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.

Differences in Subjective Transition Outcomes Between Transgender and Gender-Diverse Individuals Who Completed Mandatory Psychiatric Assessment and Those Who Received Gender-Affirmative Medical Treatment in Croatia: A Cross-Sectional Online Survey.

The aim of this study was to evaluate different aspects of transition outcomes in groups of transgender and gender diverse (TGD) people based on their transition status. We divided the 70 TGD participants (19 individuals assigned male at birth and 51 assigned female at birth) into two groups: those who had completed their psychiatric and psychological evaluation (PPE), which is mandatory in Croatia, and those who had undergone gender-affirming medical treatment (GAMT) (both gender-affirming hormone treatment and gender-affirming surgery). The online survey included sociodemographic questions and a custom-designed nine-item scale. The items were specifically designed based on the DSM-5-TR criteria for gender dysphoria to assess subjectively perceived transition outcomes. We conducted a factor analysis of the scale followed by structural equation modeling for confirmation. Chi-squared and Mann-Whitney U tests were used to compare group differences. The following three-factor structure was confirmed: better functioning, reduced body dysphoria, and satisfaction with decision. A positive influence of better functioning on satisfaction with the decision was found. In addition, our results showed that TGD individuals who had undergone GAMT scored higher on better functioning than those who had just completed PPE. Both groups consistently scored high on satisfaction with the decision, with no statistically significant differences between them. Our findings suggest that TGD individuals view gender-affirming medical care as beneficial to their overall functioning.

Association between genital gender-affirming surgery and psychiatric comorbidities in individuals with gender incongruence.

BACKGROUND: Previous studies present mixed evidence on the relationship between psychiatric comorbidities and genital gender-affirming surgery (GGAS) in individuals with gender incongruence (GI). AIM: This research aims to investigate the psychiatric comorbidity rates post-GGAS in the GI population-namely, depressive disorders, anxiety disorders, posttraumatic stress disorders, substance abuse disorder, and suicidality. METHODS: Based on the TriNetX health care database, an international database with >250 million patients, a cross-sectional study was executed comparing psychiatric comorbidity rates among cases of GI with and without GGAS. Individuals were matched for demographic and health-related variables, which included history of cardiovascular disease, diabetes, and obesity. OUTCOMES: The main focus was to establish the rates and changes in psychiatric comorbidities following GGAS. RESULTS: Among individuals with GI, the study identified 4061 with GGAS and 100 097 without. At 1 year post-GGAS, there was a significant decrease in depression (odds ratio [OR], 0.748; 95% CI, 0.672-0.833; P < .0001), anxiety (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), substance use disorder (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), and suicidality (OR, 0.530; 95% CI, 0.425-0.661; P < .0001), and these reductions were maintained or improved on at 5 years, including posttraumatic stress disorder (OR, 0.831; 95% CI, 0.704-0.981; P = .028). CLINICAL IMPLICATIONS: The findings indicate that GGAS may play a crucial role in diminishing psychiatric comorbidities among individuals with GI. STRENGTHS AND LIMITATIONS: This is the largest known study to evaluate the effect of GGAS on psychiatric comorbidities in the GI population, offering robust evidence. The reliance on the precision of CPT and ICD-10 codes for data extraction poses a limitation due to potential coding inaccuracies. CONCLUSION: The evidence suggests a significant association between GGAS and reduced psychiatric comorbidities in individuals with GI.

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.

Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US.

This cross-sectional study uses a national dataset to examine the prevalence of gender-affirming surgical procedures among minors and adults in the US.

What Is the Aim of PEDIATRIC "Gender-Affirming" Care?

The original "Dutch Protocol"-the treatment model comprised of puberty blockers, cross-sex hormones, and surgery-was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions' effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender-affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's "embodiment goals." In this article, I raise objections to autonomy-based justifications for pediatric gender-affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision-making and, consequently, put patients at risk of medical harm.

Urological focus on gender affirmation surgery.

BACKGROUND: Gender affirmation surgery plays an important role in the treatment of gender dysphoria. These procedures play a vital role in aligning individuals' physical characteristics with their gender identity, resulting in improved mental health and overall wellbeing. OBJECTIVE: This article provides an overview of genital gender affirmation surgeries, focusing on the available options and appropriate referral criteria for general practitioners and surgeons. DISCUSSION: Gender affirmation surgery necessitates a multidisciplinary approach, emphasising patient readiness, clear surgical preferences, hormonal transition and modifiable risk factors. The two primary methods for assessing patient appropriateness, the World Professional Association for Transgender Health (WPATH) guidelines and the informed consent model, are discussed. This article summarises surgical options for both trans-male and trans-female individuals, outlining procedures, benefits and potential complications. Gender affirmation surgery is set to play an increasingly important role in the management of gender dysphoria. By understanding the available options and referral processes, primary care physicians will be able to optimise care for these patients.

Gender Is a Spectrum: Evaluating Current and Novel Ways to Inquire About Gender Identity in the Health Care Setting.

PURPOSE: The use of visuals to inquire about gender in the clinical setting has been rare. We developed a survey that included a visual spectrum to assess perceptions about the most and least inclusive ways of inquiring about gender in patients with gender dysphoria. METHODS: The survey included a multiple-choice question (MCQ), free-response question, and a visual spectrum on which respondents were asked to select one box that best depicts their gender. The survey was administered to all patients diagnosed with gender dysphoria at our institution between April and June 2022. RESULTS: A total of 223 of 856 patients responded. Those with more masculine gender identities selected boxes near the visual spectrum corner of "man," whereas responses were more variable for more feminine genders. The free-response question was identified by 59% of respondents as the most inclusive. The MCQ was identified as least inclusive by 70.4%. The visual spectrum was considered the most inclusive method by the majority of patients who self-identified as woman and demiwoman/demifemale. Being asked about pronouns was extremely or very important in the health care setting for 52% of respondents, but 68.6% indicated that they are rarely or sometimes asked about their pronouns in this setting. CONCLUSIONS: The traditional MCQ format for self-identifying gender may be lacking in inclusivity and fails to represent the nuances of gender identity. Free response was considered the most inclusive way to inquire about gender among our respondents. These findings highlight the importance of formatting gender identity questionnaires to foster inclusivity for transgender patients.

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth.

PURPOSE: Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB). METHODS: In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr). RESULTS: We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group. CONCLUSION: Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

Approach to the Patient: Navigating Body Mass Index Requirements for Gender-Affirming Surgery.

Body mass index (BMI) requirements for gender-affirming surgeries (GAS) present an obstacle to gender transition for many transgender and gender diverse (TGD) people. Furthermore, TGD people have unique barriers and preferences in managing their weight that must be considered. TGD patients frequently present to their endocrinologists for individualized, gender-affirming support to meet BMI cutoffs for GAS. This Approach to the Patient article combines expertise from several disciplines, including gender-affirming hormone management, weight management, mental health, gynecology, and plastic surgery. Multidisciplinary management considerations are offered for clinicians to assist TGD patients with obesity navigate BMI requirements to access GAS.

¿Cómo se está estudiando la co-ocurrencia entre trastorno del espectro autista y disforia de género en la población adolescente? / How is the co-occurrence between autism spectrum disorder and gender dysphoria being studied in the adolescent population?

En los últimos años aumentaron las investigaciones sobre co-ocurrencia de trastorno del espectro autista (TEA) y disforia de género (DG) secundario a la necesidad de una mayor comprensión de este fenómeno clínico emergente. Objetivos: Caracterizar los estudios en torno a la co-ocurrencia entre TEA y DG en adolescentes. Metodología: Se realizó una revisión sistemática bibliográfica. Se seleccionaron los estudios que mencionaron esta correlación e incluyeron población adolescente. Resultados: La búsqueda inicial arrojó un total de 97 publicaciones. Finalmente, de acuerdo a los criterios de elegibilidad, se incluyeron 35 artículos. Existen escasos estudios enfocados sólo en adolescentes, amplios rangos de prevalencia de esta relación y heterogeneidad en los instrumentos utilizados. Conclusiones: Al evaluar individuos con DG se debiese llevar a cabo un screening de TEA, y viceversa, para no pasar por alto esta co-ocurrencia. Cabe destacar que quienes presentan TEA tienen particularidades relacionadas con el pensamiento y planificación a futuro que hay que considerar al momento de realizar cualquier tipo de tratamiento afirmativo irreversible, enmarcado dentro de un proceso terapéutico multidimensional. Palabras claves: Adolescentes, Disforia de género, Trastorno de Espectro Autista (TEA), Condición de Espectro Autista (CEA), Autismo.

Research on co-occurrence of autism spectrum disorder (ASD) and gender dysphoria (GD) increased in recent years driven by the need for greater understanding of this emerging clinical phenomenon. Objective. To characterize studies on the co-occurrence of ASD and GD in adolescents. Methodology. A systematic literature review was conducted. Studies mentioning this correlation and including adolescent population were selected. Results. The initial search showed a total of 97 publications. 35 articles were included in the review that met the eligibility criteria. There are few studies focused only on adolescents, there is a wide range of prevalence of this relationship and heterogeneity in the instruments used. Conclusions. When evaluating individuals with GD, an ASD screening should be conducted,and vice versa, to avoid overlooking this cooccurrence. It is important to note that those with ASD have particularities related to cognitive development that need to be considered when undergoing any type of irreversible affirmative treatment, within a multidimensional therapeutic process. Keywords. Adolescents, Gender dysphoria, Autism Spectrum Disorder (ASD), Autism.

Preparing for Facial Feminization Surgery.

Preparing for facial feminization surgery (FFS) or gender-affirming facial surgery is a daunting task. Patients do extensive research online to see what FFS means. Oftentimes it is the patients who are educating their physicians when discussing medical clearance or the esteemed "therapy letter." The therapy letter is a letter that details the support for surgery in a stable patient and reaffirms the need to have FFS in a person diagnosed with gender dysphoria. This typically follows the World Professional Association for Transgender Health standards-of-care guidelines. Besides having the therapy letter, patients must be counseled on concurrent mental health illnesses.

A systematic review of hormone treatment for children with gender dysphoria and recommendations for research.

AIM: The aim of this systematic review was to assess the effects on psychosocial and mental health, cognition, body composition, and metabolic markers of hormone treatment in children with gender dysphoria. METHODS: Systematic review essentially follows PRISMA. We searched PubMed, EMBASE and thirteen other databases until 9 November 2021 for English-language studies of hormone therapy in children with gender dysphoria. Of 9934 potential studies identified with abstracts reviewed, 195 were assessed in full text, and 24 were relevant. RESULTS: In 21 studies, adolescents were given gonadotropin-releasing hormone analogues (GnRHa) treatment. In three studies, cross-sex hormone treatment (CSHT) was given without previous GnRHa treatment. No randomised controlled trials were identified. The few longitudinal observational studies were hampered by small numbers and high attrition rates. Hence, the long-term effects of hormone therapy on psychosocial health could not be evaluated. Concerning bone health, GnRHa treatment delays bone maturation and bone mineral density gain, which, however, was found to partially recover during CSHT when studied at age 22 years. CONCLUSION: Evidence to assess the effects of hormone treatment on the above fields in children with gender dysphoria is insufficient. To improve future research, we present the GENDHOR checklist, a checklist for studies in gender dysphoria.

Editorial Perspective: Medical body modification in youth with gender dysphoria or body dysmorphic disorder - is current practice coherent and evidence-based?

In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.

Partial Regret After Gender Affirmation Surgery of a 35-Year-Old Taiwanese Transgender Woman.

Gender-affirming surgery (GAS) is often sought after to alleviate the distress of those who suffer from gender dysphoria (GD). While many studies have shown that a significant percentage of people benefit from this procedure, a number of individuals later regret their decision of undergoing surgery. Studies have illustrated what regret depicts, categorizing regret based on intensity, persistency, and sources, in the hopes to prevent an unwanted irreversible intervention. Here, an in-depth interview with a 35-year-old transwoman from Taiwan who underwent feminizing GAS at the age of 31 illustrates her unique cultural upbringing and the course of her regret. Her experience best matches the characteristics of true regret and major regret based on the classifications of Pfäfflin and Wiepjes, respectively, indicating that she expected GAS to be the solution to her personal acceptance issue, but, in retrospect, regretted the diagnosis and treatment as her problems were not solved and worsened to the extent of secondary dysphoria. This case report hopes to shed light on the complexity of GD and regret after GAS, while encouraging the pre-surgical evaluation of psychological comorbidities and post-surgical psychotherapy, and ensuring that patients are informed and give full consent. In addition, more elaborate, long-term, large-scale qualitative research, especially within more conservative cultural settings, is needed.

Clinical Follow-up of Two Adolescents Diagnosed with Gender Dysphoria. / Cinsiyetinden Hosnutsuzlugu Olan Iki Ergenin Klinik Izlem Süreci.

Rapid physical, psychological and sexual changes in adolescents due to the developmental process differentiate the approach to adolescents with gender dysphoria (GD) from the approach to adults. In this article, two adolescents who applied for GD and followed up for a long time are presented. The first case was assigned male at birth and defined herself as female. At the age of fifteen, a gonadotropin-releasing hormone analog was started for puberty suppression, and sex hormone was started in the follow-up. The second case's assigned sex was female and defined himself as male. At the age of sixteen years and six months, puberty suppressive treatment was started, followed by sex hormones. Both cases were able to continue their psychosocial development without any problems after the psychiatric and physical treatments they could reach on time. Although GD in adolescents cannot be resolved with puberty suppression alone, it creates time to resolve the acute problems and to search for appropriate treatment approaches in the future. Puberty suppression partially relieves and prevents the exacerbation of the dysphoria experienced by the youth diagnosed as GD, and creates time to search appropriate treatment approaches in the follow-up. Through these two cases, it is aimed to introduce the gender affirmation processes of adolescents with GD, to discuss the medical interventions in adolescence and the psychosocial effects of the process on individuals. Keywords: Gender dysphoria, gender incongruence, adolescence, gender affirmation process, puberty supression, puberty blockers.

Heterogeneity in gender dysphoria in a Brazilian sample awaiting gender-affirming surgery: a data-driven analysis.

BACKGROUND: Population heterogeneity and the lack of clinical and sociodemographic information in transgender individuals with gender dysphoria (GD) remains a challenge for specialized services in mental health and surgical procedures. It aimed to identify and describe profiles in a sample waiting for gender-affirming surgery. METHODS: A sample of 100 outpatients with GD was assessed through a structured interview, Emotion Regulation Difficulty Scale (DERS), Ruminative Response Scale (RRS), Depression, Anxiety and Stress Scale (DASS-21) and Life Satisfaction scale (SWLS). Cluster analysis was used to identify different profile categories. RESULTS: Two subgroups with different profiles were identified: with less clinical severity (LCS) and with high clinical severity (HCS) on emotional dysregulation, acute symptoms of depression, anxiety, stress and association with mental rumination. The HCS cluster had greater vulnerability in terms of psychiatric history, use of psychotropic drugs, HIV positive, child abuse and suicidal behavior. CONCLUSION: Different profiles were found regarding the vulnerability to mental health in a sample of transgender people with GD who seek a public hospital service for the same clinical-surgical objective. Longitudinal studies are essential to monitor the impact of these contrasts and to target personalized therapeutic approaches in the prevention of psychiatric disorders.

Detransition-Related Needs and Support: A Cross-Sectional Online Survey.

The aim of this study is to analyze the specific needs of detransitioners from online detrans communities and discover to what extent they are being met. For this purpose, a cross-sectional online survey was conducted and gathered a sample of 237 male and female detransitioners. The results showed important psychological needs in relation to gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices. It was also found that many detransitioners need medical support notably in relation to stopping/changing hormone therapy, surgery/treatment complications and reversal interventions. Additionally, the results indicated the need for hearing about other detransitioners' experiences and meeting each other. A major lack of support was reported by the respondents overall, with a lot of negative experiences coming from medical and mental health systems and from the LGBT+ community. The study highlights the importance of increasing awareness and support given to detransitioners.

Building a gender-affirming surgery service: The fundamentals.

BACKGROUND: As the healthcare needs of transgender patients become increasingly recognized and supported, gender-affirming surgery services are in increasing demand. However, establishing a gender-affirming surgery service is unlike many other surgical specialties and requires unique expertise and administrative support. The aim of this article is to outline the considerations for starting a gender-affirming surgery service and identify pearls for success. METHODS: In this article, we describe the critical components of building and maintaining a successful gender-affirming surgery service. We intersperse findings from our own experiences developing a gender-affirming surgery service. RESULTS: A successful gender-affirming surgery service starts by developing a clear vision of the patient population within your hospital system's area, as well as the design of your center. Establishing a center relies on early engagement of hospital administration and its continued support. A multidisciplinary team with intensive interpersonal and operative training offers the best patient experience and surgical outcomes. By following these steps, our service has been able to provide gender-affirming surgery to more than 200 patients since its inception. Future goals entail partnerships with other institutions and continued outcomes evaluation to ensure sustained success of all gender-affirming surgery services. CONCLUSION: Although there are unique challenges and considerations for establishing a gender-affirming surgery service, careful planning and stakeholder engagement allow providers to deliver high-quality care. We hope that our experience can serve as a model for future much needed gender-affirming surgery services.