Physical, Mental and Sexual Health Among Transgender Women: A Comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network

Do hormones and surgery improve the health of adults with gender incongruence? A systematic review of patient reported outcomes

BACKGROUND

Gender diverse people in Australia have higher levels of psychological stress, suicidal ideation and suicide attempts and have poorer self-reported health than cisgender people.

OBJECTIVES

To determine if adults who experience gender incongruence have improved health-related quality of life and mental health with gender affirming treatment (hormone therapy and surgery), compared with no treatment.

DATA SOURCES

PubMed, Web of Science, Embase and Psych Info.

REVIEW METHODS

A systematic review of peer-reviewed publications in English from January 2010 to October 2022. Studies were included where: participants were treated with gender affirming surgery or hormone therapy for minimum 3 months and; validated patient reported outcome measures of health-related quality of life or mental health were reported. Quality of evidence assessment was undertaken using the Let Evidence Guide Every New Decision evaluation tool.

RESULTS

Eighty-one publications were included for analysis. The systematic review indicated that there were significant improvements in the domains of mental illness, gender dysphoria, body image and health-related quality of life following gender affirming medical treatment as measured by a variety of patient reported outcomes. Meta-analysis showed significant improvement in body image (z = 4.47, P < 0.001) and health-related quality of life for psychological (z = 1.99, P = 0.047) and social relationships (z = 3.09, P = 0.002) following gender affirming surgery.

CONCLUSIONS

There is evidence that hormones and surgery as a collective for adults with gender incongruence has therapeutic value and should be considered for funding within Australia's healthcare systems. The development and implementation of patient-reported outcome tools tailored for purpose (GENDER Q) will facilitate future research.

French validation of the oMtFSFI Questionnaire for assessing the sexual function of Transgender women after vulvo-vaginoplasty

INTRODUCTION

The Operated Male-to-Female Sexual Function Index (oMtFSFI) questionnaire is the first scoring system developed to assess sexual function after gender-affirming vulvo-vaginoplasty, and was initially developed and validated in Italian. The aim of this study was to provide linguistic validation of the questionnaire in French through several steps including use of the questionnaires across a series of patients who had undergone gender-affirming vulvo-vaginoplasty between 2020 and 2022 at two French academic centers.

METHOD

The French version of the oMtFSFI questionnaire was obtained through a double translation (Italian to French) and a back-translation (French to Italian), validated by a scientific committee, and cognitively assessed by a panel of expert patients. The questionnaire was then distributed to transgender male to female patients who had undergone genital gender affirming surgery at two French academic centers.

RESULTS

The oMtFSFI score consists of 18 questions exploring 7 domains (genital self-image, desire, arousal, lubrication, orgasm, satisfaction, sexual pain). Among the sixty-four patients who responded to the questionnaire, 16 patients (25%) reported abstaining from sexual activity involving vaginal penetration at the time of the study were excluded. The mean total score was 37, corresponding to mild to moderate sexual dysfunction and 60.4% of the patients reported normal overall sexual function. The level of sexual satisfaction was normal for 68.8% of the patients and the genital self-image was normal for 52.1%. Most of the patients (79.2%) reported at least mild dyspareunia and 10.4% had critical sexual dysfunction. Surgery improved gender dysphoria in 96.7% of patients. There was a strong correlation between the overall oMtFSFI score and the happiness Visual Analog Scale (VAS) (P<0.001) as well as with the quality of life VAS (P<0.001).

CONCLUSION

The French version of the oMtFSFI questionnaire is the only scoring system specifically developed to assess sexual function after vulvo-vaginoplasty in transgender women linguistically validated in French. Its validation in French language makes it an interesting tool for research and clinical practice.

LEVEL OF EVIDENCE: 3

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

The Role of Family Support and Dyadic Adjustment on the Psychological Well-being of Transgender Individuals: An Exploratory Study

Introduction

This study aimed to measure dyadic adjustment, social support, and psychological well-being.

Methods

A research protocol composed of the Dyadic Adjustment Scale, the Outcome Questionnaire 45.2, and the Multidimensional Scale of Perceived Social Support was administered to a sample of 109 Italian transgender individuals.

Results

Higher levels of global psychological distress, symptom severity, and interpersonal relationship distress were associated with lower levels of family support and dyadic adjustment. In addition, transgender women and younger transgender individuals reported higher levels of interpersonal relationship distress.

Conclusions

The results indicate that the support and acceptance of one's partner and family of origin play a crucial role in promoting well-being. It represents an important protective factor with respect to negative psychological health outcomes.

Policy Implications

The findings emphasize the need to develop specific clinical and social practices for transgender individuals and their families. Building family and partner-centered policies and programs is particularly important to enable transgender individuals to avoid paying the emotional and psychological costs associated with rejection and non-acceptance.

Vaginal self-lubrication following peritoneal, penile inversion, and colonic gender-affirming vaginoplasty: a physiologic, anatomic, and histologic review

INTRODUCTION

Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining.

OBJECTIVES

The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV.

METHODS

We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum.

RESULTS

We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented.

CONCLUSIONS

None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.

Breaking the Binary: How Clinicians Can Ensure Everyone Receives High Quality Reproductive Health Services

The gender binary has historically defined the study and practice of reproductive and sexual healthcare. However, the male and female binary categorization of sex does not adequately define patients seeking reproductive and sexual health. Comprehensive sexual healthcare should consider diverse gender identity and non-heteronormative sexual practices, family planning, sexually transmitted infections, cancer prevention, and sexual function. Recent research suggests clinicians do not feel prepared to provide care for sexual and gender minority (SGM) patients. In this narrative review, we focus on reproductive and sexual health within the scope of obstetric and gynecologic (OB/GYN) clinical practice. We used traditional medical subject headings to summarize data from publications in peer-reviewed journals published in the last 10 years and identified barriers, facilitators and best practices for de-gendering reproductive healthcare. Following a roughly chronological care path across the lifespan, we categorized findings into the following topics: Early Care for SGM, Sexual Health, Family Planning, and Care Later in Life for SGM. We include recommendations for creating a welcoming environment, SGM inclusive training for clinicians and staff, and best practices for individualized counseling. We review suggested practices related to service delivery and clinical considerations in the provision of sexual and reproductive health care for gender and sexual minority patients.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

Pleasure please! Sexual pleasure and influencing factors in transgender persons: An ENIGI follow-up study

Background: While the importance of sexual pleasure for physical and mental health becomes increasingly evident, research on sexual pleasure in transgender persons is lacking. Recently, the first version of the Amsterdam Sexual Pleasure Index (ASPI Vol. 0.1) was validated in cisgender persons. This questionnaire aims to assess the tendency to experience sexual pleasure independent of gender, sexual orientation or anatomy. Aim: The aims of this study were threefold. First, to perform exploratory scale validation analyses of the ASPI in transgender persons. Secondly, to compare transgender sexual pleasure scores to reference data in cisgender persons. Finally, to identify factors that are associated with sexual pleasure. Methods: In a follow-up study conducted within the European Network for the Investigation of Gender Incongruence (ENIGI), online questionnaires were distributed to persons who had a first clinical contact at gender clinics in Amsterdam, Ghent or Hamburg four to six years earlier. Internal consistency of the ASPI was assessed by calculating McDonald's omega (ωt). ASPI scores were compared to scores from the cisgender population using a one sample t-test, and linear regressions were conducted to study associations with clinical characteristics, psychological wellbeing, body satisfaction and self-reported happiness. Results: In total, 325 persons filled out the ASPI. The ASPI showed excellent internal consistency (ωt, all: 0.97; transfeminine: 0.97, transmasculine: 0.97). Compared to data from cisgender persons, transgender participants had significantly lower total ASPI scores (i.e., lower sexual pleasure; transgender vs. cisgender, mean(SD): 4.13(0.94) vs. 4.71(0.61)). Lower age, current happiness and genital body satisfaction were associated with a higher tendency to experience sexual pleasure. Conclusion & discussion: The ASPI can be used to assess the tendency to experience sexual pleasure and associated factors in transgender persons. Future studies are needed to understand interplaying biopsychosocial factors that promote sexual pleasure and hence transgender sexual health and wellbeing.