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

No individual participant data were collected for this scoping review. All data underlying the findings were extracted from published reports. The protocol and study-level data extraction spreadsheet are available on the Open Science Framework (osf.io/mk6cp; osf.io/mk6cp/files/7mkrp). No custom analytic code was used.

We conducted a scoping review following the Joanna Briggs Institute (JBI) methodology for scoping reviews and reported our methods in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. 28 , 29 The protocol was pre-registered on the Open Science Framework (OSF; osf.io/mk6cp) before the review began. A comprehensive search strategy was developed with input from an information specialist (ME). We searched ten bibliographic databases from inception through 30 July 2025: MEDLINE (Ovid), MEDLINE ePub Ahead of Print (Ovid), Embase Classic+Embase (Ovid), Cochrane Central Register of Controlled Trials (Ovid), Cochrane Database of Systematic Reviews (Ovid), APA PsycINFO (Ovid), CINAHL (EBSCO), ERIC (EBSCO), Scopus (Elsevier), and Web of Science (Clarivate Analytics). The search combined controlled vocabulary (Medical Subject Headings (MeSH) and Emtree terms for pelvic pain and transgender people, e.g. “pelvic pain”, “dyspareunia”, “transgender persons”, “gender dysphoria”) with free-text keywords (e.g. “chronic pelvic pain”, “pelvic floor dysfunction”, “transmasculine”, “transfeminine”, “non-binary”, “gender-affirming hormone therapy”, “vaginoplasty”, “dilation-related pain”). The strategy was refined iteratively with the information specialist through pilot test searches. In addition to database searching, backward and forward citation chasing was performed. No language restrictions were applied. Grey literature was not systematically searched. Detailed search strategies are provided in Supplementary Appendix . References were managed in Covidence (Veritas Health Innovation, Melbourne, Australia). We included primary-data studies involving TGD adults reporting duration-defined CPP or related pelvic and genital pain outcomes. Duration-defined CPP was specified a priori as persistent or recurrent pain in the pelvic region for at least three months. 30 Because the objective was to map the wider evidence base, we also included related pelvic and genital pain outcomes within a broad chronic pain framework when chronicity was reported or implied without application of a formal CPP definition. These outcomes included dyspareunia, pelvic floor dysfunction, endometriosis-related pain, genital or pelvic pain with dilation, and other abdominopelvic pain syndromes, including symptoms persisting beyond the acute postoperative period (more than three months after surgery). We excluded studies reporting on acute postoperative pain (less than three months), studies restricted to cisgender or paediatric people (aged <18 years), conference abstracts without full peer-reviewed reports, and secondary research without original participant data. Two reviewers (RC and SGS) independently screened all titles and abstracts and assessed full-text articles for inclusion. Disagreements were resolved by discussion and consensus or third-reviewer adjudication (GRL), and reasons for exclusion were recorded. Inter-reviewer agreement at title and abstract screening was assessed using Cohen's κ. Two reviewers (RC and SGS) independently extracted data using a predefined Microsoft Excel template and inductive analytical framework, capturing study characteristics (design, setting, sample composition), pain definitions and measurement tools, and findings relevant to four domains: prevalence, potential aetiologies, assessment, and management (OSF; osf.io/mk6cp/files/7mkrp). We extracted gender identity and sex assigned at birth as reported by source studies, together with anatomy, GAHT, and surgical history when available. We did not recode these variables because terminology and ascertainment methods varied. We use sex assigned at birth only when reporting source classifications or anatomy-related findings, and gender when referring to identities and social experiences. Race and ethnicity were extracted as sociocultural variables when reported; source-defined categories and ascertainment methods were retained. No individual-level or unpublished data were sought; all data were extracted solely from published reports. Evidence was synthesised narratively without meta-analysis, consistent with scoping methodology. 28 We conducted an inductive thematic synthesis within each domain: independently generating initial codes from extracted text, iteratively comparing and grouping codes across studies, and refining categories through reviewer discussion until consensus was reached. Prevalence estimates were summarised as reported, with ranges presented where appropriate; no statistical pooling was performed given heterogeneity in design, sampling, and pain definitions. Although formal risk-of-bias assessment is not mandatory for scoping reviews, we conducted an exploratory appraisal using JBI design-specific checklists and, where applicable, the Cochrane Risk of Bias 2 (RoB 2) tool and Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I). Appraisals were used to contextualise, not exclude or weight, the evidence. Full study-level judgements are provided in Supplementary Table S3 . Descriptive summaries included report counts by design, region, and population; unique participant totals with shared cohorts counted once; source-reported gender identity and sex assigned at birth; study-level mean ages summarised as a weighted mean, between-study standard deviation, and range; and reported follow-up durations. The aggregate evidence overview and evidence-informed diagnostic framework were added during peer review as descriptive presentations of the included literature; no additional inferential analyses were performed. Ethics approval and written informed consent were not required because this scoping review used only data from publicly available published reports and involved no participant recruitment or access to identifiable individual participant data. No funding was received for this work.

Our search yielded 6534 records; after removal of 2711 duplicates, 3823 unique titles and abstracts were screened ( Fig. 1 ). Forty-two full texts were assessed; 24 reports met the inclusion criteria. Eighteen full texts were excluded for the reasons shown in Fig. 1 . Inter-reviewer agreement at title and abstract screening was high (Cohen's κ = 0·99). Fig. 1 Study selection flow chart. Reasons for exclusion at full-text screening included acute postoperative pain, lack of chronic pelvic pain (CPP) focus, absence of primary data, non-separable paediatric data, abstract-only publication, and non-transgender and gender-diverse (TGD) people. Numbers denote records at each stage according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Study selection flow chart. Reasons for exclusion at full-text screening included acute postoperative pain, lack of chronic pelvic pain (CPP) focus, absence of primary data, non-separable paediatric data, abstract-only publication, and non-transgender and gender-diverse (TGD) people. Numbers denote records at each stage according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). The 24 included reports represented 23 unique cohorts and 5527 unique TGD participants; two qualitative reports drew on the same cohort of 11 participants and were counted once. Table 1 provides an aggregate overview of the evidence base, Table 2 provides study-level characteristics, and Supplementary Table S1 provides detailed extraction data. Table 1 At-a-glance characteristics of the included evidence base (n = 24 reports). Dimension Distribution across included reports Interpretation Design Cross-sectional or psychometric quantitative/mixed studies, 10; retrospective cohorts, programme audits, or retrospective case series, 4; prospective cohorts or case series, 2; randomised trial, 1; qualitative reports, 4; case reports, 3. The evidence base was dominated by observational and descriptive designs; only one interventional trial was identified. Region North America, 13; Europe, 5; Brazil, 2; Australia, 2; international samples, 2. No included report was based in Africa or Asia, and most evidence arose from high-income settings. Population Transmasculine or other TGD people assigned female at birth, 14 reports; transfeminine people, 7; mixed TGD groups, 3. Non-binary participants and identity-specific results were inconsistently reported. GAHT and surgical context GAHT details were reported in 16 reports; 10 focused on surgical or postoperative populations. Testosterone was the predominant exposure in transmasculine studies; oestradiol and anti-androgens were less consistently detailed in transfeminine studies. Formulation, dose, serum levels, duration, anatomy, surgical technique, and time since surgery were often incomplete. GAHT and surgical counts overlap. Chronicity definition Formal duration-defined CPP criterion (persistent or recurrent pelvic, groin, or genital pain for at least 3 months), 1 report; at least 3 months documented for a related symptom or chronic-pain context, 4; no formal CPP duration criterion or unclear chronicity, 19. Most reported prevalence values represent broader pelvic or genital symptom burden and should not be interpreted as duration-defined CPP prevalence. Outcome measurement Study-specific questions, chart documentation, or generic pain scales predominated. One report used a modified Michigan Body Map with a duration-defined CPP criterion; one developed an inclusive dysmenorrhoea impact measure. No validated TGD-specific CPP patient-reported outcome measure was identified. Outcome heterogeneity precluded pooling and limits comparison across anatomy, GAHT, and surgical subgroups. Risk of bias or quality Non-randomised quantitative reports: 12 moderate, 4 serious, and 3 low concerns; qualitative reports: 2 low and 2 moderate concerns; randomised trial: some concerns. Recurring concerns were non-probability sampling, non-validated self-report, limited confounding control, small samples, and short or absent follow-up. AFAB = assigned female at birth; CPP = chronic pelvic pain; GAHT = gender-affirming hormone therapy; TGD = transgender and gender-diverse.Counts refer to source reports rather than unique cohorts; the two Eder and Roomaney reports derive from the same cohort. Table 2 Study-level characteristics and key findings on duration-defined chronic pelvic pain and related pelvic and genital pain (n = 24 reports). Study Design; country TGD n Population; transition context Key CPP/pain finding Abern et al., 2022 23 Cross-sectional survey; USA 782 Transmasculine; 59·8% on testosterone Dyspareunia 61·5%; vulvar pain 9·6%; no association with testosterone use Alappattu et al., 2024 21 Cross-sectional survey; USA 207 Post-vaginoplasty or phalloplasty 70% reported bodily pain; most pain resolved within 0–3 months; a small subset reported pain persisting 9–12 months Arruda et al., 2025 24 PROM development; Brazil 64 Transgender men; GAHT/surgery NR Validated Dysmenorrhoea-Related Impact on Functioning Scale inclusive of transgender men Buncamper et al., 2016 31 Retrospective cohort; Netherlands 475 Transfeminine; post-vaginoplasty; median follow-up 7·8 years Stenosis, fistula, and urinary complications documented; pain not systematically measured Carvalho et al., 2024 32 Cross-sectional survey; Portugal 6 TGD with endometriosis; 4 had prior surgery Approximately 10-year diagnostic delay; high sexual distress and psychosocial burden Chung et al., 2022 33 Qualitative interviews; USA 25 Transfeminine; 12 had genital surgery Genital pain, scar pain, and dyspareunia reported; provider knowledge gaps identified da Silva et al., 2024 18 Cross-sectional survey; Brazil 68 Transgender men on testosterone Any PFD 94·1%; dyspareunia 25·0%; urinary symptoms 86·7% Eder & Roomaney, 2025 a , 34 Qualitative (hermeneutic); international 11 TGD with endometriosis Symptom–dysphoria interplay; diagnostic delay; non-affirming care experiences Eder & Roomaney, 2026 a , 35 Qualitative (hermeneutic); international 11 a TGD with endometriosis “Layered” isolation from gender rejection and endometriosis; need for inclusive support Ferrando et al., 2021 36 Retrospective chart review; USA 67 Transgender men; 89·5% on testosterone; undergoing hysterectomy Preoperative pelvic pain 50·7%; endometriosis 26·9%; only approximately one-third with pain had endometriosis Ferrando et al., 2023 37 Randomised trial; USA 37 Transfeminine; postoperative PFPT versus no PFPT; 12-week follow-up No differences at 12 weeks in ease or pain with dilation, pelvic-floor symptoms, vaginal length, or subjective improvement Grimstad et al., 2020 14 , 38 Cross-sectional survey; USA 127 Transmasculine; new-onset pain after testosterone Suprapubic cramping; all reporting resolution cited hysterectomy Grimstad et al., 2023 25 Retrospective EMR cohort; USA 280 Transmasculine on testosterone ≥1 year Pelvic pain 36·0%; 71% new-onset after testosterone; associated with breakthrough bleeding Jiang et al., 2019 20 Programme audit/case series; USA 77 Transfeminine; pre- and post-vaginoplasty PFPT High preoperative PFD; pre- plus postoperative PFPT associated with lower postoperative dysfunction Kjölhede et al., 2024 39 Prospective cohort; Sweden 23 Trans men/AFAB; post-vaginectomy; 1-year follow-up Overall PFDI-20 stable; groin-flap phalloplasty subgroup worsened Krege et al., 2001 40 Case series; Germany 66 Transfeminine; post-vaginoplasty Vaginal pain during intercourse in 2 patients; >90% cosmetic satisfaction Krick, 2015 41 Case report; USA 1 Transgender woman; post-gender-affirming genital surgery; levator ani spasm Multidisciplinary physiotherapy resolved dilation pain over 13 sessions Kuhn et al., 2011 42 Cross-sectional; Switzerland 55 Transfeminine and transmasculine; median 16 years post-surgery Dyspareunia, lower abdominal pain, urinary symptoms; POP ≥ stage 2 in 7·5% Liao et al., 2024 43 Case report; USA 1 Transgender woman; post-vaginoplasty Pubic aneurysmal bone cyst causing chronic groin pain; resolved after resection O'Sullivan et al., 2020 17 Case report; Australia 1 Transgender man on testosterone for 2 years Vestibulovaginal sclerosis with focal vestibular pain; improved after excision Shirsat et al., 2024 44 Cross-sectional survey; USA/Canada 75 TGD within LGBTQ + chronic pain cohort Pelvic pain 35·3%; ACEs and sexual trauma associated with higher pain burden Tordoff et al., 2025 16 Cross-sectional with longitudinal subset; USA 2579 Trans men and gender-diverse AFAB (PRIDE Study) Duration-defined CPP prevalence 17·7% (≥3-month criterion); current testosterone associated with lower CPP prevalence Youngstrom et al., 2025 19 Qualitative interviews; USA 14 Transmasculine/GNC; 86% on testosterone Pelvic pain, post-orgasm cramping, OAB; reliance on community knowledge Zwickl et al., 2023 15 Cross-sectional survey; Australia 486 Transmasculine on testosterone Pelvic pain 72·2% after testosterone; associated with persistent menstruation and PTSD Abbreviations: ACE = adverse childhood experiences; AFAB = assigned female at birth; CPP = chronic pelvic pain; EMR = electronic medical record; GAHT = gender-affirming hormone therapy; GNC = gender nonconforming; LGBTQ+ = lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities; NR = not reported; OAB = overactive bladder; PFD = pelvic floor dysfunction; PFDI-20 = Pelvic Floor Distress Inventory-20; PFPT = pelvic floor physiotherapy; POP = pelvic organ prolapse; PROM = patient-reported outcome measure; PTSD = post-traumatic stress disorder; TGD = transgender and gender-diverse. TGD sample refers to participants contributing data relevant to duration-defined CPP or related pelvic and genital pain outcomes. Mixed-sample reports were retained where TGD subgroup data were extractable. Formal CPP definitions and chronicity thresholds varied across reports; this table distinguishes duration-defined CPP from broader pelvic and genital pain outcomes, including dyspareunia, vulvar and genital pain, dilation-related pain, pelvic-floor pain and dysfunction, endometriosis-related pelvic pain, and persistent postoperative pelvic and genital pain beyond the acute recovery period. a Eder & Roomaney 2025 and 2026 derive from the same cohort (n = 11); participants were counted once in the total. At-a-glance characteristics of the included evidence base (n = 24 reports). AFAB = assigned female at birth; CPP = chronic pelvic pain; GAHT = gender-affirming hormone therapy; TGD = transgender and gender-diverse.Counts refer to source reports rather than unique cohorts; the two Eder and Roomaney reports derive from the same cohort. Study-level characteristics and key findings on duration-defined chronic pelvic pain and related pelvic and genital pain (n = 24 reports). Abbreviations: ACE = adverse childhood experiences; AFAB = assigned female at birth; CPP = chronic pelvic pain; EMR = electronic medical record; GAHT = gender-affirming hormone therapy; GNC = gender nonconforming; LGBTQ+ = lesbian, gay, bisexual, transgender, queer, and other sexual and gender minorities; NR = not reported; OAB = overactive bladder; PFD = pelvic floor dysfunction; PFDI-20 = Pelvic Floor Distress Inventory-20; PFPT = pelvic floor physiotherapy; POP = pelvic organ prolapse; PROM = patient-reported outcome measure; PTSD = post-traumatic stress disorder; TGD = transgender and gender-diverse. TGD sample refers to participants contributing data relevant to duration-defined CPP or related pelvic and genital pain outcomes. Mixed-sample reports were retained where TGD subgroup data were extractable. Formal CPP definitions and chronicity thresholds varied across reports; this table distinguishes duration-defined CPP from broader pelvic and genital pain outcomes, including dyspareunia, vulvar and genital pain, dilation-related pain, pelvic-floor pain and dysfunction, endometriosis-related pelvic pain, and persistent postoperative pelvic and genital pain beyond the acute recovery period. Eder & Roomaney 2025 and 2026 derive from the same cohort (n = 11); participants were counted once in the total. Twenty reports were quantitative (19 non-randomised and one randomised) and four were qualitative. Designs were predominantly cross-sectional surveys and clinic-based cohorts; the evidence base also included three case reports, two programme-audit or case-series reports, and one patient-reported outcome measure development study. Thirteen reports were from North America, five from Europe, two from Brazil, two from Australia, and two used international samples. Fourteen reports focused on transmasculine or other TGD people assigned female at birth, seven on transfeminine people, and three included mixed TGD groups. Reporting anatomy, surgical history, GAHT status, and their methods of ascertainment varied substantially. Based on source-reported classifications, 747 participants were reported as transmasculine, 761 as transfeminine, 202 as non-binary or gender-nonconforming, and 3817 only as TGD without further disaggregation. Source studies reported 4642 (84·0%) as assigned female at birth and 776 (14·0%) as assigned male at birth. For 109 (2·0%), sex assigned at birth was mixed or not disaggregated at the study level. Across 19 reports providing age, the weighted mean of study-level mean ages was 28·8 years (between-study standard deviation 3·71; study-level mean range 26–59 years). Reported follow-up durations varied across studies, from 12 weeks in the shortest trial to a median of 7·8 years in the longest cohort. In the exploratory appraisal, 12 non-randomised quantitative reports had moderate, four serious, and three low risk or quality concerns; among qualitative reports, two had low and two moderate concerns, and the randomised trial had some concerns ( Supplementary Table S3 ). Common methodological limitations included non-probability sampling, non-validated pain measures, inconsistent capture of transition-related variables, and inadequate confounding control. Race and ethnicity were inconsistently reported and rarely analysed. In the only study to provide duration-defined CPP prevalence by self-identified race and ethnicity, 22% of participants selected at least one non-White identity and 15% selected multiple identities. CPP prevalence was descriptively higher among participants identifying as American Indian or Alaska Native (26·8%), Middle Eastern or North African (30·4%), another race or ethnicity (32·4%), or multiple racial or ethnic identities (21·0%) than among White participants (18·0%); however, overlapping categories and small cell sizes precluded inferential comparisons. 16 A retrospective testosterone cohort found no statistically significant association between race or ethnicity and pelvic pain, 25 and ethnicity was not associated with pain severity in a predominantly White lesbian, gay, bisexual, transgender, queer, and other sexual and gender minority (LGBTQ+) chronic-pain sample. 44 No included study was designed or powered to examine how racism, socioeconomic position, gender-related stigma, and access to affirming care jointly shaped pain or diagnostic pathways. Assessment and diagnostic methods were heterogeneous ( Supplementary Table S2 ). Most reports used study-specific items or generic pain scales without TGD-specific validation, and chronicity thresholds were inconsistently applied. Body-map tools were used to localise pelvic and genital pain, but only one study combined pelvic, groin, or genital location with an explicit three-month CPP threshold and reported a CPP prevalence estimate. 16 Clinical reports described targeted pelvic or pelvic-floor examinations 17 , 41 ; assessment of bleeding and incomplete hormonal suppression 14 , 15 , 25 ; and evaluation for postoperative stenosis, scarring, granulation tissue, neuroma, nerve irritation, urethral complications, or other structural abnormalities. 31 , 41 , 43 Imaging and, in one case, image-guided biopsy were used when focal structural pathology was suspected. 43 No included study validated a TGD-specific diagnostic algorithm. Prevalence reporting varied widely because most reports assessed related pelvic and genital pain outcomes rather than duration-defined CPP. The only study explicitly estimating duration-defined CPP reported a prevalence of 17·7% in transgender men and gender-diverse adults assigned female at birth. 16 Across studies reporting related pelvic and genital pain outcomes, symptom frequencies ranged from 9·6% to 72·2%; these heterogeneous estimates should not be interpreted as a range of CPP prevalence. 15 , 23 , 25 , 36 , 44 A chronic pain cohort reported pelvic pain in 35·3% of TGD participants, 44 while other studies reported 36·0% pelvic pain in transmasculine participants on testosterone, 25 50·7% preoperative pelvic pain in transgender men undergoing hysterectomy, 36 72·2% pelvic pain after commencing testosterone, 15 and dyspareunia in 61·5% and vulvar pain in 9·6% of transmasculine participants. 23 These estimates indicate symptom burden in selected samples rather than population-level prevalence. Several studies described new-onset cramping or suprapubic pain after initiating testosterone, sometimes with dysorgasmia or spotting despite amenorrhoea. 15 , 25 In the duration-defined CPP study, current testosterone use was associated with lower CPP prevalence than no testosterone use. 16 In two postoperative cohorts following gender-affirming urogenital surgery (n = 77 and n = 207), pelvic and genital pain, dyspareunia, and dilation-related pain were reported early after surgery, with available follow-up suggesting improvement during the first postoperative year. 20 , 21 Longer-term surgical studies also documented residual pelvic-floor, sexual, and pain-related symptoms. 40 , 42 Pelvic and genital pain outcomes also co-occurred with urinary symptoms, bowel dysfunction, and sexual pain across included reports. Four recurring, interacting, and non-mutually exclusive domains of potential aetiology were identified. Hormonal and tissue-mediated mechanisms: three studies described pelvic pain temporally associated with GAHT initiation, including new-onset cramping and suprapubic pain in transmasculine participants receiving testosterone; incomplete ovarian suppression and hypoestrogenic genitourinary effects were proposed as possible contributors. 14 , 15 , 23 One case report described vestibulovaginal sclerosis in a patient on long-term testosterone presenting with focal introital pain. 17 Pelvic floor and musculoskeletal contributors: four reports identified hypertonicity, myofascial trigger points, and coordination deficits as common correlates of dilation pain, orgasm-associated cramping, urinary urgency, and obstructed defecation, observed pre- and postoperatively and in transmasculine people on GAHT. 18 , 20 , 21 , 41 Surgical and anatomical sequelae: postoperative reports described introital and neovaginal stenosis, scarring and granulation tissue, neuroma and nerve irritation, urethral complications, and rare structural causes 31 , 41 , 43 ; pelvic floor distress, dyspareunia, and lower abdominal pain have also been documented in longer-term surgical cohorts and series. 39 , 40 , 42 Psychosocial and trauma-related factors: adverse childhood experiences, sexual trauma, and minority stress were associated with higher pain burden and multisite pain in TGD participants with pelvic pain. 15 , 44 Individual reports frequently supported more than one domain, which should not be interpreted as competing single-cause explanations. Management evidence was sparse and derived almost entirely from observational reports, programme audits, and case reports. Pelvic floor and rehabilitative approaches included manual release, down-training, biofeedback, graded exposure, and dilator retraining for dilation pain and myofascial contributors. 20 , 41 One programme report described a structured perioperative pelvic floor physiotherapy (PFPT) pathway for patients undergoing vaginoplasty. 20 The only randomised trial compared routine postoperative PFPT with no PFPT and found no differences at 12 weeks in ease or pain with dilation, pelvic-floor symptoms, vaginal length, or subjective improvement. 37 Hormonal and surgical approaches included adjustment to GAHT or adjunctive suppression (progestins, gonadotropin-releasing hormone analogues) and, in selected cases, hysterectomy, oophorectomy, lesion-directed procedures, or revision for stenosis, neuromas, strictures, or focal structural pathology. 14 , 15 , 17 , 31 , 43 Trauma-informed education, gender-affirming care, patient education on dilation and pelvic self-management, and attention to mental health comorbidities and minority-stress contexts were emphasised across several reports. 15 , 19 , 33 , 34 Psychosocial interventions were rarely formally evaluated, and no included study explicitly evaluated a specific psychotherapy modality such as cognitive behavioural therapy or acceptance and commitment therapy.

This scoping review maps duration-defined CPP and related pelvic and genital pain outcomes in TGD people across 24 reports representing 23 unique cohorts and 5527 participants, identifying four recurring and potentially interacting contributing domains: hormonal and tissue-mediated, surgical and anatomical, pelvic floor and musculoskeletal, and psychosocial and trauma-related. Confidence in prevalence estimates and causal inference is constrained by the predominance of cross-sectional designs, non-probability sampling, heterogeneous outcome definitions, and limited use of validated pain measures. Critically, most included studies reported broader pelvic and genital pain outcomes rather than duration-defined CPP, and only one study provided a directly interpretable CPP prevalence estimate. 16 Accordingly, the heterogeneous symptom estimates should not be interpreted as estimates of the same condition. Across studies, CPP and related symptoms most frequently co-occurred with urinary, bowel, and sexual dysfunction and overlapped with other chronic pain conditions, 14 , 15 , 18 , 20 , 21 , 22 , 41 , 44 consistent with sensitisation and nociplastic pain frameworks. 3 , 22 , 45 , 46 , 47 These patterns should be interpreted as mechanistic analogues from the wider pain literature rather than direct evidence in TGD people with CPP; nonetheless, the observed overlap is compatible with the interpretation that CPP in TGD people is unlikely to be reducible to a single explanatory category. Rather, the findings align with biopsychosocial models of persistent pain and underscore the need for integrated multidisciplinary assessment and management capable of addressing interacting biological, neuromuscular, and psychosocial drivers of symptom persistence. To integrate these findings, a conceptual framework was developed illustrating how the four identified domains may interact and converge on duration-defined CPP and related pelvic and genital pain in TGD adults ( Fig. 2 ). Table 3 therefore presents a pragmatic, evidence-informed framework that distinguishes duration-defined CPP from related symptoms and tailors history, examination, testing, and referral to anatomy, GAHT exposure, surgical history, and pain phenotype; it is not a validated diagnostic algorithm. Fig. 2 Conceptual framework of interacting contributors to chronic pelvic pain (CPP) and related pelvic and genital pain in transgender and gender-diverse (TGD) adults. Hormonal and tissue-mediated, pelvic floor and musculoskeletal, surgical and anatomical, and psychosocial and trauma-related factors were identified across included studies as recurring and potentially interacting contributors to CPP and related pelvic and genital pain in TGD adults. These domains may converge on symptom persistence, with or without central sensitisation, manifesting clinically as pelvic or genital pain, sexual pain, persistent postoperative pain, and urinary or bowel symptoms. Solid arrows indicate convergence on CPP and related pelvic and genital pain outcomes; dashed arrows indicate hypothesised interactions between contributing domains. The framework summarises patterns identified in the literature and should not be interpreted as evidence of causal pathways, given the predominance of cross-sectional designs, heterogeneous pain definitions, and limited longitudinal data. Table 3 Evidence-informed diagnostic framework for duration-defined chronic pelvic pain and related pelvic and genital pain in transgender and gender-diverse adults. Step Core assessment examples TGD-specific application 1. Confirm phenotype and chronicity Use a body map and 0–10 pain intensity/interference scale. Document site, onset, duration, pattern (persistent, recurrent, or cyclic), relation to bleeding, orgasm, penetration or dilation, posture or activity, urination and bowel function, and any operation. Apply the CPP label only when pelvic pain is persistent or recurrent for at least 3 months; otherwise retain the source symptom label. Record function and quality-of-life effects. 2. Establish anatomy and exposure context Inventory clinically relevant organs, hysterectomy or oophorectomy, orchiectomy or genital surgery, surgical technique and time since surgery, current or recent GAHT formulation and duration, bleeding or amenorrhoea, and dilation practices. Do not infer anatomy from gender identity or sex assigned at birth. Ask only clinically relevant questions, explain why they matter, and use the patient's language. 3. Screen for overlapping contributors Consider gynaecological or reproductive, urological, gastrointestinal, pelvic floor and musculoskeletal, neuropathic, sexual, infectious, and chronic overlapping pain contributors, alongside trauma, mood, minority stress, and prior care experiences. Multiple contributors can coexist. Avoid attributing pain to GAHT, surgery, dysphoria, or psychosocial factors alone. 4. Perform a consent-based examination Tailor abdominal, external genital or surgical-site, neurological, and musculoskeletal examination. When relevant, assess scars, stenosis, granulation tissue, focal lesions, masses, sensory change, and pelvic floor tone, tenderness, trigger points, relaxation, and coordination. Internal examination should be performed only when clinically relevant and consented. Explain each step, offer a chaperone or support person, permit pause or deferral, and refer to an experienced clinician when the examination is not feasible or acceptable. 5. Select targeted tests Use urinalysis or culture, pregnancy testing when relevant to anatomy and exposure, STI testing, blood tests, or hormone levels according to the phenotype. Use pelvic ultrasonography, MRI, other imaging, or biopsy when bleeding, a focal lesion, a mass, postoperative complication, or incomplete suppression is suspected. There is no single diagnostic test for CPP. Testing should follow symptoms, anatomy, GAHT, and surgical history rather than a routine undifferentiated panel. 6. Triage and coordinate care Arrange urgent assessment for severe acute pain, fever or systemic illness, heavy bleeding, urinary retention or obstruction, suspected fistula or wound complication, new neurological deficit, or a concerning mass. Refer to gynaecology, urology, the surgical team, pelvic floor physiotherapy, pain medicine, gastroenterology, sexual health, or mental health care as indicated. Use a multidisciplinary pathway when pain is persistent, multifactorial, or function-limiting, and maintain trauma-informed, gender-affirming communication across referrals. CPP = chronic pelvic pain; GAHT = gender-affirming hormone therapy; STI = sexually transmitted infection; TGD = transgender and gender-diverse. This pragmatic framework synthesises the included reports and established chronic pelvic pain principles; it is not a validated TGD-specific diagnostic algorithm. References: 1 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 25 , 31 , 33 , 37 , 39 , 40 , 41 , 42 , 43 , 48 . Conceptual framework of interacting contributors to chronic pelvic pain (CPP) and related pelvic and genital pain in transgender and gender-diverse (TGD) adults. Hormonal and tissue-mediated, pelvic floor and musculoskeletal, surgical and anatomical, and psychosocial and trauma-related factors were identified across included studies as recurring and potentially interacting contributors to CPP and related pelvic and genital pain in TGD adults. These domains may converge on symptom persistence, with or without central sensitisation, manifesting clinically as pelvic or genital pain, sexual pain, persistent postoperative pain, and urinary or bowel symptoms. Solid arrows indicate convergence on CPP and related pelvic and genital pain outcomes; dashed arrows indicate hypothesised interactions between contributing domains. The framework summarises patterns identified in the literature and should not be interpreted as evidence of causal pathways, given the predominance of cross-sectional designs, heterogeneous pain definitions, and limited longitudinal data. Evidence-informed diagnostic framework for duration-defined chronic pelvic pain and related pelvic and genital pain in transgender and gender-diverse adults. CPP = chronic pelvic pain; GAHT = gender-affirming hormone therapy; STI = sexually transmitted infection; TGD = transgender and gender-diverse. This pragmatic framework synthesises the included reports and established chronic pelvic pain principles; it is not a validated TGD-specific diagnostic algorithm. References: 1 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 25 , 31 , 33 , 37 , 39 , 40 , 41 , 42 , 43 , 48 . A key uncertainty emerging from transmasculine participants is the heterogeneous relationship between testosterone therapy and pelvic pain. One cross-sectional study found lower duration-defined CPP prevalence among current testosterone users than among participants not currently using testosterone. 16 Conversely, other studies report new-onset or worsened cramping or suprapubic pain after testosterone initiation, sometimes with dysorgasmia or breakthrough bleeding and with some participants reporting improvement after hysterectomy. 14 , 15 , 25 These findings should not be interpreted as demonstrating either a protective or causative effect of testosterone. Broader histological evidence outside the included review studies provides additional biological context but does not establish a causal pathway to pain. One small study of high-dose testosterone exposure described loss of intermediate and superficial vaginal epithelial layers, glycogen depletion, reduced epithelial proliferation, and lower oestrogen-receptor expression. 49 Uterine and endometrial case series demonstrate heterogeneous responses despite amenorrhoea: one reported active endometrium in 69·1% of specimens, whereas another reported proliferative endometrium in 40% and atrophic endometrium in 50%. 50 , 51 A multicentre ovarian case series found benign histopathology in all specimens, most commonly simple or follicular cysts or normal findings, with no association between testosterone duration and ovarian cysts. 38 These tissue findings may plausibly contribute to dryness, irritation, dyspareunia, bleeding, or pelvic floor guarding in some people, but direct associations with duration-defined CPP have not been demonstrated. Together, these findings support mechanistic heterogeneity: testosterone may alleviate pelvic pain in some people through suppression of cyclic uterine, ovarian, or peritoneal activity, whereas pain after initiation may reflect incomplete ovarian suppression, residual endometrial activity, or hypoestrogenic tissue effects contributing to dyspareunia and vestibular pain. 17 , 23 , 25 This interpretation aligns with experimental and clinical evidence that changes in sex steroids can alter pain sensitivity in context-dependent ways. 6 , 26 , 52 Clinically, pelvic pain during masculinising GAHT should prompt structured evaluation guided by bleeding patterns, adequacy of hormonal suppression, relevant anatomy, pelvic floor function, and established causes of pelvic pain, rather than being assumed to represent a routine effect of testosterone. 1 , 14 , 15 , 17 , 23 , 25 , 32 Gender-affirming surgery represents a second major context in which, for a minority of patients, pelvic or genital pain emerges and persists. Surveys and programme audits indicate that postoperative pelvic and genital pain, dyspareunia, and dilation-related difficulties are common early after gender-affirming urogenital surgery and often improve during the first postoperative year. 20 , 21 Long-term postoperative pelvic-floor and pain-related symptoms have nevertheless been documented, including dyspareunia and lower abdominal pain more than a decade after surgery. 42 This trajectory is compatible with the broader persistent postsurgical pain literature. 53 , 54 , 55 , 56 , 57 , 58 , 59 Reported pain generators, including stenosis, scarring, granulation tissue, neuroma or nerve irritation, urethral complications, and rare focal structural pathology, are consistent with established chronic postsurgical pain mechanisms involving peripheral injury, central sensitisation, and psychosocial context. 31 , 41 , 43 , 57 , 58 Framing postoperative pelvic pain from gender-affirming surgical care within CPP models may support routine outcome measurement, early identification of structural complications, and escalation to multidisciplinary care without pathologising gender-affirming surgery itself. 59 Across both transmasculine and transfeminine participants, pelvic floor neuromuscular impairments emerged as a recurring and potentially modifiable contributor. Hypertonicity, myofascial pain, and coordination deficits were described alongside pain with dilation, orgasm-associated cramping, and mixed urinary or bowel symptoms, both before and after surgery. 18 , 19 , 20 , 21 , 39 , 41 In transmasculine people, cramping, dyspareunia, dysorgasmia, hypoestrogenic tissue irritation, prior pain, dysphoria, or trauma may contribute to protective muscular guarding and persistent hypertonicity. In transfeminine people, pre-existing dysfunction, surgical tissue disruption or scarring, postoperative adaptation, dilation-related guarding, and altered pelvic floor coordination may contribute. Once pain is established, myofascial amplification and central sensitisation may further perpetuate symptoms in either group. 3 , 15 , 18 , 20 , 21 , 22 , 41 These mechanisms are biologically plausible but have not been established as causal pathways in the included literature. Evidence supporting rehabilitative strategies derives mainly from case reports, programme audits, and observational studies describing manual therapy, down-training, biofeedback, and dilator retraining. The only randomised trial (postoperative PFPT after vaginoplasty versus no PFPT at 12 weeks) found no superiority for routine PFPT in ease or pain with dilation, pelvic-floor symptoms, vaginal length, or subjective improvement. 37 This finding argues against routine PFPT for every patient undergoing vaginoplasty, but does not establish that targeted PFPT is ineffective in people with examination-confirmed hypertonicity, myofascial pain, coordination deficits, or function-limiting dilation pain. Across studies, observational evidence also supports standardised perioperative education, graded dilation protocols with adherence support, early recognition and management of surgical complications, and multidisciplinary follow-up with clear escalation criteria when clinically indicated. 20 , 21 , 37 Future trials should phenotype participants, measure adherence and adverse effects, and extend follow-up beyond early postoperative recovery. Race and ethnicity require explicit consideration, although the available CPP-specific evidence is limited. In the only study reporting duration-defined CPP prevalence by self-identified race and ethnicity, descriptive prevalence differed across categories, but small cell sizes, overlapping identities, and the study design precluded inferential or causal comparisons. 16 Other included studies reported no statistically significant association between race or ethnicity and pelvic pain or pain severity, but were not designed or powered for intersectional analyses and frequently enrolled predominantly White participants. 25 , 44 Race and ethnicity are sociocultural rather than biological constructs, and observed differences may reflect racism, socioeconomic conditions, geographic access, diagnostic delay, differential exposure to gender-related stigma, or other unmeasured structural determinants. Broader TGD health research has also documented racial and ethnic inequities in policy-related health experiences and access to or experience of gender-affirming surgery, although these studies did not specifically evaluate CPP. 60 , 61 Future studies should use participant-defined categories, describe ascertainment methods, avoid treating White populations as a biological reference, involve racially and ethnically diverse TGD communities in study design, and examine intersecting structural determinants rather than treating race or ethnicity solely as adjustment variables. Psychosocial adversity and minority stress may shape pain risk, persistence, disclosure, and care engagement. In TGD people, chronic exposure to stigma-related stressors, trauma, and mental health burden may interact with autonomic and hypothalamic–pituitary–adrenal regulation and central pain amplification. 4 , 9 , 10 , 11 , 62 Consistent with this, higher pain burden in LGBTQ+people has been associated with adverse childhood experiences and mental health comorbidity, 44 while qualitative studies describe dysphoria, isolation, non-affirming healthcare experiences, and delayed help-seeking. 19 , 33 , 34 , 35 , 63 These factors should not be used to psychologise symptoms or dismiss peripheral pain generators. Trauma-informed, gender-affirming communication can support trust, symptom disclosure, consent for examination and diagnostic investigation, and engagement with PFPT, dilation, rehabilitation, or surgical follow-up. 7 , 33 , 48 , 64 , 65 These findings suggest that psychosocial factors can shape symptom persistence and access to care while remaining only one component of a broader evaluation for biological, structural, and neuromuscular contributors. This scoping review has several limitations. Chronicity definitions varied or were absent across studies; most reports did not apply a duration-defined CPP definition, substantially limiting comparison of prevalence estimates. Although one study developed a dysmenorrhoea-related measure inclusive of transgender men, 24 no validated TGD-specific CPP measure was identified. Key variables, including anatomy, GAHT dosing and hormone levels, surgical history, timing relative to transition-related care, sex assigned at birth, gender identity, race, ethnicity, and their methods of ascertainment, were inconsistently reported, 15 , 23 , 24 , 25 creating potential misclassification and limiting subgroup interpretation. Many participants were recruited through specialist clinics or online convenience sampling, which may over-represent those with higher symptom burden; non-binary people, racially and ethnically marginalised people, and individuals in low-resource, rural, or non-urban settings were often under-represented or not separately analysed. The predominance of cross-sectional designs precludes causal inference. The exploratory risk-of-bias appraisal used design-specific tools that are not directly comparable and was intended to contextualise, rather than grade the certainty of, the evidence. Exclusion of grey literature and abstract-only reports may also have contributed to publication bias, particularly for surgical complications, null findings, and emerging programme evaluations. Strengths include comprehensive and preregistered methods, inclusion of diverse study designs capturing both clinical outcomes and lived experience, independent screening and extraction, and high inter-reviewer agreement (Cohen's κ = 0·99). Regarding clinical implications, these findings support an anatomy-aware, trauma-informed, gender-affirming multimodal approach to CPP in TGD people, maintaining diagnostic breadth across gynaecological, urological, gastrointestinal, musculoskeletal, neuropathic, and psychosocial domains. Assessment should distinguish duration-defined CPP from related pelvic or genital symptoms; avoid premature attribution to GAHT or gender-affirming surgery alone; and consider onset and chronicity, clinically relevant anatomy, timing relative to GAHT or surgery, bleeding and adequacy of hormonal suppression, urinary, bowel, sexual, and dilation-related symptoms, pelvic floor and neuropathic features, and psychosocial context. 1 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 25 , 31 , 33 , 37 , 41 , 43 , 48 Table 3 summarises a pragmatic, evidence-informed pathway and should not be interpreted as a validated diagnostic algorithm. Targeted examination, laboratory testing, imaging, or biopsy should be guided by the clinical presentation and suspected pathology. Evidence for treatment effectiveness remains limited; targeted pelvic floor rehabilitation may be considered when relevant dysfunction is identified, and surgical revision may be considered when structural or postsurgical contributors are present. 17 , 20 , 31 , 37 , 41 , 43 Multidisciplinary referral should be considered when pain is persistent, multifactorial, or function-limiting, particularly when urinary, bowel, or sexual symptoms coexist, pelvic floor dysfunction or postoperative complications are suspected, or trauma-related barriers complicate assessment or treatment. 18 , 19 , 21 , 33 , 37 , 39 , 48 Health systems and guideline bodies should recognise CPP as an equity-relevant outcome within gender-affirming care, with adequate access to appropriately indicated PFPT, multidisciplinary pelvic pain services, and clinician education to reduce diagnostic delay and dismissal. 6 , 8 , 20 , 37 Research priorities include using a standardised minimum duration for CPP and reporting broader pelvic or genital symptoms separately. Prospective longitudinal cohorts beginning at or before GAHT initiation are needed to estimate incidence, identify predictors, and define symptom trajectories, including potential contributions from incomplete suppression, breakthrough bleeding, hypoestrogenic tissue symptoms, pelvic floor dysfunction, and minority-stress exposure. 8 , 14 , 25 TGD-inclusive patient-reported outcome measures should be developed and validated to capture pain intensity and interference, sexual function, urinary and bowel symptoms, acceptability of assessment and treatment, and quality of life. 24 Adequately powered randomised or pragmatic trials should evaluate hormonal, rehabilitative, surgical, and multidisciplinary treatment strategies. Surgical studies should report technique, complications, persistent pain, revision procedures, function, sexual health, and short- and long-term quality of life. Where sufficiently powered and clinically relevant, analyses should be stratified by anatomy, hormone exposure and levels, prior gender-affirming surgery, age, gender identity, sex assigned at birth, race and ethnicity, and socioeconomic, geographic, and other structural determinants. Community engagement and inclusive data collection will be important to ensure that future evidence is clinically useful and equitable. In conclusion, the available evidence suggests that duration-defined CPP and related pelvic and genital pain in TGD people involve multiple overlapping potential contributors rather than a single hormonal, surgical, anatomical, or psychosocial cause. Current evidence supports structured, gender-affirming and trauma-informed multidisciplinary assessment, but remains too heterogeneous and predominantly observational to establish population-level prevalence, causal mechanisms, or treatment effectiveness with confidence. Clear definitions, validated measures, longitudinal studies, and adequately powered interventional trials are needed to move from symptom recognition towards evidence-based care.

RC conceived the review, designed the study, coordinated the project, conducted screening and data extraction, led the evidence synthesis and interpretation, and wrote the first draft of the manuscript. SGS conducted screening, full-text review, and data extraction and contributed to interpretation and manuscript drafting and revision. ME developed and refined the search strategy and conducted the literature searches. TDR, OD, BNR, and ML contributed to interpretation of the findings and critically revised the manuscript for important intellectual content. GRL contributed to the study concept and design, provided methodological oversight, contributed to search strategy development, adjudicated screening disagreements, interpreted the findings, and supervised the project. RC and SGS accessed and verified the underlying data. RC and GRL had final responsibility for the decision to submit the manuscript. All authors read and approved the final version of the manuscript.

Chronic pelvic pain (CPP), defined as non-cyclical pain persisting for at least three months and localised to the pelvis or lower abdomen, is common and extremely disabling. 1 , 2 Contributors span gynaecological, urological, gastrointestinal, vascular, neuromuscular, and neurological systems, compounded by central sensitisation (an increased responsiveness of nociceptive neurons in the central nervous system to normal or subthreshold afferent input) and psychosocial factors. 1 , 3 , 4 However, literature has focused on the epidemiology and mechanisms of CPP in cisgender people, despite evidence that sex- and gender-related biology and social context substantially shape pain experiences and treatment responses. 5 , 6 , 7 Transgender and gender-diverse (TGD) people (including transgender men [transmasculine], transgender women [transfeminine], non-binary, and other gender-diverse people) remain markedly under-represented in pain research and clinical trials, despite rapidly increasing global access to gender-affirming hormone therapy (GAHT) and surgery. 8 Within these populations, minority stress (defined as chronic stigma-related social stressors associated with marginalised group status, including structural, interpersonal, and internalised stress processes), 9 , 10 together with traumatic experiences and barriers to affirming care, may contribute to chronic pain risk while potentially interacting with the biological effects of GAHT and surgical transition. 9 , 10 , 11 , 12 Emerging evidence indicates that duration-defined CPP and a wider spectrum of pelvic and genital pain symptoms occur in TGD people across diverse clinical contexts. 13 Because chronicity was not consistently defined in the available literature, we distinguish throughout this review between “duration-defined CPP,” referring to pelvic pain for which a study explicitly applied the prespecified temporal threshold, and “related pelvic and genital pain,” referring to the broader included symptoms for which chronicity was implied or not consistently measured. In transmasculine people, both new-onset pelvic pain after testosterone initiation and lower duration-defined CPP prevalence among those currently on testosterone have been reported, suggesting multiple potential contributors including variable ovarian suppression, hypoestrogenic tissue effects, and pelvic floor dysfunction. 14 , 15 , 16 , 17 , 18 , 19 In transfeminine people, postoperative pelvic and genital pain, dyspareunia, and dilation-related difficulties after vaginoplasty have been described, with pelvic floor dysfunction and surgical sequelae proposed as contributors. 20 , 21 Pelvic pain has also been described to co-occur with urinary, bowel, and sexual symptoms and other chronic overlapping pain conditions, alongside minority-stress exposures. 8 , 10 , 11 , 22 Despite this growing literature, important measurement gaps remain: many studies use ad hoc items or generic scales that have not been validated for TGD people, chronicity thresholds are inconsistently applied, and anatomy, GAHT status, and surgical history are inconsistently captured. 15 , 23 , 24 Rising global uptake of GAHT and gender-affirming surgery, 8 recent TGD-specific studies of duration-defined CPP and related pelvic and genital pain, 14 , 15 , 21 , 25 and converging insights into hormonal-immune-neural pain mechanisms and sex and gender biases in pain care together make the synthesis of current evidence both timely and necessary. 6 , 12 , 26 , 27 This scoping review maps the global literature on duration-defined CPP and related pelvic and genital pain outcomes in TGD people, synthesising evidence on prevalence, potential aetiologies (hormonal, surgical and anatomical, pelvic floor and musculoskeletal, and psychosocial), clinical assessment and diagnostic approaches, and management strategies across transition contexts. By charting current knowledge and identifying gaps, we aim to inform affirming clinical practice and to set a research agenda for rigorous, inclusive investigation of duration-defined CPP and related pelvic and genital pain in TGD people.

TDR reports an unpaid leadership or fiduciary role with the Canadian Pain Society and payment for participation on the QUTENZA Advisory Board and Vertex Acute Pain Advisory Board. ML reports consulting fees from AbbVie, Hologic, Chugai, Gesynta, Roche Diagnostics, Afynia, and Pfizer; payment or honoraria from the American Institute of Ultrasound in Medicine, AbbVie, GE Healthcare, and Bayer; and leadership or fiduciary roles with the World Endometriosis Society Early Career Board, ISUOG Next Generation, and the Gynecologic Ultrasound Society. GRL reports grants or contracts from the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, the University of Toronto Department of Anesthesiology and Pain Medicine, the University Health Network–Sinai Health Department of Anesthesia and Pain Management, the Canadian Journal of Anesthesia, Anaesthesia, the Anesthesia Clinical Trials Unit, and the Sunnybrook AFP Innovation Fund; payment or honoraria from the University of Bonn, the Association of Anaesthetists of Great Britain and Ireland, the Neuroanaesthesia and Critical Care Society Annual Scientific Meeting, Dalhousie University Department of Anesthesia, Pain Management, and Perioperative Medicine, the University of British Columbia Whistler Anesthesia Summit, and the Washington University School of Medicine Department of Anesthesiology; and support for attending meetings or travel from the University Health Network–Sinai Health Department of Anesthesia and Pain Management. RC, SGS, BNR, ME, and OD declare no competing interests.