Psychological Pathologies and Sexual Orientation in Transgender Women Undergoing Gender Confirming Treatment

Health status of transgender people globally: A systematic review of research on disease burden and correlates

BACKGROUND AND OBJECTIVES

Transgender and gender diverse (trans) health research has grown rapidly, highlighting the need to characterize the scientific evidence base. We conducted a systematic review of peer-reviewed research on disease burden and correlates in trans adolescents and adults over a 20-month period to identify knowledge gaps and assess methodological characteristics including measurement of gender identity, community engagement, and study quality.

DATA SOURCES, ELIGIBILITY CRITERIA, AND SYNTHESIS METHODS

We searched seven databases using terms related to (a) transgender populations and (b) health or disease. Eligible studies were in English, French, or Spanish and reported original quantitative data on mental health or substance use conditions, infectious diseases, or non-communicable conditions in at least 25 trans individuals aged 15+. Quality assessment was performed in duplicate on a 10% sample of articles and findings were summarized using narrative synthesis.

RESULTS

The 328 included studies were conducted in 45 countries, with most from North America (54%) and limited research from South Asia (3%), Sub-Saharan Africa (3%), and the Middle East and North Africa (2%). Most studies used cross-sectional designs (73%) and convenience sampling (65%). Only 30% of studies reported any form of community engagement. Mental health and substance use disorders were the most studied area (77% of studies) and non-communicable conditions the least (16%). Available data indicated that trans populations experience high disease burden with considerable heterogeneity within and across settings. Of 39 articles assessed for quality, 80% were rated as fair, 18% as poor, and 3% as good quality.

CONCLUSIONS AND IMPLICATIONS

Geographic, gender-specific, and topical gaps remain in trans health, but we found more research from African countries, with transmasculine people, and on non-communicable conditions than previous syntheses. Areas for growth in trans health research include community engagement, non-binary health, chronic and age-related conditions, and health determinants.

REGISTRATION

PROSPERO CRD42021234043.

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.

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.

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.

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.