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Magnus Hirschfeld was a brilliant German doctor campaigning for the decriminalization and destigmatization of homosexuality. During the very liberal Weimar Republic (1918-1933) he published his avant-garde articles, he created his Institute of Sexual Sciences (Institut für Sexualwissenschaft), where the first published transgender surgery took place, performed on Dora Richter in 1931 (we will be interested in this first report of successful intervention) and multiplied the interventions to abolish paragraph 175, penalizing "sodomy". Ultimately the rise of Nazism forced him to flee his country and end his life in France. Hirschfeld's work remained unfinished. His political activism and his over-media coverage earned him numerous criticisms even within the gay and lesbian movement of the time. Who was this strange doctor (the Einstein of sex, as an American promoter presented him during his conferences in 1930) who combined the faults, for the time, of being at the same time Jewish, homosexual and leftist?, (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objective: To examine the temporal relationship between the anti-discrimination rules of the Affordable Care Act, which took full effect in 2017, and the incidence of commercial claims for gender-affirming care, as well as cost sharing for these services., Methods: We used a previously described algorithm to define a cohort of gender-diverse adults in the MarketScan Commercial Claims and Encounters Database. Claims for gender-affirming medical and surgical care were identified using International Classification of Diseases and Current Procedural Terminology codes plus pharmacy data; the annual incidence of surgical claims was calculated. Interrupted time series analyses were used to evaluate the temporal relationship between claims and anti-discrimination legislation. Claims data were also used to evaluate the patient contribution towards services., Results: There were 70,733 gender-diverse adults included in the study and 36,702 (51.9%) of them filed claims for gender-affirming care. The incidence of persons with claims for gender-affirming surgery increased from 0.002% in 2009 to 0.012% in 2021. Interrupted time series analyses demonstrated a greater year-to-year increase in claims after anti-discrimination policy influences took effect. This change was greatest for transmasculine chest procedures. The median lifetime net payment for gender-affirming surgery was $12,429.10 and cost sharing was $1019.20 (8.6%)., Conclusion: Commercial claims for gender-affirming surgery increased temporally with respect to implementation of anti-discrimination legislation and cost-sharing was reasonably low. However, many gender-diverse persons did not have claims for gender-affirming care, which may indicate continued out-of-pocket payment for these services., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite established medical necessity, laws prohibiting coverage discrimination, and increasing numbers of transgender and gender-diverse patients seeking gender-affirming surgery (GAS), cost and restrictive insurance policies continue to be the most common barriers. As recent legislation places further restrictions on GAS, this study aimed to provide an updated review of insurance policies and assess the relationship between legislative favorability and coverage., Methods: Insurance policies of groups representing 80% market coverage in each state were collected for gender-affirming chest, genital, and facial surgery. Policies were categorized based on previously published methodologies: never-covered, case-by-case, and preauthorization. The relationship between established scores of legislative favorability and policy coverage in each state was analyzed and compared across regions., Results: Of the 316 analyzed policies, coverage was preauthorized most often for genital (94.0%), masculinizing top (93%), feminizing top (74%), and facial reconstruction (24%). Higher legislative scores in the Northeast and West, and individual states were predictive of increased genital, facial, and all forms of adolescent GAS, but were not correlated to chest GAS., Conclusions: Compared with previous studies, our findings suggest that there is a growing acceptance of GAS as medically necessary. However, the correlation between legislative scores and genital, face, and adolescent GAS coverage may suggest increased reliance on sociopolitical factors for access in the absence of comprehensive medical guidelines, which are more established for chest reconstruction. Significantly higher coverage of masculinizing versus feminizing chest surgery suggests additional burden of proof for GAS with a cosmetic overlap., (Copyright © 2023 by the American Society of Plastic Surgeons.)

The present study sought to analyze malpractice cases related to gender affirming surgery to provide information to physicians as it may serve to minimize the risk of malpractice suits. The Westlaw and Lexis Nexis databases were queried for jury verdicts and settlements related to gender affirming surgery malpractice lawsuits. A total of 26 cases were identified between 1970 and 2020, five of which were determined relevant on further review. Motives included adverse surgical and medical outcomes, and failure to treat. All cases were decided in favor of the defendant and resulted in $0 compensatory damages., Competing Interests: Conflict of Interest This study did not receive any funding and none of the authors have no conflicts of interest to disclose. None of the authors has a financial interest in any of the products, devices, or drugs., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The traditional gender binary constitutes an integral aspect of Islamic social ethics, which has a pivotal role in shaping religious obligations, legal proceedings, and interpersonal judgments within Muslim communities. Within the familial sphere, this gender binary underscores fundamental responsibilities encompassing parenthood, filial duties, and inheritance rights. Recent years have witnessed a growing challenge to the traditional concept of the gender binary within Islamic societies. This shift is driven by increasing social libertarianism that emphasizes gender fluidity and individual choice. Hence, this article aims to critically scrutinize evolving discussions and controversies about the rights of intersex and transgender individuals, particularly issues relating to sex reassignment or gender-affirming surgery, marriage, and reproduction, from the perspective of the Sunni tradition of Islam. To support the various interpretations and insights presented here, a comprehensive and rigorous analysis is carried out on various religious texts and scholarly sources to elucidate the theological and jurisprudential positions on gender issues. It is thus concluded that Shariah offers greater flexibility in the treatment of intersex individuals compared to those with gender dysphoria because the intersex condition is viewed as a physical impairment that is not the choice of the afflicted individual. By contrast, in the case of individuals with gender dysphoria, they are willfully attempting to change their recognized biological sex, that God had naturally given to them at birth. Therefore, it is recommended that such transgender individuals deserve respectful psychological and social rehabilitation with help and guidance from religious authorities, their families, and communities., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Importance: Gender-affirming surgery is often beneficial for gender-diverse or -dysphoric patients. Access to gender-affirming surgery is often limited through restrictive legislation and insurance policies., Objective: To investigate the association between California's 2013 implementation of the Insurance Gender Nondiscrimination Act, which prohibits insurers and health plans from limiting benefits based on a patient's sex, gender, gender identity, or gender expression, and utilization of gender-affirming surgery among California residents., Design, Setting, and Participants: Population epidemiology study of transgender and gender-diverse patients undergoing gender-affirming surgery (facial, chest, and genital surgery) between 2005 and 2019. Utilization of gender-affirming surgery in California before and after implementation of the Insurance Gender Nondiscrimination Act in July 2013 was compared with utilization in Washington and Arizona, control states chosen because of geographic similarity and because they expanded Medicaid on the same date as California-January 1, 2014. The date of last follow-up was December 31, 2019., Exposures: California's Insurance Gender Nondiscrimination Act, implemented on July 9, 2013., Main Outcomes and Measures: Receipt of gender-affirming surgery, defined as undergoing at least 1 facial, chest, or genital procedure., Results: A total of 25 252 patients (California: n = 17 934 [71%]; control: n = 7328 [29%]) had a diagnosis of gender dysphoria. Median ages were 34.0 years in California (with or without gender-affirming surgery), 39 years (IQR, 28-49 years) among those undergoing gender-affirming surgery in control states, and 36 years (IQR, 22-56 years) among those not undergoing gender-affirming surgery in control states. Patients underwent at least 1 gender-affirming surgery within the study period in 2918 (11.6%) admissions-2715 (15.1%) in California vs 203 (2.8%) in control states. There was a statistically significant increase in gender-affirming surgery in the third quarter of July 2013 in California vs control states, coinciding with the timing of the Insurance Gender Nondiscrimination Act (P < .001). Implementation of the policy was associated with an absolute 12.1% (95% CI, 10.3%-13.9%; P < .001) increase in the probability of undergoing gender-affirming surgery in California vs control states observed in the subset of insured patients (13.4% [95% CI, 11.5%-15.4%]; P < .001) but not self-pay patients (-22.6% [95% CI, -32.8% to -12.5%]; P < .001)., Conclusions and Relevance: Implementation in California of its Insurance Gender Nondiscrimination Act was associated with a significant increase in utilization of gender-affirming surgery in California compared with the control states Washington and Arizona. These data might inform state legislative efforts to craft policies preventing discrimination in health coverage for state residents, including transgender and gender-diverse patients.

Purpose: Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people., Methods: According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board., Results: In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care., Conclusion: In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification., (© 2021. Italian Society of Endocrinology (SIE).)

There is an increased demand for gender affirmation surgery. Chest contouring, or "top" surgery, is especially important in the female-to-male (FtM) transgender population. This Continuing Medical Education (CME) article critically appraises the available literature on top surgery to allow plastic surgeons to understand current practices and determine the best surgical technique using a decision algorithm and the patient's preoperative anatomy and characteristics. Because a single best surgical approach does not exist due to significant variance in preoperative patient anatomy, and in order to provide a useful framework for decision making, surgical approaches described are categorized as: approach 1-remote incision procedures without skin excision; approach 2-procedures with periareolar skin excision; and approach 3-mastectomy procedures with skin excision other than periareolar skin excision. Decision algorithms that help determine the most suitable surgical technique for individual patients are reviewed. Data on complication rates and patient satisfaction will improve informed consent discussions and create realistic patient expectations.

Introduction: The access to sex-reassignment surgery is based on the existence of an unequivocal dyscrasia between the morphological sex and the objective evidence that emerges from in-depth analysis of the individual's personality. In Italy, such type of surgical intervention is subject to the authorization of a judge., Material of Study: Authors examine the recent Italian Constitutional judgement which has addressed the right to change legal sex status without the need for sex-reassignment surgery., Discussion: The Italian approach is in line with scientific evidence that the physical and mental well-being of an individual does not always require the surgical rectification of primary sexual features. Thus, sex reassignment surgery is not to be considered mandatory; rather, it should be aimed at ensuring the transsexual individual's stable psychological and physical good. From an ethical point of view, the Court's decision is very important, since it does not subordinate such fundamental rights as gender identity, healthcare and equality to prior, highly invasive surgery., Conclusions: The authors point out that critical issues and obstacles to the full implementation of the right to gender identity remain, in that this right is still subject to the authorization of a judge. This approach does not seem to be in line with the recent World Health Organization (WHO) decision to remove the "gender incongruity" from the list of mental and behavioural disorders (as it is in the current International Classification of Diseases-10, so far), to decrease the stigma surrounding such a condition., Key Words: Gender identity, Sex reassignment, Surgery, Stigma, Transsexualism, Transgender.

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

Dramatic increase of gender dysphoria in youth In the past decade there has been a dramatic increase in the number of young people with gender dysphoria seeking help for gender-confirming medical interventions. From a situation of no more than a few patients annually, there were almost 200 referrals of gender dysphoria to the Astrid Lindgren Children's Hospital in 2016. This child and adolescent psychiatric unit has the whole country as a catchment area for patients <16 years. Gender-confirming medical interventions are regulated by a special law that sets a minimum age for legal and surgical gender reassignment to 18 years. The law, which is under revision, does not prevent medical investigations, hormonal therapy, and some surgical procedures before the age of 18. Gender dysphoria is defined as a persistent desire to live and be accepted as the opposite sex, usually accompanied by a perceived inconsistency with the sex assigned at birth and a desire to change the body in accordance with the perceived sex. The cause is unknown despite attempts of etiological mapping including genetic analyses, hormonal studies and modern brain imaging techniques. Repeated studies have shown that only a minority (about 20 %) of prepubertal children with gender dysphoria will have a persistent desire for later gender-confirming medical interventions, while the majority of those whose gender dysphoria is reinforced during puberty will later meet the diagnostic criteria for gender dysphoria (DSM-5) and transsexualism (ICD-10) (so called persisters). Persisters can be offered treatment with puberty stopping hormones to avoid the development of undesirable secondary sexual characteristics. Gender-confirming medical interventions are the only recommended treatment for gender dysphoria, and early treatment facilitates the ability to successfully pass in the desired sex, which is associated with a significantly better prognosis.

Transgender women (TGW) face compounded levels of stigma and discrimination, resulting in multiple health risks and poor health outcomes. TGW identities are erased by forcing them into binary sex categories in society or treating them as men who have sex with men (MSM). In Malaysia, where both civil and religious law criminalise them for their identities, many TGW turn to sex work with inconsistent prevention methods, which increases their health risks. This qualitative study aims to understand how the identities of TGW sex workers shapes their healthcare utilisation patterns and harm reduction behaviours. In-depth, semi-structured interviews were conducted with 21 male-to-female transgender (mak nyah) sex workers in Malaysia. Interviews were transcribed, translated into English, and analysed using thematic coding. Results suggest that TGW identity is shaped at an early age followed by incorporation into the mak nyah community where TGW were assisted in gender transition and introduced to sex work. While healthcare was accessible, it failed to address the multiple healthcare needs of TGW. Pressure for gender-affirming health procedures and fear of HIV and sexually transmitted infection screening led to potentially hazardous health behaviours. These findings have implications for developing holistic, culturally sensitive prevention and healthcare services for TGW.

Legal disputes over coverage of transgender-related care may become a source of tension for Catholic health systems and other employees.

In YY v Turkey, the Second Chamber of the European Court of Human Rights (ECtHR) held that Turkey's refusal, over a period of many years, to authorise gender confirmation surgery because the applicant remained capable of procreating was a violation of the right to private life under Art. 8 of the European Convention on Human Rights. The Second Chamber's judgment acknowledges, and gives practical effect to, the 'physical and moral security' of transgender persons. YY has the potential to revolutionise gender confirming health care in Europe and will hopefully ensure that, where individuals do seek to medically transition, they need only access to treatments that are both necessary and desired. The ECtHR's decision may also impact upon the legal recognition of transgender identities. While not the direct focus of the Second Chamber's assessment, legal gender recognition is a constant theme throughout the judgment, and many of the Court's arguments are equally applicable to legal schemes for acknowledging preferred gender., (© The Author 2015. Published by Oxford University Press; all rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Do transsexual people in Chile have a right to have their gender identity or their sex reassignment legally recognized? The absence of any legislation on gender identity or transsexualism could lead us to believe that it is not the case. However, a quantitative review of decisions issued by Chilean courts during the last years on name-and sex-change requests filed by transsexual people reveals that most of these courts have accepted these requests. From the perspective of the well-being of transsexual people, this is a positive result. However, the fact that a few rejections exist reminds us of the need to enact an explicit legislation in this issue. Lastly, a qualitative analysis of those decisions suggests that the traditional reluctance of courts to interpret the law in a creative way has been overcome in these cases by the use of knowledge and discourses belonging to healthcare sciences. This is an example of an epistemological complementariness between medicine and law.

In recent years the Australian parliament has been considering the rights to protection from discrimination of intersex and gender identity disorder (GID) people. In 2013 such protections were made law in the amendment to the Sex Discrimination Act 1984, which in turn has influenced Senate inquiries into the medical treatment of intersex people. This year's Australian report describes the purview and the potential ramifications of the inquiry of the Senate Standing Committees on Community Affairs, published in October 2013, into the involuntary or coerced sterilization of intersex people in Australia.

This paper reviews the development of gender reassignment in Thailand during the period of 1975-2012, in terms of social attitude, epidemiology, surgical patients' profile, law and regulation, religion, and patients' path from psychiatric assessment to surgery. Thailand healthcare for transsexual patients is described. Figures related to the number of sex reassignment surgeries performed in Thailand over the past 30 years are reported. Transsexual individuals are only apparently integrated within the Thail society: the law system of Thailand in fact, does not guarantee to transsexuals the same rights as in other Western countries; the governmental healthcare does not offer free treatments for transsexual patients. In favor of the transsexual healthcare, instead, the Medical Council of Thailand recently published a policy entitled "Criteria for the treatment of sex change, Census 2009." The goal of this policy was to improve the care of transsexual patients in Thailand, by implementing the Standards of Care of the World Professional Association of Transgender Health. Currently, in Thailand, there are 6 major private groups performing sex reassignment surgery, and mostly performing surgery to patients coming from abroad. Particularly, the largest of these (Preecha's group) has performed nearly 3000 vaginoplasties for male-to-female transsexuals in the last 30 years.

Transsexual subjects are individuals who have a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with one's preferred sex. They seek to develop the physical characteristics of the desired gender, and should undergo an effective and safe treatment regimen. The goal of treatment is to rehabilitate the individual as a member of society in the gender he or she identifies with. Sex reassignment procedures necessary for the treatment of transsexual patients are allowed in our country, at Medical Services that have a multidisciplinary team composed of a psychologist, a social worker, a psychiatrist, an endocrinologist and surgeons (gynecologists, plastic surgeons, and urologists). Patients must be between 21 to 75 years old and in psychological and hormonal treatment for at least 2 years. Testosterone is the principal agent used to induce male characteristics in female transsexual patients, and the estrogen is the chosen hormone used to induce the female sexual characteristics in male transsexual patients. Based on our 15 years of experience, we can conclude that testosterone and estradiol treatment in physiological doses are effective and safe in female and male transsexual patients, respectively.

Gender alignment surgery was introduced into German law in 1981. Judicial guidelines for the change of first names and gender were established and transsexuality was labelled as a psychosomatic and somatopsychic syndrome and disorder, thus opening the way for treatment to the social health-care under well-defined conditions requesting cross-dressing and hormone therapy as well as psychological counselling by 2 independent psychologists or psychiatrists. In a retrospective, chart-related survey of questionnaires on male to female transsexuals it was found that patients start to suspect being born into the wrong gender at the onset of puberty, it takes them however approximately 20 years to have gender alignment surgery. More than half the patients are single at this time, while the remaining group is married or divorced with equal rates. 68% regard themselves as heterosexual, 21% lesbian and 11% were undecided. About half the patients experienced support by their families for their decision. Despite numerous secondary corrections of the surgical alignment, patients were content with the result, although emotional acceptance of the desired result took about one year. In general plastic surgical gender alignment treatment was perceived as the major contribution to harmonise their phenotype with their identity., (© Georg Thieme Verlag KG Stuttgart · New York.)

Treatment of ambiguous genitalia has reached high standards. Damage caused by the anomaly can be reduced significantly or eliminated. In a well-defined minority definite early sex assignment is not possible but preliminary, and surgical genital correction therefore is delayed. Poor results and continuous misunderstandings regarding the nature of intersex caused strong opposition from activist groups against all forms of early diagnosis, sex assignment and surgical treatment. Supported by psychologists and the media, jurisdictional actions are underway trying to change the law and prevent parents from allowing treatment of their children. In addition, institution of a moratorium has been requested to stop genital surgery on children and to establish a third sex of hermaphrodites. All this led to irritations and insecurity concerning treatment and legal risk.Analysis of the current medical situation and the laws concerning the subject reveal that there is no alternative to early sex assignment and treatment, with the exemption of a very small, but defined group. At this moment, there is no realistic legal possibility to remove the right from parents to decide for their children, create a new sex and solve problems of intersex patients by pushing them into"hermaphroditism". This would be a decision against their and their parents' will, in a society which is based on male and female gender.