Introduction
Sexual health is multifactorial and is heavily intertwined with other aspects of one’s health status as well as quality of life [
1]. Sexual dysfunction is multifactorial and can be attributed to both external and internal factors, both of which can be distressing and at times debilitating to the individual experiencing it [
2]. In current literature, sexual dysfunction is often discussed in four categories: lack of desire, orgasm/ejaculatory dysfunction, arousal dysfunction, and sexually related pain and further categorized by ICD and DSM-5 diagnoses [
3,
4].
In a meta-analysis assessing sexual dysfunction, the prevalence was 31% in cisgender men and 41% in cisgender women [
5]. Notably, the results of the studies in this meta analysis vary due to the different forms of measuring sexual function as there is no current gold standard for either sex. In determining the prevalence of sexual dysfunction in the transgender and gender diverse population, the data is much more limited and methods of assessment sparse. Transgender and gender diverse individuals (TGDI) are people whose gender identity is not in line with their sex [
6]. TGDI is an umbrella term and can include several groups of people including transmasculine, transfeminine, and non-binary individuals [
7]. Transitioning is not a requirement for being transgender, and can be social, medical and/or surgical. 1.3 million people in the United States identify as transgender [
8]. Nevertheless, disparities are stark and sexual health is not an exception. In a large survey study assessing 27,715 transgender persons in 2015, both transgender men and women frequently reported delaying health care utilization due to the fear of discrimination and past experiences of discrimination [
6]. To further analyze these disparities, the European Network for the Investigation of Gender Incongruence (ENIGI) came together as a multicenter establishment to study gender incongruence prospectively [
9]. One study from this network demonstrated a decrease in sexual aversion with trans affirming care, both medical and surgical.
The goal of trans-affirming care is to reduce gender dysphoria and affirm TGDI in who they are via medically necessary interventions. Gender dysphoria is a feeling of distress experienced by those whose gender assigned at birth is not in line with their gender identity [
7]. While social transition to the desired gender can suffice for some, medical and surgical interventions are often sought out to achieve gender euphoria, the decrease or absence of gender dysphoria [
3]. Often, issues with sexual function and satisfaction can trigger gender dysphoria, especially prior to social, medical, or surgical transition. Nevertheless, this is not to say that issues surrounding sexual function and satisfaction cannot occur post-transition of any kind for the TGDI community.
Many validated sexual satisfaction and function surveys exist for cisgender individuals. These include the Sexual Health Inventory for Men (SHIM), the Index of Male Genital Self Image (IMGSI), Female Sexual Function Index (FSFI), the Female Sexual Distress Scale, and the Female Genital Self-Image Scale (FGSIS) [
10‐
14]. Due to the differences in anatomy and life experience between cisgender and transgender individuals, these surveys cannot capture several aspects of function and experience for TGDI. For example, satisfaction with vaginal width and depth as well as genital self image of the vulva is not addressed in any of the available surveys [
15•]. Therefore, surveys are needed to be created and validated among TGDI, not only for assessment, but also for progression of surgical techniques, establishment of longitudinal post-operative care, and betterment of overall sexual health.
In this chapter we will discuss sexual function and dysfunction for TGDI. This will include the current evidence based research surrounding the topic, anatomic and hormonal considerations, pre and post-operative considerations, and future directions. Throughout the text, the authors will refer to trans men and trans women within the binary, albeit known that gender exists on a spectrum.
Prior to Medical and/or Surgical Affirming Treatments
Several factors, both mental and physical, must be considered when assessing for sexual dysfunction in TGDI prior to medical or surgical intervention as these factors contribute to one’s gender dysphoria. A systematic review of 44 studies analyzed data on sexual satisfaction, desire, arousal, orgasm, and pain [
16•]. Generally, studies found that a healthy and positive relationship can have a positive impact on general sexual function, orgasm frequency and associated pleasure [
17].
Trans Men
In a survey study of 170 trans men prior to medical or surgical intervention, 42.9% experienced low sexual desire and 28.6% experienced sexual aversion [
9]. Distress surrounding sexual activity or one’s own sexual health, which may or may not include individual anatomy, may impact general sexual satisfaction [
17,
18]. Thus, those experiencing high levels of gender dysphoria may have lower levels of sexual satisfaction. Dissatisfaction with one’s body, or body dysmorphia can heavily contribute to sexual dysfunction and plays a large role in gender dysphoria [
3]. Specifically, one study of 141 trans men demonstrated a connection between body dysmorphia and difficulty with sexual arousal in 91% of participants [
18].
Orgasm, or climax, differs per the individual and can be affected by a multitude of factors, sometimes resulting in differing intensities or its absence. While in some cases dysfunction of the orgasm is psychological in nature, in other cases it can be iatrogenic with antidepressants as a common culprit [
6]. Gender dysphoria, which is often tied to depression, is often implicated in dysfunction of orgasm in trans men. One study including 211 trans men prior to medical or surgical intervention showed a 42.9% rate of difficulty with orgasm that affected their daily life [
9].
The experience of pain in association with sexual activity can be extremely detrimental to one’s view of intimacy and overall sexual health. While there is not much data on sexual pain in trans men, one study found that 12% of 211 participants reported pain at the same frequency before and after genital reconstruction surgery [
9]. Multiple studies found that pelvic pain was the most prevalent pain experienced prior to testosterone use [
19,
20]. In one study of 351 participants, 98.3% experienced some amount of pelvic pain prior to testosterone. Of note, another study found that history of pain with orgasm prior to testosterone initiation and persistent menstruation with testosterone were both predictors of pelvic pain after testosterone initiation [
20]. Pelvic floor dysfunction remains a possibility that has not been well studied and may contribute to pelvic pain.
Trans Women
Gender affirming care is known to alleviate general distress including, but not limited to distress associated with sexual dysfunction. One study surveyed multiple treatment groups of transgender women including those with no history of hormone therapy or genital reconstruction, those who had initiated hormone therapy, and those who had undergone vaginoplasty. Those who had not undergone medical or surgical treatment had more difficulty initiating and seeking sexual contacts (40%), fear of sexual contacts (33.3%), difficulty with arousal (33.3%), and pain during sexual intercourse (28.6%) compared to those who had initiated hormone therapy (34.1%, 18.8%, 32.6%, 11.4%) and those who had undergone vaginoplasty (23%, 20.8%, 15.9%, 27.1%), respectively [
9].
In investigating the ability to achieve orgasm prior to initiation of hormonal or surgical treatment, dysfunction occurred in 46.7% of 29 participants [
9]. Dysfunction in this setting may be attributable to distress surrounding orgasm with natal anatomy as well as difficulty achieving orgasm. In the same study
, 12% of participants expressed distress associated with ejaculation. Another study of 208 trans women who had not initiated hormone therapy reported that 18.3% of participants had never experienced a pleasant orgasm [
21].
Conclusion
Both medical and surgical affirmation care is improving with the overall goal of reducing gender dysphoria. Nevertheless, there are multiple areas for growth. Trans men and women undergo medical and surgical transitions in ways that affect sexual function and satisfaction. These sexual experiences can be directly correlated to gender affirming medical and surgical interventions. Overall, despite medical and specifically surgical complications, satisfaction with transition and sexual health is high. To better assess sexual health in this community, the authors stress the importance of tools to evaluate all aspects of sexual function and satisfaction that are unique to the TGDI population.
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