Genital Hypoplasia in Gender-affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning.

PURPOSE: Penile inversion vaginoplasty uses genital skin to construct the neovaginal canal. When genital skin is insufficient, extragenital tissue is needed. The purpose of this study is to evaluate which demographic factors and intraoperative anatomical measurements are associated with skin availability and the need for extragenital tissue. MATERIALS AND METHODS: This was a prospective cohort study of patients undergoing penile inversion vaginoplasty from May 2016 through January 2021. Preoperative variables included patient demographics, orchiectomy and circumcision status, and stretched penile and scrotal skin lengths. Outcomes included measurements of available scrotal skin surface area and need for extragenital skin graft. RESULTS: A total of 235 patients were included. Patients with prior orchiectomy and shorter stretched scrotal and penile lengths had less scrotal skin available (P < .002) and were more likely to require extragenital skin grafts (P < .001). Patients with prior orchiectomy had 3 times greater odds of needing additional skin grafts. Length of time exposed to gender-affirming hormones did not predict scrotal skin availability (P = .8). CONCLUSIONS: Factors associated with need for extragenital skin grafting with penile inversion vaginoplasty were prior orchiectomy and stretched penile skin length <8 cm. Scrotal skin length >10 cm was associated with low risk for needing additional graft. Considering these factors can help with preoperative planning and patient counseling.

Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction, and Mental Health in a Cohort of Transgender Individuals.

BACKGROUND: Transgender individuals sometimes seek gender confirmation treatments (GCT), including hormone therapy (HT) and/or surgical change of the chest and genitalia ("top" and "bottom" gender confirmation surgeries). These treatments may ameliorate distress resulting from the incongruence between one's physical appearance and gender identity. AIM: The aim was to examine the degree to which individuals' body-gender congruence, body image satisfaction, depression, and anxiety differed by GCT groups in cohorts of transmasculine (TM) and transfeminine (TF) individuals. METHODS: The Study of Transition, Outcomes, and Gender is a cohort study of transgender individuals recruited from 3 health plans located in Georgia, Northern California, and Southern California; cohort members were recruited to complete a survey between 2015-2017. Participants were asked about: history of GCT; body-gender congruence; body image satisfaction; depression; and anxiety. Participants were categorized as having received: (1) no GCT to date; (2) HT only; (3) top surgery; (4) partial bottom surgery; and (5) definitive bottom surgery. OUTCOMES: Outcomes of interest included body-gender congruence, body image satisfaction, depression, and anxiety. RESULTS: Of the 2,136 individuals invited to participate, 697 subjects (33%) completed the survey, including 347 TM and 350 TF individuals. The proportion of participants with low body-gender congruence scores was significantly higher in the "no treatment" group (prevalence ratio [PR] = 3.96, 95% CI 2.72-5.75) compared to the definitive bottom surgery group. The PR for depression comparing participants who reported no treatment relative to those who had definitive surgery was 1.94 (95% CI 1.42-2.66); the corresponding PR for anxiety was 4.33 (95% CI 1.83-10.54). CLINICAL TRANSLATION: Withholding or delaying GCT until depression or anxiety have been treated may not be the optimal treatment course given the benefits of reduced levels of distress after undergoing these interventions. CONCLUSIONS: Strengths include the well-defined sampling frame, which allowed correcting for non-response, a sample with approximately equal numbers of TF and TM participants, and the ability to combine data on HT and gender confirmation surgeries. Limitations include the cross-sectional design and the fact that participants may not be representative of the transgender population in the United States. Body-gender congruence and body image satisfaction were higher, and depression and anxiety were lower among individuals who had more extensive GCT compared to those who received less treatment or no treatment at all. Owen-Smith AA, Gerth J, Sineath RC, et al. Association Between Gender Confirmation Treatments and Perceived Gender Congruence, Body Image Satisfaction and Mental Health in a Cohort Of Transgender Individuals. J Sex Med 2018;15:591-600.

National Trends in Sexual Behavior, Substance Use and HIV Testing Among United States Men Who have Sex with Men Recruited Online, 2013 Through 2017.

The American Men's Internet Survey (AMIS) is conducted annually with 10,000 men age 15 + who have sex with men (MSM). Modeling was used with 39,863 AMIS surveys from 4 cycles between December 2013 to February 2017 to identify temporal trends in sexual behavior, substance use, and testing behavior (within 12 months preceding interview) stratified by participants' self-reported HIV status. HIV-negative/unknown status MSM had significant increases in condomless anal intercourse (CAI), marijuana use, use of other illicit substances, sexually transmitted infection (STI) diagnoses, and HIV or STI testing (testing only increased among MSM age 25 +). HIV-negative/unknown status MSM had significant decrease in CAI with an HIV-positive or unknown status partner. HIV-positive MSM had significant increases in CAI, methamphetamine use, and STI diagnoses/testing. Although encouraging, the few indicators of improvement in HIV/STI sexual health practices are not consistently seen across sub-groups of MSM and may be counteracted by growing proportions of MSM engaging in CAI and acquiring STIs.

Sexually Transmitted Disease Testing and Uptake of Human Papillomavirus Vaccine in a Large Online Survey of US Men Who Have Sex With Men at Risk for HIV Infection, 2012.

National guidelines recommend annual human immunodeficiency virus (HIV)/sexually transmitted disease testing for sexually active men who have sex with men (MSM) and vaccination against human papillomavirus for MSM through age 26. A 2012 online survey of 2,794 MSM found that 51%, 36%, and 14% reported receiving human immunodeficiency virus testing, sexually transmitted disease testing, and human papillomavirus vaccination, respectively.

Management of Urologic Complications After Genital Gender-Affirming Surgery in Transgender and Nonbinary Patients.

Transgender and nonbinary (TGNB) patients are a population with unique urologic needs that are often overlooked in urologic training. Most urology residents think that learning to take care of this population is important in their training; however, there is much variation in this educational content within urology residency programs. This review provides information on the current state of teaching regarding the unique needs of caring for TGNB patients as urologists and overviews some basic principles that every urologist should know.

Addressing Urologic Health Disparities in Sexual and Gender Minority Communities Through Patient-Centered Outcomes Research.

Sexual and gender minority (SGM) communities face stigma and discrimination that impact all aspects of health. To better understand and improve their urologic health outcomes, we must study SGM patients as a distinct population and pursue research on outcomes identified as priorities to SGM communities. Patient-centered outcomes research (PCOR) is a methodology which is increasingly familiar to urologists and is crucial to adequately addressing SGM health in future urological research. We review existing literature focused on urologic outcomes of SGM populations and highlight specific PCOR initiatives built on SGM community engagement.

Use of Standardized Patients in Endocrinology Fellowship Programs to Teach Competent Transgender Care.

PURPOSE: Transgender and gender-nonconforming individuals have unique health care needs and have difficulty accessing health care services because of a lack of qualified health care providers, insurance coverage, mistreatment, and bias by the medical community. Medical trainees and physicians report a lack of education in, and exposure to, the clinical care and unique aspects of this field. We assessed the use of a standardized patient as a tool to evaluate 4 core medical competencies (patient care, medical knowledge, professionalism, and interpersonal communication) of endocrinology fellows at a single training program. METHODS: Endocrine fellows were evaluated by faculty in different aspects of transgender care and completed a self-assessment before and after the exercise. Faculty viewed the fellows during the Objective Clinical Structured Examination. Fellows were provided feedback by a faculty member and the standardized patient after the exercise. RESULTS: Deficits were found in patient care and professionalism. Fellows scored well in medical knowledge. Fellows did not report an improvement in comfort and communication skills after the exercise. Interestingly, fellows' self-assessment scores in several domains declined after the standardized patient encounter, highlighting an occasion for self-reflection and growth within the realms of cultural competency and medical knowledge. MAIN CONCLUSIONS: We conclude that use of standardized patients to teach medical competencies in transgender medicine may be one approach to improve exposure to, and training in, transgender medicine. Endocrine fellows still had discomfort treating transgender individuals after the standardized patient encounter and require other training activities that may include didactics and clinical case discussions.

Effects of gender affirming hormone therapy on body mass index in transgender individuals: A longitudinal cohort study.

INTRODUCTION: Many transgender people take hormone therapy to affirm their gender identity. One potential long-term consequence of gender affirming hormone therapy is increased body mass index (BMI), which may be associated with metabolic syndrome, cardiovascular disease and higher mortality. Only a few published studies explored changes in BMI in transgender people taking gender affirming hormone therapy (GAHT). OBJECTIVE: To examine the changes in BMI longitudinally in response to GAHT in transgender women and men. METHODS: We conducted a retrospective cohort study of transgender individuals who received GAHT from the endocrinology clinic between January 1, 2000 and September 6, 2018. Subjects who sought GAHT were included if they had two separate measurements of BMI and were excluded if they had a BMI greater than 35 kg/m2 or were missing demographic data at entry. We used a linear mixed model to analyze the longitudinal change in BMI. RESULTS: There were a total of 227 subjects included in this cohort. Among subjects already on GAHT, transgender women were receiving GAHT longer than transgender men (6.59 ± 9.35 vs 3.67 ± 3.43 years, p-value = 0.04). Over the period of 7 years, there was a significant increase in BMI in transwomen who newly initiated GAHT (p-value 0.004). There were no changes in BMI in transgender men and women already on GAHT or in transgender men who newly initiated GAHT in the study. CONCLUSION: We conclude that BMI significantly increases in transwomen but not in transmen after initiation of GAHT in a single center based in the United States. In transwomen and transmen, BMI appears to be stable following 3 to 6 years of GAHT. Future investigations should examine the causes for increased BMI in transgender women including type of GAHT, diet and lifestyle, and association with risk of metabolic syndrome and cardiovascular disease.

An Additive Mix? Acute Urinary Retention in a Patient With Benign Prostatic Hyperplasia Treated With Suboxone, Lurasidone, and Trazodone.

Treatment of psychiatric patients is frequently complicated by medical comorbidities, complex pharmacologic regimens, and side effects occurring secondarily to those regimens. Acute urinary retention is an infrequently discussed side effect of such regimens. This report describes the development of acute urinary retention (AUR) in a 60-year-old man with a history of benign prostatic hyperplasia. The patient developed AUR during treatment with combination buprenorphine/naloxone, trazodone, and lurasidone. We discuss the potential relationship of these agents to the development of this patient's AUR, the complicated neurochemical dynamic of the voiding process, and the pathologic consequences that psychotropic agents can have on that process.