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Background: Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires., Aims: The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment., Methods: Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care., Outcomes: Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth., Results: The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery., Clinical Implications: A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth., Strengths and Limitations: This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth., Conclusion: This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: The distress caused by gender incongruence has been shown to be reduced with gender-affirming care. The current study follows a cohort of patients that requested gender-affirming care at Ghent University Hospital and examines the outcome of the procedures., Methods: The prospective design with 4 assessment times allows the study to assess the evolution of self-reported quality of life (QoL) and gender incongruence throughout a medical transition process. All the participants (N = 119) received hormone therapy, 52% underwent a separate gonadectomy (N = 62), and 41% vaginoplasty or phalloplasty (N = 49)., Results: The results suggest that gender incongruence improves after surgery. QoL has slightly different trends for the different gender groups: compared to people who were assigned male at birth (AMAB), people who were assigned female at birth (AFAB) report lower QoL after gonadectomy. Meeting other transgender people facilitate QoL after starting hormone therapy. A higher number of friends after genital surgery are predictive of a better QoL., Clinical Implications: These results may be useful for clinicians working with transgender patients, as they provide information collected assessing patients soon after surgery and may raise awareness regarding the specific clinical attention that postsurgery patients need., Conclusions: QoL can be compromised after the invasive surgery, while gender incongruence is alleviated throughout the transition. Our results should be confirmed with other prospective study designs that include a longer follow-up period. Pavanello Decaro S, Van Gils S, Van Hoorde B, et al. It Might Take Time: A Study on the Evolution of Quality of Life in Individuals With Gender Incongruence During Gender-Affirming Care. J Sex Med 2021;18:2045-2055., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions., Aim: To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics., Methods: As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis., Outcomes: Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics., Results: Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care., Clinical Implications: Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare., Strengths & Limitations: We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare., Conclusion: These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932., (Copyright © 2021 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Studies about sexual functioning in trans persons have mainly focused on sexual functioning after genital gender-affirming surgery, have had small sample sizes, and have not explored the broad range of possible sexual dysfunctions. Measuring sexual functioning in trans persons during transitioning is important to determine the kind of care trans persons may need in order to regain their sexual health., Aim: The first aim of the present study was to explore the prevalence of sexual function disturbances and dysfunctions (with distress) in trans women and trans men 4 to 6 years after initial clinical entry. The second aim was to compare the prevalence of sexual dysfunctions among the various treatment trajectories and between trans persons with or without further genital treatment intentions., Methods: An online follow-up questionnaire was filled out by 518 trans persons (307 identifying predominantly feminine, 211 identifying predominantly masculine) as a part of the European Network for the Investigation of Gender Incongruence initiative. All participants had their initial clinical appointments in gender clinics in Ghent, Amsterdam, or Hamburg., Main Outcome Measure: The main outcome measures were the prevalence of sexual dysfunctions and medical treatment data, measured via self-report items., Results: The most frequent sexual dysfunctions experienced by trans women and trans men were difficulties initiating and seeking sexual contact (26% and 32%, respectively) and difficulties achieving an orgasm (29% and 15%, respectively). Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire. Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often. No significant differences were found between participants with or without further genital treatment intentions., Clinical Implications: Clinicians should consider sexual counseling after medical treatments, paying particular attention to potential social and psychological barriers to the sexual health of their patients., Strengths & Limitations: This study included all trans persons irrespective of treatment decisions, and focused on a broad range of potential sexual difficulties taking the distress criteria into account. Limitations include the cross-sectional design, the limited power for the comparison of treatment groups and the absence of validated questionnaires about sexual functioning for transgender persons., Conclusion: Sexual dysfunctions among trans men and women were very common among the various treatment groups and were unrelated to intentions to have further genital treatment. Although medical treatment may be helpful or even essential to developing good sexual health, a significant group of trans persons experienced sexual dysfunctions after genital surgery. Kerckhof ME, Kreukels BPC, Nieder TO, et al. Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study. J Sex Med 2019; 16:2018-2019., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Gender Dysphoria (GD) refers to a distress resulting from an incongruence between the individual's sex characteristics and the experience of their gender (Gender Incongruence, GI). The interaction between medical treatment of GI/GD and social support in the long-term has not been investigated sufficiently so far., Material & Methods: Using an online questionnaire, the present study investigated n=117 individuals with GI/GD assigned male and n=52 assigned female at birth that had been referred to one of the specialized clinics of the European Network for the Investigation of Gender Incongruence (ENIGI) in Belgium, the Netherlands, and Germany.They filled out a questionnaire at 2 time points within a follow-up time of 4 to 6 years after clinical entry (between 2007 and 2009). Two hierarchical regression analyses explored the effects of the sex assigned at birth, the treatment progress and social support on mental distress and satisfaction with life at follow-up in the sample., Results: A female sex assigned at birth and higher degrees of social support significantly predicted the reduction in mental distress at follow-up. An advanced stage of the individual treatment and higher social support significantly predicted an increase in overall satisfaction with life., Discussion: The results illustrate the importance of social support with regard to the outcome of medical treatment of GI/GD., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR = 6.07). Satisfied respondents' QoL scores were similar to reference values; dissatisfied or regretful respondents' scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

In gender dysphoria (GD), much of the experienced distress results from body dissatisfaction. The current study analyzed the configuration of body satisfaction in trans men and women using network analysis. In total, 485 individuals diagnosed with GD from four European countries, applying for medical treatment, filled out the Body Image Scale for Transsexuals. A six-factor model reflecting different body areas was confirmed via confirmatory factor analysis. A further configuration of body satisfaction was modelled using correlation network analysis techniques in R. Genital dissatisfaction showed limited connection with other body areas in comparison to other subscales. Body characteristics influencing social gender recognition were most centrally involved in body (dis)satisfaction in both natal sexes. In trans women these characteristics were related mostly to voice and hair, whereas in trans men these characteristics were related to muscularity and posture. Focusing on these socially influential body characteristics may provide important targets for transgender healthcare., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

We present a case report on a 53-year-old transsexual woman who developed acute painless vision loss in both eyes during cross-sex hormone treatment. After 10 months of cross-sex hormone treatment, she experienced total vision loss of the right eye and, 6 months later, vision loss to 20/63 in the left eye. After a full ophthalmic exam, bilateral sequential non-arteritic ischemic optic neuropathy (NA-ION) was diagnosed. Extensive etiological work-up revealed no cardiac abnormalities or inherited blood-clotting disorders. A manifest self-administered overdose of transdermal estrogen treatment with serum estradiol levels of 5,765 pg/ml was possibly related to the sequential bilateral NA-ION resulting in nearly total vision loss in this transsexual woman.

Background: Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results., Aims: To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder., Method: Data were collected within the European Network for the Investigation of Gender Incongruence using the Mini International Neuropsychiatric Interview - Plus and the Structured Clinical Interview for DSM-IV Axis II Disorders (n = 305)., Results: In 38% of the individuals with gender identity disorder a current DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and anxiety disorders. Furthermore, almost 70% had a current and lifetime diagnosis. All four countries showed a similar prevalence, except for affective and anxiety disorders, and no difference was found between individuals with early-onset and late-onset disorder. An Axis II diagnosis was found in 15% of all individuals with gender identity disorder, which is comparable to the general population., Conclusions: People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.

Background: Hormonal therapy and sex reassignment surgery (SRS) in transsexual persons lead to an irreversible loss of their reproductive potential. The current and future technologies could create the possibility for female-to-male transsexual persons (transsexual men) to have genetically related children. However, little is known about this topic. The aim of this study is to provide information on the reproductive wishes of transsexual men after SRS. METHODS A self-constructed questionnaire was presented to 50 transsexual men in a single-center study., Results: The majority (64%) of transsexual men were currently involved in a relationship. Eleven participants (22.0%) reported having children. For eight participants, their female partner was inseminated with donor sperm, whereas three participants gave birth before hormonal therapy and SRS. At the time of interview, more than half of the participants desired to have children (54%). There were 18 participants (37.5%) who reported that they had considered freezing their germ cells, if this technique would have been available previously. Participants without children at the time of investigation expressed this desire more often than participants with children (χ²; test: P= 0.006)., Conclusions: Our data reveal that the majority of transsexual men desire to have children. Therefore, more attention should be paid to this topic during the diagnostic phase of transition and to the consequences for genetic parenthood after starting sex reassignment therapy.

Introduction: Although sexual health after genital surgery is an important outcome factor for many transsexual persons, little attention has been attributed to this subject., Aims: To provide data on quality of life and sexual health after sex reassignment surgery (SRS) in transsexual men., Methods: A single-center, cross-sectional study in 49 transsexual men (mean age 37 years) after long-term testosterone therapy and on average 8 years after SRS. Ninety-four percent of the participants had phalloplasty., Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short Form-36 Health Survey; sexual functioning before and after SRS using a newly constructed specific questionnaire., Results: Compared with a Dutch reference population of community-dwelling men, transsexual men scored well on self-perceived physical and mental health. The majority reported having been sexually active before hormone treatment, with more than a quarter having been vaginally penetrated frequently before starting hormone therapy. There was a tendency toward less vaginal involvement during hormone therapy and before SRS. Most participants reported an increase in frequency of masturbation, sexual arousal, and ability to achieve orgasm after testosterone treatment and SRS. Almost all participants were able to achieve orgasm during masturbation and sexual intercourse, and the majority reported a change in orgasmic feelings toward a more powerful and shorter orgasm. Surgical satisfaction was high, despite a relatively high complication rate., Conclusion: Results of the current study indicate transsexual men generally have a good quality of life and experience satisfactory sexual function after SRS., (© 2011 International Society for Sexual Medicine.)

Objective: To describe sexual desire in female-to-male transsexual persons post sex reassignment surgery (SRS). The associations between serum androgen levels and sexual desire are examined., Design: Single center cross-sectional study., Methods: Forty-five female-to-male transsexual persons post SRS completed a standardized questionnaire assessing sexual desire (Sexual Desire Inventory). In addition, participants were asked questions on sexual desire before starting hormone treatment and having SRS. Serum levels of testosterone, LH and sex hormone-binding globulin were measured on fasting morning serum samples., Results: In retrospect, 73.9% of the participants reported an increase in sexual desire after hormone treatment and SRS. Solitary sexual desire scores were significantly correlated with frequency of masturbation (r=0.835; P<0.001), whereas frequency of sexual intercourse with a partner was not. No direct associations were found between testosterone and solitary or dyadic sexual desire. However, ANOVA showed an independent effect of LH on solitary sexual desire (P<0.001). Post hoc analysis revealed that female-to-male transsexual persons with elevated levels of LH, indicating suboptimal testosterone therapy, reported significantly lower solitary sexual desire levels (than those with low LH levels; P=0.007). Suppressed LH levels were also associated with having a higher need for sexual activities (P=0.009) and a higher frequency of excessive sexual desire (P=0.007)., Conclusion: Most female-to-male transsexual persons report on a marked increase in sexual desire after testosterone treatment and SRS. No direct associations between levels of testosterone and solitary or dyadic sexual desire were found. However, measures of sexual desire were inversely associated with LH levels.

Introduction: Karyotyping is often performed in transsexual individuals., Aim: Quantification and characterization of karyotype findings and abnormalities in transsexual persons., Main Outcome Measures: Karyotypes were listed both in male-to-female and in female-to-male transsexual persons., Methods: The data were collected through a retrospective study., Results: Karyotypes of 368 transsexual individuals (251 male-to-female, 117 female-to-male) are described. Normal findings were found in 97.55%. Prevalence of abnormal karyotypes was 3.19% among male-to-female, and 0.85% among female-to-male transsexuals. Nine karyotypes showed variations; Klinefelter syndrome was confirmed in three persons, whereas others displayed autosomal aberrations., Conclusion: Karyotyping is only of very limited information in the transsexual population., (© 2010 International Society for Sexual Medicine.)

Background: Low sexual desire is present in 1/3 of male-to-female transsexuals (post-operative male-to-female transsexual persons on estrogen replacement). Several studies report lower endogenous testosterone (T) levels in this group compared to community dwelling women. However, no relationship between T and sexual desire has been found in male-to-female transsexuals. Considering its role in androgen sensitivity, cytosine-adenine-guanine (CAG) trinucleotide repeat sequence in the androgen receptor (AR) might modify the relationship between T levels and sexual desire in male-to-female transsexuals., Aim: This study aims to assess the potential contribution of the number of CAG repeats in the association between T and sexual desire in male-to-female transsexuals. MATERIAL, SUBJECTS, AND METHODS: Thirty-four post-operative male-to-female transsexuals participated in a cross-sectional study. The Sexual Desire Inventory, a questionnaire measuring sexual desire, was completed. Serum levels of total (TT) and free T (FT), DHEA-S, SHBG, and LH were measured in morning blood samples. AR gene CAG repeat length was determined by automated DNA fragment analysis of exon 1 of the AR gene., Results: The CAG repeat length ranged from 14 to 28 with a median of 21. CAG polymorphism was correlated with FT (r=0.389; p=0.023) but not with TT (r=0.191; p=0.280). The observed interaction between TT and CAG was significant only for solitary sexual desire (p=0.002). The interaction of CAG repeats and FT on sexual desire failed to reach significance., Conclusions: We could not establish that CAG repeat length is a consistent modulating factor in the relationship between TT or FT and sexual desire in male-to-female transsexuals.

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking., Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS., Methods: Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited., Main Outcome Measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored., Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals., Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.