Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people.

BACKGROUND: Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries. METHODS: We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation. RESULTS: Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not. DISCUSSION: The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Increasing normality-persisting barriers: Current socio-demographic characteristics of 350 individuals diagnosed with gender dysphoria.

INTRODUCTION: The number of individuals requesting medical treatment for gender dysphoria has increased significantly within the past years. Our purpose was to examine current biographic and socio-demographic characteristics and aspects of legal gender reassignment. DESIGN: Medical files from n = 350 individuals of a German Endocrine outpatient clinic were collected from 2009 to 2017 and analysed retrospectively. RESULTS: Ratio of transwomen to transmen equates to 1:1.89 with a remarkable increase of transmen by the year 2013, showing a reversal of gender distribution compared with previous studies for the first time. Use of illegal substances or self-initiated hormone therapy was rare (4.6 and 2.1%). Satisfaction with gender-affirming hormone therapy was significantly higher in transmen than in transwomen (100% vs 96.2%, P = .005). Use of antidepressants declined significantly after onset of hormone treatment in transmen (13% vs 7%; P = .007). The number of individuals with a graduation diploma was only about half as high as in the general population (14.3% vs 27.3%), whereas unemployment rate was more than twice as high (14% vs 6.9%). Median latency between application for legal gender reassignment and definitive court decision was 9 months. CONCLUSIONS: Our data provide possible indications for a decline of psychosocial burden in individuals diagnosed with gender dysphoria over the last years. However, affected individuals are still limited in their occupational and financial opportunities as well as by a complex and expensive procedure of legal gender reassignment in Germany.

Gender-confirming Rhinoplasty.

Most surgeons who are not routinely treating gender dysphoric patients are more likely to see an isolated rhinoplasty consultation rather than a request for full facial gender confirmation surgery (FGCS). Different from other aspects of FGCS, the surgical basis of rhinoplasty is almost the same as for the cisgender population. Despite technical overlap, the care for patients seeking rhinoplasty for the indication of gender dysphoria vastly differs from that for the cisgender population. This review includes comments on gender norms and outline considerations for the preoperative work-up and operative execution as well as a comprehensive literature review.

Hysterectomy for the Transgendered Male: Review of Perioperative Considerations and Surgical Techniques with Description of a Novel 2-Port Laparoscopic Approach.

Transgendered individuals can suffer a significant amount of psychological distress that can be alleviated through hormonal treatments and/or gender-affirming surgery. The World Professional Association for Transgender Health considers a hysterectomy and bilateral salpingo-oophorectomy medically necessary gender-affirming procedures for the interested transgendered male. Several surgical approaches have been described in the literature, most of which endorse a laparoscopic approach. This review summarizes the available literature on surgical techniques in addition to reporting our institutional outcomes using a novel 2-port laparoscopic approach. Additional preoperative and perioperative considerations are needed when caring for this patient population and are reviewed.

A potential role for the dermatologist in the physical transformation of transgender people: A survey of attitudes and practices within the transgender community.

BACKGROUND: There are an estimated 700,000 or more transgender people in the United States, however their dermatologic needs are not fully established in the medical literature. Unique needs relate to hormone therapy, prior surgeries, and other aspects of physical transitioning. OBJECTIVES: By examining attitudes and practices of transgender individuals, we aimed to identify areas for which dermatologists could contribute to their physical transformation. METHODS: This cross-sectional study used an anonymous online survey, distributed via lesbian, gay, bisexual, and transgender organizations; social media; and at targeted locations and events. RESULTS: A total of 327 people completed the survey (63% men, 29% women, 9% other). Most transgender women indicated that their face was most imperative to have changed, whereas men noted their chest, in turn influencing procedures. Of women's facial procedures, hair removal predominated, followed by surgery then injectables, mostly performed by plastic surgeons. Hormone-induced facial effects varied, usually taking over 2 years for maximal effect. When choosing procedures, money was the major barrier and good aesthetic outcome the primary concern. Participants did not think that facial procedures necessitate the currently accepted prerequisites for chest and genital surgery. LIMITATIONS: This study has limited size and convenience sampling. CONCLUSION: Dermatologists could contribute to the physical transformation of transgender patients through noninvasive procedures.

[Body, rights and comprehensive health: Analysis of the parliamentary debates on the Gender Identity and Assisted Fertilization Laws (Argentina, 2011-2013)]. / Cuerpo, derechos y salud integral: Análisis de los debates parlamentarios de las leyes de Identidad de Género y Fertilización Asistida (Argentina, 2011-2013).

In this paper we present an analysis of the parliamentary debates of the Gender Identity Law (No. 26743) and the Assisted Fertilization Law (No. 26862) carried out in the Argentine National Congress between 2011 and 2013. Using a qualitative content analysis technique, the stenographic records of the debates were analyzed to explore the following questions: How was the public problem to which each law responds characterized? How was the mission of each law conceptualized? To what extent did those definitions call into question ideas of health and illness, in including in the public health system coverage for certain medical treatments of body optimization or modification? In the process of sanctioning both laws, the concepts of health and disease were put into dispute as moral categories. In this context, an expanded concept of comprehensive health arose, in which desires regarding reproduction and the body were included.

[Legal aspects and the treatment procedure of gender dysphoria in Hungary]. / A nemi dysphoria jogi vonatkozásai és a kezelés folyamata Magyarországon.

The legal process of gender transition in Hungary had previously been more developed as in most European countries, as the law enabled transsexual people to change their name and gender before or without a medical treatment, which was unique at the time. Over the years, however, lots of European countries developed legal frameworks and accepted international standards of care for the treatment of gender dysphoria that Hungary did not follow. Currently in Hungary there is no consistent legal framework of gender transition, there is no official regulation or guidelines regarding gender transition process, no institution with the obligation to accommodate the process, and there is no nominated specialist in the state health care system whose remit included dealing with transsexual patients. The information on gender transition options both to the professionals and to the patients is limited and incoherent. This paper reviews the legal aspects and clinical management process of gender dysphoria in Hungary. Some issues regarding the Hungarian practice and possible solutions based on examples from the United Kingdom are addressed within the paper.

Incorporação de novos procedimentos relativos ao processo transexualizador no âmbito do SUS / Incorporation of new procedures related to the transexualization process within SUS

Tendo em vista que a revisão da Portaria SAS nº 457 de 19 de agosto de 2008, que regulamenta o processo Transexualizador no âmbito do SUS, encontra-se em fase de finalização, esta Coordenação de Média e Alta Complexidade encaminha para conhecimento e análise desta Comissão, o impacto financeiro dos procedimentos sugeridos para incorporação: a) mastectomia simples bilateral em usuário/a sob o processo transexualizador; b) histerectomia c/ anexectomia bilateral e colpectomia em usuário/a/as sob processo transexualizador; c) cirurgias complementares de redesignação sexual; d) administração hormonal - testosterona (valor mensal); c) cirurgias complementares de redesignação sexual; d) administração hormonal - testosterona (valor mensal); acompanhamento de usuário/a/as no processo transexualizador apenas para tratamento clínico (por atendimento). Ressalta - se que a revisão da referida portaria está sendo trabalhada por técnicos, pesquisadores e especialistas afetos a área, em conjunto com o movimento social e técnicos da Coordenação Geral da Média e da Alta Complexidade/DAE/SAS, apresentamos o produto deste estudo e a solicitação de incorporação de novos procedimentos na Tabela de Procedimentos, Órteses, Próteses e materiais do SUS. Os membros da CONITEC presentes na 11ª reunião ordinária do plenário do dia 07/12/2012 recomendaram a incorporação de novos procedimentos relativos ao processo transexualizador no âmbito do SUS. Portaria nº 11, de 15 de maio de 2014. Portaria nº 11, de 15 de maio de 2014 - Torna pública a decisão de incorporar os procedimentos relativos ao processo transexualizador no Sistema Único de Saúde - SUS: mastectomia simples bilateral; histerectomia com anexectomia bilateral e colpectomia; cirurgias complementares de redesignação sexual; administração hormonal de testosterona e acompanhamento de usuários no processo transexualizador apenas para tratamento clínico.

Social, psychological and economic challenges faced by transgender individuals and their significant others: gaining insight through personal narratives.

Using narrative analysis, this study uses survey data to explore the social, psychological and economic challenges faced by transgender individuals and their significant others. With over 300 participants, this study not only validates the findings of previous yet smaller scale studies surrounding the transgender experience, it adds greater context to our current understanding, specifically because of its inclusion of significant others. Findings include participants' reports of social stigma coupled with psychological pain and economic hardship. The authors discuss the intersectionality of these three variables and the possible implications for understanding the transgender experience and that of their partners.

Self-castration by a transsexual woman: financial and psychological costs: a case report.

INTRODUCTION: The out-of-pocket cost for an elective orchiectomy, which is often not covered by health insurance, is a significant barrier to male-to-female transsexuals ready to proceed with their physical transition. This and other barriers (lack of access to a surgeon willing to perform the operation, waiting times, and underlying psychological and psychiatric conditions) lead a subset of transsexual women to attempt self-castration. Little information has been published on the financial costs and implications of self-castration to both patients and health care systems. AIM: We compare the financial and psychological costs of elective surgical orchiectomy vs. self-castration in the case of a transsexual woman in her 40s. METHODS: We interviewed the patient and her providers and obtained financial information from local reimbursement and billing specialists. RESULTS: After experiencing minor hemorrhage following the self-castration, our patient presented to the emergency department and underwent a bilateral inguinal exploration, ligation and removal of bilateral spermatic cords, and complicated scrotal exploration, debridement, and closure. She was admitted to the psychiatric service for a hospital stay of three days. The total bill was U.S. $14,923, which would compare with U.S. $4,000 for an elective outpatient orchiectomy in the patient's geographical area. CONCLUSIONS: From a financial standpoint, an elective orchiectomy could have cost the health care system significantly less than a hospital admission with its associated additional costs. From a patient safety standpoint, elective orchiectomy is preferable to self-castration which carries significant risks such as hemorrhage, disfigurement, infection, urinary fistulae, and nerve damage. Healthcare providers of transsexual women should carefully explore patient attitudes toward self-castration and work toward improving access to elective orchiectomy to reduce the number of self-castrations and costs to the overall health care system. Further research on the financial implications of self-castration from different health care systems and from a series of patients is needed.