Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction

Exploring subjective and genital sexual response in transgender women upon addition of low-dose testosterone to feminizing gender-affirming hormone therapy: a feasibility study

BACKGROUND

Transgender women using feminizing gender-affirming hormone therapy who underwent a gonadectomy generally have lower testosterone levels than cisgender women. It is unknown if testosterone supplementation can influence subjective and genital sexual response in transgender women and whether this can be measured using vaginal photoplethysmography.

AIM

This study aimed to assess the feasibility of measuring changes in subjective and genital sexual response in transgender women who underwent a penile inversion vaginoplasty after testosterone supplementation to physiological female concentrations.

METHODS

Transgender women received daily testosterone 2% transdermal gel, aiming for serum concentrations between 1.5 and 2.5 nmol/L for 12-20 weeks. Vaginal pulse amplitude (VPA) was measured during neutral, erotic fantasy, erotic film, and genital vibration stimulus blocks before and after testosterone supplementation. After each stimulus block, subjective sexual response was assessed. Sexual function, sexual excitability, and VPA measurement experience were assessed using questionnaires.

OUTCOMES

Change in mean VPA score and subjective sexual response after testosterone supplementation during neutral film, erotic fantasy, erotic film, and genital vibration.

RESULTS

Eight participants were included of whom seven completed the study. VPA during neutral film was significantly higher after testosterone supplementation [estimated ratio 2.7 (95% confidence interval {CI} 1.7-4.3), P < 0.001]. After testosterone supplementation, we observed no change in the degree of VPA response upon exposure to erotic fantasy [estimated ratio 1.4 (95% CI 0.68-2.8), P = 0.372], erotic film [estimated ratio 1.2 (95% CI 0.54-2.8), P = 0.629] and genital vibration [estimated ratio 1.2 (95% CI 0.46-2.9), P = 0.742] compared to before testosterone supplementation. After testosterone supplementation, participants reported significantly stronger feelings of sexual arousal, genital sensations, and positive affect in response to erotic fantasy and erotic film. Finally, there was a significant improvement in sexual function and sexual excitability assessed by questionnaires. VPA measurement was generally well-accepted.

CLINICAL IMPLICATIONS

Vaginal photoplethysmography can be used to assess changes in neovaginal perfusion in transgender women.

STRENGTHS & LIMITATIONS

This is the first study assessing genital and subjective sexual response to testosterone supplementation in transgender women. The lack of a placebo condition precludes any clinical conclusions.

CONCLUSION

Vaginal photoplethysmography can be used to assess changes in neovaginal vasocongestion after testosterone supplementation in transgender women. Explorative analyses suggest promising effects on subjective sexual response and an increase in general neovaginal perfusion. We found no difference in neovaginal vasocongestion after exposure to erotic stimuli before and after testosterone supplementation. Clinical benefit needs to be assessed in a blinded and placebo-controlled trial.

Pharmacotherapy of Hypoactive Sexual Desire Disorder in Premenopausal Women

OBJECTIVE

This review aims to provide an overview of pharmacologic management for hypoactive sexual desire disorder (HSDD) in premenopausal women, with a focus on available agents.

DATA SOURCES

Through a literature search on PubMed, Google Scholar, and ClinicalTrials.gov from 1999 to 2024, studies were selected using the following MeSH search terms: hypoactive sexual desire disorder, premenopause, pharmacologic management, flibanserin, bremelanotide, buspirone, bupropion, and testosterone, excluding those involving postmenopausal women or other sexual disorders. Product monographs were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language studies or those conducted in humans were considered.

DATA SYNTHESIS

Hypoactive sexual desire disorder, characterized by a lack of motivation for sexual activity, predominantly affects women aged 45 years and older. Treatment involves a multimodal approach, including nonpharmacologic interventions such as psychotherapy and lifestyle adjustments, alongside pharmacologic options. Although bupropion and buspirone may be considered off-label treatments, flibanserin and bremelanotide are the sole medications approved by the Food and Drug Administration for generalized acquired HSDD in premenopausal women. However, caution is advised due to their limited efficacy, potential adverse effects, and transparency issues in reporting.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Hypoactive sexual desire disorder, while not life-threatening, significantly impacts well-being and relationships. Pharmacotherapy, including options like flibanserin and bremelanotide, is essential within a multidisciplinary approach. Validated tools and objective measures inform tailored premenopausal HSDD care plans and aid in striking a balance between potential risks and adverse effects while maximizing meaningful clinical benefits, including for transgender individuals.

CONCLUSIONS

Clinicians must discern important distinctions between flibanserin, bremelanotide, and other agents when managing premenopausal HSDD. Further research with the most suitable clinical endpoints and consideration of patient factors are crucial before widespread adoption of flibanserin and bremelanotide. Pharmacists are encouraged to embrace this opportunity to provide premenopausal HSDD care in ambulatory and community practice settings.

"Society Isn't Designed for Us to Win": Trauma and Sexual Healthcare Experiences Among Transgender Women in the Southeastern United States

Transgender women (TGW) are disproportionately affected by sexually transmitted infections (STIs). Experienced trauma threatens TGW's commitment to sexual healthcare. Trauma-informed approaches to sexual healthcare can improve engagement. This study aimed to characterize the trauma experienced by TGW in the Southeastern US, especially related to sexual health. TGW completed in-depth individual interviews guided by the Modified Social Ecological Model (MSEM) and Minority Stress framework. Interviews explored the nature of trauma, sexual health, and their intersection in TGW's lives, and a thematic analysis was performed. Between August 2022 and January 2023, 13 TGW enrolled (69% Black, 31% White). Mental illness was common (77%). Five participants (38%) were HIV+, and seven (54%) reported lifetime STI history. Themes reflected societal (barriers to healthcare, anti-transgender legislation), community (misgendering/deadnaming), network (limited support), and individual (dysphoria, sex work, fear for physical safety, stigma, mental health conditions, race) stressors. The physical/sexual violence and resilience themes pervaded all stressor levels. Medical mistrust was exacerbated by past traumatic experiences within sexual healthcare settings. Resilience and transgender representation in healthcare settings were protective. Various experienced traumas and their cumulative effects were pervasive in the daily lives of TGW. Development of targeted interventions to improve sexual health engagement of TGW must optimize personal strengths and provide holistic support.

Using a novel and validated survey tool to analyze sexual functioning following vaginoplasty in transgender individuals

Background In the healthcare setting, transgender patients are often marginalized, face discrimination and have limited access to high-quality gender-affirming care, such as gender-affirming surgery (GAS). As a result, the available data pertaining to GAS are often based on convenience samples, and the majority of published studies in the US are cross-sectional. Transgender people may undergo GAS to align their bodies with their gender identities. There has been little emphasis on the GAS self-evaluated experience. GAS may be associated with improved quality of life in transgender people. This study aimed to analyze the functionality of transgender patients' genitals following vaginoplasty. Methods A total of 306 transgender patients responded to a validated survey for patient-reported feminizing GAS outcomes. Surveys were given to patients prior to GAS, and then 2weeks, 6months and 12months postoperatively. Pre- and post-GAS responses were compared using McNemar and Wilcoxon signed-rank tests. Self-identified race/ethnicity was available for all survey participants. All participants voluntarily took the same survey by using the same survey platform to eliminate bias. Results Five questions showed significant improvement between the 2-week and 6-month responses. These questions assessed if respondents had sensation in their clitoris (P =0.031), the frequency that clitoral stimulation was pleasurable (P =0.018), the presence of sexual activity in the past 3months (P P =0.031) and if labial irritation while walking or exercising decreased (P =0.051). Significant differences were not detected between the 6-month and 12-month responses for any of the survey questions. Conclusions The results of five different metrics regarding sexual activity and vaginal functioning showed a significant improvement for transgender people following GAS. Findings also similarly demonstrate a high success rate of sexual activity after GAS. These are significant patient-reported outcomes using tools validated for the transgender population. Respondent outcomes significantly improved between the 2-week and 6-month time period, but did not differ between the 6-month and 12-month period, suggesting the ideal time to assess the above-described patient-perceived outcomes with vaginoplasty is 6months postoperatively.

Surgical Treatment of Transgender and Gender-Diverse Individuals and Health Outcomes

Gender affirming surgeries are procedures that are used by transgender and gender diverse individuals to align their bodies to their gender identities. These have been shown to improve the mental health and wellbeing of those individuals who choose to access them. Rates of regret associated with gender affirming surgeries are low, and in addition to improving mental health and quality of life, these procedures have the potential to make it safer for transgender and gender diverse people to move through the world. This article provides a narrative review that places gender affirming surgeries in the current sociopolitical context of the United States. It describes common types of gender affirming surgery, protocols for surgical assessment, and the risks and benefits of surgery.

The use of peritoneum in female genital gender-affirming surgery: A systematic review

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen. Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty. Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8cm and width of 3.5cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty. This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.

Sexual health in transgender and gender diverse people

PURPOSE OF REVIEW

Sexual health and sexual function are critical to the wellbeing of cisgender, transgender, and gender diverse populations. To date, there has been only limited patient-focused evaluation of sexual function in transgender and gender diverse patients at several stages in their gender-affirming medical care. There remains a need to better understand the impact of gender affirming medical and surgical therapy on sexual health, and to develop evidence-based treatments to address sexual dysfunction when present.

RECENT FINDINGS

The impact of gender-affirming hormone therapy on sexual health is complex and evolves over time on treatment. Despite high incidences of complications, major genital gender-affirming surgeries such as vulvovaginoplasty and penile implant placement after phalloplasty yield high patient satisfaction. While treatments to preserve or restore erections and to improve vaginal lubrication have been trialed based upon literature in cisgender populations, there remains minimal evidence to guide medical treatment of sexual dysfunction ranging from erectile dysfunction to dyspareunia.

SUMMARY

There is a continued need for ongoing efforts to develop patient-reported outcome measures and rigorous investigation of sexual health preservation and restoration treatments in transgender and gender diverse populations.

Preventive and Sexual Health in LGBTQ+ Older Adults

Sexual health is an important but often overlooked health concern of LGBTQ + older adults. Multiple factors influence sexual health including intersecting identities; adverse life events; coping mechanisms; and psychological, social, and physical health domains. Thus, the use of a culturally competent and comprehensive person-centered approach to sexual health is warranted. In this review, we discuss approaches to engaging LGBTQ + older adults to ensure they are able to achieve their sexual health priorities and prevent new human immunodeficiency virus infections. We also discuss doxycycline postexposure prophylaxis to prevent other sexually transmitted infections and the impact of chemsex.

The Effect of Obesity on Vaginoplasty Outcomes

BACKGROUND

Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques.

METHODS

A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected.

RESULTS

A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001).

CONCLUSIONS

Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

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.

Does Genital Self-image Correspond with Sexual Health before and after Vaginoplasty?

Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty.

Methods

A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction.

Results

A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort.

Conclusions

Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.

Gender Affirmation Surgery, Transfeminine

Feminizing genital surgery for transgender women is a feasible and fulfilling intervention in alleviating gender dysphoria. Several techniques in neovaginal creation can be offered, including vulvoplasty, penile skin inversion vaginoplasty, peritoneal vaginoplasty, and enteric vaginoplasty. Complication rates are low and often managed conservatively. Favorable sexual function outcomes indicate high satisfaction rates.