Gender Dysphoria Research Articles

Nonbinary people living in a binary world: Minority stress in public and gendered places

Introduction Nonbinary gender identities are widely erased and invalidated in Western societies, due to binary normativity. The segregation by binary gender of public spaces and sports categories may cause unique sources of stress for nonbinary people, manifesting at a structural and interpersonal level. Utilizing the nonbinary minority stress framework this study explores how the dichotomous gender division of public restrooms, store dressing rooms, locker rooms, and sports categories is associated with distal and proximal dimensions of minority stress. Methods The study was conducted in Italy and involved 40 nonbinary individuals aged 19 to 36 years in a semi-structured interview. The research team comprised a diverse range of positionalities, including trans, nonbinary, queer, bisexual, lesbian, and cisgender heterosexual-allied researchers. Results Through reflexive thematic analysis combining deductive and inductive orientations, themes were organized in two macro-areas representing distal and proximal stressors. Distal stressors encompassed experiences of bullying, harassment, discrimination, social intrusiveness and control, non-affirmation, invalidation, and the burden of powerlessness. Proximal stressors included internalized invalidation, avoidance coping, negative expectations, disclosure negotiation, and gender dysphoria. Conclusion and discussion Findings showed that intrusiveness, control, non-affirmation, and social invalidation represent pervasive elements in the daily experiences of nonbinary individuals, contributing to the internalization of negative emotions referred to the self, including discomfort, shame, and a sense of social inadequacy. Nonbinary individuals may prioritize the comfort of others in social interactions, negotiating the disclosure of their identity to prevent others from feeling uneasy in their presence. Implications for clinical interventions, policy, and future research are discussed.

Long-term outcome of gender assignment in individuals with 46, XY DSD assigned female sex in multicultural society

The decision regarding sex rearing in patients with Disorders of Sex Development (DSD) is heavily connected to the shared decision-making model within multidisciplinary team. Some of these patients might develop gender dysphoria, when they become adults. We have aimed to evaluate the long-term outcomes of patients with XY DSD who underwent female gender assignment at our center. We have conducted a retrospective study of all 46, XY DSD patients who underwent female assignment in our institution over the last 30 years. we have found 25 46, XY patients who were raised as a female after birth. After excluding the Androgen insensitivity syndrome (AIS) patients we have identified 15 patients who have matched study criteria. The decision on gender rearing was made by the parents in 11(74%) and by the surgical team 2(13%) during hernia repair/inguinal exploration. In 2(13%) cases, the patients opted to continue identifying as women after learning about the pathology during adolescence. Nine (60%) out of 15 patients (age17.9±4.7 years (mean±SD)) agreed to answer questionnaires regarding sexual function and satisfaction from gender assignment. Mean follow up was 11.1±8.2 years (mean±SD). only one participant consented to respond to a questionnaire regarding sexual intercourse (homosexual). The overall FSFI score was 24 which included the scores 4, 4, 3, 4, 3, 2 in the categories desire, arousal, lubrication, orgasm, satisfaction, and pain respectively. Two patients regretted the decision of female gender assignment. The first with 5α-reductase deficiency, he made the decision for assignment himself as an adult and the other (3β-hydroxysteroid dehydrogenase) who underwent gonadectomy during inguinal exploration as a child. The rest of the patients were satisfied with the choice of gender, 2 need psychological support on the daily basis. In the study group, relationship and cohabitation were significantly later in life compared to the general population. Despite the sensitivity of the subject and cultural differences, most patients (78%) were satisfied with the decision to undergo female gender assignment. Over the years, patients require meticulous follow-up in order to consider additional interventions, and mental support if it is necessary. The two cases of later regret highlight the importance of proper education of patients, their families and medical providers upon decision on gender assignment.

Surgical outcomes in patients undergoing hysterectomy for gender dysphoria

Surgical outcomes in patients undergoing hysterectomy for gender dysphoria

Cinsel Kimlik Gelişiminin Nörobiyolojik Yapıtaşları ve Çevresel Stresörlerin Epigenetik Etkileri

In this review, we explore the intricate development of sexual identity, drawing insights from genetic, endocrinological, neuroanatomical, and neurophysiological studies. Gender identity, encapsulating an individual's internal perception as male or female, undergoes a nuanced and gradual formation, commencing early in life and progressing through distinct stages. Gender nonconformity delineates behaviors that diverge from culturally prescribed norms, while gender dysphoria encompasses the emotional distress experienced by some individuals due to a mismatch between their gender identity and assigned sex at birth. The genesis of sexual identity involves multifaceted processes spanning numerous years. Human sex differentiation involves the suppression or inactivation of specific genes, a phenomenon illuminated by genetic investigations into gender dysphoria, which have shown comparable rates of genetic variations to the general population. Nevertheless, twin studies suggest an augmented likelihood of transsexuality among family members, hinting at potential environmental influences. Brain sexual differentiation occurs during mid-to-late pregnancy due to the impact of gonadal hormones. The mechanisms underpinning the loss of feminine brain characteristics and subsequent masculinization likely involve a combination of factors, indicating a complex interplay rather than a singular cause. Studies propose that human sexual behavior is not governed by a solitary gene but rather by a network of genes dispersed across the genome. Notably, disparities in brain structures, functionalities between genders, as well as variations in endocrine and serotonin-dopamine levels, are implicated in the etiology of gender dysphoria, contributing to the understanding of this complex phenomenon situated between genders.

ITS ABOUT TIME! PARANOIA AND SELF-HARM IN GENDER MINORITY TEEN IN INDIA: A CASE REPORT

In conservative social cultures, such as those in South Asia, societal norms often lead individuals to neglect or suppress the expression of their perceived gender identity if different from their birth assignment. Gender incongruence (GI) occurs the gender identity of a person does not align with the gender assigned at birth. If GI causes significant distress or problems in functioning lasting for at least 6 months, it is described as gender dysphoria (GD). This case study contributes to understanding how gender dysphoria may result in personality disorders such as paranoid personality disorder in a conservative society. Removing societal taboos and accepting individuals with their perceived gender can lead to timely diagnosis and management of patients, preventing severe outcomes.

Thyroid Cancer Prevalence, Risk Exposure, and Clinical Features Among Transgender Female Veterans.

Transgender women experience higher-than-average rates of multiple medical conditions. Thyroid cancer occurs more frequently in those assigned female at birth than in those assigned male at birth. We sought to characterize thyroid cancer among transgender female veterans. We reviewed charts of veterans who were (1) seen in Veterans Affairs clinics across the United States from July 2017 to December 2022, (2) had an International Classification of Diseases, revision 10, diagnosis code for thyroid cancer, and (3) had an International Classification of Diseases, revision 10, diagnosis code for gender dysphoria or were assigned male at birth and ever had a prescription for estrogens. Charts of cisgender veterans were also reviewed for comparison. Compared with calculated estimates of 0.641% (95% CI, 0.572-0.724) among cisgender females and 0.187% (95% CI, 0.156-0.219) among cisgender males, the measured prevalence among transgender female veterans was 0.341% (34/9988). Average age at thyroid cancer diagnosis in this population was 53.8 (± SEM 2.61) years. A total of 32.3% (11/34) of these patients had extrathyroidal disease at diagnosis. To our knowledge, this study represents the first report of thyroid cancer prevalence among transgender women in the United States. Risk exposure among all transgender veterans including further assessment of the possible contributions of obesity, smoking, and gender-affirming hormone therapy are important future analyses.

„The Gender Reassignment” Controversy - Between Affirmation and Kind Restraining

The review article presents the phenomenon of transsexualism through the prism of the etiology, scale and dynamics of the phenomenon as well as the most controversial social consequences concerning "sex change" and the acceptance or non-acceptance of voluntary personal forms adopted by children and adolescents. Review of contemporary literature, analysis of positions on the issues of the so-called gender changes (gender reassignment, gender matching). The text shows the evolution of understanding of gender identity disorders in the ICD-10 and DSM-5 classifications as well as the controversy related to the tendencies depathologizing gender inconsistency in the ICD-11. Looking at the etiological issues we present an attempt of in-depth psychological analyzes as opposed to the dominant, reductive medical approach. In the text, we also recall the basic developmental regularities of children and adolescents, often overlooked in discussions on transsexualism. The basic developmental regularities of children and adolescents, often overlooked in discussions on transsexualism, were also reminded. As the review of the data shows the rapid increase in gender identity disorders in recent years, their pronunciation leads to emphasizing the growing role of pop culture influences on young people. There is also a lack of research on the use of puberty blockers in children/adolescents - their introduction appears to be an experiment with, in fact, unknown consequences. The analysis of developmental regularities, the transience of dysphoric tendencies and the lack of reliable scientific data on the use of puberty blockers and the consequences of taking hormones of the opposite sex lead to the conclusion that accepting voluntary personal forms proposed by children/teenagers is premature.

(PM-23) YOGA PRACTICE INTERVENTION AS A COMPLEMENTARY AND INTEGRATIVE TREATMENT FOR COMPULSIVE SEXUAL BEHAVIOR DISORDER: A PILOT STUDY

Abstract Objective Investigate the feasibility of a Yoga Practice intervention (YPI) as an integrative treatment for adult men with compulsive sexual behavior disorder (CSBD) explored through the attendance and adherence treatment protocol, and the functionality of data collection mechanisms. Methods For this study, twelve men diagnosed with CSBD and that did not present substance-use, paraphilic, psychotic, current manic or hypomanic, neurocognitive disorders, gender dysphoria, physical limitations, already practiced yoga or started psychotherapy more than six months ago were randomized in a 2-arm, double-blind clinical trial, comparing a Kundalini YPI with a supervised muscle stretching 12-week program. Participants submitted their applications online on baseline, times 1 (4 weeks), 2 (8 weeks) and time 3 (12 weeks) and the proportion of treatment and protocol adherence, teacher adherence, and allocation concealment were estimated. Results The age range was 24 to 47 years old. 58% were single or widower, 41% married or common-law; 75% were caucasians and 25% afro-descendants. The minimum schooling was elementary, (50% finished college). Average family income was $ 1130. There was no statistically significant association between sociodemographic and intervention groups. The patient attendance was 58%, patient adherence to the protocol 30%, professors' adherence to the protocol reached 100%, and the allocation concealment for the double-blind method ensured 100%. The answers of the self-responsive online questionnaires on psychopathologic variables reached 87% of the requested answers, and the daily practices at home 45%. Conclusions Although the YPI evaluated for CSBD was acceptable and functional, this pilot indicates changes in procedures to improve attendance and adherence of patients. Financing No conflict.

Navigating the gap: Unveiling the hidden minority stressors faced by trans and nonbinary clients in gender affirming pathways

Background Minority Stress Theory (MST) explains health outcome disparities among trans and gender diverse (TGD) individuals as compared to the general population, emphasizing the impact of both distal and proximal stressors on well-being. TGD individuals may encounter additional stressors when seeking access to accessing services for their gender affirming pathway (GAP), particularly in Italy where the pathway maintains a strong gatekeeping approach. Methods This research explores the experiences of 45 TGD individuals aged between 18 and 38, with the majority identifying as nonbinary (77.8%) and within the context of the institutional Italian GAP. Participants are either currently on a waiting list in an institutional GAP, or they are still questioning if the GAP is suitable for them. Through a semi-structured interview, the study investigates how TGD individuals perceive the institutional GAP and whether it acts as a source of minority stress. The research employs Codebook Thematic Analysis, informed by MST. Results Findings reveal that the Italian GAP replicate both distal and proximal stressors. Distal stressors encompass manifest aggressions, invalidation, gatekeeping, and burdening, while proximal stressors involve vicarious stress, expectations of rejections, forced concealment, gender dysphoria, and self-gatekeeping. Results indicate a greater difficulty for nonbinary individuals due to the structural negation of their identity within the GAP. Conclusion The research underlines that the current institutional GAP exacerbates stress rather than promoting well-being. It underscores the necessity for reframing the GAP to provide a tailored and inclusive space to support the many manners of affirming TGD persons without a transnormative approach.

Gender-affirming hormone therapy preserves skeletal maturation in young mice via the gut microbiome.

Gender-affirming hormone therapy (GAHT) is often prescribed to transgender (TG) adolescents to alleviate gender dysphoria, but the effect of GAHT on the growing skeleton is unclear. We found GAHT to improve trabecular bone structure via increased bone formation in young male mice and not to affect trabecular structure in female mice. GAHT modified gut microbiome composition in both male and female mice. However, fecal microbiota transfers (FMTs) revealed that GAHT-shaped gut microbiome was a communicable regulator of bone structure and turnover in male, but not in female mice. Mediation analysis identified 2 species of Bacteroides as significant contributors to the skeletal effects of GAHT in male mice, with Bacteroides supplementation phenocopying the effects of GAHT on bone. Bacteroides have the capacity to expand Treg populations in the gut. Accordingly, GAHT expanded intestinal Tregs and stimulated their migration to the bone marrow (BM) in male but not in female mice. Attesting to the functional relevance of Tregs, pharmacological blockade of Treg expansion prevented GAHT-induced bone anabolism. In summary, in male mice GAHT stimulated bone formation and improved trabecular structure by promoting Treg expansion via a microbiome-mediated effect, while in female mice, GAHT neither improved nor impaired trabecular structure.

How social is social media for transgender and gender-diverse youth? Association of online social experiences with internalizing mental health problems.

Adolescents spend a critical amount of their free time on the Internet and social media. Transgender and gender-diverse (TGD) adolescents, who report elevated rates of mental health issues, especially internalizing problems, have both positive and negative online social experiences (e.g., support and cyberbullying). This can have both beneficial and/or harmful effects on their mental health. Given the lack of research, the present study examined TGD adolescents' online (social) experiences and the association of positive and negative online social experiences with internalizing problems. The sample consisted of n = 165 TGD adolescents (11-18years) diagnosed with gender dysphoria who attended a Gender Identity Service for children and adolescents (Hamburg GIS) in Germany between January 2020 and December 2022 during the COVID-19 pandemic. Positive (use of online support networks) and negative online social experiences (cyberbullying or other adverse online interactions) were assessed using study-specific items and internalizing problems using the Youth Self-Report. Frequencies of various online (social) experiences were analyzed, and a multiple linear regression analysis was performed to test their association with internalizing problems. In total, 42% of participants reported positive online social experiences (use of online support networks) and 51% of participants reported negative online social experiences (cyberbullying or other adverse online interactions). There was no significant association between negative online social experiences and internalizing problems but between positive online social experiences and more internalizing problems (adjusted R2 = .01). TGD adolescents may seek online support, especially when struggling with mental health problems. Therefore, it is crucial to support youth navigating these online spaces more safely and positively and to empower them to buffer against potentially harmful experiences. Furthermore, strengthening offline relations with peers and family members is pivotal, given their importance for TGD adolescents' mental health.

White matter microstructure in transmasculine and cisgender adolescents: A multiparametric and multivariate study.

Adolescence is a sensitive developmental period for neural sex/gender differentiation. The present study used multiparametric mapping to better characterize adolescent white matter (WM) microstructure. WM microstructure was investigated using diffusion tensor indices (fractional anisotropy; mean, radial, and axial diffusivity [AD]) and quantitative T1 relaxometry (T1) in hormone therapy naïve adolescent cisgender girls, cisgender boys, and transgender boys (i.e., assigned female at birth and diagnosed with gender dysphoria). Diffusion indices were first analyzed for group differences using tract-based spatial statistics, which revealed a group difference in AD. Thus, two multiparametric and multivariate analyses assessed AD in conjunction with T1 relaxation time, and with respect to developmental proxy variables (i.e., age, serum estradiol, pubertal development, sexual attraction) thought to be relevant to adolescent brain development. The multivariate analyses showed a shared pattern between AD and T1 such that higher AD was associated with longer T1, and AD and T1 strongly related to all five developmental variables in cisgender boys (10 significant correlations, r range: 0.21-0.73). There were fewer significant correlations between the brain and developmental variables in cisgender girls (three correlations, r range: -0.54-0.54) and transgender boys (two correlations, r range: -0.59-0.77). Specifically, AD related to direction of sexual attraction (i.e., gynephilia, androphilia) in all groups, and T1 related to estradiol inversely in cisgender boys compared with transgender boys. These brain patterns may be indicative of less myelination and tissue density in cisgender boys, which corroborates other reports of protracted WM development in cisgender boys. Further, these findings highlight the importance of considering developmental trajectory when assessing the subtleties of neural structure associated with variations in sex, gender, and sexual attraction.

Revisiting the Link: A qualitative analysis of the diverse experiences of gender dysphoria as a subset of pervasive social dysphoria co-occurring with autism in Japan.

Studies have suggested that autistic people are more likely to experience gender dysphoria, which refers to the gender-related distress emerging from personal factors and gender norms that some transgender people experience. Transgender people are diverse; some experience gender incongruence (i.e. an incompatibility between a person's gender identity and that expected of them based on their birth-assigned gender), whereas others do not. Therefore, the association of autistic transgender people's gender dysphoria with gender incongruence varies, and the literature has overlooked such diversity. Interviews with 15 Japanese autistic transgender adults revealed diverse gender dysphoria experiences independent of gender incongruence, such as resistance to the societal gender norms themselves, physical dysphoria caused by the imposition of gender, sensory disgust related to autistic sensory sensitivities, uncertainty about the gender norms of the social majority, and the autistic burden of living in a gendered society. Moreover, we found that most participants had not only accumulated distress over gender norms (i.e. gender dysphoria) but also over pervasive social norms, termed Pervasive Social Dysphoria. Our findings suggests that future co-occurrence research and practice must affirm these internal perspectives more, such as by providing support for both gender dysphoria and Pervasive Social Dysphoria, as autistic transgender people may experience gender dysphoria as a subset of Pervasive Social Dysphoria.

Lactation induction in a transgender woman: case report and recommendations for clinical practice

BackgroundWe present a case of non-puerperal induced lactation in transgender woman. Medical literature on lactation induction for transgender women is scarce, and the majority of literature and protocols on lactation induction is based on research in cisgender women. Healthcare professionals may lack the precise knowledge about lactation induction and may therefore feel insecure when advice is requested. Subsequently, there is a rising demand for guidelines and support.MethodsPatient medical record was consulted and a semi-structured interview was conducted to explore the motive for lactation induction, the experience of lactation induction, and to gather additional information about the timeline and course of events.Case presentationIn this case a 37-year-old transgender woman, who was under the care of the centre of expertise on gender dysphoria in Amsterdam, and in 2020 started lactation induction because she had the wish to breastfeed her future infant. She was in a relationship with a cisgender woman and had been using gender affirming hormone therapy for 13 years. Prior to initiating gender affirming hormone therapy she had cryopreserved her semen. Her partner conceived through Intracytoplasmic Sperm Injection, using our patient’s cryopreserved sperm.To induce lactation, we implemented a hormone-regimen to mimic pregnancy, using estradiol and progesterone, and a galactogogue; domperidone. Our patient started pumping during treatment. Dosage of progesterone and estradiol were significantly decreased approximately one month before childbirth to mimic delivery and pumping was increased. Our patient started lactating and although the production of milk was low, it was sufficient for supplementary feeding and a positive experience for our patient.Two weeks after birth, lactation induction was discontinued due to suckling problems of the infant and low milk production.ConclusionsThis case report underlined that lactation induction protocols commonly used for cisgender women are also effective in transgender women. However, the amount of milk produced may not be sufficient for exclusive nursing. Nevertheless, success of induced lactation may be attributed to its importance for parent-infant bonding, rather than the possibility of exclusive chestfeeding.

Testosterone therapy in females is not associated with increased cardiovascular or breast cancer risk: a claims database analysis.

Testosterone therapy (TTh) has been shown to improve libido in women with sexual dysfunction, but its utilization has been limited due to concern for cardiovascular events and past studies reporting highly variable results. To assess the association of TTh in women with major adverse cardiac events (MACEs), including heart attack, stroke, or death, using a large database. The TriNetX Diamond Network was queried from 2009 to 2022. Our study cohort included adult females with ≥3 systemic testosterone prescriptions within a year. Our control cohort excluded females with any testosterone prescriptions, polycystic ovary syndrome, or androgen excess. Both cohorts excluded females with prior heart failure, unstable angina, intersex surgery (female to male), personal history of sex reassignment, or gender identity disorders. Propensity matching between the cohorts was performed. A subanalysis by age was conducted (18-55 and >55 years). We evaluated the association of TTh to the following: MACE, upper or lower emboli or deep vein thrombosis (DVT), pulmonary embolism (PE), breast neoplasm, and hirsutism within 3 years of TTh. When compared with propensity-matched controls, adult females with TTh had a lower risk of MACE (risk ratio [RR], 0.64; 95% CI, 0.51-0.81), DVT (RR, 0.61; 95% CI, 0.42-0.90), PE (RR, 0.48; 95% CI, 0.28-0.82), and malignant breast neoplasm (RR, 0.48; 95% CI, 0.37-0.62). Similarly, females aged 18 to 55 years with TTh had a lower risk of MACE (RR, 0.49; 95% CI, 0.28-0.85) and DVT (RR, 0.48; 95% CI, 0.25-0.93) and a similar risk of malignant breast neoplasm (RR, 0.62; 95% CI, 0.34-1.12). Females aged ≥56years with TTh had a similar risk of MACE (RR, 0.84; 95% CI, 0.64-1.10), DVT (RR, 0.82; 95% CI, 0.50-1.36), and PE (RR, 0.52; 95% CI, 0.26-1.05) and a significantly lower risk of malignant breast neoplasm (RR, 0.51; 95% CI, 0.38-0.68). Risk of hirsutism was consistently higher in those with TTh as compared with propensity-matched controls. Our results contribute to safety data on TTh, a therapy for sexual dysfunction in women. The TriNetX Diamond Network allows for significant generalizability but has insufficient information for some factors. We found a decreased risk of MACE among women with TTh as compared with matched controls and a similar risk of MACE in postmenopausal women while demonstrating a similar or significantly lower risk of breast cancer on age-based subanalysis.

Retrospective Study on Optimizing Breast Augmentation Outcomes in Transgender Patients: A Comprehensive Analysis of Tumescent Local Anesthesia Technique.

Tumescent local anesthesia (TLA) involves the infusion of a saline solution containing lidocaine and epinephrine into tissues to achieve localized anesthesia and vasoconstriction. While the use of TLA in sub-glandular augmentation mammoplasty has been documented, we present a modified TLA approach for primary sub-muscular breast augmentation in transgender patients based on our experience over the past years. Between the years 2014 and 2021, we performed primary sub-muscular breast augmentation on 20 transgender patients under TLA and conscious sedation. The tumescent solution consisted of 25mL of 2% lidocaine, 8mEq of sodium bicarbonate, and 1 mL of epinephrine (1mg/1mL) in 1000mL of 0.9% saline solution. Initially, the solution was infiltrated between the pectoral fascia and the mammary gland, and subsequently, during the surgery, under the pectoralis major muscle. The average volume of tumescent solution infiltrated during TLA was 740mL per breast. There were no reports of adrenaline or lidocaine toxicity, and no cases required a conversion to general anesthesia. Patients experienced no pain or discomfort during the preoperative infiltration or surgical procedure. Reoperations due to short-term complications never occurred. We observed a major complication rate of 5%, represented by 1 hematoma. Long-term complications comprised one case of implant dislocation and one occurrence of dystrophic scar formation. No cases of capsular contracture needing reoperation, asymmetry, and implant rupture occurred. In total, one individual (5%) requested larger implants. Follow-up time ranged from 30days to 1years. Overall, augmentation mammaplasty is a valuable choice for transgender women aiming to enhance their feminine characteristics and alleviate gender dysphoria. It is imperative for patients to conduct thorough research, grasp the potential pros and cons, and consult experienced healthcare professionals in transgender care. Additionally, tumescent local anesthesia (TLA) has proven to be a safe and efficient method for sub-muscular breast augmentation, providing effective pain control with minimal postoperative complications, resulting in high patient satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

(286) Impact of Hormonal Treatment in Patients with Gender Dysphoria in the First Six Months of Treatment

Abstract Introduction Gender dysphoria (GD) is a mismatch of how we feel our identity, male or female, with the biological sex. This incongruity can lead to discomfort and suffering. Prejudice and discrimination may result in additional stress, with impact on quality of life (QV). Hormonal therapy (HT) is an important part of the treatment of patients with GD and can have an impact on sexual life and QV. Objective To assess the impact of HT on sexual desire and quality of life in patients with GD throughout the first 3 to 6 months of treatment. Methods Longitudinal study of quality of life (QL) and sexual desire (SD), before and 3 to 6 months after starting HT, using the WHO WHOQOL-BREF questionnaire, which assesses the physical, psychological, social and environmental domains, of DS (dyadic and solitary) through the Sexual Desire Inventory- 2 (SDI-2) questionnaire and obtaining sociodemographic, clinical and laboratory data on patients who came to our consultation with a diagnosis of GD. Results 52 patients, with a mean age of 25.11 (18–56) years, completed the WHOQOL-BREF and SDI-2 questionnaires. 30 FtM (57.7%) and 22 MtF (42.3%). Almost half 49% (n= 26) had a comorbid psychiatric disorder. In FtM the average total testosterone (TT) increased from 0.320 ng/mL to 7.190 (+/- 2.340) ng/mL and in MtF the average TT increased from 6.86 ng/mL to 0.59 (+/- 41) ng/mL 3 to 6 months after starting HT, without serious side effects. FtM showed a significant increase in DS (p < 0.01), both dyadic and solitary, while MtF showed a non-significant decrease in SD after the start of HT. There was a non-significant improvement in the physical, social relationships and environment domains and a significant improvement in the psychological domain (p < 0.01). In the physical domain, FtM patients showed a significant improvement compared to MtF patients. 20% of patients reduced or stopped psychiatric medication. Despite the negative impact of HT on SD in MtF, there was an improvement in QoL and a reduction in the need for psychiatric medication. In FtM there was a significant improvement in the psychological and physical domain. Conclusions HT is safe, improves QoL and reduces the need for psychiatric medication in patients with GD. This improvement was significant in the psychological domain. Disclosure No.

(043) Gender-Affirming Bilateral Orchiectomy Prior to Vaginoplasty versus with Vaginoplasty: A Comparison of Preoperative Goals and Postoperative Satisfaction

Abstract Introduction Gender-affirming bilateral orchiectomy (GA-BO), defined here as either a standalone procedure and/or precursor to vaginoplasty, is associated with a decrease in gender-affirming hormone therapy (GAHT) dosages. In comparison to bilateral orchiectomy at time of gender-affirming vaginoplasty (GA-V), GA-BO is associated with shorter waitlist times, procedure duration, and outpatient recovery. While objective benefits of GA-BO have been described, there is limited qualitative data that assesses the preoperative goals and postoperative satisfaction of patients who elect GA-BO. We aim to assess the decision-guiding factors that led patients to select GA-BO, and to compare measures of patient satisfaction between GA-BO and GA-V patients. Objective To assess the decision-guiding factors that led patients to select gender-affirming bilateral orchiectomy before vaginoplasty versus with vaginoplasty, and to compare measures of patient satisfaction between groups. Methods A retrospective chart review identified 170 patients who underwent GA-BO (n=106; 64%) or GA-V (n=64; 36%) between 4/2017 and 12/2020 at our institution. Patients were emailed a link to an anonymous, online questionnaire (QualtricsTM). Results 136/170 (80%) patients completed the questionnaire: 86/136 (63%) respondents were GA-BO patients and 50/136 GA-V (37%). 78/86 (91%) of GA-BO respondents had either subsequently undergone vaginoplasty, or, planned to do so in the future. For patients who later underwent vaginoplasty, the mean reported time interval between GA-BO and vaginoplasty was 15 months [Range: 1–34 months]. Respondents prioritized the following expectations in their decision to undergo GA-BO: potential to decrease GAHT medications and dosages (reported as important by 67%), low rates of complications (56.5%), short recovery time (51.6%), and low postoperative pain (46.2%). GA-BO and GA-V patients reported high postoperative improvement in various indices of gender dysphoria and body image, with only 1/4 indices of gender dysphoria differing significantly between the two groups (Figure 1). Unsurprisingly, GA-V patients reported a significantly greater improvement in 3/3 body image indices. Conclusions GA-BO is a low-risk procedure that provides a more immediate option to decrease gender dysphoria and improve QOL. All patients who were assigned male at birth and are interested in genital gender-affirming surgery should be made aware of the advantages of GA-BO and offered GA-BO alongside GA-V. Disclosure No.

(040) Anterolateral Thigh Flap Phalloplasty: Outcomes Following Genital Gender Affirmation Surgery

Abstract Introduction Genital gender affirmation surgery (gGAS) is a key part of the management of patients with gender dysphoria. The anterolateral thigh (ALT) free flap was proposed as an alternative to the more common radial forearm free flap (RFFP) phalloplasty due to the twin advantages of a more easily hidden scar and improved flexibility in the length of the flap. A pedicled variant of the ALT flap offers greater security of vascular supply for suitable patients, and if suitable and desired the flap can be formed with an integrated urethra, facilitating voiding while standing. Objective The aim of the study is to report the contemporary surgical and functional outcomes of ALT phalloplasty. Methods All individuals undergoing ALT flap phalloplasty for genital gender affirmation surgery (GAS) between 2009 and 2023 nationwide were included. Individuals were managed in accordance with the World Professional Association for Transgender Health (WPATH) Standards of Care version 7. Data were extracted from a prospectively collected single surgeon database and medical records. Functional outcomes were assessed by non-validated questionnaire. Statistical analysis included Mann-Whitney, chi-squared, Fisher’s exact and unpaired T tests. Results Surgical outcomes: A total of 87 patients were included in the study. More than half (45, 51.7%) had an integrated urethra. The median length of stay following surgery was six days (IQR 6-7). Eleven patients (12.6%) had a 30-day Clavien-Dindo 3b complication or greater. Three patients (3.4%) experienced total flap loss. A further three patients (3.4%) had partial flap loss. Three patients (3.4%) required a salvage phalloplasty later. Thirteen patients (out of 42, 31.0%) without an integrated urethra went onto have a free flap urethroplasty. Functional outcomes: Thirty-nine individuals (44.8%) completed the patient reported outcomes questionnaire. Most patients (77%) were generally satisfied with their phalloplasty. More than half (56%) with an erectile device used their phallus for penetrative intercourse, while one in five reported experiencing orgasm using their phallus alone. Following urethral lengthening, all respondents were able to void standing. There was no significant difference in mean satisfaction scores for those with an integrated urethra compared to those without (4.18/5 vs 3.82/5, p=.45), as well as between those with or without an erectile device, respectively (3.78/5 vs 4.10/5, p=.26). Conclusions This study is one of the largest single centre cohorts of ALT flap phalloplasty reported to date. It further supports the use of the ALT flap as one of the main genital GAS options for transmen. Over half of the patients studied had an integrated urethra, the gold standard for urethral lengthening. Patient reported functional outcomes were promising, with similar scores regardless of urethral lengthening or erectile device insertion. Disclosure No.

(042) Bilateral Orchiectomy as a Standalone Gender-Affirming Procedure: Does it Compromise Skin Grafts Available for Later Vaginoplasty?

Abstract Introduction Penile inversion vaginoplasty is the gold-standard gender-affirming surgical technique for creating a neovaginal canal. While bilateral simple orchiectomy (BSO) is usually completed at the same time as vaginoplasty, long wait times associated with vaginoplasty have highlighted pre-vaginoplasty BSO as a more immediate opportunity to mitigate gender dysphoria, decrease estrogen dosages, and completely eliminate antiandrogen hormone therapy. The impact of standalone BSO on later vaginoplasty is defined by a single study that associated BSO with a decrease in scrotal skin and a need for extragenital skin grafts-findings that have fueled hesitation around pre-vaginoplasty BSO. Objective To provide a detailed comparison of pre- and intraoperative skin graft measurements and postoperative neovaginal depth between patients who underwent BSO prior to versus concurrent with vaginoplasty. Methods All consecutive patients who underwent penile inversion vaginoplasty at a single institution were identified in a retrospective chart review. Demographic characteristics and the following measurements of vaginoplasty skin grafts were collected and compared between groups: preoperative stretched penile length (measured from base to 1cm proximal to the glans ridge on gentle stretch), preoperative stretched scrotal skin length (measured on gentle stretch in two parts: from the penoscrotal junction to mid scrotum, then from midscrotum to mid perineum), and intraoperative scrotal skin tube length (defined as the amount of scrotal skin that could be harvested and tubularized on a metal dilator (Figure 1A)). Results 57 patients completed penile inversion vaginoplasty between August 2017 and May 2023: 17(30%) completed pre-vaginoplasty BSO and 40(70%) BSO concurrent with vaginoplasty (mean age ± SD = 36.6 ± 12.6y and 37.4 ± 12.8y, p>0.05). Notably, there was no significant difference in length of preoperative scrotal skin or intraoperative tubularized scrotal skin grafts (Figure 1B). While pre-vaginoplasty BSO patients had less neovaginal depth (p<0.05), they also had significantly less preoperative penile skin (p<0.01). Conclusions Contrary to the singular study in the literature, we found no between-group differences in scrotal skin measurements. Furthermore, zero patients required extragenital skin grafts to achieve mean neovaginal depth of 14.4±1.0cm, which approximates the average depth among studies reporting routine use of extragenital skin. Less neovaginal depth amongst BSO patients is expected, as this group had less penile skin available to line the canal. Findings from this study may help address patient and provider fears that BSO decreases scrotal skin available for later vaginoplasty, thereby lessening the decision-making burden of balancing the pros and cons of early BSO. Disclosure No.