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.

Disorders of Sex Development (DSD): Peer Relations and Psychosocial Well-Being

Social and emotional development is shaped by familial and extra-familial experiences especially interactions with peers. Children and adolescents with physical, behavioral or developmental differences, such as youth with disorders of sex development (DSD), may not benefit to the same degree as other children and adolescents from experiences with peers. This paper reviews current thinking about the features and effects of experiences with peers and the potential challenges of peer interactions for children and adolescents with DSD. We review findings from studies of adjustment for individuals with DSD. We finish the paper with a brief outline of a research agenda to promote the understanding of adjustment of individuals with DSD.

Mayer-Rokitansky-Küster-Hauser syndrome: sexuality, psychological effects, and quality of life

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital condition in which a genetic female is born with vaginal agenesis and a rudimentary to absent uterus. This condition affects a woman's ability to menstruate, to engage in penile-vaginal intercourse, and to bear children. Much has been published about how best to create a neovagina in women with MRKH, but little has been written about the psychological impact of MRKH and quality of life outcomes for women with the condition. A review of the extant literature published from 1955 to 2007 supports that (1) surgical or non-surgical creation of a neovagina alone does not ensure a successful psychological outcome, (2) psychological support at critical times can be helpful, and (3) how professionals use language to discuss the condition may positively or negatively influence a female's experience of MRKH. This article discusses the implications that existing knowledge has on future research and on clinical practice. Understanding how women with MRKH cope with and adjust to the condition will help healthcare professionals provide optimal care.

Secondary amoebic eye infections in mice due to Acanthamoeba sp

The aim of the present study was to determine the occurrence of eye infections accompanying the infection of the central nervous system and to demonstrate the possible tissue affinity of different strains of amoebae in subsequent infections. The results obtained demonstrate a clear correlation between the occurrence of eye infection and the degree of virulence of the strains. Amoebae isolated from eyeballs and other organs of dead mice did not exhibit any specificity in relation to the organs in subsequent infections. Irrespective of the place of isolation--be it eye or brain--in the subsequent passages, the amoebae were most often found in the brain and lungs, followed only then by the eye of the infected animals.

Extracerebral infections of Acanthamoeba spp. in mice. pathomorphological changes in tissues of infected animals

A variety of Acanthamoeba spp. pathogenic strains were isolated from water pools in the area of Poznań. In many cases amoebae invaded lungs, kidney heart, liver and diaphragm causing significant changes in these Organs. The presence of amoeba outside of CNS was found mainly in the early periods of infection. Amoeba isolated from different organs of dead animals did not exhibit any specificity in relation to the organs in following infections. Infection with both low-and high-virulent strains resulted in pathomorphological changes of similar character. However, changes induced by low-virulent parasites developed later and were less extensive.

Biosynthesis of prostaglandins in pathogenic and nonpathogenic strains of Acanthamoeba spp

The aim of the present study was to examine the biosynthesis of prostaglandins and to investigate factors conditioning their biosynthesis in pathogenic and nonpathogenic strains of Acanthamoeba spp. We established that the activity of the synthase of prostaglandins was almost identical in pathogenic and non-pathogenic strains and that the synthesis of endoperoxide prostaglandins was similar to that of other organisms up to the point at which prostaglandin H2 was produced. The course of biosynthesis in vitro can be activated by various compounds such as glutathione, albumin, and p-chloromercuribenzoic acid (p-CMB), which are either activators or inhibitors of the enzymes. We suggest that the course of biosynthesis of prostaglandins in vivo is most probably activated by tissues or constitutional liquids surrounding the parasites.

The duration of the cyst stage and the viability and virulence of Acanthamoeba isolates

The viability of Acanthamoeba cysts after they have been stored in water at 4 degrees C for a period of 24 years was determined and to estimate their present degree of virulence as compared to its primary values. The viability of 17 amoebae isolates was examined using the eosin exclusion and in vitro excystation on agar plates (NNE). After the period of 24 years, only 3 isolates were found dead. The remaining 14 isolates after inoculation on NNE gave rise to new subcultures, although the percentage of living cysts measured by eosin exclusion was low (0-5%). Separate groups of mice were inoculated intranasally with 10 subcultures characterised by varying primary virulence. It was found that in 8 groups the mice were invaded (at varying degree), and some of them died. Taking into consideration the fact that some of the examined isolates completely lost their virulence only after 8 years of the in vitro cultivation, the obtained results are very intriguing. On the ground of these results one can assume that in the natural environment the period of viability for a cyst may be not shorter than 25 years, and, which is even more essential, they can maintain their invasive properties.

The effect of the passages of Acanthamoeba strains through mice tissues on their virulence and its biochemical markers

The aim of this study was to determine the enzymatic differences in the process of increasing the degree of virulence in attenuated Acanthamoeba strains as well as strains freshly isolated from the natural environment. The data obtained in our studies indicate that by intranasal infection of mice, one can restore virulence in primary virulent strains and make virulent strains that primarily were noninvasive. The levels of peroxidase and proteinase activity measured thoroughly correlated with the increase in the degree of virulence observed during the process of making the amoeba virulent by inoculating them into mice. We observed that in cases in which the activity of peroxidase and proteinase was higher than 0.150 units/mg protein and 8 units/mg protein, respectively, some of the animals infected with the strains showing this activity of peroxidase and proteinase died. In nonvirulent strains as well as in poorly virulent strains, we observed a decidedly lower activity of these enzymes.

[Amebic keratitis-keratitis acanthamoeba]

In seventeen patients who suffered of corneal ulcer, and were negative in bacteriological and mycological examinations, parasitological tests were performed between 1990-1992. Acanthamoeba keratitis was diagnosed in one patient with characteristic corneal changes of right eye following trauma. The patient was not a contact lens wearer. The amoeba found in direct smears of scraping from corneal ulcer and isolated and cloned in in vitro conditions (isolate-clone-No. 2961) belonged to Acanthamoeba polyphaga species. The trophozoites showed a low degree of invasiveness and high virulence when tested in BALB/c mice. The authors discussed the epidemiology of Acanthamoeba keratitis and pointed out to the necessity of accurate laboratory diagnosis and discerning interpretation of the results to prevent an Acanthamoeba-phobia among the potential patients and most of all among the medical staff.

Proteolytic enzymes of pathogenic and non-pathogenic strains of Acanthamoeba spp

The aim of this work was biochemical characterization and classification of proteinases in pathogenic and non-pathogenic strains of Acanthamoeba spp. The authors showed two proteinase (acid 35 kDa and alkaline 65 kDa) which could be separated electrophoretically. Acid proteinase was inhibited by serine proteinase inhibitors such as DIFP. The second enzyme which was active at alkaline pH, was enhanced by EDTA and inhibited by iodoacetate (IAA) and (p-CMB) p-chloromercuribenzoate. These substances are known to inhibit cysteine type proteinases. The alkaline proteinase was more distinctively active in pathogenic strains and belongs to cysteine class (EC 3.4.22), whereas the acid proteinase was similar active in pathogenic and non-pathogenic strains and belong to serine class (EC 3.4.21).

Biochemical markers of pathogenicity and virulence of Acanthamoeba sp. strains

The aim of our study was to demonstrate a possible correlation between some biochemical and biological markers of the degree of virulence of the investigated strains of Acanthamoeba sp. The results obtained demonstrated a significant correlation between the activity of proteases, peroxidases, and superoxide dismutase and the degree of virulence of the strains as previously defined by tests on mice. The results also proved that the strains that killed some of the infected mice were characterized by the highest value recorded for the activity of peroxidase and the lowest value obtained for the activity of superoxide dismutase.

Pubertal disorders. Psychology and clinical management

The behavioral data reviewed herein must be viewed with caution. Although there are reports that adhere to rigorous methodology, these are the exception. Most reports do not adequately describe either the methodology used or their sample. Subjects are often of mixed endocrine diagnoses, and sometimes the results are of both boys and girls. All of these pitfalls make interpretation of results difficult and limiting. With this in mind, the following conclusions are offered. The majority of behavioral data on precocious puberty comes from studies of IPP in girls. Cognitively, IPP has been associated with average to high-average intelligence. Purportedly, the finding of lower visual-spatial skills than verbal skills in early maturing boys and girls has received equivocal support by cognitive studies of IPP individuals. Similarly, clear differences in hemispheric lateralization have not been demonstrated. Aside from increased somatic complaints during the nonmenstrual phases of their menstrual cycle, girls with IPP show a spectrum of behavior adjustments. Major psychopathology is rare. Clearly, their early development makes them look older than their actual age, which probably alters the expectations others have for them. Psychosexually, however, IPP girls develop in concert with their chronologic age and social experience, rather than their early biologic maturation. However, recent reports suggest a modest influence of hormones. In summary, these studies support an interactionist theory of human psychosexual development. Research data on IPP girls suggest that they do not significantly differ from girls who are early maturers but within the normal range. Research on these girls indicates that most negotiate their puberty without severe problems. There has been less research on IPP boys because it occurs so rarely. Most of what is understood about precocious puberty in boys comes from boys with precocious puberty secondary to poorly controlled CAH. Behavioral data on individuals with delayed puberty come almost exclusively from boys. Although CD appears to be the most frequently diagnosed form of delayed puberty and does not reflect a known pathologic process, men with CD as well as those with organic disorders appear to be at risk for psychosocial and psychosexual difficulties. These difficulties are not severe forms of psychopathology. Rather, they probably represent problems negotiating the expected adolescent lessons of psychosocial development with a physique that places them at a disadvantage. They clearly look younger than their actual chronologic age. Cognitively, as with the children with precocious puberty, there is no evidence of intellectual impairment associated with delayed puberty.(ABSTRACT TRUNCATED AT 400 WORDS)

Management of male pseudohermaphroditism: a case report spanning twenty-one years

Management of infants born with ambiguous sex organs requires the close collaboration of a team of professionals: pediatric endocrinologist, pediatric psychologist, gynecologist, and surgeon. The interdisciplinary teamwork of a group of professionals is described in the case of a patient announced at birth as a male but within days reannounced and reared as a female. Over the next 21 years, she became completely aware of her endocrine condition, including its medical classification (male pseudohermaphroditism), her chromosomal (46 XY) and gonadal (testes) status, and her early history of male sex assignment. The clinical management described herein helped this person deal effectively with her condition despite unsuccessful reconstructive vagal surgery. Substantiation of this is provided by the patient's personal comments.

Data on virilization and erotosexual behavior in male hypogonadotropic hypopituitarism during gonadotropin and androgen treatment

The goal of this investigation was to assess whether or not gonadotropin therapy enhanced the degree of virilization and psychosexual behavior of men with hypogonadotropic hypopituitarism. Pre- and post-gonadotropin assessments of virilization in four men indicated that gonadotropin therapy was associated with dramatic improvements in the degree of virilization that each man previously obtained on androgen only. Retrospective interview data on erotosexual behavior indicated improved erotosexual function on gonadotropin as compared to the prior androgen treatment. These data suggest that complete virilization in these men was partially gonadotropin dependent. Whether or not the behavioral benefits reported by these men represented a direct or synergistic effect of gonadotropin in the expression of erotosexual behavior or an indirect effect of improved virilization can not be answered by these data.

Micropenis. III. Primary hypogonadism, partial androgen insensitivity syndrome, and idiopathic disorders

This paper, the third in a series, presents data from 28 patients with micropenis categorized as primary hypogonadism (11 subjects), partial androgen insensitivity (1 subject), idiopathic (6 subjects), and etiology undetermined (10 subjects). Among the 11 patients with primary hypogonadism, 8 presented with various degrees of gonadal dysgenesis, 1 was a true hermaphrodite and 2 had the Robinow syndrome. Nine of the 28 patients were raised as females: 5 with primary hypogonadism and 4 with undetermined etiology. Eleven of the 19 patients raised as males received androgen stimulation during prepubertal years and responded with penile growth. However, this growth response was temporary and did not appear to be predictive of eventual adult size of the penis. Generally, the prestimulation size of this group of patients is more predictive of adult penile size. Only 7 of the patients raised as males have attained adult somatic growth. Three out of the three with primary hypogonadism, the subject with partial androgen insensitivity, and one of three with idiopathic micropenis have below-normal adult penile length. These limited data suggest that growth potential of the micropenis may be greater among the patients with an idiopathic state than among those with primary hypogonadism and partial androgen insensitivity.

Micropenis. II. Hypogonadotropic hypogonadism

This paper documents the case histories of 14 patients with hypogonadotropic hypogonadism and micropenis (penile length below 2.5 SD from the mean for the patient's chronlogical age, or for age corresponding to stage of sexual development). Nine of the patients were raised as males. Five of them received androgen for the purpose of stimulating penile growth: two realized normal adult penile length (-0.2 and -2.1 SD from normal mean length) whereas the other three had penile lengths significantly below the mean (-3.6, -4.6 and -5.2 SD from normal mean length). These data suggest that among hypogonadotropic patients with micropenis, those with prepubertal penile lengths between 2.5 and 3 SD below the mean may develop an adult penis of a length within the normal range. However, for those presenting with a shorter phallus, the expectation is that penile length will remain greater than 2 SD below the mean.

Micropenis. I. Criteria, etiologies and classification

A micropenis is an abnormally small penis with a normal configuration. This finding constitues a sign not a diagnosis. The etiologies may be classified as hypogonadotropic hypogonadism, primary hypogonadism, androgen insensitivity, or idiopathic; among 45 patients, the respective percentages in these categories were 31, 24, 2 and 7% with 36% as yet undiagnosed. Various clinical syndromes may include a micropenis and can be classified in one of the etiologic categories. This paper provides the criteria for determining the presence of a micropenis. A phallic length which is 2.5 or more standard deviations below the mean should be considered as abnormal; for an infant of 0 to 5 months of age, the lower limit is 1.9 cm. The technique of penile measurement, determination of etiology, guidelines for sex of rearing and psychologic, surgical and medical management are discussed.

Counseling after resection of the penis

Surgery is the most effective means of controlling or curing cancer of the penis, but management of a patient with penile cancer encompasses more than excising the lesion. Anticipatory guidance and counseling are required components of total patient care. An integral part of counseling is psychotherapy, including marital and sex therapy. This comprehensive management program is best provided by a team of health care professionals including the family physician.

Electrophoretic characterization of small free-living Amoebae

Disc electrophoresis was employed in an attempt to determine its usefulness as a means of differentiating and classifying some free-living species of amoebae. The Rp values and the percentage of similarity of the protein bands were used as taxonomic criteria. Some species of the genera Hartmanella and Naegleria were examined. The protein patterns of all species studied were highly reproducible. Four strains of Hartmannella castellanii showed an absolute identity to the original H. castellanii strain. One strain isolated by Neff and H. rhysodes were similar to all the other strains although their protein patten were not completely identical. On the other hand, H. culbertsoni, H. astronyxis and H. lammellipodia were different from all the other examined species of Hartmannella. Pathogenic N. fowleri-strains were identical to each other and were different in their protein patterns from non-pathogenic N. gruberi strain. The similarities and differences of protein bands of strains of ameobae and their correlations with other attributes were discussed. The results have shown that the disc electrophoresis appears useful in differentiating between species of Hartmannella and Naegleria.