A Qualitative Analysis of the Fertility Experience and Gender Identity in Young Women Following Hysterectomy for Benign Disease

Hysterectomy may impact young women’s perceptions of their gender identity and fertility status, with implications for quality of life. However, research into this important area is limited, particularly among women with benign disease. To investigate gender identity and fertility in this population, semi-structured interviews were conducted with 18 women who underwent hysterectomy for benign disease at age 39 or younger. Women were asked to describe their experience of hysterectomy and how it affected their perceptions of their gender identity, fertility status and overall quality of life. Thematic analysis was used to analyse and code responses. Three themes were identified; Implications of Infertility, I am a Woman and Womanhood Compromised. Within these themes, 3 sub-themes were identified. Implications of Infertility comprised three sub-themes describing women’s varied relationships with their post-hysterectomy infertility: Plans Fulfilled, Acceptable Compromise and Persistent Grief. A novel finding was that women engaged in a “trade-off”, whereby relief of gynaecological symptoms outweighed their desire for a child/further child/ren. The study also found that women with an extensive history of infertility may have more trouble adjusting to the outcomes of their hysterectomy than women who were satisfied with their fertility history. Counselling around identity and how this can be influenced by fertility status may be needed. Further research into the psychological processes involved in the “trade-off” is also needed.

Hysterectomy refers to the surgical removal of the uterus and is a major gynaecological surgery worldwide (Hammer et al., 2015). Hysterectomy may be considered for numerous reasons including benign gynaecological conditions, particularly when more conservative treatments have been ineffective or have bothersome side effects (Laughlin-Tommaso et al., 2020). For chronic conditions such as endometriosis, adenomyosis and fibroids, hysterectomy may reduce physical symptoms such as heavy menstrual bleeding and pelvic pain (Laughlin-Tommaso et al., 2020). However, women may also experience psychological, social and emotional sequelae of this procedure (Bayram & Beji, 2010;Elson, 2002), with younger and/ or pre-menopausal women affected in ways that are unique to their life stage. This may include experiencing changes in gender identity (Elson, 2002;Elson, 2005;Cabness, 2010;Solbraekke & Bondevik, 2015) and conceptualisations of fertility, which in turn may impact their quality of life. Understanding the effect of hysterectomy on women's quality of life is important, particularly as there is limited literature available to guide health professionals working in this field. Research in this area may also help women gain a better understanding of the broader risks and benefits of undergoing a hysterectomy.

Gender Identity Following Hysterectomy
Gender identity refers to a person's perception of having a specific gender and often corresponds with a person's sex at birth (Connell, 1995). Women's gender identities include traits that have traditionally been considered feminine, such as passivity, emotionality and nurturance (Connell, 1995). Hysterectomy and its associated outcomes may alter a woman's sense of femininity, and therefore her gender identity (Elson, 2005). Cessation of menstruation post-hysterectomy may partially explain this identity adjustment. There is a strong association between menstruation and female gender identity with many women perceiving menstruation as connecting them to other women and as being a process that reinforces femininity (Elson, 2002). Fertility loss in pre-menopausal women post-hysterectomy may also cause identity disruption. Some literature suggests that women's reproductive capacity informs and shapes their gender identity (Alamin et al., 2020;Bell, 2019;Miles et al., 2009). Notably, there is variation in women's experiences; some finding their sense of identity unchanged (Cabness, 2010) while others report an enhanced sense of self, likely associated with the significant reduction in gynaecological symptoms (Bell, 2019;Elson, 2002;Elson, 2005;Solbraekke & Bondevik, 2015).

Fertility Following Hysterectomy
Given the irreversible impact of hysterectomy on the ability to carry a pregnancy, investigating how this is experienced by women and what effect this may have on their quality of life beyond gender identity is important. Previous research points to increased rates of worry, sadness, low self-esteem and relationship breakdown in women experiencing infertility following benign gynaecological disease (Culley et al., 2013). Similar outcomes may be expected in women following hysterectomy; however few studies have explored this issue (Bougie et al., 2020;Farquhar et al., 2006;Leppert et al., 2007). Leppert et al. (2007) investigated women (N = 1140) following hysterectomy for benign disease and found that 14% desired a child or more children. These women tended to be younger and were more likely to have higher levels of psychological distress at the time of and following hysterectomy. While this suggests a link between removal of reproductive ability and decreased psychological wellbeing, the fertility background of the participants was not assessed, making it difficult to understand the impact of hysterectomy in the context of individual fertility history. Farquhar et al. (2006) described a relationship between hysterectomy and feelings of loss regarding fertility but did not assess women's fertility backgrounds and how this may have affected their experience of grief post-hysterectomy. Notably, both aforementioned studies included large numbers of women who were medically unable to bear children due to their older age at the time of their hysterectomy, hence infertility concerns may have been less significant than in a comparatively younger cohort.
To date, only one study has investigated fertility and quality of life following hysterectomy in younger women. Bougie et al. (2020) studied the prevalence of post-hysterectomy regret in women (N = 71) under 35 years who had undergone hysterectomy for benign conditions between 2008-2015. Participants completed a validated decision regret survey and health questionnaire. Over 90% did not regret their decision and would elect to have the hysterectomy again, despite side-effects including permanent loss of fertility. However, 23.9% of women reported wishing to have another child following hysterectomy. This research used a quantitative approach, and whilst post-hysterectomy outcomes were identified, respondents' narratives were not explored in detail. Qualitative data has the potential to add a richness to this understanding and tease out the nuances and complexities of this experience. For example, it is unclear why Bougie et al. (2020) found that the symptom relief experienced by young women following hysterectomy superseded the irreversible side-effect of fertility loss, particularly as previous studies have highlighted the negative impact of this loss (Farquhar et al., 2006;Leppert et al., 2007).

The Current Study
Further investigation is needed to understand how young women conceptualise their fertility following hysterectomy, including examining contextual information like previous childbearing and/or fertility difficulties, and age. This approach has the potential to provide information to medical professionals who are discussing the advantages and drawbacks of these procedures with their patients, and improve psychological services such as counselling, for young women. Consequently, this study aimed to investigate women aged 39 and under in terms of their perception of their gender identity and fertility following hysterectomy for benign disease, and how these perceptions may enhance or diminish their quality of life. It must be noted that this study was focused on the experiences of cis-gendered women. While the experiences of trans women undergoing hysterectomy as part gender affirming surgery are important and deserving of further scrutiny (Makhija & Mihalov, 2017), this is beyond the scope of this study.

Method
This study used a qualitative approach to allow for a comprehensive and deep exploration and understanding of the experiences of young women post-hysterectomy. Within this framework, the research was underpinned by a phenomenological epistemology. This approach aimed to produce knowledge based on the subjective and unique experiences of the women participating in this research. It was interested in the women's thoughts, feelings and reflections regarding their hysterectomy and was concerned with the quality and texture of these perceptions (Willig, 2013). The phenomenological standpoint does not necessarily try to uncover what is 'real' about the posthysterectomy experience, but rather, is interested in the diversity and complexity of this experience for different women, accepting many possible interpretations of this experience. To achieve this, the women were interviewed using a semi-structured format; while the questions aimed to explore the quality of life areas of gender identity, fertility and body image, the design of the study allowed for the emergence of unanticipated themes that impact quality of life. As such, the study has remained faithful to its phenomenological underpinnings; it displayed openness when speaking with the women and the researchers aimed to remain reflective and aware of any assumptions made when conducting the study (Sundler et al., 2019).

Recruitment
Ethics approval for the study was obtained from the Royal Women's Hospital (RWH) Human Research Ethics Committee (Project #20/27) on 11 November 2020. The current study was nested within a large-scale survey-based quantitative study at The Royal Women's Hospital (RWH). That study (the parent study) is investigating the impact of age and parity on young women's relief and regret following hysterectomy for benign disease. Some of the women who participated in the parent study also gave consent to be contacted for an interview in future. As such, the current study recruited participants from the parent study.
Initially, 21 women aged 36 or under at the time of their hysterectomy were contacted by email regarding participation. The researchers aimed to recruit the youngest possible cohort (at the time of hysterectomy) as this population was of most interest to the researchers. From the initial group of 21 women, 13 expressed an interest in participating in the study.
Approximately 1-2 months after the initial interviews, 10 more women (aged between 37-39 years at the time of their procedure) were contacted, to increase the sample size. Five provided consent, then were recruited (as above). In total, 18 women participated in the study.

Participants and Procedure
Participants were eligible to participate in the study if had undergone an elective, planned, hysterectomy for benign disease. The participants also needed to have had the hysterectomy 6-11 years before the study, needed to be aged between 18-39 years at the time of hysterectomy, and needed to have sufficient English literacy and communication skills to consent and participate in the study.
As stated, data were collected via semi-structured interviews. An interview schedule based on the empirical literature and clinical experience was developed by the first and second author (GB and DB), with significant input from the senior author (LS), a clinical psychologist and women's health expert, and associate investigators from the parent study, all gynaecologists. Interviews were conducted by DB and GB. Questions aimed at understanding the broad implications of hysterectomy on the women's quality of life, and impacts on their fertility, gender identity, psychological wellbeing and sexuality. Data describing participant characteristics were accessed from the parent study. The interview data was transcribed verbatim by GB and DB, which involved listening and re-listening to the recorded interviews and documenting what was discussed, word for word.

Researcher Positionality
In terms of reflexivity, care was taken to recognise the researcher's positions of privilege when interviewing the women, as highly educated, middle-class, cis-gendered white women. This relative position of power was dealt with in a sensitive manner, so as not to create feelings of intimidation or discomfort during the interviews. Further, the researchers took care to acknowledge their positions as outsiders to the experience of having a hysterectomy and aimed to approach the data with curiosity and interest, rather than imposing pre-conceived ideas around the procedure.

Data Analysis
NVivo (2020) software was used to store, organise and analyse the data. Thematic analysis was used, as outlined by Braun and Clarke (2006). Transcripts were read until familiarity was achieved. Codes were developed to condense the data and segment it systematically in preparation for analysis. Following this, codes were merged and relationships between them were considered in the creation of themes. Emerging themes were then refined. Data was coded until saturation was reached; that is, until no new codes or 1 3 themes emerged from the data set (Willig, 2013). Discussions about the codes and themes occurred throughout this process between DB, GB and LS. DB and GB each coded the data separately, and then reached a shared consensus on the codes and subsequent themes through discussion. Interrater reliability was tested using Cohen's kappa. LS provided oversight and feedback regarding coding, emerging themes, and the refining of themes. Illustrative quotes were identified and edited for clarity, and included in the results section to support the data. Data on participant characteristics were analysed using IBM-SPSS Statistics (Version 25).

Participant Characteristics
Eighteen women participated in interviews, which ranged from 15-90 minutes in length (Mean = 41 minutes). Mean age at the time of hysterectomy was 35-years-old and 44-years-old at interview. Most women were married and had had children prior to their hysterectomy. Endometriosis was the most common reason for the procedure. See Table 1 for detailed sample characteristics.

Themes
Analysis resulted in the emergence three themes and five subthemes. See Table 2 for a summary of themes and subthemes, frequencies, exemplary quotes and interrater reliability.

Theme 1: Implications of Infertility
This theme had three sub-themes and comprised women's conceptualisations of infertility following hysterectomy and the impact on their quality of life.

Plans Fulfilled
Over half the women reported that their childbearing plans were fulfilled before their hysterectomy, and the infertility they experienced post-hysterectomy had little negative impact on their quality of life. In some cases, the hysterectomy resulted in a sense of relief as it provided long-lasting contraception, ultimately strengthening the quality of their intimate relationships.
"I'd already had 4 kids…and I'd had my tubes tied, so I was more than happy to have the hysterectomy." (P10) "Immense relief [following hysterectomy]… because I knew there was no way I was getting pregnant… you can continue on with life and not have that worry at all." (P17) Some women did not have children at the time of hysterectomy but reported that they never wanted nor intended to have them. These women experienced a sense that their plans were fulfilled and did not report that their quality of life was negatively affected by their infertility. Rather, this was a neutral or welcome side-effect.
"I've never really cared about my fertility; I have never been interested in children. I've never wanted them… Table 1 Socio-Demographic and Clinical Characteristics of Participants *Some women had more than 1 reason for undergoing hysterectomy **Some women had more than 1 mental health diagnosis at the time of hysterectomy. Of the women diagnosed with at least one mental health condition, 22% of the diagnoses were self-reported, and 33% and 44% were given by a general practitioner or mental health practitioner, respectively Acceptable Compromise A large proportion of the women, with varied fertility backgrounds, described experiencing fleeting grief associated with their post-hysterectomy infertility. However, these feelings were largely resolved by the time of interview.
"Oh look, there are times where I wish there was another way to have gone through it all, but it is what it is, and I deal with it." (P12) "After the recovery, I thought 'Oh I want to be pregnant again'… but then going through pain and nine months and then giving birth and looking after the baby, I'm not going to do that again." (P07) In resolving this momentary grief, many considered their feelings from a pragmatic perspective. The difficulties they experienced prior to their hysterectomy (e.g., severe menstrual pain) seemed to outweigh the potential benefits of bearing children. As such, these women engaged in a 'tradeoff'; deciding that they could live with their infertility and the associated feelings of loss and grief as this came with the advantages associated with relief of their symptoms.
"I think it was just knowing that I could no longer carry a child… I'm missing that bit… But then I'll look at what I went through until I got to that point and I don't know if I could have gone another 10 years living like that (in pain)." (P04) A subgroup of women with other medical conditions (e.g., cardiac disease) also engaged in this 'trade-off'; however, their infertility was predominantly related to these associated conditions rather than the hysterectomy. "I would have had more children before I decided to have a hysterectomy. The thing is I couldn't have any more children because I have a cardiac problem…it made my decision a lot easier." (P06) Persistent Grief A minority of women expressed intense and persistent sense of grief tied to their loss of fertility. These women had complex medical histories that included a prior diagnosis of infertility.
"I've wanted to be a mum since I was 4. I literally gave up career options that would affect my ability to parent. And so when it came to the point, where I was, like, 'Oh, actually, you can't be a parent anyway' that was a real kick in the head." (P13) "Once the initial euphoria [from resolution of symptoms] had subsided, I really mourned, I really grieved it especially as my friends and my family began having children and continued having children, I felt really sad that I couldn't ever be in that position …I still feel grief about the fact that I only had one kid." (P02) While the hysterectomy may have been the event directly causing the infertility, grief pre-dated the procedure and was the culmination of multiple, historical fertility difficulties. It is possible that the finality of the hysterectomy exacerbated this pre-existing and now persistent grief in this small subgroup of women. 1 3

Theme 2: I am a Woman
The impact of the hysterectomy on participants' gender identity was relatively benign. Most participants did not identify any specific changes in the way they conceptualised their gender identity and feelings of femininity. A sense of femininity in this cis-gendered cohort appeared to be well established prior to their hysterectomy. The women synthesised this femininity and their gender identity by drawing together their roles as mothers and wives, and through their employment.
"I'm still that female role model for my kids, the female role model for students that I teach… just because I've had a hysterectomy, doesn't mean that I am less, or that something is missing… my identity is about the impact that I have on the people around me and how I can improve the people around me, if I can help them." (P16) The reported minimal impact of the hysterectomy on gender identity may have been due to the women's perception of the uterus as an internal organ, and therefore hidden from view. As such, the hysterectomy did not remove a physically visible marker of traditional femininity, thus having a reduced impact on gender identity. "I'm quite happy with who I am and what I am. I think I would feel different if I had a mastectomy because then my boobs would be missing, that would make me feel less of a woman, whereas because it was internal, it didn't particularly bother me." (P03) "Because it [the uterus] is internal… if I had to have a mastectomy, that would be a lot more impactful than having a hysterectomy." (P17) A small group of women commented that the hysterectomy contributed to increasing their feelings of femininity and womanhood, mainly due to a decrease in negative symptoms and a resulting greater sense of freedom. For example, some women commented on their enhanced capacity to participate in leisure and work activities, as they were no longer concerned about excessive bleeding or pain. While this may have improved their quality of life, these opportunities may also foster an increased sense of gender identity, as they may feel more engaged with other women and able to behave in ways that reflect their desires as women.
"It gave me confidence to feel like a woman without the stresses that come with being a woman… it took away any anxiety with the bleeding, what you can wear, what you can't wear… the confidence to have sex… I felt very feminine afterwards." (P10) "I feel a measure of freedom now more than I used to… because I don't have to be distracted by worrying about the pain." (P09)

Theme 3: Womanhood Compromised
For some women, the hysterectomy represented a partial loss of gender identity and resulted in diminished feelings of femininity. This sense of loss was tied to childbearing capacity (eg. loss of menstruation).
"Knowing that I no longer had a part of me as a woman…it took me time to realize yeah, it is cool I don't have to bleed, but I've lost a part of me as a woman." (P04) "[the hysterectomy] did make me want to just go, I'm [participant name], I'm not female. I don't even have a womb. Because apparently some people say, 'Oh, you can't be female, unless you menstruate'." (P08) Some women commented directly on their sense of identity as a mother. While this was not the case for all women, including those with their desired number of children or disinterested in becoming mothers, this was disproportionately felt by women who experienced feelings of loss and grief after their hysterectomy.
"But maybe …less motherly, because you can't be a mother… because you're not normal." (P13) I felt like [if] I wasn't going to be a mother again, perhaps I wasn't as useful as a woman." (P02) Women conceptualised their failure as a mother as intertwined with their failure as a woman, which ultimately, resulted in a diminished sense of self. In some cases, their perceived failure as both a mother and a woman resulted in negative self-perception, like poor body image.
"I felt like a failure as a mother and as a woman because my body wasn't working. I couldn't deliver my own child myself and my body wasn't working properly then, it's still not working properly now. It's failing me, it's just not good enough, it's disgusting and useless." (P01)

Discussion
Hysterectomy for benign disease is a common treatment that may impact young, pre-menopausal women in ways that may be particularly challenging at their life stage. This study aimed to understand the sequelae of this surgery on quality of life specifically regarding perceptions of fertility and gender identity. The themes identified illustrated women's varied relationships with their post-hysterectomy infertility, depending on whether their childbearing plans had been fulfilled. Most participants had completed their families by having children or had never wanted children, thus were not adversely impacted by their infertility. Many women engaged in a "trade-off" whereby relief from gynaecological symptoms outweighed their desire for a child or further children. This is a novel finding and further research into the psychological processes involved in this appraisal is needed. Notably, this "trade-off" was not experienced by all women, with a small number of individuals with extensive histories of infertility continuing to experience grief post-hysterectomy. This suggests that a subgroup of women may have more trouble adjusting to the outcomes of their hysterectomy and require additional psychological support.
Considering the post-hysterectomy infertility experiences of this cohort in the context of existing literature is challenging, due to limited data. However, the strong sense felt by women of having achieved their reproductive intentions mirrors experiences reported by post-menopausal women (Dillaway, 2020;Ilankoon et al., 2020;Salis et al., 2018), including feeling that they have not only biologically, but also psychologically, surpassed their childbearing years (particularly when paired with a sense of having completed their families) (Dillaway, 2020). While most 'young' women in this study were medically fertile at the time of their hysterectomy, they psychologically considered their childbearing years to be over as their familial plans were fulfilled. As such, they did not seem to attach significant emotional meaning to the loss of fertility; their hysterectomy simply being a process that led to improved quality of life.
Some women coped with feelings of loss associated with their infertility by reflecting on the benefits of their symptom improvement. This concept builds on the "compromise" suggested by Markovac et al. (2008), that some women resolve feelings of wanting another child by considering their lack of pain. Bougie et al. (2020) also found that women did not regret their hysterectomy, despite relatively high numbers desiring a larger family. The reasons given as to why these women could resolve the feelings of loss associated with their hysterectomy involved factors including collaborative decision-making with medical professionals and possessing a high level of perceived autonomy when considering the procedure (Bougie et al., 2020). The current study suggests that it is the "trade-off" that women make following their procedure that influences the low level of hysterectomy regret found despite the desire for a child or further children.
Unsurprisingly, this "trade-off" was not universal; a smaller number of women experienced persistent grief following their hysterectomy that was directly tied to their infertility. This is broadly consistent with other research, which indicates that fertility loss after hysterectomy may be linked to increased psychological distress and regret for some women (Leppert et al., 2007;Farquhar et al., 2006). Beyond these studies, there has been little in the literature examining the complexity and mechanisms associated with women's grief following hysterectomy. Women in the current study each felt their grief over an extended period of time, and this preceded their hysterectomy. It is possible that prior, ongoing difficulty with fertility (which may disproportionality impact women who undergo hysterectomy for benign conditions, such as endometriosis) (Culley et al., 2013), may play an important part in the onset of this psychological distress and subsequently, may worsen quality of life. These experiences of long-term grief are consistent with the infertility literature more broadly (Ferland & Caron, 2013;McBain & Reeves, 2019), including suggestions that women who remain involuntarily childless tend to experience their grief indefinitely even if they eventually adjust to their circumstances (Ferland & Caron, 2013).
Most women reported stable or enhanced gender identity post-hysterectomy, which is in line with previous literature in the cis-gendered population (Cabness, 2010;Elson, 2005;Solbraekke & Bondevik, 2015). However, the current study suggests a novel rationale for the stability of gender identity. Previously, it has been suggested that menstruation and the presence of the uterus are important factors in constructing women's gender identities (Elson, 2002) and the removal of these processes/organs may lead to diminished feelings of femininity. Yet many women in the current study did not assign this meaning to their uterus or menstruation but commented that external physical markers like breasts were more important for maintaining their femininity. This finding is reflected in literature on women undergoing mastectomy; the removal of the breasts representing a potential challenge to femininity and decreased feelings of womanliness (Glassey et al., 2016). It is possible that the removal of visible indicators of femininity is more detrimental to women's perceptions of gender identity than the removal of features hidden from personal and public view.
The idea that external expressions of femininity are important in maintaining gender identity may also explain why after hysterectomy, some women in this study experienced identity enhancement due to an increased capacity to demonstrate their femininity (e.g., ability to wear traditionally feminine dresses). This is consistent with the findings of Solbraekke and Bondevik (2015) and as such, hysterectomy may augment and strengthen a woman's sense of gender identity. Markovic et al. (2008) similarly suggested that some women could participate in more social and occupational activities post-hysterectomy, which increased their ability to embody their femininity in practice. The current study builds on this research and suggests that in the Australian context, hysterectomy may reinforce identity stability or generate identity enhancement for some women.
A small portion of participants linked their hysterectomy to a decreased sense of femininity, as their perception of themselves as mothers and women was challenged postprocedure. Notably, these participants had all experienced long-standing fertility difficulties. There is evidence that protracted infertility may not only disrupt, but also prevent the formation of gender identity in women, particularly as it pertains to femininity and womanliness (Alamin et al., 2020). The current study suggests that it is perhaps not the hysterectomy in isolation that causes gender identity disruption, but rather, that the hysterectomy further diminishes a woman's sense of gender identity which has already been impacted by infertility.
Ultimately, the contrasting themes regarding gender identity support the overarching findings of Elson (2005), who acknowledged the variability in women's relationships with their gender identity following hysterectomy. This study illustrates that women are diverse in their conceptualisations of femininity and womanhood and derive identity from different aspects of their lives. While some women tie their identity to their role as mothers (or lack thereof), others are perhaps moving towards more 'modern' perceptions of what it may mean to be a woman. For example, some women linked their identity to how well they performed in their occupational role. As such, this study suggests that whether gender identify is enhanced, stable or diminished post-hysterectomy may depend upon a woman's context and how she conceptualises her identity.

Limitations and Future Research Directions
The cross-sectional study design was both a strength and a limitation. The study aimed to recruit women once a substantial period had elapsed after their hysterectomy, so that participants had had time to process, consider and contemplate the implications of the hysterectomy on their quality of life. These longer-term reflections on the hysterectomy experience are lacking in the literature and have direct clinical utility for health professionals who may be able to communicate these longer-term experiences to women considering the procedure. However, as the average time between interview and hysterectomy was 9 years, the absence of shorter intervals may have impacted the breadth of the post-hysterectomy experiences reported. Indeed, there is evidence suggesting that women's quality of life differs depending on the length of time since recovery (for example, some women have a decreased quality of life immediately after hysterectomy which improves over time (Lee et al., 2009). It is unclear why this improvement occurs, and as the current study was not longitudinal, this trajectory could not be evaluated. However, further study of this would provide valuable information on the entirety of the post-hysterectomy experience.
Another limitation of the study was that the participants were recruited from a specialist metropolitan women's hospital (RWH). While the women would have received top-tier medical care, the study was conducted on a single site and therefore cannot be generalised to other groups of women. These include those that receive their hysterectomies in private hospitals or in regional centres, which may differ in terms of quality of care provided. Future studies might consider including women from a diverse range of private and public hospitals, to ensure that different care experiences prior, during and following hysterectomy are captured.

Practice Implications
The current study suggests that for most women who undergo hysterectomy, the procedure vastly improves quality of life. However, there are some women who experience grief associated infertility and associated gender identity difficulties. It is therefore important for health care workers to gauge each individual woman's fertility background prior to their hysterectomy. The findings from this study indicate that women with an extensive history of infertility may have more difficulty adjusting to the outcomes of their hysterectomy; thus adequate psychological supports should be available and accessible to these women. Counselling around identity and how this may be influenced by fertility status may also be required.

Conclusion
The current study sought to understand the post-hysterectomy experience of women younger than 39 at the time of surgery, specifically in relation to perceptions of fertility and gender identity. Findings from the study generally support previous literature, particularly as it pertains to improvement in quality of life. However, there are novel findings from this study that require further research. The finding that women engage in a "trade-off" where desire for a child/further child/ren is outweighed by the relief associated with the elimination of gynaecological symptoms is worthy of exploration, particularly the psychological processes involved in this appraisal. The relationship between infertility and gender identity in this study, in the specific context of hysterectomy is also an area that could be re-visited in future research. The findings from the current study can be used to form part of a preliminary evidence base around the post-hysterectomy experience and can inform health professionals working in this area.

Interview Schedule
Hello <confirm participant's name/identity> This is <name> calling/checking in about the study investigating quality of life after hysterectomy for benign disease. Thank you for agreeing to be interviewed for this study.
Let me just remind you about the study. The aim of this project is to learn more about how having a hysterectomy for benign disease affects quality of life. Specifically, we are interested in learning about the impact of hysterectomy on female identity, body image, fertility, sexual functioning and sexuality and psychological functioning. The interview is going to be recorded and will be transcribed and then analysed. The recording will be stored in a secure location and destroyed after the completion of the study. If at any point you would like me to stop the interview or the recording, please let me know and I can do that. This interview can also be conducted across multiple sessions to break it up, if needed.
If it appears that it may be appropriate to pause or stop the interview, I may suggest this. If there are any questions here that you do not want to answer, or you wish to have a break or stop, please just let me know and we can do that.
If, after or during this interview, it seems that you might benefit from psychological support, we can discuss options for referral and/or debriefing. Do you have any questions before we continue?
First, I am going to ask you a few background questions. These are not recorded. I will tell you when I am going to start the recording.
Background questions (for verification, not recorded)