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OBJECTIVE: This article reviews current research into non-antibiotic treatments for bacterial vaginosis and assesses interest in the use of alternative therapies for women's health in a non-representative sample of women. DESIGN: Literature review and online survey. SUBJECTS: A convenience sample of 192 women was selected from an online community devoted to the discussion of women's health. RESULTS: Data on alternative treatments for bacterial vaginosis are mixed. Studies have shown both positive and null effects for probiotic- and lactic acid-based treatments. The results of antiseptic studies were more uniformly positive, but the studies were generally not placebo-controlled. Women in the survey population were both interested in and experienced with alternative and complementary therapies for reproductive health problems--44% of them had used home or natural remedies to treat vaginal infections or menstrual problems, and only 20% indicated that antibiotics and antifungals would be their treatment of choice. CONCLUSIONS: Women are interested in alternative treatments for women's health problems such as yeast infections and bacterial vaginosis. Although such treatments have been investigated, further research--particularly in the form of high-quality, randomized, controlled trials--is strongly indicated. [ABSTRACT FROM AUTHOR]

Study Objective: To assess willingness to provide medication abortion among North American Society for Pediatric and Adolescent Gynecology (NASPAG) clinicians caring for adolescents and young adults (AYA) following Dobbs v. Jackson Women's Health Organization., Design: Cross-sectional online survey., Methods: Potential participants received an e-mail invitation via the NASPAG listserv. A 43-item questionnaire queried demographics, practice setting, abortion training and practice, willingness to provide medication abortion, potential or real barriers to providing medication abortion, and sentiments of abortion. Descriptive statistics, χ 2 , and Fisher's exact tests were used., Results: Of the 70 participants, 51% were willing to provide a medication abortion for an adolescent who requested it in their clinical practice. The most common barriers to providing medication abortion were legislative restrictions (47%) and dispensing pills from clinic (33%). Participants' willingness to provide a medication abortion differed by type of practice (P = .001), availability of mifepristone (P = .006), perception of state's abortion policy (P = .001), concern about legislative restrictions (P = .008), experience providing abortion (P = .04), and receipt of medication abortion training (P = .02). Willingness to provide medication abortion also differed based on various sentiments of abortion measured but not on opinion regarding legality of abortion for adolescents (P = .49)., Conclusions: Perception of state's abortion rights and concern about legislative restrictions influenced NASPAG clinicians' willingness to provide medication abortion for adolescents. Interventions to minimize legislative interference with medical care, increase abortion training, and implement medication abortion in pediatric settings may expand AYA medication abortion access., Competing Interests: Conflicts of Interest Statement K.F. is a consultant for Medicines360. No other authors have any conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Study Objective: To evaluate the efficacy and tolerability of a progestin-only pill containing 4 mg drospirenone (DRSP) as a hormonal therapy for the management of endometriosis-associated symptoms in adolescents and young adults., Design: Retrospective cohort study., Methods: A retrospective chart review was performed of all adolescents who were prescribed DRSP continuously (without placebo) for treatment of endometriosis at a single pediatric tertiary care center between 2019 and 2022. Electronic medical records were reviewed to obtain demographics and clinical characteristics of the patients. Measured outcomes included symptom resolution and medication discontinuation. The study was deemed IRB exempt., Results: A total of 61 patients with endometriosis were prescribed DRSP during the study period, with a median age of 18.9 years (SD 2.3). The majority (97%) were laparoscopically confirmed to have endometriosis, and 85% had stage I disease. Before DRSP use, the most common medications trialed were norethindrone (57%) and norethindrone acetate (68%), and 56% had at least one medical contraindication to receiving estrogen-containing therapy. Of those with follow-up, 52% established an absence of bleeding/spotting, and 67% reported less pain at follow-up. One in 4 patients discontinued DRSP during the study period, most commonly due to breakthrough bleeding., Conclusion: DRSP is a well-tolerated and effective option for the treatment of endometriosis-associated symptoms in adolescents and young adults., (Copyright © 2024. Published by Elsevier Inc.)

Many transgender young adults are unaware of the role of pre-exposure prophylaxis (PrEP) in HIV prevention. Our aim was to understand where transgender and gender-diverse young adults receive health information about HIV and PrEP and their preferences for future learning. Semistructured, qualitative individual and group interviews were done with 14 transgender and gender-diverse young adults. Interviews were transcribed verbatim and analyzed using thematic analysis. Four themes emerged from the interviews related to (1) making trustworthy education materials, (2) the importance of communities, (3) knowledge needed about PrEP, and (4) a lack of early and diverse classroom education. Transgender and genderdiverse persons are at higher risk for HIV than their cisgender peers, yet they have information gaps and hold misconceptions about preventative measures like PrEP. Such misconceptions may be addressed by early, inclusive conversations about HIV transmission and prevention.

Purpose: This study investigated the association between positive and negative family support and psychosocial outcomes among transgender and gender diverse (TGD) youth., Methods: A retrospective analysis was performed using psychological data collected from 175 TGD youth (aged 13-18 years) at time of hormone readiness assessment within a multispecialty gender clinic between May 2021 and February 2023. As part of this assessment process, TGD youth provided responses to a variety of measures, including the Youth Self-Report and the Family Environment Scale., Results: Negative family support scales were more strongly associated with more outcomes than positive support scales. The exclusion and abuse, viewing gender expression as morally wrong, and trying to change gender scales were each associated with significantly higher Youth Self-Report T-scores for internalizing problems (βs = 6.86, 6.26, 5.56, all p < .01), externalizing problems (βs = 4.58, 4.42, 4.19, all p < .02), and total problems (βs = 6.70, 6.45, 5.34, all p < .02). The explicit care and support scale was associated with significantly lower T-scores for externalizing problems (β = -3.54 p = .02) and total problems (β = -3.35, p = .04). Overall support was also associated with higher T-scores in internalizing problems (b = -2.90, p = .02), externalizing problems (β = -2.40, p = .03), and total problems (β = -2.79, p = .03)., Discussion: Family support plays a critical role in the psychosocial wellbeing of TGD youth. TGD youth reporting positive family support reported fewer mental health concerns, less experiences of nonaffirmation, and lower levels of internalized transphobia. TGD youth reporting negative family support were found to have an increased risk of suicidal ideation., (Copyright © 2024 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

We sought to determine the prevalence of sexual health counseling in patients with Duchenne muscular dystrophy in a single-institution setting. Keywords related to sexual health and development concerns were documented at least once for 75% of patients across the duration of their care. Integration of sexual health discussions was facilitated by comprehensive multidisciplinary support, particularly with the inclusion of specialists in endocrinology and adolescent medicine., Competing Interests: Declaration of Competing Interest This work was supported by the Aerosmith Endowment Fund, Boston Children's Hospital. The authors declare no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: The study aimed to evaluate adult endocrinologists' perspectives on caring for patients with congenital adrenal hyperplasia (CAH) and views on their transition from pediatric to adult care., Methods: An online survey was conducted among adult clinical endocrinologists at Harvard Medical School-affiliated hospitals from March to October 2022., Results: Most participants (25/34, 73.5 %) treat patients with CAH and expressed moderate to high confidence (23/32, 71.9 %) in their care. Those that did not treat or accept referrals cited insufficient expertise, knowledge, and resources as reasons. Only half of respondents correctly answered at least 50 % of standard of care questions. The main transition of care barrier identified was the absence of standardized policies (12/34, 35.3 %)., Conclusions: Participants, though involved in care of patients with CAH, had varied responses to standard of care questions and transition of care barriers, emphasizing the need for standardized transition protocols and additional training to ensure up-to-date clinical knowledge., (© 2024 Walter de Gruyter GmbH, Berlin/Boston.)

Background: While many transgender and gender diverse individuals rapidly achieve amenorrhea on testosterone, emerging data have identified that breakthrough bleeding can occur in up to one-third of individuals with long-term use. Breakthrough bleeding can worsen dysphoria and patients may seek management to reattain amenorrhea. Because of this, there is a need to assess efficacy of management approaches., Objective: The primary aim of the study was to evaluate methods used by patients and their providers to manage breakthrough bleeding which arises after 1 year of testosterone use. Secondary aims included describing the diagnostic approaches to breakthrough bleeding, and proposing an algorithm for classification and management of breakthrough bleeding in this patient population., Study Design: This was an institutional review board-approved single tertiary center, retrospective chart review of transgender and gender diverse individuals on testosterone gender affirming hormone therapy who experienced breakthrough bleeding after 1 year of use. Charts were reviewed to determine patient characteristics, testosterone use, and breakthrough bleeding management approaches., Results: Of the 96 individuals who had been on testosterone for 1 year and experienced breakthrough bleeding, 97% (n=93) engaged in at least 1 approach to management. The mean age at initiation of testosterone was 21.9 (standard deviation 5.4) and the median duration of time on testosterone was 54.5 months (interquartile range 33.5, 82). Only 16% (n=15) were using menstrual suppression at the time of their breakthrough bleeding episode. Breakthrough bleeding was successfully managed in 77 (79%), following between 1 and 4 attempted approaches. More than half of management attempts (63%) were successful on the first try. When management approaches were analyzed independently, the range of success associated with any particular approach was between 33% and 100%. Other than hysterectomy, which was fully successful at managing breakthrough bleeding, no approach was significantly better than no intervention. This was true both for individuals who did and did not bleed with missed testosterone doses. Regardless of what approach was used, after a failed attempt, the next attempt was successful in more than half of individuals. Of the 16 who underwent hysterectomy, 1 did so in part as a first line approach to manage breakthrough bleeding., Conclusion: In this study, use of medical management methods was not found to be superior to observation alone in the management of breakthrough bleeding. In the absence of data supporting superiority of any method, we recommend tailoring method attempts to patients' goals., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Equity, diversity, and inclusion (EDI) research is increasing, and there is a need for a more standardized approach for methodological and ethical review of this research. A supplemental review process for EDI-related human subject research protocols was developed and implemented at a pediatric academic medical center (AMC). The goal was to ensure that current EDI research principles are consistently used and that the research aligns with the AMC's declaration on EDI. The EDI Research Review Committee, established in January 2022, reviewed EDI protocols and provided recommendations and requirements for addressing EDI-related components of research studies. To evaluate this review process, the number and type of research protocols were reviewed, and the types of recommendations given to research teams were examined. In total, 78 research protocols were referred for EDI review during the 20-month implementation period from departments and divisions across the AMC. Of these, 67 were given requirements or recommendations to improve the EDI-related aspects of the project, and 11 had already considered a health equity framework and implemented EDI principles. Requirements or recommendations made applied to 1 or more stages of the research process, including design, execution, analysis, and dissemination. An EDI review of human subject research protocols can provide an opportunity to constructively examine and provide feedback on EDI research to ensure that a standardized approach is used based on current literature and practice., (Copyright © 2024 by the American Academy of Pediatrics.)

Competing Interests: No competing financial interests exist.

Background: Little is known about the maintenance of amenorrhea among transgender and gender-diverse individuals with uteri who are using long-term testosterone gender-affirming hormone therapy. Emerging data describe breakthrough bleeding among adolescents on long-term testosterone therapy and among adults who are seeking a gender-affirming hysterectomy. More studies are needed to better understand breakthrough bleeding patterns among transgender and gender-diverse individuals with uteri who are using testosterone, including the frequency, timing, and etiology of bleeding and how these patterns may differ between adults and younger populations., Objective: The primary aim of this study was to characterize the incidence and patterns of breakthrough bleeding in a cohort of transgender and gender-diverse individuals who had been on testosterone for longer than 12 months and who had uteri in situ. Secondary aims included identifying the time to first bleed for those who experienced breakthrough bleeding and the risk factors associated with breakthrough bleeding while on testosterone therapy., Study Design: This was an institutional review board-approved, single tertiary center, retrospective chart review of transgender and gender diverse individuals who had been on testosterone for at least 1 year. A primary survival analysis that evaluated the incidence of bleeding was combined with descriptive analyses and an evaluation of the factors associated with bleeding., Results: Of the 279 patients included in the analysis, the median age of testosterone initiation was 22 years (interquartile range, 19-41), and the median follow-up time was 34 months (range, 12-278). The absolute proportion of individuals who ever experienced breakthrough bleeding on testosterone was 34% (n=96; 95% confidence interval, 29-40). Patients who experienced breakthrough bleeding initiated testosterone at a younger age (20.5 vs 22.0 years; P=.04), had lower mean serum testosterone levels (389.14 vs 512.7 ng/dL; P=.001), were more likely to have a mean testosterone level <320 ng/dL (52% vs 48%; P=.001), and had higher mean estradiol levels (62% vs 49%; P=.003). Survival analyses estimated a breakthrough bleeding incidence rate of 0.09 per year (95% confidence interval, 0.07-1.0). Although 58 people underwent a hysterectomy during the follow-up period, 64% of the cohort who maintained a uterus eventually experienced breakthrough bleeding. The median time to the initial bleeding episode was 22 months (interquartile range, 12-201) after testosterone initiation., Conclusion: These results suggest that a substantial fraction of transgender and gender-diverse individuals who are using testosterone will experience at least 1 episode of breakthrough bleeding even after their initial year of testosterone use. We recommend that clinicians inform all patients that breakthrough bleeding is a common occurrence even after the first year on testosterone therapy., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Compare psychosocial function at the time of hormone readiness assessment for transgender and gender diverse (TGD) youth who received pubertal blockade to prevent a nonaffirming puberty with those who did not., Methods: Retrospective cohort study of psychological assessment data from hormone readiness evaluations conducted at a multispecialty gender clinic. Participants include all TGD youth between the ages of 13 and 17 assessed for hormone readiness between 2017 and 2021., Results: Our cohort consisted of 438 TGD youth, 40 who were prescribed pubertal blockade at Tanner stage 2 or 3, and 398 who had not. The blocker population was younger, more likely to be assigned male and affirming a female identity, and had a different racial/ethnic identity distribution. Having puberty blocked was associated with significantly lower T-scores on the Youth Self Report for internalizing problems (β = -7.4, p < .001), anxiety problems (β = -4.6, p = .003), depressive problems (β = -6.5, p < .001), stress problems (β = -4.0, p = .01), and total problems (β = -4.9, p = .003). The blocker population was also significantly less likely to report any suicidal thoughts (odds ratio = 0.38, p = .05). With the exception of increased risk of suicidal thoughts, these associations remained significant when adjusted for gender., Discussion: At the time of hormone readiness evaluation, TGD youth who received pubertal blockade at Tanner 2 or 3 were found to have less anxiety, depression, stress, total problems, internalizing difficulties, and suicidal ideation than TGD peers who had been through more of a nonaffirming puberty., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The unique psychosocial experiences of nonbinary individuals across the lifespan are understudied compared with those of binary transgender individuals. This study examined the psychosocial stressors faced by nonbinary youth compared with their binary transgender counterparts at the time of gender-affirming hormone (GAH) readiness assessment. Methods: This study compared the psychosocial functioning of nonbinary youth with their binary transgender peers, ages 14-18, utilizing the Youth Self Report (YSR) at the time of GAH readiness assessment. Clinically relevant subscale scores of the YSR were analyzed. Results: Data from 479 binary and 55 nonbinary individuals were analyzed for this study. Analysis found that nonbinary youth reported substantially more psychosocial distress in the form of total problems ( β  = 2.86, 95% confidence interval [CI] [0.15-5.56]), internalizing problems ( β  = 4.57, 95% CI [1.55-7.59]), depression ( β  = 4.52, 95% CI [1.70-7.33]), and self-harm (odds ratio 2.65, 95% CI [1.26-5.56]) than their binary transgender peers. Conclusion: Nonbinary youth experienced higher psychosocial distress compared with their binary transgender counterparts. Future research is needed to better understand the possible health disparities experienced by nonbinary people across their lifespan so that their psychosocial needs can be better met.

Abstract: Mayer-Rokitansky-Küster-Hauser syndrome is a congenital disorder typified by an underdeveloped female reproductive tract. An exploratory online survey of adults with Mayer-Rokitansky-Küster-Hauser syndrome found that many did not recall receiving the human papillomavirus vaccine, and answers to knowledge questions suggested inadequate human papillomavirus counseling. However, recalled vaccine counseling was associated with improved uptake., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Danazol is a synthetic progestin with androgenic effects that is approved by the Food and Drug Administration for treatment of endometriosis, benign fibrocystic breast disease, and hereditary angioedema. In recent years, increasing numbers of transgender and nonbinary individuals seeking menstrual suppression have been offered danazol due to its potential to both induce amenorrhea and cause reversible androgenic side effects including pigmentation of vellus hairs and voice changes, which may be desirable in this population. There are currently no studies assessing use of danazol within the transgender population for menstrual suppression., Objective: This study's primary aim was to evaluate the use of danazol as a menstrual suppression agent in transgender patients., Design: This was a retrospective multisite cohort study of all individuals who had been on danazol at two tertiary care centers between 2000 and 2022., Methods: All patients prescribed danazol were identified using a search of the electronic medical records. For demographic purposes, comparisons were made between those who did and did not use danazol for the purpose of menstrual suppression. A detailed chart review was then performed to analyze the experiences of menstrual suppression in transgender and nonbinary patients., Results: Most transgender and nonbinary patients on danazol for menstrual suppression remained on it at their most recent follow-up visit, and many charts noted improvements in gender dysphoria, pelvic pain, dysmenorrhea, endometriosis, and heavy menstrual bleeding. Most transgender patients achieved amenorrhea., Conclusion: Danazol may be a reasonable option for menstrual suppression in transgender and nonbinary patients. Our findings show its potential to not only induce amenorrhea but cause desired androgenic symptoms and improve gender dysphoria, pelvic pain, dysmenorrhea, endometriosis, and heavy bleeding. While the androgenic effects of danazol are less desirable in cisgender populations, it is an attractive option for menstrual suppression in transgender and nonbinary patients.

Background: Pelvic pain has been reported in transmasculine individuals taking testosterone. There is a need for further investigation to increase understanding of the prevalence and risk factors of this pain., Aim: We sought to determine the prevalence of pelvic pain reported by transmasculine individuals who had both a uterus and ovaries and were taking testosterone., Methods: We conducted an institutional review board-approved retrospective study of all transmasculine individuals who had been taking testosterone for at least 1 year and had a uterus and ovaries at the time of testosterone initiation. Charts of participating patients were reviewed to determine patient characteristics, testosterone use, and pelvic pain symptoms both before and after initiation of testosterone., Outcomes: Patients reported experiences of pelvic pain while on testosterone., Results: Of 280 individuals who had been on testosterone for at least 1 year, 100 (36%) experienced pelvic pain while on testosterone. Of those patients, 71% (n = 71) had not experienced pelvic pain prior to starting testosterone. There were 42 patients (15%) who had pelvic pain prior to starting testosterone, 13 (31%) of whom no longer experienced pain once starting testosterone. The median (IQR) age at initiation of testosterone was 22 (19-41) years and duration of testosterone treatment was 48 (27-251) months.Those patients who experienced pelvic pain while on testosterone were significantly more likely to have also reported pelvic pain prior to starting testosterone (29% vs 7%, P < .001). These patients were also more likely to have a pre-existing diagnosis of dysmenorrhea (27% vs 7%, P < .001), endometriosis (6% vs 2%, P = .049), or ovarian cysts and/or masses (12% vs 2% P < .001). Patients with pelvic pain were also more likely to have been on a menstrual suppression agent prior to and overlapping testosterone initiation (22% vs 12%, P = .03) and to have used menstrual suppression for longer durations (median [IQR] 18 [6-44] vs 8 [4-15] months, P = .04)., Clinical Implications: Pelvic pain is common in transmasculine individuals who are initiating testosterone treatment, although testosterone has both positive and negative effects on pelvic pain in different individuals., Strengths and Limitations: The major strengths of this study included large numbers of patients, ability to assess for documentation of pelvic pain prior to testosterone, and ability to determine an actual prevalence of pelvic pain. Major limitations included the study being a retrospective analysis in a single tertiary care center, the limitations of clinical documentation, and the lack of a standard pelvic pain evaluation process., Conclusion: More than one-third of transmasculine patients with a uterus and ovaries had pelvic pain while on testosterone, with the majority reporting onset of pain after initiating testosterone., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Context: Access to gender-affirming medical care is associated with better mental health outcomes in transgender and gender diverse youth. In 2021 and 2022, legislation aiming to ban gender-affirming medical care for youth was proposed in 24 states., Objective: This study aimed to (1) assess the impact of this legislation on pediatric providers based on legislative status of their state of practice and (2) identify the themes of concerns reported by them., Methods: A mixed-methods study was conducted via an anonymous survey distributed to pediatric endocrinology providers. Survey responses were stratified based on US state of practice, with attention to whether legislation aiming to ban gender-affirming care had been considered. Data were analyzed both quantitatively and qualitatively., Results: Of 223 respondents, 125 (56.0%) were currently providing gender-affirming medical care. A total of 103 (45.7%) respondents practiced in a state where legislation aiming to ban gender-affirming care had been proposed and/or passed between January 2021 to June 2022. Practicing in legislation-affected states was associated with negative experiences for providers including (1) institutional pressure that would limit the ability to provide care, (2) threats to personal safety, (3) concerns about legal action being taken against them, (4) concerns about their career, and (5) institutional concerns about engagement with media. Major qualitative themes emerging for providers in legislation-affected states included safety concerns and the impact of laws on medical practice., Conclusion: This study suggests that legislation aiming to ban health care for transgender youth may decrease access to qualified providers in affected states., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Endocrine Society.)

Purpose: This study sought to prospectively examine the effects of gender-affirming chest reconstruction on gender congruence and chest dysphoria in transmasculine and nonbinary adolescents and young adults., Methods: Individuals between the ages of 15-35 who were seeking gender-affirming chest surgery were enrolled as part of a broader, longitudinal study of transgender surgical experiences. Their chest dysphoria and gender congruence were measured at baseline, six months, and one year, using the Transgender Congruence and Chest Dysphoria scales. Repeated measures analysis of variance were used to detect differences in scores across assessment points. Where there were significant differences indicated, Tukey's honestly significant difference test was used to determine which differences in mean scores were significant between assessment points, as well as how results differed by demographic factors., Results: The analytical sample consisted of 153 individuals who had completed both the baseline and at least one follow-up assessment - 36 (24%) endorsing a nonbinary gender and 59 (38%) under the age of 18. Repeated measures analysis of variance indicated significant differences in gender congruence, appearance congruence, and chest dysphoria between at least two assessment points for the total sample and each subgroup (binary/non-binary and adult/minor). Honestly significant difference tests indicated no significant differences between the postoperative assessments by age or binary gender., Discusson: Gender-affirming chest reconstruction improves gender and appearance congruence and reduces chest dysphoria in both non-binary and binary populations of adolescents and young adults. These data support the need to improve access to gender-affirming chest reconstruction for adolescents and young adults and to remove legislative and other barriers to care., (Copyright © 2023 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Of the 1.6 million transgender and gender-diverse (TGD) people in the United States, approximately 700,000 are youth aged 13-24 years. Many factors make it difficult for TGD young people to identify resources for support and information related to gender identity and medical transition. These range from lack of knowledge to concerns about personal safety in the setting of increased antitransgender violence and legislative limitations on transgender rights. Web-based resources may be able to address some of the barriers to finding information and support, but youth may have difficulty finding relevant content or have concerns about the quality and content of information they find on the internet., Objective: We aim to understand ways TGD young adults look for web-based information about gender and health., Methods: In August 2022, 102 young adults completed a 1-time survey including closed- and open-ended responses. Individuals were recruited through the Prolific platform. Eligibility was restricted to people between the ages of 18-25 years who identified as transgender and were residents of the United States. The initial goal was to recruit 50 White individuals and 50 individuals who identified as Black, indigenous, or people of color. In total, 102 people were eventually enrolled., Results: Young adults reported looking on the internet for information about a broad range of topics related to both medical- and social-gender affirmation. Most participants preferred to obtain information via personal stories. Participants expressed a strong preference for obtaining information from other trans people., Conclusions: There is a need for accessible, expert-informed information for TGD youth, particularly more information generated for the transgender community by members of the community., (©Elizabeth R Boskey, Meg Quint, Rena Xu, Jessica Kremen, Carlos Estrada, Regina Tham, Kaiden Kane, Sari L Reisner. Originally published in JMIR Formative Research (https://formative.jmir.org), 15.08.2023.)

Introduction: The COVID-19 pandemic has expanded the use of telemedicine to patient populations that were previously constrained to in-person visits. Few studies have investigated the role that telemedicine plays in shaping the care of these patient populations. This project explores the impact of telemedicine for one such population: patients and parents of gender-diverse individuals seeking gender-affirming surgery., Methods: A 10-question survey using previously validated questions was completed by 34 patients and 9 parents of patients (aged 15-31) who received virtual care at the Center for Gender Surgery at Boston Children's Hospital between March 2020 and April 2021. The survey was divided into two parts. The first section collected demographic information. The second assessed participant perspectives on remote surgical gender care through a series of Likert-type and open-ended questions., Results: A total of 100% of the respondents felt that their telemedicine visit was convenient; 60% (18) of the patients and 87% (7) of the parents stated that they look forward to future use of this modality. Free responses highlighted common perspectives on remote surgical gender care, including the increased accessibility of gender-affirming care through telehealth, the limitations of telehealth for addressing physical and relational aspects of gender care, patients' desire for autonomy and privacy during telehealth visits, and parents' desire to be involved throughout their children's gender journey., Conclusion: These results demonstrate the unique ability of telemedicine, if implemented thoughtfully, to enhance outcomes for patients seeking surgical gender affirmation., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Objective: To determine if and how race impacts the 30-day outcomes of gender-affirming chest surgeries., Background: Little is currently known about how race may affect the outcomes of gender-affirming surgeries., Methods: We analyzed data from the National Surgical Quality Improvement Program (NSQIP) database of 30-day complications of gender-affirming chest surgeries from 2005 to 2019. All participants had a postoperative diagnosis code for gender dysphoria and at least one procedure code for bilateral mastectomy, bilateral breast reduction, or bilateral augmentation mammoplasty. Differences by racial group were analyzed through Pearson χ 2 and multivariate logistic regression., Results: There were no racial differences in the all-complication rates for both transmasculine and transfeminine individuals undergoing gender-affirming chest surgeries. Black patients undergoing masculinizing procedures were significantly more likely to experience mild systemic [adjusted odds ratio (aOR): 2.17, 95% confidence interval (CI): 1.02-4.65] and severe complications (aOR: 5.63, 95% CI: 1.99-15.98) when compared with White patients. Patients of unknown race had increased odds of experiencing severe complications for masculinizing procedures compared with White patients (aOR: 3.77, 95% CI: 1.39-10.24). Transmasculine individuals whose race was unknown were 1.98 times more likely (95% CI: 1.03-3.81) to experience an unplanned reoperation compared with White individuals. Black transfeminine individuals were 10.50 times more likely to experience an unplanned reoperation (95% CI: 1.15-95.51) than their White peers., Conclusions: Although overall complications are uncommon, there is evidence to suggest that there are racial disparities in certain 30-day outcomes of gender-affirming chest surgeries., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Genital reconstructive surgeries (GRS) are available for a variety of indications and populations, including transgender and gender diverse (TGD) individuals and those with intersex traits/differences in sex development (I/dsd). Despite the common outcomes of GRS for TGD and I/dsd individuals, decision making about this surgical care differs between these populations and across the lifespan. Sociocultural perspectives on sexuality and gender dominate the ethics of GRS, and reform is needed within clinical ethics to center the autonomy of TGD and I/dsd individuals in informed consent processes. Such changes are necessary to ensure justice in health care for all sex and gender diverse individuals across the lifespan., (Copyright 2023 American Medical Association. All Rights Reserved.)

While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older ( M trans  = 38 years (SD:14), M cis  = 53 years (SD: 15)) and had higher BMI than the transgender cohort ( M trans  = 26.9 (SD: 5.5), M cis  = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health ( p  = 0.001), and were more likely to have hypertension ( p  = 0.001) and diabetes ( p  = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time ( M trans  = 303 min (SD: 155), M cis  = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty ( p  = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender patients., Competing Interests: None., (© 2023 The Author(s).)

Background: The academic literature has not arrived at a consensus on the importance of body mass index (BMI) as an indicator of surgical feasibility and risk. This study evaluates board-certified plastic surgeons' and trainees' knowledge, experiences, and concerns around performing benign breast surgeries in high-BMI patients., Methods: An online survey instrument was developed and shared with plastic surgeons and plastic surgery trainees from December 2021 to January 2022., Results: There were 30 respondents (18 from Israel, 11 from the United States, and 1 from Turkey). For respondents who had BMI guidelines for performing benign breast surgeries, the median maximum BMI was 35 for all procedures. Most respondents supported or strongly supported their BMI guidelines.The majority of respondents indicated that they tended to have less training and experience in performing benign breast surgeries on high-BMI patients compared to those with BMI <30. Most respondents indicated that they were less satisfied with the results of these procedures on high-BMI patients compared to those with BMI <30. The median post-operation recovery time was indicated to be similar for high-BMI patients compared to those with BMI <30 across all procedures; however, the postoperative complication rate was indicated as higher., Conclusions: Respondents indicated that the risks of complication, more frequent need for surgical revisions, and unsatisfactory outcomes were their greatest concerns when conducting chest surgeries among high-BMI patients. Given that most surgeons practice in settings where high-BMI patients are excluded from procedure access, further research is needed to assess the extent to which these concerns reflect actual outcome differences., Competing Interests: None declared., (© 2023 The Author(s).)

Study Objective: To use a retrospective review of sexual and reproductive health (SRH) counseling that occurred during initial visits of adolescents seeking testosterone gender-affirming hormone therapy to determine the feasibility of using such visits to manage SRH DESIGN: Retrospective chart review SETTING: Children's hospital, multidisciplinary gender clinic PARTICIPANTS: Transgender male and nonbinary patients assigned female at birth (TGD-M) aged 15-17 seen for initiation of testosterone between January 1, 2010, and December 31, 2019 INTERVENTIONS: Not applicable MAIN OUTCOME MEASURE(S): Counseling on (1) testosterone impact on fertility and (2) fertility preservation; assessment of (3) desire for gender-affirming surgery, (4) sexual activity, (5) sexual orientation, and (6) human papilloma virus vaccination as documented during the initial visit., Results: Of 195 patients who met the inclusion criteria, only 3 (1.5%) had all 6 measures addressed. The median number addressed was 4 out of 6 (IQR = 2-5/6), with fertility counseling (95.9%, n = 187) being most common, followed by assessment of surgery desire (74.4%, n = 145), sexual orientation (69.2%, n = 135), and sexual activity (69.2%, n = 135). The odds of being asked about sexual orientation were 5.3 times higher in patients who endorsed sexual activity than in those who did not (P < .001; 95% CI, 9.8-10.3)., Conclusion: Providers of adolescent gender-affirming hormone therapy regularly assess and counsel on certain aspects of SRH as part of their initial visits for those seeking testosterone. Our data suggest that these initial visits for patients seeking testosterone represent an opportunity to expand SRH assessment and counseling among TGD-M adolescents., (Copyright © 2022. Published by Elsevier Inc.)

Although in most areas of practice, there is a reasonable expectation that doctors are sufficiently trained to offer care, this is not true in the case of gender-affirming procedures, which are not required learning in any surgical residency. At the current time, the field of gender surgery is too rapidly evolving, with available resources too scarce for fellowship or residency training to be a realistic requirement for offering these procedures, as the demand already outstrips the available workforce. However, patients are currently given too little information about surgeons' history with these procedures to provide truly informed consent. There is, as such, an ethical mandate to mold the culture of gender-affirming surgery such that surgeons are expected to routinely disclose relevant information about their training, experience, and outcomes to facilitate patient decision-making about care., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

This response to Kariyawasam and Rai affirms their critique of the pathologization of trans youth but forecasts a foreseeable negative outcome of their proposed elimination of diagnosis as a prerequisite to gender-affirming care (GAC) - the risk of removing GAC entirely from the medical sphere and compromising the wellbeing of those transgender individuals for whom GAC is deeply affirming. We suggest an ethical framework of GAC that expands past a focus on autonomy to incorporate a principle of respect for persons that affirms the dignity and diversity of trans youth - recognizing the need to facilitate both medical assistance and social change.

Purpose: The World Professional Association for Transgender Health (WPATH) recommends referral by a mental health professional for gender-affirming chest and genital surgeries. However, several transgender health guidelines propose an informed consent model of care to respect patient autonomy. This research aimed to understand, characterize, and asses the quality of information gathered through referral letters for patients consulting for gender-affirming surgeries., Methods: A retrospective review of electronic medical records (EMRs), including referral letters from behavioral health (BH) and primary care providers (PCPs), was conducted for patients seeking chest or genital surgery by a single surgeon between 2017 and 2019. Data were abstracted manually and included medical and gender history and documentation of WPATH-recommended surgical criteria., Results: A total of 233 patient records, including 171 PCP letters and 231 BH letters, were reviewed. With respect to documentation of surgical criteria, 92% of BH letters documented a diagnosis of gender dysphoria, 63% ability to provide informed consent, and 51% management of BH comorbidities. More than half of individuals with chronic physical health conditions did not have those conditions documented in their referral letters. Similarly, BH letters often failed to document BH diagnoses endorsed by patients. For example, while 80% of patients endorsed a diagnosis of anxiety, more than half did not have it documented in their letters. Overall, greater than half of diagnoses across BH conditions were only documented as present in the EMR., Conclusion: Referral letters only variably documented WPATH-recommended surgical criteria and did not reliably document physical and mental health comorbidities. Our research suggests that multidisciplinary pre-surgical assessment may be more useful than referral letters in some settings., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

A positive LGBTQ+ (lesbian, gay, bisexual, transgender/nonbinary, queer) workplace climate is critical for healthcare employee satisfaction, productivity, and patient care. The current study assessed LGBTQ+ workplace climate among 791 employees from a large urban pediatric hospital. Several workplace climate domains were assessed in an online survey: employee attitudes, training, experiences related to working with LGBTQ+ colleagues, patients and families, and LGBTQ+-specific experiences. For most domains, half or more of respondents perceived an affirming LGBTQ+ climate. LGBTQ+ employees perceived a less affirming climate than cisgender heterosexual employees. LGBTQ+ employees, especially transgender/nonbinary employees, experienced numerous discriminatory situations. Over 90% of participants felt competent and qualified to work with LGB patients/families; 80% felt competent and qualified to work with TNB patients/families. Themes from open-ended survery responses reflected three LGBTQ+ climate components: systemic, interpersonal, and "grassroots" (affinity group) initiatives. Findings inform strategies to improve LGBTQ+ employee experiences and competency caring for LGBTQ+ patients and families.

Introduction: Transgender men interested in achieving penetration after phalloplasty are currently limited to internal devices and makeshift supports. More options are needed to support sexual penetration after phalloplasty., Aim: This study was designed to assess the feasibility of an external erectile prosthesis (the Elator) for transgender men who have undergone phalloplasty and wish to use their neophallus for sexual penetration, assess how the device affected the sexual experiences of men and their partners, and identify any side effects and concerns., Methods: Transgender men and their partners were provided with an erectile device to use for one month. They were surveyed at 4 time points: enrollment, measurement, receipt, and after using the device, using a combination of pre-existing and device-specific measures., Main Outcome Measure: The primary outcome was whether men found it feasible to use an external penile prosthesis for sexual penetration after phalloplasty - defined as interest in, and willingness to, use the device more than once over the study period; intention to continue using the device on the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS); and no decrease in relationship satisfaction on the Gay and Lesbian Relationship Satisfaction Scale (GLRSS). The secondary outcome was an increase in sexual or relationship satisfaction with use of the device, defined as a statistically significant increase on either the Quality of Sexual Experience Scale (QSE) or the GLRSS., Results: Fifteen couples enrolled in the pilot study. Of the 10 who completed the study, only 3 found device use feasible and endorsed strongly positive experiences, while the remaining 7 found it unusable. There were no changes in QSE or GLRSS scores. Most device issues were related to proper fit., Conclusion: There is a great deal of interest in non-surgical options for achieving penetration after phalloplasty. The tested external erectile device can work well, but its utility is limited to individuals with very specific post-phalloplasty anatomy. Most individuals and couples found the device unsuitable for the neophallus and/or that it could not be used comfortably. Boskey ER, Jolly D, Mehra G, et al. Feasibility of an External Erectile Prosthesis for Transgender Men Who have Undergone Phalloplasty. Sex Med 2022;10:100560., (Copyright © 2022 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to assess the future family building desires of assigned female at birth (AFAB) transgender and gender diverse (TGD) adolescents initiating hormone therapy, and to characterize the individuals interested in adoption. Methods: This was a retrospective chart review of AFAB TGD adolescents ages 15-17 years old initiating testosterone gender-affirming hormone therapy between 2010 and 2019, analyzing interest in adoption, demographics, and gender-affirming care. Results: Of 195 AFAB TGD adolescents asked about family planning goals, 58% ( n  = 113) indicated desire for adoption in their future, and 13.3% ( n  = 26) had no desire for children. There was no difference between those who did and did not want to adopt in terms of age at time of first visit ( p  = 0.22), or race distribution ( p  = 0.45); however, straight-identified patients were more likely to desire adoption ( p  = 0.02) than people with other sexual orientations. Fifty-nine percent ( n  = 110) of those who did not have a history of adoption and/or experience with the child welfare system desired adoption, compared with 22% ( n  = 2) of those with a history (odds ratio, 5.14; 95% confidence interval, 1.04-25.39; p  = 0.05). Conclusion: Some AFAB TGD adolescents endorse adoption as their desired pathway to parenthood. Clinicians should be sensitive to the complexities of parenthood desires of AFAB TGD patients and have resources to direct patients to more information. Further research is needed to better understand why many AFAB TGD adolescents desire adoption, how this changes with age, and the barriers they face in achieving their goals.

As gender-affirming surgeries are being performed, new techniques have been developed to meet patient desires, including recent reports of several gender-affirming procedures being combined into a single operative encounter. Such a development may provide several advantages to both patients and providers. However, it is less clear whether combining these procedures affects patient safety and surgical case planning factors. To address this, we compared the complication rates and the length of hospital stay and operative time for standalone and combined gender-affirming procedures (e.g., hysterectomy and bilateral mastectomy, breast augmentation, and vaginoplasty) performed between 2005 and 2019 in the National Surgical Quality Improvement Program database. There were 1857 standalone mastectomies, 826 standalone hysterectomies, and 30 cases where they were combined. There were 379 vaginoplasties, 648 breast augmentations, and 31 cases where they were combined. There was no evidence of differences in overall health status between those undergoing combined and standalone procedures. Two-sample proportion testing did not find significant differences in any of the complications experienced between standalone and combined procedures. Similarly, two-sample t-tests did not find significant differences in the length of the hospital stays nor in the length of the operative encounter between standalone and combined masculinizing surgeries. Combining breast augmentation and vaginoplasty, however, saved an average of 97.86 min (p = .000) of operating time. These results suggest that combining gender-affirming procedures may be a safe and viable option for individuals who desire multiple gender-affirming procedures and may even be an advantageous option for patients and practitioners alike., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Purpose: For some transgender and gender-diverse (TGD) individuals, gender-affirming surgery may represent the last opportunity to engage in gamete banking (GB) and other forms of fertility preservation (FP). Previous research has assessed fertility intentions among TGD people initiating hormone therapy. The objective of this study was to describe the fertility intentions of patients seeking gender-affirming surgery. Methods: A retrospective chart review was conducted for 233 patients seeking chest or genital surgery between 2017 and 2019. Data abstracted included interest in having children (biological or non-biological) and GB, and barriers to FP. Associations between fertility intentions, sex assigned at birth, and surgical procedure sought were assessed. Results: Of the 233 records reviewed, 162 (70%) documented information about fertility intentions for patients without a history of sterilizing surgery. At initial consultation, 94% were receiving hormone therapy. Among the 60 patients seeking genital surgery, 30% expressed interest in GB and 38% were not interested in biological children. Among the 102 patients seeking chest surgery, 11% expressed interest in GB and 47% were not interested in biological children. Patients assigned male at birth were more likely to have already completed GB ( p  < 0.001). Among the patients interested in FP, 41% reported barriers to access. Conclusion: Many TGD people in our study expressed no interest in biological parenthood; however, 30% of patients seeking genital surgery expressed interest in GB. This suggests that some who defer FP when starting hormones may wish to pursue it later in life. Ongoing assessment of fertility intentions and reducing barriers to FP are integral to caring for TGD people.

Background: Gender-affirming surgery is a critical component of transgender health care, but access information is limited. The study aim was to assess workforce capacity to perform gender affirming bottom surgeries (GABSs) in the United States., Methods: A questionnaire was administered via email, phone call, or fax from February to May 2020 to 86 practices identified as performing GABS by searching 10 Web-based databases with standardized keywords. Questions assessed training capacity, surgical capacity, and surgeon experience., Results: Thirty-two of 86 practices responded, 20 met the inclusion criteria. Practices were identified in 15 states, with an average 2.4 (SD, 1.3) surgeons performing GABS per year. States with the greatest number of total providers offering GABS were Illinois (n = 21), Texas (n = 10), and Massachusetts (n = 13). No significant correlation between number of GABS types offered and geographic population density (r = -0.40, P = 0.08), or between number of providers and geographic population density (r = 0.19, P = 0.44). Vaginoplasty was most frequently performed, with the longest waitlists and highest number of waitlist additions per month. Phalloplasty was the second most common procedure, and waitlist additions per month exceeded provider capacity to perform the procedure. Most surgeons performing GABS were plastic surgeons and urologists, whereas obstetricians/gynecologists performed the majority of hysterectomies., Conclusions: This study demonstrated a shortage of providers with requisite training and experience to provide GABS. Although more robust studies are needed to better characterize the relationship between the number of patients seeking GABS and available providers, these findings indicate a need for improved training., Competing Interests: Conflicts of interest and sources of funding: The authors did not receive any funding for this study. They have no financial disclosures or conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

As part of an ongoing longitudinal study of transmasculine adolescents and young adults seeking gender-affirming surgery, this analysis examined sexual orientation and attraction in a cohort of 167 binary and nonbinary participants 15-35 years of age. Correlations were analyzed using Pearson's chi square. Binary and nonbinary transmasculine individuals had different patterns of orientation and attraction, with binary males more likely to be heterosexual and less likely to be queer ( p <0.003). Nonbinary individuals were more likely to be attracted to and have history with other nonbinary people ( p <0.01). Transmasculine sexual identities are variable, complex, and not well described by standard sexual orientation categories., Competing Interests: No competing financial interests exist., (Copyright 2022, Mary Ann Liebert, Inc., publishers.)

Objectives: To describe the effects of the coronavirus disease 2019 (COVID-19) pandemic and associated practice shifts on consultation and referral patterns of an intimate partner violence program at a large, urban children's hospital., Methods: Secondary data analyses examined COVID-19-related variations in patterns of consultations and referrals in the 11 months before the COVID-19 pandemic (April 1, 2019-February 29, 2020) and those after its emergence (April 1, 2020-February 28, 2021). χ2 analyses were used to examine differences in categorical outcomes of interest by time and practice setting, as well as differences within practice settings. Poisson regressions were used to compare the number of reasons for consultation and the number of referrals during the 2 periods., Results: Analyses revealed significant decreases in face-to-face consults (28% to 2%; P < .001) during the period after COVID-19 emergence alongside significant increases in the total number of consults (240 to 295; P < .001), primarily for emotional abuse (195 to 264; P = .007). Psychoeducation referrals also increased significantly (199 to 273; P < .001), whereas referrals to community resources decreased significantly (111 to 95; P < .001). Setting-specific analyses revealed that primary care settings were the only practice settings to demonstrate significant differences in overall number of and specific reasons for consultation and associated referral types before and after COVID-19 emergence., Conclusions: Even during a shift away from face-to-face care, there was an increase in intimate partner violence referrals after the start of the COVID-19 pandemic. These findings suggest the importance of pediatric primary care as a location for survivors to access support., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Sexual minority (lesbian, bisexual, mostly heterosexual) young women face many sexual and reproductive health disparities, but there is scant information on their experiences of chronic pelvic pain, including an absence of information on prevalence, treatment, and outcomes., Aim: The purpose of this study was to describe the characteristics of chronic pelvic pain experiences of young women by sexual orientation identity and gender of sexual partners., Methods: The analytical sample consisted of a nationwide sample of 6,150 U.S. young women (mean age = 23 years) from the Growing Up Today Study who completed cross-sectional questionnaires from 1996 to 2007., Outcomes: Age-adjusted regression analyses were used to examine groups categorized by sexual orientation identity (completely heterosexual [ref.], mostly heterosexual, bisexual, lesbian) and gender of sexual partner (only men [ref.], no partners, both men, and women). We examined differences in lifetime and past-year chronic pelvic pain symptoms, diagnosis, treatment, and quality of life outcomes. Sensitivity analyses also examined the role of pelvic/gynecologic exam history and hormonal contraceptive use as potential effect modifiers., Results: Around half of all women reported ever experiencing chronic pelvic pain, among whom nearly 90% had past-year chronic pelvic pain. Compared to completely heterosexual women, there was greater risk of lifetime chronic pelvic pain among mostly heterosexual (risk ratio [RR] = 1.30, 95% confidence interval [CI]: 1.22-1.38), bisexual (RR = 1.30, 95% CI: 1.10-1.52), and lesbian (RR = 1.23, 95% CI: 1.00-1.52) young women. Additionally, compared to young women with only past male sexual partners, young women who had both men and women as past sexual partners were more likely to report chronic pelvic pain interfered with their social activities (b = 0.63, 95% CI: 0.25-1.02), work/school (b = 0.55, 95% CI: 0.17-0.93), and sex (b = 0.53, 95% CI: 0.05-1.00)., Clinical Implications: Healthcare providers, medical education, and field-wide standards of care should be attentive to the way sexual orientation-based healthcare disparities can manifest into differential prognosis and quality of life outcomes for women with chronic pelvic pain (particularly bisexual women)., Strengths & Limitations: Our study is the first to examine a variety of chronic pelvic pain outcomes in a nationwide U.S. sample across different outcomes (ie, past-year and lifetime). Though limited by sample homogeneity in terms of age, race, ethnicity, and gender, findings from this article provide foundational insights about chronic pelvic pain experiences of sexual minority young women., Conclusion: Our key finding is that sexual minority women were commonly affected by chronic pelvic pain, and bisexual women face pain-related quality of life disparities. Tabaac AR, Chwa C, Sutter ME, et al. Prevalence of Chronic Pelvic Pain by Sexual Orientation in a Large Cohort of Young Women in the United States. J Sex Med 2022;19:1012-1023., (Copyright © 2022 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Most minors and young transgender persons wishing to undergo gender-affirming surgery need to seek specialists affiliated with gender affirmation programs in adult hospitals. Research suggests gender affirmation surgery has been established as an effective and medically indicated treatment for gender dysphoria. Although most data on gender-affirming surgeries are from adult populations, there is growing literature establishing their effectiveness in adolescents and young adults. Therefore, it is critical to evaluate the perioperative outcomes for gender-diverse youth to deliver safe and affirming care. The primary objective of this retrospective case series is to examine the perioperative characteristics and outcomes of patients with gender identity disorders (International Classification of Diseases [ICD]-10-code F64) who underwent chest reconstruction (mastectomy) and genital surgery (phalloplasty, metoidioplasty, and vaginoplasty) in a pediatric academic hospital. The secondary aim is to evaluate the value of a specialized anesthesia team for improving clinical outcomes, interdisciplinary communication, and further advancing the transgender perioperative experience. We identified 204 gender affirmation surgical cases, 177 chests/top surgeries, and 27 genital/bottom surgeries. These findings indicate gender-diverse individuals who underwent life-changing surgery at our institution had a median age of 18 years old, with many patients identifying as transmen. Our data suggests that postoperative pain was significant, but adverse events were minimal. The evolution of a specialty anesthesia team and initiatives (anesthesia management guidelines, scheduling, continuity, and education) necessitate direct care coordination and multidisciplinary planning for gender affirmation surgery in transgender youth.

With the increasing practice of gender-affirming mastectomy as a therapeutic procedure in the setting of gender dysphoria, there has come a profusion of literature on the pathologic findings within these specimens. Findings reported in over 1500 patients have not included either prostatic metaplasia or pilar metaplasia of breast epithelium. We encountered both of these findings in the course of routine surgical pathology practice and therefore aimed to analyze these index cases together with a retrospective cohort to determine the prevalence, anatomic distribution, pathologic features, and associated clinical findings of prostatic metaplasia and pilar metaplasia in the setting of gender-affirming mastectomy. In addition to the 2 index cases, 20 additional archival gender-affirming mastectomy specimens were studied. Before mastectomies, all but 1 patient received testosterone cypionate, 6/22 patients received norethindrone, and 21/22 practiced breast binding. Prostatic metaplasia, characterized by glandular proliferation along the basal layer of epithelium in breast ducts, and in one case, within lobules, was seen in 18/22 specimens; 4/22 showed pilar metaplasia, consisting of hair shafts located within breast ducts, associated with squamoid metaplasia resembling hair matriceal differentiation. By immunohistochemistry, prostatic metaplasia was positive for PSA in 16/20 cases and positive for NKX3.1 in 15/20 cases. Forty-three reduction mammoplasty control cases showed no pilar metaplasia and no definite prostatic metaplasia, with no PSA and NKX3.1 staining observed. We demonstrate that prostatic metaplasia and pilar metaplasia are strikingly common findings in specimens from female-assigned-at-birth transgender patients undergoing gender-affirming mastectomy. Awareness of these novel entities in the breast is important, to distinguish them from other breast epithelial proliferations and to facilitate accrual of follow-up data for better understanding their natural history., (© 2021. The Author(s), under exclusive licence to United States & Canadian Academy of Pathology.)

Benign breast surgery aims to treat the physical and psychological discomfort that may be associated with excess breast tissue. In this investigation, we present the first systematic examination and comparison of the determinants of pain and related symptomology in cisgender women and transmasculine individuals presenting for benign breast surgery., Methods: To complete this study, we abstracted the intake forms of 128 transmasculine and 62 cisgender female patients who presented for benign breast surgery between August 2016 and July 2020., Results: Increasing chest size was associated with significantly increased odds of reporting rash (OR 1.10 95% CI [1.01-1.10], P < 0.03), difficulty playing sports (OR 1.19 95% CI [1.09-1.29], P < 0.001), and difficulty finding clothes that fit (OR 1.21, 95% CI [1.11-1.33], P < 0.001). For individuals who bound their chests, size was also associated with difficulty exercising in a binder (OR 1.14 [1.01-1.29], P < 0.03). Looking separately at the two populations, the only factors that remained associated with pain in multivariate models were BMI (β = 0.10 [0.01-0.18], P < 0.03) for cisgender women and history of binding (β = 1.95 [0.37-3.52], P < 0.02) for transmasculine people., Conclusions: Pain does not seem to be associated with chest size in either cisgender female or transmasculine patients seeking benign breast surgery. The association between chest binding and pain in transmasculine people supports the provision of gender-affirming chest surgery to eliminate the need to bind and reduce both physical and psychological distress., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Continued provision of essential services is critical to maintaining society's functioning during a crisis. During COVID-19, lockdowns and restrictions designed to preserve the public's health forced an examination of what it means to be an essential worker. Drawing from thematic analyses of focus group data from 55 social workers employed in a large, urban, pediatric, quaternary hospital, this study examines the perspectives of hospital social workers on the meaning of the essential status designation of social work. Findings revealed themes pertaining the substance of social work, the ways in which essential status is carried out, and implications of the designation not only for the future of the profession but also for the populations who receive social work services. The discussion raised important questions about the essential role of social workers in broader health care settings. Our findings suggest that health care systems need to engage in ongoing discussions of how to maximize the efficacy of the social work workforce, both in terms of integration with medical teams and recognition of the important roles social workers play across the hospital system, and facilitate the performance of their essential functions.

Background: The clitorophallus, or glans, is a critical structure in sexual development and plays an important role in how gender is conceptualized across the life span. This can be seen in both the evaluation and treatment of intersex individuals and the use of gender-affirming masculinizing therapies to help those born with a clitoris (small clitorophallus with separate urethra) enlarge or alter the function of that structure., Objectives: To review the role of testosterone in clitorophallus development from embryo to adulthood, including how exogenous testosterone is used to stimulate clitorophallus enlargement in masculinizing gender-affirming therapy., Materials and Methods: Relevant English-language literature was identified and evaluated for data regarding clitorophallus development in endosex and intersex individuals and the utilization of hormonal and surgical masculinizing therapies on the clitorophallus. Studies included evaluated the spectrum of terms regarding the clitorophallus (genital tubercle, clitoris, micropenis, penis)., Results: Endogenous testosterone, and its more active metabolite dihydrotestosterone, plays an important role in the development of the genital tubercle into the clitorophallus, primarily during the prenatal and early postnatal periods and then again during puberty. Androgens contribute to not only growth but also the inclusion of a urethra on the ventral aspect. Exogenous testosterone can be used to enlarge the small clitorophallus (clitoris or micropenis) as part of both intersex and gender-affirming care (in transmasculine patients, up to 2 cm of additional growth). Where testosterone is insufficient to provide the degree of masculinization desired, surgical options including phalloplasty and metoidioplasty are available., Discussion and Conclusion: Endogenous testosterone plays an important role in clitorophallus development, and there are circumstances where exogenous testosterone may be useful for masculinization. Surgical options may also help some patients reach their personal goals. As masculinizing gender-affirming care advances, the options available for clitorophallus modifications will likely continue to expand and improve., (© 2021 American Society of Andrology and European Academy of Andrology.)

Study Objective: Amenorrhea is a goal of many transgender and gender diverse adolescent and young adult (TGD AYA) patients on testosterone gender-affirming hormone therapy (T-GAHT). Breakthrough bleeding can contribute to worsening gender dysphoria. Our objective was to evaluate breakthrough bleeding in TGD AYA on T-GAHT., Design: Institutional review board-approved retrospective cohort., Setting: Tertiary-care children's hospital., Participants: TGD AYA on T-GAHT >1 year., Interventions: None; observational., Main Outcome Measures: Presence of, and risk factors for, breakthrough bleeding., Results: Of the 232 patients who met inclusion criteria, one-fourth (n = 58) had 1 or more episodes of breakthrough bleeding, defined as bleeding after more than 1 year on T-GAHT. In comparing patients with breakthrough bleeding to those without, there were no significant differences between age of initiation, body mass index (BMI), race/ethnicity, testosterone type used, use of additional menstrual suppression, serum testosterone, or estradiol levels. Patients with breakthrough bleeding patients were on T-GAHT longer (37.3 ± 17.0 vs 28.5 ± 14.6 months, P < .001) and were more likely to have endometriosis (P = .049). Breakthrough bleeding began at a mean of 24.3 ± 17.2 months after T-GAHT initiation. Of those with breakthrough bleeding, 46 (79.3%) had no known cause, 10 (17.2%) bled only with missed T-GAHT doses, and 2 (3.4%) bled only when withdrawing from concomitant menstrual suppression. No breakthrough bleeding management method was found to be superior., Conclusion: Breakthrough bleeding is relatively common (25%) on T-GAHT despite early amenorrhea. Most cases do not have an identifiable cause. Our data did not show superiority of any 1 method for managing breakthrough bleeding on T-GAHT., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Transgender and gender diverse adolescent and young adults (AYA) may seek gender-affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, or requiring GAS aftercare, or those seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams. With this knowledge, reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

The value of gender-affirming genital surgery (GAGS) has been established for certain transgender or gender non-conforming patients. This study aimed to determine the availability of GAGS by state and region in the United States, and to query possible associations of access to care with healthcare legislation and local market size., Methods: This was a cross-sectional study reporting on the distribution of hospitals and private practices offering GAGS in the United States. A list of prospective gender surgeons was compiled from 18 online databases. All surgeons were individually verified and were excluded if they did not perform phalloplasty, metoidioplasty, or vaginoplasty. Pertinent legislative and transgender or gender non-conforming population data were derived from the Movement Advancement Project and the Williams Institute., Results: Seventy-one practices in the United States offered GAGS in 2019. Forty-seven percent of states did not have a practice offering GAGS. A large prospective transgender or gender non-conforming market size increased the odds of GAGS availability in a state more than did local healthcare legislation supporting insurance coverage for gender-affirming care in 2019., Conclusions: Access to gender-affirming genital surgery was highly disparate in 2019. Factors that predicted access to care, including state healthcare legislation and prospective market sizes, may indicate strategies for overcoming disparities., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)