Living without Partnered Sex in Germany. Results From the First Representative, Population-based German Health and Sexuality Survey (GeSiD).

Broader insights into the life situations of sexually inactive adults in Germany are widely unexplored. Within the nationally-representative survey GeSiD (German Health and Sexuality Survey), undertaken 2018-2019, data of 4,758 participants with lifetime interpersonal sexual experience aged 18-75 years (men: n = 2234; women: n = 2524) were analyzed in regards to partnered sexual inactivity in the past 12 months (PSI; no genital-involving sexual contact with another person). Overall, advanced age, being single and impaired health conditions were associated with PSI. Data showed gender-specific associations with PSI, such as less alcohol, smoking and drug use in women. PSI was associated with lower general life satisfaction throughout different age groups.

Factors associated with non-use of condoms among heterosexually-active single people in Germany: Results from the first representative, population-based German health and sexuality survey (GeSiD).

Background: Against the backdrop of rising STI incidence among the heterosexual population, sexually active single people are at particularly high STI transmission risk. Gaining insight into circumstances related to condoms non-use in this population is therefore important for developing effective health interventions. Methods: The nationally-representative survey, GeSiD (German Health and Sexuality Survey) undertaken 2018-2019, interviewed 4,955 people aged 18-75 years. A total of 343 heterosexually-active single participants answered a question about condom use at last sex. Data on sociodemographic characteristics, sexual behaviours and circumstances of last sex were analysed to identify independently associated factors. Results: Condom non-use at last sex was reported more commonly by participants aged >35 years than by younger participants (48.5 vs 33.7%, respectively) and more likely among longer relationships (adjusted odds ratio [AOR]: 2.43) or early loving relationships (AOR: 3.59) than in one-night-stands. It was also associated with not discussing using condoms before sex (AOR: 6.50) and with reporting non-use of condoms at sexual debut (AOR: 4.75). Conclusions: Non-use of condoms is a common STI risk behaviour among heterosexually-active single people in Germany and so needs promoting from sexual debut throughout the life course, regardless of relationship type and age, but particularly among middle-aged and older people.

[The German health and sexuality survey (GeSiD)-a brief introduction to the study]. / Die GeSiD-Studie "Gesundheit und Sexualität in Deutschland" ­ eine kurze Einführung.

Until 2020, there was no representative sex survey for Germany with published data. The GeSiD study "Health and Sexuality in Germany" is the first nationwide, representative sex survey. The aim of this paper is to provide a brief introduction to the German health and sexuality (GeSiD) survey.A total of 4955 persons (2336 men, 2619 women) aged 18-75 years were interviewed between 2018 and 2019. The computer-assisted face-to-face interviews had an extensive self-completion section and asked about a wide range of sexual behaviour and sexual health topics. Data on sexual identity, relationships, sexual behaviour, and sexual health were assessed. Data show, among other things, that only a minority of respondents had ever talked to a healthcare provider about HIV/AIDS or other sexually transmitted infections (STIs).Data show a clear need for education, information dissemination, and training in the area of sexual health.

Single and Multiple Orgasm Experience Among Women in Heterosexual Partnerships. Results of the German Health and Sexuality Survey (GeSiD).

BACKGROUND: Orgasm occurrence plays an important role in general sexual satisfaction for women. Until now, only few studies have focused on examining a broad spectrum of sexuality- and relationship-specific factors associated with orgasm in heterosexual women currently in a long-term relationship or on differences between the overall experience of orgasm and multiple orgasms. AIM: The present study aims to understand how various sexuality- and relationship-associated factors are related to experiencing partnered orgasm among heterosexual women having stable relationships in Germany. Moreover, the study aims to differentiate between the overall experience of orgasm and the experience of multiple orgasms and shed light on their impact on general sexual satisfaction. METHODS: Within the nationwide representative survey GeSiD (German Health and Sexuality Survey), n = 1,641 sexually active women aged between 18 and 75 years in heterosexual relationships reported their experience of orgasm during the latest sexual encounter. Data on the type of sexual practices, frequency of sexual activity and of masturbation, relationship satisfaction, feelings of love, closeness, and general sexual satisfaction were analyzed. OUTCOMES: The overall experience of orgasm, the experience of multiple orgasms, and associations between experiencing orgasm and sexual satisfaction. RESULTS: Frequency of sexual activity, relationship satisfaction, feelings of love and closeness were moderately to strongly positively correlated with each other and each showed positive associations with the likelihood of orgasm. Greater number of sexual practices and frequency of sexual activity were associated with an increased likelihood of experiencing multiple orgasms, which in turn was correlated with higher sexual satisfaction. CLINICAL IMPLICATIONS: In clinical and therapeutic work with women who have difficulty achieving orgasm, central issues should be the perceived relationship quality as well as regular sexual activity with the partner. STRENGTHS & LIMITATIONS: The present population-representative study is the first in Germany to identify significant factors associated with the experience of orgasm among heterosexual women in relationships. Further studies ought to include the frequency of orgasms in partnered sex over a longer period of time as well as the experience of orgasm during masturbation. CONCLUSION: The experience of orgasm for women is related to a variety of complex interpersonal mechanisms and to be associated with sexual satisfaction. Cerwenka S, Dekker A, Pietras L, et al. Single and Multiple Orgasm Experience Among Women in Heterosexual Partnerships. Results of the German Health and Sexuality Survey (GeSiD). J Sex Med 2021;18:2028-2038.

[How good is the knowledge about sexually transmitted infections in Germany? : Results of the first nationwide representative German health and sexuality survey (GeSiD)]. / Wie gut ist das Wissen über sexuell übertragbare Infektionen in Deutschland? : Ergebnisse der ersten bundesweiten repräsentativen Befragung zu Gesundheit und Sexualität (GeSiD).

BACKGROUND: Sexually transmitted infections (STIs) are a relevant risk factor for the sexual health of individuals and the population. Therefore, the level of awareness and knowledge about STIs in different population groups is of particular interest for specific prevention work. OBJECTIVES: The aim of this study was to analyze the awareness of and knowledge about nine STIs in the German population. To do so, the study examined correlations with sociodemographic variables, sexuality-related characteristics, and subjective satisfaction with the level of information. METHODS: The GeSiD study "German Health and Sexuality Survey" collected representative quantitative data from 4955 persons via face-to-face interviews on the state of knowledge about STIs. As a selection procedure, a two-step random sample was collected. Firstly, 200 sample points (municipalities) were initially selected proportionally across Germany. Secondly, a random sample of addresses was drawn from the respective residents' registration offices. The participation rate was 30.2%; the average age was 46.3 years. RESULTS: Knowledge about HIV/AIDS was widespread in all age groups, but other STIs were significantly less known. Older people and respondents with a low level of education were particularly poorly informed. Local social disadvantage and a family history of migration were also negatively correlated with knowledge about STIs. A higher number of sexual partners is related to a better level of knowledge. In addition, persons who do not describe their sexual orientation as heterosexual as well as those with a history of STIs were well informed. CONCLUSION: Heterosexual adults in Germany are insufficiently informed about the risks of STIs. Therefore, target-group-specific efforts are needed to improve knowledge about STIs in order to reduce sexual risk behavior and improve the utilization of prevention programs among socially disadvantaged groups.

Methodology of the German National Sex Survey - GeSiD (German Health and Sexuality Survey).

The German Health and Sexuality Survey (GeSiD) was carried out in 2018/2019 to provide up-to-date measures of sexual behavior, sexual attitudes and sexual lifestyles of the adult population. We describe the methods used in GeSiD which surveyed the general population in Germany aged 18-75 years (with oversampling of younger adults aged 18-35 years). This article focuses on study design, recruitment, and response rate and discusses the strategies implemented to enhance the response rate compared to the pilot study. Overall, 4.955 interviews were completed with a response rate of 30.2%. The data were weighted by age, gender, education, nationality, and region to reduce possible bias. Compared to the German 2018 census, the weighted sample provides good representativeness for selected respondent characteristics. The computer-assisted interviews consisted of a combination of face-to-face and self-completion components. They covered a broad perspective on sexual health, which included topics such as online sexual activities, pleasure, sexual dysfunction, and sexual violence. Reliable data on sexual and reproductive health in Germany are urgently needed for evidence-based prevention and health promotion work, to inform sexual health policy and for cross-national comparisons of the development of sexual behavior in Europe.

Health, Sexual Activity, and Sexual Satisfaction.

BACKGROUND: Physical and mental health disorders can markedly affect sexual activity and sexual satisfaction. Until now, there has been a lack of representative data from the German population that could serve as a basis for demonstrating specific links between sexuality and health. METHODS: In the German Health and Sexuality Survey (GeSiD), 4955 men and women in a two-step stratified random sample drawn from local resident registration offices across Germany were surveyed by questionnaire. The response rate was 30.2%. The questions involved, among other things, the respondents' selfassessment of sexual activity and sexual satisfaction, general health status, and any chronic illnesses or disabilities. RESULTS: The percentage of respondents who reported having been sexually active with one partner in the past four weeks was highest among men aged 36 to 45 and women aged 26 to 35. In male respondents, the likelyhood of having been sexually active in the past four weeks decreased from 79.1% to 59.0% and 30.1%, respec - tively, if they described their own health status as fair or bad compared with those in very good health. In female respondents the decrease was from 72.5 % to 48.0 % and 32.4%, respectively. A comparable association was found with self-reported chronic illnesses and disabilities that were perceived as impairing sexuality. Sexual satisfaction was present to a similar extent in all age groups. CONCLUSION: Self-reported physical and mental illnesses are often associated with marked impairment of sexuality. Even illnesses without any immediately evident relation to sexuality often affect aspects of sexual health. It is, therefore, advisable for physicians to address their patients' sexuality routinely in everyday clinical practice.

[Heterosexual Practices in Different Generations - Findings of a Pilot Study for "GeSiD Gesundheit und Sexualität in Deutschland (Health and Sexuality in Germany)"]. / Heterosexuelle Praktiken in unterschiedlichen Generationen ­ Ergebnisse einer Pilotstudie zu "GeSiD Gesundheit und Sexualität in Deutschland".

OBJECTIVES: There is a lack of broad representative data in Germany in order to analyze the lifetime experiences of heterosexual adults with different sexual practices. Differences between generations were investigated with regard to whether specific sexual experiences were more common in the generation aged from 18 to 30 years (the Digital Natives) than in the older generations, particularly referring to the generation of the 61- to 75-year-olds, whose sexual socialization was not yet embedded into the presence of new media. For young adults it was analyzed to what extent diversifications of the sexual repertoire can be depicted. METHODS: In a pilot-study (2) for GeSiD - Gesundheit und Sexualität in Deutschland (Health and Sexuality in Germany) - in 2017, a representative survey was carried out on 1155 persons aged from 18 to 75 years. Data from heterosexual men and women regarding lifetime experiences with different sexual practices and sexuality-related experiences were analyzed. RESULTS: In the generation of the 18 to 30 year olds, experiences with oral practices and the use of a dildo/vibrator were more common in women as well as sadomasochistic/BDSM-practices in both women and men compared with older generations. While in women there were hardly any differences between the 18 to 25 year olds and the 26 to 30 year olds, a higher percentage of young men revealed having not made a variety of sexual experiences. Oral practices, active anal stimulation and sexual role play were reported slightly more often by 26 to 30 year old men than by older ones. In the generation of the 61 to 75 year olds, experiences with oral and manual practices were reported less commonly by women as well as anal practices and the use of a dildo/vibrator by women and men in comparison with younger generations. DISCUSSION: The ongoing process of digital revolution at the end of the 20th century induced a fundamental societal change, which is also reflected in different ranges of sexual experiences in the generations. CONCLUSION: The results allow first insights into heterosexual practices among different generations in Germany that may provide valuable clues for the steering of information and education campaigns as well as a psychoeducational basis for couple and sex therapy work.

[Treatment Experiences and Social Support in Individuals with Gender Incongruence/Gender Dysphoria - A ENIGI 5 Year Follow-Up Study in Three European Countries]. / Behandlungserfahrungen und soziale Unterstützung bei Personen mit Geschlechtsinkongruenz/Geschlechtsdysphorie: Eine ENIGI 5-Jahres-Follow-Up-Studie in drei europäischen Ländern.

INTRODUCTION: Gender Dysphoria (GD) refers to a distress resulting from an incongruence between the individual's sex characteristics and the experience of their gender (Gender Incongruence, GI). The interaction between medical treatment of GI/GD and social support in the long-term has not been investigated sufficiently so far. MATERIAL & METHODS: Using an online questionnaire, the present study investigated n=117 individuals with GI/GD assigned male and n=52 assigned female at birth that had been referred to one of the specialized clinics of the European Network for the Investigation of Gender Incongruence (ENIGI) in Belgium, the Netherlands, and Germany.They filled out a questionnaire at 2 time points within a follow-up time of 4 to 6 years after clinical entry (between 2007 and 2009). Two hierarchical regression analyses explored the effects of the sex assigned at birth, the treatment progress and social support on mental distress and satisfaction with life at follow-up in the sample. RESULTS: A female sex assigned at birth and higher degrees of social support significantly predicted the reduction in mental distress at follow-up. An advanced stage of the individual treatment and higher social support significantly predicted an increase in overall satisfaction with life. DISCUSSION: The results illustrate the importance of social support with regard to the outcome of medical treatment of GI/GD.

Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study.

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR = 6.07). Satisfied respondents' QoL scores were similar to reference values; dissatisfied or regretful respondents' scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

Effects of Medical Interventions on Gender Dysphoria and Body Image: A Follow-Up Study.

OBJECTIVE: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. METHODS: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). RESULTS: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. CONCLUSIONS: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults.

This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.

Body Satisfaction and Physical Appearance in Gender Dysphoria.

Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.

Body Image in Young Gender Dysphoric Adults: A European Multi-Center Study.

The alteration of sex-specific body features and the establishment of a satisfactory body image are known to be particularly relevant for individuals with Gender Dysphoria (GD). The aim of the study was to first develop new scales and examine the psychometric properties of the Hamburg Body Drawing Scale (Appelt & Strauß 1988). For the second part of this study, the satisfaction with different body features in young GD adults before cross-sex treatment were compared to female and male controls. Data collection took place within the context of the European Network for the Investigation of Gender Incongruence (ENIGI) including 135 female-to-male (FtMs) and 115 male-to-female (MtFs) young GD adults and 235 female and 379 male age-adjusted controls. The five female and six male body feature subscales revealed good internal consistency. The ENIGI sample reported less satisfaction with overall appearance (d = 0.30) and with all of their body features than controls, but no subgroup differences for sexual orientation (FtM and MtF) and Age of Onset (FtM) were found. Body dissatisfaction was higher with regard to sex-specific body features (largest effect sizes of d = 3.21 for Genitalia in FtMs and d = 2.85 for Androgen-responsive features and genitalia in MtFs) than with those that appeared less related to the natal sex (d = 0.64 for Facial features in FtMs and d = 0.59 for Body shape in MtFs). Not only medical body modifying interventions, but also psychosocial guidance with regard to body image might be helpful for GD individuals before transitioning.

Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study.

A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.

Psychiatric characteristics in transsexual individuals: multicentre study in four European countries.

BACKGROUND: Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results. AIMS: To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder. METHOD: Data were collected within the European Network for the Investigation of Gender Incongruence using the Mini International Neuropsychiatric Interview - Plus and the Structured Clinical Interview for DSM-IV Axis II Disorders (n = 305). RESULTS: In 38% of the individuals with gender identity disorder a current DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and anxiety disorders. Furthermore, almost 70% had a current and lifetime diagnosis. All four countries showed a similar prevalence, except for affective and anxiety disorders, and no difference was found between individuals with early-onset and late-onset disorder. An Axis II diagnosis was found in 15% of all individuals with gender identity disorder, which is comparable to the general population. CONCLUSIONS: People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.

[Sexual orientation and partner-choice of transsexual women and men before gender-confirming interventions]. / Sexuelle Orientierung und Partnerwahl transsexueller Frauen und Männer vor körpermedizinischen geschlechtsanpassenden Maßnahmen.

Diverse partner relationship constellations of gender dysphoric women and men with different sexual orientations are explored in a sample of 93 persons before gender-confirming interventions in persons with female gender identity and male body characteristics (MF) and persons with male gender identity and female body characteristics (FM). While in both gender groups the majority is single, relationship patterns show differences. Apart from working life, FM already live predominantly in the new, male gender role and have partners by whom they are desired as males. In contrast, only a small proportion of MF already conduct their private lives in the new, female gender role, and they often have relationships with partners sexually attracted to males and not to their female gender identity. The findings indicate a need for differing resources for gender dysphoric women and men in the process of a transsexual course of development.

Age of onset and sexual orientation in transsexual males and females.

INTRODUCTION: With regard to transsexual developments, onset age (OA) appears to be the starting point of different psychosexual pathways. AIM: To explore differences between transsexual adults with an early vs. late OA. METHODS: Data were collected within the European Network for the Investigation of Gender Incongruence using the Dutch Biographic Questionnaire on Transsexualism (Biografische Vragenlijst voor Transseksuelen) and a self-constructed score sheet according to the DSM-IV-TR (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) criteria of Gender Identity Disorder (GID) and Gender Identity Disorder in Childhood (GIDC). One hundred seventy participants were included in the analyses. MAIN OUTCOME MEASURES: Transsexual adults who, in addition to their GID diagnosis, also fulfilled criteria A and B of GIDC ("a strong cross-gender identification,""persistent discomfort about her or his assigned sex") retrospectively were considered as having an early onset (EO). Those who fulfilled neither criteria A nor B of GIDC were considered as having a late onset (LO). Participants who only fulfilled criterion A or B of GIDC were considered a residual (RES) group. RESULTS: The majority of female to males (FtMs) appeared to have an early OA (EO = 60 [77.9%] compared to LO = 10 [13%] and to RES = 7 [9.1%]). Within male to females (MtFs), percentages of EO and LO developments were more similar (EO = 36 [38.7%], LO = 45 [48.4%], RES = 12 [12.9%]). FtMs presented to gender clinics at an earlier age than MtFs (28.04 to 36.75). The number of EO vs. LO transsexual adults differed from country to country (Belgium, Germany, the Netherlands, Norway). CONCLUSION: OA has a discriminative value for transsexual developments and it would appear that retrospective diagnosis of GIDC criteria is a valid method of assessment. Differences in OA and sex ratio exist between European countries.