Editing Gender-affirming surgery (section)

== Post-procedural considerations ==

=== Quality of life ===
Clinical research on long-term quality-of-life outcomes following surgery is limited and confounded by various factors, including small sample sizes, and baseline rates of [[mental health]] issues and suicide among transgender people compared to the general population.<ref name="Shelemy_2024">{{Cite journal | vauthors = Shelemy L, Cotton S, Crane C, Knight M |date=2024-04-03 |title=Systematic review of prospective adult mental health outcomes following affirmative interventions for gender dysphoria |journal=International Journal of Transgender Health |language=en |pages=1–21 |doi=10.1080/26895269.2024.2333525 |issn=2689-5269|doi-access=free }}</ref>

A 2020 meta-analysis found "evidence of low quality" that gender-affirming surgery, particularly [[Male chest reconstruction|chest reconstruction]] for trans men, improves quality of life.<ref name="Schall_2023" /> A 2024 systematic review found that genital surgeries significantly improved depression and dissociation, with "mixed results" for other mental health outcomes.<ref name="Shelemy_2024" />

A secondary analysis of the [[U.S. Transgender Survey]] found that gender-affirming surgery was significantly associated with lower rates of psychological distress, smoking, and suicidal ideation, compared to rates among respondents who desired surgery but had not undergone it.<ref name="Millman_2021">{{Cite web | vauthors = Millman A |date=2021-03-04 |title=Fact-checking Rand Paul's comparisons of genital mutilation and gender confirmation surgery |url=https://www.cnn.com/2021/03/04/politics/rand-paul-genital-mutilation-gender-confirmation-fact-check/index.html |access-date=2023-07-10 | work = CNN |language=en}}</ref> This was the largest controlled study on the subject to date (N=19,960), though the design of the survey and self-reported responses introduced some limitations and possible [[response bias]].<ref name="Vincent_2019" />

Gender-affirming surgery can be seen as [[human enhancement]].<ref name="g077">{{cite journal | last=Zohny | first=Hazem | last2=Earp | first2=Brian D. | last3=Savulescu | first3=Julian | title=Enhancing Gender | journal=Journal of Bioethical Inquiry | volume=19 | issue=2 | date=2022 | issn=1176-7529 | pmid=35129785 | pmc=9233637 | doi=10.1007/s11673-021-10163-7 | doi-access=free | pages=225–237 | url=https://link.springer.com/content/pdf/10.1007/s11673-021-10163-7.pdf | access-date=19 January 2025}}</ref> A 2021 review found that less than 1% of 7,928 patients regretted gender-affirming surgery.<ref name="Gaither_2018" /> 

=== Psychological and social consequences ===
{{Research paper|section|date=October 2023}}
A 2009 review in the ''International Journal of Transgenderism'' found that from 1998 onward,<ref>{{Cite journal | vauthors = Pfäfflin F, Junge A |date=1998 |title=Sex reassignment: Thirty years of international follow-up studies after sex reassignment surgery—Comprehensive review 1961–1991 |department=Book Section |journal=International Journal of Transgenderism |postscript=,}} quoted in {{Cite journal | vauthors = Monstrey S, Vercruysse Jr H, De Cuypere G |year=2009 |title=Is Gender Reassignment Surgery Evidence Based? Recommendation for the Seventh Version of the WPATH ''Standards of Care'' |journal=International Journal of Transgenderism |volume=11 |issue=3 |pages=206–214 |doi=10.1080/15532730903383799 |s2cid=58637820}}</ref> studies have shown that "the whole process of gender reassignment is effective in relieving gender dysphoria and that its positive results greatly outweighed any negative consequences", but noted methodological issues in many studies, particularly older ones.<ref>Monstrey et al.</ref> A 2010 meta-analysis in ''Clinical Endocrinology'' noted the lack of randomization and control groups and reliance of self-reporting in the studies it reviewed, reaching the conclusion "Very low quality evidence suggests that hormonal therapies given to individuals with GID as a part of sex reassignment are likely to improve gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life."<ref>{{cite journal | vauthors = Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, Montori VM | title = Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes | journal = Clinical Endocrinology | volume = 72 | issue = 2 | pages = 214–231 | date = February 2010 | pmid = 19473181 | doi = 10.1111/j.1365-2265.2009.03625.x | s2cid = 19590739 }}</ref>

Smith et al. (2001) found that among 20 patients, anxiety, depression and hostility levels were lower after gender-affirming surgery.<ref>{{cite journal | vauthors = Smith YL, van Goozen SH, Cohen-Kettenis PT | title = Adolescents with gender identity disorder who were accepted or rejected for sex reassignment surgery: a prospective follow-up study | journal = Journal of the American Academy of Child and Adolescent Psychiatry | volume = 40 | issue = 4 | pages = 472–481 | date = April 2001 | pmid = 11314574 | doi = 10.1097/00004583-200104000-00017 }}</ref> Wierckx et al. (2011), in a study of 49 trans men, found them in good self-perceived physical and mental health.<ref name="Wierckx_2011">{{cite journal | vauthors = Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, Weyers S, Hoebeke P, Monstrey S, De Cuypere G, T'Sjoen G | title = Quality of life and sexual health after sex reassignment surgery in transsexual men | journal = The Journal of Sexual Medicine | volume = 8 | issue = 12 | pages = 3379–3388 | date = December 2011 | pmid = 21699661 | doi = 10.1111/j.1743-6109.2011.02348.x }}</ref> Dhejne et al. (2011), in a study following 324 trans people who received gender-affirming surgery from 1973 to 2003, found that they "have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population"; concluding, "sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism".<ref>{{cite journal | vauthors = Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M | title = Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden | journal = PLOS ONE | volume = 6 | issue = 2 | pages = e16885 | date = February 2011 | pmid = 21364939 | pmc = 3043071 | doi = 10.1371/journal.pone.0016885 | bibcode = 2011PLoSO...616885D | doi-access = free }}</ref> Lawrence (2003), in a study of 232 trans women who underwent surgery in 1994-2000, found "None reported outright regret and only a few expressed even occasional regret."<ref>{{cite journal | vauthors = Lawrence AA | title = Factors associated with satisfaction or regret following male-to-female sex reassignment surgery | journal = Archives of Sexual Behavior | volume = 32 | issue = 4 | pages = 299–315 | date = August 2003 | pmid = 12856892 | doi = 10.1023/A:1024086814364 | s2cid = 9960176 }}</ref>

Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery.<ref>{{Cite journal | vauthors = Karpel L, Cordier B |year=2013 |title=Postoperative regrets after sex reassignment surgery: A case report |journal=Sexologies |volume=22 |issue=2 |pages=e55–e58 |doi=10.1016/j.sexol.2012.08.014}}</ref>{{Better source needed|reason=The current source is insufficiently reliable ([[WP:NOTRS]]).|date=October 2022}} During the process of gender-affirming surgery, transgender people may become victims of different social obstacles such as discrimination, prejudice and stigmatizing behaviours.<ref name="Jokić-Begić_2014">{{cite journal | vauthors = Jokić-Begić N, Lauri Korajlija A, Jurin T | title = Psychosocial adjustment to sex reassignment surgery: a qualitative examination and personal experiences of six transsexual persons in croatia | journal = TheScientificWorldJournal | volume = 2014 | pages = 960745 | year = 2014 | pmid = 24790589 | pmc = 3984784 | doi = 10.1155/2014/960745 | doi-access = free }}</ref> The rejection faced by trans people is much more severe than what is experienced by lesbians, gays, and bisexuals.<ref>{{Cite journal | vauthors = Norton AT, Herek GM |year=2013 |title=Heterosexuals' attitudes toward transgender people: findings from a national probability sample of U.S. adults |journal=Sex Roles |volume=68 |issue=11–12 |pages=738–753 |doi=10.1007/s11199-011-0110-6 |s2cid=37723853}}</ref> The hostile environment may trigger or worsen internalized transphobia, depression, anxiety and post-traumatic stress.<ref>{{Cite book | vauthors = Bockting W |title=Gender Dysphoria and Disorders of Sex Development |publisher=Springer |year=2014 |location=New York, NY, U.S. |pages=319–330}}</ref>

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity and reduce minority stress.<ref name="Jokić-Begić_2014" />{{Better source needed|reason=The current source is insufficiently reliable ([[WP:NOTRS]]).|date=October 2022}}

=== Sexuality ===
Looking specifically at transsexual people's genital sensitivities, both trans men and trans women are capable of maintaining their genital sensitivities after gender-affirming surgery. However, these are counted upon the procedures and surgical tricks which are used to preserve the sensitivity. Considering the importance of genital sensitivity in helping transsexuals to avoid unnecessary harm or injury to the genitals, allowing trans men to obtain erection by inserting a [[penile implant]] after [[phalloplasty]],<ref name="Selvaggi_2007">{{cite journal | vauthors = Selvaggi G, Monstrey S, Ceulemans P, T'Sjoen G, De Cuypere G, Hoebeke P | title = Genital sensitivity after sex reassignment surgery in transsexual patients | journal = Annals of Plastic Surgery | volume = 58 | issue = 4 | pages = 427–433 | date = April 2007 | pmid = 17413887 | doi = 10.1097/01.sap.0000238428.91834.be | s2cid = 46169398 }}</ref> the ability of trans people to experience erogenous and [[tactile sensitivity]] in their reconstructed genitals is one of the essential objectives surgeons want to achieve in gender-affirming surgery.<ref name="Selvaggi_2007" /><ref name="Hage_1993">{{cite journal | vauthors = Hage JJ, Bouman FG, de Graaf FH, Bloem JJ | title = Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience | journal = The Journal of Urology | volume = 149 | issue = 6 | pages = 1463–1468 | date = June 1993 | pmid = 8501789 | doi = 10.1016/S0022-5347(17)36416-9 }}</ref> Moreover, studies have also found that the critical procedure for genital sensitivity maintenance and achieving orgasm after phalloplasty is to preserve both the clitoral hood and the clitoris underneath the reconstructed [[phallus]].<ref name="Selvaggi_2007" /><ref name="Hage_1993" />

Erogenous sensitivity is measured by the abilities to reach [[orgasm]] in genital sexual activities, like masturbation and intercourse.<ref name="Selvaggi_2007" /> Many studies reviewed that both trans men and trans women have reported an increase of orgasms in both sexual activities,<ref name="Wierckx_2011" /><ref name="De_Cuypere_2005">{{cite journal | vauthors = De Cuypere G, T'Sjoen G, Beerten R, Selvaggi G, De Sutter P, Hoebeke P, Monstrey S, Vansteenwegen A, Rubens R | title = Sexual and physical health after sex reassignment surgery | journal = Archives of Sexual Behavior | volume = 34 | issue = 6 | pages = 679–690 | date = December 2005 | pmid = 16362252 | doi = 10.1007/s10508-005-7926-5 | s2cid = 42916543 }}</ref> implying the possibilities to maintain or even enhance genital sensitivity after gender-affirming surgery.

Most trans persons report enjoying better sex lives and improved sexual satisfaction after gender-affirming surgery.<ref name="De_Cuypere_2005" /> The enhancement of sexual satisfaction was positively related to the satisfaction of new primary sex characteristics.<ref name="De_Cuypere_2005" /> Before gender-affirming surgery, trans patients had unwanted sex organs which they were eager to remove. Hence, they were not enthusiastic about engaging in sexual activity. Transsexual individuals who have undergone gender-affirming surgery are more satisfied with their bodies and experienced less stress when participating in sexual activity.<ref name="De_Cuypere_2005" />

Most of the individuals report that they have experienced sexual excitement during sexual activity, including masturbation.<ref name="De_Cuypere_2005" /> The ability to obtain orgasm is positively associated with sexual satisfaction.<ref name="Wierckx_2011" /> Frequency and intensity of orgasm are substantially different for trans men and trans women. Almost all female-to-male individuals revealed an increase in sexual excitement and can achieve orgasm through sexual activity with a partner or via masturbation,<ref name="De_Cuypere_2005" /><ref name="Wierckx_2011" /> whereas only 85% of the male-to-female individuals are able to achieve orgasm after gender-affirming surgery.<ref>{{cite journal | vauthors = Lawrence AA | title = Sexuality before and after male-to-female sex reassignment surgery | journal = Archives of Sexual Behavior | volume = 34 | issue = 2 | pages = 147–166 | date = April 2005 | pmid = 15803249 | doi = 10.1007/s10508-005-1793-y | s2cid = 25671520 | citeseerx = 10.1.1.538.6381 }}</ref> A study found that both trans men and trans women reported qualitative change in their experience of orgasm. The female-to-male trans individuals reported that they had been experiencing intensified and stronger excitements and orgasm while male-to-female persons have been encountering longer and more gentle feelings.<ref name="De_Cuypere_2005" />

Rates of masturbation have also changed after gender-affirming surgery for both trans women and trans men. A study reported an overall increase of masturbation frequencies in most transsexuals and 78% of them were able to reach orgasm by masturbation after gender-affirming surgery.<ref name="Wierckx_2011" /><ref name="De_Cuypere_2005" /><ref name="Gómez-Gil_2014">{{cite journal | vauthors = Gómez-Gil E, Zubiaurre-Elorza L, de Antonio IE, Guillamon A, Salamero M | title = Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery | journal = Quality of Life Research | volume = 23 | issue = 2 | pages = 669–676 | date = March 2014 | pmid = 23943260 | doi = 10.1007/s11136-013-0497-3 | s2cid = 23051224 }}</ref> A study showed that there were differences in masturbation frequency between trans men and trans women; female-to-male individuals masturbated more often than male-to-female.<ref name="De_Cuypere_2005" /> The possible reasons for the difference in masturbation frequency could be associated with the surge of libido, which was caused by the testosterone therapies, or the withdrawal of gender dysphoria.<ref name="Wierckx_2011" />

Concerning trans people's expectations for different aspects of their life, the sexual aspects have the lowest level of satisfaction among all other elements (physical, emotional and social levels).<ref name="Gómez-Gil_2014" /> When comparing trans with [[cisgender]] persons of the same gender, [[trans women]] had a similar sexual satisfaction to cis women, but [[trans men]] had a lower level of sexual satisfaction to cis men. Moreover, trans men also had a lower sexual satisfaction with their sexual life than trans women.<ref name="Wierckx_2011" />