Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

The assessment of sexual wellbeing in treatment-seeking transgender individuals: a systematic review of the medical literature

International Journal of Impotence Research volume 35, pages 121–131 (2023)Cite this article

Subjects

Abstract

Sexual-wellbeing is recognized as an important aspect of quality-of-life. Yet, no overview exists of which aspects of sexual-wellbeing have been assessed in trans individuals seeking or undergoing medical treatment, nor is it clear what tools are used to evaluate the effect of medical treatment on sexual-wellbeing. First, to identify which topics pertaining to sexual-wellbeing have been assessed in transgender individuals in a medical context. Second, to determine which tools have been used for measuring aspects of sexual-wellbeing. A conceptual framework of sexual-wellbeing, was used as reference. A literature search (in PubMed, Embase, Cochrane Library) was performed up to March 10th, 2020. Studies that assessed aspects of sexual-wellbeing in transgender individuals’ medical context were included in this review. Specific sexual topics addressed in each study were extracted by two independent reviewers. Thematic analysis was performed to identify sexual themes. Additionally, tools used to measure topics related to sexuality in transgender individuals were identified. In 172 papers, a total of 178 topics related to sexual-wellbeing were identified. Ten overarching themes were identified; sexuality, enacted sexual script, sexual activities, sexual relations, sexual response cycle, genital function, sexual function, sexual pleasure, sexual satisfaction, and quality-of-sex-life. Functional aspects of sexuality are assessed most frequently. A variety of methods was used to evaluate aspects related to sexual-wellbeing in trans individuals and over 50 different tools were identified. Self-developed questionnaires were used most frequently (n = 80), followed by chart reviews (n = 50), self-developed structured interviews (n = 37) and physical examination (n = 13). 23 previously developed questionnaires were used, all of which were developed for a cisgender population. Many studies in trans individuals touch on topics related to sexual-wellbeing, however, a comprehensive conceptualisation of (10 themes of) sexual-wellbeing is still lacking. Still, no valid tool exists for assessing sexual-wellbeing in the trans population, but is much needed.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

This can be found in supplement 1.

References

  1. van de Grift TC, Elfering L, Greijdanus M, Smit JM, Bouman MB, Klassen AF, 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. Plast Reconstr Surg. 2018;142:1125–32.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Woloski-Wruble AC, Oliel Y, Leefsma M, Hochner-Celnikier D. Sexual activities, sexual and life satisfaction, and successful aging in women. J Sex Med. 2010;7:2401–10.

    Article  PubMed  Google Scholar 

  3. Klein C, Gorzalka BB. Sexual functioning in transsexuals following hormone therapy and genital surgery: a review. J Sex Med. 2009;6:2922–39. quiz 40-1

    Article  PubMed  Google Scholar 

  4. Holmberg M, Arver S, Dhejne C. Supporting sexuality and improving sexual function in transgender persons. Nat Rev Urol. 2019;16:121–39.

    Article  CAS  PubMed  Google Scholar 

  5. Thurston MD, Allan S. Sexuality and sexual experiences during gender transition: a thematic synthesis. Clin Psychol Rev. 2018;66:39–50.

    Article  CAS  PubMed  Google Scholar 

  6. Stephenson R, Riley E, Rogers E, Suarez N, Metheny N, Senda J, et al. The sexual health of transgender men: a scoping review. J Sex Res. 2017;54:424–45.

    Article  PubMed  Google Scholar 

  7. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;95:120–4.

    Article  PubMed  Google Scholar 

  8. Kim SK, Park JW, Lim KR, Lee KC. Is rectosigmoid vaginoplasty still useful? Arch Plast Surg. 2017;44:48–52.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Krege S, Bex A, Lummen G, Rubben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 2001;88:396–402.

    Article  CAS  PubMed  Google Scholar 

  10. Mukai Y, Watanabe T, Sugimoto M, Kimata Y, Namba Y. Vaginoplasty with a pudendal-groin flap in male-to-female transsexuals. Acta Med Okayama. 2017;71:399–405.

    PubMed  Google Scholar 

  11. Stanojevic DS, Djordjevic ML, Milosevic A, Sansalone S, Slavkovic Z, Ducic S, et al. Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery. Urology 2007;70:767–71.

    Article  PubMed  Google Scholar 

  12. Takamatsu A, Harashina T. Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. J Plast, Reconstructive Aesthetic Surg. 2009;62:318–25.

    Article  CAS  Google Scholar 

  13. Vesely J, Hyza P, Ranno R, Cigna E, Monni N, Stupka I, et al. New technique of total phalloplasty with reinnervated latissimus dorsi myocutaneous free flap in female-to-male transsexuals. Ann Plast Surg. 2007;58:544–50.

    Article  CAS  PubMed  Google Scholar 

  14. Papadopulos NA, Schaff J, Biemer E. Usefulness of free sensate osteofasciocutaneous forearm and fibula flaps for neophallus construction. J Reconstr Microsurg. 2001;17:407–12.

    Article  CAS  PubMed  Google Scholar 

  15. Papadopulos NA, Zavlin D, Lelle JD, Herschbach P, Henrich G, Kovacs L, et al. Combined vaginoplasty technique for male-to-female sex reassignment surgery: operative approach and outcomes. J Plast, Reconstr Aesthetic Surg. 2017;70:1483–92.

    Article  Google Scholar 

  16. van de Grift TC, Pigot GLS, Kreukels BPC, Bouman MB, Mullender MG. Transmen’s experienced sexuality and genital gender-affirming surgery: findings from a clinical follow-up study. J Sex Marital Ther. 2019;45:201–5.

  17. Kerckhof ME, Kreukels BPC, Nieder TO, Becker-Hebly I, van de Grift TC, Staphorsius AS, et al. Prevalence of sexual dysfunctions in transgender persons: results from the ENIGI follow-up study. J Sex Med. 2019;16:2018–29.

    Article  PubMed  Google Scholar 

  18. Nikkelen SWC, Kreukels BPC. Sexual experiences in transgender people: the role of desire for gender-confirming interventions, psychological well-being, and body satisfaction. J Sex Marital Ther. 2018;44:370–81.

    Article  PubMed  Google Scholar 

  19. Nobili A, Glazebrook C, Arcelus J. Quality of life of treatment-seeking transgender adults: a systematic review and meta-analysis. Rev Endocr Metab Disord. 2018;19:199–220.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Byers SR, U. Sexual well-being. APA handbook of sexuality and psychology. Washington, D.C.: American Psychological Association; 2014.

  21. Moher D, Liberati A, Tetzlaff J, Altman DG. The PG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Innovation VH. Covidence systematic review software.

  23. OCEBM Levels of Evidence Working Group: Jeremy Howick ICJLL, Paul Glasziou, Trish Greenhalgh, Carl Heneghan, Alessandro Liberati, Ivan Moschetti, et al.. The Oxford 2011 Levels of Evidence. 2011.

  24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.

    Article  Google Scholar 

  25. Djordjevic ML. Novel surgical techniques in female to male gender-confirming surgery. Transl Androl Urol. 2018;7:628–38.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;10:1431–8.

    Article  PubMed  Google Scholar 

  27. Djordjevic ML, Stanojevic D, Bizic M, Kojovic V, Majstorovic M, Vujovic S, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6:1306–13.

    Article  PubMed  Google Scholar 

  28. 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. J Am Acad Child Adolesc Psychiatry. 2001;40:472–81.

    Article  CAS  PubMed  Google Scholar 

  29. Smith YL, van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Transsexual subtypes: clinical and theoretical significance. Psychiatry Res. 2005;137:151–60.

    Article  PubMed  Google Scholar 

  30. Stojanovic B, Bizic M, Bencic M, Kojovic V, Majstorovic M, Jeftovic M, et al. One-stage gender-confirmation surgery as a viable surgical procedure for female-to-male transsexuals. J Sex Med. 2017;14:741–6.

    Article  PubMed  Google Scholar 

  31. van de Grift TC, Pigot GLS, Boudhan S, Elfering L, Kreukels BPC, Gijs L, et al. A longitudinal study of motivations before and psychosexual outcomes after genital gender-confirming surgery in transmen. J Sex Med. 2017;14:1621–8.

    Article  PubMed  Google Scholar 

  32. Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, Mullender MG, Groenman F, et al. Colpectomy significantly reduces the risk of urethral fistula formation after urethral lengthening in transgender men undergoing genital gender affirming surgery. J Urol. 2018;200:1315–22.

    Article  PubMed  Google Scholar 

  33. Ranno R, Hyza P, Vesely J, Dessy LA, Kadanka Z. An objective evaluation of contraction power of neo-phallus reconstructed with free re-innervated LD in female-to-male transsexuals. Acta Chirurgiae Plasticae. 2007;49:8–12.

    CAS  PubMed  Google Scholar 

  34. Ranno R, Vesely J, Hyza P, Stupka I, Justan I, Dvorak Z, et al. Neo-phalloplasty with re-innervated latissimus dorsi free flap: a functional study of a novel technique. Acta Chirurgiae Plasticae. 2007;49:3–7.

    CAS  PubMed  Google Scholar 

  35. Vukadinovic V, Stojanovic B, Majstorovic M, Milosevic A. The role of clitoral anatomy in female to male sex reassignment surgery. Sci World J. 2014;2014:437378.

    Article  Google Scholar 

  36. Bouman MB, van der Sluis WB, van Woudenberg Hamstra LE, Buncamper ME, Kreukels BPC, Meijerink W, et al. Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. J Sex Med. 2016;13:1438–44.

    Article  PubMed  Google Scholar 

  37. Buncamper ME, Honselaar JS, Bouman MB, Ozer M, Kreukels BP, Mullender MG. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12:1626–34.

    Article  PubMed  Google Scholar 

  38. Buncamper ME, van der Sluis WB, de Vries M, Witte BI, Bouman MB, Mullender MG. Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft? Plast Reconstr Surg. 2017;139:649e–56e.

    Article  CAS  PubMed  Google Scholar 

  39. Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32:299–315.

    Article  PubMed  Google Scholar 

  40. Lawrence AA. Sexuality before and after male-to-female sex reassignment surgery. Arch Sex Behav. 2005;34:147–66.

    Article  PubMed  Google Scholar 

  41. Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch Sex Behav. 2006;35:717–27.

    Article  PubMed  Google Scholar 

  42. Lindemalm G, Korlin D, Uddenberg N. Long-term follow-up of “sex change” in 13 male-to-female transsexuals. Arch Sex Behav. 1986;15:187–210.

    Article  CAS  PubMed  Google Scholar 

  43. Lindemalm G, Korlin D, Uddenberg N. Prognostic factors vs. outcome in male-to-female transsexualism. A follow-up study of 13 cases. Acta Psychiatr Scand. 1987;75:268–74.

    Article  CAS  PubMed  Google Scholar 

  44. Elaut E, Bogaert V, De Cuypere G, Weyers S, Gijs L, Kaufman JM, et al. Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: an exploration in male-to-female transsexuals. J Endocr Investig. 2010;33:37–41.

    Article  CAS  Google Scholar 

  45. Elaut E, De Cuypere G, De Sutter P, Gijs L, Van Trotsenburg M, Heylens G, et al. Hypoactive sexual desire in transsexual women: prevalence and association with testosterone levels. Eur J Endocrinol. 2008;158:393–9.

    Article  CAS  PubMed  Google Scholar 

  46. Papadopulos NA, Lelle JD, Zavlin D, Herschbach P, Henrich G, Kovacs L, et al. Psychological pathologies and sexual orientation in transgender women undergoing gender confirming treatment. Ann Plast Surg. 2020;84:312–6.

    Article  CAS  PubMed  Google Scholar 

  47. Rehman J, Lazer S, Benet AE, Schaefer LC, Melman A. The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients. Arch Sex Behav. 1999;28:71–89.

    Article  CAS  PubMed  Google Scholar 

  48. 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. J Urol. 1999;161:200–6.

    Article  CAS  PubMed  Google Scholar 

  49. van der Sluis WB, Bouman MB, de Boer NK, Buncamper ME, van Bodegraven AA, Neefjes-Borst EA, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med. 2016;13:702–10.

    Article  PubMed  Google Scholar 

  50. van der Sluis WB, Neefjes-Borst EA, Bouman MB, Meijerink WJ, De Boer NK, Mullender MG, et al. Morphological spectrum of neovaginitis in autologous sigmoid transplant patients. Histopathology. 2016;68:1004–12.

    Article  PubMed  Google Scholar 

  51. Zavlin D, Schaff J, Lelle JD, Jubbal KT, Herschbach P, Henrich G, et al. Male-to-female sex reassignment surgery using the combined vaginoplasty technique: Satisfaction of transgender patients with aesthetic, functional, and sexual outcomes. Aesthetic Plast Surg. 2018;42:178–87.

    Article  PubMed  Google Scholar 

  52. Zavlin D, Wassersug RJ, Chegireddy V, Schaff J, Papadopulos NA. Age-related differences for male-to-female transgender patients undergoing gender-affirming surgery. Sex Med. 2019;7:86–93.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Smith YL, Van Goozen SH, Kuiper AJ, Cohen-Kettenis PT. Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychol Med. 2005;35:89–99.

    Article  PubMed  Google Scholar 

  54. Dunford C, Bell K, Rashid T. Genital reconstructive surgery in male to female transgender patients: a systematic review of primary surgical techniques, complication profiles, and functional outcomes from 1950 to present day. Eur Urol Focus. 2020;7:464–71.

  55. Harden KP. A sex-positive framework for research on adolescent sexuality. Perspect Psychol Sci. 2014;9:455–69.

    Article  PubMed  Google Scholar 

  56. ETM Laan VK, MA Werner, HW van Lunsen, E Janssen. In pursuit of pleasure: a biopsychosocial perspective on sexual pleasure and gender. Int J Sex Health. 2021:1–21.

  57. LeBreton M, Courtois F, Journel NM, Beaulieu-Prevost D, Belanger M, Ruffion A, et al. Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women. J Sex Med. 2017;14:274–81.

    Article  PubMed  Google Scholar 

  58. Ristori J, Cocchetti C, Castellini G, Pierdominici M, Cipriani A, Testi D, et al. Hormonal treatment effect on sexual distress in transgender persons: 2-year follow-up data. J Sex Med. 2020;17:142–51.

    Article  CAS  PubMed  Google Scholar 

  59. Staples JM, Bird ER, Gregg JJ, George W. Improving the gender-affirmation process for transgender and gender-nonconforming individuals: associations among time since transition began, body satisfaction, and sexual distress. J Sex Res. 2020;57:375–83.

    Article  PubMed  Google Scholar 

  60. Lawrance K-A, Byers ES. Sexual satisfaction in long-term heterosexual relationships: the interpersonal exchange model of sexual satisfaction. Personal Relatsh. 1995;2:267–85.

    Article  Google Scholar 

  61. Martin KM, Woodgate RL. Concept analysis: the holistic nature of sexual well-being. Sex Relatsh Ther. 2020;35:15–29.

    Article  Google Scholar 

Download references

Acknowledgements

The literature search was done in collaboration with, Ralph de Vries, a medical information specialist at Amsterdam University Medical Center.

Author information

Authors and Affiliations

  1. Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands

    M. Özer, S. Poor Toulabi & M. G. Mullender

  2. Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands

    M. Özer, L. Gijs, B. P. C. Kreukels & M. G. Mullender

  3. Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands

    M. Özer, B. P. C. Kreukels & M. G. Mullender

  4. Department of Medical Psychology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands

    L. Gijs & B. P. C. Kreukels

  5. Institute for Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium

    L. Gijs

Authors
  1. M. Özer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. S. Poor Toulabi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. L. Gijs
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. B. P. C. Kreukels
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. M. G. Mullender
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Müjde Özer: methodology, conceptualisation, investigation, writing—original draft Sahaand Poor Toulabi: methodology, conceptualisation, investigation, writing, visualisation Luk Gijs: writing—review, editing and supervision Baudewijntje Kreukels: writing—review, editing and supervision Margriet Mullender: review, editing, and supervision.

Corresponding author

Correspondence to M. Özer.

Ethics declarations

Competing interests

All authors have seen and agree on the submitted version. We declare that the material is original and has not been published elsewhere.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Özer, M., Poor Toulabi, S., Gijs, L. et al. The assessment of sexual wellbeing in treatment-seeking transgender individuals: a systematic review of the medical literature. Int J Impot Res 35, 121–131 (2023). https://doi.org/10.1038/s41443-022-00529-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41443-022-00529-9

This article is cited by

Search

Advanced search

Quick links