Efficacy of topical minoxidil in enhancing beard growth in a group of transgender assigned female at birth individuals on gender affirming hormone therapy

PURPOSE

Testosterone therapy represents the cornerstone of gender affirming hormone therapy (GAHT) among t-AFAB (transgender Assigned Female At Birth) people. Minoxidil is a vasodilator drug approved for topical use for the treatment of androgenetic alopecia. The aim of the present study was to evaluate the efficacy of topical minoxidil in enhancing beard growth in a group of t-AFAB people on GAHT.

METHODS

Sixteen t-AFAB individuals with an incomplete beard development, on GAHT for at least 6 months, were enrolled. Topical minoxidil was applied to the interested facial areas. Before starting (T0), after 3 (T3) and 6 (T6) months, we evaluated facial hair growth using the Ferriman-Gallwey modified score (FGm).

RESULTS

Subjects were 26 (2.7) years old and on GAHT for 18.5 [15-54] months; using a paired match evaluation, a statistically significant facial hair growth was observed over time, in particular at T6 (median upper lip FGm 3.5 [3-4] vs 2 [1-2] at T0 and chin FGm 4 [3.25-4] vs 1 [1-2] at T0; p ≤ 0.002). Comparing the minoxidil group with a control group (n = 16) matched for age and BMI who developed a full-grown beard only with GAHT, a logistic multivariable analysis identified hirsutism before GAHT was independently positively associated with the development of a full beard [OR 15.22 (95% CI 1.46-158.82); p = 0.023].

CONCLUSIONS

This is the first study demonstrating the efficacy of topical minoxidil in enhancing facial hair growth among t-AFAB people on GAHT. Further studies will be necessary to assess whether the obtained improvements will persist after discontinuing the medication.

[Contraception for transgender men: A case report and review]

All methods of contraception used by a cisgender woman can theoretically be used by a transgender man. In practice, some contraceptives can aggravate gender dysphoria and should be discarded. On the other hand, contraceptives which make it possible to consolidate amenorrhea or to accentuate the virilization induced by taking testosterone will be better tolerated.

Healthcare discrimination and factors associated with gender-affirming healthcare avoidance by transgender women and transgender men in Thailand: findings from a cross-sectional online-survey study

BACKGROUND

Although discriminatory experiences of transgender people seeking healthcare services have been well-documented in several studies, differentiating those experiences based on gender identity/expression and related factors has been limited. The aim of this study was to compare the characteristics, experiences, attitude, and expectation toward accessing healthcare service and healthcare providers of transgender women and transgender men in Thailand.

METHODS

A cross-sectional study was conducted from October 2017 to March 2018. The data were collected from transgender women and transgender men aged ≥ 18 years old who lived in Thailand using online platform via different websites and Facebook pages of local transgender group. Binary logistic regression was used to identify the factors related to the study outcomes.

RESULTS

Of 186 transgender people who responded to the questionnaire and were eligible for the study, 73.7% (95% confidence interval [CI] = 66.7-79.8) were transgender women and 26.3% (95% CI = 20.2-33.3) were transgender men. Transgender women were more likely to seek general healthcare from non-traditional healthcare services (crude odds ratio [cOR] = 4.28; 95% CI = 1.55-11.81; P = 0.005), buy hormone treatment from non-traditional healthcare services (cOR = 3.89; 95% CI = 1.18-12.83; P = 0.026), and receive healthcare counseling from non-traditional healthcare providers (cOR = 5.16; 95% CI = 1.42-18.75; P = 0.013) than transgender men. According to the results of applying a multivariable model, transgender respondents who did not know that gender-affirming healthcare services existed in Thailand were more unwilling to receive counseling from gender-affirming healthcare providers than those who did (adjusted odds ratio = 3.70; 95% CI = 1.11-12.36; P = 0.033).

CONCLUSIONS

The findings from this cross-sectional study indicate that transgender women are more likely than transgender men to receive general healthcare and hormone treatment from non-traditional healthcare services and buy hormone treatment without a physician's supervision. We also found approximately 15% of transgender individuals who did not receive gender-affirming counseling services. Continuing to improve access to care for the transgender community, increasing public relations channels may encourage transgender people to access more healthcare services.

Histopathologic Features of Breast Tissue From Transgender Men and Their Associations With Androgen Therapy

OBJECTIVES

To assess the histopathologic features of breast tissue of transgender men (TM) undergoing gender-affirming bilateral mastectomies in relation to androgen therapy (AT).

METHODS

We reviewed 374 transgender bilateral mastectomy cases from 2017 to 2020. Of these, 314 (84.4%) patients received preoperative AT. We compared these with 127 cases of cisgender females undergoing elective breast reduction.

RESULTS

Breast specimens from TM on AT, compared with cisgender women, showed a median higher gross percentage of fibrous tissue (P < .001), reduced lobular density (P = .004), higher amount of lobular atrophy (P < .001), and lower incidence of cysts (P < .001), apocrine metaplasia (P < .001), calcifications (P < .001), columnar cell change (P = .002), and atypia (P = .003). Each additional month of AT was associated with a 2% decrease in the odds of having nonapocrine cysts (P = .02), a 5% decrease in the odds of having usual ductal hyperplasia (P = .007), and a 0.14% decrease in median lobular density (95% confidence interval, -0.18 to -0.05).

CONCLUSIONS

In this study, breast specimens from TM, particularly with a history of AT, had a higher proportion of fibrous tissue, fewer lobules, and a higher degree of lobular atrophy than cisgender females. Rare cases of atypia were not predicted by preoperative imaging or gross findings, supporting routine microscopic evaluation of these specimens.

Affirming and negotiating gender in family and social spaces: Stigma, mental health and resilience among transmasculine people in India

Research on transmasculine people's health is scant globally, including in India. We explored transmasculine people's experiences in affirming their gender in family and social spaces, and how those experiences impact mental health. In 2019, we conducted four focus groups (n = 17 participants) and 10 in-depth interviews with transmasculine people in Mumbai and Chennai. Data analyses were guided by minority stress theory and the gender affirmation model. Within family, the pressure to conform to assigned gender roles and gender policing usually began in adolescence and increased over time. Some participants left parental homes due to violence. In educational settings, participants described the enforcement of gender-normative dress codes, lack of faculty support, and bullying victimisation, which led some to quit schooling. In the workplace, experiences varied depending on whether participants were visibly trans or had an incongruence between their identity documents and gender identity. Everyday discrimination experiences in diverse settings contributed to psychological distress. Amidst these challenges, participants reported resilience strategies, including self-acceptance, connecting with peers, strategic (non)disclosure, and circumventing gendered restrictions on dress and behaviour. Interventions at social-structural, institutional, family and individual levels are needed to reduce stigma and discrimination faced by transmasculine people in India and to promote their mental health.

Transgender men's preferences when choosing obstetricians and gynecologists

BACKGROUND

Transgender men are a marginalized population with unique health care needs. However, their usage of health services is low because of considerable discrimination. A major factor in their avoidance is patient-provider interactions.

METHODS

This cross-sectional study included 102 transgender men who anonymously completed a 55-item questionnaire in clinic, between 10/2017 and 01/2019. In addition, 92 transgender women filled out the part about family physician's preferences. We examined which characteristics transgender men prefer in their obstetricians/gynecologists in order to promote their usage of healthcare services.

RESULTS

A small majority of the transgender men (54.1%) had no gender preference for their obstetrician/gynecologist, while 42.9% preferred a female obstetrician/gynecologist and 3.1% preferred a male obstetrician/gynecologist. Most transgender men with a same-gender preference preferred female obstetricians/gynecologists for both invasive procedures (e.g., pelvic examination, 97.4%) and non-invasive procedures (e.g., cesarean section, 60%). The reasons for preferences regarding invasive procedures were feeling comfortable, embarrassment and feeling that female obstetricians/gynecologists are gentler. Transgender men who preferred female obstetricians/gynecologists ranked ability (90.5%), sexual tolerance (92.9%) and gender identity tolerance (90.5%) as the top three desirable qualities of obstetricians/gynecologists, while the responders who did not prefer female ranked ability (94.6%), experience (92.9%) and knowledge (92.9%) as the top three qualities. Transgender men with female preferences considered female obstetricians/gynecologists to be more accepting of gender identity compared to the responders that did not prefer females (47.5% vs. 9.1%, P < .001)..

CONCLUSION

A small majority of the transgender men exhibited no gender preference when choosing an obstetrician/gynecologist, although 42.9% preferred females. The latter choice was associated with the assumption that female obstetricians/gynecologists are more tolerant towards their transgender men patients. Educating the medical staff about their special needs and establishing dedicated SGM centers staffed with high percentages of female healthcare providers are highly recommended.

Bone mineral density, trabecular bone score and muscle strength in transgender men receiving testosterone therapy versus cisgender men

INTRODUCTION

Data on body composition, bone mineral density (BMD) and microarchitecture between cis and trans men are scarce. Few studies have reported trabecular bone score (TBS) data for transgender men using testosterone.

EXPERIMENTAL

We studied 19 transgender men and 19 cisgender men (mean age 23.6 ± 3.4 years, p = 0.539) paired by age and body mass index (BMI). They underwent clinical and hormonal evaluation, body composition measurement, and evaluation BMD, the TBS, grip strength, the level of physical activity (IPAQ) and physical performance (SPPB).

RESULTS

Median serum testosterone levels were similar between the cisgender and transgender groups (638 vs. 685 ng/dl; p = 0.863). Mean serum estradiol levels were slightly higher in the transgender men (51.95 ± 44.26 vs. 32.26 ± 8.40 pg/ml, p = 0.005), and the median testosterone use duration in the transgender group was 24 months. Total muscle mass (44.09 ± 6.27 vs. 55.71 ± 7.28 kg, p < 0.001), and hand grip strength (28.82 ± 5.42 vs. 40.34 ± 8.03 kg, p < 0.001) were considerably lower in the transgender men. Total body BMD (1.208 ± 0.132 vs. 1.271 ± 0.081 g/cm², p = 0.008) and femoral neck BMD (1.019 ± 0.163 vs. 1.137 ± 0.166 g/cm², p = 0.016) were lower in the transgender group. The TBS was similar between groups. Thus, our data demonstrated that despite similar serum testosterone levels, transgender men undergoing testosterone therapy had lower muscle strength, muscle mass, and total body and femoral neck BMD values than cisgender men.

Vaginal approach versus laparoscopy for hysterectomy in transgender men

STUDY OBJECTIVE

To describe a vaginal approach combining vaginal hysterectomy (VH) with transvaginal natural orifice transluminal endoscopic surgery (vNOTES) bilateral salpingo-oophorectomy (BSO) for hysterectomy in transgender men and to evaluate the feasibility, safety, and surgical outcomes of this approach in comparison with laparoscopy.

MATERIAL AND METHODS

Retrospective cohort study comparing outcomes of the vaginal approach (n = 45) and laparoscopy (n = 45) in transgender men undergoing hysterectomy between May 2017 and June 2020.

RESULTS

There was one intraoperative complication (bladder injury) in the laparoscopy group, which was the reason for the only conversion from the initial surgical approach. All vaginal procedures were completed without any intraoperative complications or conversions. Patients in the vaginal approach group had shorter operative times compared to the laparoscopy group (median 60 [range, 30-130] vs median 85 [range, 63-179] minutes; P < 0.001). One patient in the vaginal approach group experienced late-onset intraabdominal bleeding and underwent reoperation on postoperative day 4 after failed expectant management. There were no reoperations in the laparoscopy group. Patients in the vaginal approach group experienced less pain at postoperative 12 h and 24 h (P values < 0.001 and < 0.001, respectively). Postoperative hospital stay was shorter in the vaginal approach group than in the laparoscopy group (median 2 [range, 1-7] vs. median 2 [range, 2-6] days; P < 0.001). There were no readmissions within 30 days after surgery in either group.

CONCLUSION

The vaginal approach combining VH with vNOTES BSO is a feasible and safe alternative to laparoscopy for hysterectomy in transgender men.

Preliminary findings for adverse childhood experiences and associations with negative physical and mental health and victimization in transmasculine adults

INTRODUCTION

Studies highlight the impact of adverse childhood experiences (ACEs) on risk for negative health outcomes in adulthood, including cancer, cardiovascular disease, substance use, and mental health. Lesbian, gay, bisexual, and transgender (LGBT) people report higher rates of ACEs than non-LGBT people, with transgender people at greatest risk.

OBJECTIVE

This study aims to comprehensively assess the prevalence of ACEs and association with health outcomes among transmasculine individuals.

PARTICIPANTS AND SETTING

A sample of 131 transmasculine individuals enrolled in a clinical trial on preventive cervical cancer screening between March 2015 and September 2016 in the United States were surveyed about ACEs and health outcomes.

METHODS

Pearson's chi-squared tests and logistic regression models were used to examine associations between self-reported ACEs prior to age 18 and the risk of various negative health outcomes in adulthood. ACEs were categorized as 0-1 ACEs, 2-3 ACEs, and 4+ ACEs.

RESULTS

Over 90% of the sample (120/131) reported at least 1 ACE; 45% (59/131) reported 4+ ACEs. Report of 4 or more ACEs increased risk for negative health outcomes and risk factors compared to 0-1 ACEs, including: depression (AOR = 5.3, 95%CI = 1.7, 16.2), suicidality (AOR = 5.2, 95%CI = 1.4, 18.8), post-traumatic stress disorder (AOR = 6.0, 95%CI (1.6, 22.8)), intimate partner violence (AOR = 5.3, 95%CI = 1.4, 18.8), and obesity (AOR = 8.2, 95%CI = 1.8, 37.2). Report of 2-3 ACEs was also significantly associated with obesity (AOR = 5.9, 95%CI = 1.3, 26.2).

CONCLUSIONS

ACEs are highly prevalent in this sample, and more attention is needed for research and intervention. This exploratory study is the first to comprehensively highlight patterns of physical and mental health risk and victimization associated with report of ACEs among transmasculine individuals. Trauma-informed screening and intervention efforts tailored to the unique needs of this population are needed to provide appropriate and effective care. Clinicians should consider routinely screening for ACEs among transmasculine youth and engage in prevention strategies to reduce health disparities. Further research is warranted to validate these findings among larger, more representative samples to better reflect the diversity of experiences and identities of transmasculine individuals and produce more reliable findings.

Surgical outcomes of testicular prostheses implantation in transgender men with a history of prosthesis extrusion or infection

Background: Testicular prostheses implantation may be used for neoscrotal augmentation in transgender men. In current literature, explantation rates range from 0.6% to 30% and most are a result of infection or extrusion. Information on the surgical path of individuals after prosthesis explantation is scarce. Aim: To assess the frequency and success rate of testicular prosthesis implantation after previous explantation due to infection or extrusion. Methods: All transgender men who underwent testicular prosthesis explantation between January 1991 and December 2018 were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording demographics, surgical and prosthesis characteristics, reoperations, and outcomes. Results: A total of 41 transgender men were included who underwent testicular prosthesis explantation in the study time period. Of these, 28 (68%) opted for new prosthesis implantation. Most explanted prosthesis had a volume ≥30cc and were replaced with an equally sized one. The postoperative course was uneventful in 19 out of 28 (68%) individuals. Explantation of one or both prostheses occurred in 7 out of 28 (25%) individuals, because of infection (n = 3, 11%) or extrusion (n = 4, 14%). Patients that experienced complications had more often a history of smoking (p = 0.049). The explantation rate was lower if a smaller or lighter prosthesis was reimplanted (p = 0.020). Discussion: Most patients opt for testicular prosthesis implantation after previous explantation due to extrusion or infection. Explantation rates are higher than after the primary implantation procedure. Results of current study can be used to inform individuals on postoperative outcomes.

Ovarian stimulation outcomes among transgender men compared with fertile cisgender women

PURPOSE

To compare assisted reproductive technology (ART) outcomes among transgender men with those of fertile cisgender women.

METHODS

This retrospective cohort study included 12 transgender men, six with no testosterone exposure and six after testosterone treatment, and 12 cisgender women (oocyte donors) who underwent ART in our institution between June 2017 and December 2019. Statistical analyses compared ART data and outcomes between three groups: cisgender women, transgender men without testosterone exposure, and transgender men after testosterone exposure. Comparisons were also made between transgender men with and without testosterone exposure.

RESULTS

The transgender men with no testosterone exposure (23.3 ± 4 years) were significantly younger than the transgender men who had undergone testosterone treatment (30.3 ± 3.8 years; P = 0.012) and the cisgender women (29.1 ± 3.1 years; P = 0.004). The amount of FSH used for ovulation induction (1999 ± 683 mIU/mL) was significantly lower among transgender men without prior testosterone exposure compared with that among cisgender women (3150 ± 487 mIU/mL; P = 0.007). There were no differences in the peak estradiol levels, the number of oocytes retrieved, the number of MII oocytes, and the oocyte maturity rates between the three groups. Five out of six testosterone-treated transgender men underwent embryo cryopreservation, and they all achieved good-quality embryos.

CONCLUSIONS

Transgender men have an excellent response to ovulation stimulation even after long-term exposure to testosterone. Oocyte/embryo cryopreservation is, therefore, a feasible and effective way for them to preserve their fertility for future biological parenting.

Fertility preservation rates among transgender women compared with transgender men receiving comprehensive fertility counselling

RESEARCH QUESTION

What is the fertility preservation rate among transgender women who have received professional fertility counselling compared with transgender men?

DESIGN

This retrospective cohort study included 56 transgender women and 56 transgender men referred for comprehensive fertility counselling at the Gender Clinic of the Tel Aviv Sourasky Medical Center's Fertility Institute between January 2017 and April 2019. Statistical analyses were performed to compare transgender men with transgender women who preserved fertility and transgender people who preserved fertility and those that did not.

RESULTS

The fertility preservation rate of transgender women was significantly higher than that of transgender men (85.7% versus 35.7%, respectively, P < 0.001). The fertility preservation rate among transgender women was associated with being older and not having undergone gender-affirming hormone (GAH) treatment. The fertility preservation rate was higher among adolescent transgender boys compared with adolescent transgender girls (35% versus 6.25%, respectively, P = 0.005). The duration of GAH treatment among the transgender men who preserved fertility was 70 months compared with 18.6 months for transgender women (P = 0.05). All transgender boys opted for oocyte cryopreservation, while half of the transgender men who had not started GAH opted for oocyte cryopreservation, and half of those who had already started on GAH opted for embryo cryopreservation.

CONCLUSIONS

High fertility preservation rates among transgender individuals were found after comprehensive fertility counselling. Fertility preservation rates among adults were higher among transgender women compared with transgender men, while the opposite was found in transgender adolescents.

Vaginal bleeding and spotting in transgender men after initiation of testosterone therapy: A prospective cohort study (ENIGI)

BACKGROUND

Previous studies have cross-sectionally described amenorrhea in cohorts of transgender men on intramuscular or subcutaneous testosterone injections. It remains uncertain which testosterone preparations most effectively suppress vaginal bleeding and when amenorrhea occurs after testosterone initiation.

AIM

To investigate the clinical effects of various testosterone preparations on vaginal bleeding and spotting in transgender men.

METHODS

This prospective cohort study was part of the European Network for the Investigation of Gender Incongruence (ENIGI). Data on the persistence and intensity of vaginal bleeding and spotting, serum sex steroid levels and body composition were prospectively and cross-sectionally assessed in 267 transgender men during a three-year follow-up period, starting at the initiation of various testosterone preparations.

RESULTS

After three months of testosterone, 17.9% of transgender men reported persistent vaginal bleeding and 26.8% reported spotting. The percentages reporting vaginal bleeding and spotting decreased over the first year of testosterone (bleeding 4.7% and spotting 6.9% at 12 months, respectively), with no participants reporting vaginal bleeding or spotting after 18 months of testosterone. Factors associated with vaginal bleeding or spotting included lower serum testosterone levels and being on testosterone gel as compared to injections (e.g., esters or undecanoate preparations). If vaginal bleeding persisted, starting progestogens at three months resulted in a decrease in the intensity of vaginal bleeding and spotting.

DISCUSSION

Transgender men and hormone-prescribing providers can be reassured that vaginal bleeding and spotting usually stop within three months after testosterone initiation. If not, serum testosterone levels should be measured and testosterone dose adjusted to achieve serum testosterone levels in the physiologic male range. Adding a progestin can be considered after three to six months if bleeding persists. Providers should be aware that cessation of bleeding can be more difficult to achieve in transgender men with lower serum testosterone levels or those on testosterone gel.

Strategies used by transmasculine and non-binary adults assigned female at birth to resist transgender stigma in healthcare

Background: Transgender stigma is rampant within healthcare systems in the United States. Transgender adults assigned female at birth - including those identifying as transmasculine or non-binary - face unique barriers, such as stigma when accessing sexual and reproductive healthcare labeled as being for "women." However, transgender and non-binary people are not passive victims to this stigma, and the medical community would benefit from understanding the actions this population takes to resist and reduce transgender stigma in healthcare. Yet, little research has attempted to understand such actions. Aims: This qualitative study aims to explore how transmasculine and non-binary adults are actively resisting and reducing the impact of transgender stigma in healthcare. Methods: In-depth semi-structured interviews were conducted with 25 transmasculine and non-binary adults assigned female at birth who were living in a metropolitan area in the mid-Atlantic United States. The research team analyzed qualitative interview data using content analysis. Results: The 25 participants ranged in age from 21 to 57, with an average age of 33 years old. Six themes were identified related to resisting and reducing transgender stigma in healthcare: (a) using social support; (b) persistence to meet one's own needs; (c) avoiding mainstream healthcare; (d) advocacy; (e) doing one's own research; and (f) strategic disclosure of transgender/non-binary identity. We detail how privilege and intersectionality connect to the use of these strategies. Discussion: Findings indicate there is value in using peer advocates and peer health literacy; in developing and nurturing support groups related to transgender/non-binary health; in developing "allies" employed within the healthcare system; in creating and maintaining lists of culturally responsive health providers and resources about navigating the healthcare system; and in offering trainings related to self-advocacy and health-related activism. These findings can be used to inform future health prevention and intervention efforts with transmasculine and non-binary adults.

Ovarian stimulation for fertility preservation or family building in a cohort of transgender men

PURPOSE

The purpose of this study was to compare ovarian stimulation and pregnancy outcomes between transgender men (1) with and without a history of testosterone use (HRT) and (2) to cisgender women.

METHODS

Retrospective chart review between January 1st 2015 and March 1st, 2019 of transgender men and cisgender women seeking ovarian stimulation (OS) matched by BMI and age. Outcomes were compared using Fisher's exact or Wilcoxon's rank sum tests.

RESULTS

Thirteen transgender men presented for OS, 7 who used HRT. When comparing transgender men with and without a history of HRT, there were no differences in the baseline follicle count, cycle length, or FSH and hmG used (p = 0.193, 0.306, 0.200, and 0.197, respectively). Transgender men who used HRT had lower peak estradiol and oocytes retrieved compared to transgender men with no HRT use; peak estradiol levels of 1175 pg/mL IQR [559.5-2684]) vs 2713.5 pg/mL IQR [2335-3105]; oocytes retrieved 12 IQR [4-26]) vs. 25.5 [18-28] (p = 0.046. and 0.038, respectively). There were no differences in the estradiol level per oocyte, meiosis II oocyte yield, or maturity rate (MII/oocytes) between the two groups (p = 1.000, 0.148, and 0.147, respectively). Peak estradiol levels were lower among transgender men compared to cisgender women (p = 0.016), but the remaining cycle characteristics were similar between the two groups. Three successful pregnancies were conceived using the oocytes of transgender men who used HRT.

CONCLUSION

HRT use may not negatively impact ovarian stimulation outcomes. Clinical pregnancies are possible from the oocytes of transgender men with a history of HRT.

Transgender men, pregnancy, and the "new" advanced paternal age: A review of the literature

Transgender men are assigned female at birth, but self-identify as male. Although some transgender men undergo gender-affirming hormonal treatment and/or surgery that preclude pregnancy, many (if not most) retain their female reproductive organs and, as a result, their capacity to become pregnant. Although the visibility of the transgender community has increased, the exposure of healthcare providers to transgender individuals, especially transgender men during pregnancy, as well as research that addresses evidence-based practice remain limited. In this review, we discuss obstetrical issues for transgender men who are ≥35 years old, termed the "new" advanced paternal age. We review preconception care and focus on fertility issues, the impact of stopping gender-affirming hormonal treatment, and age-appropriate health maintenance. We review antepartum and postpartum care, including labor and delivery, monitoring for perinatal depression, contraception, and chest feeding. Finally, we conclude with suggestions for areas for further research and study.

Transmasculine Hormone Therapy

Prescribing gender-affirming hormonal therapy in transgender men (TM) not only induces desirable physical effects but also benefits mental health. In TM, testosterone therapy is aimed at achieving cisgender male serum testosterone to induce virilization. Testosterone therapy is safe on the short term and middle term if adequate endocrinological follow-up is provided. Transgender medicine is not a strong part of the medical curriculum, although a large number of transgender persons will search for some kind of gender-affirming care. Because hormonal therapy has beneficial effects, all endocrinologists or hormone-prescribing physicians should be able to provide gender-affirming hormonal care.

HIV-related care for transgender people: A systematic review of studies from around the world

RATIONALE

Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people.

OBJECTIVE

The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people.

METHOD

Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations.

RESULTS

From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment.

CONCLUSIONS

The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.

Stigma and diurnal cortisol among transitioning transgender men

This study assessed diurnal cortisol functioning in relation to stigma-based transition-specific stressors experienced by transgender men during their transition from female to male. Sixty-five healthy transgender men undergoing testosterone therapy participated in in-person interviews through which transition-specific stressors were identified. Interviews were coded according to participant reported (1) Transitioning-identity stress; (2) Coming Out stress; (3) Gender-specific Public Bathroom stress; and (4) levels of general Perceived Stress. Participants provided fifteen salivary samples assessing cortisol diurnal rhythm over three days. Hierarchical linear models, adjusted for duration of time on testosterone therapy, body mass index, steroid-related medication use, mean awakening time, and CAR, confirmed that elevated diurnal cortisol levels at awakening were associated with transition-specific social stressors including experiencing Transitioning-identity stress, frequent Coming Out stress, and Gender-specific Public Bathroom stress. Transitioning-identity stress and Gender-specific Public Bathroom stress also predicted a steeper negative slope at awakening. General Perceived Stress was not associated with elevated cortisol or slope. These results clarify the relation of increased cortisol at awakening with a negative linear slope to perceived stigma and transition-related stress experience among transgender men.