Physical, Mental and Sexual Health Among Transgender Women: A Comparative Study Among Operated Transgender and Cisgender Women in a National Tertiary Referral Network

Francesca Vedovo MD; Lisa Di Blas PhD; Francesco Aretus MD; Marco Falcone MD; Chiara Perin PsyD; Nicola Pavan MD; Michele Rizzo MD; Girolamo Morelli MD; Andrea Cocci MD; Chiara Polito MD; Giorgio Gentile MD; Fulvio Colombo MD; Massimiliano Timpano MD; Paolo Verze MD; Ciro Imbimbo MD; Carlo Bettocchi MD; Elisabetta Pascolo Fabrici MD; Alessandro Palmieri MD; Carlo Trombetta MD

FIRST PUBLISHED: March 23, 2021 – The Journal of Sexual Medicine

DOI: https://doi.org/10.1016/j.jsxm.2021.02.006

Introduction

Gender affirming surgery (GAS) has become more common, but research on how it may affect physical, mental, and sexual health is still limited.

This study investigated physical, mental, and sexual health in a group of operated transgender women (oTW) and a group of cisgender women (cisW). Results for the two groups were compared.

Methods

The study included 125 oTW from Italy. A comparison group of 80 cisgender women volunteers was also selected.

The participants completed several online questionnaires that assessed the following:

• Depressive symptoms [Beck Depression Inventory Primary Care (BDI-PC)]
• General health [General Health Survey – Short Form 36 (SF-36)]
• Sexual function [Female Sexual Function Index (FSFI) and
• Operated Male to Female Sexual Function Index (oMtFSI).

Results and Discussion 

Overall, the response rate was 60%, with 65 oTW and 57 cisW included in the main study. Because there were few homosexual and bisexual participants, only heterosexuals were included.

Mean ages were 38.5 years and 37.3 years for transgender and cisgender women, respectively (P value >.05). Approximately 71% of oTW and 81% of cisW were in stable relationships (P value > .05). About 66% of oTW and 77% of cisW reported sexual activity during the previous month (P value > .05).

On all assessments, the scores of both oTW and cisW fell into average ranges. There were no significant differences between groups in mental and physical health.

However, transgender women had worse scores on the sexual function assessment and had higher levels of sexual dissatisfaction and sexual pain than the cisgender women. It’s possible that dyspareunia in oTW occurs because the neovagina does not lubricate on its own, and patients may not always use lubricants to make intercourse more comfortable.

Poor sexual function was linked to poor mental well-being and higher depression levels, especially for oTW. In addition, sexual function was negatively associated with years since GAS, but not with age.

Transgender women were moderately dissatisfied with their genital self-image. This finding might be due to high expectations. “[I]t frequently emerges how these patients have unrealistic expectations about the neovagina depth, dreaming of measures greater than those actually obtainable through surgery.”

Limitations 

Several limitations were acknowledged. For example, the participants were volunteers who may have been more likely to discuss their mental health or sexual problems than other types of participants. Study subjects may not represent those who live in areas with stronger social stigma. And because of the low prevalence of homosexual and bisexual participants, analyses related to sexual orientation were not made.

Conclusions

“Sexual pain and lubrication difficulties are the main domains affecting transgender women’s sexual function and this study pointed out a close connection between mental and sexual health in operated transgender women, with dyspareunia substantially predicting risk of depression in this population.

“These findings underline the importance of peri-operative counseling to make surgical expectations realistic and to educate to a proper neovagina management.”