Heterogeneity in the Desire to Undergo Various Gender-Affirming Medical Interventions Among Transgender People in Hong Kong: Findings from a Community-Driven Survey and Implications for the Legal Gender Recognition Debate

Previous estimates suggest that there are at least nine million transgender people in Asia-Pacific; however, in most countries, legal gender recognition has not been made possible or there are otherwise stringent eligibility criteria. The obligation of having undergone gender-affirming medical interventions as a basis for such recognition is being hotly debated. However, there has been little empirical evidence on the desire to undergo various gender-affirming medical interventions among transgender people. This study fills the research gap by studying Hong Kong, where a transgender person must produce medical evidence for "complete" sex reassignment surgery in order to change the sex entry on their identity card. A community-driven survey of 234 transgender people found that only 13.0% of the participants who were assigned male at birth could fit such a requirement. Strikingly, because none of the participants assigned female at birth had undergone construction of a penis or some form of a penis, all of them would be excluded from legal gender recognition. Financial reasons and reservations about surgical risks and/or techniques were the most commonly cited reasons for not undertaking the medical interventions. The findings suggest that an overwhelming majority of transgender people in Hong Kong are excluded from legal gender recognition, which fundamentally affects their civil, political, economic, social, and cultural rights. More generally, this study shows heterogeneity among transgender people in the desire for different gender-affirming medical interventions, and thus argues that the legal gender recognition debate needs to consider their concerns and self-determination.

Gender Dysphoria Publication Trends: A Bibliometric Analysis between 1900 and 2018

Objective Research on gender dysphoria (GD) has been growing over the last decades with increasing interest in understanding and characterizing the causal relationships between psychological, genetics, hormonal, and sociocultural factors. Changes and acceptance of this condition as non-pathologic have led to significant changes in general perspective and its management over time. Our objective is to carry out a bibliometric analysis to know the publication trends and quality of evidence related to gender dysphoria.

Methods A systematic search and critical review of the literature was carried out between January 1900 and December 2018 to perform a bibliometric analysis. Research was done in the following databases: OVID, PubMed, EMBASE, Scopus, Web of Science and Google Scholar. The medical subject headings (MeSh) terms used were: gender dysphoria; and surgery and psychology. The results were plotted using the VOSviewer version 1.6.8. Statistical analyses were performed with the IBM SPSS, Version 25.0.

Results A total of 1,239 manuscripts were identified, out of which 1,041 were selected. The average number of cited times per year per manuscript is 1.84 (interquartile range [IQR] 0-2.33). The average impact index was 47.8 (IQR 20-111.6). The median of total citations per manuscript was 3 (IQR 0-33.1), and the highest number of citations per manuscript was 484. Most publications focus on the psychological aspects of GD, and there is a significant amount of manuscripts related to social and anthropological issues. Most articles have a low level of scientific evidence.

Conclusion There is a great amount of published literature on GD; however, there is a significant level of disagreement in many respects on this topic. Regarding surgical gender-affirmation, there is a lack of information supported by high level of evidence to uphold the emerging expansion of medical practices.

What urologists need to know about male to female genital confirmation surgery (vaginoplasty): techniques, complications and how to deal with them

Vaginoplasty is the most commonly performed genital surgery for gender affirmation. Male-to-female (MTF) patients are roughly four times more likely to undergo genital surgery than female-to-male (FTM) patients. Penile inversion vaginoplasty is the most common technique used today, although there are also lesser used alternative methods including visceral interposition and pelvic peritoneal vaginoplasty. In general, outcomes are excellent, and many of the complications are self-limited. Most surgeons performing genital surgery for gender dysphoria adhere to the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. Currently, there are no absolute contraindications to vaginoplasty in a patient who is of the age of majority in their country, only relative contraindications which include active smoking and morbid obesity. Important complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in excellent surgical candidates by skilled surgeons, vaginoplasty can be a rewarding surgical endeavor for the patient and surgeon.

How Gender Identity and Treatment Progress Impact Decision-Making, Psychotherapy and Aftercare Desires of Trans Persons

The gender identity of trans individuals influences their treatment preferences, and this in turn seems to affect their individual treatment progress. However, there has been no research which—next to the impact of gender identity on treatment desires—has also investigated the influence of treatment progress using a measure which assumes various possible transition pathways of trans persons.Therefore, an online community survey of trans people was conducted in Germany in 2015. Data were collected via an online survey from a non-clinical sample of n = 415 trans individuals (over half assigned female at birth), aged 16–76 (Mean (M) = 38.12). Almost one fifth of participants embraced non-binary or genderqueer (NBGQ) identities. Participants progressed 60.77% (standard deviation (SD) = 35.21) through treatment at point of data collection, as measured by the individual treatment progress score (ITPS). All participants, especially participants assigned male at birth, differed significantly in desire to participate in decision-making processes based on transition progress; individuals without treatment experience had less desire to decide treatment plans. NBGQ participants assigned male at birth in early stages of transition had significantly more desire for psychotherapy during transition than participants of the same identity in later transition stages. All participants, especially binary participants, significantly differed in desire for aftercare based on transition progress; individuals without treatment experience indicated more desire for aftercare. Results indicate health professionals should expect changing treatment desires in trans individuals at various stages of transition, particularly at treatment start, and based on gender identity.

Female-to-Male Gender-Affirming Chest Reconstruction Surgery

There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

Understanding and Addressing Hair Disorders in Transgender Individuals

In the United States, an increasing number of individuals are identifying as transgender. Males at birth who identify as females are called male-to-female (MTF) transgender individuals or trans women, and females at birth who identify as males are called female-to-male (FTM) transgender individuals or trans men. The transgender patient population possess unique health concerns disparate from those of the general populace. Exogenous hormone therapy for transgender patients leads to changes in the distribution and pattern of hair growth. Exogenous testosterone can lead to male pattern hair loss and hirsutism, while estrogen therapy usually results in decreased facial and body hair growth and density. A thorough understanding of the hormonal treatments that may be used in transgender individuals as well the unique and complex biologic characteristics of the hair follicle is required for appropriate diagnosis, counseling and treatment of patients. The aim of this article is to provide a framework for understanding hair disorders in transgender individuals and effective treatment options.

Gender Dysphoria: Bioethical Aspects of Medical Treatment

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

Masculine Voices Predict Well-Being in Female-to-Male Transgender Individuals

Voices convey important social information about an individual's identity, including gender. This is especially relevant to transgender individuals, who cite voice alteration as a primary goal of the gender alignment process. Although the voice is a primary target of testosterone therapy among female-to-male (FTM) trans people, little research has explored the effects of such changes on their psychological well-being. Here, we investigated how FTMs' vocal gender related to their well-being. A total of 77 FTMs (M _age = 25.45 years, SD = 6.77) provided voice samples and completed measures of their well-being and psychological health. An independent group of 32 naïve raters (M _age = 22.16 years, SD = 8.21) subsequently rated the voice samples for masculinity. We found that FTMs whose voices sounded more congruent with their experienced gender (i.e., sounded more masculine) reported greater well-being (better life satisfaction, quality of life, and self-esteem; lower levels of anxiety and depression) than FTMs with less gender congruent (i.e., more feminine) voices (β = .48). The convergence between outwardly perceived vocal gender and gender identity brought about through hormone replacement therapy may therefore support greater well-being for FTMs.

Description of sex difference as prescription for sex change: on the origins of facial feminization surgery

This article explores the research project that led to the development of facial feminization surgery, a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of male-to-female trans- women. Conducted by a pioneering surgeon in the mid-1980s, this research consisted of three steps: (1) assessments of sexual differences of the skull taken from early 20th-century physical anthropology, (2) the application of statistical analyses taken from late 20th-century orthodontic research, and (3) the vetting of this new morphological and metric knowledge in a dry skull collection. When the 'feminine type' of early 20th-century physical anthropology was made to articulate with the 'female mean' of 1970s' statistical analysis, these two very different epistemological artifacts worked together to produce something new: a singular model of a distinctively female skull. In this article, I show how the development of facial feminization surgery worked across epistemic styles, transforming historically racialized and gendered descriptions of sex difference into contemporary surgical prescriptions for sex change. Fundamental to this transformation was an explicit invocation of the scientific origins of facial sexual dimorphism, a claim that frames surgical sex change of the face as not only possible, but objectively certain.

The case for bilateral mastectomy and male chest contouring for the female-to-male transsexual

INTRODUCTION

In the UK, funding for a bilateral mastectomy (BLM) and associated chest recontouring for female-to-male transsexuals (trans men) has been rejected by some funding authorities on a number of unsustainable grounds.

METHODS

As funding is increasingly an important area for both surgeons and referrers, we undertook a review of the small amount of literature pertaining to this issue and considered it in light of our clinical experience of this group.

FINDINGS

The literature showed that BLM is necessary for trans men to live safely and effectively in their reassigned gender role, and further that it acts as a prophylaxis against distress, ameliorates extant distress as well as providing improved quality of life and global functioning for this patient group.

A review of the content and format of transgender-related webpages

Transgender persons represent a highly diverse group of individuals who have been historically underserved, despite being disproportionately at risk for HIV (human immunodeficiency virus) and other health conditions. Despite the need for more research on transgender health issues, no review of online transgender-related resources has been conducted. The purpose of this study was to broadly characterize (1) the types of transgender-related webpages that appear as a result of keyword searches, and (2) the extent to which webpages differ in content and format depending on whether the intended audience for the webpage was transgender individuals, health professionals, or the general population. An online search using 28 keywords yielded 204 eligible webpages, of which 58% targeted transgendered individuals, 23% targeted health professionals, and 39% targeted the general public. The highest percentage of webpages appeared to be operated and/or created by transgender individuals or groups (46%), followed by for-profit businesses (17%). The majority of mental health (80%), HIV-related (89%), and primary care (100%) webpages targeted health professionals. Although various features are available that may increase user interest in and perceived credibility of a webpage, the results show that many of these features were underutilized. There appears to be significant opportunity to develop web resources that directly target unique subgroups within the transgender community to improve their health outcomes, increase the visibility of features that increase user interest and perceived credibility of webpages, and possibly train transgender individuals to seek relevant online information.