Prospective Evaluation of Psychosocial Changes After Chest Reconstruction in Transmasculine and Non-Binary Youth.

PURPOSE: This study sought to prospectively examine the effects of gender-affirming chest reconstruction on gender congruence and chest dysphoria in transmasculine and nonbinary adolescents and young adults. METHODS: Individuals between the ages of 15-35 who were seeking gender-affirming chest surgery were enrolled as part of a broader, longitudinal study of transgender surgical experiences. Their chest dysphoria and gender congruence were measured at baseline, six months, and one year, using the Transgender Congruence and Chest Dysphoria scales. Repeated measures analysis of variance were used to detect differences in scores across assessment points. Where there were significant differences indicated, Tukey's honestly significant difference test was used to determine which differences in mean scores were significant between assessment points, as well as how results differed by demographic factors. RESULTS: The analytical sample consisted of 153 individuals who had completed both the baseline and at least one follow-up assessment - 36 (24%) endorsing a nonbinary gender and 59 (38%) under the age of 18. Repeated measures analysis of variance indicated significant differences in gender congruence, appearance congruence, and chest dysphoria between at least two assessment points for the total sample and each subgroup (binary/non-binary and adult/minor). Honestly significant difference tests indicated no significant differences between the postoperative assessments by age or binary gender. DISCUSSON: Gender-affirming chest reconstruction improves gender and appearance congruence and reduces chest dysphoria in both non-binary and binary populations of adolescents and young adults. These data support the need to improve access to gender-affirming chest reconstruction for adolescents and young adults and to remove legislative and other barriers to care.

Comparing scrotoplasty complication rates in transgender and cisgender men: An ACS NSQIP study.

While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older (M trans = 38 years (SD:14), M cis = 53 years (SD: 15)) and had higher BMI than the transgender cohort (M trans = 26.9 (SD: 5.5), M cis = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health (p = 0.001), and were more likely to have hypertension (p = 0.001) and diabetes (p = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time (M trans = 303 min (SD: 155), M cis = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty (p = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender patients.

Racial Disparities in the 30-Day Outcomes of Gender-affirming Chest Surgeries.

OBJECTIVE: To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries. BACKGROUND: Little is currently known about how race may affect the outcomes of gender-affirming surgeries. METHODS: We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression. RESULTS: There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers. CONCLUSIONS: Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries.

Feasibility of an External Erectile Prosthesis for Transgender Men Who have Undergone Phalloplasty.

INTRODUCTION: Transgender men interested in achieving penetration after phalloplasty are currently limited to internal devices and makeshift supports. More options are needed to support sexual penetration after phalloplasty. AIM: This study was designed to assess the feasibility of an external erectile prosthesis (the Elator) for transgender men who have undergone phalloplasty and wish to use their neophallus for sexual penetration, assess how the device affected the sexual experiences of men and their partners, and identify any side effects and concerns. METHODS: Transgender men and their partners were provided with an erectile device to use for one month. They were surveyed at 4 time points: enrollment, measurement, receipt, and after using the device, using a combination of pre-existing and device-specific measures. MAIN OUTCOME MEASURE: The primary outcome was whether men found it feasible to use an external penile prosthesis for sexual penetration after phalloplasty - defined as interest in, and willingness to, use the device more than once over the study period; intention to continue using the device on the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS); and no decrease in relationship satisfaction on the Gay and Lesbian Relationship Satisfaction Scale (GLRSS). The secondary outcome was an increase in sexual or relationship satisfaction with use of the device, defined as a statistically significant increase on either the Quality of Sexual Experience Scale (QSE) or the GLRSS. RESULTS: Fifteen couples enrolled in the pilot study. Of the 10 who completed the study, only 3 found device use feasible and endorsed strongly positive experiences, while the remaining 7 found it unusable. There were no changes in QSE or GLRSS scores. Most device issues were related to proper fit. CONCLUSION: There is a great deal of interest in non-surgical options for achieving penetration after phalloplasty. The tested external erectile device can work well, but its utility is limited to individuals with very specific post-phalloplasty anatomy. Most individuals and couples found the device unsuitable for the neophallus and/or that it could not be used comfortably. Boskey ER, Jolly D, Mehra G, et al. Feasibility of an External Erectile Prosthesis for Transgender Men Who have Undergone Phalloplasty. Sex Med 2022;10:100560.

Can gender-affirming surgeries be safely combined? An NSQIP analysis of 30-day outcomes and case planning factors.

As gender-affirming surgeries are being performed, new techniques have been developed to meet patient desires, including recent reports of several gender-affirming procedures being combined into a single operative encounter. Such a development may provide several advantages to both patients and providers. However, it is less clear whether combining these procedures affects patient safety and surgical case planning factors. To address this, we compared the complication rates and the length of hospital stay and operative time for standalone and combined gender-affirming procedures (e.g., hysterectomy and bilateral mastectomy, breast augmentation, and vaginoplasty) performed between 2005 and 2019 in the National Surgical Quality Improvement Program database. There were 1857 standalone mastectomies, 826 standalone hysterectomies, and 30 cases where they were combined. There were 379 vaginoplasties, 648 breast augmentations, and 31 cases where they were combined. There was no evidence of differences in overall health status between those undergoing combined and standalone procedures. Two-sample proportion testing did not find significant differences in any of the complications experienced between standalone and combined procedures. Similarly, two-sample t-tests did not find significant differences in the length of the hospital stays nor in the length of the operative encounter between standalone and combined masculinizing surgeries. Combining breast augmentation and vaginoplasty, however, saved an average of 97.86 min (p = .000) of operating time. These results suggest that combining gender-affirming procedures may be a safe and viable option for individuals who desire multiple gender-affirming procedures and may even be an advantageous option for patients and practitioners alike.

Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty.

BACKGROUND: Transgender men who undergo gender-affirming phalloplasty have limited options for attaining sufficient rigidity for sexual penetration. AIM: The goal of this study was to understand interest in and concerns about internal erectile prostheses among transgender men who had undergone phalloplasty. METHODS: As part of a pilot study of an external erectile device, transgender men (n = 15) were surveyed about their interest in, and concerns about, getting an internal prosthesis. Descriptive analyses were performed for structured questions and content analysis was used to analyze open responses. OUTCOMES: Measured outcomes included closed- and open-ended questions assessing patient attitudes about internal erectile prostheses. RESULTS: Before starting the study, approximately half the men stated they were interested in getting an internal device, 20% said they weren't, and 33% said they didn't know. More than half of this postphalloplasty population stated they were somewhat or very concerned about the need for additional surgery (73%), side effects (pain, damage to the phallus; 100%), and the risk of device failure (100%). An additional 47% stated they were somewhat or very concerned about cost and 33% stated they were somewhat or very concerned about finding a surgeon. CLINICAL IMPLICATIONS: There is a need to develop appropriate alternatives to current internal prostheses for penetrative function after phalloplasty. STRENGTHS & LIMITATIONS: Generalizability of results is limited by the fact that data are from men who had enrolled in a pilot study to test an external erectile prosthesis, and as such were explicitly interested in exploring nonsurgical alternatives to attain an erection. The combination of quantitative and qualitative data demonstrates that transgender men's concerns about internal prostheses are grounded in the current evidence. CONCLUSION: Transgender men who have undergone phalloplasty have substantial concerns about the risks of getting an internal prosthesis and there is significant interest in alternatives to current devices. Boskey ER, Mehra G, Jolly D, et al. Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty. J Sex Med 2022;19:1055-1059.

Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes.

INTRODUCTION: There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men's equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty. AIM: To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction. METHODS: We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors. MAIN OUTCOME MEASURES: Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula. RESULTS AND CONCLUSION: A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique. Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294.

Barriers to Gender-affirming Surgery Consultations in a Sample of Transmasculine Patients in Boston, Mass.

Gender diverse people are increasingly pursuing gender-affirming surgery, but little is known about their experiences on accessing care. As part of the baseline assessment for an ongoing longitudinal study, we examined the types of barriers and self-reported out-of-pocket costs associated with gender-affirming surgery most commonly endorsed by transmasculine chest (top) and genital (bottom) surgery patients at their initial surgical consultation. METHODS: A brief survey was administered to a clinical sample of transmasculine patients (n = 160; age ≥15 years) seeking a gender-affirming surgery at the Center for Gender Surgery in Boston, Mass. from April 2018 to February 2020. RESULTS: The barriers most commonly endorsed by top surgery patients were insurance coverage and age. For bottom surgery patients, the most commonly endorsed barriers were getting mental health letters and readiness for surgery. Bottom surgery patients were also more likely to report barriers of readiness for surgery and cost of/access to hair removal, than top surgery patients (Ps < 0.05). Bottom surgery patients were more likely to report out-of-pocket costs related to hair removal, surgical consultation, and surgery (Ps < 0.05), whereas top surgery patients were more likely to report hormone treatment costs (P = 0.01). Average out-of-pocket costs were high (mean = 2148.31) and significantly higher for bottom surgery patients (b = 4140.30; ß = 0.64; 95% confidence interval, 3064.6-5216.0). CONCLUSIONS: Transmasculine patients experience a variety of barriers when seeking gender-affirming surgery. Presurgical requirements, insurance access, and high out-of-pocket costs may hinder access to care for many transmasculine people seeking bottom surgery.

Median Nerve Neuropathy following Radial Forearm Free Flap Phalloplasty: A Case Report.

As the transgender population increases, gender-affirming surgeries are being performed at unprecedented rates. Despite this increase, complications and long-term outcomes of gender-affirming interventions are largely understudied. We present a transgender patient who underwent radial forearm free flap (RFFF) phalloplasty as part of gender affirmation. Immediately following surgery, the patient reported paresthesia in the donor arm in the median nerve distribution followed by a neuropathic pain after 1 week. The patient complained of shooting and burning pain and reported a loss of sensation and function at the donor site. Electromyography and magnetic resonance imaging results indicated median nerve damage several inches above the donor site. The symptoms persisted for several months before spontaneously resolving. The spontaneous resolution and location of injury suggest that nerve damage occurred as a result of pneumatic tourniquet application despite adherence to all clinical guidelines for a safe tourniquet application of the same. This is the first reported case of neuropathic pain following RFFF phalloplasty occurring at the donor site. Given the large donor area and the long time of tourniquet application, surgeons offering RFFF phalloplasty must be aware of and actively counsel patients seeking this procedure about the potential for nerve-related damages before surgery.

Behavioral Health Concerns and Eligibility Factors Among Adolescents and Young Adults Seeking Gender-Affirming Masculinizing Top Surgery.

Purpose: We evaluated behavioral health histories and eligibility factors for patients seeking chest reconstruction. Methods: One hundred and fifty-eight consecutive transgender patients were seen for initial masculinizing top surgery consults between May 2017 and July 2019. Chart review was used to assess behavioral health and demographic factors, and eligibility factors related to the World Professional Association for Transgender Health (WPATH) Standards of Care. Univariate and age-adjusted regression models were used to examine the relationship between demographic and behavioral health factors and WPATH criteria. Results: The average age of patients at the time of their first consult was 18 (standard deviation = 3.3, range = 14-33). Eighty-five percent had at least one behavioral health diagnosis; 27% had three or more. Sixty-four percent endorsed a history of self-harm or suicidal ideation, 13% within the last 6 months. Thirty-two percent reported a history of marijuana use and 19% a history of nicotine use. For those prescribed testosterone, additional months on testosterone were significantly associated with male (vs. nonbinary) gender (ß = 4.64, 95% confidence interval [CI] 0.37-8.90, p = 0.033), age (ß = 0.87, 95% CI 0.41-1.34, p < 0.001), living as one's affirmed gender for over 1 year (ß = 6.37, 95% CI 1.37-11.37, p = 0.013), history of marijuana use (ß = 4.54, 95% CI 1.10-7.98, p = 0.010), and history of nicotine use (ß = 6.23, 95% CI 2.22-10.26, p = 0.003). Conclusion: Patients seeking gender-affirming masculinizing top surgery are behaviorally complex, in ways not necessarily associated with surgical eligibility. Involving a behavioral health provider in perioperative assessment can help identify and address potential risks to recovery and outcomes.

Are Prophylactic Postoperative Antibiotics Necessary after Masculinizing Mastectomy with Free Nipple Graft? A Single-institution Retrospective Review.

Antibiotic overuse, particularly in the postoperative period, has contributed substantially to increased rates of antibiotic resistance. Despite insufficient evidence to support prolonged prophylactic antibiotics following the majority of plastic surgery operations, and societal recommendations against the practice, many surgeons continue to perpetuate this cycle. Regarding "newer" operations, wherein minimal data pertaining to antibiotic use have been published, decision-making is often based on historical tradition. As such, continued communication of relevant data is essential to inform best practice guidelines. The aim of this case series was to report postoperative outcomes following chest masculinization with free nipple grafts performed according to a strict antibiotic protocol, which restricted prophylaxis to a single preoperative dose, in the absence of specific risk factors indicating a need for postoperative antibiotics. In this case series featuring 62 consecutive patients undergoing chest reconstruction with 124 free nipple grafts, there were no nipple losses or nipple graft infection events.

EXOGENOUS TESTOSTERONE DOES NOT INDUCE OR EXACERBATE THE METABOLIC FEATURES ASSOCIATED WITH PCOS AMONG TRANSGENDER MEN.

OBJECTIVE: Polycystic ovary syndrome (PCOS) is a complex condition which can include menstrual irregularity, metabolic derangement, and increased androgen levels. The mechanism of PCOS is unknown. Some suggest that excess production of androgens by the ovaries may cause or exacerbate the metabolic findings. The purpose of this study was to assess the role of increased testosterone on metabolic parameters for individuals presumed to be chromosomally female by examination of these parameters in hormone-treated transgender men. METHODS: In 2015 and 2016, we asked all transgender men who visited the Endocrinology Clinic at Boston Medical Center treated with testosterone for consent for a retrospective anonymous chart review. Of the 36 men, 34 agreed (94%). Serum metabolic factors and body mass index (BMI) levels for each patient were graphed over time, from initiation of therapy through 6 years of treatment. Bivariate analyses were conducted to analyze the impact of added testosterone. RESULTS: Regressions measuring the impact of testosterone demonstrated no significant changes in levels of glycated hemoglobin (HbA1c), triglycerides, or low-density-lipoprotein cholesterol. There was a statistically significant decrease in BMI with increasing testosterone. There was also a statistically significant decrease in high-density lipoprotein levels upon initiation of testosterone therapy. CONCLUSION: Testosterone therapy in transgender men across a wide range of doses and over many years did not result in the dyslipidemia or abnormalities in HbA1c seen with PCOS. Instead, treatment of transgender men with testosterone resulted only in a shift of metabolic biomarkers toward the average physiologic male body. ABBREVIATIONS: BMI = body mass index; HbA1c = glycated hemoglobin; HDL = high-density lipoprotein; LDL = low-density lipoprotein; PCOS = polycystic ovary syndrome.

ESTROGEN LEVELS DO NOT RISE WITH TESTOSTERONE TREATMENT FOR TRANSGENDER MEN.

OBJECTIVE: Existing transgender treatment guidelines suggest that for transmasculine treatment, there is a possible need for estrogen-lowering strategies adjunct to testosterone therapy. Further, guidelines advocate consideration of prophylactic female reproductive tissue surgeries for transgender men to avoid the possibility of estrogen-related health risks. Despite the paucity of objective data, some transgender men seek conversion inhibitors. We sought to determine estradiol levels in transgender men treated with testosterone therapy and the change in those levels with treatment, if any. METHODS: Estradiol levels were extracted from the electronic medical records of 34 anonymized transgender men treated with testosterone therapy at the Endocrinology Clinic at Boston Medical Center. Data were sufficient to observe 6 years of follow-up. RESULTS: With increased testosterone levels in trans-gender men, a significant decrease in estradiol levels was noted. There was a significant negative correlation between testosterone levels and body mass index, which may serve to explain part of the mechanism for the fall in estradiol levels. Even though the fall in estradiol levels was significant statistically, the actual levels remained within the normal male range, even with 6 years of follow-up. CONCLUSION: These data suggest that when exogenous testosterone is used to achieve normal serum male testosterone levels for transgender men, it is converted to normal male levels of estradiol, with some decline in those estradiol levels that might be attributable to a fall in fat mass. There appears to be no role for aromatase conversion inhibitors or other estrogen-reducing strategies in trans-gender men. Abbreviation: BMI = body mass index.

TESTOSTERONE LEVELS ACHIEVED BY MEDICALLY TREATED TRANSGENDER WOMEN IN A UNITED STATES ENDOCRINOLOGY CLINIC COHORT.

OBJECTIVE: Most transgender women depend on medical treatment alone to lower testosterone levels in order to align physical appearance with gender identity. The medical regimen in the United States typically includes spironolactone and estrogens. The purpose of this cross-sectional study was to assess the testosterone suppression achieved among transgender women treated with spironolactone and estrogens. METHODS: Testosterone and estradiol levels were extracted from the electronic medical records of 98 anonymized transgender women treated with oral spironolactone and oral estrogen therapy at the Endocrinology Clinic at Boston Medical Center. RESULTS: Patients starting therapy required about 9 months to reach a steady-state testosterone, with significant heterogeneity of levels achieved among patients. Patients with normal body mass index (BMI) had higher testosterone levels, whereas patients with obese BMI had lower testosterone levels throughout treatment. Stratification of patients by age or spironolactone dosage revealed no significant difference in testosterone levels achieved. At steady state, patients in the highest suppressing quartile were able to achieve testosterone levels of 27 ng/dL, with a standard deviation of 21 ng/dL. Measured serum estradiol levels did not change over time and did not correlate with dosage of estradiol administered. CONCLUSION: Among a cohort of transgender women treated with spironolactone and estrogen, the highest suppressing quartile could reliably achieve testosterone levels in the female range at virtually all times. The second highest suppressing quartile could not achieve female levels but remained below the male range virtually all of the time. One quartile was unable to achieve any significant suppression. ABBREVIATIONS: BMC = Boston Medical Center BMI = body mass index CPY = cyproterone acetate LC-MS/MS = liquid chromatography-tandem mass spectrometry Q = quartile.