Masculinizing chest-wall surgeries in transgender patients, a retrospective single-center study.

INTRODUCTION: Masculinizing chest-wall contouring surgery is an important surgical intervention for most transmasculine patients; a vast improvement in quality of life for this group of patients has been documented as a result of receiving surgery. The aim of this study was to evaluate the results of such surgeries performed at our university hospital between 2008 and 2020, as well as the current quality of life of the patients. METHODS: All 16 patients operated between 2008 and 2020 were sent a questionnaire consisting of both BREAST-Q and BODY-Q modules, considered fitting for our study purposes, as well as the BECK Depression Index and a short two-question form with space for feedback. Patients were divided into groups called double incision (DI) and periareolar (PA) depending on the surgical technique used. RESULTS: We found an overall complication percentage of 31.3%, with the DI group scoring 33.3% and PA 28.6%, while secondary aesthetic corrections were necessary for 50% of all patients. The questionnaires yielded 6 responses (37.5%). Participants rated on a scale of 1 to 10 their willingness to undergo the operation again if given the choice; the DI group averaged 10/10, and the PA group 9/10, despite the statistically significant complication and correction rates. CONCLUSIONS: Masculinizing chest-wall contouring surgery has significant complication risks. In our study, frequency of complications did not appear to depend on the surgical technique used. Additionally, the complication rates found in our low volume centre seem to be comparable with those reported from bigger units.

The use of peritoneum in female genital gender-affirming surgery: A systematic review.

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen. Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty. Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8cm and width of 3.5cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty. This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.

[Advanced Surgical Techniques in Forehead Feminization and Hairline Redefinition]. / Techniques chirurgicales avancées dans la féminisation du front et la redéfinition de la ligne des cheveux chez les patientes transgenres.

Facial Gender-Affirming Surgery (FGAS) has emerged as a transformative option for individuals who wish to align their external appearance with their asserted gender identity. This article delves into the surgical techniques employed in forehead feminization and hairline redefinition, highlighting the nuanced approaches used to modify specific facial characteristics to achieve the desired feminizing outcomes. Our extensive experience, encompassing over 2300 forehead feminization surgeries conducted over the past 16 years, provides a robust foundation for understanding the complexities and intricacies of these procedures. This knowledge is crucial for maxillofacial and plastic surgeons, as well as other healthcare professionals involved in comprehensive gender-affirming care, ensuring they are well-equipped to deliver optimal results for their patients.

Exploring Mediators of Mental Health Service Use Among Transgender Individuals in Ontario, Canada.

OBJECTIVES: To determine if and to what degree neighbourhood-level marginalization mediates mental health service use among transgender individuals. METHODS: This retrospective cohort study identified 2,085 transgender individuals through data obtained from 4 outpatient community and hospital clinics in 3 large cities in Ontario, which were linked with administrative health data between January 2015 and December 2019. An age-matched 1:5 comparison cohort was created from the general population of Ontario. Outcome measures were analysed from March 2020 to May 2022. The primary outcome was mental health service utilization, which included mental health-related visits to primary care providers, psychiatrists, mental health- and self-harm-related emergency department visits, and mental health hospitalizations. Mediation variables included ethnic concentration, residential instability, dependency, and material deprivation at the neighbourhood level and were derived from the Ontario Marginalization Index. RESULTS: This study identified 2,085 transgender individuals from participating outpatient community and hospital clinics, who were matched to the general population (n = 10,425). Overall, neighbourhood-level marginalization did not clinically mediate mental health service use. However, transgender individuals were more likely to be exposed to all forms of neighbourhood-level marginalization, as well as having higher rates of health service use across all outcome measures. CONCLUSIONS: In this study, mental health service use among transgender individuals was not clinically mediated by marginalization at the neighbourhood level. This study highlights the need to explore marginalization and mental health service use at the individual level to better understand the mental health disparities experienced by transgender individuals and to ensure that health-care services are inclusive and affirming.

Une approche d'affirmation pour les soins aux jeunes transgenres et de diverses identités de genre.

Un nombre croissant de jeunes s'identifient comme transgenres ou de diverses identités de genre. De nombreux pédiatres et dispensateurs de soins de première ligne accueilleront cette population dans leur pratique, dans le cadre de soins liés au genre ou de soins de santé généraux. Le présent document de principes se veut une ressource pour orienter les pédiatres et les dispensateurs de soins de première ligne à adopter une approche d'affirmation pour la prestation des soins réguliers à tous les jeunes. De plus, il contient de l'information visant à aider les dispensateurs à répondre aux demandes de conseils des jeunes transgenres et de diverses identités de genre et de leur famille au sujet des possibilités de transition médicale et d'orientation vers des services spécialisés s'ils le désirent et le jugent pertinent. Enfin, on anticipe que la demande de soins d'affirmation de genre continue d'augmenter, et certains dispensateurs de soins peuvent souhaiter acquérir les connaissances et les habiletés nécessaires pour amorcer les inhibiteurs d'hormones et les hormones d'affirmation de genre chez les adolescents. Le présent document ne contient pas de directives cliniques, mais de l'information fondamentale au sujet des divers éléments possibles des soins d'affirmation de genre, tout en reconnaissant que les besoins et les objectifs d'adolescents particuliers n'incluent pas automatiquement de telles interventions. D'autres ressources permettant d'acquérir les compétences nécessaires pour offrir des interventions d'affirmation de genre sont également proposées.

[The tube in tube thoracodorsal perforator flap phalloplasty]. / Phalloplastie par Lambeau perforant thoracodorsal « tube in tube ¼.

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

[Description of a vaginoplasty technique using a peritoneal flap harvested by coelioscopic approach for male-to-female gender affirmations (MtF)]. / Description d'une technique de vaginoplastie utilisant un lambeau péritonéal prélevé par voie cœlioscopie pour les affirmations de genre homme-à-femme (HtF).

AIM: The aim of this article is to provide a comprehensive description of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery, particularly in cases of insufficient depth after penile inversion vaginoplasty. RESULTS: Our short-term results reveal that the peritoneal flap vaginoplasty, adapted from the Davydov procedure, has shown significant potential for improving functional and aesthetic outcomes, including the creation of a self-lubricating neovagina. However, the complexity of the procedure requires advanced surgical expertise and appropriate postoperative care. Patient selection also plays an essential role as not all patients are ideal candidates for this procedure. CONCLUSION: Despite its promises, the widespread adoption of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery is hindered by several challenges, including the need for specialized training and potential postoperative complications. Thus, this technique should be considered as an alternative or complement to traditional methods, depending on individual patient factors. Further research and extensive clinical trials are needed to better understand its potential and limitations in order to enhance the arsenal of effective surgical options for MtF gender affirmation surgery.

[Frontal sinus anatomical scanographic study of transgender patients for feminization frontoorbitoplasty surgery]. / Étude anatomique scanographique du sinus frontal des patients transgenres en vue d'une chirurgie de frontoorbitoplastie de féminisation.

INTRODUCTION: Little is known about the anatomical elements that allow safe and predictable performance of fronto orbital surgery for facial feminization. The primary objective of this study was to analyze the characteristics (dimensions, pneumatization rate, and anterior wall thickness) of the frontal sinus in MtF transgender patients. The secondary objective was to establish reproducible criteria for CT measurements that could guide preoperative planning of frontal impaction in feminization frontoplasty (FF). MATERIALS: Fifty preoperative facial mass scans of FF surgery patients were included. The mean age of the operated patients was 34 years. The F line represented the ideal forehead tilt in the absence of a frontal hump. RESULTS: The height, width, depth, and thickness of the anterior sinus wall were 26.6mm (±5.7), 49.5mm (±11.3), 10.9mm (±3.3), and 3mm (±0.7), respectively. The mean sinus width to skull width ratio was 0.73 (±0.12). Six percent of patients had bilateral frontal sinus agenesis. An osteotomy of the anterior wall of the frontal sinus was performed in the 64% of patients with frontal sinus projection anterior to the F-line. The emergence of the supraorbital nerves from the frontal bone was through a bony notch in 73.8% of cases. CONCLUSIONS: Knowledge of the anatomy of the frontal sinus and preoperative study of the scans of the facial mass is essential for planning the FF. These characteristics guide the surgical technique of bone remodeling as well as the procedure for releasing the supraorbital nerves.

[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]. / Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme.

AIMS: The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. METHODS: In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. RESULTS: The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. CONCLUSION: Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

[Affirming one's gender: supporting and accompanying trans young people and their families]. / Affirmer son genre : soutenir et accompagner les jeunes trans et leur famille.

Support for trans teenagers and young adults is based on a comprehensive approach to care, taking into account the needs and desires of the individual and his or her environment. It involves welcoming their requests and listening to their questions, in order to help them assert themselves. The aim is to be particularly attentive to these young people, sometimes in vulnerable psychological, social and educational situations, as well as to their families, by welcoming them, listening to them and taking charge of them through multidisciplinary networks.

[Care pathways for young transgender people]. / Parcours de soins des jeunes personnes transgenres.

Gender incongruence corresponds to the mismatch between gender identity and gender/sex assigned at birth gender/sex assigned at birth. It can be accompanied by psychological distress. In line with the literature, an increase in consultations for gender incongruence has been observed, especially among young people. Multidisciplinary care should be offered to this population; here we provide an example of healthcare proposed at the university hospital of Nancy.

[Self-assessment of healthcare workers regarding the management of trans people in a university hospital]. / Auto-évaluation de professionnels de santé concernant la prise en charge des personnes trans dans un hôpital universitaire.

INTRODUCTION: Trans people face more barriers when seeking healthcare than the cisgender population probably due to a lack of knowledge, education and comfort of healthcare workers. The purpose of this study was to assess the knowledge and comfort felt by healthcare professionals in managing trans people in a French university hospital. METHODS: A self-questionnaire was emailed to healthcare professionals working in departments usually involved in the care of trans people in a French university hospital "not specialized" in medical and surgical gender transition. The questionnaire included demographic questions and Likert scales regarding their knowledge and comfort in taking care of trans people. Responses on the 7-point Likert scales were categorized into "low", "medium" and "high" groups, and responses on the 5-point Likert scales were categorized into "in favour", "neutral" and "against" groups. RESULTS: One hundred and two (29%) healthcare professionals answered the questionnaire. Half worked in surgical departments (urology, plastic surgery, gynecology), 24% worked in medical departments (endocrinology, reproductive medicine, cytogenetics) and 26% worked in psychiatry. The majority (60.3%) rated their level of knowledge as "low" and 39.7% as "medium". Sixteen percent rated their level of comfort in managing trans people as "low", 72.5% as "medium" and 11.5% as "high". A majority (77.5%) were in favor of having the costs of gender transition care covered by the national health insurance system, 16.4% were neutral and 6% were against this idea. Feelings about surgical and hormonal gender transition were overwhelmingly (96.4%) in favour or neutral and 91% were willing to get more training and education to manage trans people. CONCLUSION: The lack of comfort felt by healthcare professionals in university hospital in managing trans people seems to be related to a lack of knowledge and training in that field and not to a disagreement with the need of transgender healthcare. LEVEL OF EVIDENCE: 3.

[Accessing parenthood in a transgender context]. / Accéder à la parentalité en contexte de transidentité.

Becoming a father is a process that covers different situations. In addition to the well-known situations of traditional conception and sperm donation, there are others that need to be considered. These situations concern in particular access to parenthood for transgender men who have made a social transition.

Breast cancer in a transgender man and hypofractionated radiotherapy: A case report and review of literature.

A 77-year-old transgender man (assigned female sex at birth, gender identity male, i.e. female-to-male) was referred for a palpable mass of the right chest wall. Biopsies revealed invasive lobular breast carcinoma. After discussion by a multidisciplinary tumour board meeting, the patient was treated with total mastectomy, adjuvant hypofractionated radiation therapy, and hormone therapy. At 1.5-year follow-up, there was no sign of recurrence or long-term radiation side effects. To our knowledge, this is the first reported case of adjuvant hypofractionated radiation therapy in a transgender patient with breast cancer.

Humanizing Different Archetypal Expressions of Gender Expansiveness.

This article explores the concept of gender expansiveness. This term refers to a person's self-identifying as gender fluid, genderqueer, transgender, non-binary, gender diverse, or gender nonconforming. Young people, including older children and adolescents, increasingly are experimenting with crossing gender lines. This trend can be understood as a sociocultural process for humanizing more terrifying archetypal forms of gender diversity. Using Henderson's (1988) concept of the cultural unconscious, the author posits that current social developments among youth are attempting to bring gender expansiveness more into collective consciousness. This issue has occasioned a strong counterreaction with panicked appeals to upholding traditional gender norms and needing restrictions on gender-affirming care. Examples from myth, literature and clinical practice help to contextualize the intense emotions aroused by gender diversity. A case example shows how gender fantasies are worked through within an empathic analytic relationship. The author makes an appeal for updating and humanizing older psychological theories that have relied heavily on splits, polarities, and oppositions, all of which are more characteristic of a 20th century way of thinking about the psyche. A potential approach to incorporate gender expansiveness is through a model of the psyche as a mosaic.

Cet article explore le concept d'expansivité du genre. Ce terme fait référence à l'auto­identification d'une personne comme étant de genre fluide, genderqueer, transgenre, non binaire, de genre divers ou ne se conformant pas au genre. Les jeunes, y compris les grands enfants et les adolescents, expérimentent de plus en plus le franchissement des frontières entre les genres. Cette tendance peut être comprise comme un processus socioculturel visant à humaniser des formes archétypales plus terrifiantes de diversité de genre. En utilisant le concept de l'inconscient culturel de Henderson, l'auteur postule que les développements sociaux actuels chez les jeunes tentent d'amener l'expansivité du genre dans la conscience collective. Cette question a provoqué une forte contre­réaction; des exhortations paniquées au respect des normes de genre traditionnelles et à la nécessité de restrictions concernant les soins d'affirmation de genre. Des exemples tirés des mythes, de la littérature et de la pratique clinique aident à contextualiser les émotions intenses suscitées par la diversité des genres. Un exemple de cas montre comment les fantasmes de genre sont travaillés dans le cadre d'une relation analytique empathique. L'auteur lance un appel à la mise à jour et à l'humanisation des anciennes théories psychologiques qui se sont fortement appuyées sur des divisions, des polarités et des oppositions, et qui sont toutes caractéristiques d'une façon de penser la psyché au XXe siècle. Une approche potentielle pour intégrer l'expansivité du genre consiste à utiliser un modèle de la psyché en tant que mosaïque.

Este artículo explora el concepto de expansividad de género. Este término se refiere a la identificación de una persona como género fluido, género queer, transgénero, no­binario, género diverso o inconformidad de género. Los jóvenes, incluyendo niños mayores y adolescentes, están experimentando de manera creciente el cruzar las fronteras de género. Esta tendencia puede entenderse como un proceso sociocultural de humanización de las formas arquetípicas más aterradoras de la diversidad de género. Utilizando el concepto de Henderson del inconsciente cultural, el autor postula que los actuales desarrollos sociales entre los jóvenes intentan traer más a la consciencia colectiva, la expansividad de género. Esta cuestión ha provocado una fuerte reacción en contra, apelando al mantenimiento de las normas de género tradicionales junto a la necesidad de restringir las prácticas de cuidado dirigidas a la afirmación de género. Ejemplos de mitos, literatura y práctica clínica ayudan a contextualizar las intensas emociones que despierta la diversidad de género. Un caso clínico muestra cómo las fantasías de género pueden ser trabajadas en una relación analítica empática. El autor invita a actualizar y humanizar las antiguas teorías psicológicas que se han basado en gran medida en escisiones, polaridades y oposiciones, todas ellas más características de una forma de pensar la psique propia del siglo XX. Un enfoque potencial para incorporar la expansividad de género es a través de un modelo de la psique a modo de un mosaico.

[Contraception for transgender men: A case report and review]. / La contraception d'un homme transgenre : à propos d'un cas et revue de la littérature.

All methods of contraception used by a cisgender woman can theoretically be used by a transgender man. In practice, some contraceptives can aggravate gender dysphoria and should be discarded. On the other hand, contraceptives which make it possible to consolidate amenorrhea or to accentuate the virilization induced by taking testosterone will be better tolerated.

Branch retinal vein occlusion secondary to hormone replacement therapy in a transgender woman.

PURPOSE: To report a case of branch retinal vein occlusion (BRVO) in a transgender woman having undergone hormone replacement therapy. METHODS: Observational case report. RESULTS: A 44-year-old transgender woman on hormone replacement therapy with transdermal estradiol gel for the past 6 years was referred for sudden loss of vision and metamorphopsia in her left eye (LE) for the past 3 weeks. Best-corrected visual acuity (BCVA) was 20/20 in her right eye (RE) and 20/40 in her LE. Dilated fundus examination showed deep flame-shaped hemorrhages, cotton wool spots, and arteriovenous crossing changes. Spectral-domain optical coherence tomography (SD-OCT, Spectralis; Heidelberg Engineering, Heidelberg, Germany) showed retinal edema in the superonasal perifoveal area. Optical coherence tomography angiography (OCTA PlexElite, Carl Zeiss Meditec, Inc, Dublin, CA) revealed the presence of areas of non-perfusion, disorganization of the capillary network and capillary ectasia and dilation. The patient was treated with 3 monthly intravitreal injections of aflibercept. Three-month follow up revealed complete resolution of the macular edema, with BCVA having improved to 20/20 in the LE. CONCLUSION: As estrogen increases cardiovascular risk when used in hormone replacement therapy, RVO is a complication that must be taken into account by clinicians, especially in transgender women (male-to-female) who are more at risk.

Characterization of a transgender population in Portugal.

INTRODUCTION: Gender dysphoria (GD) is a condition in which the individual's gender identity does not correspond to their biological sex, causing significant distress. Biological males who identify as females are referred to as transgender females or as showing male-to-female GD (MtF GD) and biological females who identify as males are referred to as transgender males or as showing female-to-male GD (FtM GD). In our center, there is a multidisciplinary consultation to approach and follow patients with GD. AIM: We aimed to analyze the characteristics of the individuals who attend this consultation. METHODS: Retrospective study of individuals attending the Sexual Medicine Group Consultation. Age, comorbidities, symptom onset, and hormonal and surgical treatment were analyzed. RESULTS: In total, 114 patients were diagnosed with GD: 68.4% FtM GD and 31.6% MtF GD. Median age was 30.2±12years. Among the patients, 63.2% reported symptom onset in childhood: 14.9% between 10 and 18years, and 4.4% later than 18years. Median age at treatment initiation was 23.1±7.1years. Several individuals had concomitant medical conditions, notably smoking (n=37; 32.5%) and depression (n=26; 22.3%). The majority of (92.3% FtM GD and 88.9% MtF GD) were under hormone treatment, and about one-third had undergone some sex reassignment surgery. DISCUSSION: We found higher prevalence of FtM than MtF, in contrast with most other studies. The reasons for this are not clear. A high percentage of our patients were self-medicated. Other characteristics were similar to those previously reported. CONCLUSION: Medical requests by individuals with GD are increasing worldwide. To our knowledge, this is the first study to portray a case series in a consultation center dedicated to the diagnosis, treatment and follow-up of individuals with GD in Portugal.

[Why (and how) to think of care beyond the sexuation of bodies]. / Pourquoi (et comment) penser le soin au-delà de la sexuation des corps.

More and more young people identify as transgender or non-binary today. This can be attributed to the increased availability of vocabulary regarding gender as well as the diverse representations of trans and non-binary people in media and on social networking sites. However, medical or educational institutions are slow to change and many trans individuals still feel uncomfortable in the presence of health care providers, regardless of their specialty.

[Modalities of gynecological follow-up of transgender patients - Literature review]. / Modalités du suivi gynécologique chez les patients transgenres ­ Revue de littérature.

Transgender patients are at increased risk of cancer, sexually transmitted diseases, short- and long-term postoperative complications in patients with vaginoplasty, but also unwanted pregnancy in non-hysterectomized trans men. However, access to care is often difficult for these patients, who often do not benefit from appropriate gynecological monitoring, especially for fear of judgment or discrimination. In view of the health risks of these patients, it is essential to be able to offer them specific and adapted gynecological follow-up. To date, there are no clear recommendations regarding the gynecological follow-up of transgender patients. We relied on the recommendations of the World Professional Association of Transgender Health (W-PATH) and the Endocrine Society Guideline and performed a literature review. We carried out several searches via pubmed in order to explore one by one the different aspects of gynecological follow-up, in particular of non-hysterectomized transgender men and transgender women with a vaginoplasty. It emerges from this a lack of follow-up of transgender people, with a reluctance to consult a gynecologist, associated with the lack of knowledge and experience of health professionals. Due to the risks identical to those of the general population, added to those specific to transgender people, it is important to be able to offer these patients specialized and personalized gynecological follow-up, and to raise awareness and train health professionals on the importance of and the specificities of the gynecological follow-up of these patients.