Distinct dynamics and proximity networks of hub proteins at the prey-invading cell pole in a predatory bacterium.

In bacteria, cell poles function as subcellular compartments where proteins localize during specific lifecycle stages, orchestrated by polar "hub" proteins. Whereas most described bacteria inherit an "old" pole from the mother cell and a "new" pole from cell division, generating cell asymmetry at birth, non-binary division poses challenges for establishing cell polarity, particularly for daughter cells inheriting only new poles. We investigated polarity dynamics in the obligate predatory bacterium Bdellovibrio bacteriovorus, proliferating through filamentous growth followed by non-binary division within prey bacteria. Monitoring the subcellular localization of two proteins known as polar hubs in other species, RomR and DivIVA, revealed RomR as an early polarity marker in B. bacteriovorus. RomR already marks the future anterior poles of the progeny during the predator's growth phase, during a precise period closely following the onset of divisome assembly and the end of chromosome segregation. In contrast to RomR's stable unipolar localization in the progeny, DivIVA exhibits a dynamic pole-to-pole localization. This behavior changes shortly before the division of the elongated predator cell, where DivIVA accumulates at all septa and both poles. In vivo protein interaction networks for DivIVA and RomR, mapped through endogenous miniTurbo-based proximity labeling, further underscore their distinct roles in cell polarization and reinforce the importance of the anterior "invasive" cell pole in prey-predator interactions. Our work also emphasizes the precise spatiotemporal order of cellular processes underlying B. bacteriovorus proliferation, offering insights into the subcellular organization of bacteria with filamentous growth and non-binary division.IMPORTANCEIn bacteria, cell poles are crucial areas where "hub" proteins orchestrate lifecycle events through interactions with multiple partners at specific times. While most bacteria exhibit one "old" and one "new" pole, inherited from the previous division event, setting polar identity poses challenges in bacteria with non-binary division. This study explores polar proteins in the predatory bacterium Bdellovibrio bacteriovorus, which undergoes filamentous growth followed by non-binary division inside another bacterium. Our research reveals distinct localization dynamics of the polar proteins RomR and DivIVA, highlighting RomR as an early "hub" marking polar identity in the filamentous mother cell. Using miniTurbo-based proximity labeling, we uncovered their unique protein networks. Overall, our work provides new insights into the cell polarity in non-binary dividing bacteria.

Getting Precise about Gender and Sex Measurement: A Primer for Epidemiologists.

Accurately measuring gender and sex is crucial in public health and epidemiology. Iteratively reexamining how variables-including gender and sex-are conceptualized and operationalized is necessary to achieve impactful research. Reexamining gender and sex advances epidemiology toward its goals of health promotion and disease elimination. While we cannot reduce the complexities of sex and gender to simply an issue of measurement, striving to capture these concepts and experiences accurately must be an ongoing dialogue and practice-to the benefit of the field and population health. We assert that epidemiology must counteract misconceptions and accurately measure gender and sex in epidemiology. We aim to summarize existing critiques and guiding principles in measuring gender and sex that can be applied in practice.

Impact of hormonal therapy on HIV-1 immune markers in cis women and gender minorities.

BACKGROUND: Although sex hormones are recognized to induce immune variations, the effect of hormonal therapy use on immunity is only poorly understood. Here, we quantified how hormonal therapy use affects HIV-1 immune markers in cis women (CW) and trans women and non-binary people (TNBP) with HIV. METHODS: We considered CD4, CD8 and lymphocyte measurements from cis men (CM), CW and TNBP in the Swiss HIV Cohort Study. We modelled HIV-1 markers using linear mixed-effects models with an interaction between 'gender' (CW, TNBP) and 'hormonal therapy use' (yes/no). Models were adjusted on age, ethnicity, education level, time since start of antiretroviral therapy and use of intravenous drugs. We assessed the inflammatory effect of hormonal therapy use in 31 TNBP using serum proteomics measurements of 92 inflammation markers. RESULTS: We included 54 083 measurements from 3092 CW and 83 TNBP, and 147 230 measurements from 8611 CM. Hormonal therapy use increased CD4 count and CD4:CD8 ratio in TNBP more than in CW (pinteraction = 0.02 and 0.007, respectively). TNBP with hormonal therapy use had significantly higher CD4 counts [median = 772 cells/µL, interquartile range (IQR): 520-1006] than without (617 cells/µL, 426-892). This was similar to the effect of CW versus CM on CD4 T cells. Hormonal therapy use did not affect serum protein concentrations in TNBP. CONCLUSION: This study highlights the potential role of hormonal therapy use in modulating the immune system among other biological and social factors, especially in TNBP with HIV.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape.

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

Gender minority stress and diurnal cortisol profiles among transgender and gender diverse people in the United States.

The field of behavioral neuroendocrinology has only begun to explore the lived experiences of transgender and gender diverse (TGD) people exposed to stigma. In light of escalating attacks and legislation targeting TGD people in the United States, it is crucial to examine the physiological pathways through which gender minority stressors become embodied, impact health, and contribute to health inequities. The Trans Resilience and Health Study included baseline data collection from fall 2019 to spring 2020 from a sample of 124 TGD people, reflecting a diversity of gender identities (e.g., trans masculine, trans feminine, and nonbinary) and ages (range = 19-70 years old; M = 34.10), living in Michigan, Nebraska, Oregon, and Tennessee. These analyses examine experiences of gender-related enacted stigma in association with hypothalamic-pituitary-adrenal (HPA)-axis functioning. Among those experiencing the highest levels of enacted stigma, findings show a blunted cortisol awakening response and sluggish daily decline that resulted in elevated concentrations at bedtime compared to those experiencing less enacted stigma. These results of flattened diurnal activity are consistent with an emergent literature on discrimination as a social determinant of potential stress pathophysiology. In contrast, community connectedness was associated with a larger, more dynamic cortisol awakening response. These findings emphasize the importance of incorporating gender-minority stress and resilience measures when studying HPA-axis functioning among TGD people.

Advancing gender inclusivity for Two-Spirit, trans, nonbinary and other gender-diverse blood and plasma donors.

BACKGROUND AND OBJECTIVES: Two-Spirit, trans, nonbinary and other gender-diverse (2STGD) donors face challenges in donation. While many blood operators aim to address these challenges, to date, no empirical study with these donors has been conducted to guide their efforts. This paper reports 2STGD donors' views on a two-step approach asking donors their gender and sex assigned at birth (SAAB), and expanding gender options in donor registration. MATERIALS AND METHODS: A qualitative community-based study was conducted with 2STGD donors (n = 85) in Canada. Semi-structured, in-depth interviews were conducted from July to October 2022, audio-recorded and transcribed. Data were analysed using a thematic analytic framework. RESULTS: Participants were divided on their views of a two-step approach asking gender and SAAB. Themes underlying views in favour of this approach included the following: demonstrating validation and visibility, and treating 2STGD donors and cisgender donors alike. Themes underlying views not in favour or uncertain included potential for harm, compromising physical safety, and invalidation. All participants were in favour of expanding gender options if blood operators must know donors' gender. CONCLUSION: Results indicate that a two-step approach for all donors is not recommended unless the blood operator must know both a donor's gender and SAAB to ensure donor and/or recipient safety. Gender options should be expanded beyond binary options. Ongoing research and evidence synthesis are needed to determine how best to apply donor safety measures to nonbinary donors.

Incorporating transgender and nonbinary participants in phase 1 clinical drug trials: Current knowledge gaps and considerations.

Phase 1 clinical drug trials critically depend on the participation of healthy volunteers to evaluate the safety and pharmacokinetics of new medicinal products. Current selection criteria and health definitions often overlook the unique health profiles of transgender and nonbinary individuals, potentially excluding them from participating in these essential early-stage studies. This review aims to identify and discuss current knowledge gaps and considerations regarding the inclusion of transgender and nonbinary participants in phase 1 clinical drug trials. We highlight the need for research on how gender-affirming hormone therapy may affect drug pharmacokinetics and call for the development of inclusive biological reference ranges that account for the physiological effects of hormone therapies.

Prevalence and correlates of workplace violence: descriptive results from the National Transgender Discrimination Survey.

OBJECTIVE: To describe the lifetime prevalence of workplace harassment, physical violence and sexual assault against transgender and non-binary workers targeted due to their gender identity and to identify correlates of this workplace violence. METHODS: This descriptive cross-sectional study used data from 4597 transgender or non-binary respondents from the 2008-2009 National Transgender Discrimination Survey. Respondents reported if they had ever experienced harassment, physical violence or sexual assault at work specifically because of their gender identity. We estimated the prevalence of each type of violence stratified by gender identity, race/ethnicity, age, educational attainment, history of working in the street economy (eg, sex industry, drug sales) and if people at work knew their gender identity. RESULTS: Workplace violence was prevalent, with 50% of transgender and non-binary workers having ever experienced harassment, 7% physical violence and 6% sexual assault at work because of their gender identity. Harassment was common among all of these workers, but physical violence and sexual assault were more than twice as common among transfeminine and non-binary workers assigned male at birth, workers of colour, workers with low educational attainment and those who had ever worked in the street economy. CONCLUSIONS: Transgender and non-binary workers commonly face violence at work because of their gender identity. Workplace violence prevention programmes should incorporate ways to prevent gender identity-based violence and facilitate channels for workers to report the occurrence of discrimination and violence.

Binary and Non-binary Gender Identities, Internalizing Problems, and Treatment Wishes Among Adolescents Referred to a Gender Identity Clinic in Germany.

Clinical research on transgender and gender-nonconforming (TGNC) adolescents has focused on binary individuals or often not differentiated among gender identities. Recent studies suggest that a considerable proportion of TGNC adolescents identify as non-binary and that these youth report more internalizing problems as well as different transition-related medical treatment wishes than binary adolescents. However, the results are inconclusive, and data for the German-speaking area are lacking. Therefore, the present study aimed to assess the percentage of binary and non-binary gender identities in a German sample of clinically referred TGNC adolescents and examine associations of gender identity with internalizing problems and transition-related medical treatment wishes. The sample consisted of 369 adolescents (11-18 years, Mage = 15.43; 305 birth-assigned female, 64 birth-assigned male) who attended the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS) between 2013 and 2019. Gender identity and treatment wishes were assessed using study-specific items and internalizing problems using the Youth Self-Report. In total, 90% (n = 332) of the sample identified as binary and 10% (n = 37) as non-binary. Having a non-binary gender identity was significantly associated with more internalizing problems and with wishing for no transition-related medical treatment or only puberty-suppressing hormones. The results underscore that non-binary adolescents represent a specifically vulnerable subgroup within TGNC adolescents with unique mental health needs and treatment wishes. Future research should differentiate among various gender identities. In clinical practice, it is crucial to create an inclusive space for non-binary youth and provide mental health care if needed.

Describing Non-Binary People's Encounters with the Healthcare System: A Qualitative Study in Catalonia (Spain).

Non-binary people face numerous stressors in their daily lives, including personal, interpersonal, and environmental. These stressors gain strength when such individuals access healthcare services, and discrimination and cisgenderism become the main barrier to obtaining gender-affirming healthcare. This study aimed to describe the experiences of non-binary people regarding the care and medical attention received in Catalonia (Spain). A qualitative phenomenological study was conducted with 21 non-binary people recruited using snowball sampling in 2022. Data were gathered through open-ended interviews and analyzed using thematic analysis. Two main themes were identified, which were further classified into two categories each: Theme 1-This is me composed of the categories, "My Name and My Pronouns" and "One's Chosen Gender," and Theme 2-I do not exist for the health system consisting of "Uneducated Health System in Sexual Health" and "Feeling Like an Outsider for Being Non-Binary." Non-binary people face multiple stressors when accessing the healthcare services that makes them feel invisible, vulnerable, and marginalized. Further widespread implementation of person-centered care is essential to promote the relationship between non-binary people and the healthcare system. In addition, further sexual health training is required for all health professionals.

Discrimination, gender dysphoria, drinking to cope, and alcohol harms in the UK trans and non-binary community.

Transgender (trans) and non-binary people may be at increased risk of alcohol harms, but little is known about motives for drinking in this community. This study explored the relationship between risk of alcohol dependence, experience of alcohol harms, drinking motives, dysphoria, and discrimination within a United Kingdom sample of trans and non-binary people with a lifetime history of alcohol use. A cross-sectional survey was co-produced with community stakeholders and administered to a purposive sample of trans and non-binary people from 1 February until 31 March 2022. A total of 462 respondents were included-159 identified as non-binary and/or genderqueer (identities outside the man/woman binary), 135 solely as women, 63 solely as men, 15 as another gender identity, 90 selected multiple identities. Higher levels of reported discrimination were associated with higher risk of dependence and more reported harms from drinking. Coping motives, enhancement motives, and drinking to manage dysphoria were associated with higher Alcohol Use Disorders Identification Test scores. Social, coping, and enhancement motives alongside discrimination and drinking to have sex were associated with harms. The relationship between discrimination and risk of dependence was mediated by coping motives and drinking to manage dysphoria. Further to these associations, we suggest that reducing discrimination against trans and non-binary communities might reduce alcohol harms in this population. Interventions should target enhancement motives, coping motives and gender dysphoria. Social and enhancement functions of alcohol could be replaced by alcohol free supportive social spaces.

Estimate and needs of the transgender adult population: the SPoT study.

BACKGROUND: Despite the increasing interest in transgender health research, to date little is known about the size of the transgender and gender diverse (TGD) population. METHODS: A web-based questionnaire survey was developed, including a collection of socio-demographic characteristics and disseminated online through social media. Gender incongruence was evaluated by using a 2-item approach assessing gender recorded at birth and gender identity. The primary objective of the present population-based study was to estimate the proportion of TGD people across ages among a large sample of people who answered a web-based survey. The secondary endpoints were to identify gender-affirming needs and possible barriers to healthcare access. RESULTS: A total of 19,572 individuals participated in the survey, of whom 7.7% reported a gender identity different from the sex recorded at birth. A significantly higher proportion of TGD people was observed in the youngest group of participants compared with older ones. Among TGD people who participated in the study, 58.4% were nonbinary, and 49.1% experienced discrimination in accessing health care services. Nonbinary TGD participants reported both the need for legal name and gender change, along with hormonal and surgical interventions less frequently compared to binary persons. CONCLUSIONS: Being TGD is not a marginal condition In Italy. A large proportion of TGD persons may not need medical and surgical treatments. TGD people often experience barriers to healthcare access relating to gender identity.

Sociodemographic profile, health-related behaviours and experiences of healthcare access in Italian transgender and gender diverse adult population.

PURPOSE: Information on the general health of transgender and gender diverse (TGD) individuals continues to be lacking. To bridge this gap, the National Institute of Health in Italy together with the National Office against Racial Discriminations, clinical centres, and TGD organizations carried out a cross-sectional study to define the sociodemographic profile, health-related behaviours, and experiences of healthcare access in Italian TGD adult population. METHODS: A national survey was conducted by Computer-Assisted Web Interviewing (CAWI) technique. Collected data were compared within the TGD subgroups and between TGD people and the Italian general population (IGP). RESULTS: TGD respondents were 959: 65% assigned female at birth (AFAB) and 35% assigned male at birth (AMAB). 91.8% and 8.2% were binary and non-binary TGD respondents, respectively. More than 20% of the TGD population reported to be unemployed with the highest rate detectable in AMAB and non-binary people. Cigarette smoking and binge drinking were higher in the TGD population compared with IGP (p < 0.05), affecting TGD subgroups differently. A significant lower percentage of AFAB TGD people reported having had screening for cervical and breast cancer in comparison with AFAB IGP (p < 0.0001, in both cases). Over 40% was the percentage of AFAB and non-binary TGD people accessing healthcare who felt discriminated against because of their gender identity. CONCLUSIONS: Our results are a first step towards a better understanding of the health needs of TGD people in Italy in order to plan the best policy choices for a more inclusive public health.

Gender affirmation and mental health in prison: A critical review of current corrections policy for trans people in Australia and New Zealand.

BACKGROUND: Trans people in prison experience disproportionate rates of harm, including negative mental health outcomes, and thus require special protections. Instead, corrections policies have historically further marginalised them. This critical policy review aimed to compare corrections policies for trans people in Australia and New Zealand with human rights standards and consider their mental health impact. METHODS: Online searches were conducted on corrections websites for each state/territory in Australia and New Zealand. Drawing on the Nelson Mandela Rules and Yogyakarta Principles, 19 corrections policies relevant to placement, naming, appearance and gender-affirming healthcare for trans people were reviewed. The potential mental health impact of these policies on incarcerated trans people was discussed using the Gender Minority Stress and Resilience framework. RESULTS: Australian and New Zealand corrections policies have become more concordant with human rights standards in the past 5 years. However, gender-related discrimination and human rights violations were present in corrections policies of all jurisdictions. New South Wales and Victorian policies had the highest concordance with human rights standards, while Queensland and South Australian policies had the lowest. CONCLUSION: Policies that contribute to discrimination and minority stress may increase risk of mental health problems and suicide for incarcerated trans people. Mental health professionals working in prisons need to be aware of these risks to provide safe and accessible mental healthcare for trans people. Collaborative policy development with trans people is essential to protect the safety and rights of incarcerated trans people and consider models beyond the gender binary on which correctional systems have been founded.

Use of gender-inclusive language in genetic counseling to optimize patient care.

Providing welcoming, inclusive, and culturally competent care is essential for genetic counselors (GCs) to serve the needs of all patients, including transgender and nonbinary (TGNB) individuals. Inclusive language creates welcoming healthcare spaces and improves health outcomes for TGNB individuals. Training on gender-affirming healthcare can increase knowledge, comfort, and self-efficacy working with TGNB patients. Using a mixed-method survey, this study assessed 65 GCs' gender-inclusive communication practices and elucidated reasons for discomfort using language to determine how language builds trust and fosters patient-provider relationships, ascertain differences between specialties, and identify potential gaps in education and professional development. This study found that approximately one-third of GCs are comfortable using gender-inclusive language and just over half regularly use it with patients. Most GCs do not share their pronouns or ask patients theirs, which was not correlated with comfort levels or frequency of using gender-inclusive language. There were no significant differences based on specialty. Thematic analysis of open responses revealed GCs used gendered language to promote shared language and for clarity, some mentioning sex assigned at birth was relevant for risk assessment. Most felt the impact of gendered language depended on the patient's perspective. Twenty-five percent noted gendered language was familiar for most patients and 40% recognized negative impacts on TGNB individuals. Most GCs desired more gender-inclusivity training even though >95% had some type previously. Those who had gender-inclusivity training in their genetic counseling program were more comfortable using gender-inclusive language and were more likely to share their pronouns with patients. This study adds to the growing body of literature demonstrating GCs' desire for more gender-inclusivity education and highlights the potential importance of having this education integrated into genetic counseling training programs. GCs should continue to incorporate gender-inclusive language into their practice in concordance with the tenants of the Reciprocal Engagement Model.

'I don't want to have to teach every medical provider': barriers to care among non-binary people in the Canadian healthcare system.

It is well-known that trans and non-binary individuals experience worse health outcomes due to experiences of violence and discrimination. For this reason, accessible healthcare for trans and non-binary people is crucial. There is a lack of Canadian literature on the experiences of non-binary people within the healthcare system. This study sought to understand barriers to healthcare among non-binary people living in a mid-sized urban/rural region of Canada. Interviews were conducted between November 2019 to March 2020 with 12 non-binary individuals assigned female at birth, living in Waterloo Region, Ontario, Canada, as a part of a larger qualitative study exploring experiences within the community, healthcare and employment. Three broad themes were developed: erasure, barriers to access to healthcare, and assessing whether (or not) to come out. Sub-themes included institutional erasure, informational erasure, general healthcare barriers, medical transition healthcare barriers, anticipated discrimination, and assessing safety. Policy and institutional changes are needed to increase the safety and accessibility of healthcare services to non-binary individuals.

Bleeding beyond binaries: a critical interpretive review of trans, non-binary and gender non-conforming experiences with menstruation.

While some barriers for managing menstruation have been mitigated for cisgender women, trans, non-binary, and gender non-conforming people still struggle to navigate menstruation in a gendered society. With an increasing number of young people identifying outside of the gender binary, there is an immediate need to identify and address the barriers to managing menstruation. This review sets out to explore how trans, non-binary, and gender non-conforming people experience and navigate menstruation. Using critical interpretive synthesis methodology, nine pieces of literature including peer-reviewed journal articles, graduate theses, a book chapter, and a conference poster presentation were reviewed using thematic analysis. Four primary themes were identified: (1) menstruation is strongly gendered; (2) there exists inadequate trans, non-binary, and gender non-conforming education and healthcare training; (3) the gendering of public toilets/washrooms poses a barrier to the management of menstruation; and (4) there exists a lack of diverse participants and attention to intersectional menstruation concerns. A set of recommendations, specific to a variety of stakeholders is provided, and implications for future research are discussed.

Helping to destigmatise the use of period products for trans, masculine presenting, non-binary and gender diverse (TMNG) consumers through an inclusive communication design framework.

This study aimed to understand the experiences that trans, masculine presenting, non-binary and gender diverse (TMNG) people who menstruate have with period product packaging and marketing, and identified opportunities for improvement through an inclusive communication design framework. Semi-structured online interviews were conducted with nine TMNG consumers, allies and advocates. These revealed positive and negative experiences with the current design of period product packaging and marketing throughout the entire 'user journey', including purchasing, use and disposal. A thematic analysis of the interviews confirmed that problems exist with the lack of representation through imagery and language on period product packaging and marketing. The resulting three themes were engaged with to develop an inclusive communication design framework that included: the need for an improvement in the physical experience of periods; the need for improved mental health and emotional relationship to periods; and the need for the consideration of broader social issues such as sustainability and accessibility in relation to period product packaging and marketing.

Developing a transgender and non-binary inclusive obstetrics and gynaecology undergraduate medical curriculum in Aotearoa/New Zealand: Where are we at, and where do we need to be?

Internationally, undergraduate medical education is not currently enabling early career doctors to meet the needs of trans and gender diverse (TGD) people as healthcare consumers. This review outlines inclusion of TGD education in undergraduate medical education more broadly to contextualise curriculum development needs in obstetrics, gynaecology and reproductive medicine in Aotearoa/New Zealand. Limited, and lack of integrated content, teaching capability and current absence of TGD health knowledge as graduate outcomes, compounded by pedagogy (biomedical/binary framing) and more appropriate learning resources are indicators for curricula, and workforce, development.

Assessing Preferences of Facial Appearance in Transgender and Gender Nonbinary Patients.

BACKGROUND: We designed a survey to evaluate preferences of facial appearance in transgender male (TM), transgender female (TF) and gender nonbinary patients to better inform goals of facial gender affirming surgery (FGAS) in gender nonbinary patients. METHODS: TM/TF and nonbinary patients > 18 years old were identified via retrospective chart review and distributed an anonymized survey via email from October 3 to December 31, 2022. To assess facial preferences, AI-generated and open-source portraits were edited to create five image sets with a range of features from masculine to feminine for the forehead, mandible/chin and hairline. Data were analyzed using Fisher's exact tests and ANOVA in R-Studio. RESULTS: Survey response rate was 32% (180 patients identified via chart review, 58 respondents; TM = 5, TF = 39, nonbinary = 14). TM and TF patients as well as TF and nonbinary patients had significantly different preferences for all regions (p < 0.005; all series), while TM and nonbinary patients did not (p => 0.05; all series). TF patients consistently selected 4s with neutral or more feminine features. TM and nonbinary patients, however, demonstrated no consistent preference for either male or female features but rather a range of responses spanning extremes of both masculine and feminine options. When stratified by sex assigned at birth, nonbinary patients consistently identified preferences opposite to their assigned gender. CONCLUSION: Gender nonbinary and TM patients appear to have uniquely individual preferences regarding facial appearance that do not fit into classically masculine or feminine patterns/phenotypes. As a result, we recommend individualized preoperative planning for FGAS to achieve the optimal result in these patient populations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .