New Women: Sexological Outcomes of Male-to-Female Gender Reassignment Surgery

Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review

Background

Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS.

Results

After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general.

Discussion

The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.

ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"

INTRODUCTION

Much has been published on the surgical and functional results following Gender Affirming Surgery ('GAS') in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.

AIM

To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.

METHODS

The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.

MAIN OUTCOMES MEASURE

The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.

RESULTS

The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.

CONCLUSION

The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022;10:100471.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

Patient-Reported Outcome Measures Used in Gender Confirmation Surgery: A Systematic Review

BACKGROUND

The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument's validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient's experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments.

METHODS

A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments' validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments.

RESULTS

A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial aspects; nine evaluating function but only valid in other patient groups; five ad hoc with some formal development/validation; and two specific for gender dysphoria.

CONCLUSIONS

There is a lack of patient-reported outcome measures that are valid for the transgender population and concurrently sensitive enough to evaluate gender confirmation surgery without the influence of other gender confirming interventions. Basing research on instruments without confirmed validity decreases the validity of the study itself; thus, previous research using patient-reported outcome measures to evaluate gender confirmation surgery can be considered to have a low level of evidence. To obtain valid patient-reported outcome measures, specific for evaluating the results of gender confirmation surgery, development of new instruments or adaptation of existing instruments is needed.

Multiple Orgasms in Men-What We Know So Far

INTRODUCTION

There is much popular discussion on strategies to facilitate multiple orgasms in men (ie, 100,000+ hits in Google), yet the topic has not received an objective comprehensive review in the literature.

AIM

To review the literature on male multiple orgasms.

METHODS

We searched the literature for publications on "male multiple orgasms" and factors influencing male multiple orgasms in Google, PubMed, and PsychINFO. This yielded 15 relevant publications.

MAIN OUTCOME MEASURES

A comprehensive overview on the topic of male multiple orgasms and factors that influence the propensity of men to experience multiple orgasms.

RESULTS

Few men are multiorgasmic: <10% for those in their 20s, and <7% after the age of 30. The literature suggests 2 types of male multiple orgasms: "sporadic" multiorgasms, with interorgasmic intervals of several minutes, and "condensed" multiorgasms, with bursts of 2-4 orgasms within a few seconds to 2 minutes. Multiple orgasms appear physiologically similar to the single orgasm in mono-orgasmic men. However, in a single case study, a multiorgasmic man did not experience with his first orgasm the prolactin surge that usually occurs with orgasm in mono-orgasmic men. Various factors may facilitate multiple orgasms: (1) practicing to have an orgasm without ejaculation; (2) using psychostimulant drugs; (3) having multiple and/or novel sexual partners; or (4) using sex toys to enhance tactile stimulation. However, confirmatory physiological data on any of these factors are few. In some cases, the ability to experience multiple orgasms may increase after medical procedures that reduce ejaculation (eg, prostatectomy or castration), but what factor(s) influence this phenomenon is poorly investigated.

CONCLUSION

Despite popular interest, the topic of male multiple orgasms has received surprisingly little scientific assessment. The role of ejaculation and physiological change during the refractory period in inhibiting multiple orgasms has barely been investigated.

Quality of life and hormones after sex reassignment surgery

BACKGROUND

Transpeople often look for sex reassignment surgery (SRS) to improve their quality of life (QoL). The hormonal therapy has many positive effects before and after SRS. There are no studies about correlation between hormonal status and QoL after SRS.

AIM

To gather information on QoL, quality of sexual life and body image in transpeople at least 2 years after SRS,to compare these results with a control group and to evaluate the relations between the chosen items and hormonal status.

SUBJECTS AND METHODS

Data from 60 transsexuals and from 60 healthy matched controls were collected. Testosterone,estradiol, LH and World Health Organization Quality of Life (WHOQOL-100) self-reported questionnaire were evaluated. Student’s t test was applied to compare transsexuals and controls. Multiple regression model was applied to evaluate WHOQOL’s chosen items and LH.

RESULTS

The QoL and the quality of body image scores intranspeople were not statistically different from the matched control groups’ ones. In the sexual life subscale,transwomen’s scores were similar to biological women’s ones, whereas transmen’s scores were statistically lower than biological men’s ones (P = 0.003). The quality of sexual life scored statistically lower in transmen than intranswomen (P = 0.048). A significant inverse relationship between LH and body image and between LH and quality of sexual life was found.

CONCLUSIONS

This study highlights general satisfaction after SRS. In particular, transpeople’s QoL turns out to be similar to Italian matched controls. LH resulted inversely correlated to body image and sexual life scores.

[Surgical gender reassignment in the elderly]

BACKGROUND

Gender reassignment surgery (GRS) from male to female is increasingly being requested by older female patients.

RESULTS

To the best of our knowledge this study has for the first time investigated the correlation between the age of patients and perioperative and postoperative complications. The presented data show that an age-related limitation for this intervention due to perioperative and postoperative complications is not justified.

CONCLUSION

Health status and capability for self-sufficiency as well as physical and psychological limitations must be individually considered in order to achieve a successful postoperative course and a subjective satisfaction of patients.

Societal individualism predicts prevalence of nonhomosexual orientation in male-to-female transsexualism

There are two distinct subtypes of male-to-female (MtF) transsexuals: homosexual and nonhomosexual. The relative prevalence of these two subtypes varies dramatically between countries, but no explanation of this variability has yet been proposed. This study examined the hypothesis that the prevalence of nonhomosexual MtF transsexualism, relative to homosexual MtF transsexualism, would be higher in individualistic countries than in collectivistic countries. I analyzed data from 22 studies of MtF transsexualism, conducted in 16 countries, examining the association between percentage of nonhomosexual participants and Hofstede's (Culture's consequences: Comparing values, behaviors, institutions, and organizations across nations, 2001) Individualism Index (IDV). IDV accounted for 77% of observed variance in the percentage of nonhomosexual MtF participants (r = 0.88, p < .0001). Controlling for differences in national wealth and in Hofstede's other indices of societal values (Power Distance, Uncertainty Avoidance, and Masculinity) did not significantly change the ability of IDV to account for variance in the percentage of nonhomosexual participants. The factors that contribute to the observed association between societal individualism and the relative prevalence of nonhomosexual MtF transsexualism remain to be determined, but a greater tolerance within individualistic countries for socially disruptive gender transitions by nonhomosexual gender dysphoric men, and the availability within many collectivistic countries of socially approved transgender roles for pervasively feminine homosexual gender dysphoric men, are plausible contributors.

The DSM diagnostic criteria for gender identity disorder in adolescents and adults

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes

OBJECTIVE

To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes.

METHODS

We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I(2) statistic.

RESULTS

We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68-89%; 8 studies; I(2) = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56-94%; 7 studies; I(2) = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies; I(2) = 78%); and 72% reported significant improvement in sexual function (95% CI = 60-81%; 15 studies; I(2) = 78%).

CONCLUSIONS

Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

The controversy surrounding "The man who would be queen": a case history of the politics of science, identity, and sex in the Internet age

In 2003, psychology professor and sex researcher J. Michael Bailey published a book entitled The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. The book's portrayal of male-to-female (MTF) transsexualism, based on a theory developed by sexologist Ray Blanchard, outraged some transgender activists. They believed the book to be typical of much of the biomedical literature on transsexuality-oppressive in both tone and claims, insulting to their senses of self, and damaging to their public identities. Some saw the book as especially dangerous because it claimed to be based on rigorous science, was published by an imprint of the National Academy of Sciences, and argued that MTF sex changes are motivated primarily by erotic interests and not by the problem of having the gender identity common to one sex in the body of the other. Dissatisfied with the option of merely criticizing the book, a small number of transwomen (particularly Lynn Conway, Andrea James, and Deirdre McCloskey) worked to try to ruin Bailey. Using published and unpublished sources as well as original interviews, this essay traces the history of the backlash against Bailey and his book. It also provides a thorough exegesis of the book's treatment of transsexuality and includes a comprehensive investigation of the merit of the charges made against Bailey that he had behaved unethically, immorally, and illegally in the production of his book. The essay closes with an epilogue that explores what has happened since 2003 to the central ideas and major players in the controversy.

Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery

This study examined preoperative preparations, complications, and physical and functional outcomes of male-to-female sex reassignment surgery (SRS), based on reports by 232 patients, all of whom underwent penile-inversion vaginoplasty and sensate clitoroplasty, performed by one surgeon using a consistent technique. Nearly all patients discontinued hormone therapy before SRS and most reported that doing so created no difficulties. Preoperative electrolysis to remove genital hair, undergone by most patients, was not associated with less serious vaginal hair problems. No patients reported rectal-vaginal fistula or deep-vein thrombosis and reports of other significant surgical complications were uncommon. One third of patients, however, reported urinary stream problems. No single complication was significantly associated with regretting SRS. Satisfaction with most physical and functional outcomes of SRS was high; participants were least satisfied with vaginal lubrication, vaginal touch sensation, and vaginal erotic sensation. Frequency of achieving orgasm after SRS was not significantly associated with most general measures of satisfaction. Later years of surgery, reflecting greater surgeon experience, were not associated with lower prevalence rates for most complications or with better ratings for most physical and functional outcomes of SRS.

Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography

Men's sexual arousal patterns are category-specific: Men typically display significantly greater physiological responses to sexual stimuli depicting members of their preferred gender category. Category-specific patterns of sexual arousal have not been consistently reported in natal women. We used vaginal photoplethysmography to examine patterns of sexual arousal in 11 male-to-female (MtF) transsexuals following sex reassignment surgery (SRS) and in 72 natal women. Subjective arousal was measured with a continuous response lever. Video clips depicting sexual activity between two males, two females, or one male and one female were used as erotic stimuli. All transsexual participants displayed category-specific sexual arousal. Five homosexual transsexual participants (attracted exclusively to males before sex reassignment) showed greater genital and subjective responses to male than to female stimuli, while six nonhomosexual transsexual participants showed the opposite pattern. Vaginal pulse amplitude (VPA) was lower in transsexual participants than in natal women. The mean correlation between VPA and subjective responses was high in nonhomosexual transsexuals, but was significantly lower in homosexual transsexuals and in natal women. One transsexual participant who reported a change in sexual orientation following sex reassignment displayed VPA and subjective responses consistent with her pre-reassignment sexual orientation. We conclude that male-to-female transsexuals display male-typical category-specific sexual arousal following SRS, and that vaginal photoplethysmography is a promising methodology for studying patterns of sexual arousal in postoperative transsexuals.

Sexuality before and after male-to-female sex reassignment surgery

The sexual behaviors and attitudes of male-to-female (MtF) transsexuals have not been investigated systematically. This study presents information about sexuality before and after sex reassignment surgery (SRS), as reported by 232 MtF patients of one surgeon. Data were collected using self-administered questionnaires. The mean age of participants at time of SRS was 44 years (range, 18-70 years). Before SRS, 54% of participants had been predominantly attracted to women and 9% had been predominantly attracted to men. After SRS, these figures were 25% and 34%, respectively.Participants' median numbers of sexual partners before SRS and in the last 12 months after SRS were 6 and 1, respectively. Participants' reported number of sexual partners before SRS was similar to the number of partners reported by male participants in the National Health and Social Life Survey (NHSLS). After SRS, 32% of participants reported no sexual partners in the last 12 months, higher than reported by male or female participants in the NHSLS. Bisexual participants reported more partners before and after SRS than did other participants. 49% of participants reported hundreds of episodes or more of sexual arousal to cross-dressing or cross-gender fantasy (autogynephilia) before SRS; after SRS, only 3% so reported. More frequent autogynephilic arousal after SRS was correlated with more frequent masturbation, a larger number of sexual partners, and more frequent partnered sexual activity. 85% of participants experienced orgasm at least occasionally after SRS and 55% ejaculated with orgasm.

A sex difference in the specificity of sexual arousal

Sexual arousal is category-specific in men; heterosexual men are more aroused by female than by male sexual stimuli, whereas homosexual men show the opposite pattern. There is reason to believe that female sexual arousal is organized differently. We assessed genital and subjective sexual arousal to male and female sexual stimuli in women, men, and postoperative male-to-female transsexuals. In contrast to men, women showed little category specificity on either the genital or the subjective measure. Both heterosexual and homosexual women experienced strong genital arousal to both male and female sexual stimuli. Transsexuals showed a category-specific pattern, demonstrating that category specificity can be detected in the neovagina using a photoplethysmographic measure of female genital sexual arousal. In a second study, we showed that our results for females are unlikely to be explained by ascertainment biases. These findings suggest that sexual arousal patterns play fundamentally different roles in male and female sexuality.