Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen

Background

As genital gender-affirming surgery (GAS) is a demanding and life-changing intervention, transmen should be able to make choices about the surgical treatment based on outcomes that are most important to them, while taking into consideration the concomitant risks involved.

A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen

BackgroundGenital dissatisfaction is an important reason for transmen to undergo genital gender-confirming surgery (GCS; phalloplasty or metoidioplasty). However, little is known about motives for choosing specific techniques, how transmen benefit postoperatively, and whether psychosexual outcomes improve.AimTo evaluate motivations for and psychosexual outcomes after GCS.MethodsA longitudinal study of 21 transmen at least 1 year after GCS was conducted. Participants were recruited through their surgeon. Data were collected when they applied for surgery and at least 1 year after surgery.OutcomesData collection included semistructured questionnaires on motivations for surgery, postoperative experiences, and standardized measures of psychological symptoms, body image, self-esteem, sexuality, and quality of life (pre- and postoperative). Information on surgical complications and corrections was retrieved from medical records.ResultsMost participants underwent phalloplasty with urethral lengthening using a radial forearm flap. Although problematic voiding symptoms were prevalent, many participants were satisfied with their penile function. The strongest motivations to pursue penile surgery were confirmation of one's identity (100%), enabling sexual intercourse (78%), and voiding while standing (74%). No significant differences between postoperative and reference values were observed for standardized measures. After surgery, transmen were more sexually active (masturbation and with a partner) and used their genitals more frequently during sex compared with before surgery (31–78%).Clinical ImplicationsThe present study provides input for preoperative decision making: (i) main motives for surgery include identity confirmation, voiding, and sexuality, (ii) surgery can result in more sexual activity and genital involvement during sex, although some distress can remain, but (iii) complications and voiding symptoms are prevalent.Strength and LimitationsStudy strengths include its longitudinal design and the novelty of the studied outcomes. The main limitations include the sample size and the nature of the assessment.ConclusionCounseling and decision making for GCS in transmen should be a highly personalized and interdisciplinary practice.van de Grift TC, Pigot GLS, Boudhan S, et al. A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen. J Sex Med 2017;14:1621–1628.     

Metoidioplasty With Implantation of a Specific Semirigid Prosthesis

BackgroundMetoidioplasty is a possibility for penis reconstruction in transmen that could be enhanced by a semi-rigid prosthesis support.AimDescribe the surgical technique of metoidioplasty with implantation of a specifically designed semi-rigid prosthesis -the ZSI100D4- and analyze preliminary results.MethodsImplantation of semi-rigid prosthesis was proposed to transmen who chose metoidioplasty for genital gender affirming surgery in a specialized university hospital.OutcomesSurgical outcomes were collected from medical files. Functional outcomes and satisfaction were collected post-operatively with a questionnaire.ResultsA total of 15 patients were operated; the mean length of followup was 22 months (SD = 8.7). Median prosthesis size was 8.5 cm (range: 8.5-10). Seven (46.7%) minor complications (Clavien-Dindo grade 2; 5 wound dehiscence and 2 fistula, managed conservatively) and 1 severe (Clavien-Dindo grade 3b) complication (Hematoma that need surgical revision) occurred. Thirteen patients (86.6%) answered the questionnaire; 11 (84.6%) reported being either “very satisfied” or “satisfied” with the appearance of the new genitalia; 10 (76.9%) could void while standing; and 12 patients (92.3%) answered “not at all” to the question “do you have regrets about this surgery ?”.ConclusionImplantation of a semi-rigid prosthesis in an enlarged clitoris seems to be a valuable option and can be proposed as another possibilityfor the complex surgical answer to neophallus reconstruction in transmen. Neuville P, Carnicelli D, Paparel P, et al. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021;18:830–836.     

Patients’ Priorities Regarding Female-to-Male Gender Affirmation Surgery of the Genitalia—A Pilot Study of 47 Patients in Sweden

IntroductionNo surgical technique is reported to be the best option for gender-affirmation surgery (GAS) of the genitalia in transmen. Although patients’ preferences are central when choosing a surgical technique, no studies have evaluated this factor.AimTo investigate transmen’s priorities and preferences regarding GAS of the genitalia.MethodsFrom November 2015 to March 2016, 54 transmen with the diagnosis of gender dysphoria who were referred to Sahlgrenska University Hospital for discussion of therapeutic steps (surgery and hormonal treatments) were asked to complete a questionnaire on different attributes achievable with GAS, such as sexual and urinary function and appearance. Forty-seven patients (87%) completed the questionnaire. Age ranged from 18 to 52 years (mean = 26 years, SD = 7.4 years). At the time of interview, no patient had undergone GAS of the genitalia.Main Outcome MeasuresAnswers to completed questionnaires.ResultsSeventy-six percent of patients identified themselves as male, and 24% wrote other terms such as “mostly male,” “inter-gender” and “non-binary.” Gender identity had a significant impact on patients’ preferences for two questions: the importance of vaginal removal and the importance of having a penis that would be passable in places such as male dressing rooms. These items were more important to patients identifying themselves as male. The most important attributes requested were preserved orgasm ability and tactile sensation. The least important attribute was removal of the vagina, followed by having a penis of human material, minimal scarring, and size. The ability to urinate while standing was considered a high priority by some and a low priority by others. All answers ranged from “unimportant” to “imperative.”ConclusionThis series of patients demonstrates a considerable heterogeneity among transmen in their gender identity and preferences regarding GAS of the genitalia, which supports the need for several techniques. Patients must be accurately informed on the different techniques and their specific benefits and limitations to make an informed choice.Jacobsson J, Andréasson M, Kölby L, et al. Patients’ Priorities Regarding Female-to-Male Gender Affirmation Surgery of the Genitalia—A Pilot Study of 47 Patients in Sweden. J Sex Med 2017;14:857–864.     

Gender-Affirming Hormone Therapy Modifies the CpG Methylation Pattern of the ESR1 Gene Promoter After Six Months of Treatment in Transmen

BackgroundBrain sexual differentiation is a process that results from the effects of sex steroids on the developing brain. Evidence shows that epigenetics plays a main role in the formation of enduring brain sex differences and that the estrogen receptor α (ESR1) is one of the implicated genes.AimTo analyze whether the methylation of region III (RIII) of the ESR1 promoter is involved in the biological basis of gender dysphoria.MethodsWe carried out a prospective study of the CpG methylation profile of RIII (−1,188 to −790 bp) of the ESR1 promoter using bisulfite genomic sequencing in a cisgender population (10 men and 10 women) and in a transgender population (10 trans men and 10 trans women), before and after 6 months of gender-affirming hormone treatment. Cisgender and transgender populations were matched by geographical origin, age, and sex. DNAs were treated with bisulfite, amplified, cloned, and sequenced. At least 10 clones per individual from independent polymerase chain reactions were sequenced. The analysis of 671 bisulfite sequences was carried out with the QUMA (QUantification tool for Methylation Analysis) program.OutcomesThe main outcome of this study was RIII analysis using bisulfite genomic sequencing.ResultsWe found sex differences in RIII methylation profiles in cisgender and transgender populations. Cismen showed a higher methylation degree than ciswomen at CpG sites 297, 306, 509, and at the total fragment (P ≤ .003, P ≤ .026, P ≤ .001, P ≤ .006). Transmen showed a lower methylation level than trans women at sites 306, 372, and at the total fragment (P ≤ .0001, P ≤ .018, P ≤ .0107). Before the hormone treatment, transmen showed the lowest methylation level with respect to cisgender and transgender populations, whereas transwomen reached an intermediate methylation level between both the cisgender groups. After the hormone treatment, transmen showed a statistically significant methylation increase, whereas transwomen showed a non-significant methylation decrease. After the hormone treatment, the RIII methylation differences between transmen and transwomen disappeared, and both transgender groups reached an intermediate methylation level between both the cisgender groups.Clinical ImplicationsClinical implications in the hormonal treatment of trans people.Strengths & LimitationsIncreasing the number of regions analyzed in the ESR1 promoter and increasing the number of tissues analyzed would provide a better understanding of the variation in the methylation pattern.ConclusionsOur data showed sex differences in RIII methylation patterns in cisgender and transgender populations before the hormone treatment. Furthermore, before the hormone treatment, transwomen and transmen showed a characteristic methylation profile, different from both the cisgender groups. But the hormonal treatment modified RIII methylation in trans populations, which are now more similar to their gender. Therefore, our results suggest that the methylation of RIII could be involved in gender dysphoria.Fernández R, Ramírez K, Gómez-Gil E, et al. Gender-Affirming Hormone Therapy Modifies the CpG Methylation Pattern of the ESR1 Gene Promoter After Six Months of Treatment in Transmen. J Sex Med 2020;17:1795–1806.     

Postpartum Contraceptive Decision-Making of Parous Teens–A Qualitative Study

Study ObjectiveApproximately 25% of teens in the United States will become pregnant before the age of 18, and within 2 years, more than 31% will have a repeat pregnancy. Acknowledging that some adolescents might seek or be ambivalent toward rapid repeat pregnancy, compared with their counterparts, not using a long-acting reversible contraception method increases a teen's risk of another pregnancy in 2 years by more than 35 times. We seek to better understand the influences and factors surrounding adolescent postpartum contraceptive decision-making following the index delivery.DesignWe completed a qualitative study via focused, semistructured interviews during an inpatient postpartum course. The interview guide was modeled after those used in other studies of adolescent contraceptive decision-making, beta tested, and developed iteratively. Interviews were completed, transcribed, coded, and analyzed with the assistance of Dedoose.SettingThe study was conducted at MetroHealth Medical Center in Cleveland, Ohio.ParticipantsParous adolescents aged 13–19ResultsWe performed 12 interviews prior to reaching theoretical saturation. Themes were identified related to the participants’ prior experiences with contraception and prior and current pregnancies. The participants’ contraceptive choices were influenced by personal relationships, varying levels of autonomy, misperceptions, and changing contraceptive needs.ConclusionsWe found that adolescents’ contraceptive decision-making was influenced by their social networks and community, including their parents and friends. Mothers played a key role as adolescents transitioned to gaining more autonomy over their reproductive decisions. Providers should consistently present adolescents with comprehensive contraceptive options as a component of preventive health care.     

Pre-implantation genetic testing: decisional factors to accept or decline among in vitro fertilization patients

Purpose

Embryo testing to improve pregnancy outcomes among individuals who are seeking assisted reproduction technologies is increasing. The purpose of this study was to assess decisional factors through in-depth interviews for why women would accept or decline preimplantation genetic testing for aneuploidy (PGT-A) with in vitro fertilization (IVF).

Methods

Semi-structured telephone interviews were conducted with 37 women who were offered PGT-A with IVF during the summer 2017. Interviews lasted on average 40 min and were audio-recorded, transcribed, and analyzed using a content analysis.

Results

Results identified a number of decisional factors related to values about conception, disability, and pregnancy termination, past pregnancy experiences, optimism toward technology, and cost. Other key issues that were identified include the use of expanded carrier screening prior to IVF, maternal age, and limited education about PGT-A due to the complexity about education for IVF alone.

Conclusion

There is a need to develop decision support tools for the increasing choices of genetic testing options for patients seeking IVF. Including patients’ values, past pregnancy experiences and attitudes toward science into the decision-making process may help promote a more informed decision.

     

A Randomized Double-Blind Placebo-Controlled Pilot Trial on the Effects of Testosterone Undecanoate Plus Dutasteride or Placebo on Muscle Strength,Body Composition,and Metabolic Profile in Transmen

BackgroundWhile the effects of androgens on muscle are well described in hypogonadal men, literature is still scarce on muscular strength or size variations in transmen; in this population there are no data regarding the relative effect of testosterone (T) and its metabolite dihydrotestosterone on muscle.AimOur primary objective was to compare the effects on muscle strength of 54-week administration of testosterone undecanoate (TU) combined with the 5α-reductase inhibitor dutasteride (DT) or placebo (PL). Secondary outcomes included evaluation of body composition, bone, cutaneous androgenic effects, and metabolic variations.MethodsIn this randomized, double-blind PL-controlled pilot trial, 16 ovariectomized transmen were randomized to receive TU 1,000 mg IM at week 0, 6, 18, 30, 42 plus a PL pill orally daily (TU + PL, n = 7) or plus DT 5 mg/d (TU + DT, n = 7).OutcomesAt week 0 and 54 the following parameters were evaluated: isokinetic knee extension and flexion peak torque and handgrip strength, body composition, and bone mineral density, biochemical, hematological, and hormonal parameters.ResultsHandgrip and lower limb strength increased significantly in both groups with no differences between the 2 groups. Fat mass decreased and lean mass increased significantly similarly in both groups. Metabolic parameters remained stable in the 2 groups except for high-density lipoprotein cholesterol that was reduced in both groups. Hepatic and renal function remained normal in both groups and no major adverse effects were registered in either group.Clinical ImplicationsThese results may be particularly relevant for transmen experiencing cutaneous androgenic adverse events such as acne and androgenetic alopecia and in light of the development of non-5α-reduced androgens.Strengths & LimitationsThe strength of this study was the randomized, double-blind PL-controlled design, while the small number of subjects was definitely the biggest limitation.ConclusionFor the first time we demonstrated that the addition of DT does not impair the anabolic effects of T on muscles in transmen previously exposed to T, supporting the hypothesis that the conversion in dihydrotestosterone is not essential for this role.Gava G, Armillotta F, Pillastrini P, et al. A Randomized Double-Blind Placebo-Controlled Pilot Trial on the Effects of Testosterone Undecanoate Plus Dutasteride or Placebo on Muscle Strength, Body Composition, and Metabolic Profile in Transmen. J Sex Med 2021;18:646–655.     

Shared decision aids in pregnancy care: A scoping review

BackgroundShared decision making in pregnancy, labour, and birth is vital to woman-centred care and despite strong evidence for the effectiveness of shared decision making in pregnancy care, practical uptake has been slow.Design and AimThis scoping review aimed to identify and describe effective and appropriate shared decision aids designed to be provided to women in the antenatal period to assist them in making informed decisions for both pregnancy and birth. Two questions guided the enquiry: (i) what shared decision aids for pregnancy and perinatal care are of appropriate quality and feasibility for application in Australia? (ii) which of these decision aids have been shown to be effective and appropriate for Aboriginal and Torres Strait Islander peoples, culturally diverse women, or those with low literacy?MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) was used to conduct the review. Five key databases and selected grey literature sources were examined. English language evidence from Australia, Europe, Canada, United Kingdom, New Zealand, and United States of America produced from 2009 was eligible for inclusion, checked against apriori inclusion criteria, and assessed for quality and usability using the International Patient Decision Aid Standards.ResultsFrom a total of 5,209 search results, 35 sources of evidence reporting on 27 decision aids were included following title/abstract and full-text review. Most of the decision aids concerned decisions around birth (52%, n = 14) or antenatal screening 37% (n = 10). The quality of the decision aids was moderate to high, with most communicating risks, benefits, and choice pathways via a mix of Likert-style scales, quizzes, and pictures or graphs. Use of decision aids resulted in significant reductions in decisional conflict and increased knowledge. The format of decision aids appeared to have no effect on these outcomes, indicating that paper-based are as effective as video- or audio-based decision aids. Eleven decision aids were suitable for low literacy or low health literacy women, and six were either developed for culturally diverse groups or have been translated into other languages. No decision aids found were specific to Aboriginal and Torres Strait Islander peoples.Conclusions and implications for practiceThe 27 decision aids are readily adoptable into westernised healthcare settings and can be used by midwives or multidisciplinary teams in conjunction with women. Decision aids are designed to support women, and families to arrive at informed choices and supplement the decision-making process rather than to replace consumer-healthcare professional interaction. If given before an appointment, high quality decision aids can increase a woman's familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflict and increasing knowledge.     

The Vagina Dialogues: Genital Self-Image and Communication with Physicians About Sexual Dysfunction and Dissatisfaction Among Jewish Patients in a Women's Health Clinic in Southern Israel

IntroductionThe health-care system offers a variety of solutions for problems related to sexual dysfunction. To gain access to treatment options, women must be willing to discuss these issues with their physicians.AimTo examine the extent to which women discuss issues of sexual dysfunction with their physicians and to examine the contribution of aspects of sexual dysfunction, level of satisfaction, body image, and genital self-image to their comfort with communicating with physicians about these issues.MethodsOne hundred ten secular-appearing, Hebrew-speaking Jewish women waiting for a routine gynecological appointment at a clinic in southern Israel responded to a self-report questionnaire.Main Outcome MeasuresThe Female Sexuality Function Index was used to assess sexual dysfunction, Gray's Modified Questionnaire to assess body image, and the Genital Self-Image Scale to assess genital self-image. We compiled a new measure to assess level of comfort in discussing sexual functioning and satisfaction with a physician.ResultsForty-four percent of the women had discussed sexual functioning issues with a gynecologist. Of those, 91.7% reported that the gynecologist initiated the discussion. The proportion of participants who would consult a gynecologist about sexual dysfunction was 74.5%, but only 41% would consult a family physician. Half of the women would expect a gynecologist to initiate such consultations, but only 20% would expect a family physician to do so. In a multivariate regression analysis, genital self-image was the only significant predictor of women's comfort level with discussing sexual dysfunction with a gynecologist.ConclusionsThe respondents perceived the gynecologist, rather than the family physician, as an appropriate professional to consult regarding sexual dysfunction. However, they expected the gynecologist to initiate the discussion. Women with a positive genital self-image are more comfortable in consulting about sexual dysfunction. Gynecologists should be made aware of their significant role in eliciting women's cooperation in such consultations and in contributing to improving women's genital perception. Yulevitch A, Czamanski-Cohen J, Segal D, Ben-Zion I, and Kushnir T. The vagina dialogues: Genital self-image and communication with physicians about sexual dysfunction and dissatisfaction among Jewish patients in a women's health clinic in Southern Israel. J Sex Med 2013;10:3059–3068.     

Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women

Study ObjectiveTo identify barriers to long-acting reversible contraception (LARC) uptake among homeless young women.DesignIn this mixed methods study surveys and guided interviews were used to explore women's contraceptive and reproductive experiences, interactions with the health care system, and their histories of homelessness.SettingAll surveys and interviews were conducted at a homeless drop-in center or shelter.ParticipantsFifteen women between 18 and 24 years of age with a past year history of homelessness.InterventionsNone.Main Outcome MeasuresPerceived barriers to contraceptive use, including knowledge and access barriers and interactions with the health care system around reproductive health.ResultsConfusion about the possibility of early termination of LARC, and the perception that providers deliberately withhold selective information about contraceptive options to bias contraceptive decision-making, were 2 key new findings. Women also reported interest in visual aids accompanying verbal contraceptive counseling. Pregnancy attitudes and history of reproductive and sexual coercion also influenced contraceptive decision-making and reported interest in LARC methods.ConclusionComprehensive counseling about all contraceptive options, including LARC, are important for targeting the perceived gaps in contraceptive education and care among homeless young women.     

Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men

BackgroundSeveral treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes.AimThe aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty.MethodsA multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers.OutcomesThe primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively.ResultsOf 96 transmen included in this study with a urethral complication, 44 (46%) experienced a urethral fistula, 31 (32%) a urethral stricture, and 21 (22%) both complications simultaneously. The recurrence-free rate for urethral strictures following endoscopic management (ie, urethral dilation or direct visual internal urethrotomy) was 61% after 1, 50% after 2, and 43% after 3 years, compared to 82% following open treatment options after 1, 2, and 3 years (P = .002). Open treatment options were Heineke-Mikulicz procedure (7/9, 78% success), excision and primary anastomosis (3/3, 100%), 2-stage without graft (9/9, 100%), pedicled flap urethroplasty (1/1, 100%), and buccal mucosa graft urethroplasty (2/4 [50%] single-stage, 1/1 [100%] 2-stage). The recurrence-free rate for small urethral fistulas located at the pendulous urethra was 79% after 1, and 72% after 2 and 3 years, compared to 45% after 1, and 41% after 2 and 3 years for large fistulas, generally located at the urethral anastomoses of the fixed urethra. Treatment options for urethral fistulas were fistulectomy (26/48, 54%), fistulectomy & (redo) colpectomy (7/11, 64%), buccal mucosa graft urethroplasty (1/1, 100%), and retubularization of the urethral plate (3/4, 75%). A colpectomy before or during reoperation of a urethral fistula at the proximal urethral anastomosis showed higher success rates compared to without a colpectomy (7/11 [64%] vs 2/13 [15%] respectively, P = .03).Clinical ImplicationsThis study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen.Strengths & LimitationsStrengths were the relatively large sample size and the overview of multiple treatment options available. Limitations were the heterogeneity of the cohort, underexposure of some surgical modalities, and absence of patient-reported outcomes.ConclusionOpen surgical techniques show better long-term outcomes in the management of urethral strictures compared to endoscopic options, and a colpectomy is beneficial before or during urethral fistula repair at the proximal urethral anastomosis.de Rooij FPW, Falcone M, Waterschoot M, et al. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022;19:377–384.     

Understanding the Pregnancy Decision-Making Process Among Couples Seeking Induced Abortion

ObjectiveThe role of partners in the abortion experience is complex and poorly understood. We sought to examine how women and their partners navigate the pregnancy decision-making process.MethodsThirty couples presenting for abortion completed questionnaires exploring experiences leading to the abortion. Participants were sequestered from their partners during completion of the study, and booklets were coded to allow comparison within couples. This portion of the study explored partner involvement in the decision-making process.ResultsOne half of women had decided on abortion before informing their partner of the pregnancy. Of those who were undecided at the time of disclosure, all sought their partner’s advice. Most participants (84%) were happy with the amount of discussion that took place with their partners, although one fifth of women and nearly one third of men could have discussed it more. More women than men were happy with the discussions that took place (96.6% vs. 70.4%). Two thirds of respondents viewed the decision to have an abortion as being made by both partners, one quarter viewed the decision as being mostly the woman’s choice, and 5% viewed the decision as being mostly the male partner’s choice.ConclusionAlthough making the choice to have an abortion rests with the woman, her partner may play a role in the decision-making process, particularly when the woman is undecided. For many couples presenting for abortion, the decision is seen as being made jointly by both partners. Further research may identify opportunities to foster greater partner support throughout a woman’s abortion experience.     

Women's Selection of Mode of Birth for their Breech Presentation

ObjectiveMany studies since the Term Breech Trial have demonstrated the safety of vaginal breech birth (VBB), and today it is an option for breech presentation at term. However, women with breech presentation often face a difficult decision regarding mode of birth, especially when planned cesarean was the standard of care in the not-so-distant past. We aim to clarify the decision-making process and barriers women face when making this decision.MethodsBetween January and April 2016, women who delivered with breech presentation were approached during their postpartum hospital stay to obtain consent for the study. The follow-up, semi-structured interview probed the woman's acquisition of knowledge and supports and barriers to her choices leading up to delivery. The responses were recorded and transcribed for analysis, and themes were identified for reporting.ResultsOf the 95 women who completed the interview, 21 preferred VBB but only 1 had a VBB. Most unplanned cesarean deliveries were performed for obstetrical indications, but 5 women expressed a lack of support for VBB or did not recall being provided options. Themes were identified with respect to the influences the women experienced, including passive external, provider-based, evidence-based, and internal.ConclusionDespite the availability of options for breech pregnancy, the majority of women continue to have planned cesarean deliveries. The retrospective process reveals that women did not fully understand the eligibility criteria for VBB and all available options (including external cephalic version). Shared decision-making and continuity of care should remain a priority during the counselling process and delivery of care.     

Exploring Factors Associated with Decisions about Feminizing Genitoplasty in Differences of Sex Development

Study ObjectiveInfants with genital development considered atypical for assigned female sex may undergo feminizing genitoplasty (clitoroplasty and/or vaginoplasty) in early life. We sought to identify factors associated with parent/caregiver decisions regarding genitoplasty for their children with genital virilization.DesignLongitudinal, observational studySettingTwelve pediatric centers in the United States with multidisciplinary differences/disorders of sex development clinics, 2015-2020ParticipantsChildren under 2 years old with genital appearance atypical for female sex of rearing and their parents/caregiversInterventions/Outcome MeasuresData on the child's diagnosis and anatomic characteristics before surgery were extracted from the medical record. Parents/caregivers completed questionnaires on psychosocial distress, experience of uncertainty, cosmetic appearance of their child's genitalia, and demographic characteristics. Urologists rated cosmetic appearance. For 58 patients from the study cohort with genital virilization being raised as girls or gender-neutral, we compared these data across 3 groups based on the child's subsequent surgical intervention: (i) no surgery (n = 5), (ii) vaginoplasty without clitoroplasty (V-only) (n = 15), and (iii) vaginoplasty and clitoroplasty (V+C) (n = 38).ResultsFathers’ and urologists’ ratings of genital appearance were more favorable in the no-surgery group than in the V-only and V+C groups. Clitorophallic length was greater in the V+C group compared with the V-only group, with substantial overlap between groups. Mothers’ depressive and anxious symptoms were lower in the no-surgery group compared with the V-only and V+C groups.ConclusionsSurgical decisions were associated with fathers’ and urologists’ ratings of genital appearance, the child's anatomic characteristics, and mothers’ depressive and anxious symptoms. Further research on surgical decision-making is needed to inform counseling practices.     

Applying decision analysis to facilitate informed decision making about prenatal diagnosis for Down syndrome: a randomised controlled trial

OBJECTIVE: To evaluate decision analysis as a technique to facilitate women's decision-making about prenatal diagnosis for Down syndrome using measures of effective decision-making. DESIGN: Randomised controlled trial in a UK hospital's prenatal diagnosis clinic. INTERVENTION: Routine versus routine consultation structured by decision analysis. PARTICIPANTS: 117/132 women receiving a screen-positive maternal serum screening result participated (58 routine, 59 decision analysis). METHODS: Consultations were audio tape-recorded, transcribed and coded; questionnaires were completed after the consultation and one month later after receipt of a diagnostic test and/or the 19-week scan result. MAIN MEASURES: Test decision, subjective expected utilities, knowledge, informed decision-making, risk perception, decisional conflict, anxiety, perceived usefulness and directiveness of consultation information. RESULTS: 48/59 in the decision-aided group and 47/58 in the routine group underwent prenatal diagnosis. Informed decision-making was higher, perceived risk more realistic and decisional conflict over time lower in the decision analysis group. Decision analysis had no impact on knowledge or SEU scores, and was no more or no less directive, useful or anxiety provoking than the routine care. Consultations were six minutes longer. CONCLUSIONS: Decision analysis consultations enable women to make more informed prenatal diagnosis decisions. Professionals will need training to use this technique effectively.     

Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study

IntroductionStudies about sexual functioning in trans persons have mainly focused on sexual functioning after genital gender-affirming surgery, have had small sample sizes, and have not explored the broad range of possible sexual dysfunctions. Measuring sexual functioning in trans persons during transitioning is important to determine the kind of care trans persons may need in order to regain their sexual health.AimThe first aim of the present study was to explore the prevalence of sexual function disturbances and dysfunctions (with distress) in trans women and trans men 4 to 6 years after initial clinical entry. The second aim was to compare the prevalence of sexual dysfunctions among the various treatment trajectories and between trans persons with or without further genital treatment intentions.MethodsAn online follow-up questionnaire was filled out by 518 trans persons (307 identifying predominantly feminine, 211 identifying predominantly masculine) as a part of the European Network for the Investigation of Gender Incongruence initiative. All participants had their initial clinical appointments in gender clinics in Ghent, Amsterdam, or Hamburg.Main Outcome MeasureThe main outcome measures were the prevalence of sexual dysfunctions and medical treatment data, measured via self-report items.ResultsThe most frequent sexual dysfunctions experienced by trans women and trans men were difficulties initiating and seeking sexual contact (26% and 32%, respectively) and difficulties achieving an orgasm (29% and 15%, respectively). Compared with trans women after hormone treatment and non-genital surgery, trans women after vaginoplasty less often experienced arousal difficulties, sexual aversion, and low sexual desire. Compared with trans men without medical treatment, trans men after a phalloplasty experienced sexual aversion and low sexual desire less often. No significant differences were found between participants with or without further genital treatment intentions.Clinical implicationsClinicians should consider sexual counseling after medical treatments, paying particular attention to potential social and psychological barriers to the sexual health of their patients.Strengths & LimitationsThis study included all trans persons irrespective of treatment decisions, and focused on a broad range of potential sexual difficulties taking the distress criteria into account. Limitations include the cross-sectional design, the limited power for the comparison of treatment groups and the absence of validated questionnaires about sexual functioning for transgender persons.ConclusionSexual dysfunctions among trans men and women were very common among the various treatment groups and were unrelated to intentions to have further genital treatment. Although medical treatment may be helpful or even essential to developing good sexual health, a significant group of trans persons experienced sexual dysfunctions after genital surgery.Kerckhof ME, Kreukels BPC, Nieder TO, et al. Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study. J Sex Med 2019; 16:2018–2019.     

Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment

IntroductionEstablishing the influence of long-term, gender-affirming hormonal treatment (HT) on bone mineral density (BMD) in transgender individuals is important to improve the therapeutic guidelines for these individuals.AimTo examine the effect of long-term HT and gonadectomy on BMD in transgender individuals.Methods68 transwomen and 43 transmen treated with HT who had undergone gonadectomy participated in this study. Dual-energy x-ray absorptiometry (DXA) scans were performed to measure BMD at the lumbar spine and total hip. Laboratory values related to sex hormones were collected within 3 months of performing the DXA scan and analyzed.Main Outcome MeasureBMD and levels of sex hormones in transwomen and transmen.ResultsIn transwomen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 0.99 ± 0.15 g/cm² (n = 68) and 0.94 ± 0.28 g/cm² (n = 65). In transmen, the mean BMD values at the lumbar spine and total hip at the first DXA scan were, respectively, 1.08 ± 0.16 g/cm² (n = 43) and 1.01 ± 0.18 g/cm² (n = 43). A significant decrease in total hip BMD was found in both transwomen and transmen after 15 years of HT compared with 10 years of HT (P = .02).ConclusionIn both transwomen and transmen, a decrease was observed in total hip bone mineral density after 15 years of HT compared to the first 10 years of HT.Dobrolińska M, van der Tuuk K, Vink P, et al. Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment. J Sex Med 2019; 16:1469–1477.     

Is counselling necessary? Making the decision to have an abortion. A qualitative interview study

ABSTRACT

Objectives To explore young women's decision-making about having an abortion, in particular, how they reached the decision and with whom they discussed it.

Methods Qualitative study comprising semi-structured one-to-one interviews with 24 women aged between 16 and 20 who were waiting for, or had recently had, a surgical abortion. Interviews were recorded with the consent of the interviewees, fully transcribed, and analysed using a grounded theory approach.

Results All but one of the women had been offered counselling; one could not remember. Only two had accepted the offer of counselling, most feeling that it was unnecessary. The majority of these young women had decided that they wanted an abortion before accessing health services to request one. They had discussed their decision with someone close to them and did not feel the need to have further discussions with counsellors.

Conclusions Most young women have already made the decision to have an abortion before they approach their GP or a family planning clinic to request one. At present, counselling is voluntary in the UK. Requiring women to undergo couanselling would delay the process and for most women would be an unnecessary burden, whilst also diverting resources from those women who require counselling.     

Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures

Introduction

Hormone treatment induces feminization of the body in transwomen and masculinization in transmen. However, the effect of hormone treatment on facial characteristics is still unknown.