Symptomatic Neovaginal Candidiasis in Transgender Women After Penile Inversion Vaginoplasty: A Clinical Case Series of Five Consecutive Patients

Gynecologic Care of Transgender and Gender-Diverse People

The visibility and care of transgender and gender-diverse (TGD) people is an important component of gynecology. Transmasculine individuals require routine gynecologic and preventative care. Guidelines can be extrapolated from the cisgender female population, and using affirming language, acknowledging the challenges patients face with pelvic examination, and discussing individual gynecologic needs are important components of care. Transmasculine patients may seek hysterectomy for gender affirmation from gynecologists. Unique nuances exist in the considerations needed when preparing for hysterectomy, and patients should be thoroughly counseled with regard to concurrent vaginectomy or oophorectomy or both. Transfeminine patients often seek gynecologic care after gender-affirming surgery, and, unlike transmasculine patients, the gynecology visit is often very affirming and welcomed by patients. Becoming familiar with the perioperative and delayed postoperative care needs of transfeminine patients undergoing vaginoplasty can help improve the care provided by gynecologists. In general, prospective data on the outcomes of gender-affirming care in large cohorts of TGD patients are limited, but the body of literature is growing. Gynecologists remain central to the care of TGD patients, the academic advancement of the field of transgender health, and the advocacy needed to support this vulnerable patient population.

Familiar Infections in Novel Anatomy: Patient Reports of Sexually Transmitted Infections After Gender-Affirming Penile Reconstruction

BACKGROUND

Sexually transmitted infections (STIs) after penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations have not previously been described, despite known risk factors in the population. After T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines.

METHODS

A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups.

RESULTS

A total of 128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups from January to May 2020. Seven respondents (5.5%) self-reported 1 or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (P = 0.002). Sexually transmitted infections were correlated with reporting sex with cisgender men (P = 0.001), transgender men (P = 0.009), and transgender women (P = 0.012). Of health care access variables, only receiving health care at a community health center was correlated with STI history (P = 0.003).

CONCLUSIONS

This exploratory survey indicates that STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of postreconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of health care provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm after gender-affirming penile reconstruction.

The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People

Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

The gynecologic examination of the transfeminine person after penile inversion vaginoplasty

As more transfeminine patients (transgender and gender-diverse persons, sex assigned male at birth, who identify on the feminine spectrum of gender) are undergoing gender-affirming penile inversion vaginoplasty, gynecologists, as providers of vaginal care for both native and neovaginas, should be prepared to welcome these patients into their practice and offer long-term pelvic healthcare. Many parts of the anatomy, clinical examination, and aftercare differ from both native vaginas and other neovaginal surgical techniques. Transgender and gender-diverse patients cite a lack of clinician knowledge as a barrier to accessing affirming and competent healthcare. Although publications are emerging regarding this procedure, most focus on intraoperative and postoperative complications. These studies are not positioned to provide long-term pelvic health guidance or robust instruction on typical examination findings. This clinical opinion aims to address that knowledge gap by describing the gynecologic examination in the transfeminine person who has undergone a penile inversion vaginoplasty. We review the anatomic changes with surgery and the neovagina's physiology. We describe the examination of the vulva, vagina, and urethra and discuss special considerations for performing pelvic examinations on patients with a penile inversion vaginoplasty neovagina. We will also address common pathologic findings and their initial management. This clinical opinion originates from the expertise of gynecologists who have cared for high volumes of transfeminine patients who have undergone penile inversion vaginoplasties at tertiary care centers performing gender-affirming genital surgery, along with existing research on postpenile inversion vaginoplasty outcomes. Gynecologists should be familiar with the anatomic changes that occur with penile inversion vaginoplasty gender-affirming surgery and how those changes affect care. Providing transgender patients with comprehensive care including this sensitive examination can and should be part of the gynecologist's scope of practice.

Historical and Current State of Dermatologic Care for Sexual and Gender Minority Populations

The lesbian, gay, bisexual, transgender, and queer or questioning/sexual and gender minority (LGBTQ/SGM) community is a growing population with unique lifestyles, sexual practices, beliefs, health issues, and concerns. Although significant advances have been achieved in recent years to establish better care for LGBTQ/SGM patients, they still face insurmountable stigmatization and health care inequality. Dermatologists play an important role in LGBTQ/SGM patients' well-being because they not only treat their skin conditions, but also help them achieve desirable physical characteristics. This article discusses historical perspectives and current state of LGBTQ/SGM dermatology and attempts to define directions for future research and improvement.

Medical dermatologic conditions in transgender women

Many previous reviews and studies on transgender dermatology have highlighted the expected dermatologic manifestations of hormone affirmation therapy in transgender patients. Others have highlighted attitudes and practices of both transgender patients and medical professionals taking care of these patients. This review compiles data from other, lesser known aspects of transgender dermatology, including neovaginal concerns, neoplastic concerns (both neovaginal and cutaneous), autoimmune conditions, and the sequelae of injectable substances that have not been approved by the U.S. Food and Drug Administration. This review, like others, will be a stepping-stone and serve as an impetus for future research in transgender dermatology.