Roux-en-Y gastric bypass in a transgender patient: a case report

The frequency of transgender individuals seeking gender affirming care is increasing over the last decade. Transgender patients suffer from obesity and psychiatric illness at elevated levels compared with the general population. A 54-year-old male-to-female transition patient presented with morbid obesity, hyperlipidaemia, and weight gain 2 years after their gender-transition and hormonal therapy. She received a Roux-en-Y gastric bypass (RYGB). At 7 months postoperatively, the patient has experienced 49% excess body weight loss, her body dissatisfaction had resolved and has completed further plastic surgery. The RYGB is an effective method for weight loss as well as benefits from cardiovascular disease, cancer, metabolic related conditions, and psychosocial wellbeing. Holistic treatment in conjunction with dietetic and psychology services can help maintain long-term weight management. Bariatric surgery combined with a multidisciplinary care team addressing medical and psychiatric concerns is integral to achieving and maintaining weight loss and gender identity.

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021

Introduction:  In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods:  We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results:  We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion:  In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

Ethical considerations regarding penis transplantation surgery in transgender men-an empirical ethics study

Background

The ongoing quest to surgically create the (nearly) ideal neophallus in transgender men has led to the continuous development of transgender medicine and the proposed introduction of penis transplantation. However, both technical and ethical issues arise when developing this treatment.

Aim

We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations.

Methods

Three semistructured focus groups, consisting of different stakeholders, were organized to participate in discussions of ethical considerations retrieved from the ethics literature of transplantation and transgender medicine. Analysis of the results was performed according to empirical ethics.

Outcomes

Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men.

Results

Nineteen people participated in this qualitative study. The main domains that emerged included arguments in favor of and arguments against penile transplantation. Although the participants expressed positive attitudes toward developing this care, with acknowledgement of the current limitations stakeholders of all groups were reluctant to endorse the introduction of penile transplantation for transgender men at this point.

Clinical Implications

Under the present circumstances, all groups expressed both a wide variety of ethical considerations as well as a tendency to prefer developing alternative treatment options or improving the results of currently available treatments in relation to penile transplantation for transgender men.

Strengths and Limitations

This study was the first (empirical) study to focus on this topic and included a diversity of stakeholder perspectives. Limitations included the hypothetical nature of the discussion as well as the clinical setting in which the topic has been studied.

Conclusion

Introducing penile transplantation for transgender men, under the current circumstances, comes with a wide range of ethical considerations, which deal with personal identity, autonomy, medical risks, risk for transgender support and donor willingness, and issues regarding equality. Despite the present hesitancy to use penile transplantation, should the technical side of this treatment option develop, further research in the ethical field of penile transplantation for transgender men is recommended.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

Gender reassignment surgery - a narrative overview of anaesthetic considerations and implications

The twenty-first century, with its transforming ideology and rising acceptance, is witnessing an increased number of transgender people applying for gender reassignment surgery (GRS). The procedure of GRS is a lengthy and complex one involving the active collaboration of multiple disciplines including psychology, psychiatry, family medicine, plastic surgery, endocrinology, otolaryngology, urology, gynaecology, maxillofacial surgery, and anaesthesiology. The considerable paucity of literature regarding the management of patients presenting for GRS places health care providers at a disadvantage. It is imperative to cautiously regard the specific medical, emotional, social, and economic concerns regarding these patients. Health care providers need to be trained well to deal empathetically with such patients. The present literature about GRS deals mainly with the surgeon's perspective, while the anaesthetist's approach remains hazy. This is because GRS imposes the need for anaesthesiologists to search for better and more efficient modes of anaesthesia so as to improve prognosis and minimize the associated morbidity. Anaesthetists should understand the associated psychological aspects and effects of hormone therapy while performing an extensive and informative pre-operative evaluation to formulate an effective strategy. Providing the optimal modes for anaesthesia and keeping a cautious watch for complications along with timely intervention in the advent of the same comprise the approach for high-quality anaesthetic care. This review aims to provide a detailed overview of significant considerations and competent peri-operative outcomes in patients presenting for GRS.

Sacral Erector Spinae Plane Block for Gender Reassignment Surgery

The erector spinae plane block (ESPB) is an interfascial plane block that has been used to provide perioperative analgesia for a variety of indications. This case report describes the novel use of the sacral ESPB on a transgender patient undergoing male-to-female gender reassignment surgery for perioperative pain control. The sacral ESPB technique was described and post-operative pain score and opioid requirements were reported. The sacral ESPB was successfully used as an alternative to neuraxial, caudal, or peripheral nerve blocks for gender reassignment surgery.

Gender-Affirming Surgery for Transgender Individuals: Perceived Satisfaction and Barriers to Care

Purpose

The purpose of this study was to examine the perceived satisfaction and barriers to care for transgender patients after they decide to undergo gender-affirming surgery (GAS).

Method

A survey consisting of 21 multiple-choice and short-answer questions was distributed to transgender organizations and online forums across Canada and the United States. The data were then analyzed using descriptive statistics.

Results

There were 32 participants, 12 who identified as female to male and 20 as male to female. The mean age was 36 years, with a range of 18 to 81 years. The mean age of their first GAS was 33 years, and the range of wait time was 6 months to 7 years. Most of the participants received information about GAS from transgender websites and transgender surgery clinics (91% and 50%, respectively). Most participants (74%) felt like they had access to appropriate care and 89% felt like their surgeons provided enough information about GAS. There were 38% of participants who would change their experience with GAS. Participants stated several barriers toward receiving GAS: financial (73%), finding a physician (65%), and access to information (63%). Surgical transition was important to the quality of life for 91% of participants and 100% were happy with their decision to undergo GAS.

Conclusions

Transgender participants demonstrated that GAS is important to their quality of life and this study showed significant barriers to GAS.

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

INTRODUCTION

Gender dysphoria (GD) is a condition in which there is a marked incongruence between an individual's psychological perception of his/her sex and their biological phenotype. Gender identity disorder was officially renamed "gender dysphoria" in the DSM-V in 2013. The prevalence and demographics of GD vary according to geographical location and has not been well-documented in Ireland.

METHODS

We retrospectively reviewed medical records of 218 patients with suspected or confirmed GD referred to our endocrine service for consideration of hormonal therapy (HT) between 2005 and early 2014. We documented their demographics, clinical characteristics, and treatment during the study period.

RESULTS

The prevalence of GD in the Irish population was 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM), similar to reported figures in Western Europe. 159 of the patients were MTF and 59 were FTM, accounting for 72.9% and 27.1% of the cohort, respectively. The rate of referral has increased year-on-year, with 55 patients referred in 2013 versus 6 in 2005. Mean ages were 32.6 years (MTF) and 32.2 years (FTM). 22 of the patients were married and 41 had children, with 2 others having pregnant partners. 37.6% were referred by a psychologist, with the remainder evenly divided between GPs and psychiatric services. There were low rates of coexistent medical illness although psychiatric conditions were more prevalent, depression being a factor in 34.4% of patients. 5.9% of patients did not attend a mental health professional. 74.3% are currently on HT, and 9.17% have had gender reassignment surgery (GRS). Regret following hormonal or surgical treatment was in line with other Western European countries (1.83%).

CONCLUSION

The incidence of diagnosis and referral of GD in Ireland is increasing. This brings with it multiple social, health, and financial implications. Clear and accessible treatment pathways supported by mental health professionals is essential.

Sex Reassignment Surgery in the Female-to-Male Transsexual

In female-to-male transsexuals, the operative procedures are usually performed in different stages: first the subcutaneous mastectomy which is often combined with a hysterectomy-ovarectomy (endoscopically assisted). The next operative procedure consists of the genital transformation and includes a vaginectomy, a reconstruction of the horizontal part of the urethra, a scrotoplasty and a penile reconstruction usually with a radial forearm flap (or an alternative). After about one year, penile (erection) prosthesis and testicular prostheses can be implanted when sensation has returned to the tip of the penis. The authors provide a state-of-the-art overview of the different gender reassignment surgery procedures that can be performed in a female-to-male transsexual.