Transgender is an umbrella term that broadly describes individuals whose gender experience does not align with their sex assigned at birth and exists as a spectrum. While transgender individuals may identify as masculine or feminine within the gender binary, nonbinary individuals may identify as, but are not limited to, having 2 or more genders, no gender, moving between genders (gender fluid), or in between genders. Recent estimates suggest that there are approximately 1 million transgender and nonbinary (TGNB) adults in the United States.¹ This considerable population was designated as a health disparity population by the National Institutes of Health in 2016, meaning that TGNB people compared to their cisgender counterparts (ie people who identify with a gender that corresponds to their birth sex) have differences in determinants of health, including biological factors, the environment, health behaviors, and socioeconomic statuses that affect access to care and health care outcomes.²

Providers will encounter TGNB individuals in their practice, and it is critical that they are able to understand their unique needs and challenges. Recent studies have shown that both clinicians and medical staff lack knowledge on proper care for this vulnerable population, despite in many cases having high compassion.^2,3 Moreover, the TGNB population is not a uniform group, and the decision to pursue transition-related medical and surgical care can differ greatly from person to person.^4,5 For the provider, this means that a TGNB individual assigned male at birth may seek counseling and treatment for the same sexual symptoms as cisgender men, such as erectile dysfunction (ED).^3,6 To date, there is limited research on the sexual health, symptoms, and preferences of TGNB people. To better characterize the health of TGNB individuals, we enacted a study which used survey data to capture details about the sexual health of TGNB individuals assigned male at birth.

We obtained Institutional Review Board approval to develop and distribute a 58-question survey evaluating sexual and genitourinary health, which we deployed among the local TGNB community as well as at an international TGNB conference. Participant inclusion criteria consisted of being TGNB, assigned male at birth, and at least 18 years of age. The online survey consisted of 4 sections, 1 of which was a sexual assessment of 23 questions which included questions on sexual preferences, quality of life, and satisfaction with current sexual symptoms, as well as International Index of Erectile Function (IIEF) when appropriate. Representative questions were reviewed with 25 TGNB volunteers from the community to ensure prompts were meaningful, understandable, and relevant to the target population. Modifications were made to the survey thereafter based on recommendations from the volunteers to improve readability and applicability to the population without compromising the integrity of the validated scales. We compiled survey responses for analysis and performed group comparisons on respondents who had undergone vaginoplasty (VP) and those who had not (NVP). Respondents with a history of orchiectomy only were included in the NVP group.

Fifty-three TGNB individuals with a median age of 33 years (range 18—80) provided consent to participate in this study. Gender identities included transgender woman or transfeminine (56.6%, 30), female or woman (34.0%, 18), nonbinary (7.5%, 4), and genderqueer, gender diverse, or gender nonconforming (1.9%, 1). Eleven participants (20.8%) had a history of VP, 10 (18.9%) had undergone orchiectomy alone, and 49 (92%) were on hormone therapy at the time of participation.

We found that sexual activity was common (90.5%) in all individuals (see Table). Individuals who underwent VP engaged in penetrative vaginal sex (81.8%, 9) and use of their clitoris (100%, 11). A higher proportion of NVP respondents reported having sex with other partners (69% vs 36.3%) and receptive anal sex (52.4% vs 9.1%) than VP respondents (p=0.02). Twenty-three (55%) of the NVP respondents reported that erectile function was important to them. Many in the NVP group experienced mild to moderate ED with an average±SD IIEF erectile function score of 13.3±7.4, orgasm function score of 5.8±2.8, and sexual desire score of 5.6±2.4. Despite the importance of erectile function and presence of ED, only 11.9% (5) of individuals were on phosphodiesterase type 5 inhibitors, while 1 individual had a penile prosthesis. Among all respondents, bother and quality of life related to sexual symptoms were similar between VP and NVP groups. When asked the degree of satisfaction a respondent would feel if they were to live with their current sexual function for the rest of their life, 72.8% (8) of VP and 34.1% (14) of NVP respondents indicated that they would be somewhat, very, or completely satisfied (p=0.23).

Limitations to our study included a small sample size from a narrowed geographic region, which limits the generalizability of our findings. While the IIEF was utilized to quantify symptoms that TGNB people experience, it is a metric which was developed for the cisgender population and may not be fully representative of the full scope of erectile, sexual, or urinary symptoms that TGNB people experience. More work is needed to develop validated questionnaires which are uniquely suited to TGNB people and better reflect the symptoms that they face.

Our results highlight some of the unique challenges as well as the diversity of experiences that are present in the sexual health of transfeminine individuals. We showed that continued sexual expression and the ability to have sex after genital gender-affirming surgery were highly important to participants, in addition to a reluctance to seek care for sexually sensitive issues in this population.⁷ Many TGNB individuals experience social stigma and discrimination because of their gender identity, and this may contribute to a hesitance to seek appropriate care for bothersome sexual symptoms. It has been reported that there is a prevalence of sexual dysfunction in the TGNB population, but there has been limited research on the accessibility and utilization of urology or other specialties for sexual health concerns.^8,9 These data present a clear opportunity for providers to improve means of communication and outreach to be able to better care for their transgender patients. Further education on “Creating a Gender-Affirming Environment for Urologic Care” can be found in the April 2021 issue of AUANews.