Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know.

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.

The Effect of Formant Biofeedback on the Feminization of Voice in Transgender Women.

Differences in formant frequencies between men and women contribute to the perception of voices as masculine or feminine. This study investigated whether visual-acoustic biofeedback can be used to help transgender women achieve formant targets typical of cisgender women, and whether such a shift influences the perceived femininity of speech. Transgender women and a comparison group of cisgender males were trained to produce vowels in a word context while also attempting to make a visual representation of their second formant (F2) line up with a target that was shifted up relative to their baseline F2 (feminized target) or an unshifted or shifted-down target (control conditions). Despite the short-term nature of the training, both groups showed significant differences in F2 frequency in shifted-up, shifted-down, and unshifted conditions. Gender typicality ratings from blinded listeners indicated that higher F2 values were associated with an increase in the perceived femininity of speech. Consistent with previous literature, we found that fundamental frequency and F2 make a joint contribution to the perception of gender. The results suggest that biofeedback might be a useful tool in voice modification therapy for transgender women; however, larger studies and information about generalization will be essential before strong conclusions can be drawn.

Trends in Referrals to a Pediatric Transgender Clinic.

OBJECTIVES: We characterized referral trends over time at a transgender clinic within an integrated health system in Northern California. We identified the transition-related requests of pediatric transgender and gender-nonconforming patients and evaluated differences in referrals by age group. METHODS: Medical records were analyzed for all patients <18 years of age in the Kaiser Permanente Northern California health system who were referred to a specialty transgender clinic between February 2015 and June 2018. Trends in treatment demand, demographic data, service requests, and surgical history were abstracted from medical charts and analyzed by using descriptive statistics. RESULTS: We identified 417 unique transgender and gender-nonconforming pediatric patients. The median age at time of referral was 15 years (range 3-17). Most (62%) identified on the masculine spectrum. Of the 203 patients with available ethnicity data, 68% were non-Hispanic. During the study period, the clinic received a total of 506 referrals with a significant increase over time (P < .001). Most referrals were for requests to start cross-sex hormones and/or blockers (34%), gender-affirming surgery (32%), and mental health (27%). Transition-related requests varied by age group: younger patients sought more mental health services, and older patients sought hormonal and surgical services. Eighty-nine patients underwent gender-affirming surgeries, mostly before age 18 and most frequently mastectomies (77%). CONCLUSIONS: The increase in referrals supports the need for expanded and accessible health care services for this population. The transition-related care of patients in this large sample varied by age group, underscoring the need for an individualized approach to gender-affirming care.

Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals.

BACKGROUND: Health care for transgender and transsexual (ie, trans) individuals has long been based on a binary understanding of gender (ie, feminine vs masculine). However, the existence of non-binary or genderqueer (NBGQ) genders is increasingly recognized by academic and/or health care professionals. AIM: To gain insight into the individual health care experiences and needs of binary and NBGQ individuals to improve their health care outcomes and experience. METHODS: Data were collected using an online survey study on experiences with trans health care. The non-clinical sample consisted of 415 trans individuals. An individual treatment progress score was calculated to report and compare participants' individual progress toward treatment completion and consider the individual treatment needs and definitions of completed treatment (ie, amount and types of different treatments needed to complete one's medical transition). OUTCOMES: Main outcome measures were (i) general and trans-related sociodemographic data and (ii) received and planned treatments. RESULTS: Participants reported binary (81.7%) and different NBGQ (18.3%) genders. The 2 groups differed significantly in basic demographic data (eg, mean age; P < .05). NBGQ participants reported significantly fewer received treatments compared with binary participants. For planned treatments, binary participants reported more treatments related to primary sex characteristics only. Binary participants required more treatments for a completed treatment than NBGQ participants (6.0 vs 4.0). There were no differences with regard to individual treatment progress score. CLINICAL TRANSLATION: Because traditional binary-focused treatment practice could have hindered NBGQ individuals from accessing trans health care or sufficiently articulating their needs, health care professionals are encouraged to provide a holistic and individual treatment approach and acknowledge genders outside the gender binary to address their needs appropriately. STRENGTHS AND LIMITATIONS: Because the study was made inclusive for non-patients and individuals who decided against trans health care, bias from a participant-patient double role was prevented, which is the reason the results are likely to have a higher level of validity than a clinical sample. However, because of the anonymity of an online survey, it remains unclear whether NBGQ individuals live according to their gender identity in their everyday life. CONCLUSION: The study highlights the broad spectrum of genders in trans-individuals and associated health care needs and provides a novel approach to measure individual treatment progress in trans individuals. Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. J Sex Med 2018;15:102-113.

Comprehensive Sexuality Education as a Longitudinal Predictor of LGBTQ Name-Calling and Perceived Willingness to Intervene in School.

Comprehensive sexuality education and sexuality education that is inclusive to lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth is thought to educate and support youth in their social relations. Despite the obligation for Dutch schools to cover sexuality education in their curricula, including the topic of sexual diversity, the content that is covered varies widely across schools. With the current study, we present an overview of the content of sexuality education as reported by a sample of 601 Dutch adolescents (58.4% female youth) from six different high schools (e.g., public, Roman Catholic, protestant, anthroposophical; grades 10-12). Further, we examine whether the content or extensiveness of sexuality education at the beginning of the school year is related to a decrease in LGBTQ name-calling and an increase in the willingness to intervene when witnessing LGBTQ name-calling at the end of the school year. Adolescents completed three surveys, spaced four months apart. The results show that anatomy, STI prevention, and relationships are covered most often in sexuality education, with less attention to sexual diversity. Our longitudinal findings show that having a wide variety of topics covered in sexuality education-not just sexual diversity-was related to an increase in perceived willingness to intervene when witnessing LGBTQ name-calling by teachers or school staff, fellow students, and youth themselves (female youth). It also predicted a decrease in the occurrence of name-calling according to females. Our findings emphasize the importance of having comprehensive sexuality education in schools; it not only educates and empowers youth but also signals a safer school climate.

Ancestors of two-spirits: Historical depictions of Native North American gender-crossing women through critical discourse analysis.

Letters written by Christian men of European origin during the sixteenth-nineteenth centuries contain brief descriptions of gender-crossing individuals among indigenous Americans. Although now considered ethnocentrically biased because of the etic positioning of their authors, these historical sources are invaluable because they offer a glimpse of the ancestors of modern-day two-spirits. An application of critical discourse analysis to three depictions of gender-crossing females from the eighteenth and nineteenth centuries demonstrates that such women were favorably portrayed. These results differ dramatically from those obtained from my similar analysis of depictions of gender-crossing males. It also became evident that the three descriptions of gender-crossing women were not based on actual observations, but only on hearsay, which makes their use as primary sources questionable.

A novel method for estimating transgender status using electronic medical records.

PURPOSE: We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system. METHODS: A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews. RESULTS: Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014. CONCLUSIONS: The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.

Lay theories of gender identity disorder.

This study examined lay theories regarding gender identity disorder (GID). Pilot interviews were completed with participants (n = 10) regarding their views on possible causes and treatments of GID. Participants (mainly young British people and students; n = 124) then completed a questionnaire that was based on the interviews and a review of the salient literature on lay theories. As hypothesized, participants believed most in biomedical causes and treatments of GID. Factor analysis (with varimax rotation) identified 4 factors in relation to causes of GID: upbringing and personal factors, pregnancy and brain abnormalities, environmental factors, and biomedical causes. Five factors that were identified in relation to the cure/treatment of GID were psychological assistance and personal factors, extreme medical and behavioral changes, alternative therapies, external factors, and medical treatments. The results indicated that participants neither agreed nor strongly disagreed about causes and cures regarding GID, but that these beliefs were logically related. Limitations, particularly of sampling, were considered.

[The social background of male to female transsexuals]. / Der soziale Rahmen und Hintergrund von Mann-zu-Frau-Transsexualität.

Gender alignment surgery was introduced into German law in 1981. Judicial guidelines for the change of first names and gender were established and transsexuality was labelled as a psychosomatic and somatopsychic syndrome and disorder, thus opening the way for treatment to the social health-care under well-defined conditions requesting cross-dressing and hormone therapy as well as psychological counselling by 2 independent psychologists or psychiatrists. In a retrospective, chart-related survey of questionnaires on male to female transsexuals it was found that patients start to suspect being born into the wrong gender at the onset of puberty, it takes them however approximately 20 years to have gender alignment surgery. More than half the patients are single at this time, while the remaining group is married or divorced with equal rates. 68% regard themselves as heterosexual, 21% lesbian and 11% were undecided. About half the patients experienced support by their families for their decision. Despite numerous secondary corrections of the surgical alignment, patients were content with the result, although emotional acceptance of the desired result took about one year. In general plastic surgical gender alignment treatment was perceived as the major contribution to harmonise their phenotype with their identity.

A descriptive study of the experiences of lesbian, gay and transgender parents accessing health services for their children.

AIM: To explore the experiences of lesbian, gay and transgender families accessing health care for their children. BACKGROUND: Although lesbian, gay and transgender families are becoming more common, little is known about their health-seeking experiences. These families may be fearful about disclosing their sexual orientation or gender identity to health professionals. As a result, lesbian, gay and transgender parents may not be receiving optimal care for their children. DESIGN: Descriptive qualitative study. METHOD: Data were collected through semi-structured interviews with 11 lesbian, gay and transgender parents in Australia. RESULTS: Three themes were generated from the data: 'managing health care experiences', 'attitudes' and 'transforming bureaucracies'. Negative experiences included encountering homophobia or transphobia and being required to educate health professionals. Positive experiences occurred when both parents were acknowledged as having an equal say in their child's health care. CONCLUSION: Many health professionals lack the skill or knowledge to meet the needs of lesbian, gay and transgender families. Health services are required to ensure that all policies and procedures are inclusive of all family constellations and that staff receive relevant and up-to-date sensitivity training and create an environment that is respectful of all family groups. RELEVANCE TO CLINICAL PRACTICE: Adopting a philosophy of family centred care can enable health providers and health professionals to provide lesbian, gay and transgender families with inclusive non-discriminatory care.

Barriers to free antiretroviral treatment access among kothi-identified men who have sex with men and aravanis (transgender women) in Chennai, India.

The Indian government provides free antiretroviral treatment (ART) for people living with HIV. To assist in developing policies and programs to advance equity in ART access, we explored barriers to ART access among kothis (men who have sex with men [MSM] whose gender expression is feminine) and aravanis (transgender women, also known as hijras) living with HIV in Chennai. In the last quarter of 2007, we conducted six focus groups and four key-informant interviews. Data were explored using framework analysis to identify categories and derive themes. We identified barriers to ART access at the family/social-level, health care system-level, and individual-level; however, we found these barriers to be highly interrelated. The primary individual-level barrier was integrally linked to the family/social and health care levels: many kothis and aravanis feared serious adverse consequences if their HIV-positive status were revealed to others. Strong motivations to keep one's HIV-positive status and same-sex attraction secret were interconnected with sexual prejudice against MSM and transgenders, and HIV stigma prevalent in families, the health care system, and the larger society. HIV stigma was present within kothi and aravani communities as well. Consequences of disclosure, including rejection by family, eviction from home, social isolation, loss of subsistence income, and maltreatment (although improving) within the health care system, presented powerful disincentives to accessing ART. Given the multi-level barriers to ART access related to stigma and discrimination, interventions to facilitate ART uptake should address multiple constituencies: the general public, health care providers, and the kothi and aravani communities. India needs a national policy and action plan to address barriers to ART access at family/social, health care system, and individual levels for aravanis, kothis, other subgroups of MSM and other marginalized groups.

Transgender identity and health care: implications for psychosocial and physical evaluation.

PURPOSE: The purpose of this article is to educate nurse practitioners (NPs) regarding: (a) the definition and range of transgenderism, (b) social influences on transgender persons, and (c) health care for transgender persons. DATA SOURCES: Data sources include review of the literature in the areas of gender, gender identity, marginalized populations, and gender transition. Personal communication was also utilized. CONCLUSIONS: Transgender persons remain marginalized and may remain closeted and at risk for negative psychosocial consequences. For those that do come out, other issues present, including the navigation of gender transition and psychosocial and physical changes that may be positive and/or negative. Examples of positive effects may include satisfaction of living authentically and decrease in depression. Negative effects may include social discrimination and loss of relationships. To provide holistic care, NPs need to be aware of transgender lives in social context and of their healthcare needs. IMPLICATIONS FOR PRACTICE: Suggestions for cultivating a supportive healthcare environment include the usage of sensitive language and an appropriate health history and physical examination. Further, to help rectify the knowledge deficit regarding transgender care among healthcare providers, NP educators and preceptors may utilize this article as a resource in their work with students.

Specific cerebral activation due to visual erotic stimuli in male-to-female transsexuals compared with male and female controls: an fMRI study.

INTRODUCTION: Transsexuals harbor the strong feeling of having been born to the wrong sex. There is a continuing controversial discussion of whether or not transsexualism has a biological representation. Differences between males and females in terms of functional imaging during erotic stimuli have been previously described, revealing gender-specific results. AIM: Therefore, we postulated that male-to-female (MTF) transsexuals may show specific cerebral activation differing from their biological gender. MAIN OUTCOME MEASURE: Cerebral activation patterns during viewing of erotic film excerpts in functional magnetic resonance imaging (fMRI). METHODS: Twelve male and 12 female heterosexual volunteers and 12 MTF transsexuals before any treatment viewed erotic film excerpts during fMRI. Additionally, subjective rating of sexual arousal was assessed. Statistics were performed using the Statistical Parametric Mapping software. RESULTS: Significantly enhanced activation for men compared with women was revealed in brain areas involved in erotic processing, i.e., the thalamus, the amygdala, and the orbitofrontal and insular cortex, whereas no specific activation for women was found. When comparing MTF transsexuals with male volunteers, activation patterns similar to female volunteers being compared with male volunteers were revealed. Sexual arousal was assessed using standard rating scales and did not differ significantly for the three groups. CONCLUSIONS: We revealed a cerebral activation pattern in MTF transsexuals compared with male controls similar to female controls compared with male controls during viewing of erotic stimuli, indicating a tendency of female-like cerebral processing in transsexualism.

"Being dealt with as a whole person." Care seeking and adherence: the benefits of culturally competent care.

The purpose of this study is to characterize the relationship between identity and health care experiences (including antiretroviral therapy utilization) among HIV-positive sexual minority males. This qualitative study used grounded theory with data collection occurring through focus groups and interviews. A questionnaire was used to complete a demographic profile. The study included 47 HIV positive participants from three minorities: gay men, bisexual men and transgendered persons, gender identifying as female and or living as women. Sessions elicited information on: (1) general experiences with health care, (2) experiences with HIV antiretroviral therapies and issues surrounding access, and (3) adherence to these therapies and identity in relation to health care. These textual data revealed three themes: (1) the importance of sexual identity and its social and cultural context, (2) the differences in the health concerns between the sexual minorities and (3) a wide spectrum of experiences with the health care system that provide information surrounding the access to and adequacy of health care. Successful health care providers are aware of different issues that may play a role in the provision of health care to these sexual minorities. Providers awareness of sexual and social identity and the related different cultural values, beliefs and custom enhance care seeking and therapeutic adherence. For sexual minorities, primary care remains the most important entry point into the health care system. Cultural competence of care providers can foster patient's care seeking and adherence to treatment.

The psychoanalyst and the transsexual patient.

The author remarks on the dearth of psychoanalytic literature concerning analyses of transsexuals and of clinical experience with such patients in general. Drawing on her personal work with transsexual patients at a specialised centre, as well as with children suffering from gender identity disorders and their parents, she is able to specify the factors which, in her view, make the psychoanalysis and psychotherapy of these subjects so difficult. In particular, they are totally focused on the body and on their intention of securing sex reassignment by hormonal and surgical treatments, so that they rule out the involvement of any psychic element. The psychic functioning of these patients is illustrated by some clinical vignettes, and the transference and countertransference problems are discussed. The author shows how the patients concerned have great difficulty in accepting a psychological approach to their problems; they do not speak the language of wishes and conflict, and claim to remember nothing of their childhood or past life. She concludes that transsexualism is a narcissistic disorder in which the constitution of the self has been profoundly impaired and that it is only since analysis have embarked on the treatment of non-neurotic patients that the condition has become accessible to psychoanalytic psychotherapy or indeed to psychoanalysis. The difficulties notwithstanding, the author considers that such work is worthwhile and that patients can benefit from it.