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.

An overview of neovaginal reconstruction options in male to female transsexuals

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Continuing Medical Education: Gender Identity Disorders: Diagnostic and Surgical Aspects (CME)

Transsexualism is defined as a strong and persistent cross-gender identification with the patient's persistent discomfort with his or her sex and a sense of inappropriateness in the gender role of that sex (Diagnostic and Statistical Manual of Mental Disorders, fourth revision, text revision [DSM-IV-TR]). The disturbance is not concurrent with a physical intersex condition and causes clinical distress or impairment in social, occupational, or other important areas of functioning. The trained mental health professional is obliged to find out if the patient fulfills the criteria of an irreversible gender transposition and if he or she will benefit from medical (hormonal and surgical) sex-reassignment treatment. If a patient has absolved 12 months of real-life experience and at least 6 months of continuous hormonal treatment, the indication for surgical sex reassignment may be given. Genital sex-reassignment in male-to-female transsexuals includes vaginoplasty, preferably by inversion of penoscrotal skin flaps, clitoroplasty, and vulvoplasty. The operation may be performed in one or two sessions. In contrast to genital reassignment in male-to-female patients, no operative standards are available in female-to-male subjects. Recently, neophallus creation from sensate free forearm flaps has emerged as the most promising approach for those patients who want to have a neophallus. Other alternatives such as metoidoioplasty or neophallus reconstruction from regional flaps exist, but are also accompanied by multiple possible complications and re-interventions. Best results are to be expected when using multidisciplinary teams of plastic surgeons, urologists, gynecologists, and experts in sexual medicine in large volume centers.