Quality of Life and Body Image of Individuals with Gender Dysphoria

The effects of gender-affirming hormone therapy and mastectomy on psychopathology, body image, and quality of life in adults with gender dysphoria who were assigned female at birth

PURPOSE

Individuals with gender dysphoria (GD) may request hormone therapy and various surgical operations to change their physical characteristics. The present study aimed to investigate the effects of two treatments, mastectomy and gender-affirming hormone therapy (GAHT), on adults with GD who were assigned female at birth (GD AFAB).

METHODS

In this cross-sectional study, we gathered data from a total of 269 individuals in three groups: (a) untreated group (n = 121), (b) GAHT group (n = 84) who had been receiving treatment for at least 6 months, and (c) GAHT-MAST group (n = 64) who had been using GAHT for at least 6 months and had undergone mastectomy at least 3 months prior. All participants were asked to complete the Symptom Checklist-90-Revised (SCL-90-R), the Body Uneasiness Test (BUT), and the World Health Organization's Quality of Life Questionnaire- Brief Form, Turkish Version (WHOQOL-BREF-Tr).

RESULTS

We found that individuals in the untreated group had higher psychopathological symptoms and body uneasiness scores, and lower quality of life scores compared to both GAHT and GAHT-MAST groups. There was no difference in psychopathology between the GAHT-MAST group and the GAHT group, but body uneasiness scores were lower, and quality of life scores were higher in the GAHT-MAST group.

CONCLUSION

Our study suggests that individuals receiving GAHT improved mental health, body satisfaction, and overall quality of life. Combining mastectomy with GAHT may further enhance these benefits.

A Pilot Study on the Effect of Peer Support on Quality of Life of Adolescents with Autism Spectrum Disorder and Gender Dysphoria

Gender dysphoria (GD) and Autism Spectrum Disorder (ASD) co-occur relatively often, but there is no evidence-based treatment for this specific group. Therefore, we examined the effects of a group intervention for adolescents with ASD and GD in a pilot study with a pre-post-test design. The adolescents completed questionnaires on quality of life, self-esteem, gender dysphoric feelings, and social responsiveness. Results show that participating in this peer support group seems to increase aspects of quality of life, i.e., increased parent-reported psychological well-being and decreased psychological complaints. Even though more research is needed, these results indicate that peer support is an invaluable part of treatment for adolescents with ASD and GD.

Physical and psychosocial challenges of people with gender dysphoria: a content analysis study

BACKGROUND

The mismatch between the gender experienced by a person and the gender attributed to him/her leads to gender dysphoria. It seems that people's perception of gender dysphoria is affected by individual, cultural, and sociological factors and these factors affect different aspects of their biological, psychological, and social health. To this end, this qualitative study aimed to identify the physical, psychological, and social challenges of people with gender dysphoria referring to the Department of forensic medicine in Iran.

METHODS

This qualitative study was conducted using conventional content analysis on 9 individuals who were selected through purposive sampling. A total of 16 interviews were conducted with 9 participants. Each interview lasted 60-90 min. The participants' gender dysphoria was confirmed by the Department of forensic medicine. The data were collected through face-to-face semi-structured interviews with the participants.

RESULTS

The data revealed 3 main categories and 10 subcategories. The main categories were living in agony, confusion, and social concerns. The subcategories were annoying physical characteristics, mental suffering, disturbing sexual changes, concerns about public reaction, helplessness, surrender, the final solution, retreating to isolation, stressful family conditions, and lack of public recognition.

CONCLUSION

The findings showed that people with gender dysphoria suffer from some problems including living in agony, confusion, and social concerns. Each of these problems is associated with several challenges. It seems that most of the challenges faced by people with gender dysphoria are caused by unawareness of their conditions by the family and the public, which in turn is caused by the failure of related organizations and experts in this field to provide adequate information about the conditions of these people. Thus, the findings of the present study can have some implications for resolving the challenges faced by people with gender dysphoria.

A scoping review of research literature on eating and body image for transgender and nonbinary youth

BACKGROUND

Transgender and nonbinary (TGNB) adolescents and young adults are underrepresented in the literature on eating disorders and body image-related problems, despite increased mental health disparities and emerging research showing high associations between gender dysphoria, body image, and eating disorders among TGNB youth.

AIMS

The scoping review was designed to critically examine the research on TGNB adolescents and young adults who experience eating and body image related problems as well as clinical studies on treatment approaches and effectiveness.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this scoping review. The electronic databases of MEDLINE and PsychInfo were used for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for transgender minor children, adolescents, or young adult samples (18 to 25 years old) and address differences in eating/body-related problems by age. The relevant data was extracted and narratively summarized.

RESULTS

49 studies were identified, data extracted, and analyzed. Increased prevalence of eating disorders and body image problems were identified for TGNB youth. Body-gender congruence through gender affirming social and medical interventions (e.g., hormone therapy) were noted as significant for alleviating body image problems and facilitating eating disorder treatment. Family and social factors were not well understood in the literature and a need for increased study of TGNB youth from varied racial/ethnic, neurodiverse, and within specific identities (e.g., nonbinary) and families and cultural contexts is still needed.

CONCLUSIONS

Future research should consider the use of developmental and family theories for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, more studies are needed with those from minoritized racial and ethnic groups, neurodiversity, and varied gender identities (e.g., nonbinary and gender queer) for identifying important differences.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

A scoping review of the research literature on eating and body image for transgender and nonbinary adults

BACKGROUND

Eating disorder treatment approaches and outcome studies have historically centered almost exclusively on cisgender populations. Transgender and nonbinary (TGNB) adults are underrepresented in general and intervention research despite being at increased risk for eating and body image-related problems.

AIMS

This scoping review was designed to gather and examine the research with TGNB adults who experience eating and body image related problems, as well as clinical studies on the effectiveness of treatment approaches.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) was used for reporting this review. MEDLINE and PsychInfo were used as electronic databases for searching subject terms. Inclusion criteria for studies required the quantitative measurement or qualitative exploration of body image or eating for TGNB adults. The relevant data were extracted and summarized based on quantitative findings and qualitative themes.

RESULTS

After review of over 1258 articles, 59 studies met criteria and data were extracted and summarized. Factors associated with eating disorders and body image problems across studies suggests gender-affirming medical interventions are effective and emphasized treatment for an eating disorder is warranted alongside gender affirming medical care. Body image was associated with eating patterns aimed at meeting gendered ideals of body shape and size. There was variation in guiding theories and absence of consensus in the definition of transgender in the review studies. This likely demonstrates the changing language, social acceptance of TGNB people and identities, diagnostic criteria, and clinical conceptualizations of eating and body image.

CONCLUSIONS

Future research should consider the use of theory for guiding inclusion of salient social factors influencing eating patterns, body image, and treatment outcomes. In addition, future research is needed that centers on nonbinary and genderqueer populations, as well as those from minoritized racial and ethnic groups to inform culturally appropriate concerns, needs, and treatment modalities.

Young transgender individuals' lived experiences of facing life's challenges: a qualitative study in Iran

Introduction

In recent years, several studies have addressed the challenges and psychological issues that transgender individuals face. However, only a few studies have explored the experiences of this population in Iran. Life experiences are heavily influenced by the dominant religious and cultural conditions and common beliefs in a society. The present study aimed to investigate transgender individuals' lived experiences of facing life's challenges in Iran.

Methods

This is a qualitative study with a descriptive and phenomenological design conducted from February to April 2022. Data were collected using semi-structured, in-depth interviews with 23 transgender individuals (13 AFAB and 10 AMAB). The collected data were analyzed using Colaizzi's method.

Results

Analysis of the qualitative data resulted in the emergence of three themes and 11 subthemes. The three main themes included mental health disparities (fear of having one's secret revealed, depression and despair, suicidal thoughts, and secrecy in the family), gender dysphoria (contradictory gender identity and contradictory behaviors), and stigma and insecurity (sexual abuse, social discrimination, disrupted occupational performance, a lack of support, disrepute, and disgrace).

Conclusions

The findings of the study indicated that transgender people in Iran are exposed to considerable mental health disparities. In addition to disrepute, infamy, and stigma, transgender people face sexual abuse, social discrimination, and a lack of family social support. The results of the present study can help mental health experts and the healthcare system as a whole to adjust their mental and physical health programs according to the needs and experiences of transgender people and their families. It is recommended that future research address the problems and psychological challenges that transgender people's families have to confront.

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide: A Systematic Review

Importance

Gender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.

Objective

To identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.

Evidence Review

In this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).

Findings

In total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.

Conclusions and Relevance

In this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

Internalized transphobia predicts worse longitudinal trend of body uneasiness in transgender persons treated with gender affirming hormone therapy: a 1-year follow-up study

BACKGROUND

Given the relationship between interiorized stigma and body image, it could be hypothesized that high levels of internalized transphobia (IT) might predict higher levels of body uneasiness in subjects with gender dysphoria (GD) and worse improvement of body image after gender affirming hormone therapy (GAHT).

AIM

We sought to evaluate the relationship between IT and body uneasiness in subjects with GD and the role of IT in moderating the improvement of body image after GAHT.

METHODS

In total, 200 individuals with GD performed the baseline assessment; 99 were re-evaluated 12 months after starting GAHT. At baseline participants were evaluated through a face-to-face interview and filled self-administered questionnaires to evaluate GD (Utrecht Gender Dysphoria Scale [UGDS]), IT attitudes (Attitudes Toward Transgendered Individuals [ATTI] Scale), body uneasiness (Body Uneasiness Test, part A [BUT-A]), and general psychopathology (Symptom Checklist 90-Revised [SCL 90-R]). The same questionnaires, except ATTI, were readministered at follow-ups.

OUTCOMES

Outcomes were based on measures of the associations between IT and baseline characteristics of the sample, the longitudinal trends of GD, body uneasiness, and general psychopathology; and IT as a moderator of the longitudinal trend of body uneasiness.

RESULTS

At baseline, IT correlated with lower level of education, higher GD, and more severe body uneasiness. Longitudinal analyses showed significant improvements in GD, body uneasiness, and general psychopathology during GAHT. Moderation analysis confirmed that participants with more transphobic attitudes showed less improvement after GAHT with regard to body uneasiness (bTime*ATTI = -.002, P = .040). The Johnson-Neyman technique revealed that no significant improvement in body uneasiness was found for participants with ATTI scores lower than 71.14.

CLINICAL IMPLICATIONS

The presence of IT should be investigated in subjects with GD who require gender affirming treatments to provide specific interventions aimed at targeting this dimension.

STRENGTHS AND LIMITATIONS

Strengths of this study include the mixed cross-sectional and longitudinal design and the dimensional evaluation of the investigated constructs. Limitations include the small sample size and the limited follow-up. Furthermore, the effects of gender affirming surgery were not evaluated.

CONCLUSION

The association of IT with both baseline body uneasinessand the longitudinal course of this dimension highlighted the clinical significance of body uneasiness and the importance of making continuous efforts to improve education and information to fight societal stigmas.

The Effect of Gender-Affirming Hormones on Gender Dysphoria, Quality of Life, and Psychological Functioning in Transgender Individuals: A Systematic Review

Gender-affirming hormone therapy (GAHT) is an essential part of gender affirmation for many transgender (including people with binary and nonbinary identities) individuals and although controlled studies are unethical, there remains limited evidence on the impact of GAHT on gender dysphoria, quality of life (QoL), and psychological functioning. Some clinicians and policy makers use the lack of evidence to argue against providing gender-affirming care. The aim of this review is to systematically and critically assess the available literature on the influence of GAHT on improving gender- and body-related dysphoria, psychological well-being, and QoL. Using Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, we searched Ovid MEDLINE®, Embase®, and Ovid PsycINFO® from inception to March 6, 2019 to assess the influence of GAHT on (1) gender dysphoria, (2) body uneasiness, (3) body satisfaction, (4) psychological well-being, (5) QoL, (6) interpersonal and global functioning, and (7) self-esteem. Our search strategy found no randomized controlled trials. Ten longitudinal cohort studies, 25 cross-sectional studies, and 3 articles reporting both cross-sectional and longitudinal data were identified. While results are mixed, the majority of studies demonstrate that GAHT reduces gender dysphoria, body dissatisfaction, and uneasiness, subsequently improving psychological well-being and QoL in transgender individuals. However, all current researches are of low to moderate quality comprising longitudinal cohort studies and cross-sectional studies, making it difficult to draw clear conclusions and do not reflect external social factors unaffected by GAHT, which significantly impact on dysphoria, well-being, and QoL.

What is the evidence of effectiveness of non-pharmaceutical, non-surgical, biopsychosocial interventions for body image and pain management in individuals with endometriosis? A systematic review

Aim:

To identify and review the success of non-pharmaceutical, non-surgical biopsychosocial interventions in individuals with endometriosis, in managing pain and improving body image.

Methods:

Cochrane, EBSCO, IBSS, NICE, Open Grey, OVID, Proquest, Scopus and Science Direct were searched in April 2021, using inclusion and exclusion criteria.

Data collection and analysis:

Five randomised control trials, and one controlled clinical trial resulted from the search. Study quality was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool. Studies were synthesised by intervention type, into physical only, and physical and psychological.

Results:

Across the six papers, 323 participants were recruited, through medical records or self-referral, and treatments largely administered by specialist practitioners. From the EPHPP quality assessment,2 weak quality papers, and four moderate quality papers found improvements to pain, with large effect sizes in four papers. No studies used established body image measures to examine intervention effects on body image, and all lacked health psychology theoretical basis. There were common issues in selection bias, confounders and blinding.

Conclusion:

Without gold-standard methodology, evidence of effectiveness cannot be concluded. However, there is promising rationale if these issues are addressed.

Sexual and gender minority health in the Middle East and North Africa Region: A scoping review

Background

Researchers in studies from multiple countries suggest that sexual and gender minority people experience high rates of violence, stigma, and discrimination, as well as mistrust of health care providers and systems. Despite growing evidence related to sexual and gender minority health in North America and Europe, we know little about the health of this population in the Middle East and North Africa.

Objectives

We aimed to comprehensively examine the literature related to the health of sexual and gender minority people in the Middle East and North Africa and to identify research gaps and priorities.

Design

We conducted a scoping review informed by the framework recommended by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) tool.

Data sources

We searched the following databases: PubMed (using Medline All on the Ovid platform), PsycINFO (Ovid), CINAHL (Ebsco), and Embase (Ovid). The search strategy combined terms for the geographic region of interest (Middle East and North Africa) and the population of interest (sexual and gender minority). Each was operationalized using multiple search terms and, where available, controlled vocabulary terms.

Review Methods

Research articles were identified and assessed for inclusion using an explicit strategy. Relevant information was extracted and synthesized to present a descriptive summary of existing evidence.

Results

Research designs of the 98 articles we reviewed included quantitative (n = 73), qualitative (n = 20), and mixed methods (n = 5). Most studies were conducted in Lebanon (n = 33), Pakistan (n = 32), and Iran (n = 23) and focused mainly on gender minority individuals (n = 46) and men who have sex with men (n = 32). Five themes emerged from the review: sexual health (52; 53%); mental health (20; 20%); gender identity (17; 17%); violence and discrimination (7; 7%); and experiences with the healthcare system (2; 2%). Although researchers focused on multiple health outcomes in some studies, we included them under the theme most closely aligned with the main objective of the study.

Conclusion

Although our study is limited to few countries in the Middle East and North Africa region, we found that sexual and gender minority individuals face multiple adverse sexual and mental health outcomes and experience high rates of stigma, discrimination, and violence. More research is needed from countries outside of Lebanon, Pakistan, and Iran, including community-based participatory approaches and multi-level intervention development. Nurses and other healthcare providers in the region need training in providing inclusive care for this population.

Quality of Life, Self-Esteem, and Depression Among Thai Transgender Women Before and After Male-to-Female Gender Confirmation Surgery: A Prospective Cohort Observational Study

INTRODUCTION

Previous studies have reported low quality of life scores and a high prevalence of depression among transgender women in Thailand; however, there is still little research on the effects of gender confirmation surgery among this population.

AIM

This study aims to prospectively evaluate the overall quality of life, self-esteem, and depression status among male-to-female transgender individuals in Thailand.

METHODS

This prospective observational cohort study was conducted between January 2018 and December 2020 and included 41 participants who underwent gender confirmation surgery. All participants underwent a psychiatric evaluation and received 3 sets of questionnaires preoperatively and 6 months postoperatively to evaluate quality of life, self-esteem, and depression: the Thai abbreviated version of the World Health Organization quality of life questionnaire, the Rosenberg Self-Esteem Scale, and the Patient Health Questionnaire-9, respectively. We examined scores from each questionnaire and depression status before and after gender confirmation surgery, with P < .05 considered significant.

MAIN OUTCOME MEASURE

This study's primary outcomes measured quality of life, depression, and self-esteem before and after gender confirmation surgery.

RESULTS

Thirty-seven participants completed all sets of questionnaires (response rate 90.2%). The mean age of the participants was 26.2 ± 4.7 years at the time of surgery. Five (13.5%) participants met the criteria for mild depression preoperatively, but none did postoperatively. There were no signs of major depressive disorder, suicidal ideation, or suicidal attempts in any of the participants. There was a significant improvement in quality of life (P < .001) and self-esteem (P < .001), as well as lower depression (P < .001) after gender confirmation surgery. The greatest quality of life improvement was related to participants' sexual relationships.

CONCLUSION

Male-to-female gender confirmation surgery significantly contributes to improving quality of life, self-esteem, and depression in Thai transgender women. Persons diagnosed with gender dysphoria who intend to undergo gender confirmation surgery should be supported by healthcare providers in accessing the medical facilities and treatment needed to improve their quality of life. Chaovanalikit T, Wirairat K, Sriswadpong P. Quality of Life, Self-Esteem, and Depression Among Thai Transgender Women Before and After Male-to-Female Gender Confirmation Surgery: A Prospective Cohort Observational Study. Sex Med 2022;10:100533.

Priorities for a gender-sensitive sexually transmitted infections and human immunodeficiency virus (STIs/HIV) services: An exploratory mixed methods study

Background and Aim

Providing gender-sensitive health services is emphasized by the World Health Organization. This study aimed to assess and prioritize the needs for the gender-sensitive sexually transmitted infections/human immunodeficiency viruses (STIs/HIV) prevention services by a valid and reliable questionnaire.

Methods

This was an exploratory mixed methods sequential study in Shiraz Iran 2019. The first phase was a qualitative study on 37 providers and managers of the services who were recruited using the purposive and then snowball sampling method. In the second phase, following the content analysis of the qualitative data and a review of related literature, a questionnaire was developed and its psychometric properties were evaluated. Then, in the third phase, the questionnaire was used to assess and prioritize the needs through a quantitative descriptive cross-sectional study on all 290 providers of STI/HIV prevention services affiliated with Shiraz University of Medical Sciences.

Results

The finding of the qualitative phase showed gender-sensitive STI/HIV prevention services should provide gender-sensitive care and education by the trained personnel and manages with appropriate facilities and equipment. Providing these services also requires supportive policies, intersectoral cooperation, and community capacitation. In the second phase, a questionnaire was developed with 63 items. Assessment of psychometric properties of the questionnaire demonstrated the scale content validity index and ratio (S-CVI = 0.98 and S-CVR = 0.87, respectively), as well as the reliability of the questionnaire (internal consistency = 0.972 and intracluster correlation coefficient = 0.910). Results of the third descriptive phase of the study demonstrated the highest priorities for gender-sensitive education (92.01 ± 11.76%) and care services (92.11 ± 12.04%), respectively.

Conclusions

To improve the quality of the services, a gender-based education and care process, as well as a gender-sensitive structure, including gender-sensitive personnel, facilities, and management are necessary. Recognizing and meeting the needs for gender-sensitive services will improve the quality of the services.

Experiences of Life and Intersectionality of Transgender Refugees Living in Italy: A Qualitative Approach

Transgender refugees are at risk of experiencing increased minority stress due to experiences of trauma in their country of origin, and the intersection of multiple marginalized identities in their host country. Adopting a transfeminist and decolonial approach, the present study aimed at exploring transgender refugees' experiences of life and migration. A semi-structured interview protocol was developed, grounded in the perspectives of minority stress and intersectionality. Participants were five transgender refugees (four women and one non-binary) from different cultural/geographic contexts, professing different religions. Using thematic analysis, the researchers identified three themes: pre- and post-migration minority stress and transphobia; religion as a protective factor for gender affirmation; and individuation and the synthesis of social identities. Participants reported traumatic experiences and the inability to openly live out their gender identity in their country of origin as the main push factors to migration. They also reported feelings of isolation and experiences of victimization during interactions with the Italian asylum services, due to a lack of adequate training, racial prejudice, and transphobia. Participants demonstrated positive individuation, linked to gender affirmation treatments and religious protective factors. The interview protocol may be used by social operators to support the claims of transgender asylum seekers, and to clinically assess transgender people with an immigrant background.

The relationship between postmenopausal women's body image and the severity of menopausal symptoms

BACKGROUND

Body image is the main element of an individual's personality that may be influenced by many factors during menopause. We aimed to assess the relationship between postmenopausal women's body image with the severity of menopausal symptoms.

METHODS

This was a cross-sectional study on 300 postmenopausal women, aged 45 to 65 years old, in Tehran, Iran. We recruited the samples using the multi-stage sampling method. Tools for data collection were: 1) the Menopausal Rating Scale (MRS), 2) the Fisher's Body Image questionnaire and 3) a socio-demographic questionnaire. We analyzed data using the independent samples t-test, Pearson correlation coefficient, Spearman's correlation coefficient, and multiple linear regression tests.

RESULTS

Three hundred women aged 55.11 ± 3.99 years old, participated in the study. Mean scores for body image and MRS were 163.07 ± 21.17 (Range: 46-230) and 16.45 ± 8.38 (Range: 0-44), respectively. About 50% of women had severe symptoms of menopause (MRS score ≥ 17). There was a negative correlation between the total score and the score of all dimensions of body image with the total score and all dimensions of MRS (P < 0.001). There were also significant relationships between women's body image with: their education (P < 0.001, r = 0.20) the spouse's education (P < 0.001, r = 0.26), adequacy of monthly household income (P < 0.001, r = 0.32), marital status (P = 0.36), their occupation (P = 0.007) and housing status (P = 0.012). There was also a significant negative correlation between women's lower body organs image with the number of children (P = 0.017, r = - 0.14). According to the multiple linear regressions model, severity of menopausal symptoms (Beta = - 0.45, P < 0.001) and adequacy of monthly household income (Beta = 0.15, P = 0.005) are the significant related factors with postmenopausal women's body image.

CONCLUSIONS

Body image is correlated with menopausal symptoms of women during menopause. Therefore, it seems that interventions aimed at relieving the annoying symptoms of menopause can help to improve their body image. Also, body image could be influenced by some socio-demographic factors which should be considered in menopause health promotion programs.

Quality of Life and Perceived Social Support Before and After Sex Reassignment Surgery

This study aimed to explore the pre- and postoperative differences in quality of life and perceived social support of Female-to-Male transsexual patients who underwent mastectomy and complete hysterectomy. Sixty-three Female-to-Male female individuals who underwent complete hysterectomy and mastectomy between November 2019 and November 2020 were included in this study. Data were collected using the Personal Information Form, Multidimensional Scale of Perceived Social Support, and the World Health Organization Quality of Life Scale Short Form. The pre- and postoperative perceived social support mean scores of patients were 57.2 ± 9.0 and 74.9 ± 7.3, respectively. The pre- and postoperative quality of life mean scores of patients were 76.9 ± 8.3 and 107.8 ± 10.1, respectively. There were statistically significant differences between the measurements (p < .05). In addition, the patients whose education level was primary school, whose income was less than their expenditure, whose father was a primary school graduate, whose family had a strict family opinion on sexuality, whose family had a traditional view, and who had a high body mass index were found to have higher postoperative social support perceptions and quality of life. The patients' postoperative quality of life and perceived social support improved after sex reassignment surgery.

Short-Term Effects of Gender-Affirming Hormone Therapy on Dysphoria and Quality of Life in Transgender Individuals: A Prospective Controlled Study

Background

Gender affirming hormone therapy (GAHT), whilst considered the standard of care in clinical guidelines for the treatment of many transgender (trans) people is supported by low quality evidence. In this prospective longitudinal controlled study, we aimed to examine the effect of newly commencing GAHT on gender dysphoria and quality of life (QoL) over a 6 month period.

Methods

Adult trans (including those with binary and/or non-binary identities) people newly commencing standard full-doses of masculinising (n = 42; 35 = trans masculine, 7 = non-binary) or feminising (n = 35; 33 = trans feminine, 2 = non-binary) GAHT and cisgender participants (n=53 male, n=50 female) were recruited to participate in this longitudinal prospective study. This analysis of gender dysphoria measured by the Gender Preoccupation and Stability Questionnaire and QoL measured by the RAND Short-Form 36 Health survey at baseline, 3 and 6 months after commencement of GAHT was a prespecified secondary outcome. Dysphoria and QoL over time in those starting GAHT compared to cisgender comparison group matched for their presumed sex at birth is reported as the mean difference (95% confidence interval) adjusted for age.

Results

In trans people initiating masculinising GAHT, there was a decrease in gender dysphoria with adjusted mean difference -6.80 (-8.68, -4.91), p < 0.001, and a clinically significant improvement in emotional well-being [adjusted mean difference 7.48 (1.32, 13.64), p = 0.018] and social functioning [adjusted mean difference 12.50 (2.84, 22.15), p = 0.011] aspects of QoL over the first 6 months of treatment relative to the cisgender female comparison group. No significant differences were observed in other QoL domains. In trans people initiating feminising GAHT, there was a decrease in gender dysphoria [adjusted mean difference -4.22 (-6.21, -2.24), p < 0.001] but no differences in any aspects of QoL were observed.

Conclusions

In the short-term, our findings support the benefit of initiating masculinising or feminising GAHT for gender dysphoria. Masculinising GAHT improves emotional well-being and social functioning within 6 months of treatment. Multidisciplinary input with speech pathology and surgery to support trans people seeking feminisation is likely needed. Further longitudinal studies controlled for other confounders (such as the presence of social supports) contributing to QoL are needed.

[Quality of life after gender reassignment surgery: an overview]

BACKGROUND

 As has been proven by numerous studies, people with gender identity disorders have a reduced quality of life. Considerable psychological strain leads to depressive and anxiety disorders and increased suicidal tendencies compared with the normal population. In addition, social limitations reduce the quality of life. More and more transsexual people use the possibility of undergoing gender reassignment surgery. However, this surgery means a radical change in a patient's life. This work aims to analyse whether surgical interventions help to improve the quality of and satisfaction with life of transmen and transwomen in a long-lasting way.

METHODS

 A systematic literature search was conducted using the PubMed, Embase and Cochrane Library databases. Our analysis only included original retrospective or prospective studies concerning the quality of life after gender reassignment surgery.

RESULTS

 Twenty-seven studies were included. Quality of life was analysed retrospectively in 20 studies and prospectively in 7 studies. Four publications studied only transmen, 11 studied only transwomen, and 12 studied both. The totality of all studies examined 1849 transwomen and 869 transmen. Changes in quality of life were measured by different validated questionnaires. A significant improvement in quality of life was shown in the subareas mental, physical and social health. It was proven that patients were more satisfied with their own bodies and genders and had a higher quality of life in general.Even after gender reassignment surgery, the rates of mental disorders and mortality remained increased. Compared with the normal population, the quality of life of transsexual people was reduced.

CONCLUSION

 Numerous studies have proven that gender reassignment surgery helps to reduce the level of suffering in transmen and transwomen. Satisfaction with life, mental and physical health as well as social life improve after surgical treatment combined with endocrinologic and psychological treatment. However, compared with the normal population, the quality of life of transsexual people lags behind.

Psychosocial Differences Between Transgender Individuals With and Without History of Nonsurgical Facial Injectables

BACKGROUND

Considerable research has explored psychosocial characteristics of individuals who seek aesthetic procedures as well as psychological changes experienced after successful treatment. Little research, however, has explored the experiences of transgender individuals who have undergone nonsurgical injectable procedures (NSIPs).

OBJECTIVES

This study examined theoretically relevant psychosocial characteristics of transgender individuals who have and have not undergone NSIPs.

METHODS

An online survey of demographic and psychosocial constructs was disseminated through transgender-specific support groups and Facebook groups from December 2019 to February 2020. Psychosocial measures included self-esteem (Rosenberg Self-Esteem Inventory), anticipated discrimination (Intersectional-Anticipated Discrimination), gender identity and physicality congruence (Transgender Congruence Scale), body image (Body Image Quality of Life Inventory), and overall satisfaction with facial appearance (FACE-Q Face Overall). The Mann-Whitney U test assessed differences by history of NSIPs, and the Kruskal-Wallis test assessed gender and racial differences. A P-value of <0.05 was considered significant.

RESULTS

Participants (N = 101) were transfeminine (n = 58), transmasculine (n = 31), gender-diverse (n = 12), and mostly (71%) white. Almost two-thirds of respondents (62%) reported using NSIPs; 6 participants reported undergoing NSIPs from non-licensed providers. History of NSIPs was associated with greater self-esteem (P < 0.01), less anticipated discrimination (P < 0.01), greater physicality and gender identity congruence(P < 0.001), greater body image quality of life (P < 0.001), and greater satisfaction with overall facial appearance (P < 0.01).

CONCLUSIONS

Use of NSIPs was associated with more positive psychosocial symptoms. Experiences with NSIPs may play an important role in psychosocial functioning for transgender individuals.

LEVEL OF EVIDENCE 3

Evaluating Patient Benefit From Laryngochondroplasty

OBJECTIVES/HYPOTHESIS

To elucidate and review current literature on the surgical technique for laryngochondroplasty in male-to-female transgender patients. To determine the degree of benefit afforded to male-to-female transgender patients by laryngochondroplasty using the Glasgow Benefit Inventory (GBI).

STUDY DESIGN

Retrospective case series.

METHODS

After institutional review board approval was obtained, the GBI survey was given to patients who underwent laryngochondroplasty by the author. Demographic information was analyzed including age, race, wait time to surgery, distance traveled, median zip code income, and concomitant gender-affirming surgeries such as vaginoplasty, breast augmentation, or facial feminization.

RESULTS

From April 2016 to April 2020, 209 patients received laryngochondroplasty within the Kaiser Permanente Northern California Medical System. Of those, 91 received laryngochondroplasty with the author and were given the GBI, with 73 patients (80%) responding. Patients were on average 31.4 years old, traveled 45.4 miles to the surgical site, lived in a zip code with a median income of $86,793.61, and waited 95.7 days for surgery. Patients had a statistically significant improvement in all three subscores (general, social, and physical) of the GBI as well as in their overall score.

CONCLUSIONS

Laryngochondroplasty is a safe and effective procedure to reduce thyroid cartilage prominence (Adam's apple) in male-to-female transgender patients. There was a statistically significant improvement in the overall score and all subscores of the GBI after laryngochondroplasty LEVEL OF EVIDENCE: 4 Laryngoscope, 130:S1-S14, 2020.

A very rare case of delayed catastrophic arterial bleed post-vaginoplasty

The gold standard for male to female genital reconstruction in the UK is vaginoplasty with penile and/or scrotal skin for neovagina formation. We present a rare case of a major haemorrhage in a 46-year-old patient, 26 days post-vaginoplasty. An urgent computed tomography scan identified a large retrovesical collection, with high-density contents in keeping with recent haemorrhage, containing a 6mm pseudoaneurysm within the right lateral wall. Following resuscitation, the patient was urgently treated with successful embolization of the feeding artery (branch of the prostatic artery), with pushable coils. We highlight the importance of expedient, life-saving management in a rare post-operative complication.

Body Image Concern and Gender Identities between Transgender and Cisgender Persons from Iran

The aim was to compare body image concern and gender identities between post-operative transgender and cisgender persons. Participants included 48 transgender persons (25 trans men, 23 trans women) and 48 cisgender persons (24 cismen, 24 ciswomen). The data were collected with Littleton's Body Image Concern Inventory and the Singapore Androgyny Inventory. Results showed that body image concern was significantly higher in transgender participants compared to cisgender participants, and these scores were especially higher in trans women compared to other groups. Furthermore, trans women scored higher in the femininity subscale compared to ciswomen. Body image concern was also higher in participants with feminine gender identity compared to participants with masculine gender identity (whether they were transgender or not). Moreover, transgender persons with traditional gender identity had higher scores in body image concern in comparison to those who had nontraditional identities, as well as trans men had more Androgynous or undifferentiated identities than trans women. We also found a significant correlation between feminine subscale and body image concern. Based on our results, it seems hormonal and surgical treatments in transgender persons only can eliminate body dissatisfaction to a certain extent. The higher scores of trans women, both in body image concern and femininity, indicate that it may be harder for trans women to believe they are perceived as female by others and their bodies are adequate. Changing cultural beliefs, social values, and increasing social acceptance with the help of the media may play an important role in improving body image in the future.

Orchiectomy as Bridge or Alternative to Vaginoplasty

Simple orchiectomy for gender affirmation is a low-risk, minimally invasive, generalizable procedure that eliminates circulating endogenous testosterone, allowing reduced hormonal supplementation. This article describes a technique that serves as a step in definitive phenotypic transition while maximally preserving healthy tissue for future sex reassignment surgery. Orchiectomy should be offered routinely as a bridge or alternative to vaginoplasty, particularly in the setting of limited access to specialized centers for transgender surgery.

A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS.