The review, led by Ragav Chona and Gianni R. Lorello and conducted according to Joanna Briggs Institute methodology with pre-registration on the Open Science Framework, searched ten bibliographic databases from inception through 30 July 2025, combining controlled vocabulary for pelvic pain and transgender health with free-text keywords covering gender-affirming hormone therapy, vaginoplasty and dilation-related pain. From 6,534 records, the team screened 3,823 unique titles and abstracts and ultimately included 24 reports representing 23 unique cohorts and 5,527 transgender and gender-diverse participants. Inter-reviewer agreement at screening was nearly perfect, with a Cohen’s kappa of 0.99, and the reviewers also performed an exploratory risk-of-bias appraisal using design-specific checklists, the Cochrane RoB 2 tool and ROBINS-I.

What the synthesis found is a field dominated by observational and descriptive work. Of the 24 reports, ten were cross-sectional or psychometric studies, four were retrospective cohorts or audits, two were prospective cohorts, four were qualitative, three were case reports, and just one was a randomised trial. Thirteen reports came from North America, five from Europe, two each from Brazil and Australia, and two used international samples; no report was based in Africa or Asia. Fourteen reports focused on transmasculine people or other participants assigned female at birth, seven on transfeminine people, and three on mixed groups. Critically, only one report applied a formal duration-defined chronic pelvic pain criterion of at least three months, meaning most prevalence figures in the literature describe broader pelvic and genital symptom burden rather than chronic pelvic pain itself.

That single duration-defined study, drawing on more than 2,500 trans men and gender-diverse adults assigned female at birth in the PRIDE Study, estimated a chronic pelvic pain prevalence of 17.7 percent. Around it, heterogeneous symptom estimates ranged from 9.6 percent vulvar pain to 72.2 percent pelvic pain after starting testosterone, with dyspareunia reported in 61.5 percent of one transmasculine sample, pelvic pain in 36.0 percent of transmasculine participants on testosterone for at least a year, and 50.7 percent preoperative pelvic pain among transgender men undergoing hysterectomy. The reviewers are emphatic that these figures cannot be pooled or read as a prevalence range, because the samples, definitions and measures differ so wildly, but together they signal a real and recurrent clinical problem in selected populations.

The most scientifically intriguing thread concerns testosterone. Several studies described new-onset cramping or suprapubic pain after testosterone initiation, sometimes with dysorgasmia or breakthrough bleeding despite amenorrhoea, while the one duration-defined study found current testosterone use associated with lower chronic pelvic pain prevalence than non-use. The review argues these findings should not be read as either a protective or a causative effect. Supporting biological context comes from histological work outside the included studies: high-dose testosterone exposure has been linked to loss of vaginal epithelial layers, glycogen depletion and reduced oestrogen-receptor expression, while uterine and endometrial case series show heterogeneous responses, with some specimens showing active or proliferative endometrium despite amenorrhoea. The plausible interpretation is mechanistic heterogeneity: testosterone may suppress cyclic uterine, ovarian or peritoneal activity and ease pain in some people, while in others incomplete ovarian suppression, residual endometrial activity or hypoestrogenic tissue effects may drive dryness, irritation, dyspareunia and pelvic floor guarding.

A second major context is gender-affirming surgery. Postoperative pelvic and genital pain, dyspareunia and dilation-related difficulties are common early after urogenital surgery and, in the available follow-up, often improve during the first postoperative year, but longer-term cohorts have documented dyspareunia, lower abdominal pain and pelvic floor distress more than a decade after surgery. Reported pain generators include introital and neovaginal stenosis, scarring and granulation tissue, neuroma and nerve irritation, urethral complications, and rare structural pathology such as a pubic aneurysmal bone cyst that caused chronic groin pain and resolved after resection. The reviewers frame these trajectories within the established persistent postsurgical pain literature, involving peripheral injury, central sensitisation and psychosocial context, and argue that doing so supports routine outcome measurement and early identification of complications without pathologising gender-affirming surgery itself.

Across both transmasculine and transfeminine participants, pelvic floor neuromuscular impairments emerged as a recurring and potentially modifiable contributor, with hypertonicity, myofascial trigger points and coordination deficits described alongside dilation pain, orgasm-associated cramping and mixed urinary or bowel symptoms. One cross-sectional study of transgender men on testosterone found pelvic floor dysfunction in 94.1 percent of participants. Yet the treatment evidence is sobering: the only randomised trial, comparing routine postoperative pelvic floor physiotherapy with standard care after vaginoplasty, found no differences at 12 weeks in ease or pain with dilation, pelvic floor symptoms, vaginal length or subjective improvement. That argues against routine physiotherapy for every surgical patient, the reviewers note, but does not establish that targeted rehabilitation is ineffective for people with examination-confirmed hypertonicity, myofascial pain or function-limiting dilation pain, which case reports suggest can respond to manual release, down-training, biofeedback and graded dilator retraining.

The review also identifies psychosocial and trauma-related factors as a fourth interacting domain. Adverse childhood experiences, sexual trauma and minority stress, the chronic stigma-related stressors associated with marginalised group status, were associated with higher pain burden and multisite pain, and qualitative studies describe dysphoria, layered isolation, non-affirming healthcare experiences and delayed help-seeking among transgender and non-binary people with endometriosis, including diagnostic delays approaching ten years. The authors are careful to stress that these factors must not be used to psychologise symptoms or dismiss peripheral pain generators; rather, trauma-informed, gender-affirming communication can support trust, consent for examination and engagement with rehabilitation, while clinicians maintain diagnostic breadth across gynaecological, urological, gastrointestinal, musculoskeletal, neuropathic and psychosocial domains.

To translate the evidence into practice, the team proposes a six-step, evidence-informed diagnostic framework: confirm the pain phenotype and chronicity with a body map and validated scales; establish anatomy and exposure context, including hormone formulation, surgical history and bleeding patterns, without inferring anatomy from gender identity; screen for overlapping contributors; perform a consent-based, tailored examination; select targeted tests guided by symptoms rather than a routine panel; and triage and coordinate multidisciplinary care. The framework is explicitly pragmatic rather than validated, but it embodies the review’s central clinical message: pelvic pain during masculinising hormone therapy or after gender-affirming surgery should prompt structured evaluation, not be assumed to be a routine effect of testosterone or surgery, and no single contributor, hormonal, surgical, anatomical or psychosocial, should be blamed alone.

The limitations the authors acknowledge are as instructive as the findings. Chronicity definitions varied or were absent in 19 of 24 reports, no validated transgender-specific chronic pelvic pain measure exists, key variables such as hormone dosing, serum levels and surgical technique were inconsistently captured, and convenience sampling may over-represent those with higher symptom burden. Race and ethnicity were rarely analysed, though descriptive data hinted at higher pain prevalence among several non-White identity groups. The research agenda that follows is clear: prospective longitudinal cohorts beginning at or before hormone initiation, validated and inclusive patient-reported outcome measures, adequately powered trials of hormonal, rehabilitative, surgical and multidisciplinary strategies, and community-engaged, intersectional data collection. For now, the review’s verdict stands: chronic pelvic pain in transgender and gender-diverse people is real, common in the settings studied, and demanding of the same rigorous, biopsychosocial, equity-focused attention that has transformed care for everyone else.

Subject of Research: Chronic pelvic and genital pain in transgender and gender-diverse people

Article Title: Chronic pelvic and related genital pain in transgender and gender-diverse people: a scoping review

Article References: Chona, R., Sabbah, S. G., Englesakis, M., Di Renna, T., Drodge, O., Rosenbloom, B. N., Leonardi, M., & Lorello, G. R. (2026). Chronic pelvic and related genital pain in transgender and gender-diverse people: a scoping review. eClinicalMedicine, 101, Article 104252. https://doi.org/10.1016/j.eclinm.2026.104252

Image Credits: AI Generated

DOI: 10.1016/j.eclinm.2026.104252

Keywords: chronic pelvic pain, transgender health, gender-affirming hormone therapy, testosterone, vaginoplasty, pelvic floor dysfunction, scoping review, minority stress, central sensitisation, dyspareunia, gender-affirming surgery, pain medicine

The research team, led by sociologist Mark Regnerus of the University of Texas at Austin together with Anne Morse of the Austin Institute, drew on the 2025 Relationships in America Survey, which interviewed 5,460 English-speaking Americans aged 20 to 70. The survey was conducted by Ipsos using its KnowledgePanel, a probability-based pool designed to produce estimates representative of the national adult population. Crucially, the 2025 instrument repeated, word for word, the statement posed to respondents in the 2018 Post-Midterm Election Study: that it should be acceptable for adolescents to transition with hormones or surgery if they identify with another gender. Respondents answered on a five-point scale ranging from strongly agree to strongly disagree, and both datasets were weighted to correct for differential nonresponse, making the two waves directly comparable.

The headline finding is stark. In 2018, 26 percent of American adults agreed that adolescent medical transition should be permissible; by 2025, that figure had fallen to 21 percent, a statistically significant five-point decline. Disagreement surged even more dramatically, rising from 43 percent to 55 percent, an increase of more than twelve percentage points. Meanwhile, the share of respondents who said they neither agreed nor disagree shrank, a pattern the authors attribute to the intense media and political coverage of the issue over the intervening years, which pushed previously ambivalent citizens to form an opinion one way or the other.

The internal composition of the shift is as revealing as its magnitude. The decline in agreement came almost entirely from respondents who had previously said they simply agreed, while the share who strongly agreed showed no statistically significant change. On the other side of the ledger, the proportion who strongly disagree grew substantially and significantly, among both men and women alike. In other words, the population did not become uniformly more hostile; rather, moderate support eroded while firm opposition deepened, a signature of one-sided polarization on an issue that has become a cultural flashpoint.

Perhaps the most striking result concerns age cohorts. Because the two surveys used the same sampling frame and question wording, the researchers could track how specific birth cohorts moved between 2018 and 2025 by comparing, for example, the attitudes of people aged 30 to 34 in 2018 with those of people aged 37 to 41 in 2025. Every cohort born in 1988 or earlier showed a significant increase in disagreement. The cohort aged 35 to 39 in 2018 displayed the largest swing, with disagreement jumping from 40 percent to over 60 percent, a twenty-one-point rise. In 2018, no age cohort had a majority that disagreed with adolescent medical transition; by 2025, every cohort except those aged 32 to 36 did.

These within-cohort shifts challenge a common intuition that the attitudes of older people are fixed while younger generations gradually liberalize the national mood. Demographic churn should, if anything, have pushed support upward: older, less supportive cohorts aged out of the sample while younger, more supportive ones aged in, and the 2025 sample indeed contained more college graduates, more political liberals, and more transgender-identified respondents than the 2018 sample. Yet aggregate support still fell. The authors conclude that a period effect, a cultural shift affecting people of all ages simultaneously, accounts for a substantial portion of the change, echoing sociological research showing that aggregate attitudes often morph through intracohort change rather than generational turnover. Unusually, however, the direction here is conservative rather than liberalizing.

One cohort stands apart. Adults who were aged 25 to 29 in 2018, born between 1989 and 1993, remained the most supportive and least opposed group at both time points, even as their elders shifted beneath them. The sex dynamics within younger cohorts are also notable. Among Americans aged 20 to 24 in 2018, only 21 percent of men agreed with adolescent medical transition, compared with 42 percent of women, a wide gap. Seven years later, the men in that cohort had become somewhat more likely to agree while the women had become less so, narrowing the difference to 25 percent versus 29 percent. Across the full sample, men and women both showed significant increases in disagreement, and the most common pattern was no statistically significant difference between the sexes at all.

To probe what drives these attitudes, the team replicated the nested regression models from the original 2018 study, building from baseline demographics through sexuality and relationship variables, then religion, and finally political identity. The predictors themselves proved remarkably stable: no significant variable changed direction between the two surveys. But some effects shifted in revealing ways. In 2018, being female was significantly associated with greater support in every model; in 2025, that effect vanished once political self-identification was added, suggesting that the apparent sex difference operates indirectly through the growing alignment of women with liberal politics. Religious affiliation effects from evangelical Protestant and LDS identities, significant in 2018 even after political controls, were drowned out by political variables in 2025. Meanwhile, the coefficient for having voted for Donald Trump grew larger than any other significant coefficient, and identifying as transgender, now measured in a sample more than twice the size of 2018, emerged as a significant positive predictor of support, even though roughly a quarter of transgender-identified respondents themselves disagreed with adolescent medical transition.

The findings arrive against a backdrop of rapid legal and political change. The study period encompassed the surge of state legislation restricting gender-affirming care for minors, the Tennessee law banning puberty blockers and hormone therapy that the Supreme Court upheld in June 2025, and a 2025 executive order withholding federal funding from medical transitions for minors. Pew Research Center data cited in the paper show that support for banning such care rose ten percentage points between 2022 and 2025, with declines among Democrats as well as Republicans. The new analysis adds nuance to that picture: the liberal-to-conservative gap widened, but the widening was driven by movement among conservatives and moderates, while liberals held steady.

The authors are careful about limitations. The single survey item compresses a multifaceted issue into one agree-disagree continuum, combines hormonal and surgical interventions without distinguishing them, and says nothing about social transitions or adult care. The comparisons are cross-sectional rather than a true panel, and cannot adjust for cohort attrition through mortality or migration, though a sensitivity check on the 401 respondents who participated in both surveys found no evidence of differential attrition distorting the results. Robustness checks using ordered logistic regression and multiple imputation confirmed the substantive findings. Whether the documented decline proves durable or temporary remains an open question, but the study makes clear that public opinion on adolescent medical transition is not static, that it has moved within cohorts of both sexes, and that political identity now overshadows nearly every other predictor of where Americans stand.

Subject of Research: Cohort changes in American public attitudes toward adolescent medical gender transition between 2018 and 2025

Article Title: Cohort Change in Attitudes About Adolescent Gender Transitions Between 2018 and 2025

Article References: Regnerus, M., & Morse, A. (2026). Cohort Change in Attitudes About Adolescent Gender Transitions Between 2018 and 2025. Archives of Sexual Behavior. https://doi.org/10.1007/s10508-026-03659-z

Image Credits: AI Generated

DOI: 10.1007/s10508-026-03659-z

Keywords: public opinion, gender dysphoria, adolescent gender transition, cohort analysis, transgender health, hormone therapy, puberty blockers, gender-affirming surgery, survey research, political polarization, Archives of Sexual Behavior, period effects

The research team, led by Ermina Lee and Jules L. Madzia of the University of Cincinnati College of Medicine together with clinicians at Boston Medical Center’s GenderCare Center, set out to characterize patient-reported outcomes after gender-affirming vulvovaginoplasty, a procedure that constructs a neovaginal complex through urethroplasty, clitoroplasty, and labiaplasty. The most common surgical technique is penile inversion, in which the neuromuscular bundles of the glans are retained for clitoral reconstruction. Some patients, however, do not desire a neovagina or face elevated surgical risk, and for them vulvoplasty offers genital remodeling without the creation of a vaginal opening. Surgical management of gender incongruence is highly patient-centered, requiring shared decision-making among patients, mental health providers, and surgeons to balance individual goals for aesthetics and function.

Between August 2019 and May 2022, the researchers contacted 157 patients who had undergone surgery between September 2016 and March 2022 at their institution, where a single team of co-surgeons from urology and plastic surgery performed all procedures. Forty-one patients, or 26.1 percent, completed the electronic consent and post-surgery survey. The participants had a mean age of 45.8 years, and the median time since surgery was 167.5 days, placing most respondents in the relatively early post-operative period when self-exploration of gender identity, sexuality, and sexual function with new anatomy is still evolving. Thirty-two participants had undergone vulvovaginoplasty with creation of a vaginal opening, while nine had vulvoplasty with a zero-depth neovagina. All patients received pelvic floor physical therapy at six weeks post-operatively, including dilation coaching and counseling on sexual exploration with their new anatomy.

The survey instrument was built from adapted versions of two established questionnaires: the Female Genital Self-Image Scale, a seven-item measure of genital satisfaction, and the Female Sexual Function Index, a nineteen-item inventory considered the gold standard for assessing sexual function in heterosexual cisgender women. Because neither tool has been validated for transgender patients assigned male at birth, the researchers selected items with input from patients and gender-affirming care providers, retaining six FGSIS items and nine FSFI items rated on Likert scales. Gender congruence was assessed with seven items relating the experience of gender to quality of life over the prior two weeks, including questions about whether participants had stopped themselves from participating in activities or behaving in certain ways because of gender. Statistical analyses were performed in R, using chi-squared tests for categorical variables and t-tests for continuous variables, with significance set at p less than 0.05.

The results on gender congruence were striking. Although nearly half of participants, 47 percent, reported thinking about gender very often or often, 61 percent said they were seldom or never troubled by issues relating to gender, and 85 percent said they never felt uncertain or confused about their sense of gender. Eighty percent reported being seldom or never stopped from participating in everyday life because of their gender, and 85.3 percent said they rarely or never avoided social situations due to their sense of identity. Perhaps most tellingly, 97.6 percent of participants reported confidence in their ability to lead a satisfied life with their gender identity, a figure that speaks to the central goal of the surgery: aligning the body with the experienced self.

Genital self-image told a similarly positive story. In response to the statement that they felt positively about their genitals, 82.9 percent of participants agreed or strongly agreed, and 76 percent were satisfied with the appearance of their genitals. Most also reported comfort with intimacy and clinical care: 82.9 percent said they would feel comfortable having a sexual partner look at their genitals, and 95 percent said they would feel comfortable having a doctor examine them. Overall, 85.4 percent agreed that their genitals worked the way they were supposed to. These ratings were comparable to those previously reported for cisgender women on adapted versions of the same instruments, suggesting that the surgery can produce self-image outcomes on par with those in the populations for which the measures were originally designed.

Sexual function, by contrast, presented a more complicated picture. Among the 22 participants who had engaged in sexual activity in the past four weeks, only 40.9 percent were satisfied with their ability to reach orgasm, and of those who attempted orgasm, 87 percent reported that it ranged from slightly difficult to impossible. Overall satisfaction with sexual life was low, with 47.5 percent of all participants expressing dissatisfaction and only 32.5 percent expressing satisfaction. Most participants reported feeling sexual desire or interest infrequently, with 47.5 percent experiencing sexual interest only a few times in the past four weeks and 12.5 percent never. Yet here was the study’s most consequential finding: none of these sexual function measures predicted overall surgical satisfaction. Chi-squared tests found no significant association between agreement with the statement that they would have the operation again and procedure type, age, days since surgery, satisfaction with sexual life, satisfaction with genitals, or recent sexual activity.

The dissociation between sexual outcomes and overall well-being was consistent across subgroups. Among sexually active participants, 83.3 percent felt positively about their genitals and 95.8 percent were happier after surgery than before. Among those who had not been recently sexually active, 82.4 percent felt positively about their genitals and 94.1 percent were happier after surgery. In total, 95.1 percent of participants agreed or strongly agreed that they were overall happier after the operation, and 92.5 percent said they would choose to undergo it again. The authors point to prior research supporting this pattern: a study by Buncamper and colleagues found that patient-perceived neovaginal functionality and appearance remained high, averaging eight out of ten, more than four years after surgery, even though over half of that cohort met criteria for sexual dysfunction on the FSFI.

Why does sexual function fail to track with satisfaction? The researchers argue that sexual function is shaped by a fluid web of biological and psychosocial factors, including age, mood, desire, the subjective importance of sex, changes in genital sensation, relationships, sexual preference, and pre-existing pelvic floor dysfunction, which is prevalent among pre-operative patients but can be mitigated with pelvic floor physical therapy. The timing of the survey may also have mattered, with a median of roughly six months since surgery for the full sample and a gap between sexually active and inactive respondents. More fundamentally, the team criticizes the cis-heteronormative assumptions embedded in the FSFI, which conflates gender identity with sexuality and cannot capture how sexuality changes after vulvovaginoplasty. FSFI scores are known to be higher in heterosexual individuals than in LGBTQIA+ individuals, and heterosexual transgender women score higher than homosexual transgender women even when relationship status is equivalent, suggesting the instrument inadequately captures the intersectional experience of gender-affirming surgery.

The study’s limitations are real: a small sample from a single institution, survey tools validated only for cisgender women, no baseline pre-surgical data, and a median follow-up of 5.5 months when sexual outcomes are still evolving. Yet the authors frame the work as pilot data for a new generation of community-specific patient-reported outcome measures, such as the GENDER-Q, now undergoing field testing for transgender and gender-diverse individuals. Their conclusion is provocative and likely to reshape perioperative counseling: measures that weigh sexual function as the primary indicator of surgical success may not fully capture the broader psychosocial benefits of improved gender congruence. For many patients, the ability to move through daily life without gender-related distress, to feel at home in one’s own body, and to lead a satisfied life appears to be the outcome that matters most, and it is one that, according to this survey, gender-affirming surgery delivers at remarkably high rates.

Subject of Research: Patient-reported outcomes of gender-affirming vulvovaginoplasty in transgender adults

Article Title: Post gender-affirming vulvovaginoplasty survey of transgender adults

Article References: Lee, E., Madzia, J. L., Klein, P., Martin, M., Gomes, L., Navarra, M., Oates, R., Slama, J., & Streed, C. G., Jr. (2026). Post gender-affirming vulvovaginoplasty survey of transgender adults. BMC Plastic and Reconstructive Surgery, 2(1), Article 5. https://doi.org/10.1186/s44452-026-00018-8

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00018-8

Keywords: gender-affirming surgery, vulvovaginoplasty, vulvoplasty, transgender health, patient-reported outcomes, genital self-image, sexual function, gender congruence, penile inversion, pelvic floor physical therapy, GENDER-Q, quality of life