Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery?

INTRODUCTION: For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used. OBJECTIVE: This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population. METHODS: Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX. RESULTS: Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors. CONCLUSION: Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.

Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know.

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.

Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States.

BACKGROUND: A rising number of female-affirmed transgender adolescents are being treated with gonadotropin-releasing hormone analogues and subsequently cross-sex hormones at early or mid-puberty, with vaginoplasty as the presumed final step in their physical transition. But, despite the minimum age of 18 years defining eligibility to undergo this irreversible procedure, anecdotal reports have shown that vaginoplasties are being performed on minors by surgeons in the United States, thereby contravening the World Professional Association for Transgender Health (WPATH) standards of care (SOC). AIM: To explore surgeons' attitudes toward ethical guidelines in the SOC; any professional experiences of performing vaginoplasty on transgender minors; views of surgical risks, benefits, and harm reduction measures; and perceptions of future challenges and concerns in this area of surgical practice. METHODS: A qualitative semistructured interview approach was used to collect data from 13 male and 7 female surgeons who perform transgender vaginoplasty in the United States. OUTCOMES: Professional experiences and attitudes toward vaginoplasty in transgender minors were analyzed using the constant comparative method applied to 20 individual interview transcripts. RESULTS: While there was close agreement concerning surgical techniques, proper patient selection, and predictive elements of postoperative success, attitudes toward the SOC and the reliance on the guidelines varied. The sole practitioner model is gradually giving way to a more holistic team approach, with patient responsibility dispersed among different professionals. Different approaches to surgical training, professional standards, and fellowship programs were suggested. Several participants expressed a need for centralized data collection, patient tracking, and increased involvement of the WPATH as a sponsor of studies in this emergent population. CLINICAL IMPLICATIONS: Drawing on surgeons' attitudes and experiences is essential for the development of standards and practices. A more precise and transparent view of this surgical procedure will be essential in contributing to the updated version 8 of the WPATH SOC. STRENGTHS AND LIMITATIONS: The abundant data elicited from the interviews address several meaningful research questions, most importantly patient selection criteria, surgical methods, and issues critical to the future of the profession. Nevertheless, the limited sample might not be representative of the surgical cadre at large, particularly when exploring experiences and attitudes toward vaginoplasty in minors. A larger participant pool representing WPATH-affiliated surgeons outside the United States would improve the generalizability of the study. CONCLUSION: Taken together, the study and its findings make a significant contribution to the planned revision of the WPATH SOC. Milrod C, Karasic DH. Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States. J Sex Med 2017;14:624-634.

[The social background of male to female transsexuals]. / Der soziale Rahmen und Hintergrund von Mann-zu-Frau-Transsexualität.

Gender alignment surgery was introduced into German law in 1981. Judicial guidelines for the change of first names and gender were established and transsexuality was labelled as a psychosomatic and somatopsychic syndrome and disorder, thus opening the way for treatment to the social health-care under well-defined conditions requesting cross-dressing and hormone therapy as well as psychological counselling by 2 independent psychologists or psychiatrists. In a retrospective, chart-related survey of questionnaires on male to female transsexuals it was found that patients start to suspect being born into the wrong gender at the onset of puberty, it takes them however approximately 20 years to have gender alignment surgery. More than half the patients are single at this time, while the remaining group is married or divorced with equal rates. 68% regard themselves as heterosexual, 21% lesbian and 11% were undecided. About half the patients experienced support by their families for their decision. Despite numerous secondary corrections of the surgical alignment, patients were content with the result, although emotional acceptance of the desired result took about one year. In general plastic surgical gender alignment treatment was perceived as the major contribution to harmonise their phenotype with their identity.

Voice and physical appearance in female-to-male transsexuals.

The study aims to investigate if a similar interaction between physical appearance and voice could be found in female-to-male transsexuals as had been observed in male-to-female transsexuals. A panel of judges rated "maleness" of seven female-to-male transsexuals from video-recorded speech samples using three modes of presentation: auditory-only presentation, visual-only presentation, and audiovisual presentation. For the group of transsexuals as a whole, no significant differences were found between scores given in the auditory-only mode or the visual-only mode and those given in the audiovisual mode. Analysis of individual results, however, yielded significant differences in some individuals and there was some relation with hormone treatment. There was no significant correlation between the ratings of "maleness" in the auditory-only mode and fundamental frequency. Physical appearance in female-to-male transsexuals appears not to be a strong influencing factor in general, but may interact with gender recognition based on the voice in some individuals. The absence of a correlation between fundamental frequency and rating of maleness could mean that in female-to-male transsexuals, fundamental frequency is a relatively less important factor for gender expression or perhaps also that a higher voice in males is more accepted than a lower voice in females.

Transsexualism: a review of etiology, diagnosis and treatment.

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.