexual-wellbeing in trans individuals and over 50 different tools were identified. Self-developed questionnaires were used most frequently (n = 80), followed by chart reviews (n = 50), self-developed structured interviews (n = 37) and physical examination (n = 13). 23 previously developed questionnaires were used, all of which were developed for a cisgender population. Many studies in trans individuals touch on topics related to sexual-wellbeing, however, a comprehensive conceptualisation of (10 themes of) sexual-wellbeing is still lacking. Still, no valid tool exists for assessing sexual-wellbeing in the trans population, but is much needed.

Beyond the Binary: Sexual and Reproductive Health Considerations for Transgender and Gender Expansive Adolescents

Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.

How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons

INTRODUCTION

Tactile and erogenous sensitivity of the neophallus after phalloplasty is assumed to affect the sexual well-being of transmasculine persons and, ultimately, their quality of life. The experienced and objective sensation of the neophallus and their association are largely unknown.

AIM

This study evaluated experienced tactile and erotic sensation of the neophallus in transmasculine persons and investigated how this was related to objective tactile sensitivity.

METHODS

Between August 2017 and January 2020, 59 transmasculine persons who underwent phalloplasty were recruited to participate in a prospective follow-up study. Tactile sensitivity of the neophallus and donor-site was measured (Semmes-Weinstein Monofilament test) and compared, and participants were asked to fill out a questionnaire about experienced sensation of the neophallus and sexual wellbeing.

MAIN OUTCOME MEASURES

Experienced and objective sensation of the neophallus were measured by using a questionnaire and Semmes-Weinstein Monofilament scores.

RESULTS

Neophallic tactile sensitivity was significantly reduced compared to the donor-site (n = 44), with the proximal part being more sensitive than the distal part (median follow-up of 1.8 years, range 1.0-7.2)). Sensitivity of the neophallus was not significantly associated with the surgical flap used, yet increased significantly with follow-up time. The questionnaire was completed by 26 participants of which 24 (92.3%) experienced (some degree of) tactile sensitivity in their neophallus. Erogenous sensation was experienced by 23 (88.5%). Experienced and objectified tactile sensitivity were not significantly correlated (Spearmans's rho = 0.23, P = .26). Answers to open-ended questions showed that results often do not match expectations.

CONCLUSION

Tactile sensation of the neophallus was reduced in most transmasculine persons and improved slowly over time. A significant association between subjective and objective measures could not be detected. Although experienced sensitivity varied between individuals, the vast majority reported to have tactile and erotic sensitivity in the neophallus.Transmasculine persons should be informed that sensitivity of the neophallus will likely be reduced. Elfering L, van de Grift TC, Al-Tamimi M, et al. How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons. Sex Med 2021;9:100413.

Penile inversion vaginoplasty outcomes: Complications and satisfaction

Penile inversion vaginoplasty helps to alleviate gender dysphoria and improve quality of life in many transgender individuals. Overall, the procedure is associated with high post-operative satisfaction, even when complications occur. Adverse events related to vaginoplasty are commensurate with other genitourinary reconstructive procedures performed for other diagnoses (ie, cancer or congenital issues). Here, we explore the incidence of complications following vaginoplasty, emphasizing the challenges in defining and managing these adverse events. In addition, outcome measures to assess patient satisfaction will be reviewed.

Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men

BACKGROUND

In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL).

AIM

The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up.

METHODS

A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality.

OUTCOMES

Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction.

RESULTS

Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P < .001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P < .001) and with voiding (P = .02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P = .48 and P = .95 respectively).

CLINICAL IMPLICATIONS

Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality.

STRENGTHS & LIMITATIONS

Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey.

CONCLUSION

No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974-981.

Nipple-areola complex reconstruction in transgender patients undergoing mastectomy with free nipple grafts: a systematic review of techniques and outcomes

Nipple-areola complex (NAC) reconstruction in transgender and gender non-binary (TGNB) individuals undergoing chest wall masculinization surgery is critical for adequate satisfaction and aesthetic results. Here, we conducted a systematic review to find the various techniques and outcomes of NAC reconstruction in double-incision mastectomy and free nipple grafts (DIM-FNG). A comprehensive search of several databases was conducted based on PRISMA guidelines. We included studies that described the NAC reconstruction technique after DIM-FNG, and evaluated the surgical outcomes, or satisfaction, or aesthetic results after a minimum duration of follow-up of 6 months. Studies were assessed for risk of bias. A qualitative synthesis was performed. A total of 19 studies, comprising 1,587 patients (3,174 breasts), were included. There was a total of 14 studies using the conventional FNG technique, 4 describing new approaches for NAC reconstruction in FNG and 1 study comparing the conventional FNG technique to another alternative technique. A total of 1,347 patients underwent DIM-FNG with conventional FNG and 240 underwent alternative techniques for NAC reconstruction after DIM-FNG. Postoperative complications were low, and satisfaction was high for conventional and alternative techniques. Newer techniques aim to reshape the new NACs in an oval shape, reduce nipple size and place the NACs using the pectoralis major lateral and inferior borders as reference. In addition, a horizontal oval incision at the recipient site may avoid an undesired vertical NAC.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

BACKGROUND

Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies.

AIM

To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes.

METHODS

A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image.

OUTCOMES

Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty.

RESULTS

Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004).

CLINICAL IMPLICATIONS

These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males.

STRENGTHS & LIMITATIONS

These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire.

CONCLUSION

Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

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.

Overview on metoidioplasty: variants of the technique

Number of gender dysphoric people increased over the last few decades with positive social acceptance of transpopulation. Genital gender affirming surgeries are of utmost importance in order to adjust body to the mind of these individuals. Creation of the phallus is usually the last step in transmen transition, which remains demanding and challenging for surgeons, with different options for phalloplasty available. The ideal phallus is esthetically appealing, with preserved tactile and erogenous sensation, enables standing micturition and sexual function with minimal donor-site morbidity. Metoidioplasty, as a variant of phalloplasty, uses the hormonally hypertrophied clitoris to create the neophallus. Metoidioplasty can be considered as a method of choice for thin-built individuals looking for male genitalia with preserved erogeneity, in one-stage genital gender affirming surgery. It can be combined together with removal of reproductive organs and vaginectomy. Preoperative consultation with patients and postoperative follow-up as well as multidisciplinary approach are essential for successful treatment.This literature review aims to assess and discuss different metoidioplasty approaches with a special reference to authors' current metoidioplasty technique.

What Constitutes Sexual Dissatisfaction for Trans Masculine and Nonbinary Individuals: A Qualitative Study

The present study is aimed at understanding how trans masculine and nonbinary individuals describe aspects of their sexual dissatisfaction. Previous studies on cisgender sexual dissatisfaction have utilized narrow definitions of dissatisfaction, operationalizing it in opposition to sexual satisfaction. Moreover, the pervasive focus on the outcomes of medical intervention steps in prior sexual dissatisfaction research with trans masculine participants ignored the experiences of individuals who do not desire a medical transition or live outside of the gender binary. Participants in the current study represented a non-clinical sample of 358 trans masculine and nonbinary individuals who responded to the question: "In what ways are you dissatisfied with your sex life?" Thematic analysis revealed six overarching themes for participant dissatisfaction: 1) difficulty with orgasm, 2) partner dynamics, 3) trauma, 4) desire for different body parts, 5) gender dysphoria, and 6) medical transition. Discussion focuses on the ways in which clinicians can utilize the current findings to decrease the sexual dissatisfaction of trans masculine and nonbinary individuals.