How Can Sexual Medicine Become More Inclusive of Transgender and Non-Binary People?
Many experts acknowledge that sexual function is an important component of a person’s overall health and therefore something that should be assessed and treated by health care providers. Nevertheless, most medical definitions of sexual function and the validated tools used to measure sexual function remain very cisgendered and heteronormative (i.e., dealing only with cisgender heterosexual sex). This situation highlights a major gap in the evaluation and treatment of sexual dysfunction in transgender, non-binary, and other gender diverse individuals.
Validated tools for assessing sexual function in cisgender men and women such as the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF) often fall short or become irrelevant when assessing the sexual function of gender diverse individuals. For example, the FSFI describes intercourse as “penile penetration (entry) of the vagina” in a section on pain during intercourse. This description of intercourse does not make sense for transgender women who have not had gender-affirming surgery, and it would not be relevant for non-binary individuals who do not have penile-vaginal sex.
Similarly, the IIEF considers erection hardness a measure of a man’s sexual functioning, but a transgender man who has not transitioned would not have a phallus, and a transgender man who has undergone phalloplasty may not experience erections in the same way as a cisgender man. Again, non-binary people may or may not choose to use a penis in their sexual encounters. As such, this measurement tool is often rendered irrelevant for transgender and non-binary individuals.
Another common concern about the current validated tools for measuring sexual function is that they medicalize a lack of sexual desire when this is not necessarily an issue for some people. Sexual desire is very personal and exists on a spectrum from asexuality to very high desire, and asexual individuals do not feel distressed by an absence of sexual desire.
While some researchers and medical professionals have recommended modifying cisgender tools to provide a better measure of sexual function for transgender and non-binary individuals, others argue that this is not the best approach. In simply modifying the existing instruments, we continue to use cisgender and heterosexuality as the default type of gender identity and sexual orientation. What’s more, these tools may continue to set an expectation of sexual function that is not relevant or realistic for transgender and non-binary individuals, which can cause unnecessary dissatisfaction or distress.
Instead, these experts propose creating new tools that define and evaluate sexual functioning in transgender and non-binary individuals, perhaps taking into account a transgender person’s transition status. In this way, these tools will fit the specific needs of this population and ensure that their sexuality is treated with the same level of respect and dignity as cisgender individuals.
- Whitney, N., Samuel, A., Douglass, L., Strand, N.K., & Jahromi, A.H. (2022). Avoiding Assumptions: Sexual Function in Transgender and Non-Binary Individuals. The Journal of Sexual Medicine, 19(6), 1032-1034. DOI: https://doi.org/10.1016/j.jsxm.2022.03.214