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OBJECTIVE: To summarize current knowledge regarding management of hypergranulation in the context of gender-affirming vaginoplasty. SOURCES OF INFORMATION: There have been no studies to date examining hypergranulation treatment options following vaginoplasty. Evidence from the literature on this complication in other settings and the opinions of authorities and experts in this area were used to inform this review. MAIN MESSAGE: Hypergranulation is a common complication of vaginoplasty, but many care providers may not know how to identify or treat it. This short report will review hypergranulation after vaginoplasty, including risk factors, identification, and treatment options such as douching, silver nitrate, and topical steroids. CONCLUSION: By increasing clinicians' knowledge of this pervasive complication, patients' postsurgical care and outcomes can be improved.
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Vagina , Humanos , Femenino , Masculino , Vagina/cirugía , Cirugía de Reasignación de Sexo/métodos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/terapia , Pene/cirugía , Factores de RiesgoRESUMEN
BACKGROUND: Many studies have described barriers to gender-affirming surgery (GAS) in Canada; however, few have explored why these barriers persist. To address this knowledge gap, we sought to describe documents related to public health insurance (Medicare) for GAS to identify the types of procedures covered, variations in coverage across provinces and territories, and changes in policy over time. METHODS: We conducted a descriptive cross-sectional study using an environmental scan approach. We queried 23 government websites, the Google search engine, and an online legal database between July 2022 and April 2024 to gather gray literature documents related to GAS and Medicare. Variables from relevant documents were compiled to create a present, at-glance overview of GAS Medicare coverage for all provinces and territories and a timeline of policy changes across Canada. RESULTS: Eight provinces and three territories had documents or websites related to GAS Medicare coverage (85%). We identified 15 GAS procedures that were covered variably across Canada. Yukon (n = 14) covered the most types of GAS, while Quebec and Saskatchewan covered the least (n = 6). Mastectomy and genital surgeries were covered across Canada, but other GAS were rarely covered. Five provinces and territories provided coverage for travel-related costs. Our GAS Medicare timeline showed differential expansion of GAS coverage in Canada over the last 25 years. CONCLUSIONS : We provide previously unreported information regarding GAS Medicare coverage in Canada. We hope our findings will help patients and healthcare providers navigate a complicated public healthcare system. We also highlight barriers within GAS Medicare documents and make recommendations to alleviate those barriers.
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Cirugía de Reasignación de Sexo , Humanos , Canadá , Estudios Transversales , Femenino , Cirugía de Reasignación de Sexo/economía , Masculino , Política de Salud , Programas Nacionales de Salud , Medicare/economía , Cobertura del Seguro/estadística & datos numéricosRESUMEN
BACKGROUND: Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. METHODS: We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations. RESULTS: We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women (n = 13) and White (n = 14). Participants lived in rural (n = 4), suburban (n = 5), or urban (n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations). INTERPRETATION: Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.
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Pene , Investigación Cualitativa , Personas Transgénero , Vagina , Humanos , Femenino , Adulto , Personas Transgénero/psicología , Masculino , Vagina/cirugía , Pene/cirugía , Persona de Mediana Edad , Canadá , Cirugía de Reasignación de Sexo/psicología , Cirugía de Reasignación de Sexo/métodos , OntarioRESUMEN
OBJECTIVE: To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS: A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS: The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION: Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.
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Servicios Médicos de Urgencia , Personas Transgénero , Estrechez Uretral , Urología , Humanos , Femenino , Urólogos , Atención de Afirmación de Género , Constricción Patológica/complicaciones , Vagina/cirugía , Estrechez Uretral/etiología , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Vaginoplasty is a gender-affirming surgery that is medically necessary for some transfeminine individuals. Little research exists describing vaginal health after the initial recovery from surgery, and evidence-based guidelines for vaginal care practices are unavailable. AIM: The study sought to describe self-reported gynecological concerns and vaginal care practices among transfeminine persons who have undergone vaginoplasty. METHODS: A total of 60 transfeminine participants 18+ years of age, living in Canada, and who had undergone vaginoplasty at least 1 year prior were recruited through social media, community groups, healthcare provider referrals, and study recontact. Participants completed a cross-sectional, online questionnaire detailing demographics, gynecological concerns, and genital practices and exposures. Hierarchical clustering was used to group participants based on behavioral practices and exposures. Associations between clusters and gynecological concerns were assessed. OUTCOMES: Outcomes included self-reported gynecological concerns within the past year, recent vulvar or vaginal symptoms (past 30 days), and behavioral practices/exposures, including douching with varied products and dilating. RESULTS: Participants reported a variety of concerns in the past year, including urinary tract infection (13%) and internal hair regrowth (23%). More than half (57%) had experienced at least 1 recent vaginal symptom, most commonly malodor (27%) and vaginal bleeding (21%). Of participants, 48% were dilating weekly and 52% reported douching in the past 30 days. Four distinct clusters of vaginal practices/exposures were identified: limited exposures; dilating, no douching; dilating and douching; and diverse exposures. No significant associations between cluster membership and gynecological concerns were identified, though cluster membership was significantly associated with surgical center (P = .03). Open-text write-ins provided descriptions of symptoms and symptom management strategies. CLINICAL IMPLICATIONS: The results provide insight for clinicians on common patient-reported gynecological concerns and current vaginal care practices and exposures, including symptom management strategies. STRENGTHS AND LIMITATIONS: This was the first study to investigate vaginal health and genital practices/exposures among a community sample of transfeminine individuals. As participants self-enrolled for a detailed survey and swab collection, individuals experiencing concerns were likely overrepresented. CONCLUSION: Transfeminine individuals reported a range of gynecological concerns outside of the surgical healing period. Genital practices/exposures varied across clusters, but no clear associations between clusters and symptoms were identified; instead, practice/exposure clusters were dependent on where the individual underwent vaginoplasty. There is a need for evidence to inform diagnostics, treatments, and vaginal care guidelines to support vaginal health.
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Cirugía de Reasignación de Sexo , Personas Transgénero , Transexualidad , Femenino , Humanos , Estudios Transversales , Transexualidad/cirugía , Vagina/cirugía , Cirugía de Reasignación de Sexo/métodosRESUMEN
IMPORTANCE: Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery. OBJECTIVE: To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic. DESIGN, SETTINGS, AND PARTICIPANTS: A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables. RESULTS: The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%). CONCLUSIONS AND RELEVANCE: Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.
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Personas Transgénero , Masculino , Femenino , Humanos , Adulto , Estudios Retrospectivos , Cuidados Posoperatorios , Vagina/cirugía , Medición de Resultados Informados por el Paciente , Ontario/epidemiologíaRESUMEN
INTRODUCTION: Penile inversion vaginoplasty (PIV) remains the gold standard technique for vaginoplasty, a gender-affirming feminizing surgery, but has been associated with urinary complications; however, there is little literature synthesizing urinary complications after PIV surgery, and there is a need to compile these complications to counsel patients pre- and postoperatively on managing surgical expectations. In this systematic review, we summarize the prevalence of urinary complications following PIV. METHODS: We searched the MEDLINE, EMBASE, CINAHL, and Scopus databases in July 2020. The primary outcome was the prevalence of urinary and surgical complications in patients after penile inversion vaginoplasty. Pooled prevalence was determined from extrapolated data. ROBINS-I tool was used to assess study quality. The study was prospectively registered on PROSPERO (CRD 42020204139). RESULTS: Of 843 unique records, 27 articles were pooled for synthesis, with 3388 patients in total. Overall patient satisfaction ranged from 80-100%. The most common urological complications included poor/splayed stream (11.7%, 95% confidence interval [CI] 5.7-19.3), meatal stenosis (6.9%, 95% CI 2.7-12.7), and irritative symptoms (frequency, urgency, nocturia) (11.5%, 95% CI 2.6-25.1). Other urinary complications included retention requiring catheterization (5.1%, 95% CI 0.3-13.8), incontinence (8.7%, 95% CI 3.4-15.6), urethral stricture (4.6%, 95% CI 1.2-9.8), and urinary tract infection (5.6%, 95% CI 2.7-9.4). Most pooled studies had moderate risk of bias. CONCLUSIONS: The available evidence suggests that there is a low prevalence of urinary complications following PIV. Overall, there is a need for standardization of data in transgender surgical care to better understand surgical outcomes and improve postoperative management.
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Nephrologists are increasingly providing care to transgender, nonbinary, and gender diverse (TNBGD) individuals with chronic kidney disease. This narrative review discusses the care of TNBGD individuals from a nephrology perspective. TNBGD individuals are under-represented in the nephrology literature. TNBGD individuals are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Gender-affirming hormone therapy (GAHT) with estradiol in transfeminine individuals potentially increases the risk of venous thromboembolism and cardiovascular disease. GAHT with testosterone in transmasculine individuals potentially increases the risk of erythrocytosis and requires careful monitoring. GAHT modifies body composition and lean muscle mass, which in turn influence creatinine generation and excretion, which may impact the performance of estimated glomerular filtration rate (GFR) equations and the estimation of 24-hour urine values from spot urine albumin/protein to creatinine ratios. There are limited studies regarding TNBGD individuals with chronic kidney disease. Additional research is needed to evaluate the effects of GAHT on GFR and biomarkers of kidney function and the performance of the estimated GFR equation in TNBGD populations.
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Enfermedades Cardiovasculares , Insuficiencia Renal Crónica , Personas Transgénero , Creatinina , Humanos , Insuficiencia Renal Crónica/complicaciones , Testosterona/uso terapéuticoRESUMEN
INTRODUCTION: Transgender and gender diverse (TGD) individuals often identify with a gender different to the one assigned at birth. Transition is a term used to describe the process TGD individuals take to live as their true gender. Surgery can be a very important aspect of care for members of TGD communities. Transition-related surgery (TRS) refers to many different types of surgeries completed to meet a TGD individual's gender-related goals. While various systematic reviews have attempted to synthesise the existing peer-reviewed literature around aspects of TRS, there are few scoping reviews in this area. Our scoping review aims to address this gap through providing an up-to-date overview of the TRS literature in order to provide an overarching view of the topic. METHOD AND ANALYSIS: This review will follow the methods outlined by the Joanna Briggs Institute's methodology for scoping reviews and will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. A search of nine scientific databases resulted in 20 062 potential articles. After removing duplicates, articles will be screened for inclusion using Covidence. Data extraction and synthesis will be carried out using NVivo and reviewed by team members. ETHICS AND DISSEMINATION: As this study is a scoping review of the existing literature, no ethics review is required. The findings from this review will be disseminated through multiple pathways including open access publication, submission to conferences, social media and Listservs. The findings of the study will also be readily available to clinicians, organizations, interest groups, and policy-makers.
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Identidad de Género , Evaluación de Resultado en la Atención de Salud , Accesibilidad a los Servicios de Salud , Humanos , Recién Nacido , Literatura de Revisión como Asunto , Revisiones Sistemáticas como AsuntoRESUMEN
There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.
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Personas Transgénero , Recolección de Datos , Registros Electrónicos de Salud , Identidad de Género , Humanos , Reproducibilidad de los Resultados , Estados UnidosRESUMEN
Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research.
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Microbiota , Cirugía de Reasignación de Sexo , Personas Transgénero , Transexualidad , Femenino , Humanos , Masculino , Transexualidad/cirugía , VaginaRESUMEN
BACKGROUND: To date, there is no literature on orchiectomy as a stand-alone procedure in the transgender surgical context. AIM: To propose a simple guide to aid health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy. METHODS: We use expert opinion to provide a novel guide for simple orchiectomy in the transition-related context for health-care professionals caring for transgender and gender nonconforming individuals. A review of relevant literature was also performed focusing on simple orchiectomy and vaginoplasty surgeries for transgender and gender nonconforming individuals. MAIN OUTCOME MEASURE: We describe the indications, surgical approach, preoperative and postoperative assessment, and the risks and benefits of bilateral simple orchiectomy in the context of gender surgery. RESULTS: This article is the first, to our knowledge, to describe a structured guide to bilateral simple orchiectomy in the context of gender surgery for health-care professionals caring for transgender and gender nonconforming individuals. CLINICAL IMPLICATIONS: Bilateral scrotal orchiectomy is a simple surgical procedure that has a defined role in the surgical management of many transgender individuals. STRENGTHS AND LIMITATIONS: This article provides an approach to simple orchiectomy in the context of gender surgery for health-care professionals. Only guidelines written in English were included. The quality of the included guidelines was not evaluated, but this was beyond the scope of this review. CONCLUSION: We present a novel guide for health-care professionals caring for transgender and gender nonconforming individuals seeking bilateral simple orchiectomy in the context of gender surgery. Francis C, Grober E, Potter E, et al. A Simple Guide for Simple Orchiectomy in Transition-Related Surgeries. Sex Med Rev 2020;8:492-496.
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Orquiectomía/métodos , Cirugía de Reasignación de Sexo/métodos , Guías como Asunto , Humanos , Medición de RiesgoRESUMEN
Background : One of the more common procedures conducted through the transition-related surgeries (TRSs) program is simple orchiectomy. Due to the relative novelty of TRS in Canada, national perioperative guidelines for simple orchiectomy in the context of TRS are yet to be developed. Furthermore, there is a void in the literature describing the indications and outcomes of simple orchiectomy among transgender individuals. Aims : This study is the first descriptive case series in Canada highlighting our experience with simple orchiectomy in the context of TRS. Methods : This study retrospectively assessed data from electronic patient medical records of 16 patients who had simple orchiectomy procedures at Women's College Hospital in Toronto, Canada from August 2018 to April 2019. Data were collected using a standardized data collection form which includes patient baseline demographic data, and objective and subjective clinical outcomes. Results : Mean age at surgery was 32.6 ± 10.4 years and mean time to surgery following the initial approval of referral was 9.9 ± 8.5 weeks. A majority of referrals (n = 13, 81.3%) were from urban areas with specialized TRS services. The average time on hormones was 3.1 ± 1.9 years. In terms of post-surgical complications at the 30-day day follow-up visit, there was a single post-operative sperm granuloma reported. There were no other complications identified post-surgery in our patient case series. Discussion : In Ontario, the growing recognition of the benefits of TRS has led to the development of a publicly funded pathway to TRS surgery. This study is the first assessment of simple orchiectomy performed for TRS in Canada, and it has shown that the procedure is safe and reproducible. Due to its benefits, coordinating safe and efficient access of care for this procedure should be an important action item for health systems. This study is limited by its low sample size.