1
|
LaRosa MX, Chikarmane SA, Yu RN, Grimstad F, Chow JS. Peri-surgical imaging of intersex and gender diverse youths. Pediatr Radiol 2024:10.1007/s00247-024-05900-0. [PMID: 38520560 DOI: 10.1007/s00247-024-05900-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.
Collapse
Affiliation(s)
- Michelle X LaRosa
- Department of Radiology, Boston Children's Hospital, 300 Longwood Avenue, Main Building, 2nd Floor, Boston, MA, 02115, USA.
| | - Sona A Chikarmane
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Richard N Yu
- Department of Urology, Boston Children's Hospital, Boston, MA, USA
| | - Frances Grimstad
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Gossner J. A pictorial review of scrotal and penile pathology on computed tomography. Emerg Radiol 2024; 31:103-111. [PMID: 38194213 DOI: 10.1007/s10140-023-02198-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
Computed tomography (CT) may show a variety of scrotal and penile pathologic finding, but is usually not used as a first-line imaging due to its limited soft tissue contrast. Nonetheless, there are three main scenarios for imaging of the scrotum and penis with CT. Pathologies may be found incidentally in patients undergoing abdominal and pelvic CT scanning for different reasons. In emergency settings, CT is frequently performed, and the recognition of scrotal and penile pathologies by the reporting radiologist is crucial to ensure optimal patient treatment and outcome. If MRI scanning cannot be performed due to contraindications or is unavailable in resource, limited CT may be used for the further characterization of scrotal and penile pathology found on ultrasound. This pictorial review wants to familiarize general and emergency radiologists with the anatomy and possible pathological findings of the scrotum and penis on CT.
Collapse
Affiliation(s)
- Johannes Gossner
- Department of Diagnostic and Interventional Radiology, Evangelisches Krankenhaus Göttingen-Weende, An der Lutter 24, 37074, Göttingen, Germany.
| |
Collapse
|
3
|
D’Angelo A, Portaluri A, Caprini F, Sofia C, Ferrara F, Condorelli E, Iaccarino L, Catanzariti F, Mancino M, Trombadori CML, Belli P, Marino MA. Male Breast: A Review of the Literature and Current State of the Art of Diagnostic Imaging Work-Up. Diagnostics (Basel) 2023; 13:3620. [PMID: 38132204 PMCID: PMC10743117 DOI: 10.3390/diagnostics13243620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/21/2023] [Accepted: 12/01/2023] [Indexed: 12/23/2023] Open
Abstract
Pathological conditions affecting the male breast (MB) share some similarities with those found in women, while others are specific to men. The first part of this review provides an overview of MB disorders, exploring the most common types of MB diseases. The second part then emphasizes the state-of-the-art approaches proposed in the literature for screening and follow-up with MB cancer patients, which highlights the importance of tailored strategies for diagnosis, follow-up, and identifying high-risk populations. Considering the increasing attention in recent years on the topic, transgender individuals are also included in this review. Together with the MB, it is an understudied category thus far. This review aims to raise awareness among radiologists that MBs should be approached differently from female breasts, contributing to the advancement of medical knowledge, improving patient outcomes, and promoting early detection of MB disorders. The review also provides an update on breast cancer and screening in the transgender population.
Collapse
Affiliation(s)
- Anna D’Angelo
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Antonio Portaluri
- Department of Biomedical Sciences and Morphologic and Functional Imaging, AOU G. Martino, University of Messina, 98100 Messina, Italy; (A.P.); (C.S.); (E.C.); (F.C.); (M.A.M.)
| | - Flavia Caprini
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Carmelo Sofia
- Department of Biomedical Sciences and Morphologic and Functional Imaging, AOU G. Martino, University of Messina, 98100 Messina, Italy; (A.P.); (C.S.); (E.C.); (F.C.); (M.A.M.)
| | - Francesca Ferrara
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Elvira Condorelli
- Department of Biomedical Sciences and Morphologic and Functional Imaging, AOU G. Martino, University of Messina, 98100 Messina, Italy; (A.P.); (C.S.); (E.C.); (F.C.); (M.A.M.)
| | - Ludovica Iaccarino
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Francesca Catanzariti
- Department of Biomedical Sciences and Morphologic and Functional Imaging, AOU G. Martino, University of Messina, 98100 Messina, Italy; (A.P.); (C.S.); (E.C.); (F.C.); (M.A.M.)
| | - Matteo Mancino
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Charlotte M. L. Trombadori
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Paolo Belli
- Department of Diagnostic Imaging, Oncological Radiotherapy and Haematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (F.C.); (F.F.); (L.I.); (M.M.); (C.M.L.T.); (P.B.)
| | - Maria Adele Marino
- Department of Biomedical Sciences and Morphologic and Functional Imaging, AOU G. Martino, University of Messina, 98100 Messina, Italy; (A.P.); (C.S.); (E.C.); (F.C.); (M.A.M.)
| |
Collapse
|
4
|
Patel H, Camacho JM, Salehi N, Garakani R, Friedman L, Reid CM. Journeying Through the Hurdles of Gender-Affirming Care Insurance: A Literature Analysis. Cureus 2023; 15:e36849. [PMID: 37123806 PMCID: PMC10142323 DOI: 10.7759/cureus.36849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/29/2023] [Indexed: 03/31/2023] Open
Abstract
Gender-affirming surgery (GAS) has been proven to be successful in the treatment of gender dysphoria. The benefits of providing insurance coverage for transition-related surgeries far surpass the costs of suffering from persistent gender dysphoria, including many positive health outcomes such as decreased rates of substance use, psychiatric illness, and suicide. Despite being deemed a medical necessity, discrepancies in access to treatment and insurance coverage for GAS persist. The purpose of this review is to understand the impact of limited insurance coverage on the well-being of transgender patients. A comprehensive search was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in SCOPUS and PubMed databases using the terms "insurance" AND "gender affirming surgery." Articles in non-English languages were excluded. Data related to variations in insurance coverage for GAS in the United States were collected. Of the 67 articles reviewed, 29 met the inclusion criteria. When compared to the general population, individuals who identify as transgender have higher rates of being uninsured as of 2020, with only 30 states in the United States providing insurance coverage for transgender and gender non-binary people. Of the 30 states, only 18 provide coverage for GAS, with chondrolaryngoplasty having the highest prevalence of coverage. As evidenced in our review, the persistence of complex insurance regulations impedes transgender individuals' access to equitable care. Overall, this literature review elucidates the variability in insurance coverage as it relates to gender-affirming care. Furthermore, this review highlights the need for additional health policy reforms, in addition to improving physician awareness regarding the hurdles of navigating the insurance world as a transgender patient.
Collapse
|
5
|
Pratt-Chapman ML, Astorino J, Goyal S, Schmit B, Yap ML, Bajaj S, Angiulo E. Radiology and radiation oncology considerations for transgender and intersex patients: A qualitative study. J Med Imaging Radiat Oncol 2023; 67:185-192. [PMID: 36790031 DOI: 10.1111/1754-9485.13516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION In this qualitative study, we explored experiences of radiologists and radiation oncologists in providing clinical care to transgender, gender diverse (TGD), and intersex patients by asking about comfort level, relevant past training and training gaps, and clinical recommendations for TGD and intersex patient care. METHODS A purposive sample of radiology and radiation oncology professionals (n = 16) from diverse practice settings were interviewed on a videoconferencing platform. Transcripts were auto-populated and checked manually for accuracy. Two coders used a mix of deductive and inductive coding to identify key themes. Member checking was conducted with interviewees. RESULTS Participants reported major gaps in training, knowledge, and confidence related to all aspects of TGD and intersex patient care. Recommendations for improvements included training that encompassed key terminology, how to conduct a physical exam on TGD and intersex patients, radiology and radiation oncology adaptations for TGD and intersex patients, and care coordination among multi-disciplinary oncology team members and gender affirming care providers. Exposure to diverse TGD and intersex persons in personal and professional life contributed to higher levels of comfort among providers in caring for TGD and intersex patients. CONCLUSION Gaps in knowledge and limited confidence characterized the sample. Training at all levels is needed to improve radiology and radiation oncology care for TGD and intersex patients.
Collapse
Affiliation(s)
- Mandi L Pratt-Chapman
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA.,Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Joseph Astorino
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Sharad Goyal
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Berndt Schmit
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), UNSW Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Shiv Bajaj
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Emily Angiulo
- Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| |
Collapse
|
6
|
Stowell JT. Invited Commentary: Making Headway in Care Delivery for Transgender Patients in Radiology. Radiographics 2023; 43:e220194. [PMID: 36602926 DOI: 10.1148/rg.220194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Justin T Stowell
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224
| |
Collapse
|
7
|
Iv Kyrazis CB, Stein EB, Carroll EF, Crissman HP, Kirkpatrick DL, Wasnik AP, Zavaletta V, Maturen KE. Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations. Radiographics 2023; 43:e220124. [PMID: 36602923 DOI: 10.1148/rg.220124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
Collapse
Affiliation(s)
- Crysta B Iv Kyrazis
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Erica B Stein
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Evelyn F Carroll
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Halley P Crissman
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Daniel L Kirkpatrick
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Ashish P Wasnik
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Vaz Zavaletta
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Katherine E Maturen
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| |
Collapse
|
8
|
Soliman SB. Liquid silicone filler migration following illicit gluteal augmentation. Radiol Case Rep 2023; 18:984-990. [PMID: 36636483 PMCID: PMC9829554 DOI: 10.1016/j.radcr.2022.12.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 12/21/2022] [Indexed: 01/07/2023] Open
Abstract
The illicit use of fillers has significantly increased, especially among transgender women (transwomen) attempting to fulfill unmet gender affirmation needs. We present a case of liquid silicone filler migration to the distal lateral thigh, multiple years following an illicit gluteal augmentation, and mimicking a neoplasm. Initial clinical and imaging findings were inconclusive necessitating advanced imaging, an orthopedic oncology surgical consultation, and finally an ultrasound-guided biopsy. Knowledge of the increasing use of fillers, their complications, and imaging findings is critical as these patients commonly choose not to disclose this history. A radiologist suggesting this diagnosis may assist the clinician, who is often unaware of this history which could help prevent unnecessary imaging and invasive procedures.
Collapse
|
9
|
Crowley F, Mihalopoulos M, Gaglani S, Tewari AK, Tsao CK, Djordjevic M, Kyprianou N, Purohit RS, Lundon DJ. Prostate cancer in transgender women: considerations for screening, diagnosis and management. Br J Cancer 2023; 128:177-189. [PMID: 36261584 PMCID: PMC9902518 DOI: 10.1038/s41416-022-01989-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/29/2022] [Accepted: 09/12/2022] [Indexed: 02/08/2023] Open
Abstract
Transgender individuals represent 0.55% of the US population, equivalent to 1.4 million transgender adults. In transgender women, feminisation can include a number of medical and surgical interventions. The main goal is to deprive the phenotypically masculine body of androgens and simultaneously provide oestrogen therapy for feminisation. In gender-confirming surgery (GCS) for transgender females, the prostate is usually not removed. Due to limitations of existing cohort studies, the true incidence of prostate cancer in transgender females is unknown but is thought to be less than the incidence among cis-gender males. It is unclear how prostate cancer develops in androgen-deprived conditions in these patients. Six out of eleven case reports in the literature presented with metastatic disease. It is thought that androgen receptor-mediated mechanisms or tumour-promoting effects of oestrogen may be responsible. Due to the low incidence of prostate cancer identified in transgender women, there is little evidence to drive specific screening recommendations in this patient subpopulation. The treatment of early and locally advanced prostate cancer in these patients warrants an individualised thoughtful approach with input from patients' reconstructive surgeons. Both surgical and radiation treatment for prostate cancer in these patients can profoundly impact the patient's quality of life. In this review, we discuss the evidence surrounding screening and treatment of prostate cancer in transgender women and consider the current gaps in our knowledge in providing evidence-based guidance at the molecular, genomic and epidemiological level, for clinical decision-making in the management of these patients.
Collapse
Affiliation(s)
- Fionnuala Crowley
- Internal Medicine, Mount Sinai Morningside West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Meredith Mihalopoulos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Simita Gaglani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ashutosh K Tewari
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Che-Kai Tsao
- Department of Medicine, Division of Hematology/Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Miroslav Djordjevic
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natasha Kyprianou
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Pathology & Molecular and Cell Based Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Oncological Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rajveer S Purohit
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Dara J Lundon
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
10
|
Promoting Progress and Learning from Mistakes: Results of a Radiology Department LGBTQ Inclusion Audit. Acad Radiol 2022; 29:1833-1839. [PMID: 35466052 DOI: 10.1016/j.acra.2022.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 01/26/2023]
Abstract
RATIONALE AND OBJECTIVES As radiology programs seek to recruit and retain diverse and competitive applicants, it is important to critically review existing department policies to ensure they meet the needs of their residents. To evaluate a radiology program's inclusivity measures, an interdepartmental committee developed an "LGBTQ inclusion index" and performed an LGBTQ inclusion audit to identify gaps in policy and to craft proposals for administrative review. MATERIALS AND METHODS An LGBTQ inclusion index was compiled through the collaboration of an interdisciplinary committee of residents, faculty, institutional and community representatives. Five inclusion milestones were identified relating to department policy, department facilities, institutional culture, department culture, and community engagement. Milestones were scored as 0, for milestone not at all met, 1, for milestone partially met, and 2, for milestone completely met, with a total score of 10. Program scores were calculated for the 2018-2021 academic years. RESULTS The radiology program LGBTQ inclusion index score increased over the course of the study period. The program LGBTQ inclusion index score was 4 of 10 in 2018 and 2019, but after formation of an LGBTQ inclusion task force by the diversity and inclusion committee, increased to 7 of 10 in 2020. The LGBTQ inclusion audit identified several areas that required improvement and the committee drafted proposals to address these gaps. By 2021, the program scored 9 of 10 on the inclusion index. CONCLUSION Promoting an inclusive and affirming radiology department is an important step to providing culturally competent healthcare and mitigating health disparities. An LGBTQ inclusion audit and a robust department diversity committee can help to identify and address gaps in policy, facilities, and culture.
Collapse
|
11
|
Elyaguov J, Isakov R, Nikolavsky D. Evaluation and management of urologic complications following transmasculine genital reconstructive surgery. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Jason Elyaguov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Roman Isakov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Dmitriy Nikolavsky
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| |
Collapse
|
12
|
Abstract
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
Collapse
|
13
|
Yu H, Manos D. Confronting Our Blind Spots; the Persistent Use of Gender-specific Terminology in Radiology is Harmful. Can Assoc Radiol J 2022; 73:458-459. [PMID: 35238219 DOI: 10.1177/08465371221079196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Hang Yu
- Department of Radiology, 12359University of Manitoba Max Rady College of Medicine, Winnipeg, MB, Canada
| | - Daria Manos
- Department of Diagnostic Radiology, 3688Dalhousie University, Halifax, NS, Canada
| |
Collapse
|
14
|
Stowell JT, Jha P, Martinez-Jorge J, Middlebrooks EH, Broderick DF, Bhatt AA. Neuroradiology in Transgender Care: Facial Feminization, Laryngeal Surgery, and Beyond. Radiographics 2022; 42:233-249. [PMID: 34990322 DOI: 10.1148/rg.210080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Transgender individuals experience incongruence between their gender identity and the sex assigned to them at birth. This incongruence can cause many transgender individuals to experience distressing physical and mental discord, a diagnosis known as gender dysphoria. Craniofacial structures have distinct anthropometric characteristics that affect perceived masculinity and femininity. The face, neck, and voice are highly exposed anatomic areas that have recognizable gender-specific characteristics that may hinder a transgender individual's successful social integration and public acceptance. Reconstructive facial and laryngeal procedures are among the surgical options transgender persons may elect to undergo to better align their physical appearance with their gender identity. These include feminization surgeries such as facial feminization and reduction chondrolaryngoplasty, as well as masculinizing facial and laryngeal surgeries. Maxillofacial CT is frequently used in the preoperative evaluation of patients before facial feminization surgery (FFS). Several CT measurements guide surgeons to the optimal correction required in FFS to achieve appropriate aesthetic planes. Mapping important craniofacial landmarks to avoid untoward surgical complications is crucial. Transgender patients may encounter other neurologic complications that require neuroimaging evaluation. For example, gender-affirming hormone therapy (eg, estrogen and testosterone) may increase the risk of stroke or may influence growth of various hormone-sensitive tumors such as pituitary adenomas. Radiologists may interpret imaging examinations in transgender patients for routine care or for evaluation before and after facial and laryngeal surgeries and must be aware of the role of neuroimaging in the care of this population. An invited commentary by Callen is available online. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2022.
Collapse
Affiliation(s)
- Justin T Stowell
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Priyanka Jha
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Jorys Martinez-Jorge
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Erik H Middlebrooks
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Daniel F Broderick
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| | - Alok A Bhatt
- From the Department of Radiology, Mayo Clinic, 4500 San Pablo Rd S, Jacksonville, FL 32224 (J.T.S., E.H.M., D.F.B., A.A.B.); Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, Calif (P.J.); and Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minn (J.M.J.)
| |
Collapse
|
15
|
Lienhoop T, Green L. Breast imaging in transgender women: a review. Clin Imaging 2021; 80:283-289. [PMID: 34455238 DOI: 10.1016/j.clinimag.2021.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/29/2021] [Accepted: 07/30/2021] [Indexed: 12/30/2022]
Abstract
Transgender women are increasingly evaluated in breast imaging centers. Radiologists should be familiar with a range of imaging findings related to feminizing hormone therapy and breast augmentations as well as benign and malignant lesions seen in this population. A growing body of literature has suggested that feminizing hormone therapy may increase the risk of breast cancer, prompting professional organizations to develop screening guidelines. The aim of this paper is to review common breast imaging findings in transgender women, recent data on the association between feminizing hormone therapy and breast cancer, and guidelines for breast cancer screening. Knowing these unique imaging features in transgender women is essential for providing competent care and reducing health care disparities.
Collapse
Affiliation(s)
- Thomas Lienhoop
- Department of Radiology, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, Chicago, IL 60612, USA.
| | - Lauren Green
- Department of Radiology, University of Illinois Hospital and Health Sciences System, 1740 W Taylor St, Chicago, IL 60612, USA.
| |
Collapse
|
16
|
Grimstad F, Boskey ER, Taghinia A, Ganor O. Gender-Affirming Surgeries in Transgender and Gender Diverse Adolescent and Young Adults: A Pediatric and Adolescent Gynecology Primer. J Pediatr Adolesc Gynecol 2021; 34:442-448. [PMID: 33852937 DOI: 10.1016/j.jpag.2021.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022]
Abstract
Transgender and gender diverse adolescent and young adults (AYA) may seek gender-affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, or requiring GAS aftercare, or those seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams. With this knowledge, reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.
Collapse
Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 02115 Boston, Massachusetts; Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts.
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 02115 Boston, Massachusetts
| | - Amir Taghinia
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
| |
Collapse
|
17
|
Perry H, Fang AJ, Tsai EM, Slanetz PJ. Imaging Health and Radiology Care of Transgender Patients: A Call to Build Evidence-Based Best Practices. J Am Coll Radiol 2021; 18:475-480. [PMID: 33663757 DOI: 10.1016/j.jacr.2020.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/10/2020] [Indexed: 12/22/2022]
Abstract
Transgender people have a gender identity that differs from their natal sex and experience many forms of discrimination, including within the health care field. Although transgender patients only comprise 0.6% of the adult US population, they frequently require imaging evaluation. Few published articles provide data-driven research on optimizing education of the radiology care team and delivery of inclusive and respectful imaging care to this vulnerable population; existing data suggest prior areas of success and prior areas of failure. Here, we offer specific recommendations on how radiology care team members can better serve transgender patients and begin generating much needed evidence-based best practices to improve their imaging health and care.
Collapse
Affiliation(s)
- Hannah Perry
- Co-Division Chief/Medical Director of Breast Imaging, University of Vermont Medical Center, Larner College of Medicine, University of Vermont, Burlington, Vermont.
| | - Adam J Fang
- Division Director of Breast Imaging, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Erin M Tsai
- President, Vermont Radiological Society, University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, Vermont
| | - Priscilla J Slanetz
- Vice Chair of Academic Affairs and Associate Program Director, Diagnostic Radiology Residency, Department of Radiology, Boston University Medical Center, Boston, Massachusetts
| |
Collapse
|
18
|
Pregnall AM, Churchwell AL, Ehrenfeld JM. A Call for LGBTQ Content in Graduate Medical Education Program Requirements. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:828-835. [PMID: 34031304 DOI: 10.1097/acm.0000000000003581] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A well-developed body of literature demonstrates that lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals experience poorer health outcomes and report worse health care experiences than straight/cisgender individuals. Many reforms since 2010 have addressed the LGBTQ-related education of future health care professionals at the undergraduate medical education (UME) level; however, reforms at the graduate medical education (GME) level are lagging, and new literature suggests that didactic education at the UME level is not enough to prepare future physicians to properly and compassionately care for LGBTQ patients. Recently, the Accreditation Council for Graduate Medical Education (ACGME) implemented a major revision of its Common Program Requirements that requires residents to demonstrate, as a competence, respect and responsiveness to diverse populations. Given these revisions and the ongoing failure of many GME training programs to adequately prepare future physicians to care for LGBTQ patients, the authors argue that now is the time for the ACGME to develop and implement LGBTQ health-related residency requirements. In addition, the authors outline a path by which the academic medical community may develop and implement these requirements.
Collapse
Affiliation(s)
- Andrew M Pregnall
- A.M. Pregnall is LGBTQ health intern, Vanderbilt Program for LGBTQ Health, Vanderbilt University Medical Center, Nashville, Tennessee; ORCID: https://orcid.org/0000-0001-9629-0636
| | - André L Churchwell
- A.L. Churchwell is professor of medicine (cardiology), professor of radiology and radiological sciences, professor of biomedical engineering, and senior associate dean, Diversity Affairs, Vanderbilt University School of Medicine, and chief diversity officer, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jesse M Ehrenfeld
- J.M. Ehrenfeld is senior associate dean and director, Advancing a Healthier Wisconsin Endowment, the Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
19
|
Stowell JT, Zavaletta VA, Carroll EF, Grimstad FW. Multidisciplinary approach to imaging for gender-affirming surgery: engaging surgeons, radiologists, and patients to ensure a positive imaging experience. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:610. [PMID: 33987308 DOI: 10.21037/atm-20-6431] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Medical imaging plays an integral role in the preoperative evaluation and postoperative management of transgender and gender diverse (TGD) patients who pursue gender-affirming surgery. Radiology department encounters can be a source of anxiety for patients of any demographic, including TGD patients. Although most imaging modalities are considered "non-invasive", certain imaging procedures and other aspects of the radiology encounter could be considered quite invasive to the TGD patient. The TGD patient may be worried that the imaging examination will have to address anatomy that they feel does not align with their gender identity, or reveal some abnormality or disheartening complication of their surgery. Simultaneously, the patient must also navigate potentially uncomfortable interactions with other patients in department waiting rooms, restrooms, and changing facilities as well as with radiology staff. As the referral source to imaging facilities, providers should advocate on behalf of their TGD patients. Referring providers should work with imaging facilities to ensure their patients will receive inclusive and affirming care and not be subject to discomfort on the part of gender identity or expression. Proactive and regular communication among radiology facilities, patients, and referring providers will ensure appropriate and sensitive care for this vulnerable population. A positive imaging experience can improve patient outcomes and the relationship between healthcare providers and the TGD community they serve.
Collapse
Affiliation(s)
- Justin T Stowell
- Department of Radiology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Vaz A Zavaletta
- Department of Radiology, Division of Interventional Radiology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Frances W Grimstad
- Division of Pediatric and Adolescent Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Stowell JT, Metcalfe AM, Jha P. Imaging evaluation for the diagnosis and management of complications of gender-affirming surgeries. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:609. [PMID: 33987307 DOI: 10.21037/atm-20-6429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Gender-affirming surgeries (GS) allow transgender individuals to align their physical sexual characteristics with their gender identity, which can result in profound changes to native anatomy. Medical imaging is a useful tool for evaluation of patients who have undergone or plan to pursue GS. Given the complex nature of some GS, complications may arise. The choice of imaging modality can be guided by the clinically suspected complications. For example, urethral complications of phalloplasty are best evaluated with fluoroscopic urethrography. Pelvic magnetic resonance imaging provides detailed depiction of pelvic neo-anatomy after vaginoplasty. Many GS involve the creation of vascular pedicles for tissue grafts, which are at risk of thrombosis and graft ischemia. Doppler ultrasound and computed tomography (CT) angiography are important for diagnosis of these dreaded complications. Moreover, interventional radiologists may participate in endovascular treatments for such complications. Various imaging modalities may assist the surgeon in the postoperative evaluation of patients with suspected complications after GS, and imaging protocol modifications may be required to improve diagnostic accuracy. For example, rectal or neovaginal contrast material may be necessary to ensure accurate imaging evaluation, such as delineation of fistulas. Working together, surgeons and radiologists can ensure accurate imaging assessment while accommodating for patient comfort.
Collapse
Affiliation(s)
- Justin T Stowell
- Department of Radiology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Allie M Metcalfe
- Department of Radiology, Mayo Clinic in Florida, Jacksonville, FL, USA
| | - Priyanka Jha
- Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
21
|
Grimstad F, McLaren H, Gray M. The gynecologic examination of the transfeminine person after penile inversion vaginoplasty. Am J Obstet Gynecol 2021; 224:266-273. [PMID: 33039391 DOI: 10.1016/j.ajog.2020.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 09/11/2020] [Accepted: 10/02/2020] [Indexed: 01/11/2023]
Abstract
As more transfeminine patients (transgender and gender-diverse persons, sex assigned male at birth, who identify on the feminine spectrum of gender) are undergoing gender-affirming penile inversion vaginoplasty, gynecologists, as providers of vaginal care for both native and neovaginas, should be prepared to welcome these patients into their practice and offer long-term pelvic healthcare. Many parts of the anatomy, clinical examination, and aftercare differ from both native vaginas and other neovaginal surgical techniques. Transgender and gender-diverse patients cite a lack of clinician knowledge as a barrier to accessing affirming and competent healthcare. Although publications are emerging regarding this procedure, most focus on intraoperative and postoperative complications. These studies are not positioned to provide long-term pelvic health guidance or robust instruction on typical examination findings. This clinical opinion aims to address that knowledge gap by describing the gynecologic examination in the transfeminine person who has undergone a penile inversion vaginoplasty. We review the anatomic changes with surgery and the neovagina's physiology. We describe the examination of the vulva, vagina, and urethra and discuss special considerations for performing pelvic examinations on patients with a penile inversion vaginoplasty neovagina. We will also address common pathologic findings and their initial management. This clinical opinion originates from the expertise of gynecologists who have cared for high volumes of transfeminine patients who have undergone penile inversion vaginoplasties at tertiary care centers performing gender-affirming genital surgery, along with existing research on postpenile inversion vaginoplasty outcomes. Gynecologists should be familiar with the anatomic changes that occur with penile inversion vaginoplasty gender-affirming surgery and how those changes affect care. Providing transgender patients with comprehensive care including this sensitive examination can and should be part of the gynecologist's scope of practice.
Collapse
Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, MA; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, MA.
| | - Hillary McLaren
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, KS
| |
Collapse
|
22
|
Tirrell AR, Abu El Hawa A, Bekeny JC, Del Corral G. Outcomes in chest feminization patients with a history of illicit hormone use and silicone injections. Breast J 2021; 27:352-358. [PMID: 33578450 DOI: 10.1111/tbj.14178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/22/2023]
Abstract
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.
Collapse
Affiliation(s)
- Abigail R Tirrell
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Areeg Abu El Hawa
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Gabriel Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| |
Collapse
|
23
|
Hassan O, Sun D, Jha P. Imaging in Gender Affirmation Surgery. Curr Urol Rep 2021; 22:14. [PMID: 33515366 PMCID: PMC7847456 DOI: 10.1007/s11934-020-01029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose of Review This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation. Recent Findings The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Summary Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.
Collapse
Affiliation(s)
- Omar Hassan
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA.
| | - Derek Sun
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| | - Priyanka Jha
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| |
Collapse
|
24
|
Survey of Experiences of Transgender and Gender Nonbinary Patients During Imaging Encounters and Opportunities for Improvement. AJR Am J Roentgenol 2020; 215:1136-1142. [DOI: 10.2214/ajr.19.22558] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
25
|
Nazarian M, Bluebond-Langner R, Smereka P, Zhao L, Ream J, Hindman N. Spectrum of imaging findings in gender-affirming genital surgery: Intraoperative photographs, normal post-operative anatomy, and common complications. Clin Imaging 2020; 69:63-71. [PMID: 32659682 DOI: 10.1016/j.clinimag.2020.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/30/2020] [Accepted: 06/26/2020] [Indexed: 01/03/2023]
Abstract
Gender-affirming surgery is becoming more accessible, and radiologists must be familiar with both terminology and anatomy following gender-affirming surgical procedures. This essay will review the most common gender-affirming genital surgeries, their post-operative anatomy, and common complications by providing intraoperative photographs, illustrations, and cross-sectional images. Routine radiologic imaging recommendations for transgender patients will also be reviewed.
Collapse
Affiliation(s)
- Matthew Nazarian
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA.
| | | | - Paul Smereka
- NYU Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
| | - Lee Zhao
- NYU Langone Medical Center, 222 E 41st St, New York, NY 10017, USA.
| | - Justin Ream
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA
| | - Nicole Hindman
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA.
| |
Collapse
|
26
|
Stowell JT, Horowitz JM, Thomas S. Gender-affirming surgical techniques, complications, and imaging considerations for the abdominal radiologist. Abdom Radiol (NY) 2020; 45:2036-2048. [PMID: 31915851 DOI: 10.1007/s00261-019-02398-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.
Collapse
Affiliation(s)
- Justin T Stowell
- Department and Institution Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeanne M Horowitz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen Thomas
- Department of Radiology, Sharp Rees-Stealy Medical Group, San Diego, CA, USA.
| |
Collapse
|
27
|
Sivarajah R, Welkie J, Mack J, Casas RS, Paulishak M, Chetlen AL. A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment. JOURNAL OF BREAST IMAGING 2020; 2:101-111. [PMID: 38424883 DOI: 10.1093/jbi/wbz082] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Indexed: 03/02/2024]
Abstract
Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.
Collapse
Affiliation(s)
- Rebecca Sivarajah
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
| | - Janelle Welkie
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
- Penn State College of Medicine, Hershey, PA
| | - Julie Mack
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
| | - Rachel S Casas
- Penn State Health-Hershey Medical Center, Department of General Internal Medicine, Hershey, PA
| | - Melody Paulishak
- Penn State Health-Hershey Medical Center, Department of Surgery, Hershey, PA
| | - Alison L Chetlen
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
| |
Collapse
|