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Studies of the U.S. population in general and transgender and gender diverse (TGD) communities specifically suggest that religion and spirituality (R/S) can function in both positive and negative ways, including on health outcomes. Patients recovering from gender-affirming surgeries were asked by chaplains, during the course of spiritual care visits, to describe their R/S identities in their own words. Seventy-five responses were included in the study and were coded. Six themes and 10 sub-themes were identified. The themes were (1) centeredness in self; (2) transcendent belief system; (3) non-religious belief systems; (4) importance of prayer; (5) R/S identity and practice as fixed and consistent; and (6) R/S identity and practice as flexible, contextual, and transforming. The findings broadly reflected national data about R/S belonging, including trends related to the growing share of the population that identifies as atheist, agnostic, or spiritual but not religious; ambivalent relationships with R/S communities due to transphobia; and R/S beliefs and practices as supportive. Implications for chaplaincy practice are discussed, including the need for chaplains to understand both demographic trends and the intersections of R/S and transphobia.

Purpose of Review: An update on the latest advances in surgical decision-making for genital gender-affirming surgery (GGAS), with an emphasis on patient education from three perspectives: surgeon-team perspectives, patient perspectives, and educational resources available to the public on social media., Recent Findings: Transgender, nonbinary, and other culturally specific gender identities (TGNB) patients overwhelmingly desire an active role in the decision-making process. New developments in patient-engagement strategies help mitigate the harm of historical gatekeeping practices by centering the needs and experiences of TGNB patients to create a prioritized research agenda for GGAS effectiveness. Patient educational resources play an integral role in navigating the complexity of GGAS-surgical options, informing patients of the technical and logistical knowledge required for GGAS surgical decision-making. Peer support experiences are a critical facilitator for patient surgical decision-making, both for informed decision-making and for psychosocial support., Summary: Several developments have been made in examining shared-decision making, educational resources from the perspectives of both the surgical team and patients, and the role of social media in GGAS. Surgeons must continue to initiate robust conversations of patient goals, GGAS surgical options, the possible risk and benefit profiles of each option, and aftercare requirements, all while prioritizing patient-engagement strategies., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Regret after gender-affirming surgery (GAS) is a complex issue. Comparing regret after GAS to regret after plastic surgery operations and other major life decisions is a novel approach that can provide insight into the magnitude of this issue. A systematic review of three databases was conducted to investigate regret after common plastic surgery operations. Three separate literature reviews on regret after GAS, regret after elective operations, and regret after major life decisions were performed. A total of 55 articles examining regret after plastic surgery were included. The percentage of patients reporting regret ranged from 0 to 47.1 ​% in breast reconstruction, 5.1-9.1 ​% in breast augmentation, and 10.82-33.3 ​% in body contouring. In other surgical subspecialties, 30 ​% of patients experience regret following prostatectomy and up to 19.5 ​% following bariatric surgery. Rate of regret after GAS is approximately 1 ​%. Other life decisions, such as having children and getting a tattoo have regret rates of 7 ​% and 16.2 ​%, respectively. When comparing regret after GAS to regret after other surgeries and major life decisions, the percentage of patients experiencing regret is extremely low., Competing Interests: Declaration of competing interest This work has not been published previously, it is not under consideration for publication elsewhere, and its publication is approved by all authors. If accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The aim of this study was to evaluate different aspects of transition outcomes in groups of transgender and gender diverse (TGD) people based on their transition status. We divided the 70 TGD participants (19 individuals assigned male at birth and 51 assigned female at birth) into two groups: those who had completed their psychiatric and psychological evaluation (PPE), which is mandatory in Croatia, and those who had undergone gender-affirming medical treatment (GAMT) (both gender-affirming hormone treatment and gender-affirming surgery). The online survey included sociodemographic questions and a custom-designed nine-item scale. The items were specifically designed based on the DSM-5-TR criteria for gender dysphoria to assess subjectively perceived transition outcomes. We conducted a factor analysis of the scale followed by structural equation modeling for confirmation. Chi-squared and Mann-Whitney U tests were used to compare group differences. The following three-factor structure was confirmed: better functioning, reduced body dysphoria, and satisfaction with decision. A positive influence of better functioning on satisfaction with the decision was found. In addition, our results showed that TGD individuals who had undergone GAMT scored higher on better functioning than those who had just completed PPE. Both groups consistently scored high on satisfaction with the decision, with no statistically significant differences between them. Our findings suggest that TGD individuals view gender-affirming medical care as beneficial to their overall functioning., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system., Methods: We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations., Results: We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women ( n = 13) and White ( n = 14). Participants lived in rural ( n = 4), suburban ( n = 5), or urban ( n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations)., Interpretation: Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences., Competing Interests: Competing interests:: Gianni Lorello reports funding from the Canadian Institutes of Health Research (CIHR), Social Sciences and Humanities Research Council, the Royal College of Physician and Surgeons of Canada, and the University of Toronto, as well as remunerated positions for the Royal College of Physicians and Surgeons of Canada as well as the University of Toronto, MD Program. He is a guest editor with the Canadian Journal of Anesthesia. Emery Potter reports funding from the CIHR and consulting fees from Rainbow Health Ontario. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed., Objectives: To investigate sexual health after gender-affirming vaginoplasty for TGD patients., Data Sources: MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design., Methods: We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids., Results: Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia., Conclusions: The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014., (© 2021 American Society of Andrology and European Academy of Andrology.)

Penile inversion vaginoplasty helps to alleviate gender dysphoria and improve quality of life in many transgender individuals. Overall, the procedure is associated with high post-operative satisfaction, even when complications occur. Adverse events related to vaginoplasty are commensurate with other genitourinary reconstructive procedures performed for other diagnoses (ie, cancer or congenital issues). Here, we explore the incidence of complications following vaginoplasty, emphasizing the challenges in defining and managing these adverse events. In addition, outcome measures to assess patient satisfaction will be reviewed., (© 2021 American Society of Andrology and European Academy of Andrology.)

Background: Dermatologists have the opportunity to provide medically necessary procedures, including laser hair removal, to transgender patients for gender affirmation. Further research is required to better assess the unique dermatologic needs of this population., Objective: To examine the prevalence of dermatologic procedures among transgender people in the context of gender-affirming treatment., Methods: This cross-sectional study examined survey responses from 696 transgender persons enrolled in the Study of Transition, Outcomes, and Gender cohort. Prevalence of self-reported dermatologic procedures was examined and compared across participant subgroups., Results: Electrolysis was the most commonly reported procedure (32.9%). Transfeminine patients were more likely to use dermatologic procedures compared with transmasculine patients. Only 19 participants (2.8%) reported the use of dermal filler injections., Conclusion: Differences in utilization of dermatologic procedures were noted in transgender populations. Motivations, barriers, and optimal timing for gender-affirming dermatologic procedures among transgender persons should be examined in future studies., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature., Methods: PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized., Results: Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery., Conclusion: Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: We investigated quality of life, long-term lower urinary tract symptoms, sexual function and subjective attitudes toward surgery in adult women after feminizing genitoplasty for congenital adrenal hyperplasia., Materials and Methods: We retrospectively reviewed the medical files of all patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty from 1996 to 2018 in our tertiary center. Of those, patients older than 16 years of age were asked to answer 1 nonvalidated and 3 standardized and validated questionnaires evaluating their current mental well-being (WHO-5 Well-Being Index), lower urinary tract symptoms (ICIQ-FLUTS) and sexual function (GRISS). The anonymized answers of this cross-sectional study were compared to a control group of 50 healthy females. Student's t-test, Pearson's χ 2 test, Fisher's exact test and Spearman's rank correlation coefficient were performed. A p-value less than 0.05 was considered significant., Results: Out of 106 patients who underwent feminizing genitoplasty, 64 patients were included and 32 patients, aged 17 to 40 years (median 25.5 years), answered the questionnaires (50% response rate). The difference between congenital adrenal hyperplasia and control group mental well-being was not statistically significant (WHO-5 median score 60 and 64, respectively; p=0.82). We found no significant difference in the lower urinary tract symptoms subscales of filling, voiding or incontinence, nor in the overall lower urinary tract symptoms score (ICIQ-FLUTS overall median score 3.5 and 3, respectively; p=0.43)., Conclusions: We found in our group no abnormal mental well-being or prevalence of long-term symptoms of lower urinary tract dysfunction in adult female patients with congenital adrenal hyperplasia following feminizing genitoplasty.

During the past 10 years, academic publications that address facial feminization surgery have largely examined the technical aspects of the different surgical procedures involved and clinical evaluations of postoperative results. This Special Topic article focuses on aspects that are underdeveloped to date but useful with regard to taking the correct therapeutic approach to transgender patients who are candidates for facial gender confirmation surgery. The authors propose a protocolized sequence, from the clinical evaluation to the postoperative period, based on a sample size of more than 1300 trans feminine patients, offering facial gender confirmation surgery specialists standardized guidelines to handle their patients' needs in a way that is both objective and reproducible.

Background: There are few studies evaluating depression, self-esteem, and mental health after gender confirming treatment of transgender women. Most of these studies include different surgical techniques and nonvalidated questionnaires. With our survey, we are aiming to assess psychopathologies and mental health as well as sexuality among a group of patients treated by the same surgeon performing our self-developed combined surgical technique. This vaginoplasty approach is characterized by constructing the vaginal cavity with parts of the penile and scrotal skin as well as the longitudinally incised urethra., Materials and Methods: Forty-seven transgender women who underwent gender confirming treatment between 2007 and 2013 were included in a retrospective study. The assessment of our study group was performed by means of self-developed indication-specific questionnaires and 3 standardized questionnaires that can be compared with norm data., Results: Preoperative psychotherapy was mostly considered as helpful by the patients, yet postoperatively, only a third of our study participants were still under therapeutic treatment. Furthermore, we could show a change in sexual preference toward a more bisexual orientation. Gender confirming treatment satisfied the expectations for most of the patients and, in their opinion, should have been performed earlier. Results of the standardized Patient Health Questionnaire 4, a short depression screening questionnaire, did not significantly differ from healthy norm data. The Freiburg Personality Inventory, Revised, revealed normal emotionality and sane self-assessment within our study group. High self-esteem and significantly higher scores than norm data were found for the Rosenberg Self-esteem Scale., Conclusions: Gender confirming treatment with the combined technique is an important part of a multi-structured treatment of transgenders and does have effects on psychological well-being. It seems to decrease psychopathologies and implicates several ameliorations for transgender women. Findings need to be verified in prospective studies including preoperative evaluations.

Background: Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty., Methods: A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed., Results: A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent)., Conclusions: Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course., Clinical Question/level of Evidence: Therapeutic, III.

This article argues that the rise of bioethics in the post-WWII era and the emergence of the legal doctrine of informed consent in the late 1950s should have had a greater impact on patients with intersex traits (atypical sex development) than they did, given their emphasis on respect for autonomy and beneficence toward patients. Instead, these progressive trends collided with a turn in intersex management toward infants, who were unable to provide autonomous consent about their medical care. Patient autonomy took a back seat as parents heeded physicians' advice in an environment even more hierarchical than we know today. Intersex care of both infants and adults continues to need improvement. It remains an open question whether the abstract ideals of bioethics-respect, patient autonomy, and the requirement of informed consent-are alone adequate to secure that improvement, or whether legal actions (or the threat of litigation) or some other reforms will be required to effect such change., (© The Author(s) 2019. Published by Oxford University Press; All rights reserved. For permissions, please email: journals.permissions@oup.com.)

For individuals with gender dysphoria, gender-affirming surgeries (GAS) are one means of reducing the significant distress associated with primary and secondary sex characteristics misaligned with their gender identity. This article uses a systematic review to examine the existing literature on the psychological benefits of GAS. Findings from this review indicate that GAS can lead to multiple, significant improvements in psychological functioning. Methodological differences in the literature demonstrate the need for additional research to draw more definitive conclusions about the psychological benefits of GAS., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Learning Objectives: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty., Summary: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

Genital gender-affirming surgery (GAS) aims to alleviate feelings of gender dysphoria and support psychosexual outcomes. However, little is known of sexual activity and satisfaction of transmen after phalloplasty or metoidioplasty. A clinical follow-up study was conducted in transmen at least one year after genital GAS in order to evaluate measures of experienced sexuality. Participants ( N  = 38) received a set of self-constructed questionnaires on sexual relationships and orientation, use of genitals during sexual contact, and the experienced influence of surgery on sexuality. Twenty-nine had received phalloplasty, nine metoidioplasty. The average follow-up time was 32 months. The majority reported to be sexually active. The use and enjoyment of both chest and genitals during sexual activity increased after surgery. Other areas of improvement included arousability, sexual interest, and pleasure. Free text comments provided an insight into the role of genital sensation and sexual self-esteem in postoperative sexuality. In conclusion, genital GAS positively impacts transmen's sexuality, although possible issues with genital sensation or penetration may exist and should be communicated preoperatively. Therefore, we recommend interdisciplinary collaboration on this subject.

Objective: Gender dysphoria is estimated to occur in over 1 million people in the United States. With decreasing stigma regarding the transgender population, it is likely more patients will seek medical and surgical gender transition as parts of their treatment. However, otolaryngologists may lack training in gender-confirming surgery. This study aims to determine the current state of transgender-related education in the United States otolaryngology training programs and to evaluate trainee perceptions regarding the importance of such training., Methods: A cross-sectional survey was performed among the United States otolaryngology training programs. A representative sample of 22 training programs divided within 4 US Census regions completed a cross-sectional 9-question survey between March and May 2017. Respondents were queried regarding demographics, transgender curricular exposure (didactic and/or clinical), and perceived importance of training in transgender patient care., Results: A total of 285 trainees responded (69.3% response rate). Thirty percent of respondents reported education on or direct exposure to transgender care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to facial (masculinization or feminization) or pitch alteration surgery. Overall, the majority of respondents believed training in gender-confirming surgery is somewhat important and 63.2% supported incorporation of transgender patient care in existing subspecialty fellowship training., Conclusion: Less than one-third of otolaryngology trainees are exposed to transgender patient care. The majority of trainees endorsed the importance of residency and subspecialty fellowship training in gender-confirming surgery. To better serve the transgender population, formal didactics on gender-confirming surgery should be offered.

The present study aims to provide an overview of experiences of discrimination, harassment, and violence in a sample of Italian transsexuals who have undergone sex-reassignment surgery (SRS). Lack of support for gender transition from family members was also assessed, before and after SRS. Data were collected in the context of a multicentric study (Milan, Florence, and Bari) on SRS outcome. Patients who underwent SRS were contacted and asked to fill out a questionnaire concerning experiences of discrimination, harassment, violence, and crime they might have experienced in previous years. Seventy-two participants took part in the research: 46 were male-to-female (MtF; 64%) and 26 were female-to-male (FtM; 36%). Thirty-six percent of the total sample (with no differences between MtF and FtM) experienced at least one episode of harassment, violence, or discrimination. The workplace was reported to be the social area with the highest risk of discrimination and harassment (22% of participants). Reports of more than one incident of discrimination, harassment, and violence characterized the majority of participants in the MtF sample. Compared with previous studies carried out in other countries, a much larger proportion of participants could count on a supportive family environment before and after transition. Our results show that Italian society at large is prejudiced against transsexuals, but at a more "micro" level, having a trans person as a family member might result in a protective and tolerant attitude.

The requests for medically necessary surgical interventions for transgender individuals have steadily increased over the past several years. So too has the recognition of the diverse nature of this population. The surgeon relies heavily on the mental health provider to assess the readiness and eligibility of the patient to undergo surgery, which the mental health provider documents in a referral letter to the surgeon. The mental health provider explores the individual's preparedness for surgery, expectations, and surgical goals and communicates with the surgeon and other providers to promote positive outcomes and inform multidisciplinary care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Penile inversion vaginoplasty is the current gold standard procedure for male-to-female transgender patients seeking gender-confirming genital surgery. Although complication data have been reported extensively in the literature, studies on patient-reported outcomes are sparse. This study aimed to report both postoperative complications and patient-reported outcomes from the largest cohort in the United States to date to undergo penile inversion vaginoplasty. Ultimately, the authors hoped to identify the predictors of postoperative complications and patient satisfaction., Methods: A retrospective chart review of a single surgeon's experience with penile inversion vaginoplasty was performed from July of 2014 to June of 2016. Patient demographic data, postoperative complications, and patient-reported outcome data were collected. Data were correlated by binary logistic regression to determine predictors of postoperative complications and patient satisfaction., Results: A total of 117 patients underwent penile inversion vaginoplasty. The most common complications were granulation tissue (26 percent), intravaginal scarring (20 percent), and prolonged pain (20 percent). Overwhelmingly, patients reported "feeling positively about their genitals" (94 percent) and "would do this operation again" (94 percent). Seventy-one percent of patients reported resolution of their gender dysphoria. The top predictors of patient dissatisfaction were intravaginal scarring, prolonged pain, excessive external scarring, loss of sensation, and hematoma/excessive bleeding., Conclusions: This is the largest study of penile inversion vaginoplasty in the United States to report on both postoperative complications and patient-reported outcomes. Despite moderate complication risk, patient satisfaction remains very high after penile inversion vaginoplasty, with the majority of patients reporting improvement of their gender dysphoria., Clinical Question/level of Evidence: Risk, III.

Objective: To understand the process of sexual reassignment from the perspective of people who undergo this procedure; to know how their body image influences their day to day life and the impact on their sexuality, and to learn from transgender male experiences in order to guide the health care teams involved, so that they can provide care in a more adjusted way to actual needs., Method: Qualitative study with a total of 7 male transsexuals over 18 years of age, undergoing at least one surgery intervention for sexual reassignment, using data collection techniques such as individual, semi structured, open, audio recorded interviews and writing of reflective diaries., Results: Decision making to undergo surgery to change their body image and sexual identity is complex. Factors influencing this decision are related to: the need to accept their own body, the experience with hormonal treatments, the relationship with the family and social context and with the partner, management of their own fears, the organization of health care services, the relationship and communication with the health care professionals, and the economic aspects., Conclusions: Both professionals and health services should consider and delve into the topic with the goal to understand the meaning of sex reassignment procedures to ensure better care for transsexualism., (Copyright © 2017 Asociación Española de Andrología, Medicina Sexual y Reproductiva. Publicado por Elsevier España, S.L.U. All rights reserved.)

We assessed the outcomes of gender-affirming surgery (GAS, or sex-reassignment surgery) 4 to 6 years after first clinical contact, and the associations between postoperative (dis)satisfaction and quality of life (QoL). Our multicenter, cross-sectional follow-up study involved persons diagnosed with gender dysphoria (DSM-IV-TR) who applied for medical interventions from 2007 until 2009. Of 546 eligible persons, 201 (37%) responded, of whom 136 had undergone GAS (genital, chest, facial, vocal cord and/or thyroid cartilage surgery). Main outcome measures were procedure performed, self-reported complications, and satisfaction with surgical outcomes (standardized questionnaires), QoL (Satisfaction With Life Scale, Subjective Happiness Scale, Cantril Ladder), gender dysphoria (Utrecht Gender Dysphoria Scale), and psychological symptoms (Symptom Checklist-90). Postoperative satisfaction was 94% to 100%, depending on the type of surgery performed. Eight (6%) of the participants reported dissatisfaction and/or regret, which was associated with preoperative psychological symptoms or self-reported surgical complications (OR = 6.07). Satisfied respondents' QoL scores were similar to reference values; dissatisfied or regretful respondents' scores were lower. Therefore, dissatisfaction after GAS may be viewed as indicator of unfavorable psychological and QoL outcomes.

This study aimed to assess the body image and quality of life of individuals suffering from gender dysphoria (GD) who were undergoing different types of treatment or no treatment at all. This was a descriptive-comparative study of 90 patients with GD sorted into three groups: untreated (no hormone therapy or surgery) (n = 30), hormone therapy (n = 30), and gender-reassignment surgery (n = 30). They were recruited using convenience sampling from a hospital in Tehran, Iran. The tools for data collection were three questionnaires to assess quality of life, body image, and demographic characteristics. The results showed that scores of quality of life and body image were significantly higher in the surgery group compared to the untreated singular (p < 0.001). A significant correlation was found between the quality of life and body image of the patients (r = 0.49; p < 0.001). We concluded that gender-reassignment surgery is the most effective treatment in improving body image and quality of life among individuals with GD.

Introduction: Options for gender affirming therapy in trans men include social transitioning, mental coaching, hormonal therapy and gender affirming surgery. Research has concluded that gender affirming therapy is safe and feasible and generally leads to high satisfaction rates. However, research regarding the cost-effectiveness is scarce. Areas covered: A literature research was conducted on PubMed, Google scholar and Scopus, searching for relevant articles on the subject of the effects of gender affirming hormone therapy, gender affirming surgery and fertility in trans persons. Out of the 77 full text articles, 29 on the topic of quality of life and sexual desire following the initiation of gender affirming hormonal therapy and gender affirming surgery were selected for this review. Expert commentary: Multiple studies have shown the positive effect of gender affirming hormonal therapy and gender affirming surgery on quality of life of trans persons and several studies describe an increase in their psychological wellbeing. In addition, satisfaction rates after gender affirming surgery are high and surgery is rarely regretted. However, as only one study has addressed cost-effectiveness of gender affirming treatment in trans men, further research is necessary.

Purpose of Review: To review the literature regarding the prevalence of mental health concerns, including psychiatric diagnoses in the TGNC community., Recent Findings: Gender dysphoria is not the only mental health concern experienced by some members of TGNC people. Stigma and discrimination play a role in the development of mental health concerns. Even after reassignment surgery some members of the TGNC community is almost five times more likely to attempt suicide. Using a structured clinical psychiatric interview improves the likelihood of recognizing the presence of psychiatric diagnoses. Nonaffirming attitudes and behavior seem to predispose to psychiatric symptoms in some members of the TGNC community and impacts on family and peer relationships. Psychiatric symptoms are often hidden for fear of further discrimination., Summary: A significant proportion of the TGNC community present with mental health concerns. Clinicians should screen appropriately for these concerns. Gender affirming interventions generally have an efficacious effect.

Gender dysphoria is estimated to occur in approximately 25 million people worldwide, and can have severe psychosocial sequelae. Medical and surgical gender transition can substantially improve quality-of-life outcomes for individuals with gender dysphoria. Individuals seeking to undergo female-to-male (FtM) transition have various surgical options available for gender confirmation, including facial and chest masculinization, body contouring, and genital surgery. The World Professional Association for Transgender Health guidelines should be met before the patient undergoes surgery, to ensure that gender-confirming surgery is appropriate and indicated. Chest masculinization and metoidioplasty or phalloplasty are the most common procedures pursued, and both generally result in high levels of patient satisfaction. Phalloplasty, with a resultant aesthetic and sensate phallus along with implantable prosthetic, can take upwards of a year to accomplish, and is associated with a considerable risk of complications. Urethral complications are most frequent, and can be addressed with revision procedures. A number of scaffolds, implants, and prostheses are now in development to improve outcomes in FtM patients.

Background: The aims of our study were to identify studies that evaluated patient satisfaction after transsexual surgery, analyze existing questionnaires, and summarize their development, psychometric properties, and content., Methods: A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and quality of life following transsexual surgery were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation., Results: From 796 articles, 19 studies had sufficient data and met the inclusion criteria. Included were a total of 2299 patients and 17 patient-reported outcome measures: 10 generic instruments that assessed quality of life, 4 specific for female genital or sexual satisfaction, 2 specific for transsexual body image or gender dysphoria, and 1 specific for plastic surgery. The questionnaires were analyzed by reviewers to assess the adherence to the rules of the US FDA and the Scientific Advisory Committee of the Medical Outcomes Trust. We identified 17 individual questionnaires that were included. All measures were limited by either their development, their validation, or their content., Conclusions: There is a need for a new self-assessment tool, which should include functional, psychorelational, and cosmetic components, to measure satisfaction and quality of life of patients who have undergone transsexual surgery., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Surveys on quality of life (QOL) of male-to-female (MTF) transsexuals have found low QOL scores before and increased satisfaction scores after sex-reassignment surgery (SRS). To our knowledge, many of them lack standardized questionnaires and comparisons with normative data to evaluate different vaginoplasty techniques., Aim: To analyze patient satisfaction and QOL after SRS., Methods: Forty-seven patients participated in this study. All patients had surgery with our self-developed combined technique on average 19 months before the survey. They completed a self-developed indication-specific questionnaire concerning demographic and socioeconomic issues and postoperative satisfaction. Furthermore, a standardized self-assessment questionnaire on satisfaction and QOL (Fragen zur Lebenszufriedenheit Module [FLZ M ]; Questions on Life Satisfaction Modules ) was used. The FLZ M consists of three modules (general life satisfaction, satisfaction with health, and satisfaction with body image) with scores of weighted satisfaction for each item. Results of the general and health modules were compared with normative data., Outcomes: Demographics, QOL, general life satisfaction, satisfaction with health, and satisfaction with body image., Results: The self-developed indication-specific questionnaire showed that 91% experienced an improvement of QOL. All patients stated they would undergo SRS again and did not regret it at all. Patients stated their femininity significantly increased. For the FLZ M , the sum score for general life satisfaction (P < .001) was significantly lower than the normative data, whereas the sum score of the satisfaction with health module (P = .038) did not reach statistical significance. The two modules also showed positive trends for different items. Values of the body image module showed a significant increase in satisfaction with breasts (P < .001) and genitals (P = .002)., Clinical Implications: The findings of this survey emphasize the importance of SRS in the interdisciplinary gender-reassignment process. The detailed description of our combined technique could help to improve the surgical outcome and patient satisfaction of this complex and non-standardized surgery., Strengths and Limitations: This is the first description of a new surgical technique (combined technique) for MTF SRS. QOL was assessed by a large number of patients by standardized questionnaires and could be compared with normative data. Because this is a retrospective study, we can draw only careful conclusions for pre- and postoperative changes., Conclusion: Our self-developed combined surgical technique seemed to have a positive influence on QOL after SRS. Satisfaction with breasts, genitals, and femininity increased significantly and show the importance of surgical treatment as a key therapeutic option for MTF transsexuals. Papadopulos NA, Lellé J-D, Zavlin D, et al. Quality of Life and Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery. J Sex Med 2017;14:721-730., (Copyright © 2017 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Transgender inmates provide a conundrum for correctional staff, particularly when it comes to classification, victimization, and medical and health issues. Using LexisNexis and WestLaw and state Department of Corrections (DOC) information, we collected state statutes and DOC policies concerning transgender inmates. We utilized academic legal research with content analysis to determine whether a statute or policy addressed issues concerning classification procedures, access to counseling services, the initiation and continuation of hormone therapy, and sex reassignment surgery. We found that while more states are providing either statutory or policy guidelines for transgender inmates, a number of states are lagging behind and there is a shortage of guidance dealing with the medical issues related to being transgender.

Untreated transgender men face serious negative health care outcomes. Effective medical, surgical, and mental health treatment ameliorates these risks. Although the research is not as robust as would be ideal, hormone treatment is effective and generally well tolerated with few serious medical risks. Surgeries carry serious risks; but for most transgender men, the benefits outweigh the risks. This review describes current evidence-based medical treatments for transgender men and provides an overview of surgical therapy to enable practitioners to discuss these options with their transgender male patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Transgender women and other transfeminine spectrum people may pursue hormonal and/or surgical gender-affirming interventions. Hormone therapy includes androgen blockade and estrogen supplementation. Approaches to hormone treatment vary widely based on patient goals and physiology. Surgical procedures are available, including genital affirmation surgery, breast augmentation, and head or neck feminization procedures. Many people are unable to obtain surgeries owing to prohibitive costs and long waiting lists. Hormonal and surgical therapies improve quality of life and mental health with minimal adverse effects. Ongoing research is needed to improve understanding about specific risks of hormone therapy and surgical outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Puberty-suppressing hormonal treatment may result in penoscrotal hypoplasia in transgender women, making standard penile inversion vaginoplasty not feasible. For these patients, intestinal vaginoplasty is a surgical alternative, but knowledge on patient-reported postoperative outcomes and quality of life is lacking., Aims: To assess patient-reported functional and esthetic outcomes, quality of life, satisfaction, and sexual well-being after primary total laparoscopic intestinal vaginoplasty in transgender women., Methods: A survey study was performed on transgender women who underwent primary total laparoscopic intestinal vaginoplasty with at least 1 year of clinical follow-up. Thirty-one transgender women completed the questionnaires (median age at time of surgery = 19.1 years, range = 18.3-45.0) after a median clinical follow-up of 2.2 years (range = 0.8-7.5). Consenting women were asked to complete a combined questionnaire of the Subjective Happiness Scale, the Satisfaction With Life Scale, Cantril's Ladder of Life Scale, the Female Sexual Function Index, the Female Genital Self-Imaging Scale, the Amsterdam Hyperactive Pelvic Floor Scale-Women, and a questionnaire addressing postoperative satisfaction., Main Outcome Measures: Patient-reported functional and esthetic outcomes and postoperative quality of life., Results: Patients graded their life satisfaction a median of 8.0 (range = 4.0-10.0) on Cantril's Ladder of Life Scale. Patients scored a mean total score of 27.7 ± 5.8 on the Satisfaction With Life Scale, which indicated high satisfaction with life, and a mean total score of 5.6 ± 1.4 on the Subjective Happiness Scale. Functionality was graded a median score of 8.0 of 10 (range = 1.0-10.0) and esthetics a score of 8.0 out of 10 (range = 3.0-10.0). The mean Female Sexual Function Index total score of sexually active transgender women was 26.0 ± 6.8., Conclusion: This group of relatively young transgender women reported satisfactory functional and esthetic results of the neovagina and a good quality of life, despite low Female Sexual Function Index scores., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Sex reassignment surgery (SRS) has proved an effective intervention for patients with gender identity disorder. However, misdiagnosed patients sometimes regret their decision and request reversal surgery. This review is based on our experience with seven patients who regretted their decision to undergo male-to-female SRS., Aims: To analyze retrospectively seven patients who underwent reversal surgery after regretting their decision to undergo male-to-female SRS elsewhere., Methods: From November 2010 through November 2014, seven men 33 to 53 years old with previous male-to-female SRS underwent reversal phalloplasty. Preoperatively, they were examined by three independent psychiatrists. Surgery included three steps: removal of female genitalia with scrotoplasty and urethral lengthening, total phalloplasty with microvascular transfer of a musculocutaneous latissimus dorsi flap, and neophallus urethroplasty with penile prosthesis implantation., Main Outcome Measures: Self-reported esthetic and psychosexual status after reversion surgery and International Index of Erectile Function scores for sexual health after phalloplasty and penile prosthesis implantation., Results: Follow-up was 13 to 61 months (mean = 31 months). Good postoperative results were achieved in all patients. In four patients, all surgical steps were completed; two patients are currently waiting for penile implants; and one patient decided against the penile prosthesis. Complications were related to urethral lengthening: two fistulas and one stricture were observed. All complications were repaired by minor revision. According to patients' self-reports, all patients were pleased with the esthetic appearance of their genitalia and with their significantly improved psychological status., Conclusion: Reversal surgery in regretful male-to-female transsexuals after SRS represents a complex, multistage procedure with satisfactory outcomes. Further insight into the characteristics of persons who regret their decision postoperatively would facilitate better future selection of applicants eligible for SRS., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS)., Aim: To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100., Methods: This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS., Main Outcome Measures: Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS., Results: The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results., Conclusion: The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

From a Darwinian perspective we live to reproduce, but in various situations genetic males elect not to reproduce by choosing medical treatments leading to infertility, impotence, and, in the extreme, emasculation. For many men, infertility can be psychologically distressing. However, for certain genetic males, being infertile may improve their quality of life. Examples include (1) men who seek vasectomy, (2) individuals with Gender Dysphoria (e.g., transwomen, and modern day voluntary eunuchs), (3) most gay men, and (4) men treated for testicular and prostate cancer. Men who desire vasectomy typically have a Darwinian fitness W >1 at the time of their vasectomies; i.e., after they have their desired number of offspring or consider themselves past an age for parenting newborns. In contrast, prostate and testicular cancer patients, along with individuals with extreme Gender Dysphoria, do not necessarily seek to be sterile, but accept it as an unavoidable consequence of the treatment for their condition undertaken for survival (in case of cancer patients) or to achieve a better quality of life (for those with Gender Dysphoria). Most gay men do not father children, but they may play an avuncular role, providing for their siblings' offspring's welfare, thus improving their inclusive fitness through kin selection. In a strictly Darwinian model, the primary motivation for all individuals is to reproduce, but there are many situations for men to remove themselves from the breeding populations because they have achieved a fitness W ≥1, or have stronger medical or psychological needs that preclude remaining fertile.

Gender dysphoria (GD) (DSM-5) or transsexualism (ICD-10) refers to the marked incongruity between the experience of one's gender and the sex at birth. In this case report, we describe the use of LSD as a triggering factor of confusion in the gender identity of a 39-year-old male patient, with symptoms of psychosis and 25 years of substance abuse, who sought psychiatric care with the desire to undergo sex reassignment surgery. The symptoms of GD/psychosis were resolved by two therapeutic measures: withdrawal of psychoactive substances and use of a low-dose antipsychotic. We discuss the hypothesis that the superior parietal cortical area may be an important locus for body image and that symptoms of GD may be related to variations underlying this brain region. Finally, this case report shows that some presentations of GD can be created by life experience in individuals who have underlying mental or, synonymously, neurophysiological abnormalities.

Introduction: Gender dysphoria is a mismatch between a person's biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty)., Aims: To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period., Methods: Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported., Main Outcome Measures: Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery., Results: One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period., Conclusion: Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period., (Copyright © 2016 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Previous research has explored the affiliation and distancing strategies employed in published memoirs of gender transition. In this article, we are particularly interested in elucidating the ways in which individuals construct identities and characterize their sexualities, and how sociohistorical constraints might influence what is expressed with respect to this in personal narratives of transition. Using the memoirs of Lili Elbe (Hoyer, 1933) and Joy Ladin (2013) as conceptual brackets, this article investigates the complex relationship between the development and articulation of trans* identities and lesbian sexualities within the context of published memoirs of gender transition.

Background: There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark., Aims: (1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978-2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978-2010., Method: Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals., Results: Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years., Conclusions: No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Transsexuals vary in the sacrifices that they make while transitioning to their cross-gender group. We suggest that one influence on the sacrifices they make is identity fusion. When people fuse with a group, a visceral and irrevocable feeling of oneness with the group develops. The personal self (the sense of "I" and "me") remains potent and combines synergistically with the social self to motivate behavior. We hypothesized that transsexuals who felt fused with the cross-gender group would be especially willing to make sacrifices while transitioning to that group. Our sample included 22 male-to-female (MtF) and 16 female-to-male (FtM) transsexuals. Consistent with expectation, those who were fused with their cross-gender group (1) expressed more willingness to sacrifice close relationships in the process of changing sex than non-fused transsexuals and (2) actually underwent irreversible surgical change of their primary sexual characteristics (vaginoplasty for MtF transsexuals and hysterectomy for FtM transsexuals). These outcomes were not predicted by a measure of "group identification," which occurs when membership in the group eclipses the personal self (the "I" and "me" is subsumed by the group; in the extreme case, brainwashing occurs). These findings confirm and extend earlier evidence that identity fusion is uniquely effective in tapping a propensity to make substantial sacrifices for the group. We discuss identity fusion as a social psychological determinant of the choices of transsexuals.