Barriers to Completing Preoperative Hair Removal for Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) is a gender-affirming surgical procedure where the skin of the penis and scrotum is reconstructed into the neovaginal lining. To prevent hair-bearing skin from becoming incorporated into the neovaginal canal, transgender patients are encouraged to undergo hair removal of their external genitalia. The goal of this preoperative hair removal is to minimize the risk of potential hair-related complications after vaginoplasty. To better support patients seeking preoperative hair removal and identify current treatment barriers, we surveyed patients about their progress and satisfaction with hair removal. A cross-sectional survey was constructed to assess patient experiences with hair removal in advance of PIV. Sixty-seven patients met the inclusion criteria, of which 46 participated (68.7%). Both laser hair removal (LHR) and electrolysis were used. Although all patients had completed some preoperative hair removal at the time of survey (average of 14 sessions), the cohort completed only two-thirds of their total expected hair clearance. Multiple peri-procedural pain management therapies were employed, but overall satisfaction with pain management was low (57.4 ± 5.0 out of 100). LHR was associated with significantly lower procedural pain compared to electrolysis (p < .001). The average global satisfaction with the hair removal process was 57.9 ± 5.7 and incidents of mistreatment were associated with a statistically significant reduction in overall satisfaction (p = .02). Most patients felt that hair removal was important prior to surgery. Overall, LHR and electrolysis were both utilized as effective preoperative hair removal modalities; however, LHR has better pain tolerability than electrolysis.

Vaginal self-lubrication following peritoneal, penile inversion, and colonic gender-affirming vaginoplasty: a physiologic, anatomic, and histologic review.

INTRODUCTION: Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining. OBJECTIVES: The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV. METHODS: We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum. RESULTS: We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented. CONCLUSIONS: None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.

Serum estradiol levels decrease after oophorectomy in transmasculine individuals on testosterone therapy.

Transmasculine individuals, considering whether to undergo total hysterectomy with bilateral salpingectomy, have the option to have a concomitant oophorectomy. While studies have evaluated hormone changes following testosterone therapy initiation, most of those patients have not undergone oophorectomy. Data are currently limited to support health outcomes regarding the decision to retain or remove the ovaries. We performed a retrospective chart review of transmasculine patients maintained on high-dose testosterone therapy at a single endocrine clinic in Vancouver, British Columbia, Canada. Twelve transmasculine individuals who underwent bilateral oophorectomy and had presurgical and postsurgical serum data were included. We identified 12 transmasculine subjects as controls, who were on testosterone therapy and did not undergo oophorectomy, but additionally matched to the first group by age, testosterone dosing regimen, and body mass index. There was a statistically significant decrease in the estradiol levels of case subjects postoophorectomy, when compared to presurgical estradiol levels (P = 0.02). There was no significant difference between baseline estradiol levels between control and case subjects; however, the difference in estradiol levels at follow-up measurements was significant (P = 0.03). Total testosterone levels did not differ between control and case subjects at baseline and follow-up (both P > 0.05). Our results demonstrate that oophorectomy further attenuates estradiol levels below what is achieved by high-dose exogenous testosterone alone. Correlated clinical outcomes, such as impacts on bone health, were not available. The clinical implications of oophorectomy versus ovarian retention on endocrinological and overall health outcomes are currently limited.

Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review.

INTRODUCTION: The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention. OBJECTIVE: Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries. METHOD: We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy. RESULTS: We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes. CONCLUSION: There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;10:636-647.

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids.

BACKGROUND: Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI). AIM: We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA. OUTCOMES: Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty. RESULTS: Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction. CLINICAL TRANSLATION: The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery. STRENGTHS & LIMITATIONS: This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center. CONCLUSION: Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.

Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review.

INTRODUCTION: The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention. OBJECTIVE: Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries. METHOD: We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy. RESULTS: We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes. CONCLUSION: There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population.

Community as the teacher on issues of social responsibility, substance use, and queer health in dental education.

INTRODUCTION: In order to foster dental and dental hygiene practices that are inclusive, sensitive to diversity, equitable, and without prejudice, a call to broadly teach cultural diversity within dental and dental hygiene education has been made. The research question of this study was "to what extent can an interactive and open dialogue about substance use, queer health, and social responsibility foster transformative learning?" METHODS: A collaborative and interdisciplinary project engaged the community as a teacher over the Summer and Fall of 2019 to address issues of substance use, queer health, and social responsibility and was delivered to 55 first-year undergraduate dental and 23 third-year dental hygiene students over three educational sessions. Dental and dental hygiene students were asked to reflect, in writing, on each session using between 200 and 400 words. Textual information from students' self-reflections and from the community's feedback were analyzed thematically for content (e.g., codes and themes). RESULTS: In total, 128 written reflections-for an average of 42 reflections per session-were gathered and analyzed interactively by the authors. Three major themes emerged: feeling privileged, breaking stereotypes, and coalescing learning. Feedback from the participating community members highlighted changes to be implemented in these sessions in the future, including more opportunities for small group activities in class. CONCLUSIONS: The three major themes that emerged from the thematic analysis of the self-reflections and community member feedback (feeling privileged, breaking stereotypes, and coalescing leaning) further highlighted the impact of community-driven curricula on students' learning in regard to substance use, queer health, and social responsibility. Further work is critical to understand the impact of such a pedagogy on students' practices once they leave their undergraduate programs.