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.

Veterinary attitudes towards pre-pubertal gonadectomy of cats: a comparison of samples from New Zealand, Australia and the United Kingdom

AIM

To compare the attitudes and practices of a sample of veterinarians in New Zealand, Australia and the United Kingdom (UK) towards pre-pubertal gonadectomy of cats.

METHODS

Respondents' demographics were gathered using an electronic questionnaire distributed via professional veterinary associations in the target countries, as were minimum age at gonadectomy and typical age of puberty. Desirability of prepubertal gonadectomy was gauged using three response categories ('yes', 'no' or 'sometimes'), respondents were then able to justify the response given. Two-way Analyses of Variance (ANOVA) followed by post hoc Tukey HSD tests were used to test whether there were differences in minimum ages for gonadectomy within and between countries and between providers and non-providers of services to pounds (or animal welfare centres). Views on the desirability of prepubertal gonadectomy relative to demographics were explored using a Likelihood Ratio Test.

RESULTS

The survey received 717 responses. Most respondents believed pre-pubertal gonadectomy was either entirely or 'sometimes' desirable (556/621), few thought it was undesirable (65/621). Minimum age at gonadectomy was significantly affected by country surveyed and provision or non-provision of services for pounds. Post hoc Tukey HSD analysis indicated the mean age of both spaying and castration (4.3 months) in the UK was significantly different from both Australia (spaying: 3.4 months, castration: 3.2 months) and New Zealand (spaying: 3.4 months, castration: 3.2 months) (all p<0.001). Mean ages at spaying and castration were also significantly different (p= 0.008; p= 0.019, respectively) for non-providers (spaying: 3.9 months, castration: 3.8 months) of services to pounds when compared to providers (spaying and castration: both 3.6 months). Likelihood Ratio Tests indicated significant effects amongst countries and between genders relative to the desirability of pre- pubertal gonadectomy. Respondents from the UK were more likely to answer 'no' (p = 0.004) or 'sometimes' (p = 0.050) as compared to those from New Zealand or Australia. Females were more likely to respond with 'sometimes' as opposed to 'yes' than males. Reasons for considering pre-pubertal gonadectomy desirable or sometimes desirable focussed on reducing unwanted pregnancies and improving population control, as well as improving rates of adoption, owner compliance and cat behaviour and health.

CONCLUSIONS AND CLINICAL RELEVANCE

In general, pre-pubertal gonadectomy is considered a desirable procedure by those practitioners that responded to the survey. However age at which any such procedure occurs differs depending upon a number of factors. Differences among countries may relate to the specific veterinary association's guidelines or possibly differences in social discourse which affect perception of cats. There is substantial overlap between the reported minimum age of gonadectomy and the age at which cats can enter early puberty, allowing a window for unintentional pregnancy when pre-pubertal gonadectomy does not occur.

Non-precocial grey-faced petrel chicks (Pterodroma macroptera gouldi) show no age-related variation in corticosterone responses to capture and handling

Development patterns in birds range from precocial species, which hatch chicks largely capable of independent existence, to altricial species, chicks of which are highly dependent on their parents for extended periods. Previous work indicates precocial chicks have a robust corticosterone response from hatching whereas non-precocial and altricial chicks have a small response that increases through development. Grey-faced petrels are characteristic of most burrowing procellariiform seabirds with non-precocial chicks that are unable to locomote and are dependent on adults for food, although chicks have well developed downy plumage and can thermoregulate at or soon after hatching. Initial plasma corticosterone concentrations and corticosterone responses to handling were measured during development in semi-precocial grey-faced petrel (Pterodroma macroptera gouldi) chicks to determine whether they showed a precocial or altricial corticosterone response pattern. Chicks were sampled at six intervals through development from shortly after hatching until close to fledging. Mean corticosterone responses to handling after 30 min were high (115.9+/-10.7 ng/ml) from 2 to 4d after hatching and remained high throughout development (70-110 ng/ml). Contrary to expectations for non-precocial chicks, this pattern of corticosterone responses to handling indicates that grey-faced petrel chicks are able to perceive and respond to potential stressors from hatching, a response previously only demonstrated for precocial birds.

Corticosterone Responses of Grey‐Faced Petrels (Pterodroma macroptera gouldi) Are Higher during Incubation than during Other Breeding Stages

We report the results of the first field study examining seasonal changes in corticosterone responses of typically long-lived birds of the order Procellariiformes. In particular, we examined whether grey-faced petrels Pterodroma macroptera gouldi showed changes in circulating baseline corticosterone concentrations and corticosterone responses to a standardized handling protocol across the breeding season. Such changes have been associated with changes in body condition and variations in energy demands on adult birds through the breeding season. During early incubation, males were in significantly better condition than females that had just completed laying, whereas during late incubation, males were in significantly poorer condition than females. In spite of these differences, there was no significant difference in baseline corticosterone concentrations between sexes or among birds at different reproductive stages. However, we detected significant differences in corticosterone responses associated with a standardized handling protocol at different stages through the breeding season. Responses were significantly greater during incubation compared with the prelay period and late chick rearing. Body condition was weakly and negatively correlated with maximum and total integrated corticosterone level, indicating that some of the individual variability in stress corticosterone responses could be explained by variation in body condition. However, the largest stress response occurred during late incubation and was independent of sex, although males were in relatively poor condition and females in relatively good condition. This period coincided with the breeding stage in which energy constraints on individual adults were higher than at other periods of the reproductive cycle and birds may be physiologically primed for extended fasts.

Opioids and the treatment of chronic pain in a primary care sample

Chronic pain is a widespread, difficult problem facing clinicians. This study assessed the current medical management of a general population of patients with chronic pain in 12 family medicine practices located throughout the state of Wisconsin. Medical record audits were conducted on a sample of 209 adults. Sixty-seven percent were female with an average age of 53 years. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% (n = 31) of the practitioners, pain scales 25% (n = 29), and urine toxicology screens 8% (n = 6). This study suggests that primary care practitioners have unique opportunities to identify and successfully treat patients with chronic pain.

Detection in chimpanzees of a novel flavivirus related to GB virus-C/hepatitis G virus

Infection with hepatitis G virus (HGV) or GB virus-C (GBV-C) is widely distributed in human populations. Viruses related to GBV-C/HGV have been recovered from several New World primate species, including tamarins, owl monkeys and marmosets. To understand more about the relationship between GB viruses and their hosts, we used primers from the 5' non-coding (5'NC), non-structural 3 (NS3) and NS5 regions in nested polymerase chain reactions to screen for related viruses infecting non-captive chimpanzees (Pan troglodytes, troglodytes and verus subspecies). Sequences from the 5'NCR and NS5 regions were amplified from samples taken from 3 of 39 chimpanzees, and from one chimpanzee in the NS3 region. Sequence comparisons of each region revealed that the GB virus infecting chimpanzees was distinct from both GBV-C/HGV and from any of the known GBV-A sequences, but was more closely related to human viruses. GB viruses recovered from different chimpanzees were more diverse than variants of GBV-C/HGV found in humans, with 25% sequence divergence in the 5'NCR and 20% (9.5% amino acid) sequence divergence in NS5 between variants recovered from the troglodytes and verus subspecies, compared with 7.4% and 10.4% (1.9% amino acid) divergence amongst GBV-C/HGV variants infecting humans. Finding GBV-C/HGV-related viruses in an Old World monkey species suggests that GB-like viruses may be widely distributed in simians, and suggests a close evolutionary relationship with their natural hosts.

The complete coding sequence of hepatitis C virus genotype 5a, the predominant genotype in South Africa

Hepatitis C virus (HCV) genotype 5a is the predominant genotype in southern Africa with a high prevalence amongst infected blood donors from areas in South Africa. We have determined the nucleotide sequence corresponding to the complete coding region of an HCV isolate, EUH1480, previously classified as genotype 5a, from an Edinburgh haemophiliac. The sequence contained a single open reading frame (ORF) coding for a polyprotein of 3014 amino acids. Comparison with the polyprotein sequences from other HCV genotypes, where the ORF varies from 3008 to 3037 amino acids, showed the observed variation in size was due to differences in lengths of the envelope 2 and the nonstructural 5A proteins. The sequence divergence of HCV genotype 5 ranged from 29.4% nucleotide differences (24.91% amino acid differences) compared with genotype 1c to 32.5% nucleotide differences (30.3% amino acid differences) compared with 2a. Phylogenetic analysis of the available full length nucleotide sequences showed EUH1480 to form a branch distinct from the other HCV types, confirming the classification of type 5a as a separate genotype.

Complete coding sequence of hepatitis C virus genotype 6a

Hepatitis C virus (HCV) genotype 6a is found in a restricted part of South East Asia, including Hong Kong, Macau and Vietnam. We determined the full length coding sequence of a type 6a isolate (EUHK2) obtained from a Hong Kong blood donor. The sequence of EUHK2 contained a single open reading frame coding for a polyprotein of 3018 amino acids, within the range of 3008 to 3037 for other HCV genotypes. The full length sequence of EUHK2 showed 30.3%-32.9% nucleotide (24.3%-29.4% amino acid) sequence divergence from genotypes 1-4, but only 27.7% (20.7% amino acid) divergence from JK046 ("type 11a"). These similarity values were intermediate between those of other HCV genotypes (minimum 28.4%) and between subtypes (maximum 25%). The close evolutionary relationship of EUHK2 with JK046 was further indicated by their grouping together by phylogenetic analysis.

Elevated maternal serum alpha-fetoprotein, second-trimester oligohydramnios, and pregnancy outcome

Although the primary purpose of maternal serum alpha-fetoprotein (AFP) screening is to detect open neural tube defects, the technique is of value in the diagnosis of other fetal abnormalities. Six patients from the Alpha-Fetoprotein Screening Program, Perinatal Region IV, were found to have twice elevated maternal serum AFP levels associated with severe early second-trimester oligohydramnios. Five of the fetuses were found to have urinary tract abnormalities. The source of the elevated maternal serum AFP is not clear. Pregnancy prognosis appears poor. These cases should be thoroughly studied so that patients may be accurately informed of the recurrence risk.

Extracellular cell wall lytic enzyme from Staphylococcus aureus: purification and partial characterization

An autolysin obtained from culture fluid of Staphylococcus aureus strain 8507 was purified 3,000-fold. One milligram of this preparation (S-5DL) will solubilize 12 mg of cell wall in 1 hr. The major activity is N-acetylmuramyl-l-alanine amidase. Recovery of lytic activity in the purified preparation was repeatably only 20% of the starting level. This suggests that other cell wall lytic enzymes may be present in the starting material. The S-5DL enzyme has been compared to freeze-thaw extracted enzyme (AFZ). Both enzymes precipitate in 0.01 m KPO(4) (pH 6.0) and dissolve in 0.1 to 0.7 m NaCl. Fifty per cent of the AFZ activity and 66% of the S-5DL activity bind rapidly to cell walls of S. aureus at 0 C in the presence of magnesium ion. None of the AFZ activity and 66% of the S-5DL activity bind to cell walls at 0 C in the absence of magnesium ion. The cell walls of nine different strains of S. aureus were compared for level of native autolysin activity. These same walls after inactivation of the native autolysin were tested for susceptibility to the S-5DL enzyme.