ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”

Introduction Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. Aim To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. Methods The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. Main Outcomes Measure The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. Results The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. Conclusion The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.


INTRODUCTION
Human sexual behaviour is a complex phenomenon, both for trans and non-trans or cis individuals, orchestrated by the interaction between biological, psychological and social factors. General studies on sexual wellbeing show that having a poor physical health or a chronic illness has a negative impact on sexual wellbeing, 1,2 and that issues such as sex frequency, sexual pleasure and sexual satisfaction are strongly positively correlated with mental health. 3−6 With trans individuals, having an increased susceptibility to poor mental health outcomes due to a lack of social acceptance and/or access to care, 7 sexual health outcomes are thought to be equally affected. 8 Furthermore, for trans individuals who might be undergoing changes in body composition and perception to align these with their gender identity, specific challenges may arise making sexuality a delicate subject to deal with in counselling. 9 Additionally, data on the significance of sex steroids with respect to sexual functioning and satisfaction in cis individuals 10−20 brings about the notion that Gender Affirming Medical Interventions (GAMI), such as hormone therapy and surgical interventions, might affect sexual functioning in trans individuals.

Studies on Sexual Wellbeing
Up to now, studies on sexual wellbeing of trans individuals are scarce or often based on a small population. 21 Current literature mostly pays attention either at sexuality prior to GAMI, 22,23 or on the combined effect of hormonal and surgical interventions on sexual wellbeing. 24−34 Data on sexuality before Gender Affirming Surgery (GAS) from a multicentre prospective study in four European gender identity clinics (Amsterdam, Ghent, Hamburg, Florence, and Oslo) found no difference in frequency of the involvement of the genitalia and appraisal of genital sensation during sexual contact among individuals AMAB and AFAB (Assigned Female at Birth), prior to (GAS). 33 In a small clinical study, about half of all trans individuals prior to genital surgeries, rated their sexual life as "poor or dissatisfied" or "very poor or very dissatisfied." 22 Receiving hormone treatment, experiencing negative feelings, and having a partner, however, were found to relate to better subjective perceptions of sexual quality of life. 22 Other studies also report on the improved sexual functioning after GAS. The only available prospective study on this matter reported a significant decrease in sexual distress in trans individuals under hormone treatment. 35 Despite the perceived detrimental effects of hormone treatment on sexual function -especially in individuals AMAB (Assigned Male at Birth) 36 -sexual distress indeed is reduced after starting hormone treatment, 35 and sexual wellbeing might significantly improve by minimizing the incongruence between one's body and gender identity. 37

Defining Sexual Health in Treatment Seeking Trans Individuals
Although sexual wellbeing is considered as an important aspect of quality of life, and recent studies show considerable improvement of quality of life after GAMI and GAS, 38−40 little information is available on this subject in trans individual after GAS. 22 This position paper uses 'sexual wellbeing' as the core concept of interest. The first written definition of sexual wellbeing originates from 2014 by Byers and Rehman 41 , and € Ozer et al 42 modified this definition in the scope of treatment seeking trans individuals in 2021. 42 Sexual wellbeing in this position statement is a combination of sexuality, enacted sexual script, sexual activities, sexual relations, sexual response cycle, genital function, sexual function, sexual pleasure, sexual satisfaction and quality of sex life.

Aim
The European Society for Sexual Medicine expressed the need for a position statement on sexual wellbeing after GAS, to supplement the existing World Professional Association for Transgender Health Standards of Care, which lacks data on the effects of GAMI specifically on sexuality and sexual wellbeing. 43 This position statement is a continuation on the previous European Society for Sexual Medicine (ESSM) Position Statement on "hormonal management of adolescent and adult trans people". 2 The adjective 'trans' is used here in line with the previous ESSM Position Statement on "hormonal management of adolescent and adult trans people", 2 to refer to both binary and gender diverse individuals. This position statement therefore does not focus on differences in sexual health outcomes between binary-oriented or nonbinary trans individuals, but is aimed at reviewing the available evidence on sexual wellbeing following GAS. The position statement wishes to provide clinicians who specialize in trans-related care with recommendations about the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, on behalf of the ESSM.

METHODOLOGY
This position statement aimed at providing results on sexual wellbeing following various gender affirming surgeries, based on the results from a systematic literature review, divided into four main sections: Somatic and General Requirements before GAS, Sexual Wellbeing after GAS (studies who did not specify in gender or surgery when presenting results of sexual wellbeing), Feminizing GAS and Masculinizing GAS, each with the specific surgical procedures and their effects on sexual wellbeing.
The ESSM selected the authors based on their long-standing clinical experience and scientific involvement in specific areas of trans-related healthcare. A multidisciplinary approach was established by involvement of physicians from various specialties, including: endocrinology, oral and maxillofacial surgery, urology, plastic and gender surgery, sociology and sexology.
The search strategy was developed with aid from a research librarian of the Amsterdam University Medical Center. Relevant papers were sourced from the Medline, EMBASE, and Cochrane Library electronic databases from May 2017 until April 2020. Keywords and index terms, including applicable MeSH and Entree terms, were applied to each database. Search terms were generated under two broad headings -'gender incongruence' and 'sexual wellbeing' −to create a wide scope on the subject, and were subsequently narrowed down to sexual wellbeing after GAS.
The following MeSH terms were applied to the Medline database: sex reassignment procedures; gender dysphoria; transgender persons; transsexualism; gender incongruence; gender affirming; trans women; trans men; sexual behaviour; coitus, courtship; masturbation; orgasm; dyspareunia; intercourse; copulation; penetration; lubrication; sexual; sensation; pain; arousal; desire; pleasure; satisfaction; dysfunction; wellbeing; relation; behaviour; activity and quality of sex life were applicable for MeSH terminology.
Literature was selected, discussed among the authors and combined with their multidisciplinary knowledge and clinical expertise to establish the statements. The overall quality of evidence of the literature was low, most recommendations of this position statement are therefore low in Level of Evidence. The statements that are strongly recommended are phrased as "should" and suggestions, phrased as "is advised to" or "may". The statements were formed after consensus of all the authors. Details on the literature search, eligibility and inclusion, data extraction and quality assessment are provided in Supplement 1.
An overview of the results on sexual wellbeing following various gender affirming surgeries can be accessed through Table 1-5,7.

SOMATIC AND GENERAL REQUIREMENTS BEFORE GAS
Statement #1 The gender surgeon should be aware of the effects of smoking and BMI when considering (genital) GAS. (Level I Grade A) Statement #2 The gender surgeon should engage in shared decision making and counsel the patient on expectation management, including expected sexual outcomes, prior to GAS (Level II Grade D) Statement #3 The gender surgeon is advised to collaborate with sexologists and pelvic floor physical therapists, trained on trans related health care, if available (Level IV Grade D)

Evidence
The surgeon and anaesthesiologist are tasked with assessing the general health status, perioperative risk, and contraindications as per the American Surgical Association physical status classification system, for individuals requesting surgery. 44,45 Patients should be advised on smoking cessation and ideal weight for surgery, that is, a BMI between 18−30 kg/m 2 , prior to genital GAS. 46−48 The eventual decision for surgery in patients outside of the ideal BMI range falls upon the surgical and anaesthesiology team and should not be considered a hard Contra-Indication.
Hormone therapy may adversely affect fertility in both AFAB and AMAB individuals, 49 while GAS may terminate potential for reproduction. Fertility preservation that is, cryopreservation of semen or oocytes, embryos or ovarian tissue-may aid in facilitating future parenting options. 50 The choice between various surgical techniques for GAS is dependent on patient preference, patient anatomy and health status, and the surgeon's skillset. Choices are increasingly being made through shared decision-making. 51 The surgeon should inform the patient on the techniques available, their advantages and disadvantages, limitations with producing 'ideal' results and possible risks and complications. 52−54 How the surgeon presents surgical options, risks and benefits is of great importance. The surgeon should preferably present photos of their previous work and provide data on their complication rate. 52 Little has been published on postsurgical regret in regard to functional outcomes and complication rate. Lawrence, however, found that less complications and better functional results after vaginoplasty were associated with less postsurgical regret. 55,56 SEXUAL WELLBEING AFTER GENDER AFFIRMING SURGERY Gender Affirming Surgery (GAS) is an umbrella term for a variety of surgical procedures. 57 It is important to note that trans individuals may or may not adhere to a standard linear progression from hormone treatment to surgical procedures. 58 Sexual motivations may influence some individuals to prefer surgical interventions without prior hormone treatment, or opt out of some surgical procedures. 59 The outcomes on sexual wellbeing following GAS are found in Table 1. Fourteen studies reported on general sexual wellbeing following GAS, without specifying what kind of procedure was performed or how the participants identified gender-wise, mainly focusing on sexual activities, erogenous sensation, orgasm and sexual satisfaction. Frequency of sexual activities increased after both hormonal and surgical treatment. 26,60−62 Frequency of masturbation, however, was decreased in AMAB individuals and remained unchanged or increased in AFAB individuals. 63,64 Every patient experienced postsurgical tactile erogenous, to some extent. 33 Every AFAB individual and 85% of AMAB individuals were able to reach orgasm, 33 either through masturbation or intercourse. 26,60,61,63,65,66 Orgasm after GAS was experienced more frequently by both AMAB and AFAB individuals, 66 less frequently by AMAB individuals, 61 than by AFAB individuals. 61 Most AMAB individuals were satisfied with GAS, reporting sexual satisfaction with the possibility of penetrative sex 61,67 and   being partnered. 63 Initiating and maintaining intimate relationships became easier postoperatively. 66,68 Limited sensitivity and absence of erectile function after phalloplasty decreased sexual satisfaction in AFAB individuals. 67 Phalloplasty was not found to be a critical factor in reaching orgasm or sexual satisfaction, 61 difficulties in engaging in new sexual contacts, however, may have been a factor preoperatively. 63,64 The strongest motivation to pursue penile surgery was confirmation of one's identity. 62 Postsurgical aesthetics and functionality were satisfactory, including the ability to void while standing. 65 Disappointment following GAS resulted because of a decrease in sex drive, not being partnered or having non-functional genitalia. 69 Advice regarding postsurgical care and follow-up were provided by two studies. Kuhn et al 70 concluded that pelvic floor symptoms involving the bladder, bowel, and sexual function may occur in AMAB individuals. Lothstein et al 71 advised counselling and psychotherapy prior to surgery and continued followup after completing GAS to improve sexual wellbeing.

SURGICAL PROCEDURES FOR FEMINIZING GAS
This section addresses different types of feminizing GAS, with their respective results regarding sexual wellbeing.

Orchiectomy-Only
Statement #4 The gender surgeon is advised to consider orchiectomy-only as a viable surgical option for trans individuals AMAB (Level IV Grade D) Statement #5 The gender surgeon should counsel the trans individual AMAB on the expected effects on sexual wellbeing prior to orchiectomy (Level II Grade A) Evidence. Indications include patient preference-in not opting for vaginoplasty-and failing at meeting somatic requirements for anti-androgen use or vaginoplasty (see: somatic requirements before GAS). Orchiectomy does not provide surgical consequences for future vaginoplasty, therefore can also be performed while waiting for a future vaginoplasty. Testosterone levels below 20 ng/dL (0.7 nmol/L) have been reported in patients following orchiectomy, 72 patients should be counselled on possible adverse effects of low testosterone levels on sexual wellbeing. 73 Sexual Wellbeing After Orchiectomy. We found no studies on sexual wellbeing in trans individuals AMAB after orchiectomy-only.

Vaginoplasty
Statement #6 The gender surgeon should provide trans individuals AMAB the penile-inversion technique as the vaginoplasty of choice (Level IV Grade C) Statement #7 The gender surgeon should be capable to offer alternatives to the penile-inversion technique, in trans individuals AMAB, like: skin grafts or bowel segments to create adequate vaginal depth in cases of penoscrotal hypoplasia and inadequate penile skin length (Level IV Grade C) Statement #8 The gender surgeon is advised to counsel on vulvoplasty (or zero-depth vaginoplasty) when this is recommended by health care professionals or requested by the patient, to reduce possible future regret in trans individuals AMAB (Level IV Grade D) Statement #9 The gender surgeon should counsel trans individuals AMAB on expected sexual outcomes, pelvic floor symptoms and possible complications for any kind of vaginoplasty (Level # IV Grade D) Evidence. Vaginoplasty-comprised of vulvoplasty, penectomy, orchiectomy and vaginal canal creation-aims at obtaining an aesthetically pleasing and functional genital complex, vulva and neo-vagina, with adequate depth. 74 The vaginal canal is created between the rectum and bladder, and lined with penile skinoptionally modified with skin grafts, urethral mucosa or scrotal flaps-skin grafts-only, 75 bowel segments or peritoneum. 76 The clitoris is formed by the dorsocentral part of the glans penis, the clitoral hood is formed either from the prepuce or with penile skin. Urethral grafts may aid in vaginal lubrication and sensitivity. 77 The penile-inversion vaginoplasty is currently considered the gold standard. 78 Studies show that penile-inversion vaginoplasty is associated with satisfaction with aesthetics and function. 79,80 (See below 5.3.2).
Indications for vulvoplasty (or zero-depth vaginoplasty) include patient preference or extensive morbidity, for example, a history of rectal fistula. 81 Counselling is strongly recommended to minimize the risk of future regret. 82 Sexologists and pelvic floor physical therapists may counsel patients on dilation and aid in reducing voiding difficulties, which are not related to meatal stenosis. Consultation should preferably be commenced prior to surgery, and continued postoperatively. 83 The sexologist may address issues regarding changing sexual function, for example; in, phantom pains, sexual stimulation and arousal. 84−86 Possible complications of vaginoplasty are perforations and fistulae, haemorrhage and possible future secondary corrections. Secondary corrections are dependent on patient preference and may include resection of residual spongiosum, labiaplasty, clitoral repositioning, correction of the meatus or introitus and vaginal depth augmentation.
Sexual Wellbeing After Vaginoplasty. Sixty-one studies reported outcomes on sexual wellbeing following vaginoplasty, available in Table 2. 55     Subjective clitoral sensation was not statistically significantly correlated with sexual satisfaction.
Detection thresholds for light touch showed the highest sensitivity on the neck, followed by the anus, abdomen, clitoris, labia minora and then the vaginal opening.
Detection thresholds for pressure showed the highest sensitivity on the neck, followed by the clitoris, anus, abdomen, labia minora and the vaginal opening.
Detection thresholds for vibration showed the highest sensitivity on the clitoris; followed by the labia minora; the neck; the abdomen; and the vaginal opening and anus.
Strength of libido prior to GAS was low for 5, high for 6, NA for 2. Following GAS: low for 7 (1 of which previously high; 2 NA), moderate for 1 (previously low), high for 5. Retrospective rating of interview The following outcomes prior to GAS were associated with fair or good overall sexual adjustment after GAS: high sexual activity with a partner, strong libido, intercourse with women, and bisexual experience. High frequency of masturbation was not associated with good adjustment.   (continued) patient. 79,87,90,95,98,99,101,102,117,118,120,126 Subjective arousal and desire were similarly experienced by a majority (79,1%) of postsurgical women. 79,90,108,123,135,142 Twenty-four studies discussed whether participants could attain orgasm. 79,87,88,90,91,95,96,[98][99][100][101]104,[106][107][108][109]113,120,121,123,125,126,128,134 A majority (about 70%) could achieve orgasm, 79,87,88,90,91,95,98−101,104,106 −109,113,117,120,121,123,125,126,128,134,143 whereas less than 10% could not or had not, 79,88,90,95,99,100,107,109,120,125,143 10% had not tried 79,90,99,125 , and another 10% chose 'not applicable.' 107 Five studies applied the Female Sexual Function Index (FSFI) and reported a mean orgasm domain score ranging between 2.82 −3.9 (scores CIS women without sexual problems 5.1 SD1.1). 79,90,92,119 Finally, Zavlin et al 80 found a mean frequency of achieving orgasm of 6.73 (SD 3.32) during masturbation and 6.52 (SD 3.11) during intercourse. 80 Over half of participants masturbated regularly, 60,62,100,107, 108,120,121,123,140,144−146 and every participants had engaged in receptive vaginal activity. 79,89,90,96,104,106,114 Some, however, failed at penetrative sex, either because of short time since surgery, inadequate vaginal dimensions or pain. 79,90,114,128 Reporting on other sexual activities, for example, receptive anal sex 60,100,109,121 and-active and passive-oral sex was limited. 100,120 Whether GAS brings about a change in sexual activities remains unclear, this data and associations between presurgical and postsurgical sexual a 142 ctivity were not provided. 92,96,107,109,128,147 Overall sexual satisfaction or satisfaction with sex life (77%), 79,84,90,92,94,107,108,113,119,135,142,143 satisfaction during sex, 80,120,123 and satisfaction with orgasmic function was present in a majority of postsurgical individuals. 87,91 Some studies reported on sexual dysfunction, where sexual wellbeing was mostly defined as a lack of sexual dysfunction. Ten studies discussed pain during receptive vaginal sex in AMAB individuals; one third experienced either pain in or around the introitus, deep or superficial dyspareunia or vulvodynia. 79,80,84,88,100,113,120,125,134,143 Difficulties for AMAB individuals during penetrative sex were described in 10 studies: a third experienced difficulties or were unable to perform receptive vaginal sex, due to inadequate vaginal depth or width. 79,85,89,90,98,100,114,120,123 Breast Augmentation  Evidence. Feminizing hormone therapy might yield unsatisfactory breast development. Individuals might not reach the final stages of breast development and opt for breast augmentation, 148 which may improve feminine contour, increase subjective feelings of femininity, aid in passability and adjustment to the female gender role, and consequently increase sexual and psychosocial wellbeing. 149 Choice of augmentation technique is dependent on both patient and surgeon's preference.
Patients should be counselled on implant type, implant surface and placement. Care must be taken to properly centre the implant under the nipple-areolar complex (NAC) to prevent diverging nipples and wide cleavage. 150,151 Implant placement more medial of the NAC can be considered in individuals with a laterally placed NAC, or surgical medialization of the NAC can be pursued. 152,153 Implant use is advantageous in regard to predictability of results. Associated risks, however, are capsular contracture, implant malposition, autoimmune responses and Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). 154 Fat grafting provides an alternative to implant use, eliminating the risk of BIA-ALCL. 155 Fat grafting can be done solitary, in conjunction with implant use, as well as during secondary corrections. 156 Breast cancer screening should be performed according to the local guidelines.
Sexual Wellbeing. One study reported on sexual wellbeing following breast augmentation, finding a significant increase in sexual wellbeing four months postoperatively ( Table 3). 149  Evidence. Consulting an ENT surgeon prior to starting with speech therapy is recommended, to rule out vocal cord anatomy and functioning anomalies. Surgery may be considered if speech therapy yields unsatisfactory results. Surgical results are unpredictable. 157 Sexual Wellbeing. We found no studies on sexual wellbeing after vocal feminization surgery in AMAB individuals.

Facial Feminization Surgery (FFS)
Statement #14 The gender surgeon should treat secondary facial aspects before beginning structural facial GAS in trans individuals AMAB (Level IV Grade C) Statement #15 The gender surgeon is advised to consider adjustments of the frontonasal-orbital complex, the nose, the lower jaw and the thyroid cartilage when performing FFS in trans individuals AMAB (Level IV Grade C) Evidence. Secondary or non-skeletal facial aspects, such as hair and hairline, facial hair, skin texture, and the distribution and volume of facial fat can be heavily determined by hormonal influence, generally responding well to hormone therapy, which in itself does not interfere in any way with surgery. In addition, many AMAB will opt to undergo laser facial hair removal or electrolysis. It is therefore preferable to treat the secondary aspects before beginning structural or skeletal facial gender confirmation surgery (at least 12 months before surgery). Obtaining a female bone structure while maintaining male secondary aspects is self-defeating to both the result and the perception of the patient's femininity. The expectations for the results will be more real if the initial anticipation, both psychological and physical, is realistic. 158 Adjustments of the frontonasal-orbital complex, the nose, the lower jaw and the thyroid cartilage are elements of Facial Feminization Surgery (FFS). 159

SURGICAL PROCEDURES FOR MASCULINIZING GAS
This section addresses different types of masculinizing GAS, with their respective results regarding sexual wellbeing. Decision making is on patient preference and patient specifics. Evidence. Masculinizing chest surgery may improve dysphoria, body image, psychological and sexual wellbeing and overall quality of life, and carries importance for AFAB individuals in this regard. 38,179,180 Excess skin and glandular tissue is excised, whilst preserving subcutaneous fatty tissue to ensure flap vascularity and facilitating an acceptable contour of the chest wall. Techniques include the semi-circular technique, trans-areolar technique, concentric circular technique, free nipple technique with horizontal scar and the inferior pedicled mammaplasty technique, for "Breast size and mastectomy techniques" see Figure 1. 156,181 The semi-circular technique is applicable for very small breasts. The scar is confined to the lower half of the areola.
Limited surgical exposure carries risk of increasing postoperative hematomas. 181 The trans-areolar technique allows for correction of the nipple by nature of the scar placement through the areola, horizontally. This carries increased risk of postoperative hematomas. 156 The concentric circular technique allows for correction of excess skin through an ellipse, or circle shaped, incision. May lead to skin puckering around the areola, areolar widening-due to traction-and nipple necrosis. 156,181 The horizontal scar and free graft technique allow for correction of very large breasts. It is met with large scars, NAC depigmentation and partial graft loss. 148,181 The inferior pedicled mammaplasty technique is comparable, whilst transposing the NAC on an inferior pedicle, instead of a free graft. 156 Masculinizing hormone therapy may ameliorate breast cancer risk. 155 Patients should, however, be made aware of residual breast tissue on the entire plane of dissection. 182  Table 4. These publications mostly focused on sexual relationships and quality of sex life. Mastectomy improved quality of life and confidence in social and sexual situations, in both dressed and undressed situations. Reduction of dysphoria, improvement of body image and confidence following mastectomy affected sexual relationships positively. 38,183,184 Removal of the Female Sexual Organs Statement #17 The gender surgeon is advised to counsel on intervention options salpingo-oophorectomy, hysterectomy and vaginectomy, dependent on trans individuals AFAB preference (Level IV Grade D) Statement #18 The gender surgeon should advise routine screening, by a general practitioner or gynaecologist, for cervical cancer if the uterus remains in situ in trans individuals AFAB (Level IV Grade D) Evidence. Indications for hysterectomy include persistent blood loss, dysphoric feelings, unwanted discharge or lubrication, and within the context of GAS with urethral lengthening. Vaginectomy, and subsequent hysterectomy, maybe a required when opting for urethral lengthening, because of higher risks of developing complications. 185 The choice for salpingo-oophorectomy is dependent on patient preference-only.
Routine screening for cervical cancer should be continued. Screening for endometrial cancer should be commenced in older patients with vaginal blood loss. Evidence for positive effects of routine screening for ovarian cancer in trans individuals AFAB are lacking. We would therefore not encourage routine screening, currently. Consider counselling on HPV self-sampling to increase testing rates.
Sexual Wellbeing After Removal of the Female Sexual Organs. We found no results of studies on sexual wellbeing in trans individuals AFAB after removal of the female sexual organs.  Evidence. Metaidoioplasty can be carried out as a one-stage procedure, with removal of the female sexual organs, optional urethral lengthening, scrotoplasty and testicular implants placement. 186,187 The majority of the lengthening of the clitoris is achieved through ventral division of the urethral plate. Additional length may be obtained by dividing the clitoral suspensory ligaments. 188,189 Clitoral length should be sufficient for voiding while standing when urethral lengthening is requested, studies do not report on what is meant by "sufficient". The technique for urethral lengthening is dependent on patient anatomy and tissue quality, options include pedicled labia minora grafts and buccal mucosa grafts. Having non-overlapping suture lines and covering suture lines with vascularized tissue prevent fistulation. 146,190,191 Scrotoplasty is achieved through labial tissue, 192 testicular implants can be inserted. 192,193 Postoperative genital stretching-either manual, vacuum-assisted or withPDE5 inhibitors-may prevent genital shrinking. However, evidences on this topic are poor. 189,191,193 Choices on genital masculinization surgery are increasingly being made through shared decision-making. 51 The surgeon should inform the patient on the different options (metaidoioplasty and phalloplasty, the techniques available, their advantages and disadvantages, limitations with producing 'ideal' results and possible risks and complications. 52−54 Common minor complications are urinary tract infections and bladder overactivity. Minor urethral fistulae and strictures can be managed non-surgically, revision surgery is indicated for major fistulae and strictures, 186,194 regenerating vaginal mucosa, 186,193,194 and displaced or expelled testicular implants.

Metaidoioplasty
Sexual Wellbeing After Metaidoioplasty. Sexual wellbeing was reported on in six publications, provided in Table 5. 146,187,189,193,195−197 Five of these publications may contain an overlap in study population. 146,187,189,193,197 Metaidoioplasty provided satisfying aesthetics and positive outcomes regarding sexual wellbeing, sensation, erectile function and orgasm. Sexual arousal, which resulted in erection, and sensation were present in every individual. 146,187,189,193,197 A majority of participants had masturbated, which had not resulted in orgasm for everyone, 146,187,193,197 and insufficient length for penetrative sex proved the main disadvantage. 146,193,197 An average of 10% initially opting for metaidoioplasty, pursued conversion to phalloplasty at a later stage.

Phalloplasty or Total Phallic Construction (TPC)
Statement #24 The gender surgeon should provide trans individuals AFAB the radial free forearm flap (RFFF) phalloplasty as the technique of choice for masculinizing genital GAS in patients Evidence. Total Phallic Construction (TPC) aims at creating a phallus with acceptable aesthetics, a degree of cutaneous and erogenous sensitivity and sufficient bulk to house potential erectile prostheses. Standing urination is achieved through urethral lengthening. Techniques include: the radial free forearm flap, suprapubic pedicled pubic (PP), superficial circumflex iliac artery perforator flap (SCIP), antero-lateral thigh flap (ALT)and the latissimus dorsi flap (LD) techniques. Table 6 shows donor sites, flap types, urethral lengthening options, sensation, advantages and disadvantages of all flaps. The RFFF presents superior aesthetics and functionality, allowing for integrated urethral lengthening, 198−201 compared to other techniques, and is considered "the gold standard" by some. 202 RFFF-TPC is commonly carried out in three stages of six-month intervals: the creation of the phallus and neo-urethra, microsurgically anastomosed; glans-and coronaplasty using a full-thickness skin graft; and potential erectile prosthesis implantation. Proper preparation reduces donor-site morbidity and full-thickness skin grafts result in less scarring and discoloration. 203,204 Interposition of collagen-matrix, between the recipient site and a split-thickness skin graft, simulates the appearance of a full-thickness skin graft without hair. The pedicled pubic phallus is fashioned from a cutaneous flap that is raised from the inferior aspect of the abdominal wall, allowing for primary closure of the donor site. 205 Both the PP flap and the SCIP flap are Hair-Bearing, have poor cutaneous sensitivity and difficult urethral lengthening. Direct urethral lengthening is carries increased risk of complications, delayed incorporation of a  209 Cutaneous sensation is moderate due to the presence of one cutaneous nerve within the flap. The donor site is usually covered with split-thickness skin grafts. The LD flap allows for a larger myocutaneous flap based on the thoracodorsal artery and nerve, allowing for primary closure of the donor site. Cutaneous sensation is poor as a single motor nerve is available. 210 Urethral lengthening requires multi-stage buccal mucosa and labia minora flaps.
As stated in the metaidoioplasty section choices on genital masculinization surgery are increasingly being made through shared decision-making. 51 The surgeon should inform the patient on the different options (metaidoioplasty and phalloplasty, the techniques available, their advantages and disadvantages, limitations with producing 'ideal' results and possible risks and complications. 52−54 Sexual Wellbeing After Phalloplasty. Eighteen studies reported on sexual wellbeing after phalloplasty, provided in Table 7. 26,62,196,211−215 Outcomes for various surgical techniques were often pooled, separate results were rarely provided. Four pairs of studies may have had an overlap in study population.
Five studies reported on postsurgical sensation, which was present in 86.3%. 216−220 Most experienced partial sensation, either in the buried clitoral site, 219 the shaft, 198, 216 the neo-urethra 198 and sensation projecting to the thigh. 217 Postsurgical orgasm was discussed in three studies. Garcia et al 221 and Wierckx et al 26 reported that 92% and 97.8% were able to reach orgasm, respectively, and Van de Grift et al 196 found that orgasmic capacity increased in 18%, was unchanged in 52% and decreased in 26%.
Ten studies reported on the possibility of penetrative sex, which ranged between 38.8−85%. 205,211,212,214,216,217,219,220,222,223

CONCLUSIONS
This position statement provides healthcare providers with recommendations that may aid in decision making regarding GAS. Although findings may suggest positive outcomes regarding sexual wellbeing following vaginoplasty, mastectomy, metoidioplasty, and phalloplasty, the overall quality of evidence is still low and most recommendations of this position statement are Level of Evidence C.
Not only methods of data gathering and reporting vary, some forms of GAS are not studied at all when it comes to effects on sexual wellbeing. Therefore, we advise more research on the effects of orchiectomy-only, breast augmentation, vocal feminization surgery, facial feminization surgery and the removal of the female sexual organs on sexual wellbeing in trans individuals.
In trans individuals AMAB; breast augmentation is mostly studied with a focus on surgical techniques. Data on sensitivity, functioning and sexual wellbeing are lacking.
Next to the effects of FFS on sexual wellbeing, further research focusing on separate aspects of FFS is encouraged and necessary.
The majority of questionnaires that were applied in evaluating sexual activity after GAS in trans individuals AMAB, were validated for cis women-in heterosexual relationships, who engaged     in penetrative sex-only. A substantial portion of aforementioned participants, however, were intimate with women, or did not have sexual relationships. Therefore, the development of specific questionnaires to evaluate the effect of GAS on the sexual wellbeing in trans individuals is needed.
In trans individuals AFAB; it is known that mastectomy is a viable option in improving gender incongruence, body image, psychological wellbeing, sexual wellbeing and overall quality of life. Evidence on sexual wellbeing after mastectomy is limited, focussing mainly on quality of sex life and sexual relationships.
In masculinizing genital GAS a metaidoioplasty provides a sensate neophallus with the possibility to void standing, erotic satisfaction, and high levels of postsurgical satisfaction, with minimal donor site morbidity. However, there is need for validated questionnaires that can measure functionality, aesthetic appearance and patient satisfaction, to improve objective conclusions.
Furthermore, the unique anatomy of the male genitalia and the absence of tissue engineering options, to replace the smooth muscle of the corpora cavernosa and spongiosum, complicate TPC. The absence of comparative studies hampers selection of preferential techniques. Functional outcomes and patient satisfaction are difficult to comment on because of the lack of validated questionnaires to assess these outcomes.
Long-term effects of GAMI and GAS should also be studied, where after consensus on cancer screening in trans individuals should be formed, especially in hormone sensitive cancers or organs.
Next to the lack of studies on the effects of GAS and GAMI on sexual wellbeing, research on the development of validated questionnaires and patient-reported outcome measures may aid in producing less heterogeneous data.
To conclude, heterogeneous methods of data gathering and reporting and missing data on sexual wellbeing after orchiectomy-only, vocal feminization surgery, facial feminization surgery and the removal of the female sexual organs further complicate the ability to draw robust conclusions, together with the lack of studies on the effects of GAS and GAMI on sexual wellbeing, emphasizing the need for future research. Future research on the development of validated questionnaires and patient-reported outcome measures may aid in producing less heterogeneous data. Researchers and clinicians alike should consider exchanging data and actively involve the transgender and gender-diverse community, in a bid to further improve not only surgical care, but trans-related care as a collective.