Chest Binding and Care Seeking Among Transmasculine Adults: A Cross-Sectional Study

[Transmasculine people: Gender affirming hormonal therapy, sexual and reproductive health prevention and care, a medical review and follow-up suggestions]

Transmasculine individuals have a poor access to health care, mostly regarding the sexual and reproductive health. Despite a lack of official guidelines, they need a gynecological follow-up, the aim of this review was to describe it. The present study involved an exhaustive search of MEDLINE, 68 articles were included to analyze the impact of hormonal therapy, prevention, and care regarding sexual and reproductive health of transmasculine individuals. Despite a lack of solid data, the global literature agrees that transmasculine individuals require sexual and reproductive health care. Care must be adapted to each pathway and may be impacted by gender-affirming care. The cancer risk does not seem to be increased in this population, particularly in relation to hormonal therapy. Prevention programs do not differ from those offered to cis women in the absence of gender-affirming surgeries. Transmasculine individuals require follow-up and care adapted to their needs and their pathways. Healthcare professionals must be trained to provide such care.

Chest Binding: Sociodemographic Characteristics Among a National Sample of Transgender and Gender Diverse Adolescents

PURPOSE

There is a paucity of national data documenting chest binding practices among transgender and gender diverse (TGD) adolescents, despite the possibility that adolescents chest bind at high rates due to gender identity exploration and/or structural barriers to accessing other gender affirmation strategies.

METHODS

We used data from the 2022 LGBTQ National Teen Survey to estimate the prevalence and sociodemographic characteristics of chest binding among TGD adolescents assigned female at birth (AFAB; n = 6,080), and, in supplementary analyses, a broader sample of AFAB and intersex LGBTQ+ adolescents (n = 7,622).

RESULTS

Nearly two-thirds (63.8%) of TGD AFAB adolescents in our sample reported chest binding. More than 80% of transgender boys reported chest binding. Chest binding varied by some sociodemographics but was prevalent across many characteristics.

DISCUSSION

Chest binding is a common gender exploration and affirmation strategy among TGD AFAB adolescents. Adolescent health providers require data to inform evidence-based healthcare related to chest binding.

Addressing the Healthcare Needs of Transgender Youth in the Emergency Department

ABSTRACT

Transgender is a term that refers to individuals who identify with a gender that is different from the sex assigned to them at birth. In addition to gender dysphoria, many transgender youth experience a number of challenges including homelessness, violence, and mental health problems such as suicidality. Although transgender people represent a growing subset of the population, most providers receive very little training specific to the unique healthcare needs of transgender patients. In this CME review article, we define relevant terminology then discuss best practices for clinical encounters involving transgender youth in the emergency department. Finally, we review gender-affirming care including behavioral modifications, hormones, and surgeries for transfeminine and transmasculine individuals.

Improving the transgender patient experience in the breast imaging center

PURPOSE

This review discusses how breast centers can optimize patient experience scores among transgender patients.

FINDINGS

High patient experience scores impact patient care and compliance. Increased regulations have been enacted to ensure that health systems are effectively meeting the health concerns of sexual minorities. This will be reflected in the patient experience surveys. A leading patient survey will be assessed to help breast imaging centers optimize the transgender patient experience and question types will be provided.

SUMMARY

Breast Centers can be equipped to enhance the transgender patient experience.

Qualitative Assessment of the Experiences of Transgender Individuals Assigned Female at Birth Undergoing Gender-Affirming Mastectomy for the Treatment of Gender Dysphoria

Purpose

Evaluation and comparison of outcomes following gender-affirming mastectomy have been hindered by the lack of a validated population- and surgery-specific patient-reported outcome measure (PROM). The purpose of this study was to explore the lived experiences of transgender individuals assigned female at birth (AFAB) from before-to-after gender-affirming mastectomy to identify key qualitative themes that might inform the creation of a quantitative PROM in the future.

Methods

Identified candidates were transgender men AFAB, 18-65 years of age (mean±standard deviation: 30.3±12.2), who had undergone gender-affirming mastectomy from 2015 through 2017 (n=53). Twelve individuals participated in either focus groups (6) or phone interviews (6), carried out in a semistructured fashion. Verbatim transcriptions were anonymized. Conventional content analysis was used to code all transcripts.

Results

Content analysis identified six key themes experienced by transgender men undergoing gender-affirming mastectomy. In contrast to their experiences before surgery, participant reported that after surgery they experienced fewer symptoms of gender dysphoria, lower anxiety associated with gender dysphoria, less fear about physical safety, no need to hide a female chest shape, and that they passed as male. Also explored were themes about experiences with the health care team.

Conclusion

This study presents the first qualitative data based on the lived experiences of transgender individuals AFAB who underwent gender-affirming mastectomy. These qualitative themes should be heavily considered when creating a quantitative PROM that will fully capture the changes transgender individuals AFAB experience from before-to-after gender-affirming mastectomy.

The Role of the Athletic Trainer in Providing Care to Transgender and Gender-Diverse Patients: Considerations for Medical Affirmation-Part II

Recently, with discriminatory legislation efforts and changing participation policies in organized sports, media attention surrounding transgender and gender-diverse (TGD) individuals has increased. These changes and the historical lack of competence and education regarding the transgender patient population have resulted in subpar patient care and a misunderstanding of the athletic trainer's (AT's) role within the health care and compliance systems. This literature review is the second part of a 2-paper series, and our objective was to educate ATs on the processes relevant to medical affirmation, including compliance considerations regarding medical eligibility, and to establish the AT's role. The gender affirmation framework includes social and legal components, which are discussed in part 1 of this literature, and the medical component is thoroughly discussed in part 2. All health care providers involved in the care of TGD individuals should work collaboratively on an interprofessional care team and have a general knowledge of the gender-affirmation process, including gender-affirming hormone therapy, surgical options, known risks and complications, and the general health needs of TGD patients. With this knowledge, ATs, as point-of-care providers and members of the interprofessional care team, are uniquely positioned to help reduce health and health care disparities. Furthermore, ATs can use their knowledge to facilitate medical compliance and eligibility in the evolving policies of sporting organizations.

Musculoskeletal health considerations for the transgender athlete

BACKGROUND

In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office.

OBJECTIVE

Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting.

CONCLUSION

This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.

Meta-ethnography on Chest Dysphoria and Liberating Solutions for Transmasculine Individuals

OBJECTIVE

To describe the experience of chest dysphoria in transmasculine people and the strategies they use to address it.

DATA SOURCES

AnthroSource, PubMed, CINAHL, PsycInfo, SocIndex, and Google Scholar.

STUDY SELECTION

I searched for records written in English from 2015 and later in which authors reported qualitative findings related to chest dysphoria. These records included journal articles, dissertations, chapters, and unpublished manuscripts. I excluded records if the authors explored gender dysphoria as a whole or focused on transfeminine individuals. If authors explored gender dysphoria in general but addressed chest dysphoria, I included the record for analysis.

DATA EXTRACTION

I read and reread each record several times to fully understand the context, methods, and results. With subsequent readings, I maintained a list of key metaphors, phrases, and ideas using index cards. This allowed examination among and within records to explore relationships among key metaphors.

DATA SYNTHESIS

I identified nine eligible journal articles and used the meta-ethnographic methodology of Noblit and Hare to compare reported experiences of chest dysphoria across records. The three overarching themes I identified were (Dis)Connection to One's Body, Fluctuating Anguish, and Liberating Solutions. I identified eight subthemes within these overarching themes.

CONCLUSION

Chest dysphoria must be relieved to free patients from distress and to make them feel authentically masculine. Nurses should familiarize themselves with chest dysphoria and the liberating solutions that patients use to address it.

Transgender and gender-diverse youth: an update on standard medical treatments for gender dysphoria and the sociopolitical climate

PURPOSE OF REVIEW

Transgender and gender-diverse (TGD) youth experience a discordance between their binary sex assigned at birth and gender identity. All TGD youth benefit from compassionate care delivered by clinicians who are informed in matters of gender diversity. Some of TGD youth experience clinically significant distress, termed gender dysphoria (GD), and may benefit from additional psychological support and medical treatments. Discrimination and stigma fuel minority stress in TGD youth and thus many struggle with mental health and psychosocial functioning. This review summarizes the current state of research on TGD youth and essential medical treatments for gender dysphoria. These concepts are highly relevant in the current sociopolitical climate. Pediatric providers of all disciplines are stakeholders in the care of TGD youth and should be aware of updates in this field.

RECENT FINDINGS

Children who express gender-diverse identities continue to express these identities into adolescence. Medical treatments for GD have a positive effect on mental health, suicidality, psychosocial functioning, and body satisfaction. The overwhelming majority of TGD youth with gender dysphoria who receive medical aspects of gender affirming care continue these treatments into early adulthood. Political targeting and legal interference into social inclusion for TGD youth and medical treatments for GD are rooted in scientific misinformation and have negative impacts on their well being.

SUMMARY

All youth-serving health professionals are likely to care for TGD youth. To provide optimal care, these professionals should remain apprised of best practices and understand basic principles of medical treatments for GD.

Emergency Medicine Considerations in the Transgender Patient

Transgender patients are at high risk for poor health outcomes and many harbor fear of healthcare settings secondary to prior discrimination, perceived sensationalism, clinician unfamiliarity, and unwanted exams. It is essential to approach transgender patients without judgement and with empathy. Asking open ended questions with explanation as to why your questions are pertinent to their specific care will help create rapport and trust. Through a basic working knowledge of terminology, types of hormone therapy, non-surgical techniques, garments, and surgical procedures typically encountered by such patients, and their respective potential side effects and complications, clinicians can provide quality care to transgender patients.

Chest Wall Contouring in Transgender Men: A 20-Year Experience from a National Center

Several western countries have experienced a drastic increase of referrals to specialist gender services of transgender and gender-diverse people. Chest wall contouring is an important element in treatment of gender dysphoria. National data concerning this group have yet to be investigated. The aim of this study was to examine and evaluate the techniques and surgical outcome of chest wall contouring from the last 20 years from a single center in Norway.

Methods

This study is a retrospective review of all female-to-male patients who underwent chest wall contouring surgery at Oslo University Hospital between 2000 and 2020. Statistical analysis with comparison of techniques and evaluation of development over time was examined.

Results

In total, 333 patients underwent bilateral chest wall contouring, 209 (62.8%) with inframammary incision with free nipple graft (IM), and 124 (37.2%) with periareolar technique (PA). In 20 years, the average age decreased from 31 (19-68) to 24.9 years (17-61). Average body mass index was significantly lower in the PA-group than in the IM-group. Complication rate was 20.7%, with postoperative bleeding being the most frequent (9.6%). Revision surgery was required in 24.9% of the cases; periareolar technique required significantly more procedures.

Conclusions

The number of patients referred and operated on has increased drastically over a 20-year period. When comparing the techniques, the outcome concerning complications and revisions is at an acceptable level. Postoperative bleeding and revision surgery occur more often with the periareolar technique. There remains a knowledge gap concerning quality of life and satisfaction after surgery within this patient group.

Managing Dermatologic Effects of Gender-Affirming Therapy in Transgender Adolescents

Transgender adolescents seek gender-affirming medical care to address gender identity and incongruence. Improved understanding of the dermatologic impact of gender-affirming medical care such as pubertal suppression, hormone therapy, and surgeries can enhance patient outcome. Pubertal suppression treats dysphoria associated with development of secondary sex characteristics, including androgen-driven acne. Gender-affirming hormone therapy influences acne and hair development in transgender adolescents. Dermatologists can help manage skin effects associated with chest binding and gender-affirming hormone therapy and surgery. Provision of patient-centered gender-affirming care in dermatologic and multidisciplinary settings is essential to improve skin and overall outcomes of gender-affirming therapy.

Oxygen desaturation in a transgender man: initial concerns and recommendations regarding the practice of chest binding: a case report

BACKGROUND

Over 1.4 million US adults identify as transgender when gender identity differs from the sex assigned at birth [1]. Although transgender patients face adverse health outcomes, they remain an understudied population [2]. A 2017 study surveyed 411 practicing clinicians and found that 80% had been involved in treating a transgender patient, but 80.6% had never received training on transgender care [3]. The purpose of this report is to describe prolonged desaturation in one case of a transgender patient who wore a chest binder intraoperatively owing to a lack of preoperative recognition.

CASE PRESENTATION

A 19-year-old transgender male of African-American descent with anxiety and class 3 obesity presented for an esophagogastroduodenoscopy to evaluate a 2-year history of upper abdominal pain unresponsive to proton pump inhibitor therapy, with a plan for monitored anesthesia care. His medications included sertraline, pantoprazole, zolpidem, ergocalciferol, leuprolide, and testosterone cypionate. Preoperatively, the patient was instructed to remove all clothing and to don a patient gown while in the bathroom. The attending anesthesiologist then conducted the interview and examination in the preoperative holding area. The patient was induced with 250 mg of propofol, and reassuring respirations were noted by capnography. Respirations and oxygen saturation remained stable upon insertion of the endoscope. Four minutes later, the patient's oxygen saturation rapidly decreased to 50% and end-tidal capnography was lost. The endoscope was removed, and the patient was given 200 mg of propofol and 20 mg succinylcholine. His oxygen saturation recovered to 80% and 100% after 2 and 5 minutes, respectively, of ventilation with 100% inspired oxygen. No further oxygen desaturation was noted throughout the procedure, and the patient was closely monitored for signs of respiratory difficulty during an uneventful postoperative course. After full emergence, it was revealed that the patient had been wearing a chest binder throughout the operative procedure. The patient was counseled on the necessity to communicate the presence of this accessory prior to all future procedures.

CONCLUSION

In the clinical narrative, a healthy patient was observed to have prolonged oxygen desaturation after induction of anesthesia. Laryngospasm was suspected clinically owing to the sudden absence of end-tidal carbon dioxide. Prolonged oxygen desaturation despite appropriate interventions suggests the contribution of additional factors. We speculate that the presence of a chest binder intraoperatively predisposed the patient to more rapid oxygen desaturation less responsive to typical therapy. A chest binder would introduce mechanical restriction to the patient's breathing owing to its inherent design to compress. Although the patient was asked to remove all clothing, specific instructions were not provided regarding the removal of a chest binder. The presence of chest binding was also absent in the electronic health record, despite the documented presence of the patient's preferred gender, hormonal therapy regimen, and medical history. Ultimately, this case reflects the gap between practitioner knowledge and hospital guidelines and the practices of transgender patients. In reviewing existing literature and the potential for atelectasis with external compression, we would consider that patients refrain from chest binding for 12-24 hours before surgical procedures, resume no sooner than 24 hours after ambulation, and participate in diagnostic incentive spirometry pre- and postoperatively.

Reported Pain in Cisgender Female and Transmasculine Patients Seeking Benign Breast Surgery

Benign breast surgery aims to treat the physical and psychological discomfort that may be associated with excess breast tissue. In this investigation, we present the first systematic examination and comparison of the determinants of pain and related symptomology in cisgender women and transmasculine individuals presenting for benign breast surgery.

METHODS

To complete this study, we abstracted the intake forms of 128 transmasculine and 62 cisgender female patients who presented for benign breast surgery between August 2016 and July 2020.

RESULTS

Increasing chest size was associated with significantly increased odds of reporting rash (OR 1.10 95% CI [1.01-1.10], P < 0.03), difficulty playing sports (OR 1.19 95% CI [1.09-1.29], P < 0.001), and difficulty finding clothes that fit (OR 1.21, 95% CI [1.11-1.33], P < 0.001). For individuals who bound their chests, size was also associated with difficulty exercising in a binder (OR 1.14 [1.01-1.29], P < 0.03). Looking separately at the two populations, the only factors that remained associated with pain in multivariate models were BMI (β = 0.10 [0.01-0.18], P < 0.03) for cisgender women and history of binding (β = 1.95 [0.37-3.52], P < 0.02) for transmasculine people.

CONCLUSIONS

Pain does not seem to be associated with chest size in either cisgender female or transmasculine patients seeking benign breast surgery. The association between chest binding and pain in transmasculine people supports the provision of gender-affirming chest surgery to eliminate the need to bind and reduce both physical and psychological distress.

Chest binding in context: stigma, fear, and lack of information drive negative outcomes

Chest binding or 'binding' is a practice used by many trans and nonbinary people assigned a female sex at birth to achieve a flatter chest contour and affirm their gender. Binding allows individuals to affirm their gender in a temporary, reversible way. While many individuals who bind report negative physical symptoms, binding also often carries significant benefits for mental health and safety. In this commentary, we explain what the data do and do not say about the physical risks of binding and describe how decreasing stigma around binding will substantially reduce physical risks associated with binding and increase the benefits of the practice. As with any intervention, individuals should make an informed decision about the risks and benefits of binding. If negative physical symptoms arise, individuals can consider adjusting their binding practice or working with a healthcare provider to address these concerns.

Pathological Evaluation of Breast Specimens in Transgender Chest Masculinization: Incidental Findings and Effect of Prior Chest Binding and Androgen Therapy in 74 Consecutive Patients

Background: The rate of masculinizing chest surgery for gender affirmation continues to increase. With a paucity of literature on pathological evaluation of breast specimens in this patient population, there is a need for these data and for protocols on the handling of these specimens. Methods: A retrospective chart review was performed between 2015 and 2020 on all patients who underwent chest masculinization surgery for gender dysphoria by the senior author (J.D.K.). Inclusion criteria were any patient with sex assigned female at birth who underwent removal of breast and/or nipple areolar complex tissue for gender affirmation. Patient demographics were recorded. Bilateral breast tissue was sent for routine pathology in all cases and findings were recorded. A p-value of <0.05 was considered significant. Results: Seventy-four consecutive patients and 148 breast specimen reports were identified from a database and included in the study. The mean age was 26 years (15-49). Thirty-nine patients had a known history of chest wall binding and 60 patients had undergone preoperative androgen therapy. There was no invasive or in situ carcinoma found in any breast tissue specimens. Thirty-four patients had a benign lesion in one or both breast specimens. Atypical lobular hyperplasia was found in one patient's specimen. A history of chest wall binding was not correlated with any benign lesions (p=0.79) or stromal fibrosis (p=0.94). A history of testosterone use was not correlated with any benign lesions (p=0.35) or stromal fibrosis (p=0.20). Conclusions: The prevalence (1.4%) of significant breast pathology and of benign findings (46%) in our study closely correlates with the rates in the literature. We found no correlation between significant breast pathology or benign lesions and a history of chest wall binding or preoperative androgen therapy. We recommend all breast specimens removed during chest masculinization surgery be sent for pathological evaluation.

Chest binding and respiratory complaints in transgender men

Abstract Introduction: Chest binders are an important resource for building masculinity in transgender men without mastectomy, although they can cause respiratory and thoracic damage if misused. Objective: To analyze the association between chest binding and chest complaints in transgender men. Methods: This was a quantitative cross-sectional study conducted at the Trans Space of the Hospital das Clínicas de Pernambuco and the LGBTQI Patrícia Gomes outpatient clinic of the Lessa de Andrade polyclinic in Recife (Pernambuco State, northeastern Brazil). Sixty transgender men aged >18 years were included, and data on sociodemographics, general health, chest binding, and respiratory complaints in the thoracic region were collected. Descriptive analysis was performed, and prevalence ratios (PR) were estimated with a confidence interval (CI) of 95% to associate between binder use and complaints in the chest region. Results: The average was 27.25 years, of which 81.7% did not undergo mastectomy and 53.3% used chest binders. The use of chest binders was significantly associated with complaints in the chest region (PR = 2.73), difficulty breathing (PR = 2.27), and chest pain (PR = 1.82). Conclusion: This study demonstrated a higher prevalence of complaints in the chest and respiratory region in transgender men who use chest binders. This reinforces the need to broaden the view on the health of this population. Gender construction strategies are essential for the quality of life and mental health of transgender men, and binders are an important ally in this process.

[Patient satisfaction following gender reassignment mastectomy in female-to-male transsexual patients: a questionnaire-based analysis using a modified version of the BREAST-Q]

BACKGROUND

Mastectomy is an essential part of gender reassignment surgery for female-to-male transgender patients. Available studies indicate high patient satisfaction within this patient group; however, a standardised evaluation procedure is yet to be established.

METHOD

Based on the BREAST-Q questionnaire, we developed a modified version targeting issues concerning FM patients; hence, all questions focussing on the physiology of biologically female patients were removed or tailored to address more specific transgender issues. Post-mastectomy transgender male patients from 1991 until 2017 were contacted and evaluated based on the questionnaire. This questionnaire comprises a total of 57 questions regarding general satisfaction with the ches area, as well as specific questions regarding satisfaction with the nipple-areola complex (NAC) and topics regarding expectations, regrets, self-confidence and sex life after mastectomy.

RESULTS

Overall, we found a high level of patient satisfaction after mastectomy. The level of regret was low and all patients would repeat mastectomy if needed.

CONCLUSION

For most transgender males, mastectomy plays an essential role in gender reassignment surgery, overall leading to an improved quality of life for this patient population.

Gender-affirming care, mental health, and economic stability in the time of COVID-19: A multi-national, cross-sectional study of transgender and nonbinary people

BACKGROUND

Transgender and nonbinary people are disproportionately affected by structural barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) crisis and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and nonbinary people in multiple countries.

METHODS

We collected multi-national, cross-sectional data from 964 transgender and nonbinary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of COVID-19. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%, n = 264) and Thailand (20.6%, n = 205). A majority were nonbinary (66.8%, n = 644) or transfeminine (29.4%, n = 283). Due to COVID-19, 55.0% (n = 320/582) reported reduced access to gender-affirming resources, and 38.0% (n = 327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%, n = 392/856). One in six (17.0%, n = 112/659) expected losses of health insurance, and 77.0% (n = 724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender-affirming resources was reduced versus not.

DISCUSSION

The COVID-19 crisis is associated with reduced access to gender-affirming resources and the ability of transgender and nonbinary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve health of transgender and nonbinary communities, increased access to gender-affirming resources should be prioritized through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

The Impact of Chest Binding in Transgender and Gender Diverse Youth and Young Adults

PURPOSE

There is a sparsity of information on chest binding practices among transmasculine and gender diverse people regardless of age and even less information pertaining to adolescents and young adults (AYA). The purpose of this study was to understand binding trends in AYA and to recognize how chest binding impacts chest dysphoria and life satisfaction.

METHODS

Data were collected from eligible participants via a national online survey. In this national, cross-sectional study, 684 surveys from AYA aged 13-24 years compared those who bind and those who do not bind.

RESULTS

Most participants reported learning to bind online and were not connected to any type of gender care or community center. Participants in the binding cohort reported less "misgendering" than the nonbinding cohort, and there was a significant correlation between increased chest dysphoria and lower scores on life satisfaction.

CONCLUSIONS

This study provides insight into how AYA obtain information about binding and how binding impacts their life. It also indicates that transmasculine and gender diverse AYA will continue to bind their chest to benefit from the protective factors experienced with chest binding. This study also highlights the importance of improved education for medical providers as well as parents/guardians regarding binding to support those who experience chest dysphoria or discomfort.

Association of Chest Dysphoria With Anxiety and Depression in Transmasculine and Nonbinary Adolescents Seeking Gender-Affirming Care

PURPOSE

The purpose of this study was to determine the existence and strength of association between chest dysphoria and mental health in transmasculine and nonbinary adolescents.

METHODS

This is a cross-sectional cohort study of transmasculine and nonbinary adolescents designated female at birth between 12 and 18 years old. None had undergone prior top surgery. Patients complete the Chest Dysphoria Measure and Youth Inventory-4 (YI-4) upon presentation to our institution. Outcomes were retrospectively reviewed. The primary outcome of interest was the association between chest dysphoria and anxiety and depression symptom severity, as measured by the YI-4.

RESULTS

One hundred fifty-six patients met inclusion criteria. Mean age was 15.3 years (standard deviation [SD] = 1.7). Most patients identified as transmasculine (n = 132); 18 identified as nonbinary and 6 as questioning. Mean (SD) YI-4 symptom severity scores were 10.67 (6.64) for anxiety and 11.99 (7.83) for depression. Mean (SD) Chest Dysphoria Measure composite score was 30.15 (9.95); range 2-49. Chest dysphoria was positively correlated with anxiety (r = .146; p = .002) and depression (r = .207; p < .001). In multivariate linear regression models, chest dysphoria showed a significant, positive association with anxiety and depression, after accounting for gender dysphoria, degree of appearance congruence, and social transition status.

CONCLUSIONS

Chest dysphoria is associated with higher anxiety and depression in transmasculine and nonbinary adolescents designated female at birth. This association is independent of level of gender dysphoria, degree of appearance congruence, and social transition status. Treatment options aimed at alleviating chest dysphoria should be made accessible to adolescents and tailored to individual needs.

Care of the Transgender Patient with a Pulmonary Complaint

Individuals who identify with a gender not typically associated with their sex assigned at birth are a growing population worldwide. Guidelines to help healthcare providers navigate the care of gender minorities (GMs) are often aimed at primary care providers and may be too general for subspecialists. Pulmonologists may see GM individuals for a variety of reasons, and no reference exists that contains relevant information about GM-specific care, including unique conditions to consider. A systematic review was completed to identify unique characteristics in caring for GM patients with a pulmonary complaint.

Time to First Onset of Chest Binding-Related Symptoms in Transgender Youth

BACKGROUND AND OBJECTIVES

Most transgender individuals assigned female at birth use chest binding (ie, wearing a tight garment to flatten chest tissue for the purpose of gender expression), often beginning in adolescence, to explore their gender identity. Although binding is often critical for mental health, negative physical side effects, ranging from chronic pain to rib fractures, are common. Time to first onset of symptoms is unknown.

METHODS

A community-engaged, online, cross-sectional survey ("The Binding Health Project") enrolled 1800 assigned female at birth or intersex individuals who had ever used chest binding. Lifetime prevalence of 27 pain, musculoskeletal, neurologic, gastrointestinal, generalized, respiratory, and skin or soft tissue symptoms related to binding was assessed. Nonparametric likelihood estimation methods were used to estimate survival curves.

RESULTS

More than one-half (56%) of participants had begun binding by age 21, and 30% had begun by age 18. In 18 of 27 symptoms, the majority of people who go on to experience the event will do so within the first binding-year, but several skin-related and rare but serious outcomes (eg, rib fracture) took longer to occur. Pain presents rapidly but continues to rise in intensity over time, peaking at >5 years of binding.

CONCLUSIONS

Although many symptoms emerge quickly, others can take years to develop. Individuals and their clinicians can use this information to make informed decisions on how to structure binding practices and top surgery timing while meeting goals related to gender expression and mental health. Access to puberty blockers may delay initiation of binding, preventing binding-related symptoms in youth.

Considerations for Transgender Patients Perioperatively

With a shift in the cultural, political, and social climate surrounding gender and gender identity, an increase in the acceptance and visibility of transgender individuals is expected. Anesthesiologists are thus more likely to encounter transgender and gender nonconforming patients in the perioperative setting. Anesthesiologists need to acquire an in-depth understanding of the transgender patient's medical and psychosocial needs. A thoughtful approach throughout the entirety of the perioperative period is key to the successful management of the transgender patient. This review provides anesthesiologists with a culturally relevant and evidence-based approach to transgender patients during the preoperative, intraoperative, and postoperative periods.

Affirming Pediatric Care for Transgender and Gender Expansive Youth

Transgender and gender diverse children and youth experience significant health disparities and adverse health outcomes. Pediatricians have an opportunity to improve those outcomes by practicing gender-affirming care. This includes creating a welcoming environment through changes in office settings, intake forms, communication skills, language used, and support for families. Clinicians should be comfortable discussing social transition, puberty blockers, and gender-affirming hormone therapy with patients as needed. For clinicians caring for teenagers, adaptations in sexual health counseling and fertility counseling are necessary. Clinicians should also be aware of the trauma that has been historically inflicted by the medical and mental health system against people who identify as transgender/nonbinary, and that significant disparities exist even within this group along racial and gender lines. These aspects of caring for gender diverse youth are part of primary care pediatrics, and further education in these areas will improve access to care and health outcomes for these youth. [Pediatr Ann. 2021;50(2):e65-e71.].

Gender-affirming care, mental health, and economic stability in the time of COVID-19: a global cross-sectional study of transgender and non-binary people

BACKGROUND

Transgender and non-binary people are disproportionately burdened by barriers to quality healthcare, mental health challenges, and economic hardship. This study examined the impact of the novel coronavirus disease (COVID-19) pandemic and subsequent control measures on gender-affirming care, mental health, and economic stability among transgender and non-binary people globally.

METHODS

We collected global cross-sectional data from 964 transgender and non-binary adult users of the Hornet and Her apps from April to August 2020 to characterize changes in gender-affirming care, mental health, and economic stability as a result of the COVID-19 pandemic. We conducted Poisson regression models to assess if access to gender-affirming care and ability to live according to one's gender were related to depressive symptoms, anxiety, and changes in suicidal ideation.

RESULTS

Individuals resided in 76 countries, including Turkey (27.4%,n=264/964) and Thailand (20.6%,n=205). A majority were non-binary (66.8%,n=644) or transfeminine (29.4%,n=283). Due to the COVID-19 pandemic, 55.0% (n=320/582) reported reduced access to gender- affirming resources, and 38.0% (n=327/860) reported reduced time lived according to their gender. About half screened positive for depression (50.4%,442/877) and anxiety (45.8%,n=392/856). One in six (17.0%,n=112/659) expected losses of health insurance, and 77.0% (n=724/940) expected income reductions. The prevalence of depressive symptoms, anxiety, and increased suicidal ideation were 1.63 (95% CI: 1.36-1.97), 1.61 (95% CI: 1.31-1.97), and 1.74 (95% CI: 1.07-2.82) times higher for individuals whose access to gender- affirming resources was reduced versus not.

DISCUSSION

The COVID-19 pandemic has reduced access to gender-affirming resources and the ability of transgender and non-binary people to live according to their gender worldwide. These reductions may drive the increased depressive symptoms, anxiety, and suicidal ideation reported in this sample. To improve transgender and non-binary health globally, increased access to gender-affirming resources should be achieved through policies (e.g., digital prescriptions), flexible interventions (e.g., telehealth), and support for existing transgender health initiatives.

Emergency Care Considerations for the Transgender Patient: Complications of Gender-Affirming Treatments

The transgender population presents a unique challenge for the emergency nurse. There are types of surgeries, medications, complications, and differences in laboratory testing that are unique to transgender people. In addition, emergency nurses are increasingly encountering more transgender patients in the emergency department for care, referrals, and education. Yet, many emergency nurses lack the formal training to care for transgender patients and their families. A complete understanding of the terminology, gender-transforming surgeries, hormonal suppression and augmentation of sexual characteristics, adverse effects, complications of surgeries, and ongoing health risks owing to the altered hormonal milieu and potential risk for acquiring sexually transmitted diseases is important to provide the necessary emergency care for this emerging population.

Crowdsourcing the Ideal Nipple-Areolar Complex Position for Chest Masculinization Surgery

Chest masculinization surgery is increasing in prevalence. However, the ideal location of the nipple-areolar complex (NAC) is unknown. Our purpose was to determine the most aesthetically favorable male NAC position for use in chest masculinization through crowdsourcing.

Transgender pediatric surgical patients-Important perioperative considerations

Transgender describes a variety of identities in which an individual's gender identity is different from expected based on the sex assigned at birth. In the United States, it is estimated that over 1 million adults and 150 000 youth identify as transgender, with increasing numbers being seen in healthcare and surgical settings. These numbers will continue to rise as visibility and acceptance grow. Current guidelines recommend transition-related surgeries be reserved for older adolescents and adults. However, this is not the only circumstance in which the pediatric anesthesiologist may find themselves caring for a transgender patient. In order to provide the safest and most affirming care, it is crucial that the pediatric anesthesiologist develop a working knowledge of this unique and vulnerable population, including the potential impacts of gender-affirming treatment on their perioperative care.

A Pediatric Transgender Medicine Curriculum for Multidisciplinary Trainees

INTRODUCTION

While pediatricians should receive training in the care of transgender youth, a paucity of formal educational curricula have been developed to train learners to care for this vulnerable population.

METHODS

We developed a curriculum including six online modules and an in-person afternoon session observing clinic visits in a pediatric gender clinic. Learners-fourth-year medical students, interns, and nurse practitioner trainees-received protected time during an adolescent medicine rotation to complete the online modules (total duration: 77 minutes). For 20 learners, we assessed the impact of the entire curriculum-online modules and in-person observation-on self-perceived knowledge of considerations for transgender youth. For 31 learners, we assessed the effect of the online modules alone on knowledge and self-efficacy. Descriptive analyses illustrated changes in educational domains by learner group.

RESULTS

On evaluations of the entire curriculum (modules and observation), median self-perceived knowledge scores (1 = not at all knowledgeable/aware, 5 = extremely knowledgeable/aware) increased within learner groups: pediatric interns (from 2.3 to 4.0), nurse practitioner trainees (from 2.9 to 4.7), fourth-year medical students (from 3.3 to 4.9), and psychiatry interns (from 2.8 to 4.4). Assessment of learners completing only the online modules demonstrated increases in median knowledge and self-efficacy scores within learner groups. All learner groups highly valued the curriculum.

DISCUSSION

Our curriculum for multidisciplinary learners in the care of transgender youth was successful and well received. Increasing learner knowledge and self-efficacy is an important step towards skill development in patient care for the transgender youth population.

Female-to-Male Gender-Confirming Drainless Mastectomy May Be Safe in Obese Males

BACKGROUND

Gender dysphoria is a medical condition associated with suicidality. Transgender men who have undergone female-to-male (FTM) chest reconstruction report higher quality of life and reduced gender dysphoria. It has been reported that transgender men are at higher risk of obesity.

OBJECTIVES

The objective of this study was to compare perioperative outcomes and complications between different classes of obesity in FTM transgender patients who underwent chest masculoplasty.

METHODS

A retrospective review of 145 consecutive patients who underwent mastectomy with free nipple graft was conducted. Postoperative outcomes and complications were collected. Patients were divided into nonobese (body mass index [BMI] <30 kg/m2), obese (BMI 30-39.9 kg/m2), morbidly obese (BMI 40-49.9 kg/m2), and super obese (BMI >50 kg/m2) groups.

RESULTS

Sixty-six of the 145 patients were not obese, 52 were obese, 22 were morbidly obese, and 5 were super obese. There was a statistically significant increase in amount of breast tissue resected between each of the 4 groups (866.8 g vs 1672.4 g vs 3157.1 g vs 4827.6 g; P ≤ 0.0005) as BMI increased, respectively. There was a significant difference in operative time between the nonobese and obese groups (128.7 vs 134.6 vs 150.5 vs 171 minutes; P = 0.026). A significant increase in postoperative infections was observed between the morbidly obese, super obese, and the nonobese group (P = 0.048).

CONCLUSIONS

Chest wall reconstruction in FTM and nonbinary transgender people is important in relieving gender dysphoria. Postoperative complications were not significantly increased in obese patients (30-39.9 kg/m2). Delaying surgery for weight loss may not be necessary unless patients are morbidly obese.

LEVEL OF EVIDENCE: 4