A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen

Abstract

Background Genital dissatisfaction is an important reason for transmen to undergo genital gender-confirming surgery (GCS; phalloplasty or metoidioplasty). However, little is known about motives for choosing specific techniques, how transmen benefit postoperatively, and whether psychosexual outcomes improve. Aim To evaluate motivations for and psychosexual outcomes after GCS. Methods A longitudinal study of 21 transmen at least 1 year after GCS was conducted. Participants were recruited through their surgeon. Data were collected when they applied for surgery and at least 1 year after surgery. Outcomes Data collection included semistructured questionnaires on motivations for surgery, postoperative experiences, and standardized measures of psychological symptoms, body image, self-esteem, sexuality, and quality of life (pre- and postoperative). Information on surgical complications and corrections was retrieved from medical records. Results Most participants underwent phalloplasty with urethral lengthening using a radial forearm flap. Although problematic voiding symptoms were prevalent, many participants were satisfied with their penile function. The strongest motivations to pursue penile surgery were confirmation of one's identity (100%), enabling sexual intercourse (78%), and voiding while standing (74%). No significant differences between postoperative and reference values were observed for standardized measures. After surgery, transmen were more sexually active (masturbation and with a partner) and used their genitals more frequently during sex compared with before surgery (31–78%). Clinical Implications The present study provides input for preoperative decision making: (i) main motives for surgery include identity confirmation, voiding, and sexuality, (ii) surgery can result in more sexual activity and genital involvement during sex, although some distress can remain, but (iii) complications and voiding symptoms are prevalent. Strength and Limitations Study strengths include its longitudinal design and the novelty of the studied outcomes. The main limitations include the sample size and the nature of the assessment. Conclusion Counseling and decision making for GCS in transmen should be a highly personalized and interdisciplinary practice.

Piloting a Genital Affirmation Surgical Priorities Scale for Trans Masculine Patients

“…Looking at the limited data, postsurgical patients have retrospectively reported motivations of gender confirmation, appearance (including size), and standing to urinate, as well as sexual function goals, and some of those patients have expressed regret at the type of surgery that was chosen—although not at having genital surgery. 13 These are also the areas in which postoperative satisfaction has been addressed. 3,13,14 As such, these areas were used as the basis for the development of the initial scale, a 7-item quantitative scale with four additional open-ended questions to generate discussion about expected patient concerns, which could be used as a decision-making tool to determine both the appropriateness of a particular type of surgery and the degree to which patient expectations are realistic or not.…”

“…13 These are also the areas in which postoperative satisfaction has been addressed. 3,13,14 As such, these areas were used as the basis for the development of the initial scale, a 7-item quantitative scale with four additional open-ended questions to generate discussion about expected patient concerns, which could be used as a decision-making tool to determine both the appropriateness of a particular type of surgery and the degree to which patient expectations are realistic or not. In response to reviewer feedback, that scale was later revised to include an additional question about the importance of phallus appearance (Fig.…”

“…12 Previous research has suggested that for many trans masculine individuals, the ability to urinate while standing is a major reason for seeking genital affirmation surgery. 13 Other studies have focused more on general appearance and satisfaction with sexual function after metoidioplasty and phalloplasty. 3,14…”

European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, with Attention for Sexual Function and Satisfaction”

“…89,90 In trans AFAB people with phalloplasty, sexual activity was higher (masturbation and with partner), and they used their genitals more frequently during sex compared with before surgery (31%e78%). 91 Sexual expectations were more frequently met in the group with an erection prosthesis (compared with those without), but pain during intercourse was more often reported. 45 However, in most of the studies that were selected in the review period, the overall data were limited, heterogeneous, of very low quality, and validated measurement tools were missing.…”

Evaluation of the Decision Aid for Genital Surgery in Transmen

“…10,18 At the same time, despite extensive preoperative counseling, postoperative satisfaction varies, which has partially been attributed to a mismatch between expectations and surgical outcomes in certain individuals. 14,15,19,20 Numerous studies showed that decision aids (DAs) improve the patients' ability to make an informed choice by enhancing the patients' knowledge and participation in the process, help create more realistic expectations of potential benefits and harms of treatment, and support patients to make a decision as per their informed values. 1,21e24 No such data have been described for surgical decision-making accustomed to the transgender population.…”