Prevalence of Gender Dysphoria in Southern Brazil: A Retrospective Study

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men

PURPOSE

While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition.

METHODS

In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months.

RESULTS

A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019).

CONCLUSION

Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

Medical care for transgender individuals at a hospital in southern Brazil: why do they drop out from our service?

Objective

The objective of the study was to investigate dropout rates and discern potential factors contributing to the discontinuation of treatment provided to transgender individuals by the Transdisciplinary Gender Identity Program at the Hospital de Clínicas de Porto Alegre (PROTIG).

Methodology

This study employs a descriptive, cross-sectional, retrospective design to analyze socio-demographic and clinical data obtained from medical records of patients treated at PROTIG between 2000 and 2018. A structured form, devised by PROTIG's professional team, was utilized to extract and evaluate several variables including: age, gender, education level, diagnosis of F64 according to the International Classification of Diseases (ICD-10: Version: 2010), clinical comorbidities (coded by ICD-10), laboratory diagnosis of sexually transmitted infections, distance between patients' residence and the hospital, and year of entry into PROTIG. The patient cohort was stratified into two categories based on their duration of attendance: dropout (defined as attendance for up to 365 days) and non-dropout (attendance exceeding 365 days). Categorical variables between dropout and non-dropout groups were compared using Pearson's chi-square test. Additionally, Poisson regression analysis was utilized, employing a 95% confidence interval (CI) and setting the significance level at 0.05.

Results

The study included a total of 888 patients accessing PROTIG, with 275 (31%) classified in the dropout group. Of the patient population, 65.5% (n = 582) self-identified as transgender women, while 34.5% (n = 306) identified as transgender men. Significant differences were noted between the dropout and non-dropout groups. Specifically, differences were noted among transgender women (p < 0.001), individuals with lower levels of education (p < 0.001), those with fewer diagnoses classified under ICD-10 as F64 (p < 0.001), individuals exhibiting fewer clinical comorbidities recorded in ICD-10 (p < 0.001), and those who commenced inclusion in PROTIG after 2010 (p < 0.001).

Conclusion

There exists a notable rate of treatment discontinuation among individuals receiving care at PROTIG, with statistically significant variances observed between groups. We posit potential rationales for this discontinuation, informed by care experiences and feedback from group attendees: Increased accessibility to outpatient services in our jurisdiction for Transgender Care, along with heightened societal awareness of gender identity fostering diverse gender expression avenues devoid of reliance on gender-affirming surgical interventions.

The influence of the severity of gender dysphoria on anxiety, depression, suicidal ideation, and non-suicidal self-injury in Chinese transgender, nonbinary, and gender-diverse youth

Background: Gender dysphoria (GD) is frequently reported among transgender, nonbinary, and gender-diverse (TNG) populations, and is closely related to anxiety, depression, suicidal ideation, and non-suicidal self-injury (NSSI). This study aimed to understand how GD influences the four mental health disparities among TNG youth, and to compare these outcomes depending on the severity of GD. Methods: 96,218 College students participated in the survey, of which the analysis was run on an extracted sub-set data of 2,315 (2.40%) TNG youth, with a mean age of 19.46 (SD = 1.52). Self-reported inventories measured sociodemographic factors, the severity of GD (Utrecht Gender Dysphoria Scale-Gender Spectrum), anxiety (seven-item Generalized Anxiety Disorder Questionnaire), depression (nine-item Patient Health Questionnaire), suicidal ideation (Suicidal Behaviors Questionnaire-Revised), and NSSI (Clinician-Rated Severity of Non-Suicidal Self-Injury Scale). Binary logistic regression assessed the association between significant GD and the four psychiatric disorders. Adjusted multiple logistic regression, and directed acyclic graph (DAG) analyses were conducted to explore the activating relationship among GD, sociodemographic factors, and psychiatric disorders. Results: 1,582 (68.30%) TNG youth who experienced significant levels of GD (total scores cutoff >= 46) were entered into the analyses. Binary logistic regression displayed significantly positive associations between significant GD and anxiety, depression, suicidal ideation, and NSSI. Multiple regression models showed risk factors included poor relationship with one's father/mother, tobacco smoking, alcohol consumption, and having a lower subjective social status. While family harmony, a higher father's educational level, and partaking in exercise were protective factors that exerted distinct impacts on these four psychiatric disorders. DAG findings showed a poor relationship with one's father with significant GD via other socio-demographic characteristics, activated psychiatric disorders. Conclusions: TNG youth with higher levels of GD also exhibited more severe anxiety, depression, suicidal ideation, and NSSI. Tailored interventions should be provided to prioritize relieving those with severe GD to protect TNG youth from psychiatric outcomes further.

Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012-2021)

BACKGROUND

International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities.

AIM

To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years.

METHODS

We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses.

OUTCOMES

Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities.

RESULTS

The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years.

CLINICAL IMPLICATIONS

The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice.

STRENGTHS AND LIMITATIONS

This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals.

CONCLUSION

Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one's gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.