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Transmasculine individuals have a poor access to health care, mostly regarding the sexual and reproductive health. Despite a lack of official guidelines, they need a gynecological follow-up, the aim of this review was to describe it. The present study involved an exhaustive search of MEDLINE, 68 articles were included to analyze the impact of hormonal therapy, prevention, and care regarding sexual and reproductive health of transmasculine individuals. Despite a lack of solid data, the global literature agrees that transmasculine individuals require sexual and reproductive health care. Care must be adapted to each pathway and may be impacted by gender-affirming care. The cancer risk does not seem to be increased in this population, particularly in relation to hormonal therapy. Prevention programs do not differ from those offered to cis women in the absence of gender-affirming surgeries. Transmasculine individuals require follow-up and care adapted to their needs and their pathways. Healthcare professionals must be trained to provide such care., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objective: Gender-affirming hormone therapy (GAHT) is often used by transgender and gender-diverse individuals to align their physical appearance with their gender identity. Discontinuation rates and factors leading to discontinuation of GAHT are not fully understood. We aimed to assess the continuation and discontinuation rates of GAHT and the factors leading to discontinuation of GAHT in a systematic review of the literature., Methods: We searched PubMed from 2009 until April 01, 2024, for all published studies that described initiation, discontinuation, and reasons for discontinuation of GAHT. Studies were screened by 2 authors independently. We included 6 studies that met the inclusion and exclusion criteria published between 2021 and 2024., Results: Five studies reported GAHT discontinuation rates under 10%, whereas 1 study reported a discontinuation/lost to follow-up rate of 30.8%. Only 1 study was prospective, whereas all other studies were retrospective. Reasons for discontinuation of GAHT were described in only 2 studies. One study reported GAHT discontinuation primarily from external factors, whereas the other study suggested that GAHT discontinuation occurred due to change in gender identity., Conclusion: Current data on discontinuation of GAHT show that the rates of GAHT discontinuation appear to be low and the reasons include both external pressures and internal change of gender identity. A better understanding of the internal and external pressures that impact the decision to continue GAHT is needed in future studies., Competing Interests: Disclosure The authors have no conflicts of interest to disclose. Given their role as Editor-in-Chief for Endocrine Practice, Dr. Vin Tangpricha had no involvement in the peer-review of this article and has no access to information regarding its peer-review. Full responsibility for the editorial process for this article was delegated to Dr. Nicholas., (Copyright © 2024 AACE. Published by Elsevier Inc. All rights reserved.)

In recent years, there has been an increasing recognition of the unique healthcare needs of gender-diverse patients in Australia. With the continuous growth of referrals to gender health services, there is an increased demand for specialised dermatological care. There is still a significant knowledge gap and a lack of guidelines specifically tailored to this patient group. In this article, we will provide a brief overview of the journey of Transgender and Gender Diverse (TGD) individuals as they embark on psychological and pharmacologic treatment for gender dysphoria in Australia. We endeavour to contribute to the existing body of knowledge by examining the evidence surrounding the treatment of skin, hair and nail issues for TGD patients. This article will outline how dermatologists can assist in the care of the gender-diverse patient. Although puberty blockade (stage 1 treatments) has minimal dermatological impact, gender-affirming pharmacotherapy (stage 2 treatments) can lead to many dermatological issues including acne, patterned hair loss (PHL) and dermatitis. The dermatologist may also play a role in stage 3 treatments which include surgical or procedural interventions for gender affirmation., (© 2024 The Author(s). Australasian Journal of Dermatology published by John Wiley & Sons Australia, Ltd on behalf of Australasian College of Dermatologists.)

Introduction: Higher stress levels are linked to increased body fat and decreased bone density, effects that can be exacerbated by lifestyle choices. This is particularly relevant for transgender and gender diverse (TGD) individuals, who often face additional stress from transphobia and social stigma. However, there is limited research on how stress affects body composition and bone health in TGD individuals, particularly in relation to gender-affirming hormone therapy (GAHT). This study examines the impact of perceived stress on these factors in TGD individuals before and after one year of GAHT, compared to a cisgender control group., Methods: The study assessed 181 individuals, including 74 TGD participants (44 assigned female at birth [AFAB] and 30 assigned male at birth [AMAB]) and 107 controls (56 AFAB and 51 AMAB). Fifty-seven TGD participants completed follow-up one year after starting GAHT. Data collected included clinical history, blood tests, body composition, bone density, and quality of life assessments (Patient Health Questionnaire-9 [PHQ-9] and Perceived Stress Scale [PSS])., Results: After one year of GAHT, TGD AFAB individuals showed a bone mineral density (BMD) similar to cisgender AMAB individuals, while TGD AMAB individuals' BMD remained significantly lower than cisgender controls. TGD AFAB individuals experienced increases in muscle strength (+8% from baseline), while TGD AMAB individuals showed a 24% increase in fat mass from baseline and an approximate 8% reduction in lean mass. PSS and PHQ scores, initially higher in TGD individuals, did not change significantly after one year of GAHT. A significant correlation was found between body fat percentage and PHQ and PSS scores at baseline and one year after GAHT, respectively., Discussion: These findings reveal a complex relationship between GAHT, body composition, and perceived stress in TGD individuals, highlighting the need for further research on stress and health outcomes in this population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Ceolin, Scala, Scagnet, Citron, Vilona, De Rui, Miscioscia, Camozzi, Ferlin, Sergi, Garolla and the GIIG group.)

Objective: To compare two surgical techniques, the Wendler glottoplasty (GP) and its modification, the vocal fold shortening, and retrodisplacement of the anterior commissure (VFSRAC) associated with laser assisted voice adjustment (LAVA) cordotomy, used to feminize the voice of transgender women by increasing the fundamental frequency (F 0 )., Methods: A retrospective study of 22 trans-women (20-62 years-old) was carried out. 12 of them were treated with GP and 10 with the VFSRAC+LAVA technique. They were evaluated before surgery and 6 months after surgery and the postoperative speech therapy. Laryngostroboscopy examination, F 0 measurements, Transgender Woman Voice Questionnaire (TWVQ) assessment and the perceptual assessment using a visual analog scale (PA-VAS) were obtained from all patients., Results: Laryngostroboscopic findings showed normal vocal folds before surgery and a shortening of the vocal folds, due to the anterior glottic synechia, after surgery. Significant increases of F 0 were found in both groups but they were higher in the VFSRAC+LAVA group (47.75Hz in GP group vs 69.70Hz in VFSRAC+LAVA group). TWVQ scores showed a significant decrease in both groups although the difference was greater in the VFSRAC+LAVA group. Similarly, PA-VAS scores lowered significantly in both groups but VFSRAC+LAVA group presented the biggest decreases., Conclusion: Both surgical techniques produce the shortening of the vocal folds through an endoscopic approach and result in voices with higher vocal pitch. Of the two techniques presented, the VFSRAC+LAVA produces better results although when compared with previous studies it seems that the LAVA technique may not significantly contribute to the postoperative results. So, the VFSRAC technique followed by postoperative speech therapy could be recommended for trans-women who wish to feminize their voice., Competing Interests: DECLARATIONS OF INTEREST None., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To develop a self-efficacy questionnaire for voice modification related to gender affirmation and to examine the internal consistency and test-retest reliability of the questionnaire among a cohort of trans women., Methods: This study was undertaken in two phases. In phase I, four Speech- Language Pathologists (SLPs) and four trans women informed the development of the Self-Efficacy Scale for Voice Modification in Trans Women (SES-VMTW). In phase II, using classical test theory, data from 31 Australian and 27 Swedish trans women who completed the SES-VMTW twice with an interim period of 3-6 weeks were analyzed for internal consistency and test-retest reliability. During this second phase, the 19 items of the SES-VMTW were subcategorized by consensus among the authors into like groups., Results: Phase I resulted in the 19-item SES-VMTW and four subcategories were identified: 1) Change (items related to changing voice); 2) Perception (items related to the ability to perceive changes in voice; 3) Psychological (items related to engaging in voice practice despite psychological barriers; 4) Logistical (items related to engaging in voice practice despite logistical barriers). In Phase II, initial psychometric analysis was applied to the full questionnaire as well as to the subcategories. The Cronbach's alpha for the full questionnaire (α = 0.86) at both the test and retest timepoints indicates a high level of internal consistency. Item-total correlation analysis indicated that individual items correlated with the questionnaire total score, but that they generally correlated more strongly with the total score for the relevant subcategory. The Cronbach's alpha for the four subcategories of the SES-VMTW were variable but all coefficients exceeded 0.6, thus supporting the reliability of the new scale. Good test-retest reliability was demonstrated for the full questionnaire (intraclass correlation coefficient = 0.84; 95% confidence interval, 0.73-0.90, P < 0.001) and was moderate to good for the four subcategories., Conclusion: The findings of the current study are promising, suggesting that both the full SES-VMTW and the four subcategories can provide consistent and reliable insight into self-efficacy for trans women aiming to modify their voice as part of their gender affirmation., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Gender affirming voice training is a service provided by speech language pathologists to members of the trans and gender diverse community. While there is some evidence to support the effectiveness of this training, the evidence base is limited by a lack of prospective studies with large sample sizes. Finally, there has been only limited research investigating the effectiveness of this training when delivered on intensive (compressed) schedules, even though such schedules are used in clinical practice and may have practical benefits such as increasing service access for this vulnerable population., Methodology: This study aimed to investigate and compare the effectiveness gender affirming voice training among 34 trans individuals presumed male at birth aiming to develop a perceptually feminine/female-sounding voice. Among these 34 participants, 17 received their training on a traditional schedule (one 45-minute session per week over 12 weeks) and 17 on an intensive scheduled (three 45-minute sessions per week over 4 weeks). Building on a previous mixed methodological study which indicated that these two training groups were equally satisfied with training outcomes, the current study utilised a wide range of self-report, acoustic, and auditory-perceptual outcome measures (including self-ratings and listener-ratings of voice) to investigate training effectiveness., Discussion: Results from this study indicated that both training programs were similarly effective, producing positive statistically significant change among participants on a range of outcome measures. Participants in both groups demonstrated significant auditory-perceptual and acoustic voice change and reported increased satisfaction with voice, increased congruence between gender identity and expression, and a reduction in the negative impact of voice concerns on everyday life. However, as has been the case in past studies, training was not sufficient for all participants to achieve their goal of developing a consistently feminine/female-sounding voice., Conclusion: This study provides evidence to suggest that gender affirming voice training for transfeminine clients may be similarly effective whether delivered intensively or traditionally. This study provides evidence to support the practice of using a wide range of outcome measures to gain holistic insight into client progress in gender affirming voice training programs., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care., (© 2024 John Wiley & Sons Ltd.)

Aim: Voice interventions for transgender individuals can address several speech and voice parameters - fundamental frequency, resonance, intonation, rhythm, and intensity. In this study, we focus on fundamental voice frequency and build on existing research to test one technique that has been shown in a preliminary study to effectively adjust fundamental voice frequency in line with clients' goals., Method: More specifically, we employed an adaptation of melodic intonation therapy (MIT) to assess whether it can raise trans women's average fundamental frequency to a significant degree. Eleven trans women participated in two one-to-one therapy sessions, four weeks apart., Results: Results pointed to a statistically significant rise in both their singing and speaking fundamental frequencies following the adapted MIT therapy sessions. Participants were also successful in imitating upward fundamental frequency contours when singing and in producing them independently in the speech modality., Future Directions: Longitudinal studies are warranted to determine whether the observed positive results translate into long-term benefits.

Several dermatologic concerns are known to disproportionally affect transgender and gender-diverse (TGD) adults, but little is known about dermatologic conditions in TGD youth. This study assesses the prevalence of acne, androgenic alopecia, scarring from gender-affirming procedures, and eczema in pediatric TGD patients seen at Boston Children's Hospital between April 2021 and April 2022. The results demonstrate that, for TGD youth, the studied dermatologic concerns are common, referral rates to dermatology are low, and acne is significantly associated with testosterone use. Future studies should examine additional dermatologic concerns and barriers to accessing dermatologic care for this historically underserved population., (© 2024 Wiley Periodicals LLC.)

Gender Affirming Hormone Therapy (GAHT) is a key therapeutic approach which aims to help trans and gender diverse (or simply "trans") individuals' transition from their sex-presumed-at-birth to their experienced gender identity. Previous reviews have focused on synthesizing quantitative experiences; however, a qualitative lens is important to understand the personal journey of GAHT. This review provides a qualitative meta-synthesis of the experiences of trans people around the world who have undergone GAHT to elicit contextualized understanding of the changes experienced. Systematic searches of eight databases identified an initial 2670 papers, refined to a final 28 papers. Overall, findings suggested that the GAHT journey is unique and elicited a myriad of changes which, whilst challenging at times, were life-changing and brought about positive psychological, physical, and social changes. Other themes explored GAHT not being treated as a fix-all for associated mental health issues, the rules that govern appraisal of physical changes, how privilege and social identity evolve, and the power of affirmation. This work offers important recommendations to improve the care offered to trans people undergoing GAHT. Namely, person-centered support is essential, and peer-navigation may be a useful future direction to explore.

Gender affirming hormone treatment is an important part of the care of trans adolescents which enables them to develop the secondary sexual characteristics congruent with their identified genders. There is an increasing amount of empirical evidence showing the benefits of gender affirming hormone treatment for psychological health and social well-being in this population. However, in several countries, access to gender affirming hormone treatment for trans adolescents has recently been severely restricted. While much of the opposition to gender affirming hormone treatment for trans adolescents has in part been ideologically motivated, it also reflects a debate about whether there are harms that outweigh the benefits of the treatment. Accordingly, a systematic and comprehensive philosophical analysis of the ethics of gender affirming hormone treatment for trans adolescents is needed. Herein, I offer such an analysis that draws on the four principles of biomedical ethics by Tom Beauchamp and James Childress. Based on the considerations of beneficence, nonmaleficence, autonomy, and justice, I argue that the provision of access to gender affirming hormone treatment for consenting trans adolescents is ethically required and that the current restrictions to such treatment are ethically wrong., (© 2024. The Author(s).)

Background: There is insufficient research on how gender-affirming hormone therapy (GAHT) affects body fat modifications in transwomen from China. It is unclear whether hormone therapy affects the prevalence of obesity and blood lipid levels within this population. The current research aimed to assess how GAHT and treatment duration had an impact on the change in and redistribution of body fat in Chinese transwomen., Methods: This study included 40 transwomen who had not received GAHT and 59 who had. Body fat, blood lipid, and blood glucose levels were measured. GAHT is mainly a pharmacologic (estrogen and anti-androgen) treatment. The study also stratified participants based on the duration of GAHT to assess its impact on body fat distribution. The duration of GAHT was within one year, one to two years, two to three years, or more than three years., Results: After receiving GAHT, total body fat increased by 19.65%, and the percentage of body fat increased by 17.63%. The arm, corrected leg, and leg regions showed significant increases in fat content (+ 24.02%, + 50.69%, and + 41.47%, respectively) and percentage (+ 25.19%, + 34.90%, and + 30.39%, respectively). The total visceral fat content decreased (-37.49%). Based on the diagnostic standards for a body mass index ≥ 28 or total body fat percentage ≥ 25% or 30%, the chance of developing obesity did not change significantly. Blood glucose levels significantly increased (+ 12.31%). Total cholesterol levels (-10.45%) decreased significantly. Fat changes in those who received GAHT for one to two years were significantly different from those who did not receive GAHT., Conclusion: After receiving GAHT, total body fat and regional fat increased in Chinese transwomen, and the body fat distribution changed from masculine to feminine, especially during the first two years. However, neither the increase in total body fat percentage nor the decrease in visceral fat content didn't bring about significant changes in the incidence of obesity, nor did triglycerides or low-density lipoprotein-cholesterol., (© 2024. The Author(s).)

Background: Gender-affirming hormone therapy (GAHT) is a common medical intervention sought by transgender and gender diverse (TGD) individuals. Initiating GAHT in accordance with clinical guideline recommendations ensures delivery of high-quality care. However, no prior studies have examined how current GAHT initiation compares to recommended GAHT initiation., Objective: This study assessed guideline concordance around feminizing and masculinizing GAHT initiation in the Veterans Health Administration (VHA)., Methods: The sample included 4,676 veterans with a gender identity disorder diagnosis who initiated feminizing ( n =3,547) and masculinizing ( n =1,129) GAHT between 2007 and 2018 in VHA. Demographics and health conditions on veterans receiving feminizing and masculinizing GAHT were assessed. Proportion of guideline concordant veterans on six VHA guidelines on feminizing and masculinizing GAHT initiation were determined., Results: Compared to veterans receiving masculinizing GAHT, a higher proportion of veterans receiving feminizing GAHT were older (≥60 years: 23.7% vs. 6.3%), White non-Hispanic (83.5% vs. 57.6%), and had a higher number of comorbidities (≥7: 14.0% vs. 10.6%). A higher proportion of veterans receiving masculinizing GAHT were Black non-Hispanic (21.5% vs. 3.5%), had posttraumatic stress disorder (43.0% vs. 33.9%) and positive military sexual trauma (33.5% vs.16.8%; all p-values<0.001) than veterans receiving feminizing GAHT. Among veterans who started feminizing GAHT with estrogen, 97.0% were guideline concordant due to no documentation of contraindication, including venous thromboembolism, breast cancer, stroke, or myocardial infarction. Among veterans who started spironolactone as part of feminizing GAHT, 98.1% were guideline concordant as they had no documentation of contraindication, including hyperkalemia or acute renal failure. Among veterans starting masculinizing GAHT, 90.1% were guideline concordant due to no documentation of contraindications, such as breast or prostate cancer. Hematocrit had been measured in 91.8% of veterans before initiating masculinizing GAHT, with 96.5% not having an elevated hematocrit (>50%) prior to starting masculinizing GAHT. Among veterans initiating feminizing and masculinizing GAHT, 91.2% had documentation of a gender identity disorder diagnosis prior to GAHT initiation., Conclusion: We observed high concordance between current GAHT initiation practices in VHA and guidelines, particularly for feminizing GAHT. Findings suggest that VHA clinicians are initiating feminizing GAHT in concordance with clinical guidelines. Future work should assess guideline concordance on monitoring and management of GAHT in VHA., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Jasuja, Wolfe, Reisman, Vimalananda, Rao, Blosnich, Livingston and Shipherd.)

Aim: The Standards of Care (SOC-8) by the World Professional Association for Trans Health provide guidelines for the care of transgender and gender diverse individuals through safe and effective multi-professional interventions for physical and mental well-being. The aim of this work is to summarize the SOC-8 recommendations for childhood and adolescence, highlighting the importance of psychosocial assessment and available medical and surgical therapeutic options, and emphasizing the need for healthcare provider training., Methods: The SOC-8 recommendations are based on scientific evidence and professional consensus from experts in transgender health, developing classification criteria and access to therapies, based on systematic literature reviews (PubMed and Embase)., Results: The SOC-8 underscores the importance of assessing and preserving gender identity, supporting prepubescent individuals from a psychosocial perspective, and ensuring adolescents access to medically and surgically conforming treatments according to local legislation. It is the responsibility of healthcare providers to understand and adapt international guidelines for an inclusive clinical practice of gender diversity., Discussion and Conclusions: Gender affirmation therapies in minors require comprehensive evaluation, parental involvement, and consideration of their cognitive and emotional maturity. Treatments should also focus on preserving fertility and accessing medicalized treatments which are beneficial to the well-being of transgender and gender diverse individuals.

Objectives: Guidelines for monitoring of medications frequently used in the gender-affirming care of transgender and gender-diverse (TGD) adolescents are based on studies in adults or other medical conditions. In this study, we aimed to investigate commonly screened laboratory measurements in TGD adolescents receiving gender-affirming hormone therapy (GAHT)., Methods: TGD adolescents were recruited from 4 study sites in the United States before beginning GAHT. Hemoglobin, hematocrit, hemoglobin A1c, alanine transaminase, aspartate aminotransferase, prolactin, and potassium were abstracted from the medical record at baseline and at 6, 12, and 24 months after starting GAHT., Results: Two-hundred and ninety-three participants (68% designated female at birth) with no previous history of gonadotropin-releasing hormone analog use were included in the analysis. Hemoglobin and hematocrit decreased in adolescents prescribed estradiol (-1.4 mg/dL and -3.6%, respectively) and increased in adolescents prescribed testosterone (+1.0 mg/dL and +3.9%) by 6 months after GAHT initiation. Thirteen (6.5%) participants prescribed testosterone had hematocrit > 50% during GAHT. There were no differences in hemoglobin A1c, alanine transaminase, or aspartate aminotransferase. There was a small increase in prolactin after 6 months of estradiol therapy in transfeminine adolescents. Hyperkalemia in transfeminine adolescents taking spironolactone was infrequent and transient if present., Conclusions: Abnormal laboratory results are rare in TGD adolescents prescribed GAHT and, if present, occur within 6 months of GAHT initiation. Future guidelines may not require routine screening of these laboratory parameters beyond 6 months of GAHT in otherwise healthy TGD adolescents., (Copyright © 2024 by the American Academy of Pediatrics.)

Conflicting evidence exists about the risk of breast cancer in transgender and gender-diverse (TGD) patients treated with testosterone. This review aimed to summarize current knowledge regarding the risk of breast cancer associated with gender-affirming testosterone treatment (GATT). A systematic literature search using the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist was conducted in January 2023 through Ovid, Scopus, and Web of Science databases. English-language, peer-reviewed articles evaluating breast cancer in TGD patients after GATT that met the inclusion criteria were included. This review included 22 articles, with 14 case reports, 4 case series, and 4 retrospective cohort studies. The review identified 26 TGD patients who developed breast cancer post-GATT therapy, with inconclusive evidence on the relationship between testosterone and the risk of breast cancer in TGD patients. This uncertainty in part arises from the mechanisms governing testosterone's effects within breast tissue, with contrasting theories proposing both proliferative and antiproliferative impacts. Considering this ambiguity, it is imperative for healthcare providers to engage in informed discussions with patients prior to initiating hormone therapy to discuss potential adverse effects, including the possibility of breast cancer development in TGD individuals. Patient education and shared decision-making are essential components of responsible care in this context., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Transgender and gender-diverse (TGD) persons represent a small but growing population in the United States. Accessing inclusive, equitable, and evidence-based healthcare remains a challenge for this patient population. Many TGD persons seek gender-affirming care, including gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS), to help ameliorate the physical and mental aspects of their gender incongruence. Both GAHT and GAS induce clinically important histopathologic and anatomic changes in breast tissue. Consequently, breast care in TGD persons has become an increasingly recognized topic of importance in gender-affirming care. However, there remains a scarce but growing base of literature specifically addressing the unique healthcare needs of breast care in TGD patients. This article will review how to establish trusting patient-provider relationships for TGD patients, gender inclusivity in breast clinics and imaging centers, the influence of GAHT and GAS on breast tissue, breast cancer screening recommendations and barriers, and breast cancer risk and treatment considerations in TGD persons.

The differences between the male and female brain in cisgender individuals, those in whom there is no incongruence between the so-called biological sex and the perceived sex, are known. The genetic basis that underlies the differences observed in the brains of transgender individuals compared to cisgender individuals is also becoming known. In transgender individuals, there is a fundamental change in the connectivity of neurons in the body perception network, which may give rise to gender dysphoria. This knowledge allows for the characterization of the transgender condition and distinguishes it from transgender identities such as non-binary gender, gender fluidity, or genderqueer. Articles published assume, from the perspective of depathologization imposed by Gender Ideology, that these differences are due to a different sexual development. The societal acceptance of this perspective over the last two decades paved the way for medical interventions aimed at affirming the perceived gender, different from the genetic sex, through the continuous administration of cross-sex hormones and, in some cases, mutilating surgery. In adolescents and children, affirmation treatment of the perceived gender begins with puberty blockers, which have negative consequences for ossification and growth. The importance and irreversibility of these 'side effects' require the utmost rigor and complete information about them. Spanish law pushes the ideology to the maximum, infringing on the rights of transgender individuals. Medical ethics emphasize the necessity - the right - of a medical and psychological diagnosis, free from ideological approaches, before initiating what is being called treatment. This includes the right to information, prior to consent, about the positive and negative effects of hormonal administration. It also includes the right to the recognition of diversity among transgender individuals, especially the right to research that allows for treating the brain without altering the body. These rights must be recognized and demanded by the laws.

The proportion of transgender people has increased over time, but few cases of transgender people undergoing kidney transplantation have been described. A 41-year-old transgender man (female-to-male) had chronic kidney disease caused by IgA nephropathy. He had received testosterone therapy and sex reassignment surgeries (chest masculinization surgery, metoidioplasty, scrotoplasty, and hysterectomy-ovariectomy) since he was 19 years due to gender incongruence. He underwent a preemptive living-donor kidney transplantation from his wife. His skeletal muscle mass was closer to that of a female than that of a male and suggested that eGFR should be calculated with the equation based on the gender assigned at birth (female) rather than the gender identity (male). Moreover, the recovery of kidney function due to successful kidney transplantation decreased serum gonadotropin levels, but normalization of his sex hormone profile was not achieved. Further accumulation of experience with kidney transplantation for transgender people is needed., (© 2023. The Author(s) under exclusive licence to The Japan Society of Nephrology.)

This study explored whether self-reported barriers to accessing a health care provider, gender-affirming procedures, and relevant psychosocial measures were related to experienced gender affirmation in a cross-sectional sample of trans individuals ( N =101). Body image quality of life [ b =0.181, t (4.277) , p <0.001] and the number of gender-affirming procedures [ b =0.084, t (2.904), p =0.005] were significant predictors of transgender congruence, a measure of gender affirmation, and accounted for 40% of the adjusted variance in transgender congruence scores F (2, 89)=31.363, p <0.001, R 2 =0.413. Results suggest that experiencing a barrier to gender-affirming health care is associated with anticipation of discrimination and provides further evidence that gender-affirming health care is associated with positive psychosocial outcomes., Competing Interests: No competing financial interests exist., (Copyright 2023, Mary Ann Liebert, Inc., publishers.)

Background: Twenty years ago, the Dutch Protocol-consisting of a gonadotropin-releasing hormone agonist (GnRHa) to halt puberty and subsequent gender-affirming hormones (GAHs)-was implemented to treat adolescents with gender dysphoria., Aim: To study trends in trajectories in children and adolescents who were referred for evaluation of gender dysphoria and/or treated following the Dutch Protocol., Methods: The current study is based on a retrospective cohort of 1766 children and adolescents in the Amsterdam Cohort of Gender Dysphoria., Outcomes: Outcomes included trends in number of intakes, ratio of assigned sex at birth, age at intake, age at start of GnRHa and GAH, puberty stage at start of GnRHa, proportions of adolescents starting and stopping GnRHa, reasons for refraining from GnRHa, and proportions of people undergoing gender-affirming surgery., Results: A steep increase in referrals was observed over the years. A change in the AMAB:AFAB ratio (assigned male at birth to assigned female at birth) was seen over time, tipping the balance toward AFAB. Age at intake and at start of GnRHa has increased over time. Of possibly eligible adolescents who had their first visit before age 10 years, nearly half started GnRHa vs around two-thirds who had their first visit at or after age 10 years. The proportion starting GnRHa rose only for those first visiting before age 10. Puberty stage at start of GnRHa fluctuated over time. Absence of gender dysphoria diagnosis was the main reason for not starting GnRHa. Very few stopped GnRHa (1.4%), mostly because of remission of gender dysphoria. Age at start of GAH has increased mainly in the most recent years. When a change in law was made in July 2014 no longer requiring gonadectomy to change legal sex, percentages of people undergoing gonadectomy decreased in AMAB and AFAB., Clinical Implications: A substantial number of adolescents did not start medical treatment. In the ones who did, risk for retransitioning was very low, providing ongoing support for medical interventions in comprehensively assessed gender diverse adolescents., Strengths and Limitations: Important topics on transgender health care for children and adolescents were studied in a large cohort over an unprecedented time span, limited by the retrospective design., Conclusion: Trajectories in diagnostic evaluation and medical treatment in children and adolescents referred for gender dysphoria are diverse. Initiating medical treatment and need for surgical procedures depends on not only personal characteristics but societal and legal factors as well., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine.)

Ashley's response to our recent paper argues that a fuller appreciation of the available clinical data, of the rights of children to autonomy, and of the primary purpose of gender-affirming endocrine treatment supports the rejection of both the pathway and consent dilemmas for the treatment of gender dysphoria, as raised in this journal. In this response, we highlight certain misrepresentations of our argument, and defend our conclusions against Ashley's main objections., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Anterior glottoplasty is a commonly used treatment for voice feminization. But it remains in dispute over whether to suture of the ligament as part of the procedure., Objectives: This study aimed to explore the effect of inclusion of the vocal lamina propia., Material and Methods: Anterior webs were created in 8 excised canine larynges by sutures placed at 10%, 20%, and 30% of the vocal fold length, respectively. The suture depth was divided into two groups: epithelium layer (Shallow Suture, SS group) and deep layers of vocal fold lamina propia (Deep Suture, DS group)., Results: For anterior webs between 0% and 30%, the frequency elevation ranged from 3% to 151% of the pre-web fundamental frequency (fo) in SS group and from 13% to 222% in DS group. No significance was found between two groups at three different sutures ( p  = .486 for suture at 10% of vocal fold length, 0.686 for 20%, 0.886 for 30%, respectively)., Conclusions and Significance: The frequency in excised canine larynx increased continuously as the anterior glottic webs ranged from 0% to 30%. The inclusion of the vocal fold lamina propia does not affect the frequency elevation.

The present study aimed to determine the semen quality and cryopreservation outcomes among adolescent transgender females at the time of fertility preservation (FP) before initiating gender-affirming hormone (GAH) treatment. This retrospective cohort study included 26 adolescent transgender females who underwent FP in our Fertility Institute between 06/2013 and 10/2020. Pre-freezing semen parameters were compared to WHO 2010 reference values. Post-thaw semen parameters were used to determine the adequate assisted reproductive technology (ART). A multivariate linear regression analysis was performed to assess the impact of medical and lifestyle factors on semen quality. The mean age at which adolescent transgender females underwent FP was 16.2 ± 1.38 years. The median values of all semen parameters in our study group were significantly lower compared to the WHO data, including volume (1.46 mL vs 3.2 mL, respectively, P = 0.001 ), sperm concentration (28 × 10 6 /mL vs 64 × 10 6 /mL, P < 0.001), total sperm number (28.2 × 10 6 vs 196 × 10 6 , P < 0.001), total motility (51.6% vs 62%, P < 0.001), and normal morphology (2% vs 14%, P < 0.001). The frequency of semen abnormalities was teratozoospermia 72%, hypospermia 52%, oligozoospermia 28%, and azoospermia 4%. The median post-thaw total motile count was 0.17 × 10 6 /vial, and the quality was adequate only for ICSI in 87.7% of the thawed semen samples. No correlation was found between selected medical and lifestyle factors and poor semen parameters. Semen quality is strongly reduced among adolescent transgender females before hormone therapy and their stored sperm samples are suitable for intracytoplasmic sperm injection (ICSI) rather than conventional IVF/intrauterine insemination (IUI)., (© 2021. Society for Reproductive Investigation.)

The inclusion of transwomen into elite female sport has been brought into question recently with World Rugby banning transwomen from the elite female competition, aiming to prioritise safety over fairness and inclusion, citing the size, force and power-producing advantages conferred to transwomen. The same question is being asked of all Olympic sports including non-contact sports such as archery and shooting. As both these Olympic sports are the polar opposite to the contact sport of rugby in terms of the need to consider the safety of athletes, the IF of both archery and shooting should consider the other elements when deciding the integration of trans individuals in their sports. Studies on non-athletic transwomen have reported muscle mass and strength loss in the range of 5-10% after 1 year of their transition, with these differences no longer apparent after 2 years. Therefore, based on the current scientific literature, it would be justified for meaningful competition and to prioritise fairness, that transwomen be permitted to compete in elite archery after 2 years of GAT. Similarly, it would be justified in terms of shooting to prioritise inclusion and allow transwomen after 1 year of GAT given that the only negligible advantage that transwomen may have is superior visuospatial coordination. The impact of this considered integration of transwomen in elite sports such as archery and shooting could be monitored and lessons learned for other sports, especially where there are no safety concerns from contact with an opponent.

Transgender people may choose to affirm their gender identity with gender-affirming hormone therapy (GAHT) and/or gender-affirming surgery (GAS). The effects of GAHT and GAS on sexual health in transgender people have not been well elucidated. This systematic review aimed to appraise the current scientific literature regarding sexual desire, arousal, orgasm, pain, and satisfaction in transmen and transwomen before, during, and after gender transition. Overall, sexual dysfunction is common in both transmen and transwomen. GAHT and GAS may help to improve sexual satisfaction. More studies that focus on sexual health in the transgender population are urgently needed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Empirical evidence concerning the psychosocial health outcomes after puberty suppression and gender-affirming (GA) medical interventions of adolescents with gender dysphoria (GD) is scarce. The aim of the present study was to describe how dimensions of psychosocial health were distributed among different intervention groups of adolescents with a GD diagnosis from the Hamburg Gender Identity Service before and after treatment. Participants included n = 75 adolescents and young adults from a clinical cohort sample, measured at their initial intake and on average 2 years later (M treatment duration = 21.4 months). All cases were divided into four different intervention groups, three of which received medical interventions. At baseline, both psychological functioning and quality of life scores were significantly below the norm mean for all intervention groups. At follow-up, adolescents in the gender-affirming hormone (GAH) and surgery (GAS) group reported emotional and behavioral problems and physical quality of life scores similar to the German norm mean. However, some of the psychosocial health outcome scores were still significantly different from the norm. Because this study did not test for statistically significant differences between the four intervention groups or before and after treatment, the findings cannot be generalized to other samples of transgender adolescents. However, GA interventions may help to improve psychosocial health outcomes in this sample of German adolescents. Long-term treatment decisions during adolescence warrant careful evaluation and informed, participatory decision-making by a multidisciplinary team and should include both medical interventions and psychosocial support. The present study highlights the urgent need for further ongoing longitudinal research., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Large-scale brain network interactions have been described between trans- and cis-gender binary identities. However, a temporal perspective of the brain's spontaneous fluctuations is missing. We investigated the functional connectivity dynamics in transmen with gender incongruence and its relationship with interoceptive awareness. We describe four states in native and meta-state spaces: (i) one state highly prevalent with sparse overall connections; (ii) a second with strong couplings mainly involving components of the salience, default, and executive control networks. Two states with global sparse connectivity but positive couplings (iii) within the sensorimotor network, and (iv) between salience network regions. Transmen had more dynamical fluidity than cismen, while cismen presented less meta-state fluidity and range dynamism than transmen and ciswomen. A positive association between attention regulation and fluidity and meta-state range dynamism was found in transmen. There exist gender differences in the temporal brain dynamism, characterized by distinct interrelations of the salience network as catalyst interacting with other networks. We offer a functional explanation from the neurodevelopmental cortical hypothesis of a gendered-self., (© 2021. The Author(s).)

Objective: The rare condition 46, XY disorders of sex development (DSDs) is characterized by the female phenotype and male karyotype. We aimed to describe the genetic basis of 46, XY DSDs in nine patients and the genotype-phenotype relationships of the genes involved., Methods: Targeted next-generation sequencing (NGS) was used to analyze the underlying hereditary etiology in nine female patients with 46, XY DSDs. In silico analyses were used to predict the effects of novel variants on the protein function of the identified genes., Results: Primary amenorrhea with the absence of puberty, inguinal hernia, and clitoridauxe were common complaints. All enrolled patients had a differential etiology by genetic testing, and five novel genetic variants involved in four genes ( SRY , AR , NR5A1 , and LHCGR ) were identified. A novel nonsense variant of SRY c.51C > G was found in XY patients without testicles. Two novel heterozygous variants, i.e. c.265A > T (Ile89Leu) and c.422T > C (Val141Ala), of the LHCGR gene were found in male pseudo-hermaphroditism., Conclusions: We expanded the genetic mutation spectrum and described in detail the genotype-phenotype relationships of 46, XY DSDs. DNA sequencing for SRY should be a priority in female patients with 46, XY DSDs. NGS is useful for clarifying genetic pathogenesis and could provide a basis for clinical diagnosis and treatments of patients with 46, XY DSDs.

The medical profession is deeply involved in designating and amending the sex designations on legal records that themselves are not used clinically. The assumptions inherent in the current legal sex designation system and the criteria for amending such are being reexamined. The harms of the current legal sex designation system, especially for transgender people, have become increasingly recognized. Consequently, the appropriateness of the health care professional's participation in recording legal sex designations has been called into question. Herein, we describe the medicolegal challenges surrounding legal sex designations and their potential solutions., (Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Research Question: What are the hormonal and ovarian histological effects of a gender affirming hormonal therapy in assigned female at birth (AFAB) transgender people?, Design: Prospective observational study of 70 AFAB transgender people taking testosterone therapy before gender-affirming surgery (hystero-oophorectomy). A gynaecological ultrasonographic scan was undertaken and serum hormone concentrations measured, including anti-Müllerian hormone (AMH) and androgenic profile. Histological ovarian evaluation was assessed in both ovaries, including the developmental stages of the follicles., Results: The mean age of the population was 27.7+/-5.14 years. The main biochemical parameters were total testosterone levels 781.5 ± 325.9 ng/dl; AMH levels 3.2 ± 1.4 ng/ml; FSH and LH levels 4.9 ± 2.5 IU/l and 3.9 ± 2.9 IU/l, respectively; and oestradiol values 47.6 ± 13.7 pg/ml. Fifty-five AFAB underwent gynaecological ultrasound before surgery and antral follicles were found in 43 out of 47 ultrasounds (91.5%) (without the presence of a dominant follicle or corpus luteum). Histological follicles were mostly in the primordial stage (88.0) and 3.3% were atretic. The thickness of the tunica albuginea was widely heterogeneous (range 0.15-1.45 mm) and luteinization of the stromal cells was observed in 68.6% of the samples. A negative correlation between testosterone levels and total antral follicles was found (R s = -0.306, P = 0.029)., Conclusions: AFAB transgender people taking testosterone therapy show cortical follicle distribution in the range previously reported in fertile cisgender women of reproductive age. The follicular population may not be altered as a result of the gender-affirming hormonal therapy, although some cortical and stromal changes have been observed., (Copyright © 2021 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: The authors report no conflicts of interest.

Background and Objectives: The progression of gender-expansive behavior to gender dysphoria and to gender-affirming hormonal treatment (GAHT) in children and adolescents is poorly understood., Methods: A cohort of 958 gender-diverse (GD) children and adolescents who did not have a gender dysphoria-related diagnosis (GDRD) or GAHT at index were identified. Rates of first GDRD and first GAHT prescription were compared across demographic groups., Results: Overall, 29% of participants received a GDRD and 25% were prescribed GAHT during the average follow-up of 3.5 years (maximum 9 years). Compared with youth assigned male sex at birth, those assigned female sex at birth were more likely to receive a diagnosis and initiate GAHT with hazard ratio (95% confidence interval) estimates of 1.3 (1.0-1.7), and 2.5 (1.8-3.3), respectively. A progression to diagnosis was more common among those aged ≥15 years at initial presentation compared with those aged 10 to 14 years and those aged 3 to 9 years (37% vs 28% vs 16%, respectively). By using the youngest group as a reference, the adjusted hazard ratios (95% confidence interval) for a GDRD were 2.0 (1.3-3.0) for age 10 to 14 years and 2.7 (1.8-3.9) for age ≥15 years. Racial and ethnic minorities were less likely to receive a diagnosis or be prescribed GAHT., Conclusions: This study characterized the progression of GD behavior in children and adolescents. Less than one-third of GD youth receive an eventual GDRD, and approximately one-quarter receive GAHT. Female sex at birth, older age of initial GD presentation to medical care, and non-Hispanic white race and ethnicity increased the likelihood of receiving diagnosis and treatment., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Objectives/hypothesis: The need for gender-affirming voice care has been increasing in the transgender population in the last decade. Currently, objective treatment outcome measurements are lacking to assess the success of these interventions. This study uses neural network models to predict binary gender from short audio samples of "male" and "female" voices. This preliminary work is a proof-of-concept for further work to develop an AI-assisted treatment outcome measure for gender-affirming voice care., Study Design: Retrospective cohort study., Methods: Two hundred seventy-eight voices from male and female speakers from the Perceptual Voice Qualities Database were used to train a deep neural network to classify voices as male or female. Each audio sample was mapped to the frequency domain using Mel spectrograms. To optimize model performance, we performed 10-fold cross validation of the entire dataset. The dataset was split into 80% training, 10% validation, and 10% test., Results: Overall accuracy of 92% was obtained, both when considering the accuracy per spectrum and per patient metric. The accuracy of the model was higher for recognizing female voices (F1 score of 0.94) compared to male voices (F1 score of 0.87)., Conclusions: This proof of concept study shows promising performance for further development of an AI-assisted tool to provide objective treatment outcome measurements for gender affirming voice care., Level of Evidence: 3 Laryngoscope, 131:E1611-E1615, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objective: Understanding transgender voice is in nascent stages. This study describes voice characteristics in treatment-seeking trans women by comparing two validated questionnaires-Voice Handicap Index-10 (VHI-10) and Transsexual Voice Questionnaire (TVQ MtF )-and reports incidence of abnormal stroboscopy findings and acoustic characteristics., Methods: Retrospective review of transgender patients presenting to tertiary-care laryngology center between February 2018-February 2019. Mean VHI-10, TVQ, and Singing VHI-10 (SVHI-10) scores; audio-perceptual grade; acoustic measures; and stroboscopy findings were analyzed. VHI-10 and SVHI-10 vs TVQ MtF were compared., Results: Sixty-one trans female patients (mean age: 32 ± 11 years) were analyzed. Mean duration since start of transition was 41.5 ± 61 months. Sixty-nine percent presented full-time female in all contexts. Pathologic stroboscopy findings were found in 5%. Mean questionnaire scores were 16 ± 10 (VHI-10), 19 ± 13 (SVHI-10), and 81 ± 22 (TVQ MtF ). Correlation between VHI-10 and SVHI-10 versus TVQ MtF was weak, R = 0.47 (P = .053) and R = 0.35 (P = .17), respectively. Mean audio-perceptual grade was 0.27 ± 0.15. Mean Cepstral Spectral Index of Dysphonia (CSID, sustained vowel) was 8.5 ± 21.9. Mean Cepstral Peak Prominence (CPP) Fo and CPP Fo SD in rainbow passage were 157.3 ± 16 and 59.4 ± 15.9, respectively., Conclusion: Trans women report perceived voice handicap in speaking and singing, which appears separate from gender-related voice/communication concerns. This study is the first to report stroboscopy findings in transgender individuals, with 5% being abnormal. Stroboscopy is encouraged before initiating voice intervention in transgender patients. Preliminary evaluation suggests weak correlation between VHI-10 or SVHI-10 and TVQ MtF but requires further investigation. TVQ MtF may provide information which more specifically reflects voice concerns of trans women as compared to VHI-10 and SVHI-10., Level of Evidence: 4 Laryngoscope, 131:1071-1077, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Young transgender people increasingly seek medical help to assist them in their gender transition with hormone therapy and/or sex reassignment surgery. However, these treatments limit fertility and may make them irreversibly infertile. Studies show that the transgender population wishes to have biological children and, to help them achieve this desire for parenthood, there are techniques for preserving fertility, such as cryopreservation of gametes, embryos and ovarian or testicular tissue. However, alongside these techniques, there are ethical issues and several challenges before, during and after these procedures, that may lead young transgender people to reject these methods of preserving fertility. In conclusion, health professionals should be informed about all these dynamics between gender transition therapies and their impact on fertility, in order to better guide these individuals in their decision., (Copyright © 2019 Asociación Española de Andrología, Medicina Sexual y Reproductiva. Publicado por Elsevier España, S.L.U. All rights reserved.)

Reduction in unwanted facial and body hair is an important goal in the process of sex reassignment. Laser treatment is a popular, well-established safe and effective method of reducing unwanted hair growth. In the UK a limited number of laser treatment and electrolysis sessions are publically funded for people undergoing sex reassignment. To date, published evidence on efficacy and adverse effects (AEs) has focused on treatment of women and men not undergoing sex reassignment. In the current study, data were collected prospectively from 2015 to 2020 at a UK regional laser centre. Patients were included if they were transgender women aged > 16 years old and seeking laser treatment for unwanted hair at any body site. The study demonstrated significant reductions in hair growth and significant patient satisfaction, with no AEs. Laser treatment is a safe and effective method of managing unwanted hair growth in the transgender transfeminine population., (© 2020 British Association of Dermatologists.)

Abstract: An estimated 150,000 youth and 1.4 million adults living in the United States identify as transgender. This Committee Opinion offers guidance on providing inclusive and affirming care as well as clinical information on hormone therapy and preventive care; it also cites existing resources for those seeking information on the care of transgender adolescents. The social and economic marginalization of transgender individuals is widespread, which leads to health care inequities and poorer health outcomes for this population. To reduce the inequities experienced by the transgender community, the provision of inclusive health care is essential. Obstetrician-gynecologists should strive to make their offices open to and inclusive for all individuals and should seek out education to address health care disparities, both in their individual practices and in the larger health care system. In order to provide the best care for patients, it is useful to know which health care professionals to include in a referral network for primary care and to have many clinician and surgeon options given the many different therapies available and the different sites at which these therapies are offered. It is important to remember that although hormone therapy is a medically necessary treatment for many transgender individuals with gender dysphoria, not all transgender patients experience gender dysphoria and not everyone desires hormone treatment. Gender-affirming hormone therapy is not effective contraception. Sexually active individuals with retained gonads who do not wish to become pregnant or cause pregnancy in others should be counseled about the possibility of pregnancy if they are having sexual activity that involves sperm and oocytes. Although being knowledgeable about the medications used for gender transition and potential risks and side effects is important, specific certification for prescribing them is not required and should not be a limiting factor in helping patients access care., Competing Interests: All ACOG committee members and authors have submitted a conflict of interest disclosure statement related to this published product. Any potential conflicts have been considered and managed in accordance with ACOG’s Conflict of Interest Disclosure Policy. The ACOG policies can be found on acog.org. For products jointly developed with other organizations, conflict of interest disclosures by representatives of the other organizations are addressed by those organizations. The American College of Obstetricians and Gynecologists has neither solicited nor accepted any commercial involvement in the development of the content of this published product., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Ovarian adrenal rest tumors (OART) are tumors that develop in females with congenital adrenal hyperplasia (CAH). In contrast to their counterpart in testicles, they are exceptional and few cases have been reported in the literature. In this report, we present clinicopathological findings of a female patient with CAH due to 21-hydroxylase deficiency who was incidentally diagnosed with OART with a review of the literature. The 14-year-old patient, who was raised as a boy, developed a virilizing syndrome with high testosterone levels that were attributed to non adherence to her replacement corticosteroid therapy. She consulted for sex reassignment surgery. Pelvic ultrasound was normal. She underwent hysterectomy and bilateral adnexectomy. No abnormalities were noticed during the operation. Grossly, both ovaries were variegated with well circumscribed and lobulated, brownish-yellow nodules. Histologically, the nodules were composed of nests of large polygonal cells with centrally located nuclei and prominent nucleoli. There was mild atypia and no crystals of Reinke. Thus, the findings of the histopathological examination were consistent with bilateral OART. Histological differential diagnosis of OART can be challenging particularly with leydig cell tumor, stromal luteoma and steroid cell tumors, not otherwise specified. OART must be considered in women with CAH and persistent virilizing symptoms despite negative imaging results.

Transgender and gender nonconforming (TGNC) individuals face significant marginalization, stigma, and discrimination. Under-reporting of TGNC individuals is common since they are often unwilling to self-identify. Meanwhile, the rapid adoption of electronic health record (EHR) systems has made large-scale, longitudinal real-world clinical data available to research and provided a unique opportunity to identify TGNC individuals using their EHRs, contributing to a promising routine health surveillance approach. Built upon existing work, we developed and validated a computable phenotype (CP) algorithm for identifying TGNC individuals and their natal sex (i.e., male-to-female or female-to-male) using both structured EHR data and unstructured clinical notes. Our CP algorithm achieved a 0.955 F1-score on the training data and a perfect F1-score on the independent testing data. Consistent with the literature, we observed an increasing percentage of TGNC individuals and a disproportionate burden of adverse health outcomes, especially sexually transmitted infections and mental health distress, in this population., (©2020 AMIA - All rights reserved.)