Individually customized gender affirming genital procedures: techniques and considerations.

PURPOSE: Gender-affirming surgery is being increasingly performed for transgender and gender-diverse individuals diagnosed with gender dysphoria. However, there is a group of patients who may seek outcomes that are either a combination of or altogether different from those of binary procedures such as penile inversion vaginoplasty or phalloplasty. METHODS: We describe surgical techniques for less commonly performed gender-affirming genital procedures, in order to introduce these procedures to the medical and surgical community. RESULTS: Operative techniques for phallus-preserving vaginoplasty, vagina-preserving phalloplasty, and removal of genitalia with creation of perineal urethrostomy are described. Demographic characteristics and complications of these procedures in 16 patients are reported. CONCLUSION: Individually customized gender-affirming genital procedures, such as phallus-preserving vaginoplasty, vaginal-preserving phalloplasty, and removal of genitalia and creation of perineal urethrostomy, may better affirm the identities of some gender-diverse patients, and may also preserve desired sexual function of natal genitalia.

Psychological Assessment for Gender-Affirming Care in Transgender and Nonbinary Youth: The Companionship Model.

ABSTRACT: This article introduces The Companionship Model as a template for conducting ethical and affirming assessment sessions for transgender and nonbinary youths (TNBY) and their guardians. The Companionship Model emphasizes proactive clinical companionship as TNBY and their guardians navigate access to gender-affirming care. The model offers specific action steps for establishing a therapeutic alliance and centers TNBY and their guardians' access to resources based on the informed consent/assent process. In this article, we provide sample session questions and illustrative clinical examples.

Gender-affirming hormone treatment modalities for transfemale & non-binary transfeminine individuals: A UK perspective.

Gender incongruence and the number of people seeking gender affirming hormone treatment has dramatically risen in the last two decades. In the UK, transgender women and non-binary transfeminine individuals are typically treated with simultaneous suppression of endogenous testosterone production through anti-androgens and exogenous oestradiol replacement. Oestrogen replacement comes in different forms and is primarily given as transdermal (gel or patch) or oral preparations in the UK. Decisions around preparation choice are based on a combination of individual preference and/or mitigating the chance of complications based on individual risk profiles. Time frames to achieve female physical changes are largely predictable and managing expectations of individuals prior to commencing treatment is highly important. Common complications include venous thromboembolism, liver dysfunction and effects on fertility, thus individuals should be thoroughly counselled prior to commencing treatment. This article provides an overview of the management and considerations of gender-affirming hormone treatment in transgender women and non-binary transfeminine individuals.

Childhood Gender Diversity and Mental Health: Protocol for the Longitudinal, Observational Gender Journey Project.

BACKGROUND: Prepubertal transgender, nonbinary, and gender-diverse (TGD) children (ie, those asserting gender identity, expressing gender-role behavior outside of culturally defined norms for their sex registered at birth, or both) are presenting in greater numbers to pediatric gender clinics across the United States and abroad. A large subset of TGD children experiences gender dysphoria, that is, distress that arises from the incongruence between gender identity and sex registered at birth. A lack of consensus exists regarding care for prepubertal TGD children due, in part, to a dearth of empirical research on longitudinal developmental trajectories of gender identity, role behavior, and gender dysphoria (when present). OBJECTIVE: The objective of this National Institutes of Health-funded study is to provide evidence to inform clinical care for prepubertal TGD children by establishing a US longitudinal cohort (N=248) of prepubertal TGD children and their caregivers that is followed prospectively at 6-month intervals across 18 months. METHODS: At each timepoint, clinical and behavioral data are collected via web-based visit from child and caregiver reporters. Latent class analysis, among other methods, is used to identify subgroups and longitudinally characterize the gender identity and gender-role behavior of TGD children. These models will define longitudinal patterns of gender identity stability and characterize the relationship between TGD classes and mental and behavioral health outcomes, including the moderating role of social gender transition (when present), on these associations. RESULTS: Baseline data collection (N=248) is complete, and the identification of TGD subgroups based on gender identity and expression using latent class analysis is anticipated in 2024. The completion of all 4 waves of data collection is anticipated in July 2024, coinciding with the start of a no-cost study extension period. We anticipate longitudinal analyses to be completed by winter 2024. CONCLUSIONS: Through a longitudinal observational design, this research involving prepubertal TGD children and their caregivers aims to provide empirical knowledge on gender development in a US sample of TGD children, their mental health symptomology and functioning over time, and how family initiated social gender transition may predict or alleviate mental health symptoms or diagnoses. The research findings have promise for clinicians and families aiming to ensure the best developmental outcome for these children as they develop into adolescents. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55558.

Geriatric Pharmacotherapy Case Series: Clotting and Gender-Affirming Care.

Background A transfeminine patient is a 79-year-old with past medical history significant for type 2 diabetes mellitus, hypertension, gender dysphoria, chronic kidney disease, dyslipidemia, total left hip replacement, and recent provoked deep venous thromboembolism (DVT). She was seen by a pharmacist in a primary care clinic after her discharge from a skilled nursing facility. The patient was experiencing symptoms of gender dysphoria after discontinuation of her estradiol in setting of her DVT. Assessment Her renal function was calculated to ensure she was on appropriate dosing of her medications. Because her DVT was provoked, providers determined she would require only 3 months of anticoagulation. Her laboratory test results showed a subtherapeutic estradiol level and her estradiol was restarted. Additionally, aspirin was being prescribed for primary prevention of atherosclerotic cardiovascular disease and was discontinued. Outcome She has significant improvement in her gender dysphoria symptoms with resuming her estradiol and now has a therapeutic estradiol level. She is tolerating her direct oral coagulant well and reports good quality of life. Conclusion When reviewing medications for patients it is important to take several factors into account, including dose, appropriate indication, and patient preference. Pharmacists play a key role, through collaboration with providers, in assessing these medication-specific factors. Estradiol was stopped in this patient because of her DVT, but given her DVT was provoked after a recent surgery, it was unlikely that estradiol was the cause of her clot. Weighing the risks and benefits for any patient is important when determining what medications are appropriate to continue. Additionally, calculating renal function appropriately in a gender-non-conforming patients ensures appropriate and safe dosing.

Military Family Physicians' Readiness to Provide Gender-Affirming Care: A Serial Cross-Sectional Study.

PURPOSE: Family physicians are increasingly more likely to encounter transgender and gender-diverse (TGD) patients requesting gender-affirming care. Given the significant health inequities faced by the TGD community, this study aimed to assess changes in military-affiliated clinicians' perspectives toward gender-affirming care over time. METHODS: Using a serial cross-sectional survey design of physicians at the 2016 and 2023 Uniformed Services Academy of Family Physicians conferences, we studied participants' perception of, comfort with, and education on gender-affirming care using Fisher's Exact tests and logistic regression. RESULTS: Response rates were 68% (n = 180) and 69% (n = 386) in 2016 and 2023, respectively. Compared to 2016, clinicians in 2023 were significantly more likely to report receiving relevant education during training, providing care to >1 patient with gender dysphoria, and being able to provide nonjudgmental care. In 2023, 26% reported an unwillingness to prescribe gender-affirming hormones (GAH) to adults due to ethical concerns. In univariable analysis, female-identifying participants were more likely to report willingness to prescribe GAH (OR = 2.6, 95%CI = 1.7-4.1) than male-identifying participants. Willingness to prescribe was also associated with ≥4 h of education (OR = 2.2, 95%CI = 1.1-4.2) compared to those with fewer than 4 h, and those who reported the ability to provide nonjudgmental care compared to those who were neutral (OR = 0.09, 95%CI = 0.04-0.2) or disagreed (OR = 0.11, 95%CI = 0.03-0.39). Female-identifying clinicians were more likely to agree additional training would benefit their practice (OR = 5.3, 95%CI = 3.3-8.5). CONCLUSIONS: Although military-affiliated family physicians endorsed more experience with and willingness to provide nonjudgmental gender-affirming care in 2023 than 2016, profound gaps in patient experience may remain based on the assigned clinician. Additional training opportunities should be available, and clinicians unable to provide gender-affirming care should ensure timely referrals. Future research should explore trends across clinical specialties.

Aesthetic Considerations for Neuromodulator Use in Transgender Patients.

BACKGROUND: The aesthetic dimension of transgender experiences involves various aspects linked to the visual representation and expression of one's gender identity. Nonsurgical cosmetic procedures, such as neuromodulators, have consequently become a viable treatment option for patients with gender dysphoria because of the ability to yield significant, although temporary, results with minimal associated risks and downtime. OBJECTIVE: To comprehensively review literature pertaining to the aesthetic considerations for use of neuromodulators in transgender and nonbinary individuals. MATERIALS AND METHODS: A literature review of PubMed/MEDLINE for studies was published through January 2024 for nonsurgical facial and body modification using neuromodulators. Searches were conducted with relevant keywords. Peer-reviewed articles and their references published within the past 10 years were given emphasis in the review. RESULTS: Based on the limited publications to date, the authors prepared a comprehensive review on indications for neuromodulator treatment in this population, including brow positioning, lower face contouring, lip eversion, trapezius slimming, and leg contouring. CONCLUSION: Dermatologists play a crucial role in facilitating the achievement of gender affirmation goals.

Technical Pearls and Pitfalls of Facial Feminization Surgery: A Review of Techniques From a Single Institutional Practice.

BACKGROUND: Facial feminization surgery (FFS) is an emerging practice that falls under the broader umbrella of gender-affirming surgery. Various approaches exist to feminize the face, yet few published articles describe in detail the techniques of each component procedure. Considering the diversity of interventions employed, the objective of this manuscript is to highlight FFS techniques utilized by the senior author and create a corresponding media gallery. METHODS: All patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation between June 2017 and August 2022 were reviewed. Data were retrospectively collected from electronic medical records according to the institutional review board (IRB)-approved study protocol. Data collected and analyzed included demographics, operative documentation, and postoperative follow-up. Multimedia material was collected intraoperatively and postoperatively. RESULTS: A total of 231 patients underwent 262 operations with a total of 1224 FFS procedures. The average follow-up time was 7.7 ± 11 months. Out of the 262 operations, 24 (9.2%) patients experienced minor complications, including 3 (1.1%) with wound dehiscence, 13 (5.0%) with hematomas, and 14 (5.3%) with postoperative infection requiring antibiotics. Of those, 3 (1.1%) required a return to the operating room for washout or removal of malar implants. CONCLUSION: Although there is a consensus on the fundamental surgical principles to achieve adequate feminization of the facial architecture, the specific techniques to do so differ according to individual practices. As techniques diverge, so do their risk profiles and outcomes; techniques must, thus, align with patients' interventional goals. The material presented here is one of many that can support trainees and junior surgeons as they build a gender-affirming practice.

Gender-Affirming Hormone Treatment and Metabolic Syndrome Among Transgender Veterans.

Importance: Gender-affirming hormone treatment (GAHT) is a common therapy for transgender individuals to reduce gender dysphoria and improve quality of life. Clarifying the long-term effects of GAHT remains a priority in transgender health research. Objective: To explore whether sex hormones (estradiol and testosterone) are associated with the development of metabolic syndrome in transgender veterans compared with cisgender veterans. Design, Setting, and Participants: This retrospective, longitudinal cohort study used International Classification of Diseases, Ninth Revision and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnosis codes for gender dysphoria from the Veterans Health Administration national database to identify transfeminine and transmasculine veterans receiving documented feminizing (estradiol) or masculinizing (testosterone) treatment from January 1, 2006, to December 31, 2019, and for whom the GAHT initiation date and metabolic syndrome component-related data were available. Transgender veterans were matched to cisgender referents. Exposure: Gender-affirming hormone treatment. Main Outcomes and Measures: Metabolic syndrome z-scores were calculated based on body mass index, systolic blood pressure, and levels of high-density lipoprotein cholesterol, triglycerides, and blood glucose. Changes in mean z-scores were compared among the transgender and cisgender groups before and after the index date (corresponding to GAHT initiation) using a repeated-measures analysis of variance model. Results: The cohort included 1290 participants: 645 transgender (494 [38.3%] transfeminine, 151 [11.7%] transmasculine) and 645 cisgender (280 [21.7%] female, 365 [28.3%] male). Mean (SD) age at the index date was 41.3 (13.2) years. Metabolic syndrome z-scores changed significantly over time and differed significantly across groups. Overall, transmasculine veterans had the greatest percentage increase in mean (SEM) z-scores after vs before the index date (298.0% [57.0%]; P < .001), followed by cisgender females (108.3% [27.5%]; P < .001), cisgender males (49.3% [27.5%]; P = .02), and transfeminine persons (3.0% [10.7%]; P = .77). Conclusions and Relevance: In this cohort study, in both cisgender and transgender veterans, estradiol was associated with reduced metabolic syndrome risk, whereas testosterone was associated with increased risk. However, transmasculine individuals had the greatest risk and transfeminine individuals had the lowest risk of metabolic syndrome associated with these hormones. This is relevant for the management of metabolic syndrome risk factors in cisgender and transgender individuals and to potentially predict the risk of atherosclerotic cardiovascular disease, type 2 diabetes, systolic hypertension, insulin resistance, and nonalcoholic fatty liver disease.

Puberty suppression in adolescents with gender dysphoria: an emerging issue with multiple implications.

Controversy exists over puberty suppression (PS) in adolescents with gender dysphoria (GD). PS is preferentially achieved with GnRH analogues. By preventing the development of secondary sex characteristics, PS may improve psychological functioning, well-being, quality of life, emotional and behavioral (especially internalizing) problems and depressive symptoms, thus decreasing suicidality. PS can also extend the diagnostic period and give transgender adolescents time to explore their gender identity. GnRHa may also decrease the need for feminization/masculinization surgery. However, 2-year treatment with GnRHa may result in bone mass accrual retardation (decrease in BMD/BMAD z-scores), growth velocity deceleration (decrease in height SDS), increase in fat mass, temporary pause in oocyte/sperm maturation. The most common side effects of GnRHa are hot flashes, mood fluctuations, fatigue and headache. They are usually mild and rarely lead to GnRHa discontinuation. Based on current scientific evidence, PS could be recommended to adolescents who meet the diagnostic criteria of gender incongruence (by DSM-5 and/or ICD-11) and have long-lasting intense GD, which aggravates with puberty onset. Before initiating PS, possible mental issues should be addressed and informed consent (by the adolescent/caregiver) should be given, after counseling on probable reproductive effects of GnRHa. GnRHa can only be started after the adolescent has entered Tanner stage 2. Nevertheless, published studies are inadequate in number, small in size, uncontrolled and relatively short-term, so that it is difficult to draw safe conclusions on efficacy and safety of GnRHa. Large long-term randomized controlled trials are needed to expand knowledge on this controversial issue and elucidate the benefit and risks of PS.

Trans depathologisation and gender identity disorder in Japan: A critical discourse analysis of medical literature, 2010-2022.

Since the depathologisation movement in 2007 to challenge the pathologisation of trans identities in Western psychiatry, significant developments have occurred, including revisions to Standards of Care and diagnostic criteria such as ICD-11's gender incongruence and DSM-5's gender dysphoria, acknowledging gender diversity as an expected part of human development. This paper argues that Japanese medical models reflect global issues but also have unique aspects shaped by cultural and linguistic nuances. Using critical discourse analysis, this paper examines how depathologisation discourses are perceived in the Japanese medical community, focusing on the term seidouitsusei-syogai (gender identity disorder), presenting three ways in which seidouitsusei-syogai is used: psychiatric disorder, syogai/sikkan (impairment/disability/disorder), and diagnostic category. These uses are influenced by legal and social reforms, healthcare access and alignment with international classifications, while the medical profession's authority remains unexamined. Reflecting the structural challenges of diagnostic models in trans medicine, the interpretation of seidouitsusei-syogai differs from the English phrase 'gender identity disorder' due to the specific connotations of syogai in the Japanese context. By examining Japan's approach to depathologisation and medicalisation, this paper enriches the understanding of trans medicine and the impact of depathologisation discourse in Japan.

Peri-operative care of transgender and gender-diverse individuals: guidance for clinicians and departments.

INTRODUCTION: The objective of this document is to guide best practice to ensure the safety and dignity of transgender and gender-diverse people in the peri-operative period. While transgender and gender-diverse people may have specific health needs in relation to gender dysphoria, their health requirements go beyond their gender identity. Most doctors will provide care to someone who is transgender or gender-diverse at some stage in their career. It is therefore important that all anaesthetists are educated on specific considerations when caring for these patients. METHODS: A working party was assembled consisting of individuals with experience in direct clinical care of the relevant patient group, those who have expertise in endocrinology and gender-affirming hormones, educators on the topic of transgender and gender-diverse healthcare, and authors of both cisgender and transgender identities. After discussion among the working party, targeted searches of literature were undertaken. RESULTS: The authors initially came up with a list of over 25 recommendations which was subsequently revised to a list of 15 recommendations after further review by the working party. These included airway assessment and management; management of hormonal therapy; relevant issues in obstetric anaesthesia; and hospital infrastructure and processes. CONCLUSIONS: This document provides the first guidance produced to advise on best practice to ensure the safety and dignity of trans and gender-diverse individuals in the peri-operative period.

Testosterone and other treatments for transgender males and non-binary trans masculine individuals.

Testosterone therapy is the main hormonal treatment offered in transmen to alleviate somatic gender dysphoria. Testosterone can be administered via topical or injectable preparations to achieve physical changes resulting in masculinisation and improve quality of life for the treated individuals. The aim of our paper is to outline methods for testosterone replacement, their impact on main body systems of transmen, potential associated health risks and long term follow up. Androgen use in transgender medicine is safe with appropriate endocrine guidance and monitoring. Studies with longer follow-up period, including those who may prefer low dose testosterone, interested in pregnancy or older people may further improve the management of female-to-male transgender persons.

Gender-affirming hormone therapy for transgender and gender-diverse adults in Australia.

Gender-affirming hormone therapy (GAHT) is used by many transgender and gender-diverse adults to align physical characteristics with their gender identity, reduce gender incongruence and improve psychological functioning. This narrative review provides an overview of the initiation and monitoring of GAHT in an Australian context. Trans individuals treated with testosterone typically receive standard testosterone doses and formulations recommended for cisgender men, whereas those receiving estradiol GAHT are typically treated with estradiol in combination with an anti-androgen in those without orchidectomy. Proactive monitoring and mitigation of cardiovascular risk factors is pertinent in all transgender and gender-diverse adults and bone health is an important consideration in those using estradiol GAHT.

Mental Health Evaluation of Younger and Older Adolescents Referred to the Center of Expertise on Gender Dysphoria in Amsterdam, The Netherlands.

The present study aimed to investigate whether differences exist between younger and older presenting adolescents at the Center of Expertise on Gender Dysphoria regarding psychological functioning and autistic traits. A total of 1487 consecutively assessed adolescents between 2000 and 2018 were divided in younger presenters (age ≤ 13.9 years) and older presenters (age ≥ 14 years). Of younger presenters, 227 (41.1%) were assigned male at birth and 325 (58.9%) assigned female at birth. In older presenters, 279 (29.8%) were assigned male at birth and 656 (70.2%) assigned female at birth. Behavioral and emotional problems were assessed with the Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR). For autism traits, the Social Responsiveness Scale (SRS) was used. Compared to younger presenters, on both the CBCL and YSR older presenters had higher Total Problem (ß = 1.75, p = .005, CI 0.53-2.97, R2 = .04 and ß = 4.20, p < .001, CI 2.99-5.40, R2 = .07, respectively) and Internalizing Problem (ß = 4.43, p < .001, CI 3.13-5.74, R2 = .06 and ß = 6.69, p < .001, CI 5.31-8.07, R2 = .12, respectively) scores. Regarding autistic traits, a higher mean SRS total score was found in older presenting assigned males at birth (ß = 4.55, p = .036, CI 0.30-8.81, R2 = .34). In assigned females at birth, no statistically significant difference between older and younger presenters was found in mean SRS total score (ß = 1.19, p = .063, CI - 0.07 to 2.45, R2 = .39). Differences in mental health exist between younger and older presenting adolescents and call for an individualized approach in the clinical care of transgender adolescents.