Supporting sexuality and improving sexual function in transgender persons

Abstract

Sexuality is important for most cisgender as well as transgender persons and is an essential aspect of quality of life. For both the patient and their clinicians, managing gender dysphoria includes establishing a comfortable relationship with sexual health issues, which can evolve throughout the course of gender-affirming treatment. Gender-affirming endocrine treatment of transgender men and women has considerable effects on sex drive and sexual function. Gender-affirming surgery (GAS) can improve body satisfaction and ease gender dysphoria, but surgery itself can be associated with sexual sequelae associated with physical constraints of the new genitals or postsurgical pain, psychological difficulties with accepting the new body, or social aspects of having changed gender. In general, a positive body image is associated with better sexual function and satisfaction, but satisfaction with sexual function after GAS can be present despite dissatisfaction with the surgery and vice versa. Factors involved in the integrated experience of gender-affirming treatment and the way in which sexuality is perceived are complex, and supporting sexuality and improving sexual function in transgender patients is, correspondingly, multifaceted. As the transgender patient moves through their life before, during, and after gender-affirming treatment, sexuality and sexual function should be considered and maximized at all stages in order to improve quality of life.

Key points

  • Evaluation of sexual dysfunction in transgender persons is multidimensional.

  • Hormonal treatment is likely to increase sexual desire in transgender men and decrease desire in transgender women.

  • A reduction in sexual drive is not necessarily a concern, but can, in fact, be appreciated or even desirable for some patients.

  • Before initiating hormonal or surgical treatment, wishes and hopes about future sexual function should be explored.

  • Sexual problems in transgender persons can be trans specific or not. General principles in sexual medicine apply to both cisgender and transgender persons.

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Fig. 1: The biopsychosocial model.
Fig. 2: Vaginoplasty.
Fig. 3: Phalloplasty technique.
Fig. 4: Metoidoplasty.

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Acknowledgements

The authors would like to thank plastic surgeon H. Sigurjonsson for important feedback regarding the illustrations.

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Natural Reviews Urology thanks S. Morrison, T. v. d. Grift and the other anonymous reviewer(s) for the peer review of this manuscript.

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Holmberg, M., Arver, S. & Dhejne, C. Supporting sexuality and improving sexual function in transgender persons. Nat Rev Urol 16, 121–139 (2019). https://doi.org/10.1038/s41585-018-0108-8

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