[The first successful sex reassignment surgery: Magnus, Dora and the Institute of Sexology, Berlin in 1931]. / La première chirurgie de reassignation sexuelle réussie : Magnus, Dora et l'institut de sexologie de Berlin en 1931.

Magnus Hirschfeld was a brilliant German doctor campaigning for the decriminalization and destigmatization of homosexuality. During the very liberal Weimar Republic (1918-1933) he published his avant-garde articles, he created his Institute of Sexual Sciences (Institut für Sexualwissenschaft), where the first published transgender surgery took place, performed on Dora Richter in 1931 (we will be interested in this first report of successful intervention) and multiplied the interventions to abolish paragraph 175, penalizing "sodomy". Ultimately the rise of Nazism forced him to flee his country and end his life in France. Hirschfeld's work remained unfinished. His political activism and his over-media coverage earned him numerous criticisms even within the gay and lesbian movement of the time. Who was this strange doctor (the Einstein of sex, as an American promoter presented him during his conferences in 1930) who combined the faults, for the time, of being at the same time Jewish, homosexual and leftist?

Impact of Anti-Discrimination Legislation on Access to Gender-affirming Care: A Commercial Claims Analysis.

OBJECTIVE: To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services. METHODS: We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services. RESULTS: There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%). CONCLUSION: Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services.

Litigation in gender affirming surgery: Reviewing five decades of the medical malpractice landscape.

The present study sought to analyze malpractice cases related to gender affirming surgery to provide information to physicians as it may serve to minimize the risk of malpractice suits. The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to gender affirming surgery malpractice lawsuits. A total of 26 cases were identified between 1970 and 2020, five of which were determined relevant on further review. Motives included adverse surgical and medical outcomes, and failure to treat. All cases were decided in favor of the defendant and resulted in $0 compensatory damages.

Sex Reassignment Surgery, Marriage, and Reproductive Rights of Intersex and Transgender People in Sunni Islam.

The traditional gender binary constitutes an integral aspect of Islamic social ethics, which has a pivotal role in shaping religious obligations, legal proceedings, and interpersonal judgments within Muslim communities. Within the familial sphere, this gender binary underscores fundamental responsibilities encompassing parenthood, filial duties, and inheritance rights. Recent years have witnessed a growing challenge to the traditional concept of the gender binary within Islamic societies. This shift is driven by increasing social libertarianism that emphasizes gender fluidity and individual choice. Hence, this article aims to critically scrutinize evolving discussions and controversies about the rights of intersex and transgender individuals, particularly issues relating to sex reassignment or gender-affirming surgery, marriage, and reproduction, from the perspective of the Sunni tradition of Islam. To support the various interpretations and insights presented here, a comprehensive and rigorous analysis is carried out on various religious texts and scholarly sources to elucidate the theological and jurisprudential positions on gender issues. It is thus concluded that Shariah offers greater flexibility in the treatment of intersex individuals compared to those with gender dysphoria because the intersex condition is viewed as a physical impairment that is not the choice of the afflicted individual. By contrast, in the case of individuals with gender dysphoria, they are willfully attempting to change their recognized biological sex, that God had naturally given to them at birth. Therefore, it is recommended that such transgender individuals deserve respectful psychological and social rehabilitation with help and guidance from religious authorities, their families, and communities.

Association Between California's State Insurance Gender Nondiscrimination Act and Utilization of Gender-Affirming Surgery.

Importance: Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies. Objective: To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents. Design, Setting, and Participants: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019. Exposures: California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013. Main Outcomes and Measures: Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure. Results: A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001). Conclusions and Relevance: Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Streamlining Interstate Access to Gender-Affirming Surgeries.

This Viewpoint explains the obstacles faced by individuals seeking gender-affirming care and summarizes needed changes to improve quality of care and access to care.

SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people.

PURPOSE: Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people. METHODS: According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board. RESULTS: In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care. CONCLUSION: In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification.

Sex reassignement with or without surgery. New ethical and juridical pathways.

INTRODUCTION: The access to sex-reassignment surgery is based on the existence of an unequivocal dyscrasia between the morphological sex and the objective evidence that emerges from in-depth analysis of the individual's personality. In Italy, such type of surgical intervention is subject to the authorization of a judge. MATERIAL OF STUDY: Authors examine the recent Italian Constitutional judgement which has addressed the right to change legal sex status without the need for sex-reassignment surgery. DISCUSSION: The Italian approach is in line with scientific evidence that the physical and mental well-being of an individual does not always require the surgical rectification of primary sexual features. Thus, sex reassignment surgery is not to be considered mandatory; rather, it should be aimed at ensuring the transsexual individual's stable psychological and physical good. From an ethical point of view, the Court's decision is very important, since it does not subordinate such fundamental rights as gender identity, healthcare and equality to prior, highly invasive surgery. CONCLUSIONS: The authors point out that critical issues and obstacles to the full implementation of the right to gender identity remain, in that this right is still subject to the authorization of a judge. This approach does not seem to be in line with the recent World Health Organization (WHO) decision to remove the "gender incongruity" from the list of mental and behavioural disorders (as it is in the current International Classification of Diseases-10, so far), to decrease the stigma surrounding such a condition. KEY WORDS: Gender identity, Sex reassignment, Surgery, Stigma, Transsexualism, Transgender.

Female-to-Male Gender-Affirming Chest Reconstruction Surgery.

There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

O Processo transexualizador no SUS e a saúde mental de travestis e transexuais

Introdução: Com a criação de uma política nacional de atenção à saúde LGBT que preconiza o atendimento integral pela Portaria nº 2.836 (BRASIL, 2013), torna-se evidente a necessidade de se falar da saúde mental desse grupo. No Brasil, o diagnóstico de Transtorno de Identidade de Gênero possibilita o acompanhamento por equipe multidisciplinar e dá acesso ao tratamento e possivelmente à cirurgia. Desde 2008, ficou estabelecido pelas Portarias nº 457 e 1.707 que o processo transexualizador seria oferecido pelo SUS e no ano de 2013, a Portaria nº 2.803 veio ampliar essa assistência prestada (BRASIL, 2016). Através da Portaria nº 2.803 ficaram preconizadas como prioridades no processo transexualizador: o acolhimento feito com qualidade, o acesso aos serviços de saúde com respeito ao nome social, acesso desde a hormonioterapia até a cirurgia de adequação do corpo à identidade de gênero, e o atendimento integral. Objetivo: analisar a percepção dos usuários trans quanto ao atendimento recebido por eles em relação à promoção de sua saúde mental, no processo transexualizador oferecido pelo SUS. Método: Trata-se de uma pesquisa exploratória, com abordagem qualitativa. Participaram da pesquisa usuários transexuais em acompanhamento no Ambulatório TT, matriculados no período de 2015-2017. O quantitativo de participantes seguiu o método de amostragem por saturação, contando com 10 participantes. A coleta de dados foi feita através de entrevista semiestruturadas, onde continham informações sobre dados sociodemográficos e perguntas de avaliação de promoção de saúde mental no processo transexualizador. Resultados: tivemos uma participação de 10 usuários, todos com acompanhamento no processo de transexualização no ambulatório TT da UREDIP. Como perfil encontramos neste total de 10 participantes, duas (2) pacientes do gênero feminino e oito (8) do gênero masculino, portanto em sua maioria predomina nesse estudo o trans masculino. A média de acompanhamento neste processo é de 1 ano e 4 meses. Com relação à idade, a média foi de 29,1 anos, sendo a menor idade de 19 anos e a maior de 44 anos, ambos do gênero masculino. Todos se autodeclararam de cor parda. Na religião quando questionados as respostas foram diversificadas, sendo o maior número de católicos destes uma (1) é do genero feminino e dois (2) do gênero masculino. Chamamos atenção aqui que a participante GF2 que diz ser católica refere também ser da umbanda. Dois (2) dizem ser ateistas / sem religião, dois (2) referem ser umbandistas, dois (2) agnósticos e um (1) é espírita. A ocupação destes é diversificada, no gênero feminino uma diz ser vendedora e outra cabelereira. Já os homens trans, um (1) diz ser atendente de suplementação, um (1) Gerente de RH /DP; 1 (um) é autônomo; dois (2) são estudantes; um (1) professor de “Artes”; 1 (um) Auxiliar de produção; 1 (um) Tatuador/ Educador físico. Conclusão: Esta pesquisa proporcionou a análise da percepção dos usuários trans quanto ao atendimento recebido por eles em relação à promoção de sua saúde mental, no processo transexualizador oferecido pelo Sistema Único Saúde. Quanto ao conhecimento da transexualização, podemos dizer que a partir do ingresso desses pacientes no processo transexualizador os conflitos de ordem emocional que os acompanha desde a infância passa a ser desvendado e esclarecido, o que permite a eles o autoconhecimento com possibilidades de melhora da autoestima, autoimagem, refletindo na qualidade de vida. Pode-se observar a ausência do profissional enfermeiro específico para o programa, resumindo-se a equipe a psicologia, fonoaudiologia, nutrição, serviço social, endócrinologia. Em relação a relevância deste estudo para a enfermagem é preciso investigar o porquê da não inclusão do profissional enfermeiro na equipe multidisciplinar do processos de transexualização oferecido pelo SUS

[Dramatic increase of gender dysphoria in youth]. / Kraftig ökning av könsdysfori bland barn och unga - Tidigt insatt behandling ger betydligt bättre prognos.

Dramatic increase of gender dysphoria in youth In the past decade there has been a dramatic increase in the number of young people with gender dysphoria seeking help for gender-confirming medical interventions. From a situation of no more than a few patients annually, there were almost 200 referrals of gender dysphoria to the Astrid Lindgren Children's Hospital in 2016. This child and adolescent psychiatric unit has the whole country as a catchment area for patients <16 years. Gender-confirming medical interventions are regulated by a special law that sets a minimum age for legal and surgical gender reassignment to 18 years. The law, which is under revision, does not prevent medical investigations, hormonal therapy, and some surgical procedures before the age of 18. Gender dysphoria is defined as a persistent desire to live and be accepted as the opposite sex, usually accompanied by a perceived inconsistency with the sex assigned at birth and a desire to change the body in accordance with the perceived sex. The cause is unknown despite attempts of etiological mapping including genetic analyses, hormonal studies and modern brain imaging techniques. Repeated studies have shown that only a minority (about 20 %) of prepubertal children with gender dysphoria will have a persistent desire for later gender-confirming medical interventions, while the majority of those whose gender dysphoria is reinforced during puberty will later meet the diagnostic criteria for gender dysphoria (DSM-5) and transsexualism (ICD-10) (so called persisters). Persisters can be offered treatment with puberty stopping hormones to avoid the development of undesirable secondary sexual characteristics. Gender-confirming medical interventions are the only recommended treatment for gender dysphoria, and early treatment facilitates the ability to successfully pass in the desired sex, which is associated with a significantly better prognosis.

Transgender Inmates in Prisons.

Transgender inmates provide a conundrum for correctional staff, particularly when it comes to classification, victimization, and medical and health issues. Using LexisNexis and WestLaw and state Department of Corrections (DOC) information, we collected state statutes and DOC policies concerning transgender inmates. We utilized academic legal research with content analysis to determine whether a statute or policy addressed issues concerning classification procedures, access to counseling services, the initiation and continuation of hormone therapy, and sex reassignment surgery. We found that while more states are providing either statutory or policy guidelines for transgender inmates, a number of states are lagging behind and there is a shortage of guidance dealing with the medical issues related to being transgender.

Gender identity, healthcare access, and risk reduction among Malaysia's mak nyah community.

Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalise them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilisation patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally sensitive prevention and healthcare services for TGW.