Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional.

SUMMARY: Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

The Co-occurrence of Gender Dysphoria and Autism Spectrum Disorder in Adults: An Analysis of Cross-Sectional and Clinical Chart Data.

Quantitative studies indicate an overrepresentation of ASD in individuals with GD. This study aims to determine the prevalence of autistic traits or ASD in adults with GD using two different data collection methods: (1) cross-sectional data using the social responsiveness scale-adults (SRS-A) and the autism quotient (AQ) (n = 63). (2) Clinical chart data (n = 532). Mean SRS-A scores were significantly higher compared to a norm population. Almost 5% of the patients with GD scored above the cut-off as measured by the AQ. In 32 patients (6%), a certain ASD diagnosis was found in the patient files, which is sixfold higher compared to the general population. Significantly more "birth assigned male" were affected compared to "birth assigned female".

Transgender Research in the 21st Century: A Selective Critical Review From a Neurocognitive Perspective.

Gender dysphoria describes the psychological distress caused by identifying with the sex opposite to the one assigned at birth. In recent years, much progress has been made in characterizing the needs of transgender persons wishing to transition to their preferred gender, thus helping to optimize care. This critical review of the literature examines their common mental health issues, several individual risk factors for psychiatric comorbidity, and current research on the underlying neurobiology. Prevalence rates of persons identifying as transgender and seeking help with transition have been rising steeply since 2000 across Western countries; the current U.S. estimate is 0.6%. Anxiety and depression are frequently observed both before and after transition, although there is some decrease afterward. Recent research has identified autistic traits in some transgender persons. Forty percent of transgender persons endorse suicidality, and the rate of self-injurious behavior and suicide are markedly higher than in the general population. Individual factors contributing to mental health in transgender persons include community attitudes, societal acceptance, and posttransition physical attractiveness. Neurobiologically, whereas structural MRI data are thus far inconsistent, functional MRI evidence in trans persons suggests changes in some brain areas concerned with olfaction and voice perception consistent with sexual identification, but here too, a definitive picture has yet to emerge. Mental health clinicians, together with other health specialists, have an increasing role in the assessment and treatment of gender dysphoria in transgender individuals.

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.

Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria.

The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.

The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey.

ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members' views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).

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.

Costs of pleasure and the benefits of pain: self-perceived genital sensation, anatomy and sexual dysfunction.

UNLABELLED: Background Research has highlighted the complex association between female sexual dysfunction (FSD) and distress regarding sexual activity, with decreased physical pleasure being an important mediator. The current study aims to elucidate the association between pleasurable and painful genital sensitivity and FSD, and to further investigate whether FSD may be distressing because it prevents the experience of sexual pleasure, induces pain or both. METHODS: Sexually active women (n=256; median, 22 years; range, 18-49 years) completed web-based questionnaires, including the Self-Assessment of Genital Anatomy and Sexual Function, the Female Sexual Function Index and the Female Sexual Distress Scale. RESULTS: Women reported their clitoris to be more sensitive than their vagina in terms of having more pleasurable responses (P<0.001), but not more painful responses (P=0.49). In women with FSD (n=36), impaired self-perceived genital sensation was found: they reported significantly less sexual pleasure and orgasm intensity, and more orgasm effort and discomfort within the clitoral and vaginal area than women without FSD (n=220) (P-value<0.05). The odds of having FSD were significantly greater in women with perceived increased discomfort in the vaginal area during stimulation (odds ratio=5.59, P=0.009, 95% confidence interval: 1.53-20.39), but not in the clitoral area. CONCLUSIONS: The data provide evidence of the relevance of self-perceived genital sensitivity to sexual pleasure and overall sexual experience. Enhancing the pleasurableness of genital sensations, especially during partnered sex, could decrease the likelihood of experiencing pain and concomitant FSD.

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.

Cycle-Related Changes in Mood, Sexual Desire, and Sexual Activity in Oral Contraception-Using and Nonhormonal-Contraception-Using Couples.

Findings on women's sexuality across the menstrual cycle are inconsistent. One relatively consistent finding is a midcycle and premenstrual peak in sexual desire in freely cycling women. Results on the cycle-related effects on sexual behavior are less clear. Large proportions of reproductive-aged women use combined oral contraception (COC), but studies on potential cycle-related shifts in sexual desire and behavior are sparse. A prospective diary study assessed sexual desire, sexual behavior, and mood in 89 heterosexual couples. Women were using one of four contraceptive methods: (1) nonhormonal contraception, (2) low-dose COC containing 20 mcg ethinylestradiol and 75 mcg gestoden or desogestrel, (3) COC containing 35 mcg ethinylestradiol and 2 mg cyproteronacetate, and (4) COC containing 30 mcg ethinylestradiol and 3 mg drospirenone. No cycle effects of sexual desire were established in the COC group, but frequency of sexual intercourse declined in the last days of active pill taking. These results were similar in both female and male partners. Negative affect did not covary with sexual desire.

Prevalence of Gender Nonconformity in Flanders, Belgium.

Gender nonconformity refers to the extent to which a person's gender identity, gender role and/or gender expression differs from the cultural norms prescribed for people of a particular sex, within a certain society and era. Most data on gender nonconformity focus on the prevalence of gender dysphoria (which also includes a distress factor) or on the number of legal sex changes. However, not every gender nonconforming individual experiences distress or applies for treatment. Population-based research on the broad spectrum of gender nonconformity is scarce and more information on the variance outside the gender binary is needed. This study aimed to examine the prevalence of gender incongruence (identifying stronger with the other sex than with the sex assigned at birth) and gender ambivalence (identifying equally with the other sex as with the sex assigned at birth) based on two population-based surveys, one of 1,832 Flemish persons and one of 2,472 sexual minority individuals in Flanders. In the general population, gender ambivalence was present in 2.2 % of male and 1.9 % of female participants, whereas gender incongruence was found in 0.7 % of men and 0.6 % of women. In sexual minority individuals, the prevalence of gender ambivalence and gender incongruence was 1.8 and 0.9 % in men and 4.1 and 2.1 % in women, respectively. With a current Flemish population of about 6 million, our results indicate a total of between 17,150 and 17,665 gender incongruent men and between 14,473 and 15,221 gender incongruent women in Flanders.

Sociodemographic Characteristics of Trans Persons in Belgium: A Secondary Data Analysis of Medical, State, and Social Data.

By performing secondary data analyses of existing medical, social, and state data, this study examined the sociodemographic profile of trans persons in Belgium and gains knowledge on those who are functionally invisible in traditional epidemiological studies or clinical samples. Based on medical interventions, post-operative transsexual persons were selected from a social survey data set, to compare their sociodemographic profile with available data on legal sex changes from the Belgian National Register and with published data on clinical samples of post-operative transsexual persons. Furthermore, based on self-chosen gender identity categories in the social survey data, transsexual participants were compared with the transgender participants (those people feeling neither female nor male, or both female and male, or otherwise). The sociodemographic data on the post-operative transsexual persons from the three datasets appeared to be very similar. Based on identity categories, the data on transsexual and transgender persons from the social survey showed differences in marital status and employment. Transsexual persons were significantly more often divorced than transgender persons. Both groups differed significantly in employment status. Information about transgender people (or the "in-between" group) is too often lacking from studies but can be obtained when identity instead of medical criteria are used in research.

Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study.

PURPOSE: Total phalloplasty is rarely performed today in males with severe penile deficiency, despite its successful use in the transgender population. Can phalloplasty replicate the complexity of penile anatomy and function on the long term? METHODS: Sexual quality of life (QoL) was assessed in 10 men (aged 20-43 years) at least 1 year after phalloplasty in a single institution (80 % radial forearm flap and 20 % anterolateral thigh flap). In all but one, an erectile prosthesis was implanted on average 1 year after phallic reconstruction. Sexual QoL outcomes were compared to those of men with hypospadias repair (n = 73) and control men (n = 50). RESULTS: After phalloplasty (mean 36.9 months, 14-92 months), all men were sexually active (80 % intercourse and 100 % masturbation with orgasm and ejaculation). However, 75 % indicated to be inhibited in seeking sexual contacts, compared to 40 % of hypospadias patients (p < 0.05) and 11 % of controls (p < 0.01). Although 90 % were satisfied with the final surgical result, dissatisfaction with some aspects of genital appearance was present in 50 %. Erogenous neophallus sensitivity was said to be less than previously hoped for. Six men developed urinary complications (urethral stricture and/or fistula), and one man underwent revision of the erectile implant because of dysfunction. Nevertheless, all indicated they would choose again for phalloplasty if necessary. CONCLUSIONS: Total phalloplasty opens new horizons for the treatment of men with penile deficiency, but limitations of the technique should be emphasized prior to surgery. An exploration of patient expectations and continued follow-up including psychological support is important for optimizing psychosexual comfort.

An update on surgical and non-surgical treatments for vaginal hypoplasia.

BACKGROUND: In women with vaginal hypoplasia, such as in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) and in Complete Androgen Insensitivity Syndrome (CAIS), surgical vaginoplasty and non-surgical self-dilation treatments are available to lengthen the vagina and facilitate sexual intercourse, but the best treatment remains controversial. Vaginal dilation has been recommended as a first-line treatment, because of its less invasive character and high success rate. However, the exploration of factors associated with compliance and long-term outcome is incomplete, including whether psychological counselling needs to be embedded in treatment to maximize efficacy. It is not known if failed vaginal dilation therapy jeopardizes further surgical success outcomes, especially because in a number of these procedures ongoing vaginal dilation is required. In addition, if surgery is needed, there is a lack of evidence to inform physicians regarding the optimum surgical technique to use. Also, it is unclear whether maintenance dilation therapy in case of sexual inactivity is crucial to ensure functional success. METHODS: In view of this ongoing debate, we performed a search of all published literature (English language only) restricted to the management of vaginal hypoplasia in patients with MRKH or CAIS from 1898 to March 2013 using Pubmed, Cochrane Library and Web of Science. Of the 6700 articles initially identified, a total of 190 studies are analysed. More specifically, by establishing the risk/efficacy profile (vaginal capacity, complications and long-term durability in terms of sexual function) of the different surgical and non-surgical reconstruction techniques, we evaluate if vaginal dilation proposed as the first-line technique is justified based on the evidence. RESULTS: When anatomical success was defined as a length of ≥7 cm and functional success as coitus, all vaginoplasty techniques yielded significantly higher success rates (>90 versus 75% after vaginal dilation), irrespective of underlying diagnosis or start vaginal length. When functional success was defined as 'satisfaction with sex', including non-genital sex, differences disappeared. Failed dilation therapy does not preclude anatomical (nor functional) success if vaginoplasty afterwards is necessary. Traction vaginoplasty seems to have the highest anatomical (99%) and functional success rates (96%), whereas both split- and full-thickness skin graft procedures and intestinal procedures have the lowest successful outcomes (83-95%). Overall, complication rates were significantly lower within the vaginal dilation groups when compared with the different vaginoplasty techniques. Although no randomized control data exist regarding maintenance dilation, the available evidence suggests that continued dilation is needed to maintain patency in periods of coital inactivity. Despite the expectancy that the probability of further positive outcomes is maximized with psychological counselling, this could not be confirmed. CONCLUSIONS: As the medical literature lacks high-quality comparative outcome studies and prospective, longitudinal studies are scarce, no evidence-based treatment guidelines can be provided. However, because of the physically low complication rate and an overall success chance of 75%, vaginal dilation as first choice treatment seems to be justified. Overall, the laparoscopic Vecchietti procedure, becoming more and more available in specialized centres, is considered an appropriate surgical option in patients who are poorly compliant and failed dilation therapy, or for those who do not want to start with vaginal dilation therapy. Future approaches need to raise a wider range of psychosexually oriented questions, elucidate the relationship between vaginal depth and satisfactory outcomes and gain additional experience concerning the format of acceptable and efficient psychological care.

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.

Vaginal dilation treatment in women with vaginal hypoplasia: a prospective one-year follow-up study.

OBJECTIVE: Vaginal dilation treatment has been shown to be a (cost) effective first-line alternative to surgery in normalizing vaginal length and improving sexual function in women with vaginal hypoplasia. There remains, however, a need for prospective studies, with long-term assessment of multiple outcomes. STUDY DESIGN: This was a prospective, single-centre observational study of 16 women with Mayer-Rokitansky-Küster-Hauser syndrome (n = 12) or 46,XY disorders of sex development (n = 4). All women underwent an outpatient vaginal dilation program supervised by a psychologist and physiotherapist. At baseline (T0), stop of treatment (T1) and 1 year follow-up (T2), semistructured interviews, and validated questionnaires assessed sexual function and distress, self-esteem, vaginal perceptions, and health-related quality of life. Gynecological examinations evaluated vaginal dimensions. RESULTS: Ten women completed the program, 3 are still in the program, and dilation failed in 3 and chose vaginoplasty. Sixty-nine percent reached a normal vaginal length (≥6.5 cm) in 5.8 ± 3.3 months. Seventy percent were sexually active with pleasurable experiences at T1, 57% at T2. The significant decrease in sexual distress at T1 (P < .05) was followed by a nonsignificant increase at T2. Depressive mood symptomatology remained high at T1 and T2, related to loss of bodily integrity and fertility. The majority refused further psychological counseling. CONCLUSION: Vaginal dilation treatment should remain the cornerstone of treatment in women with vaginal hypoplasia. However, the diagnosis remains to have a negative impact on emotional well-being in the long term. The role of psychological intervention as both a primary and adjuvant treatment needs clear evaluation.

Sexual desire in trans persons: associations with sex reassignment treatment.

INTRODUCTION: Sex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross-sex hormone therapy and sex reassignment surgery on sexual desire in trans persons. AIM: This study aims to explore associations between sex reassignment therapy (SRT) and sexual desire in a large cohort of trans persons. METHODS: A cross-sectional single specialized center study including 214 trans women (male-to-female trans persons) and 138 trans men (female-to-male trans persons). MAIN OUTCOME MEASURES: Questionnaires assessing demographics, medical history, frequency of sexual desire, hypoactive sexual desire disorder (HSDD), and treatment satisfaction. RESULTS: In retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy-three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it (P = 0.03). In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD (P = 0.02). Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD (P = 0.02). CONCLUSION: HSDD was more prevalent in trans women compared with trans men. The majority of trans women reported a decrease in sexual desire after SRT, whereas the opposite was observed in trans men. Our results show a significant sexual impact of surgical interventions and both hormonal and surgical treatment satisfaction on the sexual desire in trans persons.