Gender dysphoria - prevalence and co-morbidities in an irish adult population

Complications following Breast Augmentation in Transfeminine Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. Although adverse events among breast augmentation in cisgender women are well described, their relative incidence in transfeminine patients is less elucidated. This study aims to compare complication rates after breast augmentation between cisgender women and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals.

METHODS

PubMed, the Cochrane Library, and other resources were queried for studies published up to January of 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender women.

RESULTS

Within the transfeminine group, the pooled rate of capsular contracture was 3.62% (95% CI, 0.0038 to 0.0908); the hematoma/seroma rate was 0.63% (95% CI, 0.0014 to 0.0134); the infection incidence was 0.08% (95% CI, 0.0000 to 0.0054); and implant asymmetry rate was 3.89% (95% CI, 0.0149 to 0.0714). There was no statistical difference between rates of capsular contracture ( P = 0.41) and infection ( P = 0.71) between the transfeminine versus cisgender groups, whereas there were higher rates of hematoma/seroma ( P = 0.0095) and implant asymmetry/malposition ( P < 0.00001) in the transfeminine group.

CONCLUSION

Breast augmentation is an important procedure for gender affirmation and, in transfeminine individuals, carries relatively higher rates of postoperative hematoma and implant malposition relative to cisgender women.

Factors that help and hinder transgender and nonbinary youth accessing gender care in Ireland: A multistakeholder exploration

INTRODUCTION

The purpose of this study was to identify the common factors that help and hinder transgender and nonbinary youth accessing gender-specific health care in Ireland and to identify how these factors may be perceived differently by young people seeking gender-affirming care, their parents, and health-care providers.

DESIGN

Qualitative investigation utilizing framework analysis (FA).

METHODS

In-depth one-one interviews were conducted with transgender and nonbinary youth (n = 10), parents of youth (n = 10), and gender-specific health-care providers (n = 10). Maximum variation and snowball sampling were used to recruit participants across Ireland. An interview guide codesigned with an expert panel of gender-diverse youth was utilized. Interviews were audio-recorded and transcribed verbatim. FA was used to code the data and identify key issues and recommendations.

RESULTS

Four themes were derived: (1) "Needing bricks to build" (structural factors); (2) "Enduring and convincing" (diagnostic factors); (3) "Being me, hiding me"; (personal factors); and (4) "It takes a tribe" (interpersonal factors). Each stakeholder group perceived different factors as help or hindrance in accessing care with varying intensities.

CONCLUSIONS

Paramount to the future of gender services in Ireland is the investment of resources for children and young adults. Assessment is likely to remain a component of gender care, but youth recommend distinct revisions to the assessment process. Additional research would be useful in exploring the intersection of neurodiversity and gender as it pertains to health-care navigation. Family and peer support is a strong protective factor and enabler of health-care access among youth.

CLINICAL RELEVANCE

Access to gender-specific health care remains difficult for transgender and non-binary youth. An understanding of the complexity of this healthcare navigation by healthcare professionals may help to mitigate future negative experiences. This study explores some of the clinical considerations that arise for this population from provider perspectives while elucidating the experiences of youth and parents attempting to access care. Further research is needed on longitudinal outcomes following medical and surgical interventions for transgender youth, including nonbinary identities.

Conscientious objection to caring for transgender people: An ethical right or a discriminatory attitude?

BACKGROUND

In modern society, health professionals are often asked to use their technical skills to serve purposes other than treating illnesses. In such cases, some clinicians may express ethical reluctance to fulfill their patients' preferences. Conscientious objection in health care is the refusal by providers to perform a legally valid and scientifically approved clinical intervention because of moral concerns. Although health services and staff are obliged to respect gender identity and prohibit discrimination, some clinicians may exempt themselves from caring for transgender people, citing ethical reasons. The decision of health professionals to object to medical activities related to transgender care may collide with the interests of trans people and further marginalizes the already underprivileged gender-diverse population.

AIM

This discussion paper analyses the concept of 'conscientious objection' and its application in health care settings in relation to transgender-related care.

FINDINGS AND CONCLUSION

In general, the right of health professionals to abstain from contested duties on moral grounds must be protected. However, claims to conscience cannot be accepted within centers specialized in gender transitioning and for services unrelated to gender affirmation such as routine and urgent care. Personal responsibility and discretion on the part of clinicians is the most appropriate way to compromise between protecting the moral integrity of health professionals and shielding trans persons' access to care. Guidance is proffered on how to resolve the apparent impasse emerging from the denial of various types of health services to transgender people.

Complex Psychiatric Histories and Transgender and Gender Diverse Youth

Transgender and gender diverse (TGD) individuals face higher rates of stressors driving disproportionate health risks. Although psychiatric conditions are important to consider in the context of greater health-promoting efforts for TGD youth, any mental health concerns may or may not be related to gender identity or associated dysphoria. Nevertheless, it is essential to consider the impact of complex mental health factors on decisional capacity and gender care discussions. Psychiatric care of TGD youth includes stratifying risk factors through a minority stress lens, balancing acute needs with patient and caregiver priorities, and bolstering resilience using affirming care principles.

Nutrition research and practice with transgender and gender non-conforming populations

The purpose of the present article is to describe the current state of sex and gender data collection in nutrition science research, discuss the effects of flawed data collection practices, highlight considerations for transgender and gender non-conforming populations and propose a sex- and gender-informed approach to human subjects research. Sex and gender are separate constructs that are often conflated in nutrition research and practice. Current nutrition surveillance programmes in the United States, United Kingdom and Ireland do not accurately capture sex and gender data, which undermines the accuracy of the analyses and excludes gender minorities. Transgender and gender non-conforming populations have distinct clinical and psychosocial nutrition considerations that require further research to inform nutrition policy and practice, such as anthropometric and biochemical changes with hormone therapy, eating disorders, food insecurity and nutrition as a source of empowerment or expression of gender identity. Researchers can apply a sex- and gender-informed approach to human subjects research by treating sex and gender as separate, relevant demographic data, appreciating gender as a fluid construct, and approaching data collection on gender minorities with sensitivity to privacy and confidentiality.

Fertility preservation and realignment in transgender women

Medical care for transgender people is multi-faceted and attention to individual reproductive aspirations and planning are an essential, yet often overlooked aspect of care. Given the impact of hormonal therapy and other gender affirmation procedures on reproductive function, extensive counselling and consideration of fertility preservation is recommended prior to their commencement. This review article explores the reproductive aspirations of transgender women and considers the current disparity between stated desires regarding utilisation of fertility preservation services. Current fertility preservation options and prospective treatments currently showing promise in the research arena are explored.

Barriers and Challenges in Caring for Transgender People: Implications for Clinical Practice and the Experience From a Specialized Center

Background: Transgender people often experience social exclusion and transphobic attitudes, which have an adverse impact on their socioeconomic life and health status. Within health services, -discriminatory practices and mistreatment derive from the lack of cultural competence by -healthcare providers. Objective: This article features existing barriers in the provision of healthcare to transgender populations and suggests approaches to manage the relevant challenges. Methods: A thorough review of the literature was performed, and the operation of a specialized unit wass presented. Results: Health professionals are often unskilled or unwilling to offer transgender care, while most healthcare service institutions do not offer specialized treatments. Incomplete health insurance coverage and shortages of personal income impede trans individuals' access to healthcare. Certain practices and policies are needed for scientifically and culturally competent services. Conclusions: The social vulnerability and the unique health needs of transgender persons urgently call for accessible and effective care for gender minority individuals. The integration of gender identity issues into continuous medical and nursing education is a key component of transgender-friendly care. Implications for Nursing: The integration of diversity as a core value in health services, the ability of health personnel to deliver transgender care, and the provision of insurance coverage solely based on medical needs are necessary steps to achieve social justice in healthcare.

Transgender and non-binary demographics, referrals, and comorbidities among young Irish adults (2014-2020)

BACKGROUND

Over the last 6 years, there has been a change in the demographics of people presenting to gender services in Ireland. This is in line with international trends describing a higher number of transgender men (Female-Male, FTM, AFAB) presenting to gender services as compared to transgender women (Male-Female, MTF, AMAB), and lower ages at referral. Given the changes in demographics, it would be anticipated that clinical needs may have changed. This study describes the demographics of a young Irish sample (participants aged 18-30 years old) and explores the referral pathways and clinical needs of this cohort.

METHODS

The study was performed as a retrospective chart review of 167 charts at The National Gender Service in Ireland over a five-month period.

RESULTS

Transgender men represented 62.3% of the sample, transgender women 35.3%, and transmasculine/non-binary individuals represented 2.4%. Over two-thirds of participants were on gender affirming hormone therapy or GnRH antagonists and 16.1% had undergone surgical interventions. The median time from referral received to being seen at the clinic was 450 days (481 mean). Mental health comorbidities remain high with 49.1% of youth experiencing depression, a further 15.6% low mood and 26.3% anxiety.

CONCLUSION

This is the first study to show increasing referrals of people who were assigned female at birth (AFAB) over assigned male at birth (AMAB) individuals in Ireland, and to document the clinical needs of this cohort. By understanding the changing demographics and clinical needs, we can better plan for care and service improvements.

Fertility Preservation and Reproductive Potential in Transgender and Gender Fluid Population

The gender diverse and transgender community is a minor patient group that is encountered with increasing frequency in the clinical setting, attributed to the improved awareness and access to medical facilities. Partial impairment to permanent elimination of fertility potential and outcomes depending on the treatment modality usually is a result of gender-affirming therapy, which includes both hormone therapy and surgical intervention. Although seldom conducted in the clinical field, transgender patients should be counseled on their fertility preservation options prior to medical and surgical gender transition. There is relatively limited data and clinical information regarding fertility preservation for transgender individuals. Current treatment regimens are based on protocols from fertility preservation after oncological treatments. Major barriers for the transgender population exist due to the lack of information provided and clinical narrative that is not familiar to the physician or health care provider, although there are various options for fertility preservation. A deeper understanding of this clinical agenda and the mandatory processes will ultimately result in a much more comprehensive and specific care for transgender individuals who are in great need for fertility counseling or treatment options that concern fertility preservation. In this review, current clinical approaches will be summarized and fertility preservation options along with ongoing and future clinical trials in fertility preservation for transgender individuals will be thoroughly reviewed.

An exploration of mental distress in transgender people in Ireland with reference to minority stress and dissonance theory

Introduction: Internationally mental distress is more prominent in the LGBTI community than the general population. The LGBTIreland study was set up to take stock of this in the Republic of Ireland. This paper reports on the analysis of the transgender group with reference to minority stress theory and cognitive dissonance theory. Method: An online survey was conducted addressing several aspects of mental health and distress that received responses from all groupings (n = 2,264) among which 12.3% (n = 279) identified as transgender. The survey consisted of several validated tools to measure depression, anxiety, stress (DASS-21), coping (CSES), self-esteem (RSES), alcohol and drugs misuse (AUDIT) and a variety of questions addressing demographics, experiential aspects, coping and self-related factors. Data analysis focused on predicting mental distress using DASS-general (composite of depression, anxiety and stress). Results: Transgender participants reported higher levels of mental distress, self-harm, suicidal ideation and attempts, and lower levels of self-esteem in comparison with the LGB groups, as well as the general population. Hierarchical multiple regression showed that 53% of variance in mental distress could be predicted from reduced self-esteem, the experience of harassment and not belonging in school. Furthermore, mental distress was highest among younger participants, those who were 'not out', those who had self-harmed and used avoidant coping. There was no significant difference in distress levels among those who had sought mental health support and those who had not. Conclusions: To understand mental distress in transgender people, the minority stress model is useful when taking into account both adverse external (environmental) and internal (cognitive/emotional) factors. The cognitive dissonance mechanism is essential in outlining the mechanism whereby gender incongruence is associated with psychological discomfort, low self-esteem and high mental distress.

Evaluation of personality disorders in patients with Gender Identity Disorder (GID): An update

Introduction

Gender dysphoria (GD) could cause various mental illnesses, but its main cause is unclear. GD patients also suffer from different personality disorders that increase the risk of side effects among them. The present review study is aimed to investigate the most recent studies on comorbid personality disorders in patients with GD.

Materials and Methods

Online databases were searched using related keywords for collecting any related articles. After precise reviewing the abstract of all collected articles, those with more appropriate content were included in our study.

Findings

The prevalence rate of personality disorders in GD patients has been reported to be from 15% to 80% by different studies. In line with the data from previous studies, it was revealed that borderline personality disorder is one of the most prevalent disorders among GD patients. Available comorbid personality disorders cause a wide range of side effects on the normal function of patients.

Conclusion

The majority of studies carried out on the comorbidity of personality disorders have revealed that the possibility of personality disorders in GD patients is high. Anyway, further studies are required to understand the exact effect of psychological care on personality disorders in these patients.

Does Gender Affirming Hormone Therapy Increase the Risk of Kidney Disease?

Kidney health and manifestation of disease in transgender men, women, and nonbinary individuals are not well understood. Transgender individuals commonly receive gender-affirming hormone therapy (GAHT) to align their outward appearance with their gender. Recent attention to the differences in fundamental kidney parameters has identified that transgender individuals may manifest levels of these biomarkers differently than their cisgender counterparts. Improving understanding of the differences in biomarkers and in the development of kidney disease is essential to providing appropriate kidney care to this vulnerable population. In this review, we introduce the current information related to GAHT and kidney health and highlight the significant gaps in our understanding of how GAHT may affect kidney physiology and pathophysiology.

Study protocol: navigating access to gender care in Ireland-a mixed-method study on the experiences of transgender and non-binary youth

INTRODUCTION

There has been a global increase in demand for gender-specific healthcare services and a recognition that healthcare access is complex and convoluted, even in countries with well-developed healthcare services. Despite evidence in Ireland supporting the improvement in physical and mental health following access to gender care, little is known about the local healthcare navigation challenges. Internationally, research focuses primarily on the experience of service users and omits the perspective of other potential key stakeholders. Youth experiences are a particularly seldom-heard group.

METHODS AND ANALYSIS

This study will use a sequential exploratory mixed-methods design with a participatory social justice approach. The qualitative phase will explore factors that help and hinder access to gender care for young people in Ireland. This will be explored from multiple stakeholders' perspectives, namely, young people, caregivers and specialist healthcare providers. Framework analysis will be used to identify priorities for action and the qualitative findings used to build a survey tool for the quantitative phase. The quantitative phase will then measure the burden of the identified factors on healthcare navigation across different age categories and gender identities (transmasculine vs transfeminine vs non-binary).

ETHICS AND DISSEMINATION

This study has been approved by St Vincent's Hospital Research Ethics Committee (RS21-019), University College Dublin Ethics Committee (LS-21-14Kearns-OShea) and the Transgender Equality Network Ireland's Internal Ethics Committee (TIECSK). We aim to disseminate the findings through international conferences, peer-review journals and by utilisation of expert panel members and strategic partners.

Characterization of a transgender population in Portugal

INTRODUCTION

Gender dysphoria (GD) is a condition in which the individual's gender identity does not correspond to their biological sex, causing significant distress. Biological males who identify as females are referred to as transgender females or as showing male-to-female GD (MtF GD) and biological females who identify as males are referred to as transgender males or as showing female-to-male GD (FtM GD). In our center, there is a multidisciplinary consultation to approach and follow patients with GD.

AIM

We aimed to analyze the characteristics of the individuals who attend this consultation.

METHODS

Retrospective study of individuals attending the Sexual Medicine Group Consultation. Age, comorbidities, symptom onset, and hormonal and surgical treatment were analyzed.

RESULTS

114 patients were diagnosed with GD: 68.4% FtM GD and 31.6% MtF GD. Median age was 30.2±12 years. 63.2% reported symptom onset in childhood: 14.9% between 10 and 18 years, and 4.4% later than 18 years. Median age at treatment initiation was 23.1±7.1 years. Several individuals had concomitant medical conditions, notably smoking (n=37; 32.5%) and depression (n=26; 22.3%). The majority of (92.3% FtM GD and 88.9% MtF GD) were under hormone treatment, and about one-third had undergone some sex reassignment surgery.

DISCUSSION

We found higher prevalence of FtM than MtF, in contrast with most other studies. The reasons for this are not clear. A high percentage of our patients were self-medicated. Other characteristics were similar to those previously reported.

CONCLUSION

Medical requests by individuals with GD are increasing worldwide. To our knowledge, this is the first study to portray a case series in a consultation center dedicated to the diagnosis, treatment and follow-up of individuals with GD in Portugal.

Psychosis in transgender and gender non-conforming individuals: A review of the literature and a call for more research

Epidemiological studies have described higher rates of psychotic disorder diagnoses in transgender, as compared to cisgender, individuals. With the exception of this work and a small number of published case studies, however, there has been little consideration of gender diversity in psychosis research or clinical care. In this paper, we will review and critically evaluate the limited literature on gender diversity and clinical psychosis and articulate the critical need for more work in this field, more specifically on the following areas and how they bear on clinical care: 1) diagnostic biases; 2) how chronic non-affirmation and bias, gender dysphoria, and other gender minority stressors may operate as trauma and can contribute to clinically significant psychotic symptoms; 3) the potential impact of gender-affirming care, such as hormone therapies, on mental health and barriers for receiving such care in transgender and nonbinary individuals; and 4) culturally-sensitive and gender-affirming approaches for addressing psychosis. Finally, we consider ways in which researchers may engage in ethical, gender-affirming, and accurate approaches to better address gender identity in psychosis research. We hope that such research will aid in the creation of clinical guidelines for understanding, diagnosing, and treating psychosis in gender diverse individuals.

Prevalence of Gender Dysphoria in Southern Brazil: A Retrospective Study

To ensure that public health services provide comprehensive and inclusive health care to the general population, it is important for countries to estimate how many of their citizens experience gender dysphoria and wish to receive specialized hormone treatment or gender-affirming surgery. The aim of this study was to estimate the prevalence of individuals with gender dysphoria seeking transgender health care in a public teaching hospital in southern Brazil. In this retrospective follow-up study, we analyzed the medical records and sociodemographic data of individuals aged > 15 years living in Rio Grande do Sul, Brazil, that enrolled in a specialized program to receive hormone therapy and gender-affirming surgery between 2000 and 2018. This study is the first to attempt estimating the prevalence of gender dysphoria in Rio Grande do Sul; it describes novel data on the clinical profile of individuals with gender dysphoria treated in a public hospital specialized in providing transgender health care. Prevalence estimates were calculated based on statewide annual population data in the study period. Of 934 identified individuals, 776 (601 trans women and 175 trans men) were included in this study. The overall prevalence of individuals with gender dysphoria was 9.3 per 100,000 individuals (95% CI: 8.6 to 9.8). Meanwhile, there were 15 trans women per 100,000 people (95% CI: 14 to 16) and 4.1 trans men per 100,000 people (95% CI: 3.5 to 4.8). There was a progressive increase in the number of people seeking hormone therapy and gender-affirming surgery during the study period. Future research is needed to determine the size of the trans population in other regions of Brazil and to expand the knowledge regarding gender dysphoria to allow for the development of effective public policies for people with gender dysphoria.

Experiences of transgender and non-binary youth accessing gender-affirming care: A systematic review and meta-ethnography

Objective

Transgender and non-binary individuals frequently engage with healthcare services to obtain gender-affirming care. Little data exist on the experiences of young people accessing gender care. This systematic review and meta-ethnography aimed to identify and synthesise data on youths’ experiences accessing gender-affirming healthcare.

Method

A systematic review and meta-ethnography focusing on qualitative research on the experiences of transgender and non-binary youth accessing gender care was completed between April-December 2020. The following databases were used: PsychINFO, MEDLINE, EMBASE, and CINAHL. The protocol was registered on PROSPERO, international prospective register of Systematic Reviews (CRD42020139908).

Results

Ten studies were included in the final review. The sample included participants with diverse gender identities and included the perspective of parents/caregivers. Five dimensions (third-order constructs) were identified and contextualized into the following themes: 1.) Disclosure of gender identity. 2.) The pursuit of care. 3.) The cost of care. 4.) Complex family/caregiver dynamics. 5.) Patient-provider relationships. Each dimension details a complicated set of factors that can impact healthcare navigation and are explained through a new conceptual model titled “The Rainbow Brick Road”.

Conclusion

This synthesis expands understanding into the experience of transgender and non-binary youth accessing gender-affirming healthcare. Ryvicker’s behavioural-ecological model of healthcare navigation is discussed in relation to the findings and compared to the authors’ conceptual model. This detailed analysis reveals unique insights on healthcare navigation challenges and the traits, resources, and infrastructure needed to overcome these. Importantly, this paper reveals the critical need for more research with non-binary youth and research which includes the population in the design.

Development of a computable phenotype to identify a transgender sample for health research purposes: a feasibility study in a large linked provincial healthcare administrative cohort in British Columbia, Canada

OBJECTIVES

Innovative methods are needed for identification of transgender people in administrative records for health research purposes. This study investigated the feasibility of using transgender-specific healthcare utilisation in a Canadian population-based health records database to develop a computable phenotype (CP) and identify the proportion of transgender people within the HIV-positive population as a public health priority.

DESIGN

The Comparative Outcomes and Service Utilization Trends (COAST) Study cohort comprises a data linkage between two provincial data sources: The British Columbia (BC) Centre for Excellence in HIV/AIDS Drug Treatment Program, which coordinates HIV treatment dispensation across BC and Population Data BC, a provincial data repository holding individual, longitudinal data for all BC residents (1996-2013).

SETTING

British Columbia, Canada.

PARTICIPANTS

COAST participants include 13 907 BC residents living with HIV (≥19 years of age) and a 10% random sample comparison group of the HIV-negative general population (514 952 individuals).

PRIMARY AND SECONDARY OUTCOME MEASURES

Healthcare records were used to identify transgender people via a CP algorithm (diagnosis codes+androgen blocker/hormone prescriptions), to examine related diagnoses and prescription concordance and to validate the CP using an independent provider-reported transgender status measure. Demographics and chronic illness burden were also characterised for the transgender sample.

RESULTS

The best-performing CP identified 137 HIV-negative and 51 HIV-positive transgender people (total 188). In validity analyses, the best-performing CP had low sensitivity (27.5%, 95% CI: 17.8% to 39.8%), high specificity (99.8%, 95% CI: 99.6% to 99.8%), low agreement using Kappa statistics (0.3, 95% CI: 0.2 to 0.5) and moderate positive predictive value (43.2%, 95% CI: 28.7% to 58.9%). There was high concordance between exogenous sex hormone use and transgender-specific diagnoses.

CONCLUSIONS

The development of a validated CP opens up new opportunities for identifying transgender people for inclusion in population-based health research using administrative health data, and offers the potential for much-needed and heretofore unavailable evidence on health status, including HIV status, and the healthcare use and needs of transgender people.

Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence

BACKGROUND

There is an unknown percentage of transgender and gender non-confirming individuals who undergo gender-affirmation surgeries (GAS) that experiences regret. Regret could lead to physical and mental morbidity and questions the appropriateness of these procedures in selected patients. The aim of this study was to evaluate the prevalence of regret in transgender individuals who underwent GAS and evaluate associated factors.

METHODS

A systematic review of several databases was conducted. Random-effects meta-analysis, meta-regression, and subgroup and sensitivity analyses were performed.

RESULTS

A total of 27 studies, pooling 7928 transgender patients who underwent any type of GAS, were included. The pooled prevalence of regret after GAS was 1% (95% CI <1%-2%). Overall, 33% underwent transmasculine procedures and 67% transfemenine procedures. The prevalence of regret among patients undergoing transmasculine and transfemenine surgeries was <1% (IC <1%-<1%) and 1% (CI <1%-2%), respectively. A total of 77 patients regretted having had GAS. Twenty-eight had minor and 34 had major regret based on Pfäfflin's regret classification. The majority had clear regret based on Kuiper and Cohen-Kettenis classification.

CONCLUSIONS

Based on this review, there is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population.

Gender dysphoria: prejudice from childhood to adulthood, but no impact on inflammation. A cross-sectional controlled study

INTRODUCTION

Gender dysphoria (GD) is characterized by a marked incongruence between experienced gender and one's gender assigned at birth. Transsexual individuals present a higher prevalence of psychiatric disorders when compared to non-transsexual populations, and it has been proposed that minority stress, i.e., discrimination or prejudice, has a relevant impact on these outcomes. Transsexuals also show increased chances of having experienced maltreatment during childhood. Interleukin (IL)-1β, IL-6, IL-10 and tumor necrosis factor-alpha (TNF-α) are inflammatory cytokines that regulate our immune system. Imbalanced levels in such cytokines are linked to history of childhood maltreatment and psychiatric disorders. We compared differences in IL-1β, IL-6, IL-10 and TNF-α levels and exposure to traumatic events in childhood and adulthood in individuals with and without GD (DSM-5).

METHODS

Cross-sectional controlled study comparing 34 transsexual women and 31 non-transsexual men. They underwent a thorough structured interview, assessing sociodemographic information, mood and anxiety symptoms, childhood maltreatment, explicit discrimination and suicidal ideation. Inflammatory cytokine levels (IL-1β, IL-6, IL-10 and TNF-α) were measured by multiplex immunoassay.

RESULTS

Individuals with GD experienced more discrimination (p = 0.002) and childhood maltreatment (p = 0.046) than non-transsexual men. Higher suicidal ideation (p < 0.001) and previous suicide attempt (p = 0.001) rates were observed in transsexual women. However, no differences were observed in the levels of any cytokine.

CONCLUSIONS

These results suggest that transsexual women are more exposed to stressful events from childhood to adulthood than non-transsexual men and that GD per se does not play a role in inflammatory markers.

Non-HIV chronic disease burden among transgender populations globally: A systematic review and narrative synthesis

Chronic disease is a growing concern for research, policy and clinical care. While the global burden of HIV for transgender populations has been comprehensively covered in recent systematic reviews, the same is not true for the burden of other chronic disease. The objective of this study was to review the literature on non-HIV chronic disease burden for transgender populations worldwide. A systematic review was conducted of Medline, Embase, CINAHL, PsycINFO and LGBT Life bibliographic databases for peer-reviewed scientific studies with non-HIV chronic disease prevalence data for transgender populations published any date up to February 15, 2019 without restriction on country or study design. A total of 93 studies and 665 datapoints were included in this review, comprising 48 distinct chronic disease outcomes in seven groups (cancer, cerebro/cardiovascular conditions, chronic liver and kidney disease, mental health and substance use conditions, metabolic and endocrine disorders, musculoskeletal and brain disorders, respiratory conditions, and unspecified and other conditions). The empirical literature on chronic disease among global transgender populations focuses on mental health morbidity, demonstrating an evidence gap on chronic physical health morbidity, particularly beyond that of sexual health. This review identified important gaps including in age-related conditions, inflammation-related disease and studies designed explicitly to investigate chronic disease burden among transgender populations. There is a need for high quality evidence in this area, including longitudinal population-based studies with appropriate comparison groups, and consistent measurement of both transgender status and chronic conditions.

Fertility Preservation for Transgender Individuals: A Review

Transgender individuals represent a small, albeit growing, patient population that is encountered more frequently in clinical care due to improved insurance coverage and increasing awareness. Gender-affirming treatments, including both gender-affirming hormone therapy and gender-affirming surgery, pose significant risks to fertility potential and outcomes, ranging from potentially impaired fertility rates to full elimination of reproductive potential depending on the type of treatment pursued. However, there are relatively limited data specific to fertility preservation for transgender individuals. Current approaches to treatment are extrapolated from options for fertility preservation after oncologic diagnoses. In this review, we aim to summarize current clinical approaches, fertility preservation options, and patient experiences in fertility preservation for transgender individuals. Several forms of fertility preservation options are available depending on the pubertal status of a transgender individual. Despite the multiple options for fertility preservation, major barriers exist to patient care and there are reports of mixed patient experiences. Further awareness of this clinical situation and understanding of these processes will allow for comprehensive and specialized care for transgender individuals who may otherwise miss opportunities for adequate counseling or treatment options regarding fertility preservation.

Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases

BACKGROUND

Gender affirmation surgery (GAS) is a heterogeneous group of body transformational procedures to match one's gender identity. There is a paucity of literature on the outcomes and safety profile of GAS. This study aims to examine trends and outcomes of GAS from 2010 to 2015 using the American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample databases.

METHODS

Patients with a primary diagnosis of gender dysphoria at the time of surgery were identified in both databases. Thirty-day complication rates were determined using the National Surgery Quality Improvement Program database. Patient socioeconomic status and hospital characteristics were examined using the National Inpatient Sample database.

RESULTS

The number of cases per year increased from 5 in 2010 to 231 in 2015. The overall 30-day complication rate was 5.5%. Younger age was an independent risk factor for overall complications and reoperation. Total operating time was an independent risk factor for overall complications and infection. Black/African American race was associated with an increased risk of reoperation and readmission. Most patients (80%) had income at or above the national median income level; most were self-pay or had private insurance (90%). The typical hospitals providing GAS were large, urban, nonteaching, private nonprofit institutions in the US West Coast and Northeast.

CONCLUSIONS

Gender affirmation surgery has an acceptable safety profile. The marked increase in case numbers likely reflects recent improvements in social climate and access to care. However, there are socioeconomic disparities in utilization and surgical outcomes among this already vulnerable patient population.

Epidemiology of gender dysphoria and transgender identity

This review provides an update on the epidemiology of gender dysphoria and transgender identity in children, adolescents and adults. Although the prevalence of gender dysphoria, as it is operationalised in the fifth edtion of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), remains a relatively 'rare' or 'uncommon' diagnosis, there is evidence that it has increased in the past couple of decades, perhaps reflected in the large increase in referral rates to specialised gender identity clinics. In childhood, the sex ratio continues to favour birth-assigned males, but in adolescents, there has been a recent inversion in the sex ratio from one favouring birth-assigned males to one favouring birth-assigned females. In both adolescents and adults, patterns of sexual orientation vary as a function of birth-assigned sex. Recent studies suggest that the prevalence of a self-reported transgender identity in children, adolescents and adults ranges from 0.5 to 1.3%, markedly higher than prevalence rates based on clinic-referred samples of adults. The stability of a self-reported transgender identity or a gender identity that departs from the traditional male-female binary among non-clinic-based populations remains unknown and requires further study.

Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review

Accurate estimates of the number and proportion of transgender and gender nonconforming people in a population are necessary for developing data-based policy and for planning and funding of health care delivery and research. The wide range of estimates reported in the literature is attributable primarily to differences in definitions. Other sources of variability include diverse cultural and geographic settings and important secular trends. The transgender and gender nonconforming population is undergoing rapid changes in size and demographic characteristics. More accurate and precise estimates will be available when population censuses collect data on sex assigned at birth and gender identity.

Urologic Complications After Phalloplasty or Metoidioplasty

In the past decade, issues facing transgender individuals have come to the forefront of popular culture, political discourse, and medical study. The evaluating physician should have knowledge of the reconstructed anatomy, as well as potential postoperative complications. This knowledge will aid in providing appropriate care and recognizing issues that may require specialized urologic care. Transgender anatomic definitions and a synopsis of common urologic complications specific to transmen, including urethrocutaneous fistulae, neourethral strictures, and persistent vaginal cavities are discussed.

Individuals seeking gender reassignment: marked increase in demand for services

Aims and methodTo describe the pattern of referrals and characteristics of people aged over 18 seeking gender reassignment in Oxfordshire over a 6-year period (2011-2016).

RESULTS

A total of 153 individuals attended for assessment (of 162 referred); 97 (63.4%) were natal males and 56 (36.6%) were natal females. Mean age at referral was markedly different between the two groups, with females being younger. The number of referral significantly increased over the time period, by an average of 18% per year (95% CI 1.08-1.30). Eighty-seven patients sought transition from male to female, and 46 from female to male, while a smaller group (n = 13) had non-binary presentations. Twelve patients (7.8%) had autism spectrum disorder.Clinical implicationsThere are various possible reasons for the increased demand for services for people with gender dysphoria, which we discuss here. When planning services in the UK, both the increase in overall referral rates and the apparent earlier age at referral should be taken into account.Declaration of interestNone.

Gender-Affirming Surgery in Persons with Gender Dysphoria

The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is replete with the evolving surgical and technical approaches to gender-affirming surgery, there remain critical gaps in the plastic surgery literature describing the delivery of comprehensive care to these patients. To address these gaps, the authors establish a framework that plastic surgeons can use to guide their management of patients with gender dysphoria to optimize surgical and psychosocial outcomes. First, the authors describe a timeline of events that have shaped present-day transgender medicine and characterize the current role of the plastic surgeon in the management of gender dysphoria. Subsequently, the authors discuss psychosocial and ethical considerations surrounding gender dysphoria. Finally, the authors discuss the future scope of transgender medicine.

Transgender Associations and Possible Etiology: A Literature Review

Transgender or gender dysphoria has been defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as distress resulting from the incongruence between one's experienced gender and one's assigned gender, along with a persistent and strong desire to be of another gender, and accompanied by clinically significant distress. Adolescents referred for evaluation often want hormonal therapy and several among them also express a desire for gender reassignment surgery. Furthermore, evidence shows that adolescents and adults with gender dysphoria without a sex development disorder, before gender reassignments, are at increased risk for suicide. For this review, a search of the English language scientific literature was conducted using the PubMed database. This summary discusses the associations and comorbidities of gender dysphoria and reiterates the evidence that its etiology is multifactorial. Transsexualism involves prenatal neuroanatomical changes, has a psychiatric association, and is found to be more prevalent in conjunction with schizophrenia and autism spectrum disorders. Childhood adversities and neglect are also linked to having a transgender identity. Moreover, the evidence favors a genetic predisposition. Likewise, there seems to be a growing concern with regards to the relationship between endocrine disruptors and transsexuals as well as other gender minority populations. More research needs to be done to understand the exact pathways.

Factors Associated with Gender-Affirming Surgery and Age of Hormone Therapy Initiation Among Transgender Adults

Purpose: Gender-affirming surgeries and hormone therapy are medically necessary treatments to alleviate gender dysphoria; however, significant gaps exist in the research and clinical literature on surgery utilization and age of hormone therapy initiation among transgender adults.

Methods: We conducted a retrospective review of electronic health record data from a random sample of 201 transgender patients of ages 18–64 years who presented for primary care between July 1, 2010 and June 30, 2015 (inclusive) at an urban community health center in Boston, MA. Fifty percent in our analyses were trans masculine (TM), 50% trans feminine, and 24% reported a genderqueer/nonbinary gender identity. Regression models were fit to assess demographic, gender identity-related, sexual history, and mental health correlates of gender-affirming surgery and of age of hormone therapy initiation.

Results: Overall, 95% of patients were prescribed hormones by their primary care provider, and the mean age of initiation of masculinizing or feminizing hormone prescriptions was 31.8 years (SD=11.1). Younger age of initiation of hormone prescriptions was associated with being TM, being a student, identifying as straight/heterosexual, having casual sexual partners, and not having past alcohol use disorder. Approximately one-third (32%) had a documented history of gender-affirming surgery. Factors associated with increased odds of surgery were older age, higher income levels, not identifying as bisexual, and not having a current psychotherapist.

Conclusion: This study extends our understanding of prevalence and factors associated with gender-affirming treatments among transgender adults seeking primary care. Findings can inform future interventions to expand delivery of clinical care for transgender patients.

Prevalence, Incidence, and Sex Ratio of Transsexualism in the Autonomous Region of Madrid (Spain) According to Healthcare Demand

In recent years, different studies have provided estimates of the prevalence of transsexualism with very diverse results. The purpose of this study was to ascertain the prevalence, incidence, and sex ratio of transsexualism in the autonomous region of Madrid (Spain). A total of 1234 patients who attended from 2007 to the end of 2015 in the only Gender Identity Unit (GIU) in Madrid were analyzed. Sixty-three patients were excluded for various reasons; thus, 1171 could be included: 803 male-to-female (MtF) and 368 female-to-male (FtM) transsexual patients. Transsexualism was diagnosed based on the ICD-10, World Health Organization, 1992, and/or gender identity disorder based on the DSM-IV-TR, American Psychiatric Association, 2000. The demographic statistics were calculated on the basis of the population over 15 years old of Madrid. Based on healthcare demand, the prevalence of transsexualism was 22.1 in 100,000 inhabitants: 31.2 for MtF and 12.9 for FtM, making the MtF/FtM ratio approximately 2.2:1. The incidence rate was 2.5 in 100,000 inhabitants, representing an annual average of 130 demands. Although transsexualism occurs in all countries with different rates of prevalence, in our area, this prevalence was higher than reported from other European countries. We believe that two main circumstances might influence this high prevalence: the easy accessibility and the absence of a waiting list to the GIU, and the permissive social and legal climate and openness of Spain, especially in Madrid.

PREVALENCE AND TYPES OF GENDER-AFFIRMING SURGERY AMONG A SAMPLE OF TRANSGENDER ENDOCRINOLOGY PATIENTS PRIOR TO STATE EXPANSION OF INSURANCE COVERAGE

OBJECTIVE

Transgender individuals now have many options for medical intervention, including gender-affirmation surgeries. However, it is unknown how common it is for transgender individuals to undergo these surgeries. The purpose of this cross-sectional study was to assess the prevalence of gender-affirming surgeries among transgender patients in 2015, which was immediately prior to insurance changes that made gender-affirming surgery more affordable for Massachusetts residents.

METHODS

A retrospective chart review of 99 transgender patients was performed at the Endocrinology Clinic at Boston Medical Center, an urban safety net hospital. The records for 99 transgender subjects who received treatment between 2004-2015, including 28 transmen and 71 transwomen, were examined. The outcome measures were the types of medical interventions chosen by transgender patients, which included hormone therapy, chest surgery, gonadectomy, genital surgery, and facial surgery.

RESULTS

Thirty-five percent of subjects had undergone at least one gender-affirming surgery. Transmen were more likely to have had surgery than transwomen (54% vs. 28%). Twenty-five percent of patients had chest surgery, 13% had genital surgery or gonadectomy, and 8% had facial surgery.

CONCLUSION

In 2015, a majority of transgender endocrinology clinic patients had not undergone any type of gender-affirmation surgery. Among those who did elect to have a surgery, genital surgery or gonadectomy were uncommon. The low rate of surgery among this sample of transgender patients may be attributable to the financial cost, lack of interest in surgery, or that genital surgery is not a high priority for transgender individuals relative to surgery to change visible features such as face and chest. Abbreviation: HT = hormone therapy.

Oestrogen and anti-androgen therapy for transgender women

Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.

Quality of life improves early after gender reassignment surgery in transgender women

Background

Few studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS).

Methods

We performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population.

Results

On most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined.

Conclusions

To our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group.

Level of evidence: Level III, therapeutic study.

Mental health and gender dysphoria: A review of the literature

Studies investigating the prevalence of psychiatric disorders among trans individuals have identified elevated rates of psychopathology. Research has also provided conflicting psychiatric outcomes following gender-confirming medical interventions. This review identifies 38 cross-sectional and longitudinal studies describing prevalence rates of psychiatric disorders and psychiatric outcomes, pre- and post-gender-confirming medical interventions, for people with gender dysphoria. It indicates that, although the levels of psychopathology and psychiatric disorders in trans people attending services at the time of assessment are higher than in the cis population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. The main Axis I psychiatric disorders were found to be depression and anxiety disorder. Other major psychiatric disorders, such as schizophrenia and bipolar disorder, were rare and were no more prevalent than in the general population. There was conflicting evidence regarding gender differences: some studies found higher psychopathology in trans women, while others found no differences between gender groups. Although many studies were methodologically weak, and included people at different stages of transition within the same cohort of patients, overall this review indicates that trans people attending transgender health-care services appear to have a higher risk of psychiatric morbidity (that improves following treatment), and thus confirms the vulnerability of this population.

Male Prison Inmates With Gender Dysphoria: When Is Sex Reassignment Surgery Appropriate?

Gender dysphoria (GD), a feeling of persistent discomfort with one's biologic sex or assigned gender, is estimated to be more prevalent in male prison inmates than in nonincarcerated males; there may be 3000-4000 male inmates with GD in prisons in the United States. An increasing number of U.S. prison systems now offer gender dysphoric inmates diagnostic evaluation, psychotherapy, cross-sex hormone therapy, and opportunities, albeit limited, to enact their preferred gender role. Sex reassignment surgery (SRS), however, has not been offered to inmates except in response to litigation. In the first case of its kind, the California Department of Corrections and Rehabilitation recently agreed to provide SRS to an inmate and developed policy guidelines for its future provision. In other recent cases, U.S. courts have ruled that male inmates with GD are entitled to SRS when it is medically necessary. Although these decisions may facilitate the provision of SRS to inmates in the future, many U.S. prison systems will probably remain reluctant to offer SRS unless legally compelled to do so. In this review, we address the medical necessity of SRS for male inmates with GD. We also discuss eligibility criteria and the practical considerations involved in providing SRS to inmates. We conclude by offering recommendations for physicians, mental health professionals, and prison administrators, designed to facilitate provision of SRS to inmates with GD in a manner that provides humane treatment, maximizes the likelihood of successful outcomes, minimizes risk of regret, and generates data that can help inform future decisions.

Global health burden and needs of transgender populations: a review

Transgender people are a diverse population affected by a range of negative health indicators across high-income, middle-income, and low-income settings. Studies consistently document a high prevalence of adverse health outcomes in this population, including HIV and other sexually transmitted infections, mental health distress, and substance use and abuse. However, many other health areas remain understudied, population-based representative samples and longitudinal studies are few, and routine surveillance efforts for transgender population health are scarce. The absence of survey items with which to identify transgender respondents in general surveys often restricts the availability of data with which to estimate the magnitude of health inequities and characterise the population-level health of transgender people globally. Despite the limitations, there are sufficient data highlighting the unique biological, behavioural, social, and structural contextual factors surrounding health risks and resiliencies for transgender people. To mitigate these risks and foster resilience, a comprehensive approach is needed that includes gender affirmation as a public health framework, improved health systems and access to health care informed by high quality data, and effective partnerships with local transgender communities to ensure responsiveness of and cultural specificity in programming. Consideration of transgender health underscores the need to explicitly consider sex and gender pathways in epidemiological research and public health surveillance more broadly.

Determinants of and Barriers to Hormonal and Surgical Treatment Receipt Among Transgender People

Purpose: Medical gender confirmation therapy (GCT) plays an important role in transgender health; however, its prevalence and determinants constitute an area of uncertainty. Methods: Data for this cross-sectional study were obtained from an online survey distributed from October 2012 through the end of 2013 among persons who visited the social media sites of a transgender education and social networking meeting. Eligible respondents (n=280) were persons whose gender identity was different from their sex assigned at birth and who responded to questions about previously received or planned hormonal therapy (HT), chest reconstruction, or genital surgery. Multivariable logistic regression models examined how receipt and plans to receive different GCT types were associated with participants' characteristics and gender identity. Results: The respective percentages of ever and current HT were 58% and 47% for transwomen and 63% and 57% for transmen. Genital surgery was reported by 11 participants; all transwomen. Relative to transmen, transwomen were thrice more likely to report plans to undergo genital surgery. By contrast, transmen were more than 10 times as likely as transwomen to have had or planned chest surgery. Older participants and those who were in a committed relationship were less likely to plan future GCT. Having health insurance was not associated with GCT receipt. Treatment cost was named as the main problem by 23% of transwomen and 29% of transmen. Accessing a qualified healthcare provider for transgender-related care was listed as the primary reason for not receiving surgery by 41% of transmen and 2% of transwomen. Conclusions: Prevalence of GCT differed across subgroups of participants and was lower than corresponding estimates reported elsewhere. The variability of results may reflect differences in recruitment procedures and response rates; however, it is also possible that it may be driven by geographic, socioeconomic, and health-related heterogeneity of the transgender population.

Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review

INTRODUCTION

A systematic review and meta-analysis was conducted to evaluate how various definitions of transgender affect prevalence estimates.

AIMS

To evaluate the epidemiology of transgender and examine how various definitions of transgender affect prevalence estimates and to compare findings across studies that used different methodologies, in different countries, and over different periods.

METHODS

PubMed, EMBASE, and Medline were searched to identify studies reporting prevalence estimates of transgender in a population. All studies were grouped based on the case definition applied to the numerator. Summary estimates were derived using a random-effects model for total prevalence of transgender and for male-to-female and female-to-male subgroups. Overall and stratum-specific meta-prevalence estimates (mPs) and 95% confidence intervals (CIs) were accompanied by tests for heterogeneity and meta-regressions to assess sources of heterogeneity.

MAIN OUTCOME MEASURES

The main outcome measure was population prevalence of transgender. Secondary outcomes included gender-specific prevalence estimates for male-to-female and female to male subgroups.

RESULTS

Thirty-two studies met the inclusion criteria for systematic review. Of those, 27 studies provided necessary data for a meta-analysis. Overall mP estimates per 100,000 population were 9.2 (95% CI = 4.9-13.6) for surgical or hormonal gender affirmation therapy and 6.8 (95% CI = 4.6-9.1) for transgender-related diagnoses. Of studies assessing self-reported transgender identity, the mP was 871 (95% CI = 519-1,224); however, this result was influenced by a single outlier study. After removal of that study, the mP changed to 355 (95% CI = 144-566). Significant heterogeneity was observed in most analyses.

CONCLUSION

The empirical literature on the prevalence of transgender highlights the importance of adhering to specific case definitions because the results can range by orders of magnitude. Standardized and routine collection of data on transgender status and gender identity is recommended.

A novel method for estimating transgender status using electronic medical records

PURPOSE

We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system.

METHODS

A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews.

RESULTS

Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014.

CONCLUSIONS

The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.

A novel method for estimating transgender status using electronic medical records

PURPOSE

We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system.

METHODS

A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews.

RESULTS

Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014.

CONCLUSIONS

The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.

Gender Dysphoria in Adults

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater client autonomy, and improved understanding of the benefits and limitations of current treatment modalities.

Systematic Review and Meta-Analysis of Prevalence Studies in Transsexualism

Background

Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data.

Methods

Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed.

Results

The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years.

Conclusions

The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.