Age at First Experience of Gender Dysphoria Among Transgender Adults Seeking Gender-Affirming Surgery

Is gender dysphoria associated with increased hospital cost per stay among patients hospitalized for depression? Focus on the racial and regional variance in US hospitals

Introduction

Individuals with gender dysphoria do not identify with their sex assigned at birth and face societal and cultural challenges, leading to increased risk for depression, anxiety, and suicide. Gender dysphoria is a DSM-5 diagnosis but is not necessary for transition therapy. Additionally, individuals with gender dysphoria or who identify as gender diverse/nonconforming may experience "minority stress" from increased discrimination, leading to a greater risk for mental health problems. This study aimed to identify possible health disparities in patients hospitalized for depression with gender dysphoria across the United States. Depression was selected because patients with gender dysphoria are at an increased risk for it. Various patient and hospital-related factors are explored for their association with changes in healthcare utilization for patients hospitalized with depression.

Methods

The National Inpatient Sample was used to identify nationwide patients with depression (n = 378,552, weighted n = 1,892,760) from 2016 to 2019. We then examined the characteristics of the study sample and investigated how individuals' gender dysphoria was associated with healthcare utilization measured by hospital cost per stay. Multivariate survey regression models were used to identify predictors.

Results

Among the 1,892,760 total depression inpatient samples, 14,145 (0.7%) patients had gender dysphoria (per ICD-10 codes). Over the study periods, depression inpatients with gender dysphoria increased, but total depression inpatient rates remained stable. Survey regression results suggested that gender dysphoria, minority ethnicity or race, female sex assigned at birth, older ages, and specific hospital regions were associated with higher hospital cost per stay than their reference groups. Sub-group analysis showed that the trend was similar in most racial and regional groups.

Conclusion

Differences in hospital cost per stay for depression inpatients with gender dysphoria exemplify how this community has been disproportionally affected by racial and regional biases, insurance denials, and economic disadvantages. Financial concerns can stop individuals from accessing gender-affirming care and risk more significant mental health problems. Increased complexity and comorbidity are associated with hospital cost per stay and add to the cycle.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Psychological Symptoms and Service Utilization in Prepubertal and Pubertal Transgender and Gender-Diverse Patients

STUDY OBJECTIVE

To describe the demographic characteristics and psychological symptoms of gender-diverse patients and to compare symptoms between prepubertal and pubertal subgroups METHODS: This was a retrospective chart review of all gender-diverse patients seen by at least 1 provider at the Nemours Gender Wellness Program from March 2015 to December 2020. The extracted data included demographic and psychosocial characteristics at baseline and 1-year follow-up visits. Pubertal status was determined by Tanner staging by a pediatric endocrinologist or gynecologist. Descriptive statistics were used to compare these variables between prepubertal and pubertal subgroups.

RESULTS

Our sample included 177 individuals at baseline and 96 subjects at the 1-year follow-up visit. Most patients were White (83.0%), non-Hispanic (92.0%), transgender male (72.9%), and pubertal (90.4%). Compared with prepubertal patients, at the baseline visit, pubertal patients had significantly higher rates of current (68.1% vs 17.6%, P < .001) and lifetime (80.0% vs 23.5%, P < .001) depressive symptoms, current anxiety symptoms (70.0% vs 41.2%, P = .01), lifetime suicide attempts (12.5% vs 0%, P < .001), and a formal diagnosis of an eating disorder (5.0% vs 0%, P < .001). Symptoms did not change significantly over time from baseline to the 1-year follow-up visit.

CONCLUSION

We found elevated rates of psychological symptoms and diagnoses in gender-diverse youth, with higher rates in pubertal compared with prepubertal patients. By elucidating how the psychosocial characteristics of gender-diverse children and adolescents differ based on pubertal status, these data can be used to improve current outreach and treatment strategies for transgender pediatric patients.

Physical and psychosocial challenges of people with gender dysphoria: a content analysis study

BACKGROUND

The mismatch between the gender experienced by a person and the gender attributed to him/her leads to gender dysphoria. It seems that people's perception of gender dysphoria is affected by individual, cultural, and sociological factors and these factors affect different aspects of their biological, psychological, and social health. To this end, this qualitative study aimed to identify the physical, psychological, and social challenges of people with gender dysphoria referring to the Department of forensic medicine in Iran.

METHODS

This qualitative study was conducted using conventional content analysis on 9 individuals who were selected through purposive sampling. A total of 16 interviews were conducted with 9 participants. Each interview lasted 60-90 min. The participants' gender dysphoria was confirmed by the Department of forensic medicine. The data were collected through face-to-face semi-structured interviews with the participants.

RESULTS

The data revealed 3 main categories and 10 subcategories. The main categories were living in agony, confusion, and social concerns. The subcategories were annoying physical characteristics, mental suffering, disturbing sexual changes, concerns about public reaction, helplessness, surrender, the final solution, retreating to isolation, stressful family conditions, and lack of public recognition.

CONCLUSION

The findings showed that people with gender dysphoria suffer from some problems including living in agony, confusion, and social concerns. Each of these problems is associated with several challenges. It seems that most of the challenges faced by people with gender dysphoria are caused by unawareness of their conditions by the family and the public, which in turn is caused by the failure of related organizations and experts in this field to provide adequate information about the conditions of these people. Thus, the findings of the present study can have some implications for resolving the challenges faced by people with gender dysphoria.

Age of first experience of gender incongruence among transgender and non-binary individuals

OBJECTIVE

Gender incongruence (GI) is a condition in which an individual's gender identity, role, and expression differ from their assigned sex. This study aimed to evaluate when GI first arises in transgender and non-binary individuals seeking hormone therapy and their years living untreated in South Korea.

METHODS

This retrospective study analyzed GI patients seeking gender-affirming hormone therapy (GAHT) or surgery between 2015 and 2021. The recorded data included gender identity, legal transition status, age of onset of GI, age at the initiation of therapy, and total therapy duration.

RESULTS

In total, 337 patients were enrolled, including 149 (44.2%) transgender men, 153 (45.4%) transgender women, and 35 (10.4%) non-binary individuals. The mean age of onset of GI was 10.6 years (standard deviation, 5.1). Of the total patients, 29% had an onset of GI before age 6 years (preschool), 61% before age 12 (elementary-school), and 87% before age 15 (middle-school). Patients lived with GI for almost 14 years before GAHT initiation at a median age of 23.0 years. 90% of transgender men, 82.3% of transgender women, and 85% of non-binary patients disclosed their gender identities to their families. Regarding social transition, 31.5% of transgender men, 16.3% of transgender women, and none of the non-binary patients (P<0.005) changed their legal gender markers.

CONCLUSION

Many transgender and non-binary individuals experience GI early in life. These findings emphasized the need for early evaluation, timely gender-affirming care, and more accessible legal processes for gender marker changes in South Korea, aiming to enhance the safety and well-being of these individuals.

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Assessment of Transgender/Gender-Expansive Accessibility in Inpatient Pediatric Mental Health Facilities

Purpose

This study surveyed a national sample of inpatient pediatric behavioral health facilities on policies related to care for transgender and gender-expansive (TGE) youth to assess adherence to best practices.

Methods

Staff/providers at youth inpatient psychiatric facilities were recruited by phone or email. Participants completed an electronic survey on facilities' training policies, staff comfort related to gender diversity, and other policies related to caring for TGE youth.

Results

Of 479 potential participating facilities, 124 surveys were initiated and 59 were completed. Measures to ensure accessibility to TGE patients are present in many facilities surveyed, with most reporting that their facility had nondiscrimination policies in place (86.2%) and required training on working with TGE patients (52.5%). A minority of participants (12.1%) reported that their facility roomed TGE youth based on sex assigned at birth, although only a small portion roomed based on gender identity alone (19.0%). Slightly more than two-thirds stated that their facility had individual restrooms available. Most participants (74.6%) stated that facility staff were comfortable discussing gender diversity in general, although this was less common for other topics related to TGE patient care.

Conclusion

Our survey highlights efforts made by inpatient behavioral health facilities to ensure accessibility of services to TGE youth, although our results showed notable differences across facilities. Given inconsistent federal protections for TGE patients, there remains a need for efforts to ensure that TGE youth are receiving all possible support in these treatment settings, such as accessible restrooms and bedroom assignments, as well as the opportunity to room with peers.

A comprehensive analysis of YouTube videos on gender affirmation surgery

INTRODUCTION AND HYPOTHESIS

The objective was to comprehensively analyze YouTube™ videos focusing on genital gender-affirmation surgery (GAS) from the perspective of urologists and gynecologists and to utilize results to create educational videos for transgender individuals with accurate and engaging content.

METHODS

A YouTube search was performed using the keywords "Metoidioplasty," "Phalloplasty," "Gender affirmation surgery," "Transgender surgery," "Vaginoplasty," and "Male-to-female surgery." Video results that were duplicated, non-English, of low relevance, non-audio, and/or short duration (under 2 min) were excluded. The upload source was classified as university/nonprofit physician or organization, health information websites, medical advertisement/for-profit organizations, or individual patient experience. Viewer engagement metrics were obtained for each video. Each video was evaluated using the DISCERN, Global Quality Score (GQS), and Patient Education Materials Assessment Tool for audio-visual content (PEMAT A-V) tools.

RESULTS

A total of 273 videos were evaluated. Viewer engagement metrics of videos from the patient experience group were higher than those of both universities/nonprofit physicians and medical advertisement/for-profit groups. DISCERN and GQS scores were significantly lower in videos uploaded by the patient experience group than in each of the other upload sources. More videos covered female-to-male (FtM) transition (168, 61.5%) than covered male-to-female (MtF; 71, 26.0%), and both (34, 12.5%). MtF transition videos had significantly higher total view counts than videos from the other groups (p<0.001). The like counts of videos were significantly higher in both MtF transition and FtM transition groups than for videos explaining both types of transition within the same video. The total DISCERN score was significantly lower in FtM transition videos than in the other content groups. Two educational videos were prepared, informed by the tools and results of this study, and hosted on YouTube.

CONCLUSIONS

The findings suggest that genital GAS videos with less technical content have higher audience engagement. This information should be used to aid medical organizations when creating YouTube content to provide accurate information to larger audiences in the transgender community.

National Estimates of Gender-Affirming Surgery in the US

Importance

While changes in federal and state laws mandating coverage of gender-affirming surgery (GAS) may have led to an increase in the number of annual cases, comprehensive data describing trends in both inpatient and outpatient procedures are limited.

Objective

To examine trends in inpatient and outpatient GAS procedures in the US and to explore the temporal trends in the types of GAS performed across age groups.

Design, Setting, and Participants

This cohort study includes data from 2016 to 2020 in the Nationwide Ambulatory Surgery Sample and the National Inpatient Sample. Patients with diagnosis codes for gender identity disorder, transsexualism, or a personal history of sex reassignment were identified, and the performance of GAS, including breast and chest procedures, genital reconstructive procedures, and other facial and cosmetic surgical procedures, were identified.

Main Outcome Measures

Weighted estimates of the annual number of inpatient and outpatient procedures performed and the distribution of each class of procedure overall and by age were analyzed.

Results

A total of 48 019 patients who underwent GAS were identified, including 25 099 (52.3%) who were aged 19 to 30 years. The most common procedures were breast and chest procedures, which occurred in 27 187 patients (56.6%), followed by genital reconstruction (16 872 [35.1%]) and other facial and cosmetic procedures (6669 [13.9%]). The absolute number of GAS procedures rose from 4552 in 2016 to a peak of 13 011 in 2019 and then declined slightly to 12 818 in 2020. Overall, 25 099 patients (52.3%) were aged 19 to 30 years, 10 476 (21.8%) were aged 31 to 40, and 3678 (7.7%) were aged12 to 18 years. When stratified by the type of procedure performed, breast and chest procedures made up a greater percentage of the surgical interventions in younger patients, while genital surgical procedures were greater in older patients.

Conclusions and Relevance

Performance of GAS has increased substantially in the US. Breast and chest surgery was the most common group of procedures performed. The number of genital surgical procedures performed increased with increasing age.

Models of Gender Dysphoria Using Social Media Data for Use in Technology-Delivered Interventions: Machine Learning and Natural Language Processing Validation Study

BACKGROUND

The optimal treatment for gender dysphoria is medical intervention, but many transgender and nonbinary people face significant treatment barriers when seeking help for gender dysphoria. When untreated, gender dysphoria is associated with depression, anxiety, suicidality, and substance misuse. Technology-delivered interventions for transgender and nonbinary people can be used discretely, safely, and flexibly, thereby reducing treatment barriers and increasing access to psychological interventions to manage distress that accompanies gender dysphoria. Technology-delivered interventions are beginning to incorporate machine learning (ML) and natural language processing (NLP) to automate intervention components and tailor intervention content. A critical step in using ML and NLP in technology-delivered interventions is demonstrating how accurately these methods model clinical constructs.

OBJECTIVE

This study aimed to determine the preliminary effectiveness of modeling gender dysphoria with ML and NLP, using transgender and nonbinary people's social media data.

METHODS

Overall, 6 ML models and 949 NLP-generated independent variables were used to model gender dysphoria from the text data of 1573 Reddit (Reddit Inc) posts created on transgender- and nonbinary-specific web-based forums. After developing a codebook grounded in clinical science, a research team of clinicians and students experienced in working with transgender and nonbinary clients used qualitative content analysis to determine whether gender dysphoria was present in each Reddit post (ie, the dependent variable). NLP (eg, n-grams, Linguistic Inquiry and Word Count, word embedding, sentiment, and transfer learning) was used to transform the linguistic content of each post into predictors for ML algorithms. A k-fold cross-validation was performed. Hyperparameters were tuned with random search. Feature selection was performed to demonstrate the relative importance of each NLP-generated independent variable in predicting gender dysphoria. Misclassified posts were analyzed to improve future modeling of gender dysphoria.

RESULTS

Results indicated that a supervised ML algorithm (ie, optimized extreme gradient boosting [XGBoost]) modeled gender dysphoria with a high degree of accuracy (0.84), precision (0.83), and speed (1.23 seconds). Of the NLP-generated independent variables, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) clinical keywords (eg, dysphoria and disorder) were most predictive of gender dysphoria. Misclassifications of gender dysphoria were common in posts that expressed uncertainty, featured a stressful experience unrelated to gender dysphoria, were incorrectly coded, expressed insufficient linguistic markers of gender dysphoria, described past experiences of gender dysphoria, showed evidence of identity exploration, expressed aspects of human sexuality unrelated to gender dysphoria, described socially based gender dysphoria, expressed strong affective or cognitive reactions unrelated to gender dysphoria, or discussed body image.

CONCLUSIONS

Findings suggest that ML- and NLP-based models of gender dysphoria have significant potential to be integrated into technology-delivered interventions. The results contribute to the growing evidence on the importance of incorporating ML and NLP designs in clinical science, especially when studying marginalized populations.

Perioperative Experiences of Transgender Adults Seeking Gender-Affirming Surgery: A Qualitative Interview Study

Purpose

Transgender individuals have been systemically excluded from U.S. health care, creating barriers and disparities that other populations do not face. Gender-affirming surgery represents an emerging treatment modality for gender dysphoria, however, little is known about how transgender patients experience the perioperative pathway. This study sought to characterize the experiences of transgender patients seeking gender-affirming surgery and identify opportunities for improvement.

Methods

A qualitative study was conducted at an academic medical center between July and December 2020. Semistructured interviews were conducted after a postoperative encounter with adult patients who had undergone gender-affirming surgery within the past year. A purposive sampling strategy was used to maximize representation across surgery types and surgeons. Recruitment continued until thematic saturation was reached.

Results

All invited patients agreed to participate, yielding 36 interviews (response rate=100%). Four major themes emerged. First, gender-affirming surgery was described as a major life event, often reflecting years of personal decision making and research. Second, participants stressed the importance of surgeon investment, surgeon experience caring for transgender patients, and individualized care in developing a strong relationship with their care team. Third, self-advocacy was necessary to navigate the perioperative pathway and overcome barriers. Last, participants discussed a lack of equity and provider awareness regarding transgender health issues, including correct pronoun usage, terminology, and insurance coverage.

Conclusion

Patients undergoing gender-affirming surgery encounter unique perioperative barriers to care, which would benefit from targeted interventions in the health care system. To improve the pathway, our findings support the creation of multidisciplinary gender-affirmation clinics, greater emphasis on transgender care in medical education, and insurance policy reforms aimed at promoting consistent and equitable coverage.

Medical considerations in the care of transgender and gender diverse patients with eating disorders

Transgender and gender diverse (TGD) individuals are at increased risk for the development of eating disorders, but very little has been published with regards to the unique aspects of their medical care in eating disorder treatment. Providing gender affirming care is a critical component of culturally competent eating disorder treatment. This includes knowledge of gender affirming medical and surgical interventions and how such interventions may be impacted by eating disordered behaviors, as well as the role of such interventions in eating disorder treatment and recovery. TGD individuals face barriers to care, and one of these can be provider knowledge. By better understanding these needs, clinicians can actively reduce barriers and ensure TGD individuals are provided with appropriate care. This review synthesizes the available literature regarding the medical care of TGD patients and those of patients with eating disorders and highlights areas for further research.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one's gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.

Mental health in transgender individuals: a systematic review

Several lines of evidence indicate the prevalence of mental health disorders in Transgender (TG) individuals is higher than that of cisgender individuals or the general population. In this systematic review, we aim to propose a summary of some of the most significant research investigating mental health disorders' prevalence among this population. We performed a double-blind systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting (PRISMA) on PUBMED/MEDLINE and SCOPUS, specifically using peer-reviewed articles examining the mental health status of transgender (TG) individuals. This review did not exclude any research based on publication date. The last search was performed in February 2022. The employed search strategy led to the selection of 165 peer-reviewed articles. The majority of these papers presented a cross-sectional design with self-reported diagnoses and symptoms, signaling a significant prevalence of mental health disorders amongst TG Individuals. Of the reviewed articles, 72 examined the prevalence of mood and anxiety disorders; 8 examined eating disorders; 43 examined the prevalence of suicidal or self-harm ideation or behaviors; 5 papers examined the prevalence of trauma and stress-related disorders; 10 examined the frequency of personality disorders; 44 examined substance use disorders; and 9 papers examined the prevalence of autism spectrum disorder. Finally, 22 studies reported on the prevalence of TG individuals diagnosed with co-morbid mental health disorders or unspecified mental disorders. Our findings coincide with existing research, which indicates TG individuals do experience a higher prevalence of mental health disorders than that of the general population or cisgender individuals. However, further research is needed to address the existing gaps in knowledge.

Complex psychiatric comorbidities in Thai trans women: A case series

Trans women (TW) have a high prevalence of poor mental health. Gender-affirming treatments could reduce distress regarding their gender incongruity. However, psychiatric comorbidities might complicate the management or even confirmation of being transgender. We reported three TW with complex mental illnesses, including anxiety disorder with cultural explanation, neurodevelopmental disorders with cross-dressing, and severe personality disorder accompanied by major depression. All cases received both psychiatric and gender-affirming treatments, which demonstrated promising outcomes. Along with gender dysphoria (GD), psychiatric comorbidities also altered these TW's identity and manifestations. Recognition of such conditions would be beneficial in providing care for all TW, both with and without GD.

Inmune-mediated inflammatory rheumatic diseases in transgender people: A scoping review

BACKGROUND

In immune-mediated inflammatory rheumatic diseases (IMIRD), there are differences between cis-men and cis-women in epidemiology, clinical feature, therapeutic approach, treatment response, and prognosis. In transgender individuals, information concerning IMIRD is not substantial. The assessment of information concerning rheumatic diseases in transgenders is crucial because transgenders may undergo treatments with potential impacts on IMIRD. We aim to collect and discuss current knowledge on IMIRD in transgender individuals, determine the coverage of the literature, identify the knowledge gaps, and highlight opportunities for future research.

METHODS

We did a scoping review of publications collected through a systematic search of transgender patients with any IMIRD. Data sources were Medline, Embase, and Web of Knowledge. Synthesis of results and qualitative review of data information was collected in tables. A semi-quantification of the quality of the articles reporting clinical studies was performed.

RESULTS

There were 11 transwoman, and 3 transmen cases of systemic lupus erythematosus (5 cases), skin lupus erythematosus (2), systemic sclerosis (4), anti-synthetase syndrome (1), rheumatoid arthritis (1) and ankylosing spondylitis (1). Eleven were de novo cases and three had prior history of IMIRD and developed a comorbidity after starting hormone replacement therapy. The clinical expression of the disease was variable. Two transwomen and one transman developed thrombotic events. The lupus skin lesions in one transman improved following testosterone treatment. No clinical studies were identified. Quality of publications was disparate.

CONCLUSION

Although the number of cases is small, most cases of IMIRD occur in transwomen. The absence of solid data warrants caution in establishing recommendations regarding hormone replacement therapy in transgenders with IMIRD. There is an essential need for the consideration of cisgender and transgender particularities in future research on IMIRD.

Outcomes in chest feminization patients with a history of illicit hormone use and silicone injections

Transfeminine patients facing barriers to gender confirming surgery sometimes pursue illicit feminization procedures such as "street" hormones and silicone injections. These procedures often yield complications and disfigurement, making surgeons and insurance companies wary of secondary breast reconstruction. This clinical series assesses illicit treatment among our transfeminine breast surgery patients and describes the presentation, surgical approaches, and outcomes of each patient. A retrospective review of transfeminine patients who underwent chest feminization surgery with a single provider between March 2018 and March 2020 identified patients with a history of illicit hormones or silicone injections. Demographics, comorbidities, preoperative diagnoses and symptoms, surgical details, and postoperative outcomes were collected. Patients were contacted for a follow-up survey concerning outcomes and satisfaction. Of the 41 transfeminine patients reviewed, eight (19.5%) had previous illicit treatment. Seven (17.1%) used non-prescribed hormones, and three (7.3%) received silicone breast injections. Two patients presented with symptoms from silicone injections; the remaining were asymptomatic. Six patients underwent subglandular breast augmentation, one had a reduction mammoplasty, and one underwent an implant exchange. Only one patient had postoperative complications that healed without surgical intervention. This series emphasizes the need to assess the prevalence of silicone injections and illicit hormone use among transgender chest feminization patients. The use of these substances was relatively high in our population compared to national averages; however, there is a low risk of postoperative complications. Providers may perform breast surgery in patients with a history of illicit augmentation practices after careful evaluation and surgical planning.

Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Gender-Affirming Genital Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Services

BACKGROUND

To date, a comprehensive state-by-state assessment of transgender transition-related health care coverage for gender-affirming hormone therapy (GAHT) and genital gender-affirming surgery (GAS) has not been reported.

AIMS

The aims of this study were 1) to verify which U.S. states' Medicaid systems do/do not cover GAHT and GAS; 2) to assess the ease/difficulty for patients to determine whether GAHT and GAS are Medicaid-covered benefits; and 3) to understand possible state-related predictors of Medicaid coverage for gender-affirming care.

METHODS

We reviewed the official Medicaid Handbook and website for all 51 states (+D.C.) and 5 territories to confirm whether GAHT and GAS are covered benefits. When indeterminate, we called the Medicaid office in each state, and for many, Medicaid managed care organizations (MCOs), and individual in-state providers, to confirm coverage. We recorded our experiences, number of, and duration of phone calls to confirm coverage.

OUTCOMES

The main outcome was a definitive answer from the state/territory's Medicaid program or MCOs regarding whether GAHT and GAS are/are not covered benefits. Secondary outcome measures included responses we received and the total number/duration of phone calls necessary to confirm coverage.

RESULTS

Only 12 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAHT in their Medicaid Handbook/webpages. We confirmed that 34 of 51 state Medicaid programs do cover GAHT, whereas 9 of 51 states' and 2 of 5 territories' do not. We could not confirm coverage of GAHT in 8 of 51 states and 3 of 5 territories. Only 26 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAS in their Medicaid Handbook/webpages. We confirmed that 25 of 51 state Medicaid programs do cover GAS, whereas 22 of 51 states' and 3 of 5 territories' do not. We could not confirm coverage of GAS in 4 of 51 states and 2 of 5 territories. Up to 12 calls, lasting up to 125 minutes, were required to confirm coverage for GAHT/GAS.

CLINICAL IMPLICATIONS

Our findings indicate that important health care access barriers/disparities exist today and warrant improvement.

STRENGTHS & LIMITATIONS

To our knowledge, this is the most comprehensive assessment of transgender transition-related health care coverage. Limitations include possible bias, as it could be that we were more persistent than actual patients would be to determine service coverage, and a lack of specificity regarding which specific hormone formulations or procedures are/are not covered.

CONCLUSION

Our findings show that only 34 of 51 (67%) states' Medicaid programs include GAHT and 25 of 51 (49%) include GAS as covered benefits. Our experience suggests that the process to confirm coverage can be especially time-consuming and frustrating for patients. Zaliznyak M, Jung EE, Bresee C, et al. Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Genital Gender-Affirming Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Service. J Sex Med 2021;18:410-422.

Endocrine treatment of transgender individuals: current guidelines and strategies

INTRODUCTION

This review summarizes gender affirming medical and surgical care available to transgender individuals, along with proposals to improve medically and culturally appropriate care.

AREAS COVERED

Transgender individuals are those whose gender identity differs from that recorded at birth (usually based on visualization of external sexual anatomy). In order to align the body with the patient's gender identity, clinicians can provide hormone therapy (HT) to bring sex hormone levels to the range associated with the patient's gender identity. At steady state, monitoring for maintenance of levels, as well as for known risks and complications, is required. Treating clinicians should have knowledge of trans assessment criteria, hormone therapy, surgical options, primary care, and mental health needs of transgender patients. A narrative literature review was conducted using Pubmed and EMBASE with articles then selected for relevance. The initial search terms were: androgen suppression, antiandrogen, breast development, chest reconstruction, cisgender, estrogen, fertility preservation, gender-affirming surgery, gender identity, gender incongruence, genital reconstruction, hormone replacement, hyperlipidemia, orchiectomy, prolactin, prostate atrophy, spermatogenesis, spironolactone, testosterone, thrombogenesis, transgender, and virilization.

EXPERT OPINION

Although guidelines exist and examples of training are available, systematic formal training must be implemented to truly mainstream high-quality gender-affirming health care .

Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes

INTRODUCTION

Various methods have been described to create a functional neovagina with feminizing (male-to-female) gender affirming surgery. Intestinal vaginoplasty using ileal or colon segments confers natural mucus production and greater canal depth with primary vaginoplasty. In this work we describe an alternative approach to primary and salvage vaginoplasty using right colon. We focus on relative advantages compared to use of other bowel segments, and we review patient outcomes.

METHODS

Transgender women who had previously undergone primary vaginoplasty underwent laparoscopic right colon vaginoplasty at our center between 12/2017 and 7/2019. Demographic, medical, outcome, and satisfaction data was collected and retrospectively reviewed.

RESULTS

Twenty-two consecutive transgender women patients underwent laparoscopic right colon vaginoplasty. Mean age was 39.3 years. There were two intraoperative complications:1 injury of the ileocolic pedicle, and 1 minor bladder injury. Four of 22 patients (18.2%) had short-term complications (< 30 days): 3 had postoperative ileus/small bowel obstruction and 1 had intra-abdominal hemorrhage. All were managed conservatively. Six of 22 patients (27.3%) experienced a total of 14 long-term complications (> 30 days): 1 developed Crohn's (not involving the neovagina); 1 developed late small bowel obstruction (SBO) (managed conservatively); 5 developed neovagina prolapse; 4 developed stenosis (2 at the vaginal introitus, and 2 had extrinsic obstruction at the recto-vaginal junction (all underwent successful laparoscopic surgical correction); and 3 were diagnosed with diversion neovaginitis (all treated conservatively). All complications were successfully treated with conservative and/or surgical intervention. All (100%) patients reported satisfaction with neovagina function and appearance.

CONCLUSION

This is the only outcomes series of transgender women patients who have undergone right colon vaginoplasty, to date. Our study finding suggests that laparoscopic right colon for primary or salvage vaginoplasty has several important advantages over use of Sigmoid colon or Ileum, and is a reliable technique whose complications can be managed successfully, with favorable, satisfactory long-term outcomes.

The Desire and Status of Gender-Affirming Hormone Therapy and Surgery in Transgender Men and Women in China: A National Population Study

BACKGROUND

Gender-affirming hormone therapy and surgery are important medically necessary approaches to transgender care. However, few related data exist in China.

AIM

To understand the desire and access of transgender cares in the Chinese transgender men and women population.

METHODS

A cross-sectional self-selecting survey targeting the Chinese transgender population was conducted in 2017 using a snowball sampling method. Participants completed an online questionnaire anonymously. Gender identity was verified by specifically designed questions. Data analysis of this study was performed in 2019.

OUTCOMES

The main outcome was the status of receiving transgender medical care, including the desire vs actual state of receiving gender-affirming hormone treatment and gender-affirmation surgery, methods of accessing hormonal therapy and surgery, and risky behaviors associated with obtaining treatments.

RESULTS

Of the total 2060 valid questionnaires, there were 1,304 transgender individuals (626 transgender men and 678 transgender women), with a median age of 22 (interquartile range, 19-26) years. Among them, 1,036 (79.4%) expressed desires for hormonal therapy, but of 1,036, 741 (71.5%) considered it difficult to obtain medications from doctors. Of 1,036 individuals, 275 (26.5%) and 172 (16.6%) had thoughts or behaviors of self-injury, respectively, when lacking access to hormone therapy. Of 1,036 individuals, 602 (58.1%) had used hormones. Of those 602 hormone users, 407 (67.6%) had ever obtained medications from informal drug dealers, and 372 (61.8%) of them did not perform regular monitoring. 868 of 1,303 (66.6%) participants had received or wanted to undergo gender-affirming surgeries, but 710 of 868 (81.8%) considered the surgery resources not adequate or very scarce.

CLINICAL IMPLICATIONS

The transgender medical resources in China are scarce, and many transgender individuals have engaged in high-risk activities to access care.

STRENGTHS & LIMITATIONS

This is the first study to focus on the current status of gender-affirming hormone therapy and surgery in the Chinese transgender population, providing valuable and real-world data for understanding the need for transgender health care in China. But, the online questionnaire could not provide the prevalence and other epidemiologic information about transgender individuals in China, and the survey did not address specific medication regimens, dosages, sex hormone levels, and specific hormone therapy-related or surgery-related adverse events.

CONCLUSION

Significant improvement in access to gender-affirming medical and surgery care is needed in China. Liu Y, Xin Y, Qi J, et al. The Desire and Status of Gender-Affirming Hormone Therapy and Surgery in Transgender Men and Women in China: A National Population Study. J Sex Med 2020;17:2291-2298.