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Larshans et al. Plast Aesthet Res. 2025;12:7 https://dx.doi.org/10.20517/2347-9264.2024.154 Page 11 of 13

Two patients who experienced rectovaginal fistula completed the current questionnaire. Both underwent
successful reoperation and received bowel vaginoplasty within 18 months of their initial surgery. Despite
their complications, both patients reported positive life satisfaction. Specifically, both responded that “life as
a whole is quite satisfying” (Li-Sat-11, Question 1) and that they “rarely have not enjoyed life” (GCLS,
Question 10). Furthermore, one patient reported never feeling life was meaningless, never having thoughts
of cutting or harming their chest, genitals, or surrounding areas, and never having thoughts of self-harm or
suicide. The second patient reported “rarely” feeling life was meaningless, “rarely” having thoughts of self-
harm, and “sometimes” having thoughts of hurting themselves or taking their own life (GCLS, Questions 9,
8, and 7, respectively).

However, with only two patients experiencing such a major complication, the sample size is too small to
draw statistically significant conclusions regarding the relationship between surgical complications and the
risk of self-harm or suicidal ideation.

Strengths and weaknesses
A non-response analysis would have been beneficial because many patients did not respond to the survey.
Understanding the characteristics of non-respondents could help to determine whether their absence
introduced biases.

The lack of baseline data on patients’ QoL and mental health before surgery is a major limitation hindering
the assessment of the impact of GAS on self-harm and suicidal thoughts.

Additionally, not accounting for patient-specific diagnoses (such as mental illnesses) limits our
understanding of the distinct risks associated with suicidal behavior. Identifying the individual
psychological profiles and diagnoses of the participants could yield deeper insights into the factors that
contributed to thoughts of self-harm or suicidal ideation postoperatively.

Finally, for the next studies, we also recommend using the Female Sexual Function Index (FSFI) and Female
Genital Self-Image Score (FGSIS).

In conclusion, our findings highlighted the critical issues of thoughts of self-harm or suicidal ideation that
affected almost one-third of transgender women who have undergone GAS to some degree. Although the
levels reported in our study were lower than those reported in other studies, the prevalence remains
concerning and requires further attention. However, the study also showed that most participants reported
enjoying their lives, feeling overall satisfaction, and finding meaning and purpose in life post-GAS. These
findings underscore the need for both access to GAS and continued psychological support for this group.
Improving QoL is the primary goal in the care of transgender individuals undergoing these procedures.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Selvaggi G, Larshans C, Georgas K, Rahimzadeh K, Olsson EM
Performed data acquisition, as well as providing administrative, technical, and material support: Selvaggi G,
Larshans C, Georgas K, Rahimzadeh K, Olsson EM