[Brain characteristics of transgender individuals and consequences of gender assignment treatment]. / Características cerebrales de las personas transexuales y consecuencias del tratamiento de asignación de género.

The differences between the male and female brain in cisgender individuals, those in whom there is no incongruence between the so-called biological sex and the perceived sex, are known. The genetic basis that underlies the differences observed in the brains of transgender individuals compared to cisgender individuals is also becoming known. In transgender individuals, there is a fundamental change in the connectivity of neurons in the body perception network, which may give rise to gender dysphoria. This knowledge allows for the characterization of the transgender condition and distinguishes it from transgender identities such as non-binary gender, gender fluidity, or genderqueer. Articles published assume, from the perspective of depathologization imposed by Gender Ideology, that these differences are due to a different sexual development. The societal acceptance of this perspective over the last two decades paved the way for medical interventions aimed at affirming the perceived gender, different from the genetic sex, through the continuous administration of cross-sex hormones and, in some cases, mutilating surgery. In adolescents and children, affirmation treatment of the perceived gender begins with puberty blockers, which have negative consequences for ossification and growth. The importance and irreversibility of these 'side effects' require the utmost rigor and complete information about them. Spanish law pushes the ideology to the maximum, infringing on the rights of transgender individuals. Medical ethics emphasize the necessity - the right - of a medical and psychological diagnosis, free from ideological approaches, before initiating what is being called treatment. This includes the right to information, prior to consent, about the positive and negative effects of hormonal administration. It also includes the right to the recognition of diversity among transgender individuals, especially the right to research that allows for treating the brain without altering the body. These rights must be recognized and demanded by the laws.

Gender-affirming hormone therapy and cardiovascular health in transgender adults.

A growing number of people identify as transgender and gender non-binary in the USA and worldwide. Concomitantly, an increasing number of patients are receiving gender-affirming hormone therapy (GAHT) to achieve gender congruence. GAHT has far-ranging effects on clinical and subclinical markers of cardiovascular risk. Transgender patients also appear to be at higher risk for cardiovascular diseases compared to their cisgender peers and the impact of gender-affirming therapy on cardiovascular health is unclear. Studies on the effect of GAHT on cardiovascular outcomes are confounded by differences in GAHT regimens and methodological challenges in a diverse and historically hard-to-reach population. Current cardiovascular guidelines do not incorporate gender identity and hormone status into risk stratification and clinical decision-making. In this review, we provide an overview on the cardiometabolic impact and clinical considerations of GAHT for cardiovascular risk in transgender patients.

Laboratory Changes During Gender-Affirming Hormone Therapy in Transgender Adolescents.

OBJECTIVES: Guidelines for monitoring of medications frequently used in the gender-affirming care of transgender and gender-diverse (TGD) adolescents are based on studies in adults or other medical conditions. In this study, we aimed to investigate commonly screened laboratory measurements in TGD adolescents receiving gender-affirming hormone therapy (GAHT). METHODS: TGD adolescents were recruited from 4 study sites in the United States before beginning GAHT. Hemoglobin, hematocrit, hemoglobin A1c, alanine transaminase, aspartate aminotransferase, prolactin, and potassium were abstracted from the medical record at baseline and at 6, 12, and 24 months after starting GAHT. RESULTS: Two-hundred and ninety-three participants (68% designated female at birth) with no previous history of gonadotropin-releasing hormone analog use were included in the analysis. Hemoglobin and hematocrit decreased in adolescents prescribed estradiol (-1.4 mg/dL and -3.6%, respectively) and increased in adolescents prescribed testosterone (+1.0 mg/dL and +3.9%) by 6 months after GAHT initiation. Thirteen (6.5%) participants prescribed testosterone had hematocrit > 50% during GAHT. There were no differences in hemoglobin A1c, alanine transaminase, or aspartate aminotransferase. There was a small increase in prolactin after 6 months of estradiol therapy in transfeminine adolescents. Hyperkalemia in transfeminine adolescents taking spironolactone was infrequent and transient if present. CONCLUSIONS: Abnormal laboratory results are rare in TGD adolescents prescribed GAHT and, if present, occur within 6 months of GAHT initiation. Future guidelines may not require routine screening of these laboratory parameters beyond 6 months of GAHT in otherwise healthy TGD adolescents.

Acoustic outcomes and voice-related quality of life in male-to-female transsexuals undergoing Wendler glottoplasty: a single-centre experience.

INTRODUCTION: Many transsexual women seek to feminise their voice through pitch elevation surgeries so that it becomes congruent with their gender identity. This study aims to determine the safety and effectiveness of Wendler glottoplasty (WG) in vocal feminisation through the assessment of acoustic and aerodynamic parameters of the voice, as well as voice-related quality of life (QoL) in male-to-female transsexuals. MATERIAL AND METHODS: We retrospectively reviewed the medical records of transsexual women who underwent WG for voice feminisation at our institution between 2016 and 2023. All acoustic and aerodynamic analyses, a voice self-assessment, and a videolaryngostroboscopic evaluation were performed in the immediate preoperative period and at the follow-up visit 6 weeks after the procedure. RESULTS: A total of 11 patients with a mean age of 32.73 years were included. After WG, there was a significant fundamental frequency and speaking fundamental frequency increase of 109.64 Hz and 83.48 Hz, respectively (p < 0.001), representing an average rise by 9.71 semitones and 8.36 semitones (STs), respectively. No significant differences were found between the mean pre- and postoperative values of fundamental frequencies, frequency range, upper limit of the frequency range of spoken voice, and maximum phonation time. Contrarily, the mean lower limit of frequency range rose by 75.56 Hz (p < 0.001), representing an average increase of 10.56 STs. None of the assessed spirometric parameters changed significantly after WG (p > 0.05). The mean overall Voice Handicap Index (VHI) and Voice-Related Quality of Life (V-RQOL) scores significantly improved after the surgery, decreasing by 24.54 points (p = 0.008) and 11.5 points (p = 0.001), respectively. A significant improvement was observed in the functional and emotional domains of VHI. Additionally, significantly fewer patients considered the overall quality of their voice to be "poor" after WG. CONCLUSIONS: WG constitutes an effective method of surgical voice feminisation in male-to-female transsexuals with concurrent improvement in their voice-related QoL. Furthermore, it remains a safe procedure without persistent complications and negative influence on the acoustic-aerodynamic measures of the voice.

Clinically Relevant Laboratory Monitoring of Gender-Affirming Hormone Therapy in Transgender People-Experiences from a Teaching Hospital in the Netherlands.

BACKGROUND: Transgender care is shifting from academic to nonacademic settings leading to use of common (immunoassay) compared to sophisticated (mass spectrometry) methods to monitor estradiol and testosterone during gender-affirming hormone therapy (GAHT). The type of assay can influence results and have significant implications for clinical decision making. An evidence gap is present in recommendations regarding the assay needed to monitor GAHT. The present study aimed to summarize current evidence and evaluate immunoassay estradiol and testosterone concentrations in transgender people visiting a nonacademic hospital for GAHT. METHODS: Clinical practice guidelines on GAHT and scientific literature on assay methodologies were screened and summarized. Laboratory and medical data from 252 patients who visited the transgender outpatient clinic of the Maasstad Hospital for GAHT between 2020 and 2022 were retrospectively analyzed. RESULTS: Our research showed that the most used clinical practice guidelines for GAHT provide hormonal target values without recommending a preferred method. A comprehensive literature search on agreement between immunoassay and mass spectrometry showed substantial heterogeneity in results. Retrospective analysis of our immunoassay measured data in transgender people showed hormonal changes during GAHT that are to be expected from the medication used. CONCLUSIONS: We demonstrate that laboratory monitoring of GAHT in a nonacademic hospital can be done safely by immunoassay in most cases. Only in cases where clinical observation is discordant with the hormonal results do more sophisticated methods need to be deployed. A best practice model was proposed for transgender care in nonacademic hospitals.

Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol.

BACKGROUND: Twenty years ago, the Dutch Protocol-consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)-was implemented to treat adolescents with gender dysphoria. AIM: To study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol. METHODS: The current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria. OUTCOMES: Outcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery. RESULTS: A steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB. CLINICAL IMPLICATIONS: A substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents. STRENGTHS AND LIMITATIONS: Important topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design. CONCLUSION: Trajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well.

Kidney transplantation for a transgender male.

The proportion of transgender people has increased over time, but few cases of transgender people undergoing kidney transplantation have been described. A 41-year-old transgender man (female-to-male) had chronic kidney disease caused by IgA nephropathy. He had received testosterone therapy and sex reassignment surgeries (chest masculinization surgery, metoidioplasty, scrotoplasty, and hysterectomy-ovariectomy) since he was 19 years due to gender incongruence. He underwent a preemptive living-donor kidney transplantation from his wife. His skeletal muscle mass was closer to that of a female than that of a male and suggested that eGFR should be calculated with the equation based on the gender assigned at birth (female) rather than the gender identity (male). Moreover, the recovery of kidney function due to successful kidney transplantation decreased serum gonadotropin levels, but normalization of his sex hormone profile was not achieved. Further accumulation of experience with kidney transplantation for transgender people is needed.

Uma teoria psicológica transfeminista: sobrevivendo aos escombros da saúde mental brasileira / A transfeminist psychological theory: surviving the debris of brazilian mental health / Una teoría psicológica transfeminista: sobrevivir a los escombros de la salud mental brasileña

Este artigo reflete sobre os modos como a cisnormatividade, conceito impulsionado pelos transfeminismos, tem auxiliado na composição da psicologia de maneira histórica. Ao elaborar uma crítica sobre como a violência de gênero está expressivamente presente no território brasileiro, discute-se como tem sido pensada a saúde mental, esfera que, uma vez inserida nesse contexto mais amplo, está sendo convocada a produzir saídas criativas em relação aos sujeitos que são alvo de discriminações transfóbicas. Na busca de deslocar o olhar do indivíduo para o social, foi realizado um estudo bibliográfico para investigar os diferentes impactos que a cisnormatividade opera em nossos currículos psicológicos, gerando efeitos na prática e na própria profissão. A aposta está em reconhecer outras epistemologias como projetos éticos e políticos a uma psicologia contemporânea, e a contribuição transfeminista a "outra" clínica. É nesse sentido que este trabalho se destina a pensar um modo de cuidado que esteja baseado na singularidade, mas que, ao mesmo tempo, seja capaz de dedicar alguma atenção ao paradigma normativo que nos guia como terapeutas.(AU)

This article reflects on the ways that cisnormativity, a concept boosted by transfeminisms, has played a historical role in the composition of psychology. Elaborating a criticism on how gender violence is expressively present in the Brazilian territory, we discuss how mental health is conceived, a sphere that, inserted in this wider context, is invited to create creative solutions related to the subjects who are the target of transphobic discrimination. Trying to shift the focus from the individual to the collective, a bibliographical study was conducted to recognize the different impacts that cisnormativity has in our psychological curriculums, having effects on the practice and on the profession itself. The goal is to recognize other epistemologies as ethical and political projects for contemporary psychology and the transfeminist contribution to "another" clinic. It is in this sense that this work aims to think about a form of care that is based on singularity, but that can also pay attention to the normative paradigm that guides us as therapists.(AU)

Este artículo reflexiona sobre las formas en que la cisnormatividad, un concepto impulsado por los transfeminismos, ha tenido un papel en la composición de la psicología de manera histórica. Al elaborar una crítica sobre como la violencia de género está expresamente presente en el territorio brasileño, se discute cómo se ha pensado la salud mental, dominio que, una vez insertado en este contexto más amplio, es convocado a producir soluciones creativas con relación a los sujetos que son objeto de discriminación transfóbica. Al desviar el enfoque del individuo hacia lo social, se realizó un estudio bibliográfico para investigar los diferentes impactos que tiene la cisnormatividad en nuestros planes de estudios psicológicos, generando efectos en la práctica y en la propia profesión. El foco está en reconocer otras epistemologías como proyectos éticos y políticos para la psicología contemporánea y la contribución transfeminista a una "otra" clínica. En este sentido, este trabajo pretende pensar en una forma de cuidado que se basa en la singularidad, al mismo tiempo que sea capaz de dedicar cierta atención al paradigma normativo que a nosotras nos guía como terapeutas.(AU)

El cambio de identidad de género en la adolescencia. ¿Qué nos enseña la forma-serie? / Gender Identity Change in Adolescence What Does the Form-Series Teach Us?

A las series televisivas les corresponde la posición del analista ya que interpretan el mundo, afirma Gérard Wajcman (2010; 2019). Siguiendo esta premisa hemos seleccionado episodios de dos series actuales, The Good Doctor y New Amsterdam, para abordar nuestro objeto de estudio: el cambio de identidad de género en la adolescencia. En ambos escenarios ficcionales se aborda el mismo dilema: adolescentes transgénero que solicitan una intervención quirúrgica de reasignación de sexo. Tres serán las aristas a ser exploradas sobre esta cuestión: la (no) identidad sexual ­ el yo y sujeto del inconsciente ­ el Otro como comunidad de goce. Para ello, se tendrán en consideración aportes del Psicoanálisis en interlocución con la Teoría de la performatividad queer y la normativa vigente en Argentina. La lectura clínica de la "forma-serie" resulta, entonces, un recurso metodológico novedoso y preciso para el tratamiento de los síntomas actuales desde la perspectiva de la subjetividad

According to Gérard Wajcman (2010; 2019), there is a correspondence between television series and the position of the analyst, since the series interpret the world. The Good Doctor and New Amsterdam, to address our object of study: gender identity change in adolescence. In both fictional scenarios, the same dilemma is addressed: transgender adolescents who request a sex reassignment surgery. There will be three edges to be explored on this issue: the (non) sexual identity - the self and subject of the unconscious - the Other as a community of enjoyment. For this, contributions from Psychoanalysis will be taken into consideration in dialogue with the Theory of queer performativity and the regulations in force in Argentina. The clinical reading of the "form-series" is, then, a novel and precise methodological resource for the treatment of current symptoms from the perspective of subjectivity

Reflexões bioéticas sobre o acesso de transexuais à saúde pública / Bioethical reflections on the access of transgender individuals to public health / Reflexiones bioéticas sobre el acceso de los transexuales a la salud pública

Resumo No Brasil os transexuais, indivíduos cuja identidade de gênero diverge do sexo biológico, são marginalizados pela sociedade e encontram dificuldades para acessar o Sistema Único de Saúde. O presente estudo buscou identificar essas dificuldades por meio de revisão integrativa de artigos publicados nos últimos cinco anos nas bases SciELO, LILACS, MEDLINE, Campus Virtual de Saúde Pública, Base de Dados de Enfermagem e ColecionaSUS. Foram obtidos 26 artigos, dos quais apenas nove satisfizeram os critérios de inclusão, e, a partir das referências destes, incluíram-se mais nove trabalhos, totalizando 18. Os resultados mostram que as dificuldades encontradas são: hostilidade no atendimento; desrespeito ao nome social; despreparo técnico-científico dos profissionais; dificuldade de acesso aos procedimentos transgenitalizadores; e preconceito. Portanto, é imprescindível aplicar intervenções para minimizar a segregação dessas pessoas, sendo necessário mais pesquisas nessa área.

Abstract In Brazil, transgender individuals, those whose gender identity differs from the assigned biological sex, are marginalized by society and face difficulties in accessing the Unified Health System. This study sought to identify these difficulties by carrying out an integrative review of papers published in the SciELO, LILACS, MEDLINE, Virtual Campus for Public Health, Base de Dados de Enfermagem, and ColecionaSUS databases, in the last five years. Of the 26 articles found, only nine met the inclusion criteria. Based on their references other nine papers were included, thus totaling 18. Results point to the following difficulties encountered: hostility in care; disrespect for the social name; technical and scientific unpreparedness of professionals; difficulty of access to gender reassignment procedures; and prejudice. It is therefore of paramount importance to implement interventions to minimize segregation, and invest in further research on this topic.

Resumen En Brasil, los transexuales, individuos cuya identidad de género diverge del sexo biológico, son marginados por la sociedad y encuentran dificultades para acceder al Sistema Único de Salud. El presente estudio trató de identificar dichas dificultades por medio de la revisión integradora de artículos publicados en los últimos cinco años en las bases SciELO, LILACS, MEDLINE, Campus Virtual de Saúde Pública, Base de Dados de Enfermagem y ColecionaSUS. Se obtuvieron 26 artículos, de los cuales solo nueve cumplieron con los criterios de inclusión, y, con base en sus referencias, se incluyeron otros 9, lo que resultó en 18 trabajos. Los resultados constataron las siguientes dificultades: hostilidad en la atención; falta de respeto al nombre social; falta de preparación técnico-científica de los profesionales; dificultad de acceso a los procedimientos de transgenitalización; y prejuicio. Por lo tanto, es esencial aplicar intervenciones para minimizar la segregación de estas personas, así como para promover más investigaciones en esta área.

Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care.

Importance: Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care. Objective: To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality. Design, Setting, and Participants: This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021. Exposures: Time since enrollment and receipt of PBs or GAHs. Main Outcomes and Measures: Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome. Results: Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded "I don't know" or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51). Conclusions and Relevance: This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.

Breaking the Binary: The Approach to Chest Masculinizing Gender-Affirming Surgery in Trangender Men.

BACKGROUND: The purpose of mastectomy for the transgender patient is to produce a masculine appearance of the chest. A number of algorithms have been proposed for selecting the surgical technique. A holistic and surgical approach to transgender men includes our experience-based classification system for selecting the correct surgical technique. OBJECTIVES: To present and discuss the Transgender Standard of Care and our personal experience. METHODS: Data were collected from the files of female-to-male transgender persons who underwent surgery during 2003-2019. Pictures of the patients were also analyzed. RESULTS: Until May 2021, 342 mastectomies were performed by the senior author on 171 patients. The 220 mastectomies performed on 110 patients until November 2019 were included in our cohort. Patient age was 13.5 to 50 years (mean 22.5 ± 6.1). The excision averaged 443 grams per breast (range 85-2550). A periareolar approach was performed in 14 (12.7%), omega-shaped resection (nipple-areola complex on scar) in 2 (1.8%), spindle-shaped mastectomy with a dermal nipple-areola complex flap approach in 38 (34.5%), and a complete mastectomy with a free nipple-areola complex graft in 56 (50.9%). Complications included two hypertrophic scars, six hematomas requiring revision surgery, three wound dehiscences, and three cases of partial nipple necrosis. CONCLUSIONS: A holistic approach to transgender healthcare is presented based on the World Professional Association for Transgender Health standard of care. Analysis of the data led to Wolf's classification for female-to-male transgender mastectomy based on skin excess and the distance between the original and the planned position of the nipple-areola complex.

The Role of Estrone in Feminizing Hormone Treatment.

CONTEXT: In trans women, hormone treatment induces feminization; however, the degree of feminization varies from person to person. A possible contributing factor could be estrone, a weak estrogen that interferes with the estrogen receptor. OBJECTIVE: We assessed whether estrone is involved in feminization induced by hormone treatment. METHODS: This prospective cohort study, with follow-up of 1 year, included 212 adult trans women at a gender identity clinic, who were starting gender-affirming hormone treatment between July 2017 and December 2019, median age 25 years. Change in fat percentage and breast development were assessed. RESULTS: After 12 months of hormone treatment, estrone concentration was 187 pmol/L (95% CI, 153-220) in transdermal and 1516 pmol/L (95% CI, 1284-1748) in oral estradiol users. Fat percentage increased by 1.2% (interquartile range [IQR], 0.3-4.8) in transdermal and 4.6% (IQR, 2.5-5.9) in oral estradiol users. This was not associated with estrone concentrations in transdermal (+4.4% (95% CI, -4.0 to 13) per 100 pmol/L increase in estrone concentration) nor in oral estradiol users (-0.7% [95% CI, -1.7 to 0.3]). Breast volume increased by 69 mL (IQR, 58-134) in transdermal and 62 mL (IQR, 32-95) in oral estradiol users. This was not associated with estrone concentrations in transdermal (+14% [95% CI, -49 to 156] per 100 pmol/L increase in estrone concentration) nor oral estradiol users (+11% [95% CI -14 to 43]). CONCLUSIONS: Change in fat percentage and breast development in trans women were not associated with estrone concentrations nor with administration route. Therefore, measurement of estrone concentrations does not have a place in the monitoring of feminization in trans women.

Testosterone Therapy With Subcutaneous Injections: A Safe, Practical, and Reasonable Option.

CONTEXT: Injections with intramuscular (IM) testosterone esters have been available for almost 8 decades and not only result in predictable serum testosterone levels but are also the most inexpensive modality. However, they are difficult to self-administer and associated with some discomfort. Recently, subcutaneous (SC) administration of testosterone esters has gained popularity, as self-administration is easier with this route. Available data, though limited, support the feasibility of this route. Here we review the pharmacokinetics and safety of SC testosterone therapy with both long- and ultralong-acting testosterone esters. In addition, we provide guidance for clinicians on how to counsel and manage their patients who opt for the SC route. EVIDENCE ACQUISITION: Systematic review of available literature on SC testosterone administration including clinical trials, case series, and case reports. We also review the pharmacology of testosterone absorption after SC administration. EVIDENCE SYNTHESIS: Available evidence, though limited, suggests that SC testosterone therapy in doses similar to those given via IM route results in comparable pharmacokinetics and mean serum testosterone levels. With appropriate training, patients should be able to safely self-administer testosterone esters SC with relative ease and less discomfort compared with the IM route. CONCLUSION: Although studies directly comparing the safety of SC vs IM administration of testosterone esters are desirable, clinicians should consider discussing the SC route with their patients because it is easier to self-administer and has the potential to improve patient adherence.

Defending two dilemmas.

Ashley's response to our recent paper argues that a fuller appreciation of the available clinical data, of the rights of children to autonomy, and of the primary purpose of gender-affirming endocrine treatment supports the rejection of both the pathway and consent dilemmas for the treatment of gender dysphoria, as raised in this journal. In this response, we highlight certain misrepresentations of our argument, and defend our conclusions against Ashley's main objections.

Approach to the Patient: Pharmacological Management of Trans and Gender-Diverse Adolescents.

Internationally, increasing numbers of children and adolescents with gender dysphoria are presenting for care. In response, gender-affirming therapeutic interventions that seek to align bodily characteristics with an individual's gender identity are more commonly being used. Depending on a young person's circumstances and goals, hormonal interventions may aim to achieve full pubertal suppression, modulation of endogenous pubertal sex hormone effects, and/or development of secondary sex characteristics congruent with their affirmed gender. This is a relatively novel therapeutic area and, although short-term outcomes are encouraging, longer term data from prospective longitudinal adolescent cohorts are still lacking, which may create clinical and ethical decision-making challenges. Here, we review current treatment options, reported outcomes, and clinical challenges in the pharmacological management of trans and gender-diverse adolescents.

Adolescent Transgender Females Present Impaired Semen Quality That Is Suitable for Intracytoplasmic Sperm Injection Even Before Initiating Gender-Affirming Hormone Treatment.

The present study aimed to determine the semen quality and cryopreservation outcomes among adolescent transgender females at the time of fertility preservation (FP) before initiating gender-affirming hormone (GAH) treatment. This retrospective cohort study included 26 adolescent transgender females who underwent FP in our Fertility Institute between 06/2013 and 10/2020. Pre-freezing semen parameters were compared to WHO 2010 reference values. Post-thaw semen parameters were used to determine the adequate assisted reproductive technology (ART). A multivariate linear regression analysis was performed to assess the impact of medical and lifestyle factors on semen quality. The mean age at which adolescent transgender females underwent FP was 16.2 ± 1.38 years. The median values of all semen parameters in our study group were significantly lower compared to the WHO data, including volume (1.46 mL vs 3.2 mL, respectively, P = 0.001 ), sperm concentration (28 × 106/mL vs 64 × 106/mL, P < 0.001), total sperm number (28.2 × 106 vs 196 × 106, P < 0.001), total motility (51.6% vs 62%, P < 0.001), and normal morphology (2% vs 14%, P < 0.001). The frequency of semen abnormalities was teratozoospermia 72%, hypospermia 52%, oligozoospermia 28%, and azoospermia 4%. The median post-thaw total motile count was 0.17 × 106/vial, and the quality was adequate only for ICSI in 87.7% of the thawed semen samples. No correlation was found between selected medical and lifestyle factors and poor semen parameters. Semen quality is strongly reduced among adolescent transgender females before hormone therapy and their stored sperm samples are suitable for intracytoplasmic sperm injection (ICSI) rather than conventional IVF/intrauterine insemination (IUI).

Facial Gender Surgery: Systematic Review and Evidence-Based Consensus Guidelines from the International Facial Gender Symposium.

BACKGROUND: Increasing societal acceptance of transgender people has led to broader availability of gender surgery and rapid growth in transition-related operations. Facial gender surgery aims to modify patients' facial features to be more congruent with their physical expression of gender, reducing gender dysphoria and improving quality of life. Growth in research and technique evolution has not kept pace with growth in clinical volume. Therefore, the first International Facial Gender Symposium was held at Johns Hopkins University in 2019, convening surgeons who perform facial gender surgery to share ideas and assess the state of clinical evidence. METHODS: To review the literature on facial gender surgery, the authors developed a search strategy for seven electronic databases (PubMed, PsycINFO, Embase, CINAHL, Web of Science, Cochrane, and Gender Studies) through May of 2019, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. RESULTS: Based on the English language literature and clinical experience, the authors suggest guidelines for screening, management, and appropriate surgical technique for patients undergoing facial gender surgery. They highlight facial gender surgery as a medically necessary intervention and identify shortcomings in current guidelines. CONCLUSIONS: Facial gender surgery represents a complex array of craniofacial and soft-tissue procedures that require application of advanced skills and decision-making. Facial gender operations are not cosmetic, are medically necessary, and require development of new CPT codes specific to facial gender surgery. It is imperative to create educational programs and methods to define sufficient training for facial gender surgery surgeons. Research priorities include better procedural outcomes data, more quality-of-life studies, and insight into variation in both patient and procedural subgroups.