Male-to-Female MtF gender affirmation surgery GAS comprises the creation of a functional and aesthetic perineogenital complex. This study aimed to evaluate the effect of GAS on sexuality. We retrospectively surveyed all MtF transsexual patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between and In total, we received completed questionnaires after a median of 5.
Of the study participants, Of those who had sexual intercourse, Most patients were satisfied with the sensitivity of the neoclitoris The self-estimated pleasure of sexual activity correlated significantly with neoclitoral sensitivity but not with neovaginal depth. There was a significant correlation between the ease with which patients were able to become sexually aroused and their ability to achieve orgasms. In conclusion, orgasms after surgery were experienced more intensely than before in the majority of women in our cohort and neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than neovaginal depth.
Male-to-female MtF gender affirmation surgery GAS comprises the resection of all clearly defining features of male genitalia. The aim is the formation of a perineogenital complex in appearance and function as feminine as possible [ 1 ] with a sensitive clitoris to enable orgasms.
GAS should be performed by a surgeon with specialized competence in genital reconstructive techniques [ 2 ]. There is a broad agreement that GAS has a positive impact on gender dysphoria [ 3 — 13 ]. The inversion of penile skin is used by most gender surgeons. While some trans and gender nonconforming people do not require surgical therapy to express their preferred gender role and identity, others see GAS as a pivotal step to relieve their gender dysphoria [ 14 ].
GAS might reduce risk of stigmatization and discrimination in venues like swimming pools and health clubs or when dealing with authorities [ 2 , 15 ]. Without doubt surgery has a positive effect on subjective wellbeing and sexual function [ 16 — 18 ]. Bartolucci et al. However effects of GAS in this field remain unclear so far. This study aimed to evaluate the effect of GAS on sexuality and satisfaction with sexual life of MtF-transgender patients.
Our study cohort comprised all MtF patients who had undergone GAS with penile inversion vaginoplasty at the Department of Urology, University Hospital Essen, Germany, between and , as has been previously reported [ 6 ]. Transsexualism was diagnosed by two independent mental healthcare professionals competent to work with gender dysphoric adults in accordance with 10th version of the International Classification of Diseases ICD All patients were contacted by mail using their last known address and asked if they would be willing to answer the questionnaire.
Patients who had not sent back the questionnaire could not be followed up due to previous anonymization. The Mann—Whitney U test was used to compare satisfaction scale distribution of two independent samples. This nonparametric test was used in preference to the t-test because the Shapiro—Wilk test indicated that distribution was not normal.
In total, completed questionnaires were received, all of which were included in the evaluation response rate However, the average age of a comparable cohort of patients at our department between and [ 21 ] was Not all patients completed the questionnaire, so for some questions the total number of responses was not The results are given in absolute numbers and percentage in relation to total participants or number of answers.
After a median of 5. Twenty of the patients Time since GAS did not correlate with the frequency of intercourse and the self-rated intensity of orgasms. There was neither an association of the extent to which women felt female themselves nor with the degree to which they felt considered as women with time since surgery. In our cohort, 18 In total, 38 subjects This question was not answered by 27 individuals When asked how satisfied the women were with the depth of the neovaginal canal, 19 were very satisfied We asked our patients whether it was easy to get sexually aroused.
Of these 91 women 22 Frequency of achieved orgasms changed in our cohort after GAS. Of all patients 41 Of the residual 78 women 41 Figure 5 shows a detailed illustration. We received feedback regarding pleasure of sexual activity from 88 women Of these respondents 31 The better the sexual arousal, the easier it was to achieve an orgasm.
Studies often stress the emphasis on functional or aesthetic aspects after GAS [ 5 — 7 , 23 — 25 ] or, at best, on sexual quality of life before GAS [ 20 , 26 ]. To our best knowledge, this is the first study placing a particular focus on sexual life after MtF GAS. In our study, sexual attraction was referred to the self-perceived sexual identity on the basis of self-identification. A representative study with over In our study, the percentage of homosexuality gay and lesbian related to self-perceived gender was much higher.
This could be because the interviewees knew the interrogators well, had generally revealed their sexual orientation beforehand, and had no fear of societal stigmatization. There is also the possibility that the rate of homo- and bisexuality is, in fact, higher in transsexuals compared with nontranssexuals.
Regarding asexuality, we followed the definition of Prause and Graham who found that asexuality is defined to be a lack of sexual interest or desire, rather than a lack of sexual experience [ 34 ].
He found both biological and psychosocial factors contributing to the development of asexuality. A reduced sensitivity of the neoclitoris could therefore be a prognostic factor for asexuality. Our results support this assumption.
The sensitivity of the neoclitoris correlated with the ability of sexual arousal and achieving an orgasm, as well as with the self-estimated pleasure of sexual activity. In our cohort, satisfaction with the sensitivity of the neoclitoris was higher than with the depth of the neovaginal canal. This could be due to the time of questioning, which was a median of 5. While neoclitoral sensitivity is unlikely to diminish, it is more likely that the neovaginal canal shrinks over time. The longer the period after GAS is, the more prevalent the stenosis of the neovaginal canal seems to be [ 36 ].
Ineffective dilatation of the neovaginal canal is obviously a key factor contributing to neovaginal stenosis. Postsurgical sexuality plays an important role in overall satisfaction and depends substantially on the functionality of the neovagina [ 5 , 6 ]. The self-reported enjoyment of sexual activity correlated significantly and to a greater extent with neoclitoral sensitivity than with neovaginal dimensions, which was not significant. Though genital dimensions were not surveyed in our study, penile size often exceeds the depth of the vaginal canal in natal women without causing problems with, or pain during, sexual intercourse.
However in contrast to a skin derived vaginal canal of transgender women the vagina of natal women is able to expand 2. In this retrospective study we could not rule this out. However, we previously introduced a measurement tool to assess semiquantitatively the sensitivity with a customary brush and a tuning fork [ 40 ] which could be used for future studies on this topic.
Though the rate of women, who were able to achieve an orgasm, was lower in the present study than in an earlier cohort from our department [ 9 ], our data aligns well with comparable studies of a similar size [ 11 , 19 , 41 — 43 ]. Interestingly, Dunn et al. In total These results are roughly in line with a study by Buncamper et al. Since it is very unlikely that handling of the neurovascular bundle during surgery will make the neoclitoris more sensitive than the glans penis was before, a possible explanation could be that postoperative patients were able to experience orgasm for the first time in a body that matched their perception.
Furthermore, a decline in sexual desire after sex reassignment therapy hormonal and surgical could contribute to an altered orgasmic experience [ 46 ]. Interestingly, in their systematic review, Guillamon et al. Moreover, receiving hormonal treatment was one of the factors related to a better subjective perception of sexual quality of life [ 20 ]. Rolle et al. It is unclear whether this could explain differences in subjective orgasm experience before and after GAS.
Further prospective studies with a larger sample size are needed to validate this preliminary aspect. Suicide is a very unlikely reason for nonparticipation since the suicide rate after successful GAS is not higher than in the general population [ 49 ].
However, contacting trans-female patients for long-term follow-up is generally difficult [ 3 , 37 , 50 — 54 ] particularly in countries like Germany where there is no central registration. Another reason is that patients often move following successful surgery [ 5 ]. However, this cannot be verified retrospectively.
To our best knowledge, this was the first study to survey sexuality after MtF GAS in a very detailed way. In the majority of women, orgasms after surgery were experienced more intense than before. In our cohort, neoclitoral sensitivity seems to contribute to enjoyment of sexual activity to a greater extent than the depth of the neovaginal canal.
This study has been conducted without external funding. Hess et al. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Journal overview. Special Issues. Hess , 1 A. Henkel, 1 J. Bohr, 2 C. Rehme, 1 A. Panic, 1 L.