Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth

Shifting Paradigms: A Deep Dive Into Public Perceptions of Gender-affirming Surgery

Background

Given the growing demand for gender-affirming surgery (GAS) in recent years, it is essential to explore the public perceptions of GAS. Understanding the public's opinions and attitudes toward GAS will provide valuable insights for shaping educational initiatives to enhance public knowledge and awareness.

Methods

This cross-sectional study used the Prolific Academic platform to distribute an online survey among adult participants residing in the United States in August 2023.

Results

Of 1005 completed survey responses, 50% of respondents were 41 years of age or older, 51% were women, and 73% were White. A total of 18% identified as part of the LGBTQIA+ community, and most (37%) resided in the southern United States. The majority of participants (78%) did not personally know anyone who underwent GAS, and 74% believed that plastic surgeons mainly perform GAS. Only 22% felt healthcare professionals were well qualified to provide gender-affirming care. Media's effect on GAS acceptance was assessed to be mostly negative (33%) or very negative (12%). About 33% favored both public and private health insurance coverage for GAS, whereas 35% opposed insurance coverage. Most respondents strongly agreed (32% and 34%) or agreed (33% and 37%) that GAS aligns with gender identity and improves mental health. Regarding minimum age, most partakers (43%) supported 18 years, whereas 38% endorsed 21 years.

Conclusions

This study sheds light on the public perceptions of GAS. These insights underscore the need for targeted educational efforts to increase awareness, rectify misconceptions, and promote a deeper understanding of GAS within society.

Differences in cardiorespiratory fitness by gonadotropin-releasing hormone agonist treatment before and after testosterone in transgender adolescents

There are known sex differences in cardiorespiratory fitness (CRF). Little is known about the impact of pubertal blockade with a gonadotropin-releasing hormone agonist (GnRHa) followed by hormone therapy on CRF for transgender adolescents. We aimed to 1) determine the effect of GnRHa monotherapy on CRF and mitochondrial function and associations with metabolomic profiles and 2) evaluate changes after 1 and 12 mo of testosterone therapy among transgender adolescents. Participants assigned female at birth (n = 19, baseline age of 15.0 ± 1.0 yr) from two groups: GnRHa+ (n = 8) and GnRHa- (n = 11) were examined at baseline and 1- and 12-mo post-testosterone therapy in a longitudinal observational study to assess cardiorespiratory fitness, mitochondrial respiration, and metabolic profile. Fasted morning labs included assessment of metabolomics and peripheral blood mononuclear cell mitochondrial respiration and degree of mitochondrial coupling (respiratory control ratio, RCR). A graded cycle ergometer test was performed. Baseline differences were evaluated between groups. Changes were compared with mixed linear regression models evaluating time (baseline, 1 mo, and 12 mo), group (GnRHa treatment yes/no), and their interaction. At baseline GnRHa+ individuals had higher relative V̇o2peak (30.1 ± 4.83 vs. 25.24 ± 4.47 mL/kg/min, P = 0.042) than GnRHa- individuals. In regression models, GnRHa+ individuals had a significant increase in peak watts (P = 0.011) and total exercise time (P = 0.005) after 12 mo of testosterone (P = 0.012) but not GnRHa- individuals. GnRHa+ individuals have significantly higher RCR under carbohydrate (P = 0.0007) and lipid (P = 0.0002) conditions than GnRHa+ individuals. Pretreatment with GnRHa positively influences peak CRF and mitochondrial respiration in adolescent transgender males undergoing testosterone therapy.NEW & NOTEWORTHY This study demonstrates differences in exercise capacity and mitochondrial respiration at baseline based on whether or not individuals had feminizing puberty blocked. Individuals who had puberty blocked had greater improvements in cardiopulmonary exercise testing parameters after 12 mo of testosterone than those who went through feminizing puberty.

Breast Surgery in Adolescents: Cisgender Breast Reduction Versus Transgender and Nonbinary Chest Masculinization

PURPOSE

Both breast reduction surgery (BRS) in adolescent girls and chest masculinization surgery (CMS) transgender and nonbinary (TGNB) individuals improve physical discomfort and psychological well-being. Nonetheless, CMS in adolescents is highly contested due to concerns regarding safety and capacity for consent. Here, we compare both procedures to quantify trends in incidence, minimum age, and surgical outcomes.

METHODS

The National Surgical Quality Improvement Program database was queried from 2018 to 2021 for cisgender and TGNB adolescents 18 years or younger who underwent BRS or CMS. Our primary outcome was the incidence of postoperative complications within 30 days of surgery. Multivariate logistic regression was performed to determine if CMS was associated with postoperative complications.

RESULTS

Of 2504 adolescents, the majority (n = 2186 [87.3%]) were cisgender female patients who underwent BRS, compared with TGNB adolescents (n = 318 [12.7%]) who underwent CMS. BRS patients were younger at time of surgery (mean [SD] 16.7 [1.2], 17.5 [0.9]; P < 0.001). The minimum age for BRS was consistently 2 to 3 years younger than that for CMS (12.1 to 12.6 years vs 14.0 to 15.1 years). A comparable frequency of BRS and CMS patients developed 1 or more complications within 30 days of surgery (n = 98 [4.5%], n = 13 [4.1%]; P = 0.775).

CONCLUSION

Cisgender female adolescents undergo breast surgery at a 7-fold rate compared with TGNB adolescents and do so at significantly younger ages. Given the favorable effects of BRS and CMS on psychosocial well-being and their comparable surgical risk of complications, our data help recontextualize the concerns surrounding adolescent CMS.

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.

Comparing Gender Congruency in Nonsurgical versus Postsurgical Top Surgery Patients: A Prospective Survey Study

Background

Gender dysphoria can result in reduced quality of life. Treatments include hormone replacement therapy (HRT) and gender-affirming surgery. Our study compared congruency, satisfaction, and discrimination in patients who underwent top surgery and HRT versus HRT alone. We hypothesized improved outcomes in top surgery patients but that lack of access is a common barrier.

Methods

Transgender and nonbinary subjects who underwent at least 6 months of HRT were recruited and answered questions on gender congruency, discrimination, and barriers to care. Surgical patients were asked about postoperative satisfaction using the BREAST-Q. A Mann-Whitney test compared survey responses between study arms.

Results

One hundred twelve eligible subjects completed the survey. Surgical subjects answered significantly more positively (P < 0.001) on all questions regarding gender congruency. The greatest difference was observed in how subjects' physical bodies represented their gender identity, where the surgery group rated higher on the five-point Likert scale by 2.0 points (P < 0.001). Surgical patients also reported less violence, verbal abuse, and discrimination (P < 0.003). Within the hormone arm, 87.1% stated desire for surgery and 62.5% declared barriers to surgery, with cost and insurance coverage representing the most common barriers. Finally, surgical subjects reported high satisfaction on the BREAST-Q, scoring more than 3.0 in all categories of breast augmentation and more than 2.6 for breast reduction on a four-point Likert scale.

Conclusions

Top surgery, in addition to HRT, significantly improves gender congruency and decreases discrimination and abuse, compared with HRT alone. Unfortunately, barriers including cost and lack of insurance continue to be obstacles for care.

Masculinizing Chest Reconstruction in Adolescents and Young Adults: An Analysis of National Surgical Quality Improvement Program Data

BACKGROUND

Masculinizing chest reconstruction (MCR) has been shown to improve quality of life and gender dysphoria in transmasculine adult patients. As nationwide access to gender-affirming care expands, more adolescents are seeking MCR. However, there is a paucity of literature examining patient characteristics, safety, and disparities among this population.

METHODS

Cases of MCR were selected from the pediatric and adult American College of Surgeons and National Surgical Quality Improvement Program. Adolescent (18 years and older) and young adult (aged 19-25 years) transgender patients were analyzed for differences in demographics, comorbidities, surgical characteristics, and postoperative complications.

RESULTS

A total of 1287 cases were identified, with an adolescent cohort of 189 patients. The proportion of White patients to other races was greater among adolescents than young adults (91.2% vs 82.4%, P = 0.007). Of adolescents and young adults, 6.0% and 11.1% identified as Hispanic/Latino, respectively (P = 0.059). Rates of all-cause postoperative complications were similar between adolescents (4.2%) and young adults (4.1%). Multivariate binary logistic regression showed that Black or African American patients experienced more all-cause postoperative complications than other races after controlling for American Society of Anesthesiologists classification, age group, and body mass index (odds ratio, 2.8; 95% confidence interval, 1.3-5.9; P = 0.008).

CONCLUSIONS

Masculinizing chest reconstruction is equally safe for transmasculine adolescent and young adult patients. However, our data point to racial disparities in access to care and postoperative outcomes. An intersectional approach is needed to better understand the unique health care needs and barriers to care of minority transgender youth.

"Difficult to Find, Stressful to Navigate": Parents' Experiences Accessing Affirming Care for Gender-Diverse Youth

Purpose: Gender-diverse youth (GDY) face significant health disparities, which can be mitigated by gender-affirming medical care. Understanding parents' experiences seeking care for their GDY can identify barriers to care and improve access. This study sought to understand parents' experiences accessing gender-affirming medical care with their GDY. Methods: We asked parents of GDY in the United States to describe their experiences with gender-affirming medical care through a single open-ended item on an online survey disseminated through social media in February of 2020. Open-ended survey responses were analyzed through inductive thematic analysis by two authors using an iteratively developed codebook adjudicated by consensus. This codebook was used to identify key themes. Results: We analyzed 277 responses from majority White (93.9%) parents from 41 U.S. states. Themes included (1) Experiences accessing care: finding a provider, financial and insurance-related considerations, the impact of geography on care access; (2) Experiences receiving care: factors in successful or unsuccessful patient-provider interactions, differing approaches to initiating care, sense of community with other families; and (3) Outcomes related to receiving care: how care for their child was perceived to be lifesaving or helped their child thrive. Conclusions: Parents highlighted how access to gender-affirming medical care improved their GDY's health and wellbeing, and described numerous barriers they experienced with finding and receiving this care. Given the evidence that gender-affirming medical care mitigates health disparities, providers, policymakers, insurance companies, and health systems leaders should urgently address these challenges to ensure equitable receipt of care for all GDY.

Prospective Evaluation of Psychosocial Changes After Chest Reconstruction in Transmasculine and Non-Binary Youth

PURPOSE

This study sought to prospectively examine the effects of gender-affirming chest reconstruction on gender congruence and chest dysphoria in transmasculine and nonbinary adolescents and young adults.

METHODS

Individuals between the ages of 15-35 who were seeking gender-affirming chest surgery were enrolled as part of a broader, longitudinal study of transgender surgical experiences. Their chest dysphoria and gender congruence were measured at baseline, six months, and one year, using the Transgender Congruence and Chest Dysphoria scales. Repeated measures analysis of variance were used to detect differences in scores across assessment points. Where there were significant differences indicated, Tukey's honestly significant difference test was used to determine which differences in mean scores were significant between assessment points, as well as how results differed by demographic factors.

RESULTS

The analytical sample consisted of 153 individuals who had completed both the baseline and at least one follow-up assessment - 36 (24%) endorsing a nonbinary gender and 59 (38%) under the age of 18. Repeated measures analysis of variance indicated significant differences in gender congruence, appearance congruence, and chest dysphoria between at least two assessment points for the total sample and each subgroup (binary/non-binary and adult/minor). Honestly significant difference tests indicated no significant differences between the postoperative assessments by age or binary gender.

DISCUSSON

Gender-affirming chest reconstruction improves gender and appearance congruence and reduces chest dysphoria in both non-binary and binary populations of adolescents and young adults. These data support the need to improve access to gender-affirming chest reconstruction for adolescents and young adults and to remove legislative and other barriers to care.

Temporal Trends in Gender Affirmation Surgery Among Transgender and Non-Binary Minors

BACKGROUND

Over the last decade, a greater number of transgender or non-binary (TGNB) minors have been seeking gender affirmation surgery (GAS). Given the recent concerns about the potential harm of GAS in TGNB minors, we sought to determine the incidence and postoperative outcomes of GAS among TGNB minors.

METHODS

We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, 2018-2021, for minors aged 17 years or younger. The primary outcome was the frequency and type of GAS plotted over time. The secondary outcome was the incidence of postoperative complications within 30 days following GAS. Descriptive statistics were calculated. Linear regression was performed to assess the association between the incidence of GAS and time in years.

RESULTS

A total of 108 TGNB minors were identified. The mean (SD) age was 16.9 (0.8) years without significant variation over time. There was a significant increase in the number of GAS per year over four years (P<.001). Nevertheless, only two (1.9%) patients underwent GAS below the age of 15 (13.9 and 14.5 years). Chest masculinization surgery (CMS) was the predominant procedure type among TGNB minors (n=102, 94.4%). There was no incidence of major complications (mortality, bleeding, sepsis, unplanned intubation) except for unplanned reoperation for hematoma evacuation (n=3, 2.8%). The incidence of minor complications (surgical site infection, wound dehiscence) was low (n=1, 0.9%), each).

CONCLUSIONS AND RELEVANCE

GAS in minors, primarily in the form of CMS, has been increasing over time. CMS in minors is a safe procedure with rare complications.

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.

Sex Differences in Athletic Performance: Perspectives on Transgender Athletes

Sex hormone concentrations, particularly testosterone, are primary determinants of sex-based differences in athletic and sports performance, and this relationship may inform fair competition and participation for athletes. This article describes the sex-based dichotomy in testosterone and the implications for sex-based differences in individual sports performance, including factors that relate to athletic performance for transgender individuals, and areas of future investigation.

Age-related Outcomes of Chest Masculinization Surgery: A Single-surgeon Retrospective Cohort Study

Many transmasculine individuals face chest dysphoria, an emotional distress associated with breast development. The definitive management for reduction of existing breast tissue and alleviation of chest dysphoria comes in the form of chest masculinization surgery. Over the years, a substantial increase in the number of youth seeking gender-affirming chest masculinization surgery was observed globally. The study was hypothesized to answer the question as to whether the age limit of chest masculinization surgery should be lowered to include adolescents.

Methods

A retrospective cohort study was conducted, based on the experience of a single surgeon over a period of 20 years.

Results

Two-hundred eight patients were included in this cohort. Patients were divided into two equal groups based on their age. No statistically significant differences between the groups were observed in terms of resected breast tissue (P = 0.62 and 0.30, for the right and left breast, accordingly), auxiliary liposuction (P = 0.30), liposuction volume (P = 0.20), procedure (P = 0.15), postoperative drains (P = 0.79), and surgery duration (P = 0.72). Statistically significant differences were found in the 18 years or younger group, with lower rates of complication (P < 0.001), lower rates of revision surgery (P = 0.025), and higher satisfaction rankings (P < 0.001). Apart from age, no other factors were found to potentially explain the different rates of complications between the age groups.

Conclusion

Patients aged 18 or younger opting for chest masculinization surgery experience fewer complications and revision procedures while having higher satisfaction rates with the surgical outcome.

Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults

Importance

Transgender and nonbinary (TGNB) adolescents and young adults (AYA) designated female at birth (DFAB) experience chest dysphoria, which is associated with depression and anxiety. Top surgery may be performed to treat chest dysphoria.

Objective

To determine whether top surgery improves chest dysphoria, gender congruence, and body image in TGNB DFAB AYA.

Design, Setting, and Participants

This is a nonrandomized prospective cohort study of patients who underwent top surgery between December 2019 and April 2021 and a matched control group who did not receive surgery. Patients completed outcomes measures preoperatively and 3 months postoperatively. This study took place across 3 institutions in a single, large metropolitan city. Patients aged 13 to 24 years who presented for gender-affirming top surgery were recruited into the treatment arm. Patients in the treatment arm were matched with individuals in the control arm based on age and duration of testosterone therapy.

Exposures

Patients in the surgical cohort underwent gender-affirming mastectomy; surgical technique was at the discretion of the surgeon.

Main Outcomes and Measures

Patient-reported outcomes were collected at enrollment and 3 months postoperatively or 3 months postbaseline for the control cohort. The primary outcome was the Chest Dysphoria Measure (CDM). Secondary outcomes included the Transgender Congruence Scale (TCS) and Body Image Scale (BIS). Baseline demographic and surgical variables were collected, and descriptive statistics were calculated. Inverse probability of treatment weighting (IPTW) was used to estimate the association of top surgery with outcomes. Probability of treatment was estimated using gradient-boosted machines with the following covariates: baseline outcome score, age, gender identity, race, ethnicity, insurance type, body mass index, testosterone use duration, chest binding, and parental support.

Results

Overall, 81 patients were enrolled (mean [SD] age, 18.6 [2.7] years); 11 were lost to follow-up. Thirty-six surgical patients and 34 matched control patients completed the outcomes measures. Weighted absolute standardized mean differences were acceptable between groups with respect to body mass index, but were not comparable with respect to the remaining demographic variables baseline outcome measures. Surgical complications were minimal. IPTW analyses suggest an association between surgery and substantial improvements in CDM (-25.58 points; 95% CI, -29.18 to -21.98), TCS (7.78 points; 95% CI, 6.06-9.50), and BIS (-7.20 points; 95% CI, -11.68 to -2.72) scores.

Conclusions and Relevance

Top surgery in TGNB DFAB AYA is associated with low complication rates. Top surgery is associated with improved chest dysphoria, gender congruence, and body image satisfaction in this age 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.

Multicenter Analysis of Cardiometabolic-related Diagnoses in Transgender and Gender-Diverse Youth: A PEDSnet Study

CONTEXT

Studies on cardiometabolic health in transgender and gender-diverse youth (TGDY) are limited to small cohorts.

OBJECTIVE

This work aimed to determine the odds of cardiometabolic-related diagnoses in TGDY compared to matched controls in a cross-sectional analysis, using a large, multisite database (PEDSnet).

METHODS

Electronic health record data (2009-2019) were used to determine odds of cardiometabolic-related outcomes based on diagnosis, anthropometric, and laboratory data using logistic regression among TGDY youth vs controls. The association of gender-affirming hormone therapy (GAHT) with these outcomes was examined separately among TGDY. TGDY (n = 4172) were extracted from 6 PEDSnet sites and propensity-score matched on 8 variables to controls (n = 16 648). Main outcomes measures included odds of having cardiometabolic-related diagnoses among TGDY compared to matched controls, and among TGDY prescribed GAHT compared to those not prescribed GAHT.

RESULTS

In adjusted analyses, TGDY had higher odds of overweight/obesity (1.2; 95% CI, 1.1-1.3) than controls. TGDY with a testosterone prescription alone or in combination with a gonadotropin-releasing hormone agonist (GnRHa) had higher odds of dyslipidemia (1.7; 95% CI, 1.3-2.3 and 3.7; 95% CI, 2.1-6.7, respectively) and liver dysfunction (1.5; 95% CI, 1.1-1.9 and 2.5; 95% CI, 1.4-4.3) than TGDY not prescribed GAHT. TGDY with a testosterone prescription alone had higher odds of overweight/obesity (1.8; 95% CI, 1.5-2.1) and hypertension (1.6 95% CI, 1.2-2.2) than those not prescribed testosterone. Estradiol and GnRHa alone were not associated with greater odds of cardiometabolic-related diagnoses.

CONCLUSION

TGDY have increased odds of overweight/obesity compared to matched controls. Screening and tailored weight management, sensitive to the needs of TGDY, are needed.

Factors that drive mental health disparities and promote well-being in transgender and nonbinary people

Transgender (or trans) is an umbrella term for individuals who experience their gender differently from what is associated with the sex they were assigned at birth. Individuals who are nonbinary experience their gender outside binary conceptions of gender. Although research has predominantly focused on negative mental health outcomes for transgender and non-binary (TNB) individuals, an emergent literature has begun to explore protective and health-promoting factors and dimensions of psychological well-being. In this Review, we discuss the sociocultural context for TNB people, beginning with a brief history of TNB identity before highlighting frameworks for understanding the higher prevalence of certain mental health concerns among TNB individuals. Next, we summarize the predictive factors associated with higher rates of depression, anxiety, suicidality, trauma-related concerns, disordered eating behaviours and substance use. We also review TNB coping, resilience and resistance to anti-trans stigma, as well as psychological well-being, flourishing and gender euphoria. Tying these topics together, we discuss affirming interventions for reducing mental health disparities and promoting psychological health in TNB individuals and communities. We conclude by discussing future research directions.

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

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Legislation restricting gender-affirming care for transgender youth: Politics eclipse healthcare

In the past two years, in 25 US states, bills have been introduced to restrict access to gender-affirming medical care for minors. Some have already become law. We show how these bills, while purporting to “protect” trans youth, are really an assault on their ability, along with their parents’ and physicians’, to make healthcare choices and to receive medically necessary care. We discuss the evidence-based guidelines for the care of these patients, the positions taken by major medical societies against these bills, and the landscape of legal challenges that are being brought against these enacted laws.

Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents

Background

There are over 150,000 transgender adolescents in the United States, yet research on outcomes following gender-affirming mastectomy in this age group is limited. We evaluated gender-affirming mastectomy incidence, as well as postoperative complications, including regret, in adolescents within our integrated health care system.

Methods

Gender-affirming mastectomies performed from January 1, 2013 - July 31, 2020 in adolescents 12-17 years of age at the time of referral were identified. The incidence of gender-affirming mastectomy was calculated by dividing the number of patients undergoing these procedures by the number of adolescents assigned female at birth ages 12-17 within our system at the beginning of each year and amount of follow-up time within that year. Demographic information, clinical characteristics (comorbidities, mental health history, testosterone use), surgical technique, and complications, including mention of regret, of patients who underwent surgery were summarized. Patients with and without complications were compared to evaluate for differences in demographic or clinical characteristics using chi-squared tests.

Results

The incidence of gender-affirming mastectomy increased 13-fold (3.7 to 47.7 per 100,000 person-years) during the study period. Of the 209 patients who underwent surgery, the median age at referral was 16 years (range 12-17) and the most common technique was double-incision (85%). For patients with greater than 1-year follow-up (n=137, 65.6%), at least one complication was found in 7.3% (n=10), which included hematoma (3.6%), infection (2.9%), hypertrophic scars requiring steroid injection (2.9%), seroma (0.7%), and suture granuloma (0.7%); 10.9 % underwent revision (n=15). There were no statistically significant differences in patient demographics and clinical characteristics between those with and without complications (p>0.05). Two patients (0.95%) had documented postoperative regret but neither underwent reversal surgery at follow-up of 3 and 7 years postoperatively.

Conclusion

Between 2013-2020, we observed a marked increase in gender-affirming mastectomies in adolescents. The prevalence of surgical complications was low and of over 200 adolescents who underwent surgery, only two expressed regret, neither of which underwent a reversal operation. Our study provides useful and positive guidance for adolescent patients, their families, and providers regarding favorable outcomes with gender-affirming mastectomy.

Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults

OBJECTIVE

To examine associations between recalled access to gender-affirming hormones (GAH) during adolescence and mental health outcomes among transgender adults in the U.S.

METHODS

We conducted a secondary analysis of the 2015 U.S. Transgender Survey, a cross-sectional non-probability sample of 27,715 transgender adults in the U.S. Using multivariable logistic regression adjusting for potential confounders, we examined associations between access to GAH during early adolescence (age 14-15), late adolescence (age 16-17), or adulthood (age ≥18) and adult mental health outcomes, with participants who desired but never accessed GAH as the reference group.

RESULTS

21,598 participants (77.9%) reported ever desiring GAH. Of these, 8,860 (41.0%) never accessed GAH, 119 (0.6%) accessed GAH in early adolescence, 362 (1.7%) accessed GAH in late adolescence, and 12,257 (56.8%) accessed GAH in adulthood. After adjusting for potential confounders, accessing GAH during early adolescence (aOR = 0.4, 95% CI = 0.2-0.6, p < .0001), late adolescence (aOR = 0.5, 95% CI = 0.4-0.7, p < .0001), or adulthood (aOR = 0.8, 95% CI = 0.7-0.8, p < .0001) was associated with lower odds of past-year suicidal ideation when compared to desiring but never accessing GAH. In post hoc analyses, access to GAH during adolescence (ages 14-17) was associated with lower odds of past-year suicidal ideation (aOR = 0.7, 95% CI = 0.6-0.9, p = .0007) when compared to accessing GAH during adulthood.

CONCLUSION

Access to GAH during adolescence and adulthood is associated with favorable mental health outcomes compared to desiring but not accessing GAH.