Advertisement

ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”

Open AccessPublished:December 28, 2021DOI:https://doi.org/10.1016/j.esxm.2021.100471

      Abstract

      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. Müjde Özer, Sahaand Poor Toulabi, Alessandra D. Fisher, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2021;XX:XXXXXX.

      Key Words

      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,
      • Verschuren JEA
      • Enzlin P
      • Dijkstra PU
      • et al.
      Chronic disease and sexuality: a generic conceptual framework.
      ,
      • Whipple B.
      The benefits of sexual expression on physical health.
      and that issues such as sex frequency, sexual pleasure and sexual satisfaction are strongly positively correlated with mental health.
      • Meston CM
      • Frohlich PF.
      The psychobiology of sexual and gender identity disorders.
      • Ein-Dor T
      • Hirschberger G.
      Sexual healing: daily diary evidence that sex relieves stress for men and women in satisfying relationships.
      • W P
      The social in the sexual: een sociologische studie naar gezondheid, seksueel welbevinden en seksuele responsiviteit. PhD thesis.

      De Graaf H, Wijsen C. Seksuele Gezondheid in Nederland. 2017.

      With trans individuals, having an increased susceptibility to poor mental health outcomes due to a lack of social acceptance and/or access to care,
      • Wilson EC
      • Chen Y-H
      • Arayasirikul S
      • et al.
      The impact of discrimination on the mental health of trans*female youth and the protective effect of parental support.
      sexual health outcomes are thought to be equally affected.
      • Kerckhof ME
      • Kreukels BPC
      • Nieder TO
      • et al.
      Prevalence of sexual dysfunctions in transgender persons: results from the enigi follow-up study.
      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.
      • Wallwiener S
      • Strohmaier J
      • Wallwiener LM
      • et al.
      Sexual function is correlated with body image and partnership quality in female university students.
      Additionally, data on the significance of sex steroids with respect to sexual functioning and satisfaction in cis individuals
      • Corona G
      • Rastrelli G
      • Morgentaler A
      • et al.
      Meta-analysis of Results of testosterone therapy on sexual function based on international index of erectile function scores.
      • Santoro N
      • Worsley R
      • Miller KK
      • et al.
      Role of estrogens and estrogen-like compounds in female sexual function and dysfunction.
      • Davis SR
      • Davison SL
      • Donath S
      • et al.
      Circulating androgen levels and self-reported sexual function in women.
      • Randolph Jr., JF
      • Zheng H
      • Avis NE
      • et al.
      Masturbation frequency and sexual function domains are associated with serum reproductive hormone levels across the menopausal transition.
      • Bancroft J.
      The endocrinology of sexual arousal.
      • Travison TG
      • Morley JE
      • Araujo AB
      • et al.
      The relationship between libido and testosterone levels in aging men.
      • Turna B
      • Apaydin E
      • Semerci B
      • et al.
      Women with low libido: correlation of decreased androgen levels with female sexual function index.
      • Burrows LJ
      • Basha M
      • Goldstein AT.
      The effects of hormonal contraceptives on female sexuality: a review.
      • Davis SR
      • Moreau M
      • Kroll R
      • et al.
      Testosterone for low libido in postmenopausal women not taking estrogen.
      • Redmond GP.
      Hormones and sexual function.
      • Yassin AA
      • Saad F.
      Plasma levels of dihydrotestosterone remain in the normal range in men treated with long-acting parenteral testosterone undecanoate.
      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.
      • Bradford NJ
      • Spencer K.
      Sexual pleasure in transgender and gender diverse individuals: an update on recent advances in the field.
      Current literature mostly pays attention either at sexuality prior to GAMI,
      • Bartolucci C
      • Gomez-Gil E
      • Salamero M
      • et al.
      Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery.
      ,
      • Cerwenka S
      • Nieder TO
      • Cohen-Kettenis P
      • et al.
      Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study.
      or on the combined effect of hormonal and surgical interventions on sexual wellbeing.
      • Kronawitter D
      • Gooren LJ
      • Zollver H
      • et al.
      Effects of transdermal testosterone or oral dydrogesterone on hypoactive sexual desire disorder in transsexual women: results of a pilot study.
      • Kim GW
      • Kim SK
      • Jeong GW.
      Neural activation-based sexual orientation and its correlation with free testosterone level in postoperative female-to-male transsexuals: preliminary study with 3.0-T fMRI.
      • Wierckx K
      • Van Caenegem E
      • Elaut E
      • et al.
      Quality of life and sexual health after sex reassignment surgery in transsexual men.
      • Kim GW
      • Jeong GW.
      Neural mechanisms underlying sexual arousal in connection with sexual hormone levels: a comparative study of the postoperative male-to-female transsexuals and premenopausal and menopausal women.
      • Sturup GK.
      Male transsexuals: a long-term follow-up after sex reassignment operations.
      • Costantino A
      • Cerpolini S
      • Alvisi S
      • et al.
      A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery.
      • Beckwith N
      • Reisner SL
      • Zaslow S
      • et al.
      Keuroghlian AS. factors associated with gender-affirming surgery and age of hormone therapy initiation among transgender adults.
      • Elaut E
      • Bogaert V
      • De Cuypere G
      • et al.
      Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: an exploration in male-to-female transsexuals.
      • Kraemer B
      • Hobi S
      • Rufer M
      • et al.
      Partner relationship and sexuality of female-to-male transsexuals.
      • Selvaggi G
      • Monstrey S
      • Ceulemans P
      • et al.
      Genital sensitivity after sex reassignment surgery in transsexual patients.
      • de Cuypere G
      • Elaut E
      • Heylens G
      • et al.
      Long-term follow-up: psychosocial outcome of belgian transsexuals after sex reassignment surgery.
      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).
      • Selvaggi G
      • Monstrey S
      • Ceulemans P
      • et al.
      Genital sensitivity after sex reassignment surgery in transsexual patients.
      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.”
      • Bartolucci C
      • Gomez-Gil E
      • Salamero M
      • et al.
      Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery.
      Receiving hormone treatment, experiencing negative feelings, and having a partner, however, were found to relate to better subjective perceptions of sexual quality of life.
      • Bartolucci C
      • Gomez-Gil E
      • Salamero M
      • et al.
      Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery.
      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.
      • Ristori J
      • Fisher AD
      • Cipriani A
      • et al.
      PS-01-005 The effect of hormonal treatment on sexual distress in transgender persons: a two-year follow-up study.
      Despite the perceived detrimental effects of hormone treatment on sexual function - especially in individuals AMAB (Assigned Male at Birth)
      • McCabe MP
      • Sharlip ID
      • Lewis R
      • et al.
      Risk factors for sexual dysfunction among women and men: a consensus statement from the fourth international consultation on sexual medicine 2015.
      - sexual distress indeed is reduced after starting hormone treatment,
      • Ristori J
      • Fisher AD
      • Cipriani A
      • et al.
      PS-01-005 The effect of hormonal treatment on sexual distress in transgender persons: a two-year follow-up study.
      and sexual wellbeing might significantly improve by minimizing the incongruence between one's body and gender identity.
      • Fisher AD
      • Castellini G
      • Fanni E
      • et al.
      Cross-sex hormone treatment and psychobiological changes in transsexual persons: 2-years follow-up data.

       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,
      • van de Grift TC
      • Elfering L
      • Greijdanus M
      • et al.
      Subcutaneous mastectomy improves satisfaction with body and psychosocial function in trans men: findings of a cross-sectional study using the BODY-Q chest module.
      • Nobili A
      • Glazebrook C
      • Arcelus J.
      Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis.
      • Satterwhite T
      • Morrison SD
      • Ludwig DC
      • et al.
      Abstract: prospective quality of life outcomes after facial feminization surgery.
      little information is available on this subject in trans individual after GAS.
      • Bartolucci C
      • Gomez-Gil E
      • Salamero M
      • et al.
      Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery.
      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
      • Byers ES
      • Rehman US.
      Sexual well-being.
      , and Özer et al
      • Özer PT
      • Gijs Kreukels
      • Mullender
      Sexual wellbeing in gender incongruent individuals: towards sex positive definition and assessment.
      modified this definition in the scope of treatment seeking trans individuals in 2021.
      • Özer PT
      • Gijs Kreukels
      • Mullender
      Sexual wellbeing in gender incongruent individuals: towards sex positive definition and assessment.
      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.
      • Coleman E
      • Bockting W
      • Botzer M
      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”.
      • Whipple B.
      The benefits of sexual expression on physical health.
      The adjective ‘trans’ is used here in line with the previous ESSM Position Statement on “hormonal management of adolescent and adult trans people”,
      • Whipple B.
      The benefits of sexual expression on physical health.
      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 non-binary 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.
      Table 1Sexual wellbeing following gender affirming surgery
      StudyDesignSample sizeAge rangeSexual TopicsMethods/ToolsOutcomes regarding Sexual Wellbeing
      Cohen-Kettenis et al 1997

      Sexual Reassignment of Adolescent
      • Cohen-Kettenis PT
      • van Goozen SH.
      Sex reassignment of adolescent transsexuals: a follow-up study.
      Follow-up study49 AMAB

      20 AFAB
      19–27Sexual activity, intercourse, orgasm, relationship, masturbation, satisfaction with sex lifeSemi-structured interviewSexually active: n = 13

      Orgasm: 77%

      No partner at time of interview or had never had one: 57%

      Masturbation: 50% < 1/mo or never, 43% >1/mo; AMAB decrease in frequency, AFAB no change or increase Sexual satisfaction: 71% satisfied, 14% neutral view, 14% were dissatisfied
      Jarolim et al 2000

      Surgical conversion of genitalia
      • Jarolim L.
      Surgical conversion of genitalia in transsexual patients.
      Outcome meassure452 AMAB

      30 AFAB
      17–51Lubrication, orgasm, clitoral activityChart reviewVaginoplasty (n = 29):

      Sexual stimulation leads to production of urethral secretions which served as natural lubrication.

      Enabled coitus with orgasm



      Metoidioplasty (n = 28):

      Preserved erotogenic clitoral activity
      Johansson et al 2010

      A Five-Year Follow-Up
      • Johansson A
      • Sundbom E
      • Hojerback T
      • Bodlund O.
      A five-year follow-up study of Swedish adults with gender identity disorder.
      Follow-up study425 AMAB

      17 AFAB
      18–60Relationships, sexual orientation, sex life, sexual impairmentSemi-structured interview, self-developed questionnaireSexual impairment after GAS: 5% AMAB

      Sex life: 70% better, 25% unchanged, 5% worsened

      Partner relations: 62% better, 30% unchanged, 8% worsened
      Kuhn et al 2011

      Vaginal prolapse, pelvic floor
      • Kuhn A
      • Santi A
      • Birkhauser M.
      Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals.
      Follow-up study452 AMAB

      3 AFAB
      No dataSexual activity: satisfaction, frequencySheffield prolapse questionnaireStable relationship: 71%

      75% considered sex life to interfere to some degree with enjoyment of life (better and/or worse)

      Most were sexually satisfied and had sex on a regular basis
      Lief et al 1993

      Orgasm in the postoperative
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      Outcome meassure414 AMAB

      9 AFAB
      27–63Frequency of sex (not restricted to coitus, orgasmic capacity, reasons for anorgasmia, sexual satisfaction, sexual preferenceSelf-developed questionnaireAMAB

      Orgasm: 10 anorgasmic, 10/14 Orgasmic before, 8 lost capacity, 4/14 anorgasmic before, 2 gained capacity

      Reasons for anorgasmia: dissatisfied with vaginal depth or cosmesis

      Frequency of sex: 75% increase

      Sexual satisfaction: 9/14 increase in satisfaction



      AFAB

      Orgasm: 7/9 Orgasmic, through masturbation, intercourse, and oral sex. 6 anorgasmic before: 4 gained capacities

      Reasons for anorgasmia: dissatisfied with masculinity level of body

      Frequency of sex: 100% increase

      Same people reporting being orgasmic report being sexually satisfied.

      Sexual satisfaction: 6/9 increase in satisfaction
      Lobato et al 2006

      Follow-Up of Sex Reassignment
      • Lobato MI
      • Koff WJ
      • Manenti C
      • et al.
      Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort.
      Follow-up study418 AMAB

      1 AFAB
      18–47Satisfaction with sexual experience, partnerships, and relationship with family members, sexually active, frequency of sex, pleasurability of sex.Self-developed questionnaireSexually active: 95%

      More frequent sex: 64.7%

      Pleasurability of sex: 83.3%

      Partnership

      Initiating and maintaining relationship easier post SRS: 64.7%

      Relationship pre-op: 52.6%

      Relationship post-op: 73.7%

      Satisfaction with sexual experience

      poor or very poor post-op: 11.2%

      Improvement of sexual experience post-op: 83.3%
      Lothstein et al 1980

      The postsurgical transsexual
      • Lothstein LM.
      The postsurgical transsexual: empirical and theoretical considerations.
      Group comparison / Follow-up study48 AMAB

      6 AFAB
      21–42Sexual adjustment and

      functioning, improvement sex life,

      sexual activity, number of sexual partners, orgasm, sexual behaviour, partnering
      Self-developed questionnaireAMAB

      Improvement sex life 67%

      Sexual activity & number of sexual partners: no increase

      Orgasm: 2 ejaculatory sensations

      Sexual behaviour: more flexible and spontaneous (engaging more frequently in oral, anal, and vaginal intercourse)

      Partnering: tended to seek out new partners, 64% no relationship



      AFAB

      Improvement sex life 67%

      Sexual activity & number of sexual partners: no increase

      Partnering: kept the same partners, 64% no relationship
      Rakic et al 1996

      The outcome of sex reassignment
      • Rakic Z
      • Starcevic V
      • Maric J
      • Kelin K.
      The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes.
      Follow-up study422 AMAB

      10 AFAB
      19–47Orgasm, number of sex partners, sexual activity, satisfaction with relationshipsSelf-developed questionnaire: 'Adjustment to Sex Reassignment Surgery'Relationship satisfaction: 87%

      Sexual partner: AMAB 23%, AFAB 80%

      Several sexual partners: AMAB 50%

      Orgasm: 50%
      Selvaggi et al 2007

      Genital sensitivity after sex reassignment
      • Selvaggi G
      • Monstrey S
      • Ceulemans P
      • et al.
      Genital sensitivity after sex reassignment surgery in transsexual patients.
      Outcome meassure4

      30 AMAB

      27 AFAB
      No dataOrgasm, sensitivityInterview and physical examination: Semmes-Weinstein, vibration tests (biothesiometer)The reconstructed genitalia obtain

      tactile and erogenous sensitivity

      Orgasm: AMAB 85%, AFAB 100%
      Smith et al 2001

      Adolescents With Gender Identity Disorder
      • Smith YL
      • van Goozen SH
      • Cohen-Kettenis PT.
      Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study.
      Group comparison / Follow-up study47 AMAB

      13 AFAB
      15–19Orgasm, relationship status, sexual orientation, intercourse, sexual functioningSelf-developed questionnaire, Utrecht Gender Dysphoria Scale (UGS), Body Image Scale (BIS)Sexual partner: 10 patients

      Satisfaction with sex life: 1 FM was dissatisfied (could not have intercourse with a “normal” penis)

      Several AFAB: difficult to live

      without a penis

      know their potential sexual partner well. Masturbation: AMAB –>decrease in masturbation frequency, AFAB–> increase or no change.

      Orgasms: 69%

      Sexual orientation: stayed compatible
      Sorensen 1981

      A follow-up study
      • Sorensen T.
      A follow-up study of operated transsexual females.
      Outcome meassure48 AFAB30–60Intercourse, sexual satisfaction, masturbation, orgasm, sensitivity, ability to perform intercourse, importance of sexual activity, painStructured interviewSexual partner: all patients

      Sexual satisfaction: only from clitoris (all); 5 satisfactory, 3 unsatisfactory

      Masturbation: all, >2 a wk

      Orgasm: all

      Intercourse: 2 with phalloplasty with rib, but with pain, 6 with dildo

      Importance of sexual activity: essential in a life with a partner to all

      Pain: during intercourse in the 2 patients with phalloplasty from rib
      Tsoi et al 1993

      Follow-up study of
      • Tsoi WF.
      Follow-up study of transsexuals after sex-reassignment surgery.
      Outcome meassure445 AMAB

      36 AFAB
      20–36Satisfaction with: sexual activities, organ functioning, sex status, sex organSemi-structured interview, self-developed questionnaireGood or satisfactory sexual activity:

      MtF 64% vs FtM 61%

      Good or satisfactory sex organ function:

      MtF 91% vs FtM 39%

      Good or satisfactory sex status:

      MtF 95% vs FtM 81%

      Good or satisfactory sex organ:

      MtF 91% vs FtM 39%
      van de Grift et al 2017 A longitudinal study
      • van de Grift TC
      • Pigot GLS
      • Boudhan S
      • et al.
      A Longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen.
      Follow-up study421 AFABMean 40.1 ySexual activity (type of activity), sexual preference and change in preference, partnering, sexual satisfactionSelf-developed questionnaire, chart review, Body Image Scale (BIS)Female partner 63,2%

      Male partner 10,5%

      Single 26,3%

      Sexual function: metoidioplasty higher sexual satisfaction

      Postop sexual activity: more masturbation and sexual activity, genitals more freq used (31% vs 78%)

      More pleasure, confidence, passive role

      Changed sexual orientation (“exclusively to men” to “primarily to women”).

      Grade for sex life: 5.5 of 10 (SD 2.6) à “impossibility to penetrate/no erection prosthesis”, “not sexually active”, “penile size/sensation” and “partner issues”
      Wierckx et al 2011 Quality of life and
      • Wierckx K
      • Van Caenegem E
      • Elaut E
      • et al.
      Quality of life and sexual health after sex reassignment surgery in transsexual men.
      Follow-up study449 AFAB22–54Relationship status, sexual preference, sexual activities (frequency, type of activity, pain), sexual wellbeing, masturbation, sexual satisfaction, orgasm, arousalSelf-developed questionnaireTreatment phase differed within the group

      Relationship 63,3%

      Attracted to females 85,7%

      Partner: heterosexual woman 77,4%

      Frequency of sex:

      Never 22,2%

      1-2/month 48,1%

      Several times a week 29,6%

      Sex satisfaction: (very satisfied) 64,2%



      Erection prosthesis (n = 32)

      Frequency of masturbation:

      Less than monthly- daily

      Aroused easily: majority

      Orgasm through masturbation: majority

      Orgasm by intercourse: majority

      Change in orgasmic feeling: 58,3%

      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.
      • Saklad MMD.
      Grading of patients for surgical procedures.
      ,
      • Owens WD.
      American society of anesthesiologists physical status classification system in not a risk classification system.
      Patients should be advised on smoking cessation and ideal weight for surgery, that is, a BMI between 18–30 kg/m2, prior to genital GAS.
      • Hoogendoorn JM
      • Simmermacher RK
      • Schellekens PP
      • et al.
      Adverse effects if smoking on healing of bones and soft tissues.
      • Bamgbade OA
      • Rutter TW
      • Nafiu OO
      • Dorje P.
      Postoperative complications in obese and nonobese patients.
      • Berrington de Gonzalez A
      • Hartge P
      • Cerhan JR
      • et al.
      Body-mass index and mortality among 1.46 million white adults.
      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,
      • Hembree WC
      • Cohen-Kettenis PT
      • Gooren L
      • et al.
      Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline.
      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.
      • Mattawanon N
      • Spencer JB
      Schirmer DA, 3rd, Tangpricha V. Fertility preservation options in transgender people: a review.
      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.
      • van de Grift TC
      • Mullender MG
      • Bouman MB.
      Shared decision making in gender-affirming surgery. implications for research and standards of care.
      The surgeon should inform the patient on the techniques available, their advantages and disadvantages, limitations with producing ‘ideal’ results and possible risks and complications.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      • Özer M
      • Pigot GLS
      • Bouman M-B
      • et al.
      Development of a decision aid for genital gender-affirming surgery in transmen.
      • Mokken SE
      • Özer M
      • van de Grift TC
      • et al.
      Evaluation of the decision aid for genital surgery in Transmen.
      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.
      • Coleman E
      • Bockting W
      • Botzer M
      • et al.
      Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7.
      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.
      • Lawrence AA.
      Factors associated with satisfaction or regret following male-to-female sex reassignment surgery.
      ,
      • Jiang DD
      • Gallagher S
      • Burchill L
      • et al.
      Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty.

      Sexual Wellbeing After Gender Affirming Surgery

      Gender Affirming Surgery (GAS) is an umbrella term for a variety of surgical procedures.
      • Colebunders B
      • Brondeel S
      • D'Arpa S
      • et al.
      An update on the surgical treatment for transgender patients.
      It is important to note that trans individuals may or may not adhere to a standard linear progression from hormone treatment to surgical procedures.
      • Wiepjes CM
      • Nota NM
      • de Blok CJM
      • et al.
      The Amsterdam cohort of gender dysphoria study (1972-2015): trends in prevalence, treatment, and regrets.
      Sexual motivations may influence some individuals to prefer surgical interventions without prior hormone treatment, or opt out of some surgical procedures.
      • Beek TF
      • Kreukels BP
      • Cohen-Kettenis PT
      • et al.
      Partial treatment requests and underlying motives of applicants for gender affirming interventions.
      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.
      • Wierckx K
      • Van Caenegem E
      • Elaut E
      • et al.
      Quality of life and sexual health after sex reassignment surgery in transsexual men.
      ,
      • Sorensen T.
      A follow-up study of operated transsexual females.
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      • van de Grift TC
      • Pigot GLS
      • Boudhan S
      • et al.
      A Longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen.
      Frequency of masturbation, however, was decreased in AMAB individuals and remained unchanged or increased in AFAB individuals.
      • Cohen-Kettenis PT
      • van Goozen SH.
      Sex reassignment of adolescent transsexuals: a follow-up study.
      ,
      • Smith YL
      • van Goozen SH
      • Cohen-Kettenis PT.
      Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study.
      Every patient experienced postsurgical tactile erogenous, to some extent.
      • Selvaggi G
      • Monstrey S
      • Ceulemans P
      • et al.
      Genital sensitivity after sex reassignment surgery in transsexual patients.
      Every AFAB individual and 85% of AMAB individuals were able to reach orgasm,
      • Selvaggi G
      • Monstrey S
      • Ceulemans P
      • et al.
      Genital sensitivity after sex reassignment surgery in transsexual patients.
      either through masturbation or intercourse.
      • Wierckx K
      • Van Caenegem E
      • Elaut E
      • et al.
      Quality of life and sexual health after sex reassignment surgery in transsexual men.
      ,
      • Sorensen T.
      A follow-up study of operated transsexual females.
      ,
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      ,
      • Cohen-Kettenis PT
      • van Goozen SH.
      Sex reassignment of adolescent transsexuals: a follow-up study.
      ,
      • Jarolim L.
      Surgical conversion of genitalia in transsexual patients.
      ,
      • Rakic Z
      • Starcevic V
      • Maric J
      • Kelin K.
      The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes.
      Orgasm after GAS was experienced more frequently by both AMAB and AFAB individuals,
      • Rakic Z
      • Starcevic V
      • Maric J
      • Kelin K.
      The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes.
      less frequently by AMAB individuals,
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      than by AFAB individuals.
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      Most AMAB individuals were satisfied with GAS, reporting sexual satisfaction with the possibility of penetrative sex
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      ,
      • Tsoi WF.
      Follow-up study of transsexuals after sex-reassignment surgery.
      and being partnered.
      • Cohen-Kettenis PT
      • van Goozen SH.
      Sex reassignment of adolescent transsexuals: a follow-up study.
      Initiating and maintaining intimate relationships became easier postoperatively.
      • Rakic Z
      • Starcevic V
      • Maric J
      • Kelin K.
      The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes.
      ,
      • Lobato MI
      • Koff WJ
      • Manenti C
      • et al.
      Follow-up of sex reassignment surgery in transsexuals: a Brazilian cohort.
      Limited sensitivity and absence of erectile function after phalloplasty decreased sexual satisfaction in AFAB individuals.
      • Tsoi WF.
      Follow-up study of transsexuals after sex-reassignment surgery.
      Phalloplasty was not found to be a critical factor in reaching orgasm or sexual satisfaction,
      • Lief HI
      • Hubschman L.
      Orgasm in the postoperative transsexual.
      difficulties in engaging in new sexual contacts, however, may have been a factor preoperatively.
      • Cohen-Kettenis PT
      • van Goozen SH.
      Sex reassignment of adolescent transsexuals: a follow-up study.
      ,
      • Smith YL
      • van Goozen SH
      • Cohen-Kettenis PT.
      Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study.
      The strongest motivation to pursue penile surgery was confirmation of one's identity.
      • van de Grift TC
      • Pigot GLS
      • Boudhan S
      • et al.
      A Longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen.
      Postsurgical aesthetics and functionality were satisfactory, including the ability to void while standing.
      • Jarolim L.
      Surgical conversion of genitalia in transsexual patients.
      Disappointment following GAS resulted because of a decrease in sex drive, not being partnered or having non-functional genitalia.
      • Johansson A
      • Sundbom E
      • Hojerback T
      • Bodlund O.
      A five-year follow-up study of Swedish adults with gender identity disorder.
      Advice regarding postsurgical care and follow-up were provided by two studies. Kuhn et al
      • Kuhn A
      • Santi A
      • Birkhauser M.
      Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals.
      concluded that pelvic floor symptoms involving the bladder, bowel, and sexual function may occur in AMAB individuals. Lothstein et al
      • Lothstein LM.
      The postsurgical transsexual: empirical and theoretical considerations.
      advised counselling and psychotherapy prior to surgery and continued follow-up 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,
      • Oefelein MG
      • Feng A
      • Scolieri MJ
      • Ricchiutti D
      • Resnick MI.
      Reassessment of the definition of castrate levels of testosterone: implications for clinical decision making.
      patients should be counselled on possible adverse effects of low testosterone levels on sexual wellbeing.
      • Rastrelli G
      • Guaraldi F
      • Reismann Y
      • et al.
      Testosterone Replacement therapy for sexual symptoms.

       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.
      • Karim RB
      • Hage JJ
      • Bouman FG
      • et al.
      Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals.
      The vaginal canal is created between the rectum and bladder, and lined with penile skin- optionally modified with skin grafts, urethral mucosa or scrotal flaps-skin grafts-only,
      • Nijhuis THJ
      • Özer M
      • van der Sluis WB
      • et al.
      The Bilateral pedicled epilated scrotal flap: a powerful adjunctive for creation of more neovaginal depth in penile inversion vaginoplasty.
      bowel segments or peritoneum.
      • Horbach SE
      • Bouman MB
      • Smit JM
      • et al.
      Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques.
      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.
      • Perovic SV
      • Stanojevic DS
      • Djordjevic ML.
      Vaginoplasty in male transsexuals using penile skin and a urethral flap.
      The penile-inversion vaginoplasty is currently considered the gold standard.
      • Selvaggi G
      • Bellringer J.
      Gender reassignment surgery: An overview.
      Studies show that penile-inversion vaginoplasty is associated with satisfaction with aesthetics and function.
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Zavlin D
      • Schaff J
      • Lelle JD
      • et al.
      Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes.
      (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.
      • Jiang D
      • Witten J
      • Berli J
      • et al.
      Does depth matter? factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women.
      Counselling is strongly recommended to minimize the risk of future regret.
      • van der Sluis WB
      • Steensma TD
      • Timmermans FW
      • et al.
      Gender-confirming vulvoplasty in transgender women in the netherlands: incidence, motivation analysis, and surgical outcomes.
      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.
      • Manrique OJ
      • Adabi K
      • Huang TC
      • et al.
      Assessment of pelvic floor anatomy for male-to-female vaginoplasty and the role of physical therapy on functional and patient-reported outcomes.
      The sexologist may address issues regarding changing sexual function, for example; in, phantom pains, sexual stimulation and arousal.
      • Djordjevic ML
      • Stanojevic DS
      • Bizic MR.
      Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.
      • Lawrence AA.
      Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery.
      • Ramachandran VS
      • McGeoch PD.
      Occurrence of phantom genitalia after gender reassignment surgery.
      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.
      • Lawrence AA.
      Factors associated with satisfaction or regret following male-to-female sex reassignment surgery.
      ,
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      • Zavlin D
      • Schaff J
      • Lelle JD
      • et al.
      Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes.
      • Jiang D
      • Witten J
      • Berli J
      • et al.
      Does depth matter? factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women.
      ,
      • Djordjevic ML
      • Stanojevic DS
      • Bizic MR.
      Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.
      ,
      • Lawrence AA.
      Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery.
      ,
      • Amend B
      • Seibold J
      • Toomey P
      • et al.
      Surgical reconstruction for male-to-female sex reassignment.
      ,
      • Blanchard R
      • Legault S
      • Lindsay WR.
      Vaginoplasty outcome in male-to-female transsexuals.
      ,
      • Bouman FG.
      Sex reassignment surgery in male to female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Brotto LA
      • Gehring D
      • Klein C
      • et al.
      Psychophysiological and subjective sexual arousal to visual sexual stimuli in new women.
      ,
      • Buncamper ME
      • van der Sluis WB
      • de Vries M
      • et al.
      Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft?.
      ,
      • Cardoso da Silva D
      • Schwarz K
      • Fontanari AM
      • et al.
      WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals.
      ,
      • Collyer F
      • Heal C.
      Patient satisfaction with sex re-assignment surgery in New South Wales, Australia.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      ,
      • Freundt I
      • Toolenaar TA
      • Huikeshoven FJ
      • et al.
      Jeekel H. A modified technique to create a neovagina with an isolated segment of sigmoid colon.
      ,
      • Giraldo F
      • Esteva I
      • Bergero T
      • et al.
      Corona glans clitoroplasty and urethropreputial vestibuloplasty in male-to-female transsexuals: the vulval aesthetic refinement by the Andalusia Gender Team.
      ,
      • Goddard JC
      • Vickery RM
      • Qureshi A
      • et al.
      Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.
      ,
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      ,
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      ,
      • Jarolim L
      • Sedy J
      • Schmidt M
      • et al.
      Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks.
      ,
      • Kanhai RC.
      Sensate vagina pedicled-spot for male-to-female transsexuals: the experience in the first 50 patients.
      ,
      • Karim RB
      • Hage JJ
      • Bouman FG
      • et al.
      The importance of near total resection of the corpus spongiosum and total resection of the corpora cavernosa in the surgery of male to female transsexuals.
      ,
      • Kim SK
      • Park JH
      • Lee KC
      • et al.
      Long-term results in patients after rectosigmoid vaginoplasty.
      ,
      • Kim SK
      • Park JW
      • Lim KR
      • et al.
      Is rectosigmoid vaginoplasty still useful?.
      ,
      • Krege S
      • Bex A
      • Lummen G
      • et al.
      Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.
      ,
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      ,
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      ,
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Long-term follow-up of "sex change" in 13 male-to-female transsexuals.
      ,
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases.
      ,
      • Manrique OJ
      • Sabbagh MD
      • Ciudad P
      • et al.
      Gender-confirmation surgery using the pedicle transverse colon flap for vaginal reconstruction: a clinical outcome and sexual function evaluation study.
      ,
      • Mate-Kole C
      • Freschi M
      • Robin A
      A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • et al.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery.
      ,
      • Mukai Y
      • Watanabe T
      • Sugimoto M
      • et al.
      Vaginoplasty with a pudendal-groin flap in male-to-female transsexuals.
      ,
      • Papadopulos NA
      • Lelle JD
      • Zavlin D
      • et al.
      Psychological pathologies and sexual orientation in transgender women undergoing gender confirming treatment.
      ,
      • Papadopulos NA
      • Zavlin D
      • Lelle JD
      • et al.
      Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes.
      ,
      • Perovic SV
      • Stanojevic DS
      • Djordjevic ML.
      Vaginoplasty in male to female transsexuals using penile skin and urethral flap.
      ,
      • Raigosa M
      • Avvedimento S
      • Yoon TS
      • et al.
      Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients.
      ,
      • Reed HM
      • Yanes RE
      • Delto JC
      • et al.
      Non-grafted vaginal depth augmentation for transgender atresia, our experience and survey of related procedures.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Rehman J
      • Melman A.
      Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome.
      ,
      • Salgado CJ
      • Nugent A
      • Kuhn J
      • et al.
      Primary sigmoid vaginoplasty in transwomen: technique and outcomes.
      ,
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      ,
      • Seyed-Forootan K
      • Karimi H
      Seyed-Forootan NS. autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery.
      ,
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      • Soli M
      • Brunocilla E
      • Bertaccini A
      • et al.
      Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris.
      • Stanojevic DS
      • Djordjevic ML
      • Milosevic A
      • et al.
      Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.
      • Stein M
      • Tiefer L
      • Melman A.
      Followup observations of operated male-to-female transsexuals.
      • Tavakkoli Tabassi K
      • Djavan B
      • Hosseini J
      • et al.
      Fold-back perineoscrotal flap plus penile inversion vaginoplasty for male-to-female gender reassignment surgery in circumcised subjects.
      • Thalaivirithan BM
      • Sethu M
      • Ramachandran DK
      • et al.
      Application of embryonic equivalents in male-to-female sex reassignment surgery.
      • Toolenaar TA
      • Freundt I
      • Huikeshoven FJ
      • et al.
      The occurrence of diversion colitis in patients with a sigmoid neovagina.
      • van der Sluis WB
      • Bouman MB
      • de Boer NK
      • et al.
      Long-term follow-up of transgender women after secondary intestinal vaginoplasty.
      • van der Sluis WB
      • Neefjes-Borst EA
      • Bouman MB
      • et al.
      Morphological spectrum of neovaginitis in autologous sigmoid transplant patients.
      • Wagner S
      • Greco F
      • Hoda MR
      • et al.
      Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients.
      • Weyers S
      • Elaut E
      • De Sutter P
      • et al.
      Long-term assessment of the physical, mental, and sexual health among transsexual women.
      • Wu JX
      • Li B
      • Li WZ
      • et al.
      Laparoscopic vaginal reconstruction using an ileal segment.
      • Zavlin D
      • Wassersug RJ
      • Chegireddy V
      • et al.
      Age-related differences for male-to-female transgender patients undergoing gender-affirming surgery.
      • Cocci A
      • Rosi F
      • Frediani D
      • et al.
      Male-to-Female (MtoF) gender affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty).
      • di Summa PG
      • Watfa W
      • Krahenbuhl S
      • et al.
      Colic-based transplant in sexual reassignment surgery: functional outcomes and complications in 43 consecutive patients.
      • Hess J
      • Henkel A
      • Bohr J
      • et al.
      Sexuality after male-to-female gender affirmation surgery.
      • Watanyusakul S.
      Vaginoplasty modifications to improve vulvar aesthetics.
      Postoperative genital sensitivity- defined as clitoral sensation, orgasmic sensation and genital sensation-was conserved in almost every patient.
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Amend B
      • Seibold J
      • Toomey P
      • et al.
      Surgical reconstruction for male-to-female sex reassignment.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      ,
      • Goddard JC
      • Vickery RM
      • Qureshi A
      • et al.
      Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.
      ,
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      ,
      • Jarolim L
      • Sedy J
      • Schmidt M
      • et al.
      Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks.
      ,
      • Kanhai RC.
      Sensate vagina pedicled-spot for male-to-female transsexuals: the experience in the first 50 patients.
      ,
      • Perovic SV
      • Stanojevic DS
      • Djordjevic ML.
      Vaginoplasty in male to female transsexuals using penile skin and urethral flap.
      ,
      • Raigosa M
      • Avvedimento S
      • Yoon TS
      • et al.
      Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Soli M
      • Brunocilla E
      • Bertaccini A
      • et al.
      Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris.
      Subjective arousal and desire were similarly experienced by a majority (79,1%) of postsurgical women.
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      ,
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      ,
      • Weyers S
      • Elaut E
      • De Sutter P
      • et al.
      Long-term assessment of the physical, mental, and sexual health among transsexual women.
      ,
      • Elaut E
      • De Cuypere G
      • De Sutter P
      • et al.
      Hypoactive sexual desire in transsexual women: prevalence and association with testosterone levels.
      Table 2Sexual wellbeing following vaginoplasty
      StudyDesignLoESample sizeAge rangeSexual topicsMethods/ToolsOutcomes regarding Sexual Wellbeing
      Amend et al 2013, Surgical reconstruction
      • Amend B
      • Seibold J
      • Toomey P
      • et al.
      Surgical reconstruction for male-to-female sex reassignment.
      Outcome measures313 AMAB20–54Intercourse, satisfaction, neo-clitoral sensation, vaginal depth, orgasmSelf-developed structured interview23 (96%) were satisfied with neo-clitoral sensitivity, which led to orgasm.

      Neo-clitoral sensation was excellent in 18, good in 5, and unsatisfactory in 1. Eight (33 %) had engaged in intercourse, without the need for lubrication. None experienced intravaginal hair growth or loss of vaginal capacity.
      Blanchard et al 1983, Vaginoplasty outcome
      • Blanchard R
      • Legault S
      • Lindsay WR.
      Vaginoplasty outcome in male-to-female transsexuals.
      Outcome measures322 AMABOrgasm, intercourse, self-reported depth adequacy, pain/discomfort during sex, discomfort after sex, frequency of sex, sexual orientationStructured interview, pelvic exam19 (86,4%) had intercourse at least once: 8 experienced no pain, 2 did always, 5 did initially or after a period of sexual inactivity, 4 did slightly. 3 experienced discomforts after sex
      Bouman et al 1988, Sex reassignment
      • Bouman FG.
      Sex reassignment surgery in male to female transsexuals.
      Outcome measures476 AMABNo dataSexual intercourse, satisfaction during sex, neo-vaginal dimensions,Chart review3 had complaints due to small vaginal diameter, one was unable to perform receptive vaginal sex. 30 had intercourse with men, 11 with men, 15 had not.
      Bouman et al 2016, Patient-Reported
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      Follow-up study431 AMAB18–45Vaginal intercourse, neo-vaginal dimensions, sexual arousal, sexual feelings, orgasm, desire, lubrication, satisfactionFemale Sexual Function Index, Female Genital Self-Image Scale, Short Questionnaire for Self-Evaluation of Vaginoplasty, Amsterdam Hyperactive Pelvic Floor Scale—Women21 were sexually active, 16 had sex more than once. Every participant experienced sexual arousal. 84 % could reach orgasm, 4% could not, and 12% had not tried.
      Brotto et al 2005, Psychophysiological and
      • Brotto LA
      • Gehring D
      • Klein C
      • et al.
      Psychophysiological and subjective sexual arousal to visual sexual stimuli in new women.
      Prospective cross-sectional study315 AMAB21–65Thoughts/desire, Frequency of sexual activity, receptivity/initiation, relationship satisfaction, problems affecting sexual function, sexual arousal, non-genital

      physical arousal, genital arousal, pleasure from direct genital stimulation, orgasm (eg, clitoral stimulation,

      intercourse, vibrator use, fantasy), satisfaction with orgasmic

      function, dissatisfaction

      or distress, effects of erotic stimuli, objective arousal: using a vaginal pulse amplitude
      Self-developed questionnaire during Vaginal pulse amplitude (VPA), Brief Index of Sexual Functioning for Women (BISF-W);

      Detailed Assessment

      of Sexual Arousal (DASA);
      4 were sexually active, 6 were able to achieve orgasm. 10 were satisfied with their orgasmic function, 3 (20%) dissatisfied or distressed.
      Buncamper et al 2015, Aesthetic and
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      Retrospective cross- sectional survey449 AMAB29–53Sexually activity, desire, arousal, lubrication, orgasm, satisfaction, comfort, sexual intercourse, neo-vaginal dimensions, sexual feelingsFemale Sexual Function

      Index (FSFI), Amsterdam Hyperactive Pelvic Floor Scale-Women (AHPFS-W), Female Genital Self-Imaging Scale, short questionnaire for self-evaluation of vaginoplasty
      36 were sexually active, 27 had attempted intercourse (3 of those tried but were unable). 83.7% had reached orgasm, 10.2% had not, 6.1% had not tried. Orgasmic sensation was equal in 22.4%, less in 28.6%, more in 46.9% and was missing in 2%, compared to prior to vaginoplasty. Provoked vulvodynia was scored with a mean of 1.33 (SD 0.75; 5-point scale from never - very often). Self-reported sexual arousal was present in 44.
      Buncamper et al 2017, Penile Inversion
      • Buncamper ME
      • van der Sluis WB
      • de Vries M
      • et al.
      Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft?.
      Group comparison4100 AMAB18–68Sexually activity, desire, arousal, lubrication, orgasm, satisfaction, comfort, sexual intercourse, neo-vaginal dimensions, sexual feelingsFemale Sexual Function

      Index (FSFI), Female Genital Self-Imaging Scale
      42 had been sexually active in the last 4 weeks. Median score for vaginal functionality: 8 (range 2–10; 1–10 scale, 10 being better; n = 45).
      Cardoso da Silva. et al 2016, WHOQOL-100
      • Cardoso da Silva D
      • Schwarz K
      • Fontanari AM
      • et al.
      WHOQOL-100 before and after sex reassignment surgery in brazilian male-to-female transsexual individuals.
      Follow-up study447 AMAB16–54Marital status, sexual activityWHOQOL-1005 were in a stable relationship, 42 were not.
      Cocci et al 2019, Male-to-female
      • Cocci A
      • Rosi F
      • Frediani D
      • et al.
      Male-to-Female (MtoF) gender affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty).
      Outcome measures494 AMABM 29.5 yIntercourse, erogenous sensitivityNot specified81 (86.1%) had intercourse. Erogenous sensitivity during dilatation, intercourse or

      masturbation was present in 78 (82.9%).
      Collyer et al 2002, Patient satisfaction
      • Collyer F
      • Heal C.
      Patient satisfaction with sex re-assignment surgery in New South Wales, Australia.
      Outcome measures457 AMAB21–35Orgasm, sexual satisfactionSelf-developed questionnaire34 patients were more sexually satisfied post-surgery; 17 patients had no change; 4 patients were less satisfied.
      di Summa et al 2019, Colic-based
      • di Summa PG
      • Watfa W
      • Krahenbuhl S
      • et al.
      Colic-based transplant in sexual reassignment surgery: functional outcomes and complications in 43 consecutive patients.
      Outcome measures443 AMAB22–69Satisfaction with the appearance/dimensions of the genitals, satisfaction with genital function (ing), orgasm (clitoral, vaginal or both), difficulties achieving orgasm, dyspareuniaRetrospective chart review, custom questionnaireOf n = 28

      10 (35.7%) was very satisfied with sexual functioning, 14 (50%) satisfied, 4 (14.3%) unsatisfied, none very unsatisfied.

      25 (89.3%) was satisfied or very satisfied with vulvar appearance, 3 (10.7%) unsatisfied, none very unsatisfied.
      Djordjevic et al 2011, Rectosigmoid vaginoplasty
      • Djordjevic ML
      • Stanojevic DS
      • Bizic MR.
      Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.
      Outcome measures427 AMAB

      59 women
      18–57Vaginal dimensions, mucous production, sexual satisfaction, sexual activity, time till first intercourse, painFSFI, interviewSexual function was rated satisfactory in 21, 6 were unsatisfied. 73 individuals of the entire cohort were sexually active, separate results not provided. 27 experienced temporary mild bleeding and dyspareunia.
      Eldh et al. 1993, Construction of
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      Outcome measures420 AMABNo dataOrgasm, sexual function, clitoral sensation, intercourseChart review20 could reach orgasm through masturbation or intercourse. 19 (95%) were pleased with their neo-clitoral sensation, 1 (5%) had no sensitivity.
      Freundt et al 1993, A modified
      • Freundt I
      • Toolenaar TA
      • Huikeshoven FJ
      • et al.
      Jeekel H. A modified technique to create a neovagina with an isolated segment of sigmoid colon.
      Outcome measures423 AMAB16–52Sexual relations, vaginal function, sexual satisfaction, intercourseStructured interview, pelvic examination5 had regular intercourse, 4 women occasionally, 1 did not. Sexual satisfaction was rated good by 2, satisfactory by 2, doubtful by 5, and unsatisfactory by 1. 2 were satisfied with sex life (20%), 4 were neutral, and 4 dissatisfied.
      Giraldo et al. 2004, Corona glans
      • Giraldo F
      • Esteva I
      • Bergero T
      • et al.
      Corona glans clitoroplasty and urethropreputial vestibuloplasty in male-to-female transsexuals: the vulval aesthetic refinement by the Andalusia Gender Team.
      Outcome measures416 AMAB,20–41OrgasmChart review16 were able to achieve orgasm.
      Goddard et al. 2007, Feminizing genitoplasty
      • Goddard JC
      • Vickery RM
      • Qureshi A
      • et al.
      Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.
      Outcome measures4233 AFAB, 70 (follow-up)19–76Clitoral sensation, sexual arousal, vaginal dimensions, intercourse, orgasmTelephone questionnaireOf 70 with follow-up, 64 had a neo-clitoris and 62 a vaginal canal: 14 had regular intercourse. 31 could reach clitoral orgasm.

      Of 183 with neo-clitoral formation: neo-clitoris was sensitive in 158, insensitive in 5, NA in 20. 4 experienced painful or uncomfortable clitoral sensations.
      Hess et al 2016, Modified preparation
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      Follow-up study496 AMAB19–62Neo-clitoral sensation, orgasmSemi-quantitative grading of neo-clitoral sensitivityAssessment of sensitivity by brushing over the clitoris with a brush, and pallesthesia by placing a 64 Hz tuning fork on the clitoris. A semi quantitative scoring system was formed by accumulating both: grade 0, no tactile sensation and complete pallanesthesia; grade 1, reduced pallesthesia and no tactile sensation; grade 2, intact pallesthesia and reduced tactile sensation; grade 3, complete pallesthesia and tactile sensation.

      n = 79: 11 had grade 1, 12 grade 2, and 56 grade 3. After second-stage (cosmetic corrections).

      n = 73: 59 could reach orgasm, 7 could not despite trying, 7 (9.6%) had not tried.
      Hess et al 2018, Sexuality after
      • Hess J
      • Henkel A
      • Bohr J
      • et al.
      Sexuality after male-to-female gender affirmation surgery.
      Follow-up study4119 AMAB16–68Sexual orientation, intercourse, frequency of sex, orgasm, orgasm frequency and sensation, satisfaction with clitoral sensitivity, satisfaction with the appearance/dimensions of the genitals, satisfaction with sex life, pleasurability of sex, sexual arousalUnspecified questionnaire33.7% were heterosexual, 37.6% lesbian, and 22.8% bisexual.

      67 (56.3%) did not have regular intercourse. Of those who had sexual intercourse, 55.8% rated orgasm more intense following GAS, 20.8% who felt no difference.

      73.9% were satisfied with neo-clitoral sensitivity, and 67.1% with vaginal depth.



      Of n = 88: sexual activity was always pleasurable for 31 (35.2%), sometimes pleasurable for 44 (50.0%), and never pleasurable for 13 (14.8%).
      Imbimbo et al 2009, A report from
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      Outcome measures4163 AMAB21–59Sexual activity, type of sexual activity, orgasm, masturbation, Satisfaction with sexual life, vaginal dimensionsTelephone questionnaire124 were sexually active: 60 had receptive vaginal sex, 75 receptive anal sex. 32 had masturbated. Satisfaction with sexual life post-surgery was improved in 75% and worsened or unchanged in 25%.
      Jarolim et al 2009, Gender reassignment
      • Jarolim L
      • Sedy J
      • Schmidt M
      • et al.
      Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks.
      Outcome measures4129 AMAB18–54Neo-clitoral erogenous sensation, orgasm, lubricationChart reviewOf n = 98: 92 (94%) had erogenous sensitivity of the neo-clitoris had. 64 (65%) reached orgasm 3 mo., some with urethral secretions,

      which provided lubrication.
      Kanhai et al 2016, Sensate vagina
      • Kanhai RC.
      Sensate vagina pedicled-spot for male-to-female transsexuals: the experience in the first 50 patients.
      Outcome measures450 AMAB19–65Erogenous sensation in both clitoral pediclesChart review46 (92%) experienced erogenous sensitivity and 41 (82 %) sexual sensations in the clitoris. 44 (88%) experienced erogenous sensitivity and 31 (62 %) sexual sensitivity of the sensate pedicled spot.
      Jiang et al 2018, Does depth matter
      • Jiang D
      • Witten J
      • Berli J
      • et al.
      Does depth matter? factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women.
      Outcome measures430 AMAB28–74Relationship status, orgasm, sexual activity.Case-seriesOf n = 14: 4 (29%) could achieve orgasm, 3 (21%) could not. 7 (50%) were not sexually active.

      Of n = 30: 17 (57%) were married or in a stable relationship, 13 (43%) were not.
      Karim et al 1991, The importance of
      • Karim RB
      • Hage JJ
      • Bouman FG
      • et al.
      The importance of near total resection of the corpus spongiosum and total resection of the corpora cavernosa in the surgery of male to female transsexuals.
      Outcome measures413 AMAB23–51Swelling and narrowing of vagina during sexual arousalChart review10 experienced vaginal swelling and narrowing during sexual arousal, none did after removal of the corpora spongiosa and cavernosa, none did after removal of the tissue.
      Kim et al 2003, Long-term results
      • Kim SK
      • Park JH
      • Lee KC
      • et al.
      Long-term results in patients after rectosigmoid vaginoplasty.
      Outcome measures428 AMAB22–50Vaginal dimensions, sexual intercourse, lubricant use, pain during intercourse, orgasm, vaginal bleeding during intercourseCross-sectional study22 (78.6%) had intercourse: 1 experienced abdominal pain and 2 vaginal bleeding during intercourse, and 19 could reach orgasm during intercourse.
      Kim et al 2017, Is Rectosigmoid
      • Kim SK
      • Park JW
      • Lim KR
      • et al.
      Is rectosigmoid vaginoplasty still useful?.
      Outcome measures444 AMAB

      29 vaginal agenesis

      8 female

      pseudohermaphroditis

      3 gynaecologic malignancies after radical pelvic surgery
      23–47Sexual intercourse, orgasmChart review79 (94%) had intercourse: 72 experienced orgasms, 2 had mild

      intermittent abdominal pain, 6 long-lasting abdominal pain, and 6 a small amount of vaginal bleeding after intercourse.
      Krege et al 2001, Male-to-female
      • Krege S
      • Bex A
      • Lummen G
      • et al.
      Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.
      Follow-up study466 AMAB20–57Sexual intercourse, problems during intercourse, recurrent bleeding after intercourse, clitoral orgasm, vaginal dimensionsSelf-developed questionnairen = 31 with follow-up: 27 (87%) could reach clitoral orgasm, 18 (58.1%) had intercourse, 8 (25.8%) had problems during intercourse (1 swelling of remnants of the corpus spongiosum; 1 problem intravaginal suture line; 2 pains during intercourse; 1 recurrent bleeding after).
      Lawrence et al 2003, Factors associated
      • Lawrence AA.
      Factors associated with satisfaction or regret following male-to-female sex reassignment surgery.
      Follow-up study4232 AMAB19–72Vaginal dimensions, vaginal lubrication, vaginal discharge, sensation to touch at the vaginal opening, sensation to touch deep in the vagina, vaginal pain with penetration, vaginal erotic sensation, clitoral touch sensation, clitoral erotic sensation, clitoral pain, sexual attraction, sexual experience, arousalSelf-developed questionnaireThe number of surgical complications was negatively correlated, and functional results were positively correlated with the absence of regret regarding vaginoplasty. The amount of psychotherapy and the number of complications were negatively, and functional results were positively correlated with happiness with the results of vaginoplasty.
      Lawrence et al 2005, Sexuality before
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      Follow-up study4232 AMAB19–72Sexual orientation, number of sexual partners, frequency of sexual activity, stable partnered relationships, sexual arousal to cross-dressing or cross-gender fantasy, frequency and characteristics of orgasm after GASSelf-developed questionnaireOf n = 226: 76% had postsurgical sexual experiences (28% had mostly female partners, 38% mostly male, 25 % bisexual).



      Of n = 226: 214 (95%) were sexually active prior to surgery, 12 (5.3%) were not. 72% had mostly female partners, 8% mostly male, 15% bisexual.



      Of n = 227, 217 (95.6%) had masturbated: 82 (36%) almost always orgasm during masturbation, 27 (12%) > half the time, 33 (15%) did < half the time, 34 (15%) rarely, 41 (18%) never, and 10 (4%) NA.



      Of n = 217: orgasm prior to and after surgery was almost identical for 4 (2%), very similar for 19 (9%), somewhat similar for 53 (24%), slightly similar for 52 (24%), entirely different for 57 (26%), NA for 32 (15%) .



      Of n = 218: orgasm after surgery was much more pleasurable for 65 (30%), somewhat more pleasurable for 45 (21%), about as pleasurable for 35 (16%), somewhat less pleasurable for 35 (16%), much less pleasurable for 8 (2%), NA for 30 (14%).



      Of n = 217: 52 (24%) almost always released fluids during orgasm, 22 did > half of the time for 22 (10%), 17 (8%) did < half of the time, 29 (13%) did rarely, 40 (18%) never, and 57 (26%) NA.
      Lawrence et al 2006, Patient-reported complications
      • Lawrence AA.
      Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery.
      Follow-up study4232 AMAB19–72Vaginal dimensions, vaginal lubrication, vaginal discharge, sensation to touch at the vaginal opening, sensation to touch deep in the vagina, vaginal pain with penetration, vaginal erotic sensation, clitoral touch sensation, clitoral erotic sensation, clitoral pain, sexual attraction, sexual experience, arousal, frequency of orgasmSelf-developed questionnaireMean rating on 0–10 scale, 10 being better, were: 7.8 (SD 2.4) for overall happiness with genital sexual function after GAS; 4.4 (SD 2.8) for vaginal lubrication; 7.1 (SD 2.4) for mean rating for pain with vaginal penetration.



      Frequency of achieving orgasm was significantly associated with overall happiness with sexual function. Individuals who could never orgasm were significantly less happy with their sexual function than others.
      LeBreton et al 2017, Genital Sensory
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      Outcome measures328 AMAB25–60Genital sensitivity, overall satisfaction (patient's satisfaction with the appearance of their genitals, sexual functioning, and clitoral sensitivity), frequency of sexual activities (masturbation, mutual masturbation, vaginal intercourse, anal stimulation, anal intercourse, and oro-genital stimulation)

      orgasm frequency with each of these activities.
      Genital sensitivity: Semmes-Weinstein monofilaments (light touch), vulvalgesiometer (pressure), vibralgic 4 device (vibration),

      questionnaire developed by Lothstein and Shinar, self-developed questionnaire, Derogatis Fantasy Scale.
      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.



      Frequencies of sexual activities ranged from: 0 = N.A.; 1 = < 1/y, 2 =< 1/mo; 3= 1/mo; 4 = 2/mo; 5 = 1/wk; 6 = several times/week; 7 = 1/day; 8 = >1/d.

      20 (80%) had experienced orgasm. Mean frequencies of achieving orgasm prior to and after having GAS, respectively, were 0.90 (SD 1.38) and 0.56 (SD 1.36) for masturbation, 0.50 (SD 1.47) and -0.24 (SD 1.27) for mutual masturbation, 1.00 (SD 1 .29) and -0.12 (SD 1.09) for vaginal intercourse (penetrative and receptive, respectively), -1.18 (SD 1.30) and -0.16 (SD 1.52) for receptive oral sex, -0.14 (SD 1.36) and -0.36 (SD 1.15), and -0.05 (SD 1.47) and 0.08 (SD 1.04).



      Prior to GAS: mean frequency of receptive anal sex was 3.20 (SD 2.63), 2.40 (SD 2.71) for insertive vaginal sex, 2.32 (SD 2.75) for receptive oral sex, and 3.20 (SD 2.48) for receptive anal stimulation.

      Following GAS: mean frequency of receptive vaginal sex was 3.44 (SD 2.49), 2.04 (SD 2.54) for receptive anal sex, 3.48 (SD 2.45) for receptive oral sex, and 2.48 (SD 2.69) for receptive anal stimulation.

      The difference between pre- and postoperative frequency of receptive oral sex was statistically significant.
      Lindemalm et al 1986, Long-term
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Long-term follow-up of "sex change" in 13 male-to-female transsexuals.
      Evaluation of GAS413 AMAB27–62Sexual adjustment, sexual function, libido, sexual activity, orgasm, partner relationsSemi structured interview, chart reviewOf n = 12: 11 (92%) were sexually active prior to GAS, 1 (8%) was not. Following GAS, 10 (77%) were sexually active.



      Orgasm prior to GAS: 9 (69.2%) could, 1 (7.7%) could not, unclear for 3 (23.1%).

      Orgasm after GAS: 6 (46.2%) could (2 with ejaculation), 6 (46.2%) could not, unclear for 1 (7.6%).



      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.
      Lindemalm et al 1987, Prognostic factors
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases.
      Evaluation of GAS413 AMAB27–62Sexual adjustment, libido, sexual activity

      with partner, number of partners, orgasm, object choice, partner relations
      Retrospective rating of interviewThe 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.
      Manrique et al 2018, Gender-Confirmation

      • Manrique OJ
      • Sabbagh MD
      • Ciudad P
      • et al.
      Gender-confirmation surgery using the pedicle transverse colon flap for vaginal reconstruction: a clinical outcome and sexual function evaluation study.
      Evaluation of rectosigmoid vaginoplasty415 AMAB18–32Sexual functionRetrospective chart review, Female Sexual Function Index (FSFI), Female Genital Self-Image Scale (FGSIS)One (6.7%) had by narrowing at the introitus, which required intervention. The mean Female Sexual Function Index

      score was 28.6 (range, 24–31). Every individual achieved normal sexual function (FSFI ≥ of 25)
      Mate-Kole et al 1990, A controlled study
      • Mate-Kole C
      • Freschi M
      • Robin A
      A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals.
      Outcome measures440 AMAB (20 postop, 20 preop)21–53Sexual interest, sexual relationshipsChart reviewSexual interest during follow-up of 2 years for n = 20 following GAS was unchanged for 4, 15 were more active, none were less active. Sexual interest for n = 20 awaiting surgery remained unchanged for 17, 0 were more active, 3 were less active.
      Morrison et al 2015, Long-Term Outcomes
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • et al.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery.
      Outcome measures483 AMAB36–78Dyspareunia, need for lubricant, mucorrhea, orgasmic capacity, sexual functionPhone interview; chart reviewOf n = 44: 43 (98%) were able to orgasm. Of n = 34: 13 (38%) experienced dyspareunia. Of n = 27: 7 (26%) needed lubrication during intercourse. Average rating for satisfaction for n = 24 was 4.24 (1–5 scale).
      Mukai et al 2017, Vaginoplasty with
      • Mukai Y
      • Watanabe T
      • Sugimoto M
      • et al.
      Vaginoplasty with a pudendal-groin flap in male-to-female transsexuals.
      Outcome measures415 AMABM 34.2 (SD 4.0)Intercourse, pain, vaginal dimensionsChart review14 (93.3 %) had intercourse. 1 (6.7%) experienced discomfort during intercourse, because of neovaginal depth of 5–6 cm.
      Papadopulos et al 2020, Psychological Pathologies
      • Papadopulos NA
      • Lelle JD
      • Zavlin D
      • et al.
      Psychological pathologies and sexual orientation in transgender women undergoing gender confirming treatment.
      Follow-up study447 AMAB18–57Improvement of sex life, sexual orientation, change in sexual preferenceCustom questionnaire29 (61.7%) experienced an improvement of sex life following GAS.



      Prior to surgery: 12 (25.5%) were heterosexual, 22 (46.8%) homosexual, 11 (23.4%) bisexual, and 2 (4.3%) other. Following surgery n = 46, 15 (32.6) were heterosexual, 10 (21.7%) were homosexual gay, 21 (45.7%) were bisexual.
      Papadopulos et al 2017, Combined vaginoplasty
      • Papadopulos NA
      • Zavlin D
      • Lelle JD
      • et al.
      Combined vaginoplasty technique for male-to-female sex reassignment surgery: Operative approach and outcomes.
      Follow-up study440 AMABM 38.6 (SD 12.6)Vulvar sensitivity, vaginal dimensionsChart review and follow-upMost women reported normal labial and vaginal sensitivity, and strong clitoral sensitivity.
      Perovic et al 2000, Vaginoplasty in
      • Perovic SV
      • Stanojevic DS
      • Djordjevic ML.
      Vaginoplasty in male to female transsexuals using penile skin and urethral flap.
      Outcome measures489 AMAB18–56Orgasm, vaginal sensitivity, vaginal moisture, intercourse, vaginal dimensionsInterview73 (82%) had orgasmed, 69 (79%) were having intercourse. Presence of vaginal moisture was satisfactory for 71 (80%) and unsatisfactory for 16 (18%)
      Raigosa et al 2015, Male-to-Female
      • Raigosa M
      • Avvedimento S
      • Yoon TS
      • et al.
      Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients.
      Outcome measures460 AMAB19–50Frequency and quality of intercourse, orgasm, vaginal dimensions, clitoral sensationInterview (direct questioning during follow-up)52 (86%) had regular intercourse. Clitoral sensitivity was acceptable and led to orgasm for all participants.
      Reed et al 2015, Non-grafted Vaginal
      • Reed HM
      • Yanes RE
      • Delto JC
      • et al.
      Non-grafted vaginal depth augmentation for transgender atresia, our experience and survey of related procedures.
      Outcome measures418 AMABNo dataVaginal dimensions, sexual functionFSFI and clinical examinationOf n = 10: FSFI domain scores (lubrication 3,7; desire 3,5; arousal 4,0; orgasm 3,9; satisfaction 3,6; pain 4,7) were ≥ mid-range. Average total score was 23.4 (r 2–36).
      Rehman et al 1999, The reported sex
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      Outcome measures428 AMAB18–44QoL, sexual orientation, sexual activity, type of sexual contact (oral, anal, vaginal, other), sexual satisfaction, orgasm (ability and importance), lubricant use, reasoning for sexual inactivityInterview, self-developed questionnaire15 (53.6%) had intercourse, all had some degree of pain during sex and all were using some form of lubricant. 7 (25%) had masturbated. 14 (50%) reported satisfaction from sexual activities and experienced orgasm most of the time, quality and intensity of orgasms were better postoperatively. 15 (53.6%) could orgasm, 7 (25%) orgasmed infrequently and 6 (21.4%) could not orgasm.
      Rehman et al 1999

      Formation of
      • Rehman J
      • Melman A.
      Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome.
      Outcome measures410 AMAB23–60Clitoral sensitivity, QoL, sexual orientation, sexual activity, type of sexual contact (oral, anal, vaginal, other), sexual satisfaction, orgasm (ability and importance), lubricant use, reasoning for sexual inactivityInterview, self-developed questionnaireEvery individual had intercourse and reported satisfactory sexual activities.

      9 (90%) could orgasm (2 experienced neo-clitoral necrosis, 1 one could not achieve orgasm). Clitoris sensitivity was good with sensitivity to touch, vibration and light pressure in 8 (80%).
      Salgado et al 2018, Primary Sigmoid
      • Salgado CJ
      • Nugent A
      • Kuhn J
      • et al.
      Primary sigmoid vaginoplasty in transwomen: technique and outcomes.
      Outcome measures412 AMABM 47 (SD 15.4)Vaginal dimensions, reported sensation, intercourse, satisfaction with depth, odour and excessive secretionsChart review5 (42%) had intercourse and reported satisfaction with vaginal depth and pleasurable sensitivity.

      None experienced malodour or excessive secretions.
      Schroder et al 1999, New women
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      Outcome measures417 AMAB35–58Orgasm, masturbation, sexual fantasies, intercourse, relationship status, sexual orientation, sexual satisfaction, genital and breast sensitivity, arousal, sexual desirePostoperative Male-to-Female Questionnaire (Carroll & Schroder, 1993a), New Woman's Gynaecological Index (NWGI) (Schroder, 1993), Stress Inventory (Carroll, 1985),

      Postoperative Male-to-Female Interview (Carroll & Schroder, 1993b), vaginal plethysmography
      Mean self-reported rating of sexual satisfaction was 5.4 (0–10 scale, 10 is better).



      11 (64.7%) could orgasm through masturbation (8 with ease, 3 with difficulty): 5 achieved multiple orgasms, and 5 ejaculated.

      Of n = 16 sexually active (approximately half had intercourse): 9 orgasmed during partnered activity (4 through penile-vaginal penetration, 3 through masturbation with a partner present).
      Seyed-Forootan et al 2018, Autologous Fibroblast
      • Seyed-Forootan K
      • Karimi H
      Seyed-Forootan NS. autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery.
      Group comparison/follow-up study424 AMABFibroblast: 28 SD 4y

      Amnion: 32 SD 3y
      Vaginal dimensions, secretions, intravaginal sensitivity, orgasm, intercourse, satisfaction with intercourseSelf-developed questionnaire, interview, clinical examination of vaginal dimensionsNeo-vaginal sensitivity and lubrication was good for everyone. 18 (75%) had sexual experiences: 93.7% of the fibroblast and 87.5% of the amnion group were satisfied with orgasm and intercourse.
      Sigurjónsson et al 2017, Long-Term Sensitivity
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      Outcome measures422 AMAB23–63Clitoral sensitivity, orgasm, sexual dysfunctionSemmes-Weinstein monofilaments, Bio-Thesiometer, self-developed scaleAverage clitoral tactile thresholds were 12.5 g/mm2, average vibration threshold was 0.3 m. Surgical complications were not associated with diminished clitoral sensitivity or orgasmic capacity.
      Soli et al 2008, Male to female
      • Soli M
      • Brunocilla E
      • Bertaccini A
      • et al.
      Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris.
      Outcome measures415 AMAB21–60Orgasm, clitoral sensitivityInterview, self-developed questionnaire7 (46.7%) experienced some form of climax during intercourse. Clitoral sensitivity was present and pleasant for every individual, and was present during digital examination by the authors.
      Stanojevic et al 2007, Sacrospinous ligament

      • Stanojevic DS
      • Djordjevic ML
      • Milosevic A
      • et al.
      Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.
      Outcome measures462 AMAB18–58Ability to perform intercourseChart review42 (76%) had intercourse.
      Stein et al 1990, Follow-up observations
      • Stein M
      • Tiefer L
      • Melman A.
      Followup observations of operated male-to-female transsexuals.
      Follow-up study422 AMAB20–49Orgasm, vaginal intercourse,

      pain during intercourse,

      need for lubricants
      Interview, physical examination2 (14.3%) had never orgasmed, 6 (43%) seldom, 2 (14.3%) usually, NA for 4 (28.6%). Orgasm was not at all important for sexual satisfaction for 3 (21.4%), somewhat important for 6 (42.9%), very important for 1 (7.1%), NA for 4.

      7 (31.8%) had intercourse: 1 (14.3%) used lubricants always, 3 (42.9%) often, 1 (14.3%) never, unknown for 2 (28.6%).



      Of n = 9: 6 (66.7%) had intimate lovers prior to GAS, 3 (33.3%) did not.
      Tavakkoli Tabassi et al 2014, Fold-back
      • Tavakkoli Tabassi K
      • Djavan B
      • Hosseini J
      • et al.
      Fold-back perineoscrotal flap plus penile inversion vaginoplasty for male-to-female gender reassignment surgery in circumcised subjects.
      Outcome measures4112 AMABM 25.8 (SD 3.3)Satisfaction with functionChart review96 (85.7%) were satisfied with the appearance and function, 16 (14.3%) were dissatisfied (10 due to depth or stenosis, 6 due to aesthetics).
      Thalaivirithan et al 2018, Application of embryonic
      • Thalaivirithan BM
      • Sethu M
      • Ramachandran DK
      • et al.
      Application of embryonic equivalents in male-to-female sex reassignment surgery.
      Outcome measures430 AMAB21–42Satisfaction with sexual function, frequency of sexual activities (oral, anal), orgasm, sexual satisfactionChart review26 (86.6%) could orgasm, 30 (100%) had intercourse. Frequency of receptive, oral sex increased and anal sex decreased significantly following GAS.



      Satisfaction with sexual function and the appearance of the labia, vulva and clitoris was good-very good for 98% (5-point scale, unsatisfactory-very good).



      Sexual satisfaction was statistically (positively) correlated with vaginal function and depth, clitoral sensation, appearance of the vulva/labia minora, and natural lubrication and negatively correlated with depression scores.
      Toolenaar et al 1993, The occurrence of
      • Toolenaar TA
      • Freundt I
      • Huikeshoven FJ
      • et al.
      The occurrence of diversion colitis in patients with a sigmoid neovagina.
      Cross-sectional study411 AMAB

      6 women with MRKHS
      AMAB: 22–48

      MRKHS: 19–28
      Intercourse, lubricantSelf-developed questionnaire, clinical examination14 (82.4%) had regular intercourse, 3 (17,6%) did not have a sexual partner. 15 (88,2%) made use of lubricants. 13 (76.5%) experienced white discharge, 15 (88,2%) slight blood loss (6 following intercourse, 9 spontaneously). 3 experienced vaginal cramping (1 solely following sex).
      van der Sluis et al 2016, Long-Term
      • van der Sluis WB
      • Bouman MB
      • de Boer NK
      • et al.
      Long-term follow-up of transgender women after secondary intestinal vaginoplasty.
      Outcome measures424 AMAB22–73Intercourse, adequacy of vaginal dimensions, sexual arousal, orgasm, desire, lubrication, sexual satisfaction, discomfortFemale Sexual Function Index (FSFI), Amsterdam Hyperactive Pelvic Floor Scale for Women, (AHBBS) Female Genital Self-Imaging Scale (FGSIS), self-developed questionnaire8 (89%) had intercourse, 1 had never. Mean FSFI satisfaction domain score was 4.2 (SD 1.3), mean score for orgasm 4.0 (SD 2.2). 8 (89%) had performed (frequent) penetrative intercourse, orgasm was possible through direct neo-clitoral stimulation.



      8 (89%) had intercourse frequently, depth was adequate. 1 did not have intercourse (identified as asexual). Sexual arousal was possible, orgasm could be reached through neo-clitoral stimulation.



      Mean rating for neovaginal functionality was 7.3 (SD 1.8; 1–10 scale), appearance was 7.4 (SD 1.9)
      van der Sluis et al 2016, Morphological spectrum
      • van der Sluis WB
      • Neefjes-Borst EA
      • Bouman MB
      • et al.
      Morphological spectrum of neovaginitis in autologous sigmoid transplant patients.
      Outcome measures426 AMAB19–52Sexual activity (type of activity), sexual preference, lubricant use, condom use, vaginal symptoms (discharge, odour, pain)Self-developed questionnaire, clinical examination (biopsies, vaginal swabs)8 (31%) reported discharge, 4 (15%), 1 (4%) reported tenesmus, 4 (15%) neovaginal pain (3 of which during deep penetration).
      Wagner et al 2010, Male-to-female
      • Wagner S
      • Greco F
      • Hoda MR
      • et al.
      Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients.
      Outcome measures450 AMAB25–52Satisfaction with vaginal dimensions, orgasm, intercourse, pain during sexSelf-developed questionnaire35 (70%) had achieved clitoral orgasm, 42 (84%) had regular intercourse (2 of which reported pain during intercourse).
      Watanyusakul 2019, Vaginoplasty Modifications
      • Randolph Jr., JF
      • Zheng H
      • Avis NE
      • et al.
      Masturbation frequency and sexual function domains are associated with serum reproductive hormone levels across the menopausal transition.
      Outcome measures4580 AMAB18–65Vaginal depthNot specifiedAverage depth >1 y follow-up was 16.0 cm.
      Weyers et al 2009, Long-term assessment

      • Weyers S
      • Elaut E
      • De Sutter P
      • et al.
      Long-term assessment of the physical, mental, and sexual health among transsexual women.
      Follow-up study350 AMABM43.06 (SD 10.42)Importance of sex, sexual functioning, relationships (status and quality), sexual preferenceFemale Sexual Function Index (FSFI), serum hormone levels, self-developed questionnaire3 (6%) were not interested in sex. Median score for importance of sex in a relationship was 6 (interquartile range 5–9; 0–10 scale).



      Mean FSFI total score was 16.95 (SD 10.04). Overall FSFI scores were positively correlated with sexual satisfaction, general health perception and satisfaction with female appearance as perceived by others. FSFI total scores were highest for heterosexual individuals, intermediate for bisexual and lowest for homosexual individuals. There was no correlation between estradiol levels and mode of estrogen administration with testosterone levels and FSFI scores.
      Wu et al 2009, Laparoscopic vaginal

      • Wu JX
      • Li B
      • Li WZ
      • et al.
      Laparoscopic vaginal reconstruction using an ileal segment.
      Outcome measures411 AMAB

      67 DSD women

      7 Cis women
      AMAB: M 23.5 (SD 3.8)

      DSD: M 24.7 (SD 4,6)

      Cis: M 47.8 (SD 4.1)
      Intercourse (time between surgery and first contact), orgasm, lubrication, satisfaction with sexual life, vaginal dimensions, dyspareunia, bleeding during intercourseChart review, self-developed questionnaire71 (88.8%) was sexually active. More than half reported frequent orgasms, and 90% reported adequate lubrication for intercourse. None reported dyspareunia, use of external lubrication, or mild bleeding during intercourse.
      Zavlin et al 2017, Male-to-Female
      • Zavlin D
      • Schaff J
      • Lelle JD
      • et al.
      Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes.
      Follow-up study449 AMAB, 40 with questionnaire resultsM 38.6 (|SD 12.6)Intercourse (satisfaction with), (satisfaction with) orgasmic capacity, orgasm, masturbation, (satisfaction with) clitoral sensitivity, pain during masturbation or intercourse, sexual orientationSelf-developed questionnaireMean scores for satisfaction on 0–10 scale (10 is better) with:

      orgasm 8.21 (SD 2.47, n = 38); preoperative intercourse 3.29 (SD 2.75, n = 7); postoperative intercourse 6.7 (SD 2.03, n = 23).



      Mean rating of clitoral sensation was 8.53 (SD 1.93, n = 40), and erogenous clitoral sensation was 8.48 (SD 2.04, n = 40). Mean rating of pain during masturbation or intercourse was 2.33 (SD 2.89; n = 39; 10 is extreme pain).



      7 (17.5%) engaged in regular intercourse prior to GAS, 57.5% following GAS.
      Zavlin et al 2019, Age-Related Differences
      • Zavlin D
      • Wassersug RJ
      • Chegireddy V
      • et al.
      Age-related differences for male-to-female transgender patients undergoing gender-affirming surgery.
      Cross-sectional study440 AMAB19-66Sexual orientation, marital status, frequency of intercourse, sexual preference, satisfaction with intercourse, sexually active,Self-developed questionnaireFollowing GAS, younger individuals were mostly attracted to men (52.6%), later-onset individuals mostly to women or both (85.7%). Younger trans individuals were more frequently sexually active (73.7% vs 42.9%).
      Twenty-four studies discussed whether participants could attain orgasm.
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Amend B
      • Seibold J
      • Toomey P
      • et al.
      Surgical reconstruction for male-to-female sex reassignment.
      ,
      • Blanchard R
      • Legault S
      • Lindsay WR.
      Vaginoplasty outcome in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Brotto LA
      • Gehring D
      • Klein C
      • et al.
      Psychophysiological and subjective sexual arousal to visual sexual stimuli in new women.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      ,
      • Freundt I
      • Toolenaar TA
      • Huikeshoven FJ
      • et al.
      Jeekel H. A modified technique to create a neovagina with an isolated segment of sigmoid colon.
      ,
      • Goddard JC
      • Vickery RM
      • Qureshi A
      • et al.
      Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      • Jarolim L
      • Sedy J
      • Schmidt M
      • et al.
      Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks.
      ,
      • Kim SK
      • Park JH
      • Lee KC
      • et al.
      Long-term results in patients after rectosigmoid vaginoplasty.
      ,
      • Krege S
      • Bex A
      • Lummen G
      • et al.
      Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Long-term follow-up of "sex change" in 13 male-to-female transsexuals.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • et al.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Rehman J
      • Melman A.
      Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome.
      ,
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      ,
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      ,
      • Soli M
      • Brunocilla E
      • Bertaccini A
      • et al.
      Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris.
      ,
      • Stein M
      • Tiefer L
      • Melman A.
      Followup observations of operated male-to-female transsexuals.
      ,
      • Wagner S
      • Greco F
      • Hoda MR
      • et al.
      Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients.
      A majority (about 70%) could achieve orgasm,
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Amend B
      • Seibold J
      • Toomey P
      • et al.
      Surgical reconstruction for male-to-female sex reassignment.
      ,
      • Blanchard R
      • Legault S
      • Lindsay WR.
      Vaginoplasty outcome in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Brotto LA
      • Gehring D
      • Klein C
      • et al.
      Psychophysiological and subjective sexual arousal to visual sexual stimuli in new women.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      ,
      • Goddard JC
      • Vickery RM
      • Qureshi A
      • et al.
      Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      • Jarolim L
      • Sedy J
      • Schmidt M
      • et al.
      Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks.
      ,
      • Kim SK
      • Park JH
      • Lee KC
      • et al.
      Long-term results in patients after rectosigmoid vaginoplasty.
      ,
      • Krege S
      • Bex A
      • Lummen G
      • et al.
      Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Long-term follow-up of "sex change" in 13 male-to-female transsexuals.
      ,
      • Morrison SD
      • Satterwhite T
      • Grant DW
      • et al.
      Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery.
      ,
      • Perovic SV
      • Stanojevic DS
      • Djordjevic ML.
      Vaginoplasty in male to female transsexuals using penile skin and urethral flap.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Rehman J
      • Melman A.
      Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome.
      ,
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      ,
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      ,
      • Soli M
      • Brunocilla E
      • Bertaccini A
      • et al.
      Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris.
      ,
      • Stein M
      • Tiefer L
      • Melman A.
      Followup observations of operated male-to-female transsexuals.
      ,
      • Wagner S
      • Greco F
      • Hoda MR
      • et al.
      Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients.
      ,
      • Freund K
      • Langevin R
      • Zajac Y.
      The transsexual syndrome in homosexual males.
      whereas less than 10% could not or had not,
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Blanchard R
      • Legault S
      • Lindsay WR.
      Vaginoplasty outcome in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Eldh J.
      Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
      ,
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      ,
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      ,
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      ,
      • Lindemalm G
      • Korlin D
      • Uddenberg N.
      Long-term follow-up of "sex change" in 13 male-to-female transsexuals.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      ,
      • Freund K
      • Langevin R
      • Zajac Y.
      The transsexual syndrome in homosexual males.
      10% had not tried
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Hess J
      • Hess-Busch Y
      • Kronier J
      • et al.
      Modified preparation of the neurovascular bundle in male to female transgender patients.
      ,
      • Sigurjonsson H
      • Mollermark C
      • Rinder J
      • et al.
      Long-term sensitivity and patient-reported functionality of the neoclitoris after gender reassignment surgery.
      , and another 10% chose ‘not applicable.’
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      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).
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.
      ,
      • Buncamper ME
      • van der Sluis WB
      • de Vries M
      • et al.
      Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft?.
      ,
      • Reed HM
      • Yanes RE
      • Delto JC
      • et al.
      Non-grafted vaginal depth augmentation for transgender atresia, our experience and survey of related procedures.
      Finally, Zavlin et al
      • Zavlin D
      • Schaff J
      • Lelle JD
      • et al.
      Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes.
      found a mean frequency of achieving orgasm of 6.73 (SD 3.32) during masturbation and 6.52 (SD 3.11) during intercourse.
      • Zavlin D
      • Schaff J
      • Lelle JD
      • et al.
      Male-to-female sex reassignment surgery using the combined vaginoplasty technique: satisfaction of transgender patients with aesthetic, functional, and sexual outcomes.
      Over half of participants masturbated regularly,
      • Sorensen T.
      A follow-up study of operated transsexual females.
      ,
      • van de Grift TC
      • Pigot GLS
      • Boudhan S
      • et al.
      A Longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen.
      ,
      • Imbimbo C
      • Verze P
      • Palmieri A
      • et al.
      A report from a single institute's 14-year experience in treatment of male-to-female transsexuals.
      ,
      • Lawrence AA.
      Sexuality before and after male-to-female sex reassignment surgery.
      ,
      • LeBreton M
      • Courtois F
      • Journel NM
      • et al.
      Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women.
      ,
      • Rehman J
      • Lazer S
      • Benet AE
      • et al.
      The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.
      ,
      • Rehman J
      • Melman A.
      Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome.
      ,
      • Schroder M
      • Carroll RA.
      New women: sexological outcomes of male-to-female gender reassignment surgery.
      ,
      • Hess J
      • Henkel A
      • Bohr J
      • et al.
      Sexuality after male-to-female gender affirmation surgery.
      ,
      • Bentler PM.
      A typology of transsexualism: gender identity theory and data.
      • De Cuypere G
      • T'Sjoen G
      • Beerten R
      • et al.
      Sexual and physical health after sex reassignment surgery.
      • Djordjevic ML
      • Bizic MR.
      Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery.
      and every participants had engaged in receptive vaginal activity.
      • Buncamper ME
      • Honselaar JS
      • Bouman MB
      • et al.
      Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals.
      ,
      • Bouman FG.
      Sex reassignment surgery in male to female transsexuals.
      ,
      • Bouman MB
      • van der Sluis WB
      • van Woudenberg Hamstra LE
      • et al.
      Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia.