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Objectives Despite regular gender-affirming hormone therapy (GAHT), the presence of uterine bleeding can occur occasionally and cause profound discomfort. This study aimed to evaluate the histologic features and immunohistochemical expression of estrogen (ER), progesterone (PR), and androgen receptors (AR) in the endometrium and myometrium of transgender men receiving testosterone therapy and relate them to clinical and hormonal characteristics. Design Retrospective cross-sectional study. Methods Thirty-four transgender men undergoing gender-affirming surgery were included. Clinical, sociodemographic, and laboratory data as well as anatomopathological and immunohistochemical findings were evaluated. Results The participants' mean age was 42.35 (SD, 10.00) years, and body mass index was 28.16 (SD, 5.52) kg/m2. The mean GAHT duration before surgery was 5.36 (SD, 3.24) years. The mean testosterone levels were 814.98 (SD, 407.13) ng/dL, and estradiol levels were 55.22 (SD, 25.27) pg/mL. The endometrium was atrophic in 61.8%, proliferative in 17.6%, and secretory in 20.6%. Immunohistochemical receptor analysis revealed that endometrial epithelial cells expressed ER (90%) and PR (80%), with a lower expression of AR (30%). In stromal tissue, the median ER, PR, and AR expression was lower than that in the epithelium (60%, 70%, and 25%, respectively). The myometrium showed high expression of PR (90%) and ER (70%), with the highest expression of AR (65%) being localized to this region. Conclusions In the present study, GAHT induced an atrophic condition of the endometrium in two-thirds of the transgender men, with a limited AR expression in the endometrial region. The present results suggest that testosterone-based GAHT for a mean of 5 years is safe in transgender men achieving amenorrhea. [ABSTRACT FROM AUTHOR]

Objectives HIV pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but some seroconversions occur due to poor adherence or PrEP discontinuation. Our objective was to estimate the incidence of PrEP discontinuation and describe the reasons and factors associated with discontinuations. Methods A retrospective cohort was conducted in three French hospitals between January 2016 and June 2022. PrEP users who attended at least twice within 6 months during study period were included and followed up until December 2022. The incidence rate of PrEP discontinuation was estimated by censoring lost to follow up individuals. Factors associated with PrEP discontinuations were identified using a multivariate Cox model. Results A total of 2785 PrEP users were included, with 94% men and 5% transgender people. Median age was 35 years. By December 2022, 653 users had stopped PrEP (24%). The incidence rate was 10.8 PrEP discontinuations for 100 person-years (PY). The main causes of discontinuation were being in a stable relationship (32%), and not judging the treatment useful anymore (12%). Individuals who discontinued PrEP were younger [<29, HR = 1.45 (1.17–1.80)], and more likely to be women [HR = 2.44 (1.50–3.96)] or sex workers [HR = 1.53 (0.96–2.44)]. They were more likely to report PrEP side effects [HR = 2.25 (1.83–2.77)] or ≥2 sexually transmitted infections [HR = 1.87 (1.53–2.27)] during the last year. Conclusion The incidence of PrEP discontinuations was quite low compared to rates observed in other cohorts. Users who stopped PrEP were sometimes still exposed to HIV, emphasizing the need for targeted interventions to prepare and support PrEP discontinuations and limit seroconversion risk. [ABSTRACT FROM AUTHOR]

Background: To investigate the erythropoietic activity and safety aspects of testosterone undecanoate (TU) injections in transgender men, assigned female at birth. Methods: Twenty-three men (13 hypogonadal cisgender men and 10 transgender men) who initiated TU at the study start (naïve) and 15 men (10 hypogonadal cisgender men and 5 transgender men) on steady-state treatment with TU (non-naïve) were included in this prospective 1-year observational study. A control group of 32 eugonadal cisgender men was investigated once at baseline. Complete blood count, testosterone in serum and saliva, and plasma lipids, and liver enzymes were assessed. Results: For naïve transgender men, a significant increase in hemoglobin concentration was noted (mean (SD)), 141 (8) g/L to 151 (13) g/L, while no increase was seen in naïve hypogonadal cisgender men. At the end of the study, naïve transgender men exhibited comparable levels of hemoglobin, hematocrit, and testosterone levels in serum and saliva to hypogonadal cisgender men, as well as to the eugonadal cisgender men. During the study, HDL-cholesterol decreased significantly in naïve transgender men, 1.4 (0.4) mmol/L to 1.2 (0.4) mmol/L, P = 0.03, whereas no significant change was noted in naïve hypogonadal cisgender men. Liver enzymes remained unchanged in all groups. Conclusions: After 12 months of treatment with TU in naïve transgender men, hemoglobin and hematocrit increased to levels within the cisgender male reference range. A slight decrease in HDL-cholesterol was seen in naïve transgender men but liver enzymes remained unchanged. [ABSTRACT FROM AUTHOR]

Background: Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited. Aim: To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth. Methods: There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model. Outcomes: We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW). Results: TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models. Clinical Implications: When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety. Strengths and Limitations: To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions. Conclusion: Men and women (cisgender and transgender) tend to significantly overestimate penis length and width. [ABSTRACT FROM AUTHOR]

Background People who are transgender may utilize masculinizing or feminizing gender-affirming hormonal therapy. Testosterone and oestrogen receptors are expressed throughout the cardiovascular system, yet the effects of these therapies on cardiovascular risk and outcomes are largely unknown. We report the case of a young transgender man with no discernible cardiovascular risk factors presenting with an acute coronary syndrome. Case summary A 31-year-old transgender man utilizing intramuscular testosterone masculinizing gender-affirming hormonal therapy presented with central chest pain radiating to the left arm. He had no past medical history of hypertension, dyslipidaemia, diabetes, or smoking. Electrocardiography demonstrated infero-septal ST depression, and high-sensitivity troponin-I was elevated and increased to 19 686 ng/L. He was diagnosed with a non–ST-segment elevation myocardial infarction. Inpatient coronary angiography confirmed a critical focal lesion in the mid right coronary artery, which was managed with two drug-eluting stents. Medical management (i.e. aspirin, ticagrelor, atorvastatin, ramipril, and bisoprolol) and surveillance of residual plaque disease evident in the long tubular left main stem, proximal left anterior descending, and proximal circumflex vessels was undertaken. The masculinizing gender-affirming hormonal therapy was continued. Discussion Despite a greater awareness of the potential risk of increased cardiovascular disease in transgender people, the fundamental lack of data regarding cardiovascular outcomes in transgender people may be contributing to healthcare inequalities in this population. We must implement better training, awareness, and research into transgender cardiovascular health to facilitate equitable and evidence-based outcomes. [ABSTRACT FROM AUTHOR]

Gender-affirming hormone therapy (GAHT) leads to changes in body composition, secondary sex characteristics and in the distribution and pattern of hair growth. Transgender individuals undergoing GAHT may experience altered hair growth patterns that may be affirming and desirable, or undesirable with a subsequent impact on their quality of life. Given increasing numbers of transgender individuals commencing GAHT worldwide and the clinical relevance of the impact of GAHT on hair growth, we systematically reviewed the existing literature on the impact of GAHT on hair changes and androgenic alopecia (AGA). The majority of studies used grading schemes or subjective measures of hair changes based on patient or investigator's examination. Very few studies used objective quantitative measures of hair parameters but demonstrated statistically significant changes in hair growth length, diameter and density. Feminizing GAHT with estradiol and/or antiandrogens in transgender women may reduce facial and body hair growth and also can improve AGA. Masculinizing GAHT with testosterone in transgender men may increase facial and body hair growth as well as induce or accelerate AGA. The impact of GAHT on hair growth may not align with a transgender person's hair growth goals and specific treatment for AGA and/or hirsutism may be sought. Further research on how GAHT affects hair growth is required. Gender-affirming hormone therapy induces physical changes including in hair parameters. This article summarizes how hair changes have been assessed and any underlying management for undesired hair growth/hair loss. [ABSTRACT FROM AUTHOR]

Context A recent US national survey of the health status of the male transgender population has raised awareness about the little-studied relationship between testosterone hormone therapy in transgender men and cardiovascular outcomes. Objective The aim of this systematic review was to assess the relationship between cross-sex hormone therapy in transgender men and lipid profiles and cardiovascular risk. Data Sources The PubMed, SciELO, SpringerLink, and EBSCOhost databases were searched up to March 2021 for studies assessing the association between cross-sex hormone therapy and the incidence of outcomes related to cardiovascular disease in transgender men over 18 years of age. Data Extraction Data extracted were sorted into clinical data (systolic, diastolic, and mean blood pressure), anthropometric data (body mass index, weight, waist circumference, fat mass, and lean mass), and biochemical data (triglycerides, total cholesterol, low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], very low-density lipoprotein cholesterol [VLDL-C], and the HDL-C to LDL-C ratio). Data Analysis Study quality was appraised independently by two reviewers using the Cochrane tools for assessment of methodological quality or risk of bias in nonrandomized studies, and the Newcastle-Ottawa Scale was applied. Of 735 studies identified, 11 were included in the review. Most studies reported no change in cholesterol or triglyceride levels after hormone treatment. A reduction in HDL-C levels was observed in 7 of 11 studies, although this alone cannot be considered a cardiovascular risk factor. Likewise, clinical and anthropometric findings showed no changes predictive of cardiovascular risk. Conclusions Although these findings suggest that hormone therapy may lead to a decrease in HDL-C levels and an increase in LDL-C levels, they are insufficient to establish a relationship with cardiovascular disease. Furthermore, no significant effects on metabolic and anthropometric values were found. Further studies with higher quality and longer follow-up periods are needed to establish cardiovascular risk. Systematic Review Registration PROSPERO registration number CRD 42020212560. [ABSTRACT FROM AUTHOR]

Background The ongoing quest to surgically create the (nearly) ideal neophallus in transgender men has led to the continuous development of transgender medicine and the proposed introduction of penis transplantation. However, both technical and ethical issues arise when developing this treatment. Aim We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations. Methods Three semistructured focus groups, consisting of different stakeholders, were organized to participate in discussions of ethical considerations retrieved from the ethics literature of transplantation and transgender medicine. Analysis of the results was performed according to empirical ethics. Outcomes Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men. Results Nineteen people participated in this qualitative study. The main domains that emerged included arguments in favor of and arguments against penile transplantation. Although the participants expressed positive attitudes toward developing this care, with acknowledgement of the current limitations stakeholders of all groups were reluctant to endorse the introduction of penile transplantation for transgender men at this point. Clinical Implications Under the present circumstances, all groups expressed both a wide variety of ethical considerations as well as a tendency to prefer developing alternative treatment options or improving the results of currently available treatments in relation to penile transplantation for transgender men. Strengths and Limitations This study was the first (empirical) study to focus on this topic and included a diversity of stakeholder perspectives. Limitations included the hypothetical nature of the discussion as well as the clinical setting in which the topic has been studied. Conclusion Introducing penile transplantation for transgender men, under the current circumstances, comes with a wide range of ethical considerations, which deal with personal identity, autonomy, medical risks, risk for transgender support and donor willingness, and issues regarding equality. Despite the present hesitancy to use penile transplantation, should the technical side of this treatment option develop, further research in the ethical field of penile transplantation for transgender men is recommended. [ABSTRACT FROM AUTHOR]

Background: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. Aim: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. Methods: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. Outcomes: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. Results: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. Clinical Implications: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. Strengths and Limitations: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. Conclusions: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution. [ABSTRACT FROM AUTHOR]

This article discusses a rare histologic phenomenon called mammary pilar metaplasia, which involves the differentiation of mammary epithelia into hair matric. The case presented in the article is of a 43-year-old woman with bilateral milky nipple discharge and hyperprolactinemia. The patient underwent various tests and procedures, including an MRI scan and lumpectomy, which revealed atypical ductal hyperplasia and the presence of dilated ducts with mature hair shafts. Mammary pilar metaplasia is typically observed in gender-affirming mastectomies and in a specific genetic syndrome, but the etiology in this case remains unclear. [Extracted from the article]

STUDY QUESTION Can spindle transfer (ST) overcome inferior embryonic development of in vitro matured ovarian tissue oocytes (OTO-IVM) originating from testosterone-treated transgender men? SUMMARY ANSWER ST shows some potential to overcome the embryo developmental arrest observed in OTO-IVM oocytes from transgender men. WHAT IS KNOWN ALREADY OTO-IVM is being applied as a complementary approach to increase the number of oocytes/embryos available for fertility preservation during ovarian tissue cryopreservation in cancer patients. OTO-IVM has also been proposed for transgender men, although the potential of their oocytes remains poorly investigated. Currently, only one study has examined the ability of OTO-IVM oocytes originating from transgender men to support embryo development, and that study has shown that they exhibit poor potential. STUDY DESIGN, SIZE, DURATION Both ovaries from 18 transgender men undergoing oophorectomy were collected for the purposes of this study, from November 2020 to September 2022. The patients did not wish to cryopreserve their tissue for fertility preservation and donated their ovaries for research. All patients were having testosterone treatment at the time of oophorectomy and some of them were also having menses inhibition treatment. PARTICIPANTS/MATERIALS, SETTING, METHODS Sibling ovaries were collected in either cold or warm medium, to identify the most optimal collection temperature. Cumulus oocyte complexes (COCs) from each condition were isolated from the ovarian tissue and matured in vitro for 48 h. The quality of OTO-IVM oocytes was assessed by calcium pattern releasing ability, embryo developmental competence following ICSI, and staining for mitochondrial membrane potential. In vitro matured metaphase I (MI) oocytes, germinal vesicle (GV) oocytes, and in vivo matured oocytes with aggregates of smooth endoplasmic reticulum (SERa) were donated from ovarian stimulated women undergoing infertility treatment and these served as Control oocytes for the study groups. ST was applied to overcome poor oocyte quality. Specifically, enucleated mature Control oocytes served as cytoplasmic recipients of the OTO-IVM spindles from the transgender men. Embryos derived from the different groups were scored and analysed by shallow whole genome sequencing for copy number variations (CNVs). MAIN RESULTS AND THE ROLE OF CHANCE In total, 331 COCs were collected in the cold condition (OTO-Cold) and 282 were collected in the warm condition (OTO-Warm) from transgender men. The maturation rate was close to 54% for OTO-Cold and 57% for OTO-Warm oocytes. Control oocytes showed a calcium releasing ability of 2.30 AU (n = 39), significantly higher than OTO-Cold (1.47 AU, P  = 0.046) oocytes (n = 33) and OTO-Warm (1.03 AU, P  = 0.036) oocytes (n = 31); both values of calcium release were similar between the two collection temperatures. Mitochondrial membrane potential did not reveal major differences between Control, OTO-Warm, and OTO-Cold oocytes (P  = 0.417). Following ICSI, 59/70 (84.2%) of Control oocytes were fertilized, which was significantly higher compared to 19/47 (40.4%) of OTO-Cold (P  < 0.01) and 24/48 (50%) of OTO-Warm oocytes (P  < 0.01). In total, 15/59 (25.4%) blastocysts were formed on Day 5 in the Control group, significantly higher than 0/19 (0%) from the OTO-Cold (P  = 0.014) and 1/24 (4.1%) in OTO-Warm oocytes (P  = 0.026). Application of ST rescued the poor embryo development, by increasing the Day 5 blastocyst rate from 0% (0/19) to 20.6% (6/29) (P  = 0.034), similar to that in the ICSI-Control group (25.4%, 15/59). A normal genetic profile was observed in 72.7% (8/11) of OTO-Cold, 72.7% (8/11) of OTO-Warm and 64.7% (11/17) of Control Day 3–Day 5 embryos. After ST was applied for OTO-IVM oocytes, 41.1% (7/17) of the embryos displayed normal genetic patterns, compared to 57.1% (4/7) among ST-Control Day 3–Day 5 embryos. LARGE SCALE DATA N/A. LIMITATIONS, REASONS FOR CAUTION Due to the limited access to human oocytes and ovarian tissue, our results should be interpreted with some caution, as only a limited number of human oocytes and embryos could be investigated. WIDER IMPLICATIONS OF THE FINDINGS The results of this study, clearly indicate that OTO-IVM oocytes originating from transgender patients are of inferior quality, which questions their use for fertility preservation. The poor quality is likely to be related to cytoplasmic factors, supported by the increased blastocyst numbers following application of ST. Future research on OTO-IVM from transgender men should focus on the cytoplasmic content of oocytes or supplementation of media with factors that promote cytoplasmic maturation. A more detailed study on the effect of the length of testosterone treatment is also currently missing for more concrete guidelines and guidance on the fertility options of transgender men. Furthermore, our study suggests a potentially beneficial role of experimental ST in overcoming poor embryo development related to cytoplasmic quality. STUDY FUNDING/COMPETING INTEREST(S) A.C. is a holder of FWO grants (1S80220N and 1S80222N). A.B. is a holder of an FWO grant (1298722N). B.H. and A.V.S. have been awarded with a special BOF (Bijzonder Onderzoeksfonds), GOA (Geconcerteerde onderzoeksacties) and 2018000504 (GOA030-18 BOF) funding. B.H. has additional grants from FWO-Vlaanderen (Flemish Fund for Scientific Research, G051516N and G1507816N) and Ghent University Special Research Fund (Bijzonder Onderzoeksfonds, BOF funding (BOF/STA/202109/005)), and has been receiving unrestricted educational funding from Ferring Pharmaceuticals (Aalst, Belgium). The authors declare that they have no conflict of interest. TRIAL REGISTRATION NUMBER N/A. [ABSTRACT FROM AUTHOR]

Background Past studies have demonstrated better mental health and well-being among transgender youth who had accessed gender-affirming care. However, few existing studies have assessed unmet need for gender-affirming care as a social determinant of mental health inequities. Methods Data on unmet need for gender-affirming care, distress and suicidality were analysed from the 2018 Counting Ourselves nationwide community-based survey of transgender people in Aotearoa/New Zealand. Associations between unmet need for gender-affirming care and mental health indicators were tested for transgender youth within the sample (aged 14–26 years; n  = 608; M age = 20.5). Results Transgender youth reported unmet needs ranging from 42% for gender-affirming hormone to 100% for feminizing surgeries and voice surgeries. Overall unmet need for gender-affirming care was associated with worse mental health. Trans men with an unmet need for chest reconstruction (84%) scored an average of 7.13 points higher on the K10 Psychological Distress Scale relative to those whose need had been met. Participants reporting unmet need for hormones (42%) had twice the odds (adjusted odds ratios = 2.01; CI = 1.02–3.98) of having attempted suicide in the last 12 months. Conclusions Dismantling barriers to accessing gender-affirming care could play a crucial role in reducing mental health inequities faced by transgender youth. [ABSTRACT FROM AUTHOR]

Introduction In recent years, the U.S. Veterans Health Administration (VHA) has seen an increasing population of transgender and gender diverse (TGD) veterans accessing care. Approximately 139 per 100,000 VHA users had a gender identity disorder diagnosis documented in 2018 compared to 32.9 per 100,000 in 2013. Despite TGD patients being overrepresented within VHA, TGD veterans may distrust or face unique barriers with various aspects of the VHA, including health services research. Existing VHA health research focused on TGD populations is largely limited to secondary analyses of electronic health record data. Identifying strategies to enhance primary data collection is crucial for more deeply investigating health care challenges experienced by TGD veterans using VHA care. Additionally, describing health topics of importance for TGD veterans is important for making the research agenda more patient-centered. In this study, we offer veterans' recommendations for researchers working with underrepresented populations based on our findings. Materials and Methods From September through October 2019, 30 TGD veterans were recruited through VHA lesbian, gay, bisexual, transgender, and queer/questioning Veteran Care Coordinators (LGBTQ+ VCC) located nationwide. Semi-structured interviews were used to explore barriers and facilitators to research participation, recommendations for improving outreach and engagement, and overall perspectives about priorities in health services research. Transcripts were independently and jointly reviewed and coded by two TGD research analysts, including a veteran using VHA care. Codes were derived inductively. Themes were identified using conventional content analysis. The VA Pittsburgh Healthcare System institutional review board approved this study. Results Participants cited privacy concerns of being "outed" and potentially having VHA benefits revoked, in addition to a level of distrust in researchers' intentions as barriers to participating in studies. Facilitators for participating included feeling a sense of serving the TGD community and accessibility to study locations, especially VHA-affiliated sites. Suggestions for recruitment included tailored messaging and using other TGD peers or affirming VHA staff (e.g. LGBTQ+ VCCs) for study outreach. Mental health and gender-affirming hormone therapy were the most understudied topics identified by participants. Additionally, participants prioritized the inclusion and study of underrepresented subpopulations, such as transgender women of color, transgender men, and non-binary/gender diverse veterans, in future research. Conclusions By harnessing the VHA LGBTQ+ VCC network, this study recruited a national sample of TGD veterans to provide insight on methods for more effectively engaging TGD veterans in research and elicited their suggestions for health services research topics. The findings provide numerous suggestions for medicine and public health that are ripe for future research endeavors. Despite the study's lack of gender, racial, and ethnic diversity, findings highlight the need for engagement and study of underrepresented veteran populations. These suggested areas of focus for research in combination with valuable insight on research participation provide researchers with guidance for developing research agendas and designing recruitment and data collection methods that can facilitate future primary research advancing health services research involving TGD patients. Similarly, VHA and non-VHA researchers conducting research involving other underrepresented populations can also gain insight from these findings. [ABSTRACT FROM AUTHOR]

Background Mental health needs of transgender individuals can be complex with individual, social, and medical factors impacting symptoms. This study examines predictors of mood or anxiety problems among transgender individuals seeking hormone therapy (HT). Methods A retrospective chart review was conducted at 2 clinics providing gender-affirming HT. Cross-sectional data from initial patient encounters (N = 311) were used in this study. Bivariate correlations and multiple logistic regression analyses were carried out. Results Transgender women (TW) were 2.2 times more likely to have mood or anxiety problems while transgender men (TM) were 2.6 times more likely as the number of medical comorbidities increased. For both TW and TM, White race significantly increased the likelihood of mood or anxiety problems. Neither previous nor current HT were associated with mood or anxiety problems for TW and TM. However, receiving multiple gender-affirming procedures decreased the likelihood of mood or anxiety problems for TM. Conclusions Gender-affirming care and addressing comorbidities can be important aspects of mental health needs for transgender individuals. [ABSTRACT FROM AUTHOR]

Background Pelvic cancers are among the most common cancers, impacting millions of individuals worldwide annually. However, little is known about the impact of more rare pelvic cancers on the sexual health of females. Aim In this study we explored sexual health experiences of female pelvic cancer survivors (FPCS) and their healthcare providers (HCP) in order to identify the most salient impacts of pelvic cancer on sexual function. Methods In this qualitative study, semi-structured online interviews were conducted with 15 female patients with vulvar, vaginal, uterine, ovarian, endometrial, cervical, bladder, and/or colorectal cancers. Additionally, semi-structured online interviews were conducted with HCPs who treat pelvic cancers (n = 9). For data analysis, qualitative framework analysis was used. Outcomes We used the collected data and analysis of findings to establish recommendations including ways to improve sexual health and function in female survivors of pelvic cancer. Results Most FPCS experienced negative impacts on their sexual health and function through increased pain and dryness, bleeding due to atrophy, decreased libido, and psychosocial issues such as body dysmorphia. Females with the rarer vulvar and vaginal cancers faced additional challenges to their sexual health such as shortening of vaginal canals, high levels of neuropathy, lack of sexual activity with their partners, and suicidal ideation. FPCS had unmet sexual health needs, which can be attributed to lack of appropriate training by HCPs and lack of resources and availability of services. Although HCPs recognized the importance of providing sexual healthcare, they lacked confidence in their ability to facilitate a conversation on sexual health with their patients, and often avoided this topic. Clinical implications The sexual health outcomes of FPCS can be improved by providing targeted training for HCPs, developing standard resources for sexual health, and integrating tiers of support, including group interventions and counseling. Strengths and limitations The main strength of this study is that data were collected from HCPs as well as FPCS, thus providing a more in-depth overall picture of the current strengths and weaknesses of the resources for sexual health support available for this patient population. A limitation of this study is that the experiences of transgender men were not captured. Conclusions Sexual difficulties are very common in all FPCS, particularly survivors of vulvar and vaginal cancers. Improvement of sexual health outcomes is needed in this patient population, which can be achieved by providing more training for HCPs, developing robust resources for FPCS and their sexual health, and providing more opportunities for tiered support. [ABSTRACT FROM AUTHOR]

Objectives: To assess the histopathologic features of breast tissue of transgender men (TM) undergoing gender-affirming bilateral mastectomies in relation to androgen therapy (AT).Methods: We reviewed 374 transgender bilateral mastectomy cases from 2017 to 2020. Of these, 314 (84.4%) patients received preoperative AT. We compared these with 127 cases of cisgender females undergoing elective breast reduction.Results: Breast specimens from TM on AT, compared with cisgender women, showed a median higher gross percentage of fibrous tissue (P < .001), reduced lobular density (P = .004), higher amount of lobular atrophy (P < .001), and lower incidence of cysts (P < .001), apocrine metaplasia (P < .001), calcifications (P < .001), columnar cell change (P = .002), and atypia (P = .003). Each additional month of AT was associated with a 2% decrease in the odds of having nonapocrine cysts (P = .02), a 5% decrease in the odds of having usual ductal hyperplasia (P = .007), and a 0.14% decrease in median lobular density (95% confidence interval, -0.18 to -0.05).Conclusions: In this study, breast specimens from TM, particularly with a history of AT, had a higher proportion of fibrous tissue, fewer lobules, and a higher degree of lobular atrophy than cisgender females. Rare cases of atypia were not predicted by preoperative imaging or gross findings, supporting routine microscopic evaluation of these specimens. [ABSTRACT FROM AUTHOR]

It is currently unknown whether there are differences in desire for gender affirming medical treatment (GAMT) between binary and non-binary transgender individuals, although the latter seek treatment less prevalently. To investigate differences between binary and non-binary individuals on received GAMT, desire for GAMT, and motives for (not) wanting GAMT, and to explore the association between having an unfulfilled treatment desire and general and sexual well-being. We conducted an online questionnaire in a community sample of 125 transgender men, 72 transgender women, and 62 non-binary transgender individuals (age: M = 30.4, SD = 11.31, range 18-69). Undergone GAMT, GAMT desire, motives for (not) wanting (further) GAMT, Utrecht Gender Dysphoria Scale, Satisfaction With Life Scale, Hospital Anxiety and Depression Scale, Global Measure of Sexual Satisfaction, transgender-specific body image worries, and sexual self-concept discrepancies. Binary transgender participants reported having undergone more GAMT procedures than non-binary transgender participants (P <.001 for both gender affirming hormone treatment (GAHT) and gender affirming surgery (GAS)). While binary participants reported a stronger desire for GAHT compared to non-binary participants (X2 (1, N = 93) = 32.63, P <.001), the groups did not differ in their desire for GAS (X2 (1, N = 247) = 0.68, P =.411). Binary and non-binary participants reported similar reasons for wanting treatment, mostly related to body and/or gender incongruence and gender affirmation. In terms of not wanting treatment, the non-binary group reported their gender identity as the most important reason, while the binary group mostly mentioned possible medical complications. The majority of both groups had an unfulfilled treatment desire (69% of binary participants and 64.5% of non-binary participants), which was related to lower levels of general life satisfaction (P <.001) and sexual satisfaction (P =.005), more anxiety (P =.006) and transgender-specific body image worries (P <.001), and larger sexual self-concept discrepancies (P <.001 for actual and/or ideal, P <.001 for actual and/or ought). Systemic barriers to GAMT (especially GAS) should be removed not only for binary but also for non-binary identifying transgender individuals to decrease the discrepancy between treatment desire and actually seeking treatment. This study was the first to systematically investigate differences in treatment desire motives between binary and non-binary transgender individuals, while also showing the possible negative consequences of an unfulfilled treatment desire. Given the online character of the study, results may not generalize to the broader transgender community. Similarly to binary transgender individuals, many non-binary transgender individuals have a desire for GAMT, and not being able to receive GAMT has a negative effect on their mental and sexual health. Further efforts should be made to make GAMT accessible for all transgender individuals, regardless of gender identity. Kennis M, Duecker F, T'Sjoen G, et al. Gender Affirming Medical Treatment Desire and Treatment Motives in Binary and Non-Binary Transgender Individuals. J Sex Med 2022;19:1173–1184. [ABSTRACT FROM AUTHOR]

Data collected from a validation substudy permit calculation of a bias-adjusted estimate of effect that is expected to equal the estimate that would have been observed had the gold standard measurement been available for the entire study population. In this paper, we develop and apply a framework for adaptive validation to determine when sufficient validation data have been collected to yield a bias-adjusted effect estimate with a prespecified level of precision. Prespecified levels of precision are decided a priori by the investigator, based on the precision of the conventional estimate and allowing for wider confidence intervals that would still be substantively meaningful. We further present an applied example of the use of this method to address exposure misclassification in a study of transmasculine/transfeminine youth and self-harm. Our method provides a novel approach to effective and efficient estimation of classification parameters as validation data accrue, with emphasis on the precision of the bias-adjusted estimate. This method can be applied within the context of any parent epidemiologic study design in which validation data will be collected and modified to meet alternative criteria given specific study or validation study objectives. [ABSTRACT FROM AUTHOR]

Introduction: The ideal length, circumference, and appearance of the penis are important to the self-confidence and body image of most men. To date, only 2 works have assessed preferred erect (but not flaccid) penis length, and only among cis-gender women. No study has evaluated preferred aesthetics--ideal erect and flaccid penile length, or, glans-shape and size preferences among cis-gender and transgender and non-binary individuals. These preference domains are especially important with genital gender-affirming surgery (gGAS) because length and glans-shape are entirely elective and technique-based, and help define neophallus appearance. Lastly, outlining the planned glans shape on a neophallus can be technically challenging, and, to date no publications have reported offering trans men input/choices. Objective: 1) To query ideal for flaccid and erect penis length across all individuals, across cis- and transgender identities; 2) Determine specific likes/dislikes among all subjects for 7 different glans-shape examples; and 3) Among men undergoing phalloplasty, creation of glans-shape stencils for use in the OR, as a means to offer patients choice, and, to ensure that the final product aligns with patient's choice. Methods: An anonymous, online survey (QualtricsTM) evaluated glans preferences among 7 realistic prosthetic penis models shown. Participants were queried about their age, sex, gender, sexual orientation, and their ideal flaccid and erect penis length. Stencils were created based on 6 penis models. Subsequently, 7 transmen-subjects were able to choose the most-preferred glans shape and the stencil was applied before glansplasty surgery (Figure 1). Glansplasty results were assessed 12-weeks post-operatively (Figure 1c;E-F). Results: 74 participants took the survey, (mean age of 35.3, Range: 23–59). 43/74 (58%) self-identified as men, and 28/74 (38%) identified as men, including 7 trans men (Table 1a). Men reported a mean ideal flaccid and erect length of 4.5 and 6.3-inches, respectively, while women reported a length of 5.2 inches and 6.16-inches, respectively. Women had a wider range of responses for both ideal flaccid and erect penile length (p>0.05) (Table 1b). For glans-shape preference, across all groups (independent of sex or sexuality), the "most-liked" options were A and E, and "most-disliked" were B and D (Figure 2). Among the 7 transmen undergoing glansplasty, 5/7 (71%) chose glans-shape C, and 1/7 (14%) each chose glans-shapes A and E, for their own phallus. Conclusions: This is the first study to survey both men and women regarding ideal erect penile length, and the first regarding ideal flaccid penile length and glans-shape preferences. Our data suggests that the ideal erect and flaccid length are longer (within 2SD) than the mean values for cis-men of 5.16-inches and 3.61-inches respectively, (Miles et al., BJUI, 2014) but there is greater variability among women's responses. Regarding glans-shape, most preferred a more tapered, bullet-like tip for the distal glans and a less prominent glans ridge. Finally, our glansplasty stencils are easy to use, yield excellent aesthetic results, and the option to choose their own glans shape is highly appreciated by patients. Disclosure: No. [ABSTRACT FROM AUTHOR]

Transgender men who undergo gender-affirming phalloplasty have limited options for attaining sufficient rigidity for sexual penetration. The goal of this study was to understand interest in and concerns about internal erectile prostheses among transgender men who had undergone phalloplasty. As part of a pilot study of an external erectile device, transgender men (n = 15) were surveyed about their interest in, and concerns about, getting an internal prosthesis. Descriptive analyses were performed for structured questions and content analysis was used to analyze open responses. Measured outcomes included closed- and open-ended questions assessing patient attitudes about internal erectile prostheses. Before starting the study, approximately half the men stated they were interested in getting an internal device, 20% said they weren't, and 33% said they didn't know. More than half of this postphalloplasty population stated they were somewhat or very concerned about the need for additional surgery (73%), side effects (pain, damage to the phallus; 100%), and the risk of device failure (100%). An additional 47% stated they were somewhat or very concerned about cost and 33% stated they were somewhat or very concerned about finding a surgeon. There is a need to develop appropriate alternatives to current internal prostheses for penetrative function after phalloplasty. Generalizability of results is limited by the fact that data are from men who had enrolled in a pilot study to test an external erectile prosthesis, and as such were explicitly interested in exploring nonsurgical alternatives to attain an erection. The combination of quantitative and qualitative data demonstrates that transgender men's concerns about internal prostheses are grounded in the current evidence. Transgender men who have undergone phalloplasty have substantial concerns about the risks of getting an internal prosthesis and there is significant interest in alternatives to current devices. Boskey ER, Mehra G, Jolly D, et al. Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty. J Sex Med 2022;19:1055–1059. [ABSTRACT FROM AUTHOR]

Background Minority stress via discrimination, stigmatization, and exposure to violence can lead to development of mood and anxiety disorders and underlying neurobiochemical changes. To date, the neural and neurochemical correlates of emotion processing in transgender people (and their interaction) are unknown. Methods This study combined functional magnetic resonance imaging and magnetic resonance spectroscopy to uncover the effects of anxiety and perceived stress on the neural and neurochemical substrates, specifically choline, on emotion processing in transgender men. Thirty transgender men (TM), 30 cisgender men, and 35 cisgender women passively viewed angry, neutral, happy, and surprised faces in the functional magnetic resonance imaging scanner, underwent a magnetic resonance spectroscopy scan, and filled out mood- and anxiety-related questionnaires. Results As predicted, choline levels modulated the relationship between anxiety and stress symptoms and the neural response to angry and surprised (but not happy faces) in the amygdala. This was the case only for TM but not cisgender comparisons. More generally, neural responses in the left amygdala, left middle frontal gyrus, and medial frontal gyrus to emotional faces in TM resembled that of cisgender women. Conclusions These results provide first evidence, to our knowledge, of a critical interaction between levels of analysis and that choline may influence neural processing of emotion in individuals prone to minority stress. [ABSTRACT FROM AUTHOR]

Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641–649. [ABSTRACT FROM AUTHOR]

Phalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. To evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. Between 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients' demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. Patients' demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. Optimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. This retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. The Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty. Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661–668. [ABSTRACT FROM AUTHOR]

Objectives: There are limited data on cervical screen results from female-to-male (FTM) transgender patients. Herein, we compiled demographic information and cervical screen testing on FTM transgender patients and compared with age-appropriate controls.Methods: A search of our previous and current databases was performed for Papanicolaou (Pap) tests from patients taking testosterone and/or with a diagnosis of gender dysphoria, transsexualism, or transvestism. Patient data were reviewed. Relative risks of abnormal Pap smear and human papillomavirus (HPV) infection were calculated against age-matched controls.Results: Eighty-nine Pap tests from FTM transgender individuals were identified, with a mean age of 31.3 years (range, 21-60 years). The Pap test diagnoses were distributed as follows: negative for intraepithelial lesion (n = 84, 94.4%), atypical squamous cells of undetermined significance (n = 0), low-grade intraepithelial lesion (n = 4, 4.5%), and high-grade squamous intraepithelial lesion (n = 1, 1.1%). Fifty (56.2%) patients had concurrent high-risk HPV testing with four (8%) positive results. Relative risk was 0.625 (95% confidence interval [CI], 0.25-1.59; P = .32) for an abnormal Pap test and 0.55 (95% CI, 0.19-1.52; P = .24) for HPV compared with 267 age-matched controls. Of note, 13.5% of patients older than 21 years had documentation of never having a prior Pap test in our medical record.Conclusions: In our study, FTM transgender individuals were not at a higher or lower risk of HPV infection or abnormal Pap test result compared with women. However, larger studies are needed to support our findings. [ABSTRACT FROM AUTHOR]

Introduction: Gender affirming healthcare is a multidisciplinary field that includes (but is not limited to) the following interventions: hormonal therapy and gender affirming surgery (chest surgery, hysterectomy, oophorectomy, metoidioplasty, phalloplasty, etc.). Gender-affirming hormone therapy has been shown to positively impact orgasm duration and satisfaction level among both transgender men and women. Research on sexual wellbeing after gender affirming surgery (GAS) indicates positive effects on sexual health outcomes; however, the literature lacks sufficient studies to make evidence-based recommendations. Objective: To synthesize and review the current state of literature on sexual outcomes following gender affirming hysterectomies as background to inform a planned study on this topic. Methods: This project is a literature review of peer-reviewed journal articles on sexual function and pleasure outcomes following hysterectomies, with a particular focus on gender affirming hysterectomies. We considered various cohort studies, systematic reviews, position statements, and meta-analyses in our review. Results: No research currently exists on sexual function or orgasm experience after gender affirming hysterectomy. Current literature exploring sexual function post-hysterectomy only includes cisgender populations (indications typically include cancer risk reduction, pelvic pain, and/or abnormal uterine bleeding). Studies have found mixed results regarding sexual function in cisgender women post-hysterectomy and/or oophorectomy, including changes to anxiety and depression, sexual health and wellness, both in a positive and negative direction. Other analyses found no significant change in sexual function post-hysterectomy in cisgender women. Based on these findings, hysterectomies have mixed effects on sexual satisfaction & function in cisgender populations but there is no data to guide transgender populations. Conclusions: More research is needed on sexual health outcomes (i.e., sexual pleasure, arousal, and orgasm) after gender affirming surgery, as very few studies examine the role of sexual function, including desire, arousal, pain and orgasm in patients' lives post-GAS. No studies investigate sexual satisfaction post-gender affirming hysterectomy despite it being an important GAS for transgender men. Research on this procedure in this specific population will inform evidence-based practices and recommendations, elucidate sex outcomes when the main indication for a hysterectomy is gender affirmation, and advance our understanding of sexual pleasure overall. This author team is initiating a study to address this critical question. Disclosure: No. [ABSTRACT FROM AUTHOR]

Objective: Gender-affirming hormone therapy for female-to-male transsexuals is based on testosterone administration. Testosterone therapy (TT) is associated with side effects such as arteriosclerosis and insulin resistance, among others. This review aims to synthesize the main findings in the literature regarding these adverse effects and identify gaps in knowledge that will guide future studies Methodology: A systematic review of the literature was carried out with search strategies based on Mesh terms. The bibliographic databases PubMed, Embase, and SCOPUS were selected, and the following search algorithm was applied. We included clinical trials, meta-analyses, systematic reviews, and cohort studies. The articles were evaluated by three investigators, who initially reviewed the title and abstract and determined whether the article met the inclusion criteria. We followed the recommendations of the PRISMA statement for this process. Results: The search provided a total of 93 articles (PubMed n = 61, Embase n = 2, Scopus n = 30). Four duplicates were eliminated. Finally, 22 articles met the inclusion criteria. Two studies found hematologic side effects of TT; 4 studies evidenced an increase of metabolic profile without any clinically significant side effects, 1 cohort showed an incidence of hepatic failure of 0.6% in the first year. 2 studies showed that TT was associated with endothelial disfunction and a proinflammatory state. 1 study showed an increase in body weight and lean mass and reduction in body fat. 3 studies showed that TT has no association with an increased risk of breast cancer. 1 study reported a high prevalence of acne with a highest value at 6 months post initiation of therapy. Conclusions: The use of TT showed side effects on metabolic profile bases without clinically significant repercussions. Additionally, even after showing endothelial damage, no cardiovascular events were reported. Further studies are required about this topic. Figure 1. Flowchart Selection of items according to PRISMA 2020. Financing: No conflict. [ABSTRACT FROM AUTHOR]

Introduction: In the 21st century, the transgender population begun to have greater visibility and advances within the health field in terms of gender reassignment. This transition covers four aspects which includes legal, social, surgical reassignment and hormone therapy. Although the word transgender is no longer in the disorders section, it's still seen as a disease. For this reason, the transgender population continues to be pathologized. In Bogotá, Colombia, information on the processes that encompass gender reassignment is currently not sufficient. Objective: To understand the perception of transgender men about the four aspects of the female-to-male gender reassignment currently taking place in Bogotá. Method: Qualitative descriptive study with biographical/narrative design carried out using semi-structured interviews were conducted with 4 transgender men over 18 years who have completed at least one of the aspects in Bogotá. These interviews were audio recorded, transcribed and analyzed. The results were divided into 2 dimensions, which were subdivided into various categories. Results and discussion: Once gender reassignment began, most transgender men opt to start with the social aspect because it allows them to present themselves to society in their desired way. After this, they continued with the legal, hormonal and surgical aspects according to each person's preference. As a result, a lack of protocols and poor follow-up of health care guidelines for adequate care of this population were evident. Financing: No conflict. [ABSTRACT FROM AUTHOR]

Several treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes. The aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty. A multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers. The primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively. Of 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). This study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen. Strengths 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. Open 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. [ABSTRACT FROM AUTHOR]

Introduction: Excess visceral fat increases the risk of type 2 diabetes and cardiovascular disease and is influenced by sex hormones. Our aim was to investigate changes in visceral fat and the ratio of visceral fat to total body fat (VAT/TBF) and their associations with changes in lipids and insulin resistance after 1 year of hormone therapy in trans persons. Methods In 179 trans women and 162 trans men, changes in total body and visceral fat estimated with dual-energy X-ray absorptiometry before and after 1 year of hormone therapy were related to lipids and insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR)] with linear regression analysis. Results In trans women, total body fat increased by 4.0 kg (95% CI 3.4, 4.7), while the amount of visceral fat did not change (-2 grams; 95% CI -15, 11), albeit with a large range from -318 to 281, resulting in a decrease in the VAT/TBF ratio of 17% (95% CI 15, 19). In trans men, total body fat decreased with 2.8 kg (95% CI 2.2, 3.5), while the amount of visceral fat did not change (3 g; 95% CI -10, 16; range -372, 311), increasing the VAT/TBF ratio by 14% (95% CI 10, 17). In both groups, VAT/TBF was not associated with changes in blood lipids or HOMA-IR. Conclusions Hormone therapy in trans women and trans men resulted in changes in VAT/TBF, mainly due to changes in total body fat and were unrelated to changes in cardiometabolic risk factors, which suggests that any unfavorable cardiometabolic effects of hormone therapy are not mediated by changes in visceral fat or VAT/TBF. [ABSTRACT FROM AUTHOR]

Gender affirmation surgeries are performed to decrease the patient's dysphoria and improve quality of life. Preservation of the vaginal canal with reproductive organs is uncommon though becoming increasingly discussed in trans men. This series examines surgical complexities of vaginal and/or reproductive organ preservation in patients undergoing phalloplasty, highlighting considerations for safety and well-being. Two patients who underwent phalloplasty met inclusion and exclusion criteria for the study and were treated in accordance with World Professional Association for Transgender Health standards. We retrospectively reviewed patients' medical records and extracted demographic data. Phallus and clitoral sensation, ability for penetrative intercourse and treatment of gender incongruence were assessed postoperatively. At an average of 22 months postoperatively, both flaps survived with tactile sensation two-thirds down the shaft, and the clitoris of both maintained erogenous sensation from stimulation. Gender incongruence was described to be reduced, and both patients were able to receive penetrative vaginal intercourse. [ABSTRACT FROM AUTHOR]

Study Question: Is the functional ovarian reserve in transgender men affected by testosterone therapy?Summary Answer: Serum anti-Müllerian Hormone (AMH) levels slightly decrease during testosterone treatment but remain within the normal range, suggesting preserved follicular ovarian reserve.What Is Known Already: Few small studies have investigated the impact of gender-affirming treatment on reproduction in transgender men. Conflicting results were reached concerning ovarian morphology and AMH levels in this context.Study Design, Size, Duration: The study consisted of two arms. The first arm was a prospective pilot study, which enrolled 56 transgender men (median age 22.5 [interquartile range (IQR)-19-27.7] years), 27 of whom had polycystic ovary syndrome (PCOS), prior to the initiation of gender-affirming testosterone therapy. A structured assessment was conducted prior to, and at 3 and 12 months after treatment initiation. The second arm was a cross-sectional study that comprised 47 transgender men (median age 24 [IQR-20-31] years) who received testosterone for a median duration of 35 [IQR 13-62] months. The main outcome measures were serum AMH and antral follicle count (AFC) as indices of ovarian follicular reserve.Participants/materials, Setting, Methods: The study was conducted at a tertiary center for transgender health. Gender-affirming therapy was administered according to standard practice. AFC was determined by pelvic (abdominal or transvaginal) ultrasound and blood collection for measurements of AMH, testosterone, estradiol, LH and FSH was performed at the designated time-points.Main Results and the Role Of Chance: Prospective arm for the entire group we observed a decrease of 0.71 ng/ml in AMH levels between baseline and 12 months (P = 0.01). When expressed in age-specific percentiles, AMH went from the 47.37th to the 40.25th percentile at 12 months (P < 0.001). In a sub-group analysis, a decline of 9.52 points in age-specific percentile was seen in subjects with PCOS (P < 0.001), while no changes were detected in the non-PCOS group. Testosterone treatment did not affect AFC over time in the entire cohort. In the sub-group analysis, a mean decrease of 5.0 follicles was detected between baseline and the 12 months assessment (P = 0.047) only in subjects with PCOS. In the cross-sectional study, AMH inversely correlated with age but not with treatment duration. Notably AMH did not deviate from the 50th age-specific percentile. Finally, four men fathered biological children after being under testosterone treatment for up to 12 years.Limitations, Reasons For Caution: The limited sample size of the pilot study should be kept in mind. An additional limitation is the lack of a control group in the prospective study, as each participant served as his own control. Also, roughly 40% of the ultrasound examinations were performed transabdominally, potentially affecting the accuracy of the AFC measurements.As study participants were quite young, our reassuring data may not apply to older transgender men, either because of an age-related decline in ovarian reserve or to possible long-term effects of testosterone therapy. Furthermore, the chances for fertility preservation may be more limited in subjects with PCOS.Wider Implications Of the Findings: This is an additional contribution to the emerging evidence that prolonged testosterone treatment may not be a major obstacle to later fertility potential in transgender men desirous of having children. Larger confirmatory studies, and particularly more with reproductive outcome data, are needed for evidence-based fertility counseling prior to treatment initiation in these subjects.Study Funding/competing Interest(s): This study received no funding. The authors have no competing interests to declare.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Context: Erythrocytosis is a known side effect of testosterone therapy that can increase the risk of thromboembolic events.Objectives: To study the prevalence and determinants in the development of erythrocytosis in trans men using testosterone.Methods: A 20-year follow-up study in adult trans men who started testosterone therapy and had monitoring of hematocrit at our center (n = 1073).Results: Erythrocytosis occurred in 11% (hematocrit > 0.50 L/L), 3.7% (hematocrit > 0.52 L/L), and 0.5% (hematocrit > 0.54 L/L) of trans men. Tobacco use (odds ratio [OR] 2.2; 95% CI, 1.6-3.3), long-acting undecanoate injections (OR 2.9; 95% CI, 1.7-5.0), age at initiation of hormone therapy (OR 5.9; 95% CI, 2.8-12.3), body mass index (BMI) (OR 3.7; 95% CI, 2.2-6.2), and pulmonary conditions associated with erythrocytosis and polycythemia vera (OR 2.5; 95% CI, 1.4-4.4) were associated with hematocrit > 0.50 L/L. In the first year of testosterone therapy hematocrit increased most: 0.39 L/L at baseline to 0.45 L/L after 1 year. Although there was only a slight continuation of this increase in the following 20 years, the probability of developing erythrocytosis still increased (10% after 1 year, 38% after 10 years).Conclusion: Erythrocytosis occurs in trans men using testosterone. The largest increase in hematocrit was seen in the first year, but also after the first years a substantial number of people present with hematocrit > 0.50 L/L. A reasonable first step in the care for trans men with erythrocytosis while on testosterone is to advise them to quit smoking, to switch to a transdermal administration route, and if BMI is high, to lose weight. [ABSTRACT FROM AUTHOR]

In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL). The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up. A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction. Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P <.001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P <.001) and with voiding (P =.02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P =.48 and P =.95 respectively). Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey. : No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974–981. [ABSTRACT FROM AUTHOR]

Cardiovascular (CV) implications of long-term gender affirming hormonal treatment (GAHT) in transgender individuals still remain largely unknown. To evaluate changes in the 30-year Framingham cardiovascular disease (CVD) risk in a large cohort of transgender individuals after the start of GAHT. In a multicenter prospective study, a consecutive series of 309 participants (165 transmen and 144 transwomen) was evaluated during a 2-year follow-up. Prospectively, after the start of GAHT a physical examination was performed and blood samples were drawn. CVD risk was calculated for each person, according to the Framingham 30-year CVD risk estimate. Changes in CV risk factors and 30-year Framingham CVD risk during GAHT. In transmen testosterone-induced lipid profile alterations may have a clinical relevance on the individual long-term CVD risk. The strength of the present study is the possibility to predict long-term CV outcomes in transgender individuals receiving GAHT based on a short observation; whereas the main limitation is that CVD risk prospective changes mainly represent the expression of risk factors changes during GAHT. In transwomen a significant decrease in triglycerides, total cholesterol and LDL-cholesterol was observed during the 2-year follow-up (P <.05), whereas unfavorable lipid changes – such as increased total cholesterol, triglycerides, and LDL cholesterol levels and decreased HDL cholesterol levels (P <.05)- occurred after the start of GAHT in transmen. These changes in risk factors led to an increase in the risk of general and hard CVD events based on lipid profile over time in transmen (P =.001 and P =.005, respectively). No significant changes in general and hard CVD risk based on lipid profile were observed in transwomen over time. Our findings confirmed the unfavorable lipid changes in transmen after the start of GAHT even during a longer follow-up, empathizing the potential clinical impact of these modifications on individual long-term CVD risk. Cocchetti C, Castellini G, Iacuaniello D, et al. Does Gender-Affirming Hormonal Treatment Affect 30-Year Cardiovascular Risk in Transgender Persons? A Two-Year Prospective European Study (ENIGI). J Sex Med 2021;18:821–829. [ABSTRACT FROM AUTHOR]

Metoidioplasty is a possibility for penis reconstruction in transmen that could be enhanced by a semi-rigid prosthesis support. Describe the surgical technique of metoidioplasty with implantation of a specifically designed semi-rigid prosthesis -the ZSI100D4- and analyze preliminary results. Implantation of semi-rigid prosthesis was proposed to transmen who chose metoidioplasty for genital gender affirming surgery in a specialized university hospital. Surgical outcomes were collected from medical files. Functional outcomes and satisfaction were collected post-operatively with a questionnaire. A 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 ?". Implantation of a semi-rigid prosthesis in an enlarged clitoris seems to be a valuable option and can be proposed as another possibility for 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. [ABSTRACT FROM AUTHOR]

Context: Individuals with gender dysphoria can receive gender-affirming h ormone therapy. Different guidelines mention a severe risk of liver injury within the first months af ter the start of treatment with anabolic androgenic steroids, anti-androgens, and oral contraceptives, which is pot entially fatal. Objective: The incidence of liver injury in a transgender population usin g gender-affirming hormone therapy. Design: Multicentre prospective study with 1933 transgender individual s, who started with hormone therapy between 2010 and 2020. Methods: The following parameters were analysed before hormone therapy, after 3 months, and after 12 months of hormone therapy: alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and gamma-glutamyltransferase (GGT). Both male and female reference values were considered. Liver injury was defined as either an elevation of 2× upper limit of normal (ULN) of ALP, 3× ULN of ALT, or 3× ULN of AST. Results: 889 transgender women and 1044 transgender men were included in the analysis. The incidence of liver injury within 12 months after the start of hormone therapy, wit hout attribution to alcohol abuse, medical history, or comedication was 0.1 and 0.0%. in transgender women according to female and male reference intervals respectively, and 0.6 and 0.4% in transgender men (female and male reference intervals). Conclusion: The incidence of liver injury is found to be very low. We, the refore, conclude that liver enzyme monitoring within the frame of the risk of liver injury due to hormone the rapy is not necessary for a transgender population. [ABSTRACT FROM AUTHOR]

Introduction: The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective: To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods: Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results: After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions: Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Cross-sex hormones in female-to-male (FtM) transgender individuals play a crucial role in brain plasticity. Brain activity associated with sexual arousal in FtM transgenders receiving cross-sex hormones is poorly understood. Objective: This study aimed to compare brain activation patterns associated with sexual arousal between FtM transgenders and premenopausal women using a 3.0 Tesla functional magnetic resonance imaging (fMRI). Methods: This study included 13 FtM transgenders (mean age: 43.2±6.4 years) and 13 premenopausal women (mean age: 41.5 ± 8.3 years). The FtM transgender individuals, who have had sex-reassignment surgery, received testosterone supplementary therapy. Sexual orientation was evaluated using the Kinsey sexuality rating scale (0 = exclusively heterosexual; 6 = exclusively homosexual). Serum sex hormones were measured, including free testosterone (free-T), estradiol (E2), follicle-stimulating, and luteinizing hormones. Visual sexual stimulation began with a 30-s cross fixation (rest condition), followed by a 30-s natural documentary (neutral condition), 540-s erotic video (sexual activation condition), then a 30-s cross fixation (rest condition). The fMRI data were post-processed using SPM8 software. Results: The average rating of the Kinsey scale in the FtM transgenders was 5.6 ± 0.5, indicating their sexual orientation falls within the category of homosexual. The FtM transgenders showed significant increases in the free-T levels (18.8±18.9 pg/mL vs. 0.4±0.4 pg/mL, p < 0.001) and significant decreases in the E2 levels (45.4±32.0 pg/mL vs. 279.2±247.3 pg/mL, p = 0.001) compared with premenopausal women. The brain areas with significantly higher activities during visual sexual stimuli in the FtM transgenders compared with premenopausal women included the superior parietal lobule, middle occipital gyrus, and superior frontal gyrus (p < 0.001). Conclusions: This study illustrates the specific brain activation patterns associated with sexual arousal in female-to-male (FtM) transgenders. These findings could contribute to our understanding of the neural mechanisms associated with sexual arousal in relation to the levels of sexual hormones in FtM transgenders. This research was supported by grants from the National Research Foundation funded by the government (MSIT; 2022R1A2C2007809, 2021R1C1C2011748). Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. Objective: We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients. Methods: Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. UOP from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+). Results: The aggregate number of 12-hour shift UOP observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml) (Table 1). Conclusions: Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). The difference in urinary drainage is likely explained by the suprapubic catheter tip and drainage inlet residing in a more gravity-dependent location, within the funnel-shaped bladder neck (Figure 1). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: The placement of Penile Prosthesis (PP) in transgender men with a neophallus is technically demanding and poses challenges specifically related to the extracorporal proximal anchoring of the cylinders owing to the lack of proximal corpora. We herein designed a novel Trans-Obtutrator Repositioning Sling (TOROS) for the proximal PP cylinder anchoring in a phallus of cisgender man or a neophallus of transgender man. Objective: To assess the safety and efficacy of this novel surgical approach for the extracorporal proximal PP cylinder anchoring (TOROS) in two patients (cisgender and transgender) through refashioned use of the AdVanceTM Male Sling System (Boston Scientific). We herein present one video (first patient) to demonstrate step by step surgical technique. Methods: Two patients were included. First patient is a 38-year-old cisgender male with a history of micropenis who underwent anterolateral thigh phalloplasty in 2017 presents for PP insertion. Second patient is 35 year old transgender with history of right free flap forearm phalloplasty 2019 with prior failed PP revision presents with perineal pain at level of proximal PP cylinder. Both patients consented and elected to proceed. Results: After careful identification of neophallus vascular pedicle with handheld doppler, a perineal midline incision was made. The space within the neophallus was carefully dissected, dilated up to 11mm with Hegar dilator and measured for upcoming PP cylinder. Next and similar AdVance Male Sling surgical approach, the Adductor Longus tendon identified as a landmark, a trocar was inserted carefully through the obturator foramen around the inferior ischiopubic ramus. The sling was pulled via perineal incision and refashioned into socket-like sling to house the proximal end of PP cylinder or Rear Tip Extender (RTE) (in this case). To further reinforce this connection, sling flanges wrapped around and suture fixated. Next a single-cylinder Ambicor PP (Boston Sci) is inserted. PP pump placed into the left perineal side. Total PP length was 15cm+2cm RTE. PP appeared cycling well. Skin closed in layers. Patient had an uneventful post-op course and discharged on POD #3. At the 6-week mark, the patient had no post-op complaints or complications. The patient has been able to cycle the penile implant twice daily without issue and satisfied with the outcome of the procedure. Conclusions: Extra-corporal anchoring of PP cylinders using TOROS is a novel, feasible and potentially changing approach in cisgender or transgender men. Proximal anchoring of the cylinders on the inferior pubic ramus and ramus of the ischium through the modified and refashioned use of trans-obturator male sling mimic natural anatomical attachment of the proximal corpora, and the same approach can applied in a transgender man neophallus with apparent good stability with and without axial loading. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Historically, inflatable penile prostheses (IPP) insertion in a neophallus has an estimated 40-50% surgical revision rate. Objective: To review the surgical outcomes of a single center's experience with the infrapubic approach to insertion of the IPP after phalloplasty in transmen. Methods: The infrapubic prosthesis insertion after phalloplasty (IPIP) technique involves a horizontal incision anterior to the pubic symphysis, which allows dissection of the neophallus channel, the Space of Retzius, and the scrotal pocket. Surgical outcomes using the Titan (Coloplast, Minneapolis, MN) IPP by a single surgeon (MLC) were analyzed between October 2017 and June 2023. Complications were reviewed and categorized into erosions, infections, device malposition and malfunction, and less common events like necrosis and urinary tract injury. Results: The IPIP technique was performed on 175 phalloplasty patients by a single surgeon (MLC): 156 patients had a prior RF phalloplasty, and 19 had a prior ALT phalloplasty. The mean followup was 32.8 months. Surgical revision was required in 35 patients (20%). There were 10 pump erosions through the neoscrotum, 1 glans erosion, 9 infections, 6 pump malpositions in the neoscrotum, 6 cylinder malposition in the neophallus, 3 mechanical malfunctions with broken tubing, 2 urethral injuries, 2 bladder injuries, and 1 glans necrosis. There were no instances of implant detachment from the pubic bone anchor site, osteomyelitis, nor total phallus loss. Conclusions: Data for the IPIP technique using the commercially available Coloplast Titan IPP suggest a reduction in neophallus prosthetic surgical revision rates compared to previous reports. Longer term studies with patient reported outcomes are required for further evaluation. Disclosure: Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific. [ABSTRACT FROM AUTHOR]

Introduction: The ideal length, circumference, and appearance of the penis are important to the self-confidence and body image of most men. To date, only 2 works have assessed preferred erect (but not flaccid) penis length, and only among cis-gender women. No study has evaluated preferred aesthetics--ideal erect and flaccid penile length, or, glans-shape and size preferences among cis-gender and transgender and non-binary individuals. These preference domains are especially important with genital gender-affirming surgery (gGAS) because length and glans-shape are entirely elective and technique-based, and help define neophallus appearance. Lastly, outlining the planned glans shape on a neophallus can be technically challenging, and, to date no publications have reported offering trans men input/choices. Objective: 1) To query ideal for flaccid and erect penis length across all individuals, across cis- and transgender identities; 2) Determine specific likes/dislikes among all subjects for 7 different glans-shape examples; and 3) Among men undergoing phalloplasty, creation of glans-shape stencils for use in the OR, as a means to offer patients choice, and, to ensure that the final product aligns with patient's choice. Methods: An anonymous, online survey (QualtricsTM) evaluated glans preferences among 7 realistic prosthetic penis models shown. Participants were queried about their age, sex, gender, sexual orientation, and their ideal flaccid and erect penis length. Stencils were created based on 6 penis models. Subsequently, 7 transmen-subjects were able to choose the most-preferred glans shape and the stencil was applied before glansplasty surgery (Figure 1). Glansplasty results were assessed 12-weeks post-operatively (Figure 1c; E-F). Results: 74 participants took the survey, (mean age of 35.3, Range: 23–59). 43/74 (58%) self-identified as men, and 28/74 (38%) identified as men, including 7 trans men (Table 1a). Men reported a mean ideal flaccid and erect length of 4.5 and 6.3-inches, respectively, while women reported a length of 5.2 inches and 6.16-inches, respectively. Women had a wider range of responses for both ideal flaccid and erect penile length (p>0.05) (Table 1b). For glans-shape preference, across all groups (independent of sex or sexuality), the "most-liked" options were A and E, and "most-disliked" were B and D (Figure 2). Among the 7 transmen undergoing glansplasty, 5/7 (71%) chose glans-shape C, and 1/7 (14%) each chose glans-shapes A and E, for their own phallus. Conclusions: This is the first study to survey both men and women regarding ideal erect penile length, and the first regarding ideal flaccid penile length and glans-shape preferences. Our data suggests that the ideal erect and flaccid length are longer (within 2SD) than the mean values for cis-men of 5.16-inches and 3.61-inches respectively, (Miles et al., BJUI, 2014) but there is greater variability among women's responses. Regarding glans-shape, most preferred a more tapered, bullet-like tip for the distal glans and a less prominent glans ridge. Finally, our glansplasty stencils are easy to use, yield excellent aesthetic results, and the option to choose their own glans shape is highly appreciated by patients. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Gender affirming hormone therapy (GAHT) is part of the transition for many transgender and nonbinary (TGNB) individuals. Additionally, it has become increasingly more common for TGNB youth to receive puberty blockers (GnRH agonist) to halt the pubertal progression. There have been few studies investigating sexual function and desire either during or after puberty blockers (PB) and/or GAHT. Objective: Our aim was to qualitatively evaluate the sexual experience of TGNB individuals during or following PB and/or GAHT, and outline any potential differences between the two groups. Methods: We performed an IRB approved two institutional study on the effect of PB and/or GAHT on sexual function and desire. The GAHT group (n=16): individuals who started GAHT (estrogen or testosterone) >18 years. The PB+GAHT group (n=10): subjects with current or past GnRH agonist use +GAHT. All 26 enrolled subjects were interviewed using an open-ended topical guide. Qualitative analysis was performed by hand coding the interview transcripts using Constructivist Grounded Theory qualitative methods. Results: A total of 26 TGNB (20 assigned male at birth, 6 assigned female at birth: 18 transgender women, 5 transgender men, 3 non-binary) subjects ages 18-25y were interviewed about the effect of PB and/or GAHT on their sexual function and desire. Our analysis uncovered several themes that were consistent between groups (Table 1). Conclusions: Themes were similar for both groups. Half the participants in each group reported feeling no regrets regarding hormone therapy, and the other half reported that they wished they had started hormones sooner. Two notable differences were identified between groups: those on PB+GAHT reported "less dysphoria" as a positive change in sexual desire, and the GAHT group reported more enjoyable sexual experiences since being on hormones. Interestingly, results did not reveal any significant differences between groups. The most prominent theme that arose in both groups was that the positive changes in sexual function and desire outweighed any negative changes that arose. Disclosure: No. [ABSTRACT FROM AUTHOR]

Introduction: Many transgender and nonbinary (TGNB) individuals seek out puberty blockers (PB) to stop the progression of unwanted changes from endogenous puberty and/or gender affirming hormone therapy (GAHT) to aid in their medical transition. There has been limited research assessing the effect of these hormone therapies on sexual function and desire, especially in comparing GAHT and PB+GAHT. Objective: Our aim was to compare the effect of GAHT and PB+GAHT on sexual function and desire of TGNB individuals during or following hormone therapy. Methods: We performed an IRB approved two institutional study on the effect of GAHT and/or PB on sexual function and desire in adults. The GAHT group (n=12) included individuals who started GAHT (estrogen or testosterone) >18 years old. The PB group (n=10) included subjects with current or past history of GnRH agonist use (>10 years old). Enrolled subjects completed the validated Changes in Sexual Functioning Questionnaire (CSFQ). The CSFQ was validated in adults to assess medication-related changes in sexual functioning. The questionnaire is specific to sex assigned at birth with a male and female version. The answers were scored in total and separated into sexual function and sexual desire subscales. Scores in each group were compared using unpaired t-tests. Results: A total of 22 TGNB (16 assigned male at birth and 6 assigned female at birth: 14 transgender women, 5 transgender men, 3 non-binary) subjects ages 18-25 completed the CSFQ about the effect hormone therapy had on sexual function and desire. There was no difference between groups in total scores (t = 0.8, p = 0.05) or in categories of sexual function (t = 0.3, p = 0.05) and desire (t = 0.8, p = 0.05). There were an equal number of participants in both groups whose results showed sexual dysfunction in total (n=2 per group) and in categories of sexual function (n=7 per group) and desire (n=3 per group). The cause of their dysfunction is unclear at this time and is to be investigated in the future. Interestingly, despite meeting quantitative criteria for sexual dysfunction, 6 participants answered that their sexual life brings them "much" or "great" enjoyment or pleasure. Conclusions: Based on our results, while there were >70% of subjects in each group with impaired sexual function, there were no differences in effect on sexual function and desire between subjects on GAHT vs. PB+GAHT. Additionally, the scores for both groups did not differ substantially from scores of cisgender individuals (Keller, et al 2006). In fact, both the GAHT and PB+GAHT groups scored higher on average in the sexual desire category compared to cisgender individuals. Prospective data collection will help us clarify further whether starting age of pubertal blockers and hormone therapy affects sexual function and desire. Disclosure: No. [ABSTRACT FROM AUTHOR]

Study Question: Does testosterone use in females affect reproductive potential, particularly with regard to the production of fertilizable gametes?Summary Answer: Testosterone (T) injections given to post-pubertal female mice caused virilization and although the ovaries were smaller than controls they were still responsive and produced fertilizable eggs when superovulated.What Is Known Already: Studies to examine the effects of testosterone on reproductive potential in transgender males are lacking. Recently, a model was developed that simulates many aspects of testosterone use in transgender males in order to look at reproductive effects of testosterone in female mice. This study found masculinizing effects on the mice but did not find significant deficits on the number of ovarian follicles; however, effects of testosterone use on ovarian stimulation and fertilizability of oocytes were not investigated.Study Design, Size, Duration: A total of 66, 6-week-old Hsd:NSA (CF-1) female mice and six Hsd:ICR (CD-1) male mice were used for this study. Mice were injected s.c. with 400 µg T or sesame oil once a week for 6 weeks and were either killed 1 week after the sixth injection (active exposure group), or 6-7 weeks after the final T injection (washout group).Participants/materials, Setting, Methods: Both active exposure and washout groups were further subdivided into three groups: unstimulated, equine CG (eCG)-stimulated or eCG/hCG-stimulated. eCG-stimulated mice were killed 44-48 h after eCG injection. eCG/hCG-stimulated mice were injected with eCG, followed 48 h later with hCG. Mice were killed ∼13-18 h after the hCG injection. Data collected included daily vaginal cytology, terminal testosterone levels, ovary weights and histology, number of oocytes/eggs collected in each group, and cleavage to the two-cell stage following IVF.Main Results and the Role Of Chance: Testosterone-treated mice had testosterone levels elevated to the level of male mice and ceased cycling. Ovaries were significantly smaller in testosterone-treated mice, but they contained normal cohorts of follicles and responded to gonadotrophin stimulation by ovulating similar numbers of eggs as controls, that fertilized and cleaved in vitro.Limitations, Reasons For Caution: Mice were treated for only 6 weeks, whereas many transgender men use testosterone for many years before considering biological children, and developmental competence was not assessed. Importantly, a mouse system may not perfectly simulate human reproductive physiology.Wider Implications Of the Findings: The current standard of care for transgender men who desire biological children is to cease testosterone therapy prior to ovarian stimulation, but the necessity for stopping testosterone is not known. Our model demonstrates that it is possible for testosterone-suppressed ovaries to respond to gonadotrophic stimulation by producing and ovulating fertilizable eggs, thereby obviating the need for testosterone cessation prior to ovarian stimulation. In time, these results may provide insights for future clinical trials of fertility treatment options for transgender men.Study Funding/competing Interest(s): This study was funded by the Reproductive Endocrinology and Infertility fellowship program through UConn Health Graduate Medical Education (to C.B.B.). The authors have no competing interests.Trial Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Objectives: Transgender people may face serious challenges with their sexual experiences such as sexual behavior (ie the type and frequency of sexual activity) and sexual experience (eg their sexual pleasure) at various stages of the diagnosis and treatment process. The aim of the study was to assess sexual behavior, to assess the quality of sexual life at various stages of the process of diagnosis and treatment of transgender people. Methods: 104 transgender people who are sexually active were qualified for the study. The study was conducted in two medical centers. The research tool used in the study was the original questionnaire and the Life Satisfaction Scale (SWLS), the Sexual Satisfaction Questionnaire (KSS). Results: The author's study also showed that both transgender women and transgender men after SRS achieve statistically higher results on the KSS scale compared to people before surgical gender reassignment. Moreover, it was found that trans people who accept their genitals have statistically higher scores of sexual satisfaction. There was no correlation between SRS and the stage of the diagnosis and treatment process and the act of masturbation. Additionally, it was indicated that transsexual people who experienced homosexual intercourse before legal gender reassignment had a higher sexual satisfaction score. Conclusions: Transgender women are characterized by a higher sense of life satisfaction than transgender men at every stage of the diagnosis and treatment process. Transgender men are characterized by a higher assessment of sexual satisfaction during hormone treatment after legal gender correction in relation to transgender women. Surgical sex reassignment operations determine the assessment of sexual satisfaction among transgender people. Conflicts of Interest: No Conflicts of Interest. [ABSTRACT FROM AUTHOR]

Objectives: Our study aim is to analyze the surgical and functional outcomes after urethral reconstruction in consecutive series of transgender men who underwent genital gender-confirming surgery. Methods: A retrospective monocentric cohort study was conducted. From 2015 to 2022, patients who underwent urethral lengthening in the context of GGCS were enrolled. Surgical outcomes and postoperative complications were reported. Three questionnaires were administered to evaluate patients' urinary function (CCO-EPIC, ICIQ-SF) and patients' psychological well-being (BDI - scale of depression). A 6-item ad hoc created questionnaire was administered to inquire patients' reported outcomes. Results: 31 patients were included in the study. 11 underwent metoidioplasty (Group A), while 20 underwent phalloplasty with different techniques (Group B). The descriptive characteristics between the two groups were comparable, except for the BMI resulting greater in Group B (p-value 0.012). Average follow-up was 18 months (±18SD). Mean operative time was 160 minutes (±43 SD). No significant intraoperative complications occurred. Early postoperative complication rate resulted significantly higher for group B (83.3% p-value 0.034). The most frequent complication, urethral fistula, healed in all cases after prolonged catheterization. Overall 9.6% of patients needed a surgical revision to address urethral complications. CCO-EPIC and ICIQ-SF administered preoperatively and 1-year after surgery showed worsening in urinary function (p-value = 0.04 and p-value = 0.02 respectively), BDI score showed a significant improvement in postoperative settings (p-value= 0.02). 82 % of the patients after 1-year follow-up were satisfied with the procedure and 81 % declared that surgery had a positive impact on their quality of life. The main limitations of the study are the limited follow-up, the non-randomized nature of the study and the small number of patients. Conclusions: Urethral reconstruction in the context of GGCS is a challenging reconstructive surgery burdened by high incidence of postoperative complications. Despite that, it may contribute to improve the psychological well-being of transgender men. Conflicts of Interest: This study is free from commercial influence or bias and the authors had no conflict of interest. [ABSTRACT FROM AUTHOR]

Whereas mounting work has begun to document the neural correlates underlying sexual arousal (SA) in humans, the associations between gender identity and the brain correlates of SA as well as their hormonal contributions remain unknown. This study investigated neural activation to sexual arousal in transgender and cisgender persons. 20 transgender men and 19 transgender women (TW) already living in their identified gender were compared to 21 cisgender men (CM) and 19 cisgender women. Participants viewed erotic and neutral video clips while undergoing 3 Tesla magnetic resonance imaging. Group-specific brain activation, brain functional connectivity, and brain-hormone associations within the neurophenomenological model of sexual arousal (Stoleru et al, 2012). Consistent with the model, participants activated most of its components. However, between-group differences were mostly showing larger activation for CM relative to any of the other 3 groups. Moreover, functional connectivity analyses (psychophysiological interactions) indicated unique patterns for CM, cisgender women, and TW in how different components of SA communicated with one another. Finally, androgens in transgender men and estrogens in TW correlated negatively with parietal cortex and primary (sensori-) motor regions, respectively, while CM showed positive correlations of androgens with parietal cortex, somatosensory regions, and the insula. Data provide information on neurobiological changes in sexual arousal during treatment with gender-affirming hormone therapy. Although a limitation is the lack of pretreatment data, the present study provides comprehensive information including brain activation, functional connectivity, and hormonal associations in a large sample. The results highlight a complex picture of the neural correlates of SA in gender identity and sex assigned at birth. Mueller SC, Wierckx K, T'Sjoen G. Neural and Hormonal Correlates of Sexual Arousal in Transgender Persons. J Sex Med 2020;17:2495–2507. [ABSTRACT FROM AUTHOR]

Genital gender-affirming surgery (gGAS) with urethral lengthening (UL) in transgender men is associated with high urological complication and reoperation rates. Since 2009, we offer gGAS without UL to avoid these complications. The aim of this study was to assess what portion of the transgender men opted for gGAS without UL and to assess functional, surgical outcomes, and patient satisfaction after gGAS without UL. Retrospective data were collected from patients' charts. The International Prostate Symptom Score, uroflowmetry, and 24-hour frequency voiding chart were used to assess voiding, and a self-constructed semistructured questionnaire was used to assess patient-reported outcomes. Transgender men who underwent gGAS without UL between January 2009 and January 2018 were included, and 56 transgender men were approached to complete the patient-reported outcome measurement. The simple statistical analysis combined with the Mann-Whitney U test and the Wilcoxon signed-rank test was used. 68 transgender men were included. Median follow-up time was 24 (6–129) months. Uroflowmetry and the International Prostate Symptom Score were completed by 44 transgender men, whereas 13 completed the frequency voiding chart preoperatively and postoperatively, respectively. The patient-reported outcome measurement was completed by 40 of 56 (71%) transgender men. Postoperative surgical and urological complications occurred in 9 of 68 (13%) and 8 of 68 (12%) patients, respectively. Storage and voiding function remained unchanged. The median quality of life because of urinary symptoms was scored as "pleased." Sexual functioning and voiding were scored satisfactory and very satisfactory in 18 of 40 (45%) and 21 of 40 (53%) patients, respectively. The number of patients satisfied with the penis and neoscrotum was 25 of 40 (63%) and 26 of 40 (65%), respectively. Increased self-esteem was reported by 32 of 40 (80%), 32 of 40 (80%) would undergo the surgery again, and 28 of 40 (70%) would recommend it to others. gGAS without UL should be part of the surgical armamentarium in centers performing gender-affirming surgery. Strengths of this study comprise the number of patients, the completeness of data, incorporation of patient-reported outcomes, and description of a relatively new surgical approach that may be well-suitable for a subgroup of transgender men. Limitations are the retrospective study design and the lack of validated questionnaires. gGAS without UL shows good surgical and urological outcomes. After extensive counseling, the majority of this selective group of patients shows favorable patient-reported outcomes. Pigot GLS, Al-Tamimi M, Nieuwenhuijzen JA, et al. Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men—A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction. J Sex Med 2020;17:2478–2487. [ABSTRACT FROM AUTHOR]