What do patients with Peyronie's disease expect from therapy? A prospective multi-center study

BACKGROUND

Little is known about patients' pre-treatment expectations in Peyronie's disease (PD).

OBJECTIVE

To evaluate in detail patients' expectations of conservative therapy and surgery.

PATIENTS AND METHODS

This multi-center study prospectively enrolled 317 PD patients, who were scheduled to receive conservative therapy or surgery between 2019 and 2022 at the Department of Urology of the University Medical Center Hamburg-Eppendorf, and the Center of Reproductive Medicine and Andrology, University Medical Center Muenster, both Germany. The primary end-point was patients' pre-treatment expectations of conservative therapy and surgery, measured with the Stanford Expectations of Treatment Scale (SETS). Secondary end-points included patient-reported psychological and physical symptoms, penile pain, symptom bother and erectile function, measured with the Peyronie's disease questionnaire (PDQ) and International Index of Erectile Function Erectile Function Domain (IIEF-EF).

RESULTS

In total, 239 (75%) and 78 (25%) patients were scheduled for the conservative therapy and surgery, respectively. Patients undergoing surgery had higher positive and negative mean SETS expectations scores (14 vs. 11, p < 0.001; 9.6 vs. 6.0, p < 0.001). In multivariable analysis, surgery was an independent predictor of positive and negative patients' pre-treatment expectations (all p ≤ 0.001). In thematic analysis, patients undergoing surgery emphasized distinct themes of pre-treatment expectations. Patients undergoing surgery had higher mean PDQ symptom bother as well as higher psychological and physical symptom scores (14 vs. 10, p < 0.001; 9.2 vs. 7.1, p = 0.001). There were significant positive correlations between SETS negative expectation score and PDQ symptom bother (|ρ| = 0.25; p < 0.001) as well as PDQ psychological and physical symptoms score, respectively (|ρ| = 0.21; p = 0.001).

CONCLUSION

PD patients expect both more benefit and more harm from surgery. In addition, patients undergoing surgery have more psychological and physical symptoms and more symptom bother. To set realistic expectations, it is of pivotal importance to assess patients' expectations before starting treatment.

(De-)centralized health care delivery, surgical outcome, and psychosocial health of transgender and gender-diverse people undergoing vaginoplasty: results of a retrospective, single-center study

PURPOSE

Previous research on genital gender-affirming surgery lacked to build a framework that took various surrounding factors into account. E.g., transgender health care services are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). The present study investigated the effects of different structural and clinical aspects of gender-affirming genital surgery on psychosocial outcomes.

METHODS

We surveyed former transgender and gender-diverse people who completed a vaginoplasty between 2014 and 2018. 45 participants were included in the study. We calculated hierarchical linear regression analyses to assess the relationship between psychosocial outcome measures (gender congruence, mental health, quality of life) and different aspects of gender-affirming genital surgery (e.g., setting of service delivery). To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identify predictors that are actually related to the outcomes.

RESULTS

A non-responder analysis revealed no systematic bias in the recruitment procedure. Treatment satisfaction was a significant predictor for gender congruence. Moreover, we found the setting of service delivery (centralized, decentralized) to predict psychological health and the physical health dimension of quality of life. The effect sizes of our models were moderate to high, and models explained up to 26% of the total variance with a power up to 0.83.

CONCLUSION

The present study is an exploratory attempt into the manifold relationships between treatment-related factors (e.g., aesthetic outcome), the setting of service delivery, and their effects on gender-affirming genital surgery.

Exploring the Relationship between (De-)Centralized Health Care Delivery, Client-Centeredness, and Health Outcomes-Results of a Retrospective, Single-Center Study of Transgender People Undergoing Vaginoplasty

Introduction: Transgender health care interventions (e.g., gender-affirming surgery) support transgender and gender-diverse people to transition to their gender and are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different institutions spread over several locations). In this exploratory study, we investigated the relationship between centralized and decentralized delivery of transgender health care, client-centeredness, and psychosocial outcomes. Methods: A retrospective analysis of 45 clients undergoing vaginoplasty at one medical center was conducted. Mann-Whitney U tests assessed differences regarding five dimensions of client-centeredness and psychosocial outcomes between the health care delivery groups. To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identified predictors that were actually related to the outcomes. Results: All aspects of client-centered care were scored average or high. Decentralized delivery of care was more client-centered in terms of involvement in care/shared decision-making and empowerment. However, participants from decentralized health care delivery settings scored lower on psychosocial health (p = 0.038-0.005). Conclusions: The factor of (de-)centralized health care delivery appears to have a significant impact on the provision of transgender health care and should be investigated by future research.

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

BACKGROUND

Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people's desired decision-making role within TRMI and factors that influence these desires.

AIMS

The study investigated trans people's desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.

METHODS

Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.

OUTCOMES

Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.

RESULTS

The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.

CLINICAL IMPLICATIONS

A desired decision-making role cannot be predicted based on the trans person's sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.

STRENGTHS AND LIMITATIONS

This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.

CONCLUSION

This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.

Pleasure please! Sexual pleasure and influencing factors in transgender persons: An ENIGI follow-up study

Background: While the importance of sexual pleasure for physical and mental health becomes increasingly evident, research on sexual pleasure in transgender persons is lacking. Recently, the first version of the Amsterdam Sexual Pleasure Index (ASPI Vol. 0.1) was validated in cisgender persons. This questionnaire aims to assess the tendency to experience sexual pleasure independent of gender, sexual orientation or anatomy. Aim: The aims of this study were threefold. First, to perform exploratory scale validation analyses of the ASPI in transgender persons. Secondly, to compare transgender sexual pleasure scores to reference data in cisgender persons. Finally, to identify factors that are associated with sexual pleasure. Methods: In a follow-up study conducted within the European Network for the Investigation of Gender Incongruence (ENIGI), online questionnaires were distributed to persons who had a first clinical contact at gender clinics in Amsterdam, Ghent or Hamburg four to six years earlier. Internal consistency of the ASPI was assessed by calculating McDonald's omega (ω_t). ASPI scores were compared to scores from the cisgender population using a one sample t-test, and linear regressions were conducted to study associations with clinical characteristics, psychological wellbeing, body satisfaction and self-reported happiness. Results: In total, 325 persons filled out the ASPI. The ASPI showed excellent internal consistency (ω_t, all: 0.97; transfeminine: 0.97, transmasculine: 0.97). Compared to data from cisgender persons, transgender participants had significantly lower total ASPI scores (i.e., lower sexual pleasure; transgender vs. cisgender, mean(SD): 4.13(0.94) vs. 4.71(0.61)). Lower age, current happiness and genital body satisfaction were associated with a higher tendency to experience sexual pleasure. Conclusion & discussion: The ASPI can be used to assess the tendency to experience sexual pleasure and associated factors in transgender persons. Future studies are needed to understand interplaying biopsychosocial factors that promote sexual pleasure and hence transgender sexual health and wellbeing.

Components of Good Sex in Young Urban Trans People Assigned Female at Birth: A Qualitative Interview Study

BACKGROUND

Prevalence of sexual dissatisfaction and dysfunction is high in trans people, as reflected in lower sexual pleasure scores compared to cis people.

AIM

The aim of this study is to explore components of good sex and sexual pleasure in young, urban trans people assigned female at birth (AFAB).

METHODS

16 semi-structured interviews were conducted with young urban AFAB trans people. The interviews were analysed using qualitative content analysis.

OUTCOMES

Main outcomes were providing participants components of good sex and sexual pleasure.

RESULTS

Regarding components of good sex, the participants of this study described various influences on their ability to relax as well as strategies to increase relaxation during sex. Next to general influences on relaxation, the ability to relax was influenced by the way their partners interacted with them and thus how accepted they felt in their identities and feeling safe. Further, transition and coming-out status, physical and sexual function changes due to hormone therapy and gender affirming surgeries, specific sexual techniques and aids, social constructs and the circumstances in which sex took place were important. Strategies to increase relaxation included using aids such as penis prostheses, preferring certain sexual practices, that is, being more dominant or on eye-level, reducing visual aspects, drinking alcohol, and deconstructing gender and sexual norms.

CLINICAL IMPLICATIONS

When working with trans clients, inhibitors of relaxation should be assessed and addressed, which could include working on clients believes about trans sexuality, gendered sexual scripts or various techniques to reduce body dysphoria, if present, during sexual practices.

STRENGTHS & LIMITATIONS

Following a non-clinical community sampling with no treatment-related dependency between researchers and participants, the sample provides an open access to the participating trans people's sexuality. However, the sample is small, selective, and it includes only able-bodied trans people from Christian religious backgrounds.

CONCLUSION

Next to sexual problems and dysfunctions, future research on the relationship between medical transition and sexuality should additionally address positive aspects of sexuality, such as sexual pleasure and sexual satisfaction, and its possible function as a resource pre, during and post transition.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Sexual Self-Esteem and Psychological Burden of Adults With Neurofibromatosis Type 1

Neurofibromatosis type 1 (NF1) is one of the most common tumor predisposition syndromes which primarily affects the skin. NF1 is characterized by various degrees of skin tumors and pigmentation abnormalities such as café-au-lait macules. Other skin diseases, such as psoriasis or neurodermatitis, have a negative influence on sexuality and quality of life and represent a psychological burden for those affected. The present study investigated the extent to which skin tumors (disfigurement) are related to sexuality and psychosocial factors in NF1 individuals. An anonymous online survey was carried out on Facebook and the webpage of the German Neurofibromatosis Association and a total of 166 persons participated. Of these participants, 92 were affected by NF1.74 healthy persons took part in the survey as a comparative group. Results show a significant relation between sexuality, body image, quality of life and the presence of depressive symptoms of the NF1 affected persons. Individuals with NF1 show a more negative sexual self-esteem. These concerns should be taken into account in NF1- related health care approaches.

Interdisciplinary, internet-based trans health care (i²TransHealth): study protocol for a randomised controlled trial

INTRODUCTION

Living in an area with no or deficient structures for trans health care is disadvantageous for trans people. By providing an internet-based health care programme, i²TransHealth aims at reducing structural disadvantages for trans people living in areas lacking specialised care. The e-health intervention consists of video consultations and a 1:1 chat with a study therapist. Additionally, the i²TransHealth network cooperates with physicians, who especially offer crisis intervention close to the participants' place of residence. The aim of this study is to evaluate the (cost-)effectiveness of the internet-based health care programme for trans people compared with a control (waiting) group. The following research questions will be examined with a sample of 163 trans people: Does a 4-month treatment with the i²TransHealth internet-based health care programme improve patient-reported health-outcomes? Is i²TransHealth cost-effective compared with standard care from a societal or health care payers' perspective? Does the participation in and support by i²TransHealth lead to an increase of trans-related expertise in the physician network?

METHODS AND ANALYSIS

In a randomised controlled trial, the outcomes of an internet-based health care programme for trans people will be investigated. In the intervention group, participants are invited to use i²TransHealth for 4 months. Participants allocated to the control group will be able to start with their transition-related care after 4 months of study participation. The primary outcome measure is defined as the reduction of psychosomatic symptoms, as assessed by the Brief Symptom Inventory-18, 4 months after using the i²TransHealth programme. Participants in both groups will undergo an assessment at baseline and 4 months after using i²TransHealth.

ETHICS AND DISSEMINATION

Positive ethical approval was obtained from the Hamburg Medical Association (PV7131). The results will be disseminated to service users and their families via media, to health care professionals via professional training and meetings and to researchers via conferences and publications.

TRIAL REGISTRATION NUMBER

NCT04290286.

PROTOCOL VERSION

22 December 2021 (V.1.0).

[Transgender health and healthcare during the COVID‑19 pandemic: a cross-sectional online survey in German-speaking countries]

BACKGROUND AND OBJECTIVE

Since spring of 2020, the COVID‑19 pandemic has disrupted our day-to-day lives and led to negative consequences in various areas of life, including mental and physical wellbeing. In this article, we take a closer look at the situation of trans people, who - due to experiences with discrimination and marginalization as well as their specific health-related interests - could be characterized by a particular vulnerability.

METHODS

Using an online cross-sectional survey, which we designed collaboratively with experts from the trans community, we investigated the mental and physical health of trans people from German-speaking countries and their access to trans-related healthcare during the COVID‑19 pandemic in the period from 1 May 2020 to 31 January 2021.

RESULTS

Since the beginning of the COVID‑19 pandemic, trans people have experienced barriers in access to gender-affirming treatments, mental health services, and COVID‑19-related medical care. At the same time, trans people reported being affected by chronic diseases disproportionately more often than the general population, including those leading to a higher risk for poorer outcomes of a COVID‑19 infection. Moreover, the participants reported being exposed to many risk factors associated with higher mental distress (e.g., having a chronic illness, belonging to a minority based on a non-heterosexual orientation, or having a low income).

DISCUSSION

The results of this survey indicate that prior vulnerabilities with regards to health problems and the restricted access to an informed and qualified transgender healthcare were exacerbated by the COVID‑19 pandemic.

Centralized and Decentralized Delivery of Transgender Health Care Services: A Systematic Review and a Global Expert Survey in 39 Countries

Introduction

Transgender health care is delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). However, the health care delivery setting has not gained attention in research so far. Based on a systematic review and a global expert survey, we aim to investigate its role in transgender health care quality.

Methods

We performed two studies. In 2019, we systematically reviewed the literature published in databases (Cochrane, MEDLINE, EMBASE, Web of Science) from January 2000 to April 2019. Secondly, we conducted a cross-sectional global expert survey. To complete the evidence on the question of (de-)centralized delivery of transgender health care, we performed a grey literature search for additional information than the systematic review and the expert survey revealed. These analyses were conducted in 2020.

Results

Eleven articles met the inclusion criteria of the systematic review. 125 participants from 39 countries took part in the expert survey. With insights from the grey literature search, we found transgender health care in Europe was primarily delivered centralized. In most other countries, both centralized and decentralized delivery structures were present. Comprehensive care with medical standards and individual access to care were central topics associated with the different health care delivery settings.

Discussion

The setting in which transgender health care is delivered differs between countries and health systems and could influence different aspects of transgender health care quality. Consequently, it should gain significant attention in clinical practice and future health care research.

Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study

BACKGROUND

While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.

AIM

To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.

METHODS

As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.

OUTCOMES

Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.

RESULTS

Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.

CLINICAL IMPLICATIONS

Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.

STRENGTHS & LIMITATIONS

We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.

CONCLUSION

These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.

Experienced barriers of care within European treatment seeking transgender individuals: A multicenter ENIGI follow-up study

Objectives: To evaluate the experienced barriers of care for treatment-seeking trans individuals (TSTG) in three large European clinics. Methods: An online follow-up questionnaire was filled out by 307 TSTG individuals as part of the research protocol of the European Network for the Investigation of Gender Incongruence (ENIGI). Data was collected during follow-up in 2017/2018, around 5 years after participants had their initial clinical appointments in Ghent (Belgium), Amsterdam (the Netherlands), or Hamburg (Germany). Background characteristics, country, treatment characteristics and mental health were analyzed in relation to experienced barriers of care (EBOC, measured though agreement with statements). Results: The majority of participants reported various EBOC, oftentimes more than one. The most-frequently reported EBOCs pertained to the lack of family and friends' support (28.7%, n = 88) and travel time and costs (27.7%, n = 85), whereas around one-fifth felt hindered by treatment protocols. Also, a significant share expressed the feeling that they had to convince their provider they needed care and/or express their wish in such way to increase their likelihood of receiving care. A higher number of EBOCs reported was associated with more mental health problems, lower income and female gender. Conclusions: A substantial number of TSTG individuals within three European health care systems experiences EBOCs. EBOCs relate to both personal and systemic characteristics. These findings can help health care providers and centers to improve care. More research must be done to better understand the diversity among TSTG individuals and the corresponding barriers experienced. Supplemental data for this article is available online at https://doi.org/10.1080/26895269.2021.1964409.

Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study

BACKGROUND

The number of adolescents presenting with gender dysphoria (GD) in healthcare services has increased significantly, yet specialized services offering transition-related care (TRC) for trans youth is lacking.

AIM

To investigate satisfaction with TRC, regret, and reasons for (dis)satisfaction with transition-related medical interventions (TRMIs) in trans adolescents who had presented to the Hamburg Gender Identity Service for children and adolescents (Hamburg GIS).

METHODS

Data were collected from a clinical cohort sample of 75 adolescents and young adults diagnosed with GD (81% assigned female at birth) aged 11 to 21 years (M = 17.4) at baseline and follow-up (on a spectrum of ongoing care, on average 2 years after initial consultation). To determine progress of the youth's medical transitions, an individual treatment progress score (ITPS) was calculated based on number of desired vs received TRMIs.

OUTCOMES

Main outcome measures were satisfaction with TRC at the time of follow-up, ITPS, social support, reasons for regret and termination of TRC, and (dis)satisfaction with TRMIs.

RESULTS

Participants underwent different stages of TRMIs, such as gender-affirming hormone treatment or surgeries, and showed overall high satisfaction with TRC received at the Hamburg GIS. Regression analysis indicated that a higher ITPS (an advanced transition treatment stage) was predictive of higher satisfaction with TRC. Sex assigned at birth, age, and time since initial consultation at the clinic showed no significant effects for satisfaction with TRC, while degree of social support showed a trend. No adolescents regretted undergoing treatment at follow-up. Additional analysis of free-text answers highlighted satisfaction mostly with the physical results of TRMI.

CLINICAL IMPLICATIONS

Because youth were more satisfied with TRC when their individual transition (ITPS) was more progressed, treatment should start in a timely manner to avoid distress from puberty or long waiting lists.

STRENGTHS AND LIMITATIONS

This study is one of the first to report on treatment satisfaction among youth with GD from Europe. The ITPS allowed for a more detailed evaluation of TRMI wishes and experiences in relation to satisfaction with TRC and may close a gap in research on these treatments in adolescent populations. However, all participants were from the same clinic, and strict treatment eligibility criteria may have excluded certain trans adolescents from the study. Low identification rates with non-binary identities prevented comparisons between non-binary and binary genders.

CONCLUSION

The study highlights the role of TRMI and individual treatment or transition progress for youth's overall high satisfaction with TRC received at the Hamburg GIS. Nieder TO, Mayer TK, Hinz S, et al. Individual Treatment Progress Predicts Satisfaction With Transition-Related Care for Youth With Gender Dysphoria: A Prospective Clinical Cohort Study. J Sex Med 2021;18:632-645.

Barriers to Accessing Health Care in Rural Regions by Transgender, Non-Binary, and Gender Diverse People: A Case-Based Scoping Review

Research shows an overrepresentation of trans people in vulnerable socioeconomic situations, primarily due to experiences of discrimination. At the same time, rural or suburban living areas often lack specialized trans-related health care, which a majority of trans people rely on to some extent. Taken together, the lack of both socioeconomic resources and access to trans-related health care can exacerbate health-related distress and impairment for trans people. We illustrate this problem using case vignettes of trans people from rural and suburban areas in (Northern) Germany. They are currently participating in an e-health intervention and randomized controlled trial (RCT) called i²TransHealth, whose case vignettes provided the impetus for the scoping review. The scoping review analyzes the impact of place of residence and its intersection with barriers to accessing trans-related health care. PubMed and Web of Science Data bases were searched for relevant studies using a search strategy related to trans people and remote, rural, or suburban residences. 33 studies were selected after full-text screening and supplemented via reference list checks and study team expertise by 12 articles addressing the living conditions of remotely living trans people and describing requirements for trans-related health care. The literature on trans people living remotely reveals intersections of trans mental health with age, race, gender expression, geographic location, community size, socioeconomic status, discrimination experiences, and attitudes towards health care providers. Several structural health care barriers are identified. The role of health care professionals (HCPs) for remotely living trans people is discussed. There is no need assuming that rural life for trans people is inevitably worse for health and well-being than urban life. Nevertheless, some clear barriers and health disparities exist for trans people in remote settings. Empowering trans groups and diversity-sensitive education of remote communities in private and institutional settings are needed for respectful inclusion of trans people. Facilitating access to trans-related health care, such as through video-based e-health programs with HCPs, can improve both the health and socioeconomic situation of trans people.

[Diagnostics, counselling and treatment in the context of gender incongruence, gender dysphoria and trans health : Practical information regarding the S3 guideline]

INTRODUCTION

This paper introduces the German S3-guideline Gender Incongruence, Gender Dysphoria and Trans Health: Diagnostics, Counselling and Treatment that was finalized in October 2018.

OBJECTIVES

The objective of the guideline group was to adapt the 1997 Standards for Treatment and Expert Opinion on Transsexuals to current scientific developments and research results and to make them applicable for appropriate health care in Germany.

METHODS

The treatment recommendations of the guideline are based on empirical evidence which was systematically researched and evaluated. In a structured consensus process, the guideline group, who is representative for the target group, and a stakeholder group of trans people in Germany agreed on 100 recommendations.

RESULTS

The guideline aims to individualize and deregulate the field of trans health care. Reasonable options for the treatment of gender incongruence and/or gender dysphoria are identified. Based on empirical and clinical evidence, a procedure is recommended which is tailored to the individual conditions of the treatment.

CONCLUSION

The guideline reflects the current international state of trans health care on the basis of empirical evidence and relates it to the German health care system. Its application should be backed up by clinical and therapeutic expertise.

[Feminizing Genital Gender-affirmative Surgery in Centralized and Decentralized Health Care Settings - The Hamburg TransCare study]

BACKGROUND

Gender Dysphoria (GD, formerly known as transsexualism) describes distress and impairment in an individual caused by the incongruence between the experienced gender and the sex assigned at birth (Gender Incongruence: GI). Transgender health care focusses on gender-affirmative treatments (e. g., hormone therapy) and associated needs (e. g., psychotherapy). Moreover, genital surgery is considered an effective treatment to reduce GI/GD and improve mental health and quality of life. Interdisciplinary cooperation between the associated medical facilities is regarded as evidence-based health care.

OBJECTIVES

To date, THC is delivered in zwei different health care settings: interdisciplinary and centralized from one medical institution vs. decentralized, spread over several medical institutions. In Germany, individuals with GI/GD access health care mostly in decentralized structures. The consequences of feminizing genital surgery carried out in centralized and decentralized health care structures in terms of quality and effectiveness have not been investigated so far. The goal of the TransCare study is to prospectively examine individuals with GI/GD seeking feminizing genital surgery regarding demographics and clinical characteristics as well as to analyze the influence of centralized and decentralized health care settings on the psychosocial and clinical outcome.

MATERIALS AND METHODS

To recruit a valid and comprehensive sample, participants were questioned prospectively.

RESULTS

The results of the study should help gain new insights into the influence of centralized and decentralized health care settings carrying out feminizing genital surgery on psychosocial and clinical outcomes for the patients.

CONCLUSION

Based on the TransCare study, we suggest that health care should be improved according to individual patient needs.

Being Trans Without Medical Transition: Exploring Characteristics of Trans Individuals from Germany Not Seeking Gender-Affirmative Medical Interventions

Until recently, trans persons were expected to align their sex characteristics as much as possible with the opposite sex. Today, research and health care, as well as the diagnostic criteria from DSM-5 and ICD-11, reflect a broader understanding of trans individuals. It encompasses diverse identities and treatment requests, including trans individuals not wanting or having decided against gender-affirmative medical interventions (GAMI). The present study explored this insufficiently studied group by (1) reviewing the existing literature regarding trans individuals not seeking GAMI and by (2) exploring their demographic and trans-related characteristics in a non-clinical online convenience sample from Germany. The literature review found one large survey with a single question on trans individuals not seeking GAMI. Beyond that, only community literature addressed the topic. The analyzed sample consisted of 415 trans participants, of whom 220 were assigned female at birth (AFAB) and 195 were assigned male at birth (AMAB). Fourteen (3.4%) reported neither previous nor planned GAMI (AFAB = 9, AMAB = 5). Trans individuals not seeking GAMI were significantly older and more often reported to identify with a non-binary gender. The two interdependent, central reasons for refusing GAMI were the avoidance of transition-related suffering and the lack of necessity for treatment. The diversification of gender, as reflected in the increasing visibility of non-binary or genderqueer gender identities, seems to go hand in hand with a diversification of transition-related treatment, including the option not to seek GAMI.

Ethical Aspects of Mental Health Care for Lesbian, Gay, Bi-, Pan-, Asexual, and Transgender People: A Case-based Approach

The lives of lesbian, gay, bi-, pan-, asexual, and transgender (LGBTA+/LGBT) people are not considered to be standard in society, unlike those of heterosexual cisgender people. This can lead to prejudices against LGBT people and may negatively influence their access to high-quality health care. Medical and mental health care have been characterized by attitudes (psycho-)pathologizing LGBT lives and therefore supported the stigmatization of LGBT people in the service of heteronormativity. Mental health professionals (MHPs) largely have transferred principles guiding counseling and psychotherapy with heterosexual (straight) cisgender persons to treatment of LGBT individuals without considering the specific features of LGBT lives. This is true even if the treatment is not exclusively LGBT-related, but can address LGBT-unrelated issues. To counteract this, the present paper aims to provide an insight into ethically sound mental health care for LGBT people. By applying the principles of biomedical ethics, we have analyzed how LGBT individuals can be discriminated against in mental health care and what MHPs may need to offer LGBT-sensitive high-quality mental health care. We argue that MHPs need LGBT-related expertise as well as LGBT-related sensitivity. MHPs should acquire specialist knowledge for the diverse lives and the challenges of LGBT people. We encourage MHPs to develop an understanding of how their own implicit attitudes towards LGBT people can affect treatment. However, the demand for special training should not be mistaken as a demand for a specific type of mental health care. The principles of general psychotherapy are equally the basis of psychotherapy with LGBT people.

[Transgender in Adolescence: State of the Art and Future Research Needs]

Transgender in adolescence is currently a widely discussed topic, additionally reflected by an increasing prevalence in clinical practice. The present review of the available literature on transgender, trans* , gender dysphoria or gender incongruence in youth reports results on the long-term results of medical interventions for the psychological well-being, prevalence, referral rates and sex ratio, developmental pathways, current developments and the role of the social environment. Finally, implications for clinical care and future research will be discussed.

European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction"

BACKGROUND

There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice.

AIM

We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction.

METHODS

The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available.

OUTCOMES

The foci of the study are assessment and hormonal aspects of trans health care.

RESULTS

As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment.

CLINICAL IMPLICATIONS

This is an up-to-date ESSM position statement.

STRENGTHS & LIMITATIONS

These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited.

CONCLUSION

This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.

Sexual Behavior, Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study

BACKGROUND

One of the most prominent etiological theories of gender incongruence in trans women proposes a paraphilic erotic target location error (ie, autogynephilia) as a causal factor in gynephilic (ie, exclusively gynephilic and bisexual) trans women. We hypothesized that a paraphilic erotic target location should manifest itself in various aspects of sexual behavior, solitary and dyadic sexual desire, and psychosexual experience.

AIM

To compare sexual behavior, sexual desire, and psychosexual experience of exclusively gynephilic and bisexual trans women with that of androphilic trans women to explore whether their sexuality differs substantially.

METHODS

Trans women diagnosed with gender dysphoria (Diagnostic and Statistical Manual of Mental Disorders-5) were recruited at 4 transgender healthcare centers in Germany. The present study analyzed items on sexual behavior, desire, and experience of a self-report questionnaire, collected as part of a cross-sectional multicenter study.

MAIN OUTCOMES

Multiple aspects of sexuality were examined using self-constructed items. Sexual desire was measured using the Sexual Desire Inventory and psychosexual experience using the Multidimensional Sexuality Questionnaire.

RESULTS

Significantly more exclusively gynephilic than androphilic trans women reported a history of sexual arousal in relation to cross-dressing. However, little evidence was found that gynephilic and androphilic sexual desire, behavior, and psychosexual experience differ profoundly. Interestingly, a statistically non-significant trend indicated that gynephilic trans women who had not yet undergone gender affirming surgery showed the highest levels of sexual desire (solitary and dyadic), whereas the opposite was the case for androphilic trans women.

CLINICAL TRANSLATION

Data of this study indicate that sexual orientation does not appear to be a good predicator for sexual behavior, desire, and psychosexual experience in trans women.

STRENGTHS AND LIMITATIONS

We investigated sexual desire and experience using standardized and evaluated measures such as the Sexual Desire Inventory and Multidimensional Sexuality Questionnaire. Future studies with a larger sample size should investigate how different gender affirming medical intervention might have diverging influences on sexual behavior, desire, and experience.

CONCLUSION

Ultimately, this study found little evidence for the hypothesis that sexual behavior, sexual desire, and psychosexual experience differ substantially in gynephilic (exclusively gynephilic and bisexual) and androphilic trans women. Laube JS, Auer M, Biedermann SV, et al. Sexual Behavior, Desire, and Psychosexual Experience in Gynephilic and Androphilic Trans Women: A Cross-Sectional Multicenter Study. J Sex Med 2020;17:1182-1194.

Mapping key stakeholders' position towards interdisciplinary transgender healthcare: A stakeholder analysis

Trans individuals experience an incongruence between their sex characteristics and their gender which might cause significant distress called gender dysphoria. Gender dysphoria is commonly treated using transition-related healthcare services, like sex hormones and surgeries, ideally in interdisciplinary settings. The stakeholder environment of an interdisciplinary transgender healthcare centre (ITHC) is considered key in delivering high-quality healthcare. Therefore, a stakeholder analysis was performed seeking to improve stakeholder relationships and service quality through an evidence-based approach. Quantitative data were collected using a questionnaire administered cross-sectionally, and covering attitude towards the ITHC, influence of and influence on stakeholders, level of knowledge about the ITHC, importance of the ITHC for stakeholders and types of interests. The analysis used primary data, collected July to August 2015. N = 79 key stakeholders were identified and n = 42 (53.2%) participated in the survey. Participants were categorised analytically into four stakeholder groups: trans groups, trans health experts, healthcare system and admin departments of the ITHC. Although participants reported low values (e.g. average values on a 5-point Likert scale; importance: 2.54; influence on the ITHC: 2.43), the attitude of the four stakeholder groups towards the ITHC were positive overall. The attitudes varied, however, depending on the group, for example trans health experts and trans groups reported the highest values for most items. The results demonstrate the importance of systematically analyzing stakeholder positions in order to make appropriate policy decisions, improving stakeholder relationships and assuring long-term high-quality healthcare provision. Subsequently, an action plan was developed, focusing on the two groups with the highest values (trans health experts, trans groups). Selected measures are discussed. If stakeholders are to play their part in providing high-quality, interdisciplinary trans healthcare, they need regular information on the latest developments and recurring feedback of their interests and requirements for the ITHC.

The Needs of LGBTI People Regarding Health Care Structures, Prevention Measures and Diagnostic and Treatment Procedures: A Qualitative Study in a German Metropolis

(1) Background: Studies indicate that lesbian, gay, bisexual, transgender and intersex (LGBTI) people constantly face challenges and disadvantages in the health care system that prevent them from getting the best possible patient-centered care. However, the present study is the first to focus on LGBTI-related health in a major German metropolis. It aimed to investigate health care structures, prevention measures and diagnostic as well as treatment procedures that LGBTI individuals need in order to receive appropriate patient-centered health care and health promotion. (2) Methods: Following a participatory approach, five expert interviews with LGBTI people with multiplier function, i.e., people who have a key role in a certain social milieu which makes them able to acquire and spread information in and about this milieu, and three focus groups with LGBTI people and/or health professionals were conducted. Qualitative data were analyzed according to the principles of content analysis. (3) Results: The specific needs of LGBTI individuals must be recognized as a matter of course in terms of depathologization, sensitization, inclusion, and awareness. Such an attitude requires both basic knowledge about LGBTI-related health issues, and specific expertise about sufficient health care services for each of the minorities in the context of sex, sexual orientation and gender identity. (4) Conclusions: For an appropriate approach to LGBTI-centered health care and health promotion, health professionals will need to adopt a better understanding of specific soft and hard skills.

A Cross-Sectional Multicenter Study of Multidimensional Body Image in Adolescents and Adults with Gender Dysphoria Before and After Transition-Related Medical Interventions

Persistent feelings of gender dysphoria (GD) are accompanied by distress and body dissatisfaction in most clinically referred adolescents and adults. Transition-related medical interventions (e.g., puberty suppression, hormones, or surgery) may alleviate body dissatisfaction. The aim of the present cross-sectional study was to compare multidimensional body image across clinically referred adolescents and adults undergoing different transition-related medical interventions. Two clinical samples of adolescents (n = 82) and adults (n = 120) referred to specialized departments of four different transgender health services in Germany participated in the study. In total, 202 individuals from the female-to-male (FtM individuals) and male-to-female (MtF individuals) spectrum aged 14-74 years were included at different stages of their transition. Four scales assessing multidimensional aspects of body image (measured by the Body Image Assessment Questionnaire, FBeK) were compared across three groups: sample, gender, and medical interventions (while controlling for age and treatment duration). The results indicated less favorable body image scores compared with the norm in both adolescents and adults with GD. Individuals who had undergone transition-related medical interventions presented a significantly better body image on two of the four scales. Differences according to gender and age were also present. These findings suggest that medical interventions, especially gender-affirming hormones and surgery, are generally beneficial to the body image in individuals with GD. However, not all of the less favorable outcomes in multidimensional body image were positively influenced by the treatment conditions and may thus benefit from additional integrative counseling before and during transition.

Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals

BACKGROUND

Health care for transgender and transsexual (ie, trans) individuals has long been based on a binary understanding of gender (ie, feminine vs masculine). However, the existence of non-binary or genderqueer (NBGQ) genders is increasingly recognized by academic and/or health care professionals.

AIM

To gain insight into the individual health care experiences and needs of binary and NBGQ individuals to improve their health care outcomes and experience.

METHODS

Data were collected using an online survey study on experiences with trans health care. The non-clinical sample consisted of 415 trans individuals. An individual treatment progress score was calculated to report and compare participants' individual progress toward treatment completion and consider the individual treatment needs and definitions of completed treatment (ie, amount and types of different treatments needed to complete one's medical transition).

OUTCOMES

Main outcome measures were (i) general and trans-related sociodemographic data and (ii) received and planned treatments.

RESULTS

Participants reported binary (81.7%) and different NBGQ (18.3%) genders. The 2 groups differed significantly in basic demographic data (eg, mean age; P < .05). NBGQ participants reported significantly fewer received treatments compared with binary participants. For planned treatments, binary participants reported more treatments related to primary sex characteristics only. Binary participants required more treatments for a completed treatment than NBGQ participants (6.0 vs 4.0). There were no differences with regard to individual treatment progress score.

CLINICAL TRANSLATION

Because traditional binary-focused treatment practice could have hindered NBGQ individuals from accessing trans health care or sufficiently articulating their needs, health care professionals are encouraged to provide a holistic and individual treatment approach and acknowledge genders outside the gender binary to address their needs appropriately.

STRENGTHS AND LIMITATIONS

Because the study was made inclusive for non-patients and individuals who decided against trans health care, bias from a participant-patient double role was prevented, which is the reason the results are likely to have a higher level of validity than a clinical sample. However, because of the anonymity of an online survey, it remains unclear whether NBGQ individuals live according to their gender identity in their everyday life.

CONCLUSION

The study highlights the broad spectrum of genders in trans-individuals and associated health care needs and provides a novel approach to measure individual treatment progress in trans individuals. Koehler A, Eyssel J, Nieder TO. Genders and Individual Treatment Progress in (Non-)Binary Trans Individuals. J Sex Med 2018;15:102-113.

Needs and concerns of transgender individuals regarding interdisciplinary transgender healthcare: A non-clinical online survey

This study investigates the needs and concerns transgender (short: trans) individuals have concerning trans healthcare (THC) in interdisciplinary THC centres. Trans individuals’ gender does not (fully/constantly) match their sex assigned at birth. To be able to live in their gender role and to prevent or minimise gender dysphoria, they might require a multidisciplinary set of transition related healthcare services. The current shift from the traditionally highly regulated, hierarchical and pathologising approach to THC towards a more patient-centred approach has highlighted the importance of trans patients’ satisfaction with treatment processes and results. As the still influential regulations have a negative effect on patient satisfaction, and might also keep trans individuals from seeking transition related treatment, it is crucial to investigate what trans individuals, whether patients or not, need and fear regarding transition related healthcare. Against the backdrop of mixed reactions received from the local trans community regarding the foundation of the Interdisciplinary Transgender Healthcare Centre Hamburg (ITHCCH), Germany, this study seeks to determine what trans individuals need with respect to THC in order to guarantee for high quality service provision at the ITHCCH. To this end, an online questionnaire was developed. The researchers employed a participatory approach to questionnaire development by involving a working group consisting of local trans support group representatives and (THC) specialists (N = 4). The sample consisted of N = 415 trans-identified individuals aged between 16 and 76. Most of them were based in Germany. 85.2% (n = 382) reported experience with transition related healthcare and 72.5% (n = 301) had (additional) treatments planned. Analysis revealed a need for communication and feedback opportunities. Furthermore, during the treatment process, addressing individual needs was considered crucial by participants. They agreed moderately with concerns towards THC centres. 96.5% of participants would like high decision-making power concerning treatment-associated decisions. The results demonstrate the importance of patient-centred THC that takes patients' individual needs and realities into consideration and involves patients in decision-making processes.

[Quality development within interdisciplinary transgender healthcare : Results and implications of a participatory research project]

Both internationally and nationally, the objective has been set to offer specialized, coordinated, and interdisciplinary treatment to individuals with rare clinical needs, such as trans individuals (e. g., transsexual, transgender). The Interdisciplinary Transgender Health Care Center Hamburg (ITHCCH) is the first and only center in Germany to integrate all disciplines relevant to trans healthcare (THC).The research project seeks to generate valid information to support quality development and assure high-quality treatment at the ITHCCH. This was done by (a) investigating needs and concerns of trans individuals regarding interdisciplinary THC, and (b) analyzing attitudes and interests of key stakeholders.Using a participatory approach involving a work group (representatives of trans support groups and local THC professionals), researchers developed an online survey focusing on trans individuals' needs and concerns. Data from N = 415 trans-identified participants were analyzed using quantitative and qualitative methods. In addition, a short survey was used to record key stakeholders' attitudes and interests towards the ITHCCH.Healthcare offers accessed by trans individuals as part of transition related treatment vary in focus and number. For example, take-up numbers of genital surgery differ between binary and non-binary trans individuals. Crucial aspects impacting on THC quality are structural characteristics, communication/social aspects, individuality, and professionalism/quality.To ensure successful, high-quality interdisciplinary THC, feedback from (potential) patients and stakeholders is crucial. In addition, both structural development and optimizing individuality and flexibility throughout the treatment process are key. This poses a considerable challenge to the sector of THC provision.

Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking

Since the beginning of contemporary transition-related care at the outset of the 20th century, sexual orientation has ben considered to be closely connected with gender identity and the developmental trajectories of trans people. Specifically, health professionals have regarded the anticipated post-transitional heterosexual behaviour of trans adults as predictive of a good outcome of cross-sex hormones and gender-confirming surgeries. This article reviews the current literature according to the question of whether the sexual orientation of trans people is linked to outcome measures following transition-related interventions. A comprehensive review was undertaken using the Medline database, searching for empirical studies published between 2010 and 2015. Out of a total of 474 studies, only 10 studies reported a follow-up of trans adults and assessed sexual orientation in the study protocol at all. Sexual orientation was predominantly assessed as homosexual versus non-homosexual related to sex assigned at birth. Only one 1 of 10 follow-up studies found a significant association according to the outcome between groups differentiated by sexual orientation. Empirically there is no link between sexual orientation and outcome of transition-related health care for trans adults. In order to provide comprehensive health care, we recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions; however, this knowledge should not drive, but simply inform, such comprehensive care.

Non-binary or genderqueer genders

Some people have a gender which is neither male nor female and may identify as both male and female at one time, as different genders at different times, as no gender at all, or dispute the very idea of only two genders. The umbrella terms for such genders are 'genderqueer' or 'non-binary' genders. Such gender identities outside of the binary of female and male are increasingly being recognized in legal, medical and psychological systems and diagnostic classifications in line with the emerging presence and advocacy of these groups of people. Population-based studies show a small percentage--but a sizable proportion in terms of raw numbers--of people who identify as non-binary. While such genders have been extant historically and globally, they remain marginalized, and as such--while not being disorders or pathological in themselves--people with such genders remain at risk of victimization and of minority or marginalization stress as a result of discrimination. This paper therefore reviews the limited literature on this field and considers ways in which (mental) health professionals may assist the people with genderqueer and non-binary gender identities and/or expressions they may see in their practice. Treatment options and associated risks are discussed.

Transgender health care in Germany: Participatory approaches and the development of a guideline

Health care of individuals who experience their gender not, not completely and/or not continuously in line with their sex assigned at birth has been organized for a long time in an area of conflict between the right for self-determination of transgender individuals and the fear of incorrect decisions among mental health professionals. The German Standards for the Treatment and Diagnostic Assessment of Transsexuals, published in 1997, were an attempt to regulate this area of conflicts within the German health system. Meanwhile, in view of the seventh version of the international Standards of Care published by the World Professional Association for Transgender Health (WPATH) as well as based upon recent judgments of the Federal Constitutional Court in Germany, the German standards must be exigently revised. In consequence, the Deutsche Gesellschaft für Sexualforschung (DGfS, German Society for Sex Research) has begun to substitute the above-mentioned standards with an evidence-based guideline aiming at an improvement of the service quality. This article introduces the history of transgender care in Germany, describes the background and the procedures of the current guideline development, and discusses how participatory approaches might improve the health care situation for transgender peeople in Germany.

Body Image in Young Gender Dysphoric Adults: A European Multi-Center Study

The alteration of sex-specific body features and the establishment of a satisfactory body image are known to be particularly relevant for individuals with Gender Dysphoria (GD). The aim of the study was to first develop new scales and examine the psychometric properties of the Hamburg Body Drawing Scale (Appelt & Strauß 1988). For the second part of this study, the satisfaction with different body features in young GD adults before cross-sex treatment were compared to female and male controls. Data collection took place within the context of the European Network for the Investigation of Gender Incongruence (ENIGI) including 135 female-to-male (FtMs) and 115 male-to-female (MtFs) young GD adults and 235 female and 379 male age-adjusted controls. The five female and six male body feature subscales revealed good internal consistency. The ENIGI sample reported less satisfaction with overall appearance (d = 0.30) and with all of their body features than controls, but no subgroup differences for sexual orientation (FtM and MtF) and Age of Onset (FtM) were found. Body dissatisfaction was higher with regard to sex-specific body features (largest effect sizes of d = 3.21 for Genitalia in FtMs and d = 2.85 for Androgen-responsive features and genitalia in MtFs) than with those that appeared less related to the natal sex (d = 0.64 for Facial features in FtMs and d = 0.59 for Body shape in MtFs). Not only medical body modifying interventions, but also psychosocial guidance with regard to body image might be helpful for GD individuals before transitioning.

Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults

This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.

German medical students' interest in and knowledge about human sexuality in 1972 and 2012

INTRODUCTION

During the 1970s, a growing number of medical schools began to recognize the importance of medical education concerning human sexuality. Currently, most medical schools provide at least some instruction in human sexuality.

AIM

In light of this development, the present study aimed to compare the interest in and knowledge about human sexuality of medical students from two different time periods.

METHODS

The answers to a self-constructed questionnaire of 236 students in 1972 were compared with those of 259 students in 2012. Students were asked whether they were interested in education regarding human sexuality and which specific topics they felt should be included in the medical curriculum. The students' knowledge in the following domains was assessed: sexual development, sexual behavior, sexual physiology and psychology, and sexual medicine.

MAIN OUTCOME MEASURES

The two cohorts were compared with regard to those specific sexuality-related topics in which the students were most and least interested in. Furthermore, the number of correct responses to the knowledge questions was compared.

RESULTS

While in 1972, 99.2% of the students were interested in medical education about human sexuality, in 2012, 80.3% showed an interest. The connection of disorders from different medical disciplines with sexuality was rated as most interesting by both the students from 1972 and 2012. Medical students from 2012 gave 50.3% correct answers to the knowledge questions, whereas students from 1972 correctly answered 46.3% of the questions.

CONCLUSIONS

Although interest in education concerning human sexuality has decreased, the majority of students view it as an important topic. Nevertheless, medical students still lack knowledge about important aspects of human sexuality (e.g., psychosexual development and relative safety of different contraceptives). Therefore, more time should be dedicated to education concerning human sexuality and its cultural, societal, and health aspects in particular.

Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study

A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.