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

Surgical outcomes after gender-affirming hysterectomies: a consecutive case series of 72 patients

BACKGROUND

Hysterectomy is a significant component of gender-affirming treatment for transgender individuals. The choice of surgical technique and associated complications have been studied, but very few studies have used a standardised classification system to grade surgical complications. This study aimed to describe our hospital's experience on gender-affirming hysterectomies with regards to patient demographics, surgical techniques, and postoperative complications using a validated classification system.

METHODS

The study is a prospective follow-up case-series study of 72 consecutive patients undergoing gender-affirming hysterectomy at Karolinska University Hospital between 2016 and 2023. Patient demographics (age and mean body mass index), tobacco and alcohol habits, medical history and comorbidities, route of hysterectomy, complications and 30-days postoperative outcomes were reported. Surgical complications were graded according to the Clavien-Dindo classification system.

RESULTS

The study population, with an average age of 27.6 years, presented diverse medical conditions, with psychiatric diagnoses being the most prevalent. The most common procedure was total laparoscopic hysterectomy, with low intraoperative blood loss. Surgical complications were rare, and primarily required minimal interventions. The 30-day Clavien-Dindo postoperative complication rate of grade II or higher was 19%, although only 4% experienced complications necessitating re-surgery (grade III or higher). Postoperative follow-up emerged as a critical aspect, with 22% of patients seeking non-elective medical attention within the first month, often due to vaginal bleeding or abdominal pain.

CONCLUSIONS

Our findings support the safety and feasibility of gender-affirming hysterectomies, particularly when performed laparoscopically, with very few severe complications observed using a validated scoring system. Extensive follow-up care, as well as addressing common postoperative concerns, is essential. Despite a relatively small sample size and lack of a control group, this study provides valuable insights into transgender healthcare from a previously unstudied region. Future research should preferably include larger cohorts, multicentre and registry-based studies.

A Randomized Controlled Trial Comparing Testosterone Enanthate and Testosterone Undecanoate as a Gender Affirming Hormonal Therapy in Trans Males

OBJECTIVE

Testosterone is the only available gender affirming hormonal therapy (GAHT) for female-to-male (FtM) transsexuals, to alleviate gender dysphoria and to obtain desired masculinizing effects. The objective is to study the effect of two different formulations of testosterone- testosterone enanthate (TE) and testosterone undecanoate (TU) on various clinical, biochemical and hormonal parameters.

DESIGN

This is a prospective randomized controlled trial conducted over a period of 28 months in a Transgender multi-specialty clinic. Fifty-eight testosterone naive transgender men, randomized into two groups, 29 received TE and the remaining 29 received TU.

PATIENTS AND MEASUREMENTS

The variables assessed were cessation of menstrual cycles, onset of facial and body hair, deepening of voice, waist-to-hip ratio, clitoromegaly, muscle strength, hematological, lipid, liver functions and gonadal hormonal profile. The changes were compared at baseline, 6 months and 1 year following TE and TU and compared between the groups.

RESULTS

Both groups had desired masculinizing effects at the end of 1 year. There was a statistically significant increase in hemoglobin, hematocrit, LDL cholesterol and testosterone levels with a simultaneous decrease in HDL and estradiol levels at 1 year in both the groups with no statistical significance between the groups, despite the lesser number of injections received by TU group than TE group (6 vs. 18).

CONCLUSION

Both TE and TU is safe, effective and well tolerated GAHT among FtM transsexuals with no significant differences in clinical, biochemical and hormonal parameters. Testosterone undecanoate was preferred at the end of 1 year due to its long dosing intervals.

Current opinions invited review: testosterone and transgender medicine

PURPOSE OF REVIEW

Transgender individuals have a gender identity incongruent with their sex assigned at birth. Social, medical and surgical methods are often affirming. This review focuses on updates from the last 18 months mainly in testosterone use in masculinising gender-affirming hormone therapy (GAHT) in postpubertal adults, and also antiandrogens for suppression or blockade of endogenous testosterone in feminising GAHT. Mental and sexual healthcare are vital for many transgender patients, but are not the focus of this review.

RECENT FINDINGS

There has been a considerable increase in publications regarding testosterone GAHT in recent years, though narrative reviews, opinion pieces and case series continue to dominate. There has also been a notable increase in prospective studies and valuable data particularly from large longitudinal cohorts and studies aiming to refine GAHT prescribing and better understand long-term effects on aspects such as fertility, cardiometabolic and bone health as well as adverse effects.

SUMMARY

Testosterone GAHT is life changing. Increased research will help GAHT optimisation, and improve understanding of tissue-specific impacts and long-term safety. Longer-term data, prospective studies and utilisation of novel research tools and approaches are needed to enrich our understanding and prescribing of testosterone and its blockers in GAHT.

Fostering Equity: Assessing Access to Transgender Health Education in US Medical School Curricula

PURPOSE

Medical educators have increasingly advocated for the importance of training medical students in the care of transgender and gender diverse (TGD) patients, as the paucity of TGD-specific education among medical students may perpetuate inequities in care. However, little is known about medical students' current exposure to TGD care. The purpose of the study was to characterise the current exposure of TGD care within undergraduate medical education across the United States and Puerto Rico.

METHOD

Medical students from accredited allopathic (160) and osteopathic (60) medical schools in the United States and Puerto Rico were invited to participate in an anonymous survey between January 2024 and April 2024. The survey included questions relating to student exposure to several components of TGD care and their perceived importance of receiving such training.

RESULTS

In total, 461 students from 20 medical schools submitted at least partial responses to the survey. Overall, 68.2% (311/456) of students reported that their school's curriculum had explicit didactic training in the care of TGD patients, and only 33.0% (150/455) reported that their school's curriculum had explicit clinical training. Additionally, 78.4% (344/439) of students perceived receiving such training as very important after starting medical school.

CONCLUSIONS

While many medical students reported having explicit didactic training inclusive of TGD patients, clinical exposure is overall lacking. Most medical students endorsed the importance of training in the care of TGD patients. Medical school curricula should incorporate more dedicated didactic and clinical training in the care of TGD patients to better serve the TGD population.

Autistic and non-autistic transgender youth are similar in gender development and sexuality phenotypes

Increasing rhetoric regarding the common intersection of autism and gender diversity has resulted in legislation banning autistic transgender youth from accessing standard of care supports, as well as legislative efforts banning all youth gender care in part justified by the proportional over-occurrence of autism. Yet, no study has investigated whether autistic and non-autistic transgender youth present fundamentally different gender-related phenotypes. To address this gap, we extensively characterized autism, gender diversity, and sexuality among autistic and non-autistic transgender binary youth (N = 66, Mage = 17.17, SDage = 2.12) in order to investigate similarities and/or differences in gender and sexuality phenotypes. Neither autism diagnostic status nor continuous autistic traits were significantly related to any gender or sexuality phenotypes. These findings suggest that the developmental and experiential features of gender diversity are very similar between autistic and non-autistic transgender adolescents. Future research is needed to determine whether the similarity in profiles is maintained over time into adulthood.

Sexually Transmitted Infection Considerations for Transgender and Gender Expansive Persons

Transgender and gender expansive persons (TGE) are at increased risk for sexually transmitted infections (STIs) compared with other demographic groups and face barriers to health care access that may limit their ability to obtain testing and treatment. Herein, we highlight unique, yet vital, aspects of STI screening and treatment in TGE persons utilizing a gender-affirming care approach, including best practices for gender-inclusive care and special considerations for TGE persons who have undergone gender-affirming hormone therapy and/or surgery. Opportunities exist to improve sexual health in TGE persons, which can be achieved through culturally competent, gender inclusive STI testing and treatment.

Turkish physicians' approach to lesbian, gay, bisexual, transgender, and other gender and sexual minority individuals and their sexual health

Background

Lesbian, gay, bisexual, transgender, and other gender and sexual minority (LGBT+) individuals often face healthcare disparities, and physicians' knowledge, attitudes, and clinical preparedness significantly impact access to competent care.

Aim

This study evaluated Turkish physicians' perspectives, knowledge, and clinical approaches to LGBT+ sexual health, highlighting educational and clinical gaps.

Methods

A nationwide cross-sectional survey was conducted among physicians from 10 specialties involved in LGBT+ sexual health. The survey, administered anonymously via Google Forms between June 4, 2024, and February 1, 2025, included sociodemographic questions and items assessing attitudes, clinical experience, and guideline familiarity. Statistical analyses included descriptive statistics, chi-square, Fisher's exact tests, and binary logistic regression to identify predictors of physician attitudes and perceived competence.

Outcomes

The primary outcome was to assess physicians' perspectives, competency, and willingness to provide LGBT+ healthcare, including gender-affirming procedures.

Results

Among 745 participants, 58.8% considered LGBT+ identities normal, while 22.9% classified them as psychiatric disorders. Perceiving LGBT+ identities as normal was significantly associated with being female (OR = 3.12, 95% CI: 1.96-4.96, P < .001), prior experience treating LGBT+ patients (OR = 2.22, 95% CI: 1.60-3.07, P < .001), and physician specialty. This view was most common among psychiatrists (P = .012) and child and adolescent psychiatrists (P = .015). Physicians' views were primarily shaped by education (43.2%) and socio-cultural environment (40.9%). Although 63.9% had treated LGBT+ patients, only 28.2% felt competent, and 11.5% were aware of relevant guidelines. Only 18% of surgical specialists supported gender-affirming procedures. The most commonly cited reason for reluctance was lack of surgical experience (44.8%), along with concerns related to religious beliefs, absence of a surgical team, and potential surgical complications. Ethical dilemmas were evident, as 58.3% believed LGBT+ patients face discrimination in healthcare, and 21.9% supported a physician's right to refuse care based on personal beliefs.

Clinical Implications

Enhancing physicians' education and competency in LGBT+ healthcare through structured training and standardized guidelines is crucial to improving equitable healthcare delivery.

Strengths and Limitations

This study provides novel insights into physicians' attitudes and practices regarding LGBT+ healthcare in Turkey. However, self-reported data may introduce response bias, and findings may not be fully generalizable to other regions.

Conclusion

Significant educational and clinical gaps persist in LGBT+ healthcare. Addressing these through structured training programs, standardized protocols, and multidisciplinary collaboration is essential to ensuring competent, inclusive, and ethical medical care.

Transgender and gender diverse youths' experiences of healthcare: A systematic review of qualitative studies

Transgender and gender-diverse (TGD) populations are identified as high-risk for negative healthcare outcomes. Limited data exists on experiences of TGD youths in healthcare. The review aim is to systematically review literature on healthcare experiences of TGD youths. Seven electronic databases were systematically searched for relevant studies. Pre-determined eligibility criteria were used for inclusion with a double-screening approach. Sixteen studies were included. Studies included were quality appraised, data were extracted, and findings were synthesized narratively. Four narratives were identified including experiences of: accessing care, healthcare settings and services, healthcare providers, and healthcare interventions. Long waiting times, lack of competent providers, and fear were reported as challenges to accessing gender-affirming care. Negative experiences occurred in mental health services and primary care, while school counseling and gender clinics were affirming. Puberty blockers and hormone-replacement therapy were identified as protective factors. TGD youths are at risk of negative health outcomes due to an under resourced healthcare system. Further research is needed to assess interventions implemented to improve TGD youth's experiences.

Sexual Assault Nurse Examiner Knowledge and Confidence in Providing Care for Transgender Patients Following Sexual Assault

The transgender population experiences disproportionate rates of sexual assault (SA) compared with the cisgender population. Sexual assault nurse examiners (SANEs) have specialized education to provide care to victims of SA across the lifespan; however, training related to the care of transgender individuals following sexual assault is not always represented in SANE education. This leads to a lack of knowledge and confidence in providing care to transgender victims and can result in inequitable care and poor outcomes. To explore forensic nurses' knowledge and confidence in the care of the transgender population following SA, a descriptive, cross-sectional survey design was employed and distributed to two professional forensic nursing organizations. A total of 240 survey responses were received. The majority of participants reported that content related to transgender sexual assault (TGSA) was not part of their SA education. Nearly 60% perceived their knowledge and confidence in providing TGSA care as "beginner" or "developing" and almost all "agree" or "strongly agree" that additional TGSA education would be beneficial to them. As over half of participants have provided care to a TGSA patient and more than 80% expect to provide care in the future, it is imperative include standardized content related to TGSA care as part of core SANE curriculum and to offer continuing education to address the gap in current SANE TGSA knowledge and practice.

Transphobia in the United Kingdom: a public health crisis

Background

The moral panic surrounding trans, non-binary, and gender diverse (TGD) lives in the United Kingdom (UK) has been incited by high-level political and government actors and exacerbated by pervasive misinformation in social and press media. This hostile environment contributes to increasing interpersonal violence and social exclusion experienced by TGD people. Structural and interpersonal discrimination—conceptualised as minority stress—is understood to elicit physiological and psychological stress responses that predispose TGD individuals to a range of adverse health outcomes, including cardiovascular disease, and risk behaviours such as alcohol use.

Main body

Health disparities among TGD people in the UK are driven by a combination of minority stress, barriers to general healthcare, and disadvantage across multiple social determinants of health. Limited access to gender-affirming healthcare compounds these disparities, contributing to stark differences in morbidity and mortality relative to cisgender populations. Preventive healthcare engagement is also disproportionately low among TGD individuals, further exacerbating long-term health risks. The intersection of social exclusion, policy-driven discrimination, and systemic healthcare inequities places TGD people at significant and potentially increasing risk of poor health outcomes.

Conclusions

The health disparities faced by TGD people in the UK constitute a real-time public health crisis that demands urgent and sustained intervention. TGD people must be central to shaping the strategic direction of a coordinated and adequately resourced response to these harms.

Menstrual Dysphoria and Preferences for Menstrual Suppression in Transgender and Gender-Diverse Youth

INTRODUCTION

Menstruation can present a significant challenge for transgender and gender-diverse (TGD) individuals. While menstrual suppression can help alleviate this experience, research on the topic remains scarce. This study aimed to assess menstruation-related discomfort experienced by TGD individuals and to identify their preferences for menstrual suppression methods MATERIAL AND METHOD: This cross-sectional study was conducted between December 2021 and September 2023 with a sample of TGD individuals (n=21) aged 12-24, experiencing menstrual dysphoria. Participants completed an initial questionnaire assessing menstruation-related discomfort, followed by counseling on menstrual suppression options, including combined oral contraceptives, progestin-only pills, depot medroxyprogesterone acetate injection, levonorgestrel-releasing intrauterine device, and the etonogestrel implant. A second questionnaire evaluated factors influencing method preferences and documented the chosen suppression method. Descriptive statistical analyses were performed, with continuous variables presented as mean ± standard deviation and ordinal variables as numbers and percentages.

RESULTS

The conditions most frequently associated with severe discomfort related to menstruation were gender incongruence (81%), the carrying and use of menstrual products (95.2%), and the purchase of menstrual products (85.7%). The most popular method of menstrual suppression was combined oral contraceptives (63.1%). Several factors were identified as influencing the choice of method, including the estrogen content, frequency of use, and the necessity of a gynecological examination or visiting a different health facility.

CONCLUSIONS

The study underscores the considerable distress that menstruation can cause in TGD youth. Moreover, the importance of personalized, patient-centered counseling is emphasized, with the objective of empowering individuals to make decisions based on their specific needs.

Methods of family building used by sexual and gender minority adults in the United States

STUDY QUESTION

What methods are used by sexual and gender minority (SGM) parents to build their families?

SUMMARY ANSWER

SGM parents used diverse methods to build their families, which varied both by gender identity and age.

WHAT IS KNOWN ALREADY

Despite experiencing significant barriers to becoming parents, 63% of SGM adults aged 18-35 years old are considering having children or expanding their family. Data on US same-sex couples demonstrate that although most same-sex parents (68%) are genetically related to their children, they are more likely to adopt, foster, and be step-parents compared with different-sex couples.

STUDY DESIGN, SIZE, DURATION

Cross-sectional analysis of 2018-2020 data from The PRIDE Study, a community-engaged longitudinal cohort study of SGM adults living in the USA. This analysis included 2122 SGM parents with 4712 children (median of 2 children per parent).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Primary exposures were SGM subgroups (cisgender sexual minority men, cisgender sexual minority women, gender diverse people assigned female at birth [AFAB], gender diverse people assigned male at birth [AMAB], transgender men, and transgender women) and age cohorts (18-39, 40-54, and 55 and older). The primary outcome was method of family building, grouped into three overarching categories defined as (1) pregnancy from sexual activity, (2) pregnancy without sexual activity (e.g. use of donor gametes, surrogacy), and (3) a method other than pregnancy (e.g. adoption, fostering, step-parenting). We used logistic regression models to evaluate differences in methods of family building used by SGM subgroup and age groups.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, 56% of SGM adults became parents through pregnancy from sexual activity, 14% became parents through pregnancy without sexual activity, and 28% became parents from a method other than pregnancy. Transgender women, gender diverse parents, and cisgender men had a higher odds of using pregnancy through sexual activity to become parents and were less likely to become parents using pregnancy without sexual activity compared with cisgender women. Conversely, transgender men were less likely to use pregnancy through sexual activity (aOR 0.57, 95% CI 0.44, 0.73) and over twice as likely to use methods other than pregnancy (aOR 2.39, 95% CI 1.86, 3.06) compared to cisgender women. Parents aged 18-39 and 40-54 years old were twice as likely to use pregnancy without sexual activity compared with parents aged 55+ years old (Age 18-39: aOR 2.16, 95% CI: 1.55, 2.99; Age 40-54: aOR 1.92, 95% CI: 1.39, 2.66).

LIMITATIONS, REASON FOR CAUTION

Our convenience sample was predominantly White. We are unable to infer information about the preferred methods or attempted but unsuccessful methods of family building.

WIDER IMPLICATIONS OF THE FINDINGS

The number of SGM parents is likely to grow, given that younger generations are more likely to identify as SGM, desire children, and have access to medically assisted reproduction. Clinicians must be aware of the diversity of methods SGM parents used to become parents and the financial, legal, and institutional barriers that SGM people navigate when building their families.

STUDY FUNDING/COMPETING INTEREST(S)

Funding for this work was provided by the Stanford Maternal and Child Health Research Institute Seed Grant program to J.O.M. and S.L. and the Stanford University School of Medicine Department of Obstetrics and Gynecology. Research reported in this article was partially funded through a Patient-Centered Outcomes Research Institute (PCORI) Award [award number PPRN-1501-26848] to M.R.L. The statements in this article are solely the responsibility of the authors and do not necessarily represent the views of PCORI, its Board of Governors or Methodology Committee, or the National Institutes of Health. J.O.M. was partially supported by the National Institute of Diabetes, Digestive, and Kidney Disorders [grant number K12DK111028]. A.F. was partially supported by the National Institute on Drug Abuse [grant number K23DA039800]. The funding sponsors had no role in study design; the data collection, analysis, and interpretation of data; the writing of the report; the decision to submit the article for publication; or the preparation of the manuscript. Dr Obedin-Maliver has received grants and consultation fees from Ibis Reproductive Health, Hims and Hers Health Inc., Folx Health Inc., Sage Therapeutics and Upstream Inc. on topics unrelated to this work. Dr Lunn received consultation fees from Hims and Hers Health Inc., Folx Health Inc., Otsuka Pharmaceutical Development and Commercialization, Inc., and the American Dental Association on topics unrelated to this work. All other authors have no conflicts of interest to report.

TRIAL REGISTRATION NUMBER

None.

The Health Needs and Management of Young People Accessing Paediatric Hauora Tāhine (Transgender Health) Services in Te Tai Tokerau

AIMS

Gender diverse tamariki and rangitahi (children and young people) have unique medical care needs. It is essential that this group receives timely and individualised care, provided locally and includes access to psychological support. We sought to describe the health needs and management of young people accessing Paediatric Hauora Tāhine (Transgender Health) services in the Te Tai Tokerau region of Aotearoa (New Zealand).

METHODS

A retrospective review of referrals and secondary care records of all patients referred to Te Tai Tokerau General Paediatric Department for Hauora Tāhine care from 1 January 2020 to 30 June 2023. Medical management provided, time to first assessment, access to mental health support, and fertility counselling were described.

RESULTS

Forty-five young people living in this region received Hauora Tāhine care. Mean (range) age at referral was 13 (8-15) years. Ten (22%) were Māori. Twenty-seven (60%) had co-existing mental health diagnoses and 5 (11%) had had a previous suicide attempt. Fourteen (31%) had possible or confirmed autism spectrum disorder (ASD). Median (interquartile range) time from referral to first specialist appointment was 90 (53-157) days. All received psychological support. Fifteen (33%) did not require medical treatment to affirm gender identity. Twenty-one (68%) had pubertal suppression with Lucrin and 10 (36%) with other menstrual suppressants. Gender-affirming hormone treatment was prescribed to 11 (24%), who also had prior psychology assessment and fertility discussions.

CONCLUSION

Gender diverse young people require a range of treatments to support their gender identity. There is a high level of co-existing mental health needs and ASD in this group.

Self-Reported Health Care Disparities and Barriers Among LGBTQIA+ Individuals: Implications for Equitable Health Care Delivery

BACKGROUND AND OBJECTIVES

Nearly 24 million adults in the United States identify as LGBTQIA+, facing significant health disparities due to discrimination, structural barriers, and lack of culturally competent health care. This study explores health care disparities, barriers, facilitators, and the association of perceived discrimination on LGBTQIA+ health care.

METHODS

Participants were recruited from June 2023 to January 2024 using convenience sampling methods via LGBTQIA+ organizations and social media platforms. A total of 501 participants completed a REDCap survey, with 255 providing complete data. The survey queried demographics, physical and mental health, and health care utilization. Data analysis included descriptive statistics and CHERRIES guidelines.

RESULTS

Participants reported significant barriers to care, including being uninsured (22%), geographic distance (33%), fear of negative reactions (26%), and past trauma (23%). Discrimination in health care settings was reported by 83%, impacting access. High rates of homelessness (26%), food insecurity (73%), and chronic medical conditions (92%) were reported. Approximately 55% reported head trauma, 26% experienced intimate partner violence-related head injuries, and only 44% sought care for head injuries. Moderate depressive and anxiety symptoms were common, and 49% screened positive for possible PTSD.

CONCLUSIONS

This study highlights barriers to care reported by LGBTQIA+ individuals, emphasizing the need for culturally informed services. Addressing these disparities requires education, cultural humility, and systemic reforms to reduce disparities in health care for LGBTQIA+ individuals.

Cisnormativity and the frustration of core emotional needs among transgender and gender diverse individuals

INTRODUCTION

Cisnormativity is a sociocultural narrative that contributes to the marginalisation of transgender and gender diverse (TGD) people. The schema therapy model theorises that humans have five core emotional needs that must be met to support psychological well-being. Experiences of marginalisation may result in TGD people feeling as if their core emotional needs are not being met. Integrating the schema therapy model with an ecological systems perspective, this study aimed to examine how manifestations of cisnormativity across different levels of the social ecology impact the extent to which TGD people feel their core emotional needs are met.

METHODS

An online qualitative survey was completed by 101 TGD adults, and the data were analysed using reflexive thematic analysis.

RESULTS

Cisnormativity greatly impacted TGD people in ways that reflected the denial of numerous core emotional needs under the schema therapy model. The frustration of these needs was represented in four themes: disconnection and rejection; representation and reputation; suppressing and performing gender; and autonomy. The sources for these unmet needs were present across multiple levels of people's ecological systems.

CONCLUSION

Integrating an ecological systems perspective with the schema model demonstrated how the sociocultural context can directly and indirectly interfere with the meeting of core emotional needs. Some of the needs constructs demonstrated conceptual overlap, necessitating further investigation of the schema therapy model. This study documented the wide-ranging impacts of cisnormativity on TGD people, highlighting novel considerations that should be incorporated into the schema therapy model and models of TGD mental health and well-being.

A systematic review of developments in mHealth smartphone applications for Transgender and Gender Diverse individuals

Transgender and gender diverse (TGD) individuals face significant healthcare barriers, resulting in inequities and unmet needs. Mobile health (mHealth) applications offer promising solutions by providing accessible, cost-effective, personalized, and gender-affirming care. This systematic review, conducted using PRISMA 2020 guidelines and the PICO framework, screened 5005 records from 4 databases and included 11 articles. The review aimed to identify key features of mHealth apps developed for TGD individuals, focusing on theoretical frameworks, design strategies, and their approaches to addressing healthcare barriers. Key challenges in developing mHealth apps include implementing systemic changes in healthcare settings to combat stigma and discrimination, grounding app development in TGD-specific theoretical frameworks, adequately addressing stressors and protective factors, and overcoming methodological limitations that hinder the evaluation of health outcomes. Overcoming these challenges requires rigorous research methodologies, inclusive designs, reliance on evidence-based TGD frameworks, and stronger collaboration among researchers, healthcare providers, and TGD communities.

[Gender-Affirming Top Surgery for Gender Incongruence/Dysphoria: A Literature Review and Alignment with the New German S2k Guidelines on Mastectomy and Breast Augmentation]

"Top surgery", which refers to gender-affirming chest procedures, is one of the most common surgeries for individuals with gender incongruence (GI). These surgeries include breast augmentation or mastectomy and aim to align the physical appearance with gender identity. This review is based on the newly published German S2k guideline "Surgical Measures for Gender Incongruence" and offers a comprehensive overview of current breast surgery techniques and relevant literature.A literature analysis was conducted based on data from PubMed from 1973 to July 2024. The analysis included 122 studies on gender-affirming chest surgeries for individuals with GI. The core statements were extracted and summarized.Gender-affirming chest surgeries, including both breast augmentation and mastectomy, generally lead to significant improvements in the well-being of individuals. Breast augmentations often involve silicone implants or autologous fat grafting. Mastectomies for chest flattening aim to create a smooth, masculine-contoured or neutral chest while preserving nipple sensation. The choice of surgical technique largely depends on breast size, the degree of ptosis, and skin elasticity. Patient satisfaction with the surgical outcomes is consistently high, underscoring the importance of these procedures.This review provides a comprehensive overview of current surgical techniques for chest surgeries in individuals with gender incongruence. With the growing number of transgender and non-binary patients, clear surgical guidelines are increasingly important to meet the high demands and address complex anatomical challenges. The new German S2k guideline, developed by German experts from various participating disciplines, supports this need. The high patient satisfaction with surgical outcomes underscores the significance of these procedures for improving quality of life.

Muscle strength changes and physical activity during gender-affirming hormone therapy: A systematic review

BACKGROUND

Higher muscle strength is associated with improved overall health and lower mortality. Muscle strength changes during gender-affirming hormone therapy is possibly linked to gender-affirming hormone therapy modality, age at initiation, gender-affirming hormone therapy duration, and physical activity.

AIM

To review published literature on muscle strength changes during gender-affirming hormone therapy.

METHODS

Studies were included if they met the PICOS criteria; P: transgender individuals ≥18 years, I: gender-affirming hormone therapy, C: gender-affirming hormone therapy-naïve transgender persons or cisgender controls, O: muscle strength and physical activity in relation to muscle strength, S: prospective cohorts or cross-sectional.

RESULTS

Fifteen studies with data on 1206 transgender persons (722 transmasculine persons, median age 23-37 years and 484 transfeminine persons, median age 27-41 years) were included. Prospective design was used in eight out of 15 studies (two out of eight on transmasculine, two out of eight on transfeminine, and four out of eight on both) and seven out of 15 were cross-sectional (two out of seven on transmasculine, four out of seven on transfeminine, and one out of seven on both). Isometric elbow flexion/extension, lower body strength, and handgrip strength were assessed in one out of 15 studies, four out of 15, and 12 out of 15 studies, respectively. Bias rating was moderate to high.

PROSPECTIVE STUDIES

Masculinizing gender-affirming hormone therapy resulted in increased (four out of six studies) or unchanged (two out of six studies) muscle strength, while feminizing gender-affirming hormone therapy resulted in decreased (three out of six studies) or unchanged (three out of six studies) muscle strength. Muscle strength changes mainly occurred during the first year after initiating gender-affirming hormone therapy and age at initiation had no impact.

CROSS-SECTIONAL STUDIES

Transmasculine and transfeminine persons had higher strength compared with cisgender women, but lower strength than cisgender men. Physical activity was unchanged during gender-affirming hormone therapy in five out of prospective studies, while transfeminine persons were less physically active than cisgender men in five out of five prospective studies.

CONCLUSION

Muscle strength appeared to increase during masculinizing gender-affirming hormone therapy and decrease during feminizing gender-affirming hormone therapy, whereas physical activity was unchanged. Given high risk of bias, more research is necessary. Improving transgender care requires engagement of transgender persons in physical activity.

Puberty blockers for gender dysphoria in youth: A systematic review and meta-analysis

AIM

Gender dysphoria (GD) refers to the psychological distress associated with the incongruence between one's sex and one's gender identity. To manage GD, individuals may delay the development of primary and secondary sex characteristics with the use of puberty blockers. In this systematic review, we assess and summarise the certainty of the evidence about the effects of puberty blockers in individuals experiencing GD.

METHODS

We searched Medline, Embase, PsychINFO, Social Sciences Abstracts, LGBTQ+ Source and Sociological Abstracts from inception to September 2023. We included observational studies comparing puberty blockers with no puberty blockers in individuals aged <26 years experiencing GD, as well as before-after and case series studies. Outcomes of interest included psychological and physical outcomes. Pairs of reviewers independently screened articles, abstracted data and assessed risk of bias. We performed a meta-analysis and assessed the certainty of a non-zero effect using the grading of recommendations assessment, development and evaluation (GRADE) approach.

RESULTS

We included 10 studies. Comparative observational studies (n=3), comparing puberty blockers versus no puberty blockers, provided very low certainty of evidence on the outcomes of global function and depression. Before-after studies (n=7) provided very low certainty of evidence addressing gender dysphoria, global function, depression, and bone mineral density.

CONCLUSIONS

There remains considerable uncertainty regarding the effects of puberty blockers in individuals experiencing GD. Methodologically rigorous prospective studies are needed to understand the effects of this intervention.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42023452171.

Hemostatic parameters in transgender women receiving gender-affirming hormone therapy: A shift to a cisgender female pattern?

Transgender women have an increased incidence of venous thromboembolism (VTE) compared with cisgender individuals. However, data on hemostatic parameters in this population are scarce. We aimed to evaluate hemostatic parameters in transgender women receiving gender-affirming hormone therapy (GAHT) compared with cisgender controls. We conducted a cross-sectional study including 40 transgender women (sample size based on prior calculation), and age- and body mass index-matched cisgender women (n = 25) and cisgender men (n = 25) as controls. Blood samples were collected between 2016 and 2023. We assessed hemostatic parameters (plasminogen activator inhibitor-1 [PAI-1], free protein S, vascular cell adhesion molecule-1, antithrombin, anticoagulant protein C, prothrombin time activity, thrombin time), hormonal profile (estradiol, sex hormone-binding globulin, estrogen dose, total testosterone, and free androgen index), and inflammatory markers (fibrinogen, C-reactive protein, and leukocyte count). Transgender women (mean [SD] age, 30.6 [8.0] years; median GAHT duration, 36.5 months) and cisgender women had similar hemostatic and inflammatory parameters. Compared with cisgender men, transgender women had higher PAI-1 levels (p = 0.001) and lower free protein S levels (p = 0.023). No differences were found in other hemostatic parameters between the groups. In conclusion, transgender women on long-term GAHT had higher levels of PAI-1 and lower levels of free protein S than cisgender men, indicating a slightly more prothrombotic profile. However, their hemostatic and inflammatory parameters were similar to those of cisgender women, suggesting a shift towards a female pattern. Factors beyond GAHT may contribute to the increased risk of VTE in this population.

Review of venous thromboembolism (VTE) risk, evaluation, and treatment in individuals on estrogen-based gender-affirming hormone therapy

Epidemiological studies of transgender women suggest that these individuals experience higher rates of venous thromboembolism than their cisgender peers. Several factors likely increase this risk, including medication use, comorbidities, and social determinants of health. Estrogen-based gender-affirming hormone therapy is critical for helping patients address unwanted secondary sexual characteristics and induce physical changes in accordance with their gender identity. However, the use of estrogen-based gender-affirming hormone therapy may increase the risk of venous thromboembolism. This review article summarizes the current evidence describing venous thromboembolism risk among patients using various forms of estrogen, including transgender and cisgender individuals. The article also discusses strategies for managing venous thromboembolism in patients using estrogen-based gender-affirming hormone therapy and methods to reduce venous thromboembolism risk.

Use of gonadotropin-releasing hormone agonists in transgender and gender diverse youth: a systematic review

Introduction

Puberty suppression using gonadotropin-releasing hormone agonists (GnRHa) is a reversible medical intervention that halts endogenous puberty, allowing transgender and gender-diverse (TGD) adolescents to avoid the development of secondary sexual characteristics that may cause psychological distress. This pause in pubertal progression provides time to explore gender identity or facilitates alignment with affirmed gender in those with an established identity. While widely used, long-term evidence on the efficacy and safety of GnRHa in this population remains limited. This systematic review aims to synthesize current data on the benefits and potential risks of GnRHa in TGD adolescents.

Methods

We conducted a comprehensive literature search across PubMed, EMBASE, Cochrane Library, and other databases, covering studies published from February 2011 to February 2024. Eligible studies included adolescents under 18 with gender dysphoria or incongruence treated with GnRHa, reporting outcomes related to efficacy or side effects. Fifty-one studies met inclusion criteria, and data on physical health, mental health, bone density, fertility, and adverse events were extracted and assessed using the GRADE approach.

Results

Of the 51 studies, 22 were rated as moderate to high-quality evidence. GnRHa effectively suppressed puberty and secondary sex characteristics. Effects on growth and body composition varied; bone mineral density declined during treatment, particularly in AMAB individuals. Mental health improved significantly, including reduced depression, anxiety, and suicidality-especially when GnRHa was followed by gender-affirming hormone therapy (GAHT). Quality of life improved over time, while body dissatisfaction often persisted during suppression and improved after GAHT or surgery. No moderate- or high-quality evidence was found on fertility, sexual function, or cancer risk.

Conclusion

GnRHa is effective in halting puberty and improving mental health in TGD adolescents. However, key clinical and ethical considerations-such as bone health monitoring, fertility counseling, psychological support, and informed decision-making-must guide treatment. Long-term safety remains uncertain, particularly regarding skeletal health, reproductive outcomes and cancer risk. A precision medicine approach and co-produced longitudinal studies are essential to support safe, individualized care.

Systematic review registration

https://www.crd.york.ac.uk, identifier CRD42024528334.

XYGO: proposing a new holistic measure of gender identity and sexual orientation

Gender identity (GI) and sexual orientation (SO) are key aspects of an individual's sexual identity, which is a major driver of human sexuality. Although definitions for GI and SO have been long established and represented in clinical and theoretical research, often without acknowledgement of their relationship to one another, the ideal means by which they should be measured is unclear. Various tools for measurement have been proposed, each presenting different methodological approaches along with their respective flaws and issues. By providing a comprehensive overview of the major instruments for measuring GI and SO, the XYGO tool aims to integrate their strengths by developing a new, cohesive and inclusive perspective on sexual identity, taking into consideration both dimensions of this unique characteristic of human sexuality. This holistic perspective integrates these components into a single construct capable of providing a more immediate and tailored interpretation to facilitate everyday clinical practice and potentially improve research in sexual medicine and psychosexology.

Gender-Related Medical Experiences of Youth Who Have Detranstioned

People whose gender does not align with their sex assigned at birth can undergo a medical transition process, so their body reflects their gender. However, some people interrupt this process temporarily or permanently, which is often referred to as "detransition." Media coverage of detrans experiences tend to attribute this phenomenon to a lack of medical gatekeeping. However, research has shown detransitions are highly unpredictable. The aim of this article is to examine the medical experiences of youth who have detransitioned during various stages of the process from transition to today. Twenty-five interviews with 15-25-year-old youth who detransitioned were conducted. Thematic analysis led to the development of six themes: facing gatekeeping and invalidation during transition, accessing trans care, lacking adequate support during transition, finding support in detransition, lacking support in detransition, leaving the medical system. Our results question the usefulness of gatekeeping to prevent detransition and shows that it tends to erode the trust relationship between youth and practitioners and stifle gender exploration. Validation, support, information giving as well as exploration without constrain, or expectation of outcome seems to be a more helpful way forward to work with gender diverse youth.

The Role of Affirming Language

This Viewpoint discusses the ways in which clinicians can support transgender patients in the face of a growing number of antitransgender policies in the US.

Body Mass Index a Potential Risk Factor Following Gender Reassignment Surgeries: A Systematic Review and Meta-Analysis

AIM/BACKGROUND

This review aims to explore the intersection of two significant and timely medical topics: obesity and gender-affirming surgeries. It seeks to determine whether obesity is associated with a higher complication rate in patients undergoing various types of these surgeries.

METHODS

A systematic search was conducted using PubMed, Embase and Google Scholar to identify studies meeting the inclusion criteria for this review. Postoperative outcomes were the primary focus, with data analyzed to compare complication rates between patient groups.

RESULTS

The first meta-analysis, which compared complication rates based on different BMI ranges, revealed a statistically significant relationship between obesity (BMI ≥ 30 kg/m2) and increased postoperative complications. Specifically, obese patients experienced a higher complication rate compared to non-obese patients (BMI < 30 kg/m2). The final risk ratio (RR) was 0.46, with 95% confidence intervals (CI) of 0.23 to 0.70. The second meta-analysis assessed the mean BMI of patients who experienced at least one complication versus those who had a complication-free postoperative course. The overall outcome did not differ significantly from zero, indicating no strong connection between BMI and the presence of complications. The final mean difference (MD) was 0.18, with 95% CI ranging from - 0.10 to 0.47.

CONCLUSION

BMI is a relevant factor within the broader category of surgical risk factors that medical professionals should carefully consider. Previous systematic reviews and meta-analyses have consistently shown a higher frequency of operative complications in obese patients compared to their non-obese counterparts. Although the precise extent of BMI's influence remains uncertain, obesity should be regarded as a potential contributor to postoperative complications following gender-affirming surgeries.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Critically appraising the cass report: methodological flaws and unsupported claims

BACKGROUND

The Cass Review aimed to provide recommendations for the delivery of services for gender diverse children and young people in England. The final product of this project, the Cass report, relied on commissioned research output, including quantitative and qualitative primary research as well as seven systematic reviews, to inform its recommendations and conclusions.

METHODS

We critically evaluated the Cass report and the research that was commissioned to inform it. To evaluate the Risk of Bias within the seven systematic reviews commissioned by the Cass Review, we applied the ROBIS tool - a domain-based assessment of risk of bias within systematic reviews. It focuses on four domains (i) study eligibility criteria, (ii) identification and selection of studies, (iii) data collection and study appraisal, and (iv) synthesis and findings. To maintain rigour, the ROBIS tool was applied to each systematic review by two independent assessors, within Covidence, with conflicts resolved by an additional two independent assessors. We also conducted a detailed critical evaluation of the methods used in the survey of gender services for young people in Europe, the two quantitative studies of health records, and the qualitative study on the experience of gender dysphoria among young people and the claims made in the Cass report based on these studies.

RESULTS

Using the ROBIS tool, we identified a high risk of bias in each of the systematic reviews driven by unexplained protocol deviations, ambiguous eligibility criteria, inadequate study identification, and the failure to integrate consideration of these limitations into the conclusions derived from the evidence syntheses. We also identified methodological flaws and unsubstantiated claims in the primary research that suggest a double standard in the quality of evidence produced for the Cass report compared to quality appraisal in the systematic reviews.

CONCLUSIONS

We discuss these issues in relation to how evidence regarding gender affirming care is framed, the wider political context, and the future for gender affirming care. The Cass report's recommendations, given its methodological flaws and misrepresentation of evidence, warrant critical scrutiny to ensure ethical and effective support for gender-diverse youth.

Equality in Physical Activity and Exercise Opportunities for the Transgender Community

Environmental and social barriers in spaces designed to foster physical activity and exercise (PA&E) engagement can cause transgender individuals to feel unsafe or excluded. These can include fitness facilities and changing rooms, as examples, predominantly due to a lack of inclusivity. This stems from inadequate resources and education among PA&E professionals, facilities and staff, and healthcare providers. Unique considerations for transgender individuals helps create more safe and inclusive opportunities for health promoting engagement in PA&E. In this perspective the authors aim to provide context and guidance to enhance PA&E consideration for inclusion in this marginalized community. Collectively, this proactive approach ensures equal access to PA&E and fosters a supportive environment for transgender individuals.

Experience with gender affirming hormones and puberty blockers (gonadotropin releasing hormone agonist): a qualitative analysis of sexual function

BACKGROUND

Gender-affirming medical therapy (GAMT), including puberty blockers (PB) and gender-affirming hormone therapy (GAHT), is part of the transition for many transgender and nonbinary (TGNB) individuals; however, there have been few studies investigating sexual function and desire during GAMT, and no reports on individuals who received PB.

AIM

We aimed to qualitatively evaluate the sexual experience of TGNB individuals during GAMT and identify significant and consistent themes that arose from our analysis.

METHODS

We performed an Institutional Review Board-approved two-institutional study. Our study group (n = 63) included individuals who had received or were receiving puberty blockers (GnRHa) and/or GAHT (estrogen or testosterone) at the time of enrollment.

OUTCOMES

The enrolled subjects were interviewed using an open-ended topic-based guide, and qualitative analysis was performed by hand coding the interview transcripts using Constructivist Grounded Theory qualitative methods until thematic saturation was reached.

RESULTS

A total of 63 TGNB subjects (33 transgender women, 20 transgender men, 10 non-binary, or another gender identity), aged 18-25 years, were interviewed about the effect of GAMT on their sexual function and desire. Our analysis uncovered several themes that were consistent among subjects from different subgroups. Half the participants reported feeling no regrets regarding GAMT therapy, and the other half reported that they wished they had started GAMT sooner. Two notable themes were identified: many subjects reported "less dysphoria" as a positive change in sexual desire, and others reported more enjoyable sexual experiences since being on GAMT. The subgroup of subjects with a history of GnRHa use did not differ in their experiences and responses from the subgroup on GAHT alone, which indicated no negative effect of GnRHa on sexual function.

CLINICAL IMPLICATIONS

Our results illuminate the need for providers to discuss the potential impacts of GAMT on sexual function and desire with transgender and nonbinary patients.

STRENGTHS & LIMITATIONS

An important strength of this study is the open-ended interview design. This design allowed subjects to speak freely and openly about their experience. One limitation is a relatively small sample size, particularly of the puberty blocker (GnRHa) subgroup. A more robust sample is needed to further investigate the effect of GAMT on sexual function and desire in TGNB individuals, specifically those receiving GnRHa.

CONCLUSION

Themes were similar for all subjects; however, the most prominent theme among our subjects was that the positive changes in sexual function and desire outweighed any negative changes.

Defining Goals of Transfeminine Individuals Seeking Gender-Affirming Voice Therapy: A Qualitative Study

PURPOSE

The purpose of this study was to examine transfeminine individuals' goals for gender-affirming voice care and what they consider success in gender-affirming voice therapy.

METHOD

Fifteen transfeminine individuals completed semistructured interviews prior to commencement of gender-affirming voice care. Interviews explored individuals' voice goals, expectations for treatment, and desired treatment outcomes. Interviews were transcribed and analyzed by four speech-language pathologists with experience in gender-affirming voice using a grounded theory approach. Line-by-line, open, and axial coding were conducted to identify themes and subthemes.

RESULTS

Four dominant themes and 12 subthemes were identified from the interviews. Dominant themes included the following: (a) Individuals hope that voice therapy will reduce adverse voice-related experiences, (b) individuals expect successful voice therapy to facilitate specific voice goals, (c) individuals expect successful voice therapy to facilitate communication across varying contexts, and (d) individuals want specific guidance in voice therapy. Past adverse experiences included being misgendered or feeling isolated due to vocal function. Specific voice goals included having a voice that was perceived as more feminine, higher in pitch, and produced with less mental and phonatory effort. Participants hoped that success in voice therapy would facilitate occupational voice use, phone use, and interactions with strangers. They also expressed a desire for specific strategies or exercises to achieve desired voice changes.

CONCLUSIONS

Transfeminine individuals seeking gender-affirming voice training have specific goals and expectations for voice therapy, which are driven by past experiences, interactional partners, and communicative context. Future study should continue to clarify the manner in which patient experiences drive voice outcomes in this population.

Clinical characteristics of transgender patients with breast cancer: a single institution experience

Breast cancer presents unique complexities for transgender individuals. This retrospective study characterized breast cancers in 14 transgender and nonbinary patients treated at a specialized transgender health center from 2016 to 2023. Patients with a median age of 53 (31-65 years) were identified using international classification of disease-10 codes. Most (86%) were aged 40 or older and eligible for screening mammography. The cohort included 6 trans men, 7 trans women, and one genderqueer individual. Diagnoses included ductal carcinoma in situ (36%), lobular carcinoma in situ (7%), stage 1 (29%), stage 2 (21%), and breast implant-associated anaplastic large cell lymphoma (7%). Screening mammography diagnosed 29%, 43% presented with a mass, and 29% were detected during pre-surgical imaging. Half had estrogen-based gender-affirming hormone therapy (GAHT) and half testosterone-based, with mean GAHT durations of 16.6 years. Biomarker profiles revealed 67% estrogen receptor (ER)-positive and 33% ER-negative cancers. This study highlights underutilized screening mammography and diverse cancer subtypes in this underserved population.

Web-based gender affirming treatment decision aid for youth and caregivers: A pilot study

ABSTRACT

Transgender and gender diverse (TGD) youth and their caregivers, seeking gender affirming treatment (GAT) such as puberty blockers or hormone therapy, must understand complex medical information to participate in shared decision making. Decision aids are one method to provide treatment-based information and enhance shared decision making. This pilot study aimed to develop and evaluate the effect of a web-based decision aid on GAT in a pediatric gender care clinic. This cross-sectional, pre-, and postintervention design study included treatment-naive TGD youth aged 13-25 years or caregivers ( N = 10). Participants were evaluated for their knowledge, fertility attitudes, decisional conflict, and acceptability of the intervention. All participants had high mean GAT knowledge (7.8 [SD = 1.3] vs. 7.4 [SD = 1.8], p = .509) and low mean decisional conflict (18.1 [SD = 19.9] vs. 10.9 [SD = 12.9], p = .187) scores pre- and postintervention. The decision aid reduced decisional conflict in both youth and caregivers but had no change in knowledge scores. Many youth did not want children (66.7%) but felt it was important to learn about the effects of GAT on future fertility (100%). Most participants (80%) found that the decision aid was helpful for their decision-making process. Future testing is needed to evaluate its usefulness in a larger, more diverse sample.

The US Supreme Court Joins the Debate Over Gender Dysphoria

US v. Skrmetti is a legal case currently pending before the US Supreme Court that addresses the constitutionality of a Tennessee statute that prohibits gender-affirming medical care for transgender individuals who have not yet reached the legal age of adulthood, and who are diagnosed with gender dysphoria. Twenty-five other states have similar bans that apply to adolescents diagnosed with gender dysphoria, who are seeking treatment recommended by a physician and who are supported by their parents. Treatment involves gonadotropin-releasing hormone agonists, such as leuprolide or histrelin, which are approved by the Food and Drug Administration for use in children with central precocious puberty and are commonly prescribed off-label for adolescents. The purpose of puberty-blocking drugs is to suppress the onset of hormonal changes of puberty to facilitate the youth's anticipated transgender transition when the youth does reach the legal age of adulthood. Certainty about the time available for a youth to consider their gender identity, with the guidance of a professional support team, minimizes the risk of disruptive anxiety that's associated with near-term onset of sexual maturation involving development of irreversible secondary sex characteristics. This Commentary presents the legal arguments in the case and discusses relevant medical literature on this important issue in anticipation of the US Supreme Court's decision on the Tennessee law.

Traditional and individual care pathways in gender-affirming healthcare for transgender and gender-diverse individuals - results from the ENIGI follow-up study

Treatment requests in transgender healthcare are heterogenous and not all transgender and gender-diverse individuals want to undergo the various transition-related medical interventions offered. This study aims to explore demographic and treatment-related predictors associated with different transgender care pathways in a multicenter, multinational clinical setting. In this follow-up study, 539 adult participants from Belgium, Germany, and the Netherlands took part and were categorized as following a 'traditional' care pathway (i.e., undergoing all transition-related interventions), an 'individual' care pathway (i.e. any course of treatment deviating from the traditional pathway), or 'no care' pathway (i.e. not seeking transition-related medical interventions.). We analyzed differences in demographic (e.g., gender identity) and clinical variables (e.g., treatment satisfaction), conducting logistic regression analysis and descriptive subgroup analysis. Participants with a non-binary gender were 6.7 times more likely to follow an individual care pathway, while participants with higher treatment satisfaction were less likely to follow an individual care pathway (Odds Ratio: 0.6). We identified four patterns of individual transgender care pathways, some as a function of the sex assigned at birth. The present study provides valuable insights into demographic and treatment-related predictors associated with different transgender care pathways. Healthcare providers should be aware of individual transgender care pathways and the association with (non)-binary genders to provide tailored transgender healthcare and ensure individualized, high-quality service provision.

Underinvested, Under-Referred, and Underserved: Applying a Gender Equity Continuum Framework in Cancer Control Continuum Programs and Policies to Expand to Transgender and Nonbinary Populations

Gender-inclusive and gender-specific approaches are critically needed in cancer control continuum services to recognize and meet the needs of transgender and nonbinary (trans) populations. Current research, programs, and policies largely cater to cisgender populations and subscribe to a binary, gendered cisnormative ideology, both within health care systems and insurance policies, leaving trans people's cancer prevention and treatment needs neglected. Such disparities can be attributed to the significant gap in funding and research to address trans cancer prevention and treatment. We discuss the research, program, and policy implications of cisnormative practices and provide recommendations for promoting gender-inclusive and specific services across the cancer control continuum with the goal of eliminating cancer disparities and improving cancer outcomes for people of all gender groups, including trans populations.

Individualized and innovative gender healthcare for transgender and nonbinary youth

Increasing numbers of transgender and nonbinary youth are now accessing gender-affirming medical interventions, which have been demonstrated to improve health and well-being. This Perspective addresses how the needs of transgender and nonbinary youth, up to age 18, can be addressed through individualized gender-embodiment care. We first review standard medical therapies, including gonadotropin-releasing hormone analogues, 17β-oestradiol, testosterone, steroidal antiandrogens and progestins, followed by presenting novel approaches to individualizing gender healthcare for transgender and nonbinary youth, consisting of selective oestrogen receptor modulators, 5α-reductase inhibitors, aromatase inhibitors and non-steroidal antiandrogens. Ethical guidance for off-label prescribing is provided, grounded in the principles of evidence, benefit, safety, respect, care, communication, transparency, equity and innovation. These ethical principles are applied in three clinical scenarios in which off-label therapies are considered. We conclude that standard medical therapies are ethically justified and that novel therapies can be ethically acceptable when carefully considered in the context of an individual youth's care plan and taking into account the available theoretical, clinical and research evidence as well as the potential benefits and potential risks. In keeping with the principle of innovation, we encourage clinicians and researchers to share evidence of medical innovations that support the gender health of transgender and nonbinary youth.

Analgesic benefits of regional anesthesia in the perioperative management of transition-related surgery: a systematic review

INTRODUCTION

Transition-related surgery is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients is nuanced and potentially complicated by higher rates of mood and substance use disorders. Regional anesthetic techniques are known to reduce pain severity and opioid requirements; however, little is known regarding the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery.

METHODS

We performed a systematic review of the literature to evaluate original reports characterizing the analgesic effectiveness of regional anesthetic techniques for patients undergoing chest and/or genital transition-related surgery. Our primary outcomes were pain severity and opioid requirements on the first postoperative day.

RESULTS

Of the 1863 records identified, 10 met criteria for inclusion and narrative synthesis. These included two randomized controlled trials, three cohort studies, and five case reports/series, comprising 293 patients. Four reports described 243 patients undergoing chest surgery, of whom 86% were transgender men undergoing mastectomy with pectoralis nerve blocks or local anesthetic instillation devices. The remaining six reports comprised 50 patients undergoing genital surgery, of whom 56% were transgender women undergoing vaginoplasty with erector spinae plane blocks or epidural anesthesia. Three studies directly compared regional techniques to parenteral analgesia alone. Two of these studies reported lower pain scores and opioid requirements on the first postoperative day with nerve blocks compared with none while the third study reported no difference between groups. Complications related to regional anesthetic techniques were rare among patients undergoing transition-related surgery.

DISCUSSION

Despite the ever-growing demand for transition-related surgery, the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery is very understudied and insufficient to guide clinical practice. Our systematic review of the literature serves to underscore regional anesthesia for transition-related surgery as a priority area for future research.

Caring for the LGBTQIA+ Patient: A Best-Practices Primer on Language, Sexual Function Considerations, and Health Disparities in Gynecologic Care

Despite representing a growing percentage of the global population, queer patients (i.e., lesbian, gay, bisexual, transgender, intersex, and/or asexual; LGBTQIA+) continue to experience significant disparities in gynecologic healthcare. Common barriers to inclusive care include discriminatory healthcare experiences, difficulty finding identity-affirming providers, and systemic lack of competency in addressing queer-specific medical needs. Such barriers arise out of heteronormative assumptions, limited provider training, and insufficient understanding of diverse sexual and gender identities. This narrative review examines gynecologic care considerations for lesbian, gay, bisexual/pansexual, asexual, intersex, and transgender patients. We review research documenting how queer patients delay or avoid healthcare due to fear of judgment, discrimination, and inadequate provider understanding. Our review highlights unique healthcare needs across different queer identities, including inclusive and culturally-sensitive sexual health screening that includes (but is not centered solely on) queer-specific sexual practices; considerations for transgender patients undergoing gender-affirming care; and incorporating intersectionality into assessment, treatment planning, and delivery. Finally, we make direct recommendations for caring for queer patients, including developing inclusive intake processes; training healthcare teams in affirming, non-discriminatory practices; using gender-neutral language; recognizing the diversity of sexual and gender identities; and addressing minority stress and its impacts on health.

Changes in affect variability after starting gender-affirming hormone therapy

Negative affect variability is determined by how often and how strongly negative affect changes over time. Cisgender women report greater variability in affect than cisgender men. It has been suggested that sex hormone changes may influence affect variability. Transgender people frequently opt to use sex hormones in the form of gender-affirming hormone therapy (GAHT), but the extent to which GAHT can change negative affect variability is not yet clear. Therefore, this study aims to study changes in negative affect variability after starting GAHT. We have included data from 92 participants from the RESTED study: 47 persons starting masculinizing hormones (MH), i.e. testosterone, and 45 persons starting feminizing hormones (FH), i.e., estrogens and anti-androgens. Participants completed up to 7 consecutive daily diaries at each of three time points: before starting GAHT, and after 3 and 12 months of GAHT. The daily diaries collected participants' reports on symptoms related to negative affect: experienced low mood, less interest, tense feelings and restless feelings. We have used linear mixed models to compare negative affect variability during one week, corrected for mean negative affect, between groups (MH versus FH) and measurement time points. Results show that in the MH group, variability in tense feelings and restless feelings decreased after 3 and 12 months of GAHT, respectively. In the FH group, variability in low mood increased after 3 months and 12 months of GAHT, as did variability in restless feelings after 12 months of GAHT. Group comparisons indicate significant group differences in changes in variability in low mood and restless feelings, with stronger increases in variability of negative affect in the FH group compared to MH group after 3 and 12 months of GAHT. Our findings indicate that variability patterns in negative affect in transgender persons change after starting GAHT, with participants who start masculinizing hormones moving to a profile which more closely resembles that of cisgender men and participants who start feminizing hormones moving to a profile which more closely resembles that of cisgender women. Future studies should focus on measuring both negative and positive affect variability during GAHT, preferably through multiple measurements per day, taking into account diverse social and daily contextual factors during GAHT.

Access to Care in the LGBTQIA+ Population

Access to surgical health care for the LGBTQIA+ community is often limited by education gaps, systemic biases, and stigmatization. Sexual and gender minority (SGM) individuals, who face higher risks of certain health issues like cancer, mental health disorders, and STIs, often encounter barriers such as provider knowledge gaps and fear of prejudice. Addressing these challenges requires comprehensive education for both providers and patients, workforce development, and policy changes. Effective solutions include tailored health approaches, such as proper STI screenings, HPV vaccination, and affirming care practices. Expanding access to knowledgeable, inclusive providers and implementing supportive health care policies can improve health outcomes for SGM patients, ensuring equitable and patient-centered care.

Injectable Estradiol Dosing Regimens in Transgender and Nonbinary Adults Listed as Male at Birth

Context

Many transgender and nonbinary (TGNB) individuals assigned male at birth (AMAB) seek hormone therapy to achieve physical and emotional changes. Standard therapy includes estradiol, with or without an antiandrogen. Our clinical observations suggest that currently recommended injectable estradiol dosing may lead to supratherapeutic estradiol levels.

Objective

We sought to evaluate whether lower-than-recommended doses of injectable estradiol were effective in achieving serum estradiol and testosterone goals.

Methods

We conducted a retrospective cohort study to evaluate injectable estradiol dosing in treatment-naive AMAB individuals initiating hormone therapy. Data from a single provider at an academic center from January 2017 to March 2023 were analyzed. A total of 29 patients were eligible for inclusion. The primary variables of estradiol dosage, serum estradiol, and testosterone levels were analyzed over 15 months.

Results

The average estradiol dose decreased from 4.3 to 3.7 mg weekly (P < .001) during the study period with a final on-treatment estradiol level of 248 pg/mL. All individuals achieved a testosterone level of less than 50 ng/dL during the study period. The average initial on-treatment testosterone level was not significantly different from average final on-treatment measurement of 24.0 mg/dL (P = .95). Spironolactone use at study initiation was not associated with a lower initial on-treatment testosterone level, though it was associated with a lower estradiol level of 285 pg/dL compared to 427 pg/dL for those on estradiol monotherapy (P = .017).

Conclusion

Lower doses of injectable estradiol can achieve therapeutic estradiol levels with excellent testosterone suppression. Spironolactone was not associated with additional testosterone suppression and may result in lower estradiol levels.

Child Maltreatment, Mental Health Disorders, and Health Risk Behaviors in People With Diverse Gender Identities

This study examined rates of mental health disorders and health risk behaviors in people with diverse gender identities and associations with five types of child maltreatment. We used data from the Australian Child Maltreatment Study (ACMS), a nationally representative survey of Australian residents aged 16 years and more, which was designed to understand the experience of child maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, exposure to domestic violence). Mental disorders-major depressive disorder, generalized anxiety disorder (GAD), alcohol use disorder, post-traumatic stress disorder (PTSD), and health risk behaviors-smoking, binge drinking, cannabis dependence, self-harm, and suicide attempt in the past 12 months were assessed. People with diverse gender identities who experienced child maltreatment were significantly more likely to have GAD (43.3%; 95% CI [30.3, 56.2]) than those who had experienced child maltreatment who were either cisgender men (13.8%; [12.0, 15.5]) or cisgender women (17.4%; [15.7, 19.2]). Similarly, higher prevalence was found for PTSD (21.3%; [11.1, 31.5]), self-harm (27.8%; [17.1, 38.5]) and suicide attempt (7.2%; [3.1, 11.3]) for people with diverse gender identities. Trauma-informed approaches, attuned to the high likelihood of any child maltreatment, and the co-occurrence of different kinds may benefit people with diverse gender identities experiencing GAD, PTSD, self-harm, suicidal behaviors, or other health risk behaviors.

Fertility in transgender and gender diverse people: systematic review of the effects of gender-affirming hormones on reproductive organs and fertility

BACKGROUND

Transgender and gender diverse (TGD) people seek gender-affirming care at any age to manage gender identities or expressions that differ from their birth gender. Gender-affirming hormone treatment (GAHT) and gender-affirming surgery may alter reproductive function and/or anatomy, limiting future reproductive options to varying degrees, if individuals desire to either give birth or become a biological parent.

OBJECTIVE AND RATIONALE

TGD people increasingly pursue help for their reproductive questions, including fertility, fertility preservation, active desire for children, and future options. Their specific needs certainly require more insight into the effects of GAHT on gonads, gametes, and fertility. This systematic review aims to provide an overview of the current knowledge on the impact of GAHT on gonads, gametes, fertility, fertility preservation techniques, and outcomes.

SEARCH METHODS

This review was registered in the PROSPERO registry under number CRD42024516133. A literature search (in PubMed, Embase, and Web of Science) was performed with a medical information specialist until 15 November 2024.

OUTCOMES

In all TGD people using GAHT, histological changes have been reported.Using testosterone GAHT, ovarian cortical and stromal changes were reported by various studies. In most studies, persistent activity in folliculogenesis can be concluded based on the descriptions of the follicle count, distribution, and oocyte retrieval yield. However, there may be a negative effect on the fertilization rate in the presence of testosterone. Reports of successful ovarian stimulation, fertilization, pregnancies, and live births have been published, describing cases with and without testosterone discontinuation.After using oestrogen GAHT, testes are reported to be more atrophic, including smaller seminiferous tubules with heavy hyalinization and fibrosis. Spermatogenic levels varied widely from complete spermatogenesis to meiotic arrest with spermatids, to spermatogonial arrest, Sertoli cells only, or even tubular shadows. Oestrogen and anti-androgen treatment causes higher proportions of sperm abnormalities (i.e. low total sperm count, low sperm concentration, poor sperm motility) or azoospermia. However, after cessation, this may be restored.

WIDER IMPLICATIONS

Although knowledge of the effect of GAHT is growing, blind spots remain to be uncovered. Therefore, additional research in this specific population is needed, preferably comparing outcomes before and after the start of GAHT. This may help to reveal the pure impact of GAHT on reproductive functioning. Research suggestions also include investigations into the reversibility of the GAHT effect, especially for those who start transition at a young age. Looking carefully at the presented data on GAHT effects on gonads and gametes, the correct advice is to assess and reassess reproductive wishes and preferences repeatedly, and also to explore individual fertility preservation needs during gender-affirming treatment, given the expanding knowledge and therapy opportunities. Finally, concerns regarding long-term health outcomes and quality of life of children born by the use of gametes preserved after exposure to GAHT require prospective follow-up studies.

"I don't think I have been out of fight or flight. Ever." Transgender people's experiences in inpatient psychiatric treatment

BACKGROUND

Historically, marginalized groups have been deemed unwell and deserving of correction, resulting in disproportionate use of inpatient psychiatric institutionalization. Despite changes over the last hundred years, individuals from marginalized groups continue to experience poor treatment in inpatient psychiatric settings. Transgender people are marginalized in a society where it is assumed that all individuals exist solely as woman or man with predetermined roles influenced by innate biology based on their sex assigned at birth, i.e. gender essentialism. This contributes to mental health disparities (e.g., depression, anxiety, suicidal thoughts, and suicide attempts), which may result in higher acuity symptoms, leading to overrepresentation in inpatient psychiatric settings. Yet, little is known about transgender people's experiences during inpatient psychiatric treatment.

OBJECTIVE

To describe the experiences of transgender people in inpatient psychiatric treatment.

DESIGN

A qualitative descriptive study.

SETTING

Interviews were held in person or over Zoom.

PARTICIPANTS

Adults who self-identified as transgender and had been admitted to inpatient psychiatric treatment during the last five years were recruited to participate through community organizations, social media, and word of mouth.

METHODS

Semi-structured interviews were conducted between March 2019 and June 2022. Data were analyzed using thematic analysis.

RESULTS

Participants (N = 15) described experiences within inpatient psychiatric treatment. The first theme, gender essentialism causes stigmatizing experiences through structural and enacted power, was characterized by deliberate or accidental misgendering, gender treated as irrelevant to care, pathologized gender diversity, and withholding of gender-affirming needs. The second theme, psychological and emotional strain as the price paid for enforced gender essentialism, included examples of drained emotional resources, powerlessness, and worsening of gender dysphoria. Lastly, the theme actions in disruption of the structural gender essentialist power illustrated how the gender essentialist systems in place can be interrupted and resisted by transgender patients and healthcare professionals.

CONCLUSIONS

Power structures are embedded in psychiatric hospital policies and practices, as well as the physical layout of the hospital, operating under the assumption that all patients are either man or woman based on their sex assigned at birth. Healthcare professionals may unintentionally or deliberately reinforce these structures, further marginalizing transgender patients. Healthcare professionals have the opportunity to disrupt these harmful systems by advocating for and implementing changes that challenge gender essentialism. Creating care environments that incorporate gender diversity allows transgender individuals to focus on their mental health and recovery, rather than expending emotional resources navigating a system that overlooks or invalidates their identities.

SOCIAL MEDIA ABSTRACT

Inpatient psychiatric treatment reinforces gender essentialism, subjecting transgender patients to stigma and mistreatment. Participants described experiences of frequent misgendering, dismissal of gender-affirming needs, and emotional strain from navigating a system designed for non-transgender patients, leading to worse mental health symptoms, including gender dysphoria, and feelings of powerlessness. Healthcare professionals reinforce these harmful systems deliberately or unintentionally. However, instances of disruption by healthcare professionals and transgender participants were observed leading to the creation of affirming experiences despite the prevailing gender essentialism. Future opportunities to disrupt these structures include advocating for systemic change, engaging in patient-centered care, and developing inclusive policies. By creating inpatient psychiatric environments that accommodate gender diversity, healthcare providers could allow transgender patients to focus on their mental health and recovery, rather than combating stigma. Inclusive care can shift the focus from navigating systemic transphobia to healing.

"Creating ourselves:" A qualitative analysis of DIY HRT practices in nonbinary adults

Engaging in 'do it yourself' hormone replacement therapy (DIY HRT), including accessing hormones through non-medical pathways or self-altering one's prescribed dosage, is a common way trans people fulfill their transition-related needs. Although extant research has primarily focused only on binary trans populations, "DIYing" is particularly salient for those who are not seeking a binary transition. This paper shares findings from a qualitative, in-depth interview-based study with nonbinary adults who engage in DIY HRT practices and medical providers who prescribe HRT. Through participant's narratives, DIY HRT emerged as both a mode of knowledge production, a site of communal care, and a practice through which participants could support themselves and their communities and achieve bodily autonomy. These findings indicate that nonbinary trans people may opt to DIY due to systemic disinvestment in the production of knowledge and quality care within trans healthcare, choosing instead to engage with the wealth of knowledge and resources that exist in DIY HRT sites and communal care networks.

Clinicopathologic analysis and digital pathology evaluation of orchiectomy specimens in gender-affirmation surgery

Gender-affirmation therapies for transgender and gender diverse (TGD) individuals has been increasing in numbers in recent years. TGD patients usually undergo various forms of hormonal replacement therapy (HRT) followed by bilateral orchiectomy. We aimed to characterize the histological and biochemical alterations in these specimens. From 2018-2023, 63 TGD individuals undergone gender-affirming orchiectomy. Atrophic changes, decreased spermatogenesis, and reduced mean tubule diameter with basement membrane thickening, as well as maturation arrest and aspermatogenesis were identified. A subset of specimens (n = 81, 64.8 %) showed germ cell nucleomegaly with cytological atypia mimicking germ cell neoplasia in situ, and detailed digital pathology and immunohistochemical were performed to distinguish this finding from true neoplastic processes. To our knowledge, this is the largest single-center cohort of gender-affirming orchiectomy specimens.

No significant drug-drug interaction between oral TAF-based PrEP and feminizing hormone therapy among transgender women in Thailand: the iFACT-3 study

INTRODUCTION

Concerns regarding potential drug-drug interaction (DDI) between feminizing hormone therapy (FHT) and HIV pre-exposure prophylaxis (PrEP) may hinder PrEP use among transgender women. We assessed the potential DDI between FHT and emtricitabine-tenofovir alafenamide (F/TAF)-based PrEP among transgender women.

METHODS

Transgender women without HIV who never underwent orchiectomy were enrolled between January and February 2022. Oral FHT (oestradiol valerate 2 mg and cyproterone acetate 25 mg) was initiated at baseline and continued until week 9, while oral PrEP (F/TAF 200/25 mg) was initiated at week 3 and continued until week 12. Intensive blood sampling was performed at weeks 3 and 9 to assess the impact of PrEP on FHT; and weeks 9 and 12 to assess the impact of FHT on PrEP. Pharmacokinetics (PKs) of plasma oestradiol (E2), TAF, tenofovir (TFV) and emtricitabine (FTC); urine TFV and FTC; and tenofovir-diphosphate (TFV-DP) and emtricitabine-triphosphate (FTC-TP) in peripheral blood mononuclear cells (PBMCs) and rectal tissues were assessed.

RESULTS

Eighteen participants completed all PK visits. No significant differences in PK parameters for plasma E2, TAF and TFV were observed with FHT and F/TAF administration. The geometric mean of FTC AUC0-24 at week 9 was 9% lower than at week 12, but the 90% CI (0.88-0.95) remained within the 80-125% range. There were no significant differences in PBMCs and rectal tissues TFV-DP and FTC-TP concentrations when F/TAF was administered with FHT.

CONCLUSIONS

No bidirectional clinically significant DDI between FHT and F/TAF-based PrEP was observed across systemic and local tissue anatomical compartments, supporting the use of oral F/TAF-based PrEP among transgender women.

CLINICAL TRIAL NUMBER

NCT04590417.