Quality of Life and Satisfaction in Transgender Men After Phalloplasty in a Retrospective Study.

BACKGROUND: Partly as a result of the increasing attention directed toward transgender individuals and despite much research work on the topic of quality of life (QOL) of transgender, there is still a lack of studies using standardized questionnaires in their evaluation. AIMS: We designed a survey to evaluate the influence of surgery after phalloplasty (osteofasciocutaneous fibula free flap or osteofasciocutaneous radial free forearm flap) on QOL, emotional stability, self-esteem, and psyche of postoperated transgender men. METHODS: The present study included 32 transgender men who had undergone gender-affirming surgery (GAS) exclusively in our department between 2000 and 2012. Apart from our self-developed, indication-specific questionnaire with questions on socioeconomic and demographic data as well as postoperative satisfaction, the testing instrument included 4 frequently used, standardized testing instruments, which we compared with normative data. These included (a) a self-assessment test Fragebogen zur Lebenszufriedenheit with questions on QOL consisting of 3 modules (general satisfaction, satisfaction with health, and satisfaction with body image/outer appearance), (b) the Freiburg Personality Inventory, (c) the Rosenberg Self-Esteem Questionnaire, and (d) the Patient Health Questionnaire 4. FINDINGS: Our self-developed, indication-specific questionnaire showed that 88% of our patients were very satisfied with the aesthetic result, 75% have had sex after surgery, and 72% were very satisfied with sexual function after GAS. Eighty-one percent had a strong improvement of QOL, and 91% would undergo the same treatment again. Eighty-four percent would recommend GAS to others. All patients lived as men fulltime. DISCUSSION: Our study reveals that GAS plays an important part in the interdisciplinary treatment of transgender individuals as it improves the QOL in transgender men in most aspects of everyday life and has a positive influence on the patients' psyche and self-esteem in a retrospective study.

Psychological Pathologies and Sexual Orientation in Transgender Women Undergoing Gender Confirming Treatment.

BACKGROUND: There are few studies evaluating depression, self-esteem, and mental health after gender confirming treatment of transgender women. Most of these studies include different surgical techniques and nonvalidated questionnaires. With our survey, we are aiming to assess psychopathologies and mental health as well as sexuality among a group of patients treated by the same surgeon performing our self-developed combined surgical technique. This vaginoplasty approach is characterized by constructing the vaginal cavity with parts of the penile and scrotal skin as well as the longitudinally incised urethra. MATERIALS AND METHODS: Forty-seven transgender women who underwent gender confirming treatment between 2007 and 2013 were included in a retrospective study. The assessment of our study group was performed by means of self-developed indication-specific questionnaires and 3 standardized questionnaires that can be compared with norm data. RESULTS: Preoperative psychotherapy was mostly considered as helpful by the patients, yet postoperatively, only a third of our study participants were still under therapeutic treatment. Furthermore, we could show a change in sexual preference toward a more bisexual orientation. Gender confirming treatment satisfied the expectations for most of the patients and, in their opinion, should have been performed earlier. Results of the standardized Patient Health Questionnaire 4, a short depression screening questionnaire, did not significantly differ from healthy norm data. The Freiburg Personality Inventory, Revised, revealed normal emotionality and sane self-assessment within our study group. High self-esteem and significantly higher scores than norm data were found for the Rosenberg Self-esteem Scale. CONCLUSIONS: Gender confirming treatment with the combined technique is an important part of a multi-structured treatment of transgenders and does have effects on psychological well-being. It seems to decrease psychopathologies and implicates several ameliorations for transgender women. Findings need to be verified in prospective studies including preoperative evaluations.

Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes.

BACKGROUND: Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. METHODS: Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. RESULTS: Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p < 0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p < 0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale. CONCLUSION: Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Male-to-Female Sex Reassignment Surgery Using the Combined Technique Leads to Increased Quality of Life in a Prospective Study.

BACKGROUND: The authors' previous research showed that various plastic surgical procedures can increase a patient's quality of life in its different aspects. In a prospective setting, they evaluated whether sex reassignment surgery has similar effects for male-to-female transgender patients compared to baseline data before sex reassignment surgery. METHODS: All 39 patients who underwent their first-stage male-to-female sex reassignment surgery between October of 2012 and January of 2014 received one set of questionnaires preoperatively (time 0) and approximately 6 months after their final operation (time 1). Each set contained self-developed, indication-specific questions combined with the standardized validated Questions on Life Satisfaction, Modules (German version) questionnaire, the Freiburg Personality Inventory, the Rosenberg Self-Esteem Scale, and the Patient Health Questionnaire, which were compared to available norm data. RESULTS: The mean patient age was 38.6 years. The majority of the patients were highly educated, childless, and single. Significant improvements were found in the Questions on Life Satisfaction, Modules (German version), especially for the items "partnership," "ability to relax," "energy," "freedom from anxiety," "hair," "breast," and "penis/vagina" (p < 0.01). Furthermore, the patients appeared more emotionally stable (p = 0.03), showed higher self-esteem (p = 0.01), and showed much lower depression/anxiety (p < 0.01). CONCLUSIONS: The positive study findings were confirmed with the results from prior retrospective studies. However, medical literature focuses largely on surgical and functional satisfaction and not overall quality of life. In addition, standardized questionnaires are used rarely and solely retrospectively, with the risk of recall bias. The increased quality of life of transgender women postoperatively endorses sex reassignment surgery as a valuable option for these patients. CLINICAL QUESTON/LEVEL OF EVIDENCE: Therapeutic, IV.

Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes.

BACKGROUND: Several therapy options exist for male-to-female (MTF) transgenders desiring sex reassignment. Surgery includes numerous different procedures. Of those, vaginoplasty is predominant and aims at providing attractive esthetics and fully functional genitals. This study aimed to present the surgical results of our modified combined vaginoplasty technique in a consecutive patient cohort. METHODS: We included 40 MTF transgender patients who underwent a two-stage sex reassignment surgery (SRS) in an observational prospective study between September 2012 and January 2014. Demographic characteristics, medical and surgical history, operative details, and outcomes after surgery were documented. Postoperatively, 23 patients received a pelvic examination following the standardized protocol. RESULTS: Measured vaginal depth was 11.77-14.99 cm depending on the size of the dilator used (25-40 mm). Vaginal, clitoral, and labial sensitivities were intact and favorable in all examined patients. Nineteen women (47.5%) opted for breast augmentations to achieve a feminine cosmesis, making it the most common nongenital operation. Complications were mostly minor and temporary. Severe adverse events, such as wound infections (n = 3), colon injuries (3), short (1) or narrow (1) vaginas, or partial clitoral necroses (1), were rare and immediately addressed by the surgical team. No vaginal construction was lost, and no secondary reconstructive approaches were required. CONCLUSION: Satisfactory physical results and favorable low rates of complications endorse our combined technique for MTF SRS. These findings, however, need to be confirmed by other research groups as well. Therefore, in our opinion, MTF SRS remains an evolving area of development, whose research is aiming to establish a state-of-the-art surgical technique.

Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery.

BACKGROUND: Surveys on quality of life (QOL) of male-to-female (MTF) transsexuals have found low QOL scores before and increased satisfaction scores after sex-reassignment surgery (SRS). To our knowledge, many of them lack standardized questionnaires and comparisons with normative data to evaluate different vaginoplasty techniques. AIM: To analyze patient satisfaction and QOL after SRS. METHODS: Forty-seven patients participated in this study. All patients had surgery with our self-developed combined technique on average 19 months before the survey. They completed a self-developed indication-specific questionnaire concerning demographic and socioeconomic issues and postoperative satisfaction. Furthermore, a standardized self-assessment questionnaire on satisfaction and QOL (Fragen zur LebenszufriedenheitModule [FLZM]; Questions on Life SatisfactionModules) was used. The FLZM consists of three modules (general life satisfaction, satisfaction with health, and satisfaction with body image) with scores of weighted satisfaction for each item. Results of the general and health modules were compared with normative data. OUTCOMES: Demographics, QOL, general life satisfaction, satisfaction with health, and satisfaction with body image. RESULTS: The self-developed indication-specific questionnaire showed that 91% experienced an improvement of QOL. All patients stated they would undergo SRS again and did not regret it at all. Patients stated their femininity significantly increased. For the FLZM, the sum score for general life satisfaction (P < .001) was significantly lower than the normative data, whereas the sum score of the satisfaction with health module (P = .038) did not reach statistical significance. The two modules also showed positive trends for different items. Values of the body image module showed a significant increase in satisfaction with breasts (P < .001) and genitals (P = .002). CLINICAL IMPLICATIONS: The findings of this survey emphasize the importance of SRS in the interdisciplinary gender-reassignment process. The detailed description of our combined technique could help to improve the surgical outcome and patient satisfaction of this complex and non-standardized surgery. STRENGTHS AND LIMITATIONS: This is the first description of a new surgical technique (combined technique) for MTF SRS. QOL was assessed by a large number of patients by standardized questionnaires and could be compared with normative data. Because this is a retrospective study, we can draw only careful conclusions for pre- and postoperative changes. CONCLUSION: Our self-developed combined surgical technique seemed to have a positive influence on QOL after SRS. Satisfaction with breasts, genitals, and femininity increased significantly and show the importance of surgical treatment as a key therapeutic option for MTF transsexuals. Papadopulos NA, Lellé J-D, Zavlin D, et al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med 2017;14:721-730.