Sexual behavior and sexual health of transgender women and men before treatment: Similarities and differences

The Need to Look at Transgender and Gender Diverse People's Health: A Preliminary Descriptive Report on Pain, Sexual Distress, and Health Profile of Five Transmasculine People and One Non-Binary Person with Endometriosis

The sexual health of transgender and gender diverse (TGD) people with endometriosis has been overlooked, and important emotional experiences, such as sexual distress and its correlates, have been ignored. This has prevented a more comprehensive look at the health experiences of TGD individuals. This descriptive online survey study preliminarily explored the experiences of pain symptoms, sexual distress, and mental health of N = 6 TGD individuals diagnosed with endometriosis. Descriptive results showed a mean delay of 10 years from the onset of symptoms to the diagnosis. Endometriosis-related pain was a common symptom, although with low to moderate intensity. Results also showed higher mean levels of pain impact, powerlessness and lack of control, somatization, depression, anxiety, and sexual distress, and lower mean levels of emotional well-being, social support, and worse self-image compared to reports on cisgender women with endometriosis in the literature. These results suggested that sexual and mental health in the context of TGD people with endometriosis has specificities and may be associated with factors that need to be accounted for to provide comprehensive and socially just healthcare, such as the recognition of the impact of endometriosis treatment on symptoms of gender dysphoria. To achieve sexual health equity for TGD people, continuous and updated professional training and inclusive research with multiple informants are necessary.

The behavioral component of sexual inhibition and its relation with testosterone levels: An fMRI study in transgender and cisgender individuals

Many transgender individuals report having difficulties with initiating and seeking sexual contacts. Relatively to cisgender individuals, transgender individuals are more likely to avoid sexual activity, indicating that the groups might differ in the neural underpinnings of the behavioral component of sexual inhibition. In this fMRI study, transgender (n = 33) and cisgender (n = 34) participants performed an Approach Avoidance Task (AAT) assessing sexual inhibition. We found that over the entire sample, the task elicited brain activation commonly associated with general and sexual inhibition, for instance in the bilateral insula, right inferior parietal lobule, and right inferior and middle frontal gyri. Upon investigating group differences between transgender and cisgender participants, we mainly found similarities in neural activation during the task. However, there were group differences in regions involved in decision making processes (left middle temporal gyrus) and sexual response inhibition (right anterior cingulate cortex and left inferior parietal lobule). In order to investigate whether these group differences were modulated by testosterone levels, we performed ROI-analyses assessing the relationship between testosterone and neural activation during the AAT (controlling for sex assigned at birth), but no correlations were found. On the whole brain level, however, we found that testosterone correlated positively with cerebral activation in the right claustrum (a region associated with sexual arousal) during the approach of sexual stimuli in the transgender group. Overall, these findings indicate that transgender and cisgender individuals mostly show similarities in their neural response to a sexual Approach-Avoidance task, and that testosterone levels are unlikely to play an important role.

Gender Dysphoria and Sexual Euphoria: A Bayesian Perspective on the Influence of Gender-Affirming Hormone Therapy on Sexual Arousal

Self-reported sexual orientation of transgender individuals occasionally changes over transition. Using functional magnetic resonance imaging, we tested the hypothesis that neural and behavioral patterns of sexual arousal in transgender individuals would shift from the assigned to the experienced gender (e.g., trans women's responses becoming more dissimilar to those of cis men and more similar to those of cis women). To this aim, trans women (N = 12) and trans men (N = 20) as well as cisgender women (N = 24) and cisgender men (N = 14) rated visual stimuli showing male-female, female-female or male-male intercourse for sexual arousal before and after four months of gender-affirming hormone therapy. A Bayesian framework allowed us to incorporate previous behavioral findings. The hypothesized changes could indeed be observed in the behavioral responses with the strongest results for trans men and female-female scenes. Activation of the ventral striatum supported our hypothesis only for female-female scenes in trans women. The respective application or depletion of androgens in trans men and trans women might partly explain this observation. The prominent role of female-female stimuli might be based on the differential responses they elicit in cis women and men or, in theory, the controversial concept of autogynephilia. We show that correlates of sexual arousal in transgender individuals might change in the direction of the experienced gender. Future investigations should elucidate the mechanistic role of sex hormones and the cause of the differential neural and behavioral findings.The study was registered at ClinicalTrials.gov (NCT02715232), March 22, 2016.

The Importance of Safely Prescribing Hormones in the Transgender Community

The transgender community is rapidly growing, necessitating further education and understanding of their unique healthcare needs. Gender affirmation is a multistep process, which generally begins with transgender individuals socially transitioning by adopting a new name, pronouns, and appearance changes, such as hair and clothing, to express themselves. Additional gender affirmation treatment can be achieved through medical therapy with hormones and surgical intervention. Here, we report the case of an 18-year-old transgender man who presented to his primary care provider for a referral to initiate a medical transition with testosterone therapy. The patient practiced penetrative vaginal sex without contraception. The patient presented to the clinic eight months later with amenorrhea, thick coarse facial and body hair, oily skin, irritable moods, and a 20-lb weight gain. A pregnancy test revealed a positive result. A healthy baby girl was delivered at 40 weeks' gestation. This case demonstrates the importance of addressing contraception during the masculinization process in individuals who continue to practice vaginal intercourse. Healthcare providers should seek to establish a clinical environment free of discrimination and stigma to allow patients to feel comfortable describing potential triggers of gender dysphoria. We encourage medical practitioners to discuss all methods of birth control with transgender male patients and choose the contraceptive that best allows for a seamless medical transition.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Breaking Healthcare Barriers for Transgender Individuals With Rare Tumor Presentation

Transgender persons can experience healthcare barriers and potentially suffer from preventable health disparities. Some challenges these individuals may face include the lack of provider education, social stigma, socioeconomic barriers to care, and insurance instability. Combating this problem requires systemic changes. Unfortunately, there are limited data on providers' perspective on taking care of transgender persons, and healthcare delivery systems are often unequipped to adequately manage these patients. This case presentation exemplifies many of these challenges. A 47-year-old transgender female with a history of testicular cancer, presented with bleeding from a lump on her neck. A computed tomography (CT) scan of the neck revealed a large mass suspicious of malignancy. Pathology identified metastatic colorectal adenocarcinoma. Esophagogastroduodenoscopy, colonoscopy, positron emission tomography scan, CT abdomen/pelvis, and serum tumor marker showed no evidence of a primary gastrointestinal malignancy. This presentation likely represents a late relapse of a residual, metastatic germ cell tumor with malignant somatic transformation. This case was greatly impacted by social determinants of health. The patient did not identify with her male anatomy, which delayed the detection of the initial testicular malignancy. In the post-operative period, the patient did not attend follow-up appointments to avoid discussing her male genitalia. When tumor relapse did occur, the patient experienced financial, insurance, and transportation instability; this delayed medical care and allowed the mass to grow to an extraordinary size.