Gender Transition Research Articles

Progesterone in gender-affirming therapy of trans women.

Progesterone is an endogenous steroid hormone with an important role for the physiology of the female reproductive system and the mammary gland. It has additional significant actions in other tissues, such as the cardiovascular system, the central nervous system, and bones. The present article explores potential clinical implications from the addition of bioidentical progesterone to gender-affirming treatment of trans women. For this purpose, it provides an overview of the physiological action of progesterone in target tissues and speculates on possible benefits for gender transitioning. Progesterone is expected to exert moderate anti-androgen action through suppression of the hypothalamic-pituitary-gonadal axis and inhibition of the conversion of testosterone to dihydrotestosterone. It may also contribute to breast maturation. In the long-term, progesterone could prevent bone loss and protect cardiovascular health. The potential benefits are mainly inferred by extrapolating evidence from biological actions in cisgender women and medical assumptions and hence, clinicians need to be cautious when applying these data into practice. Further research is needed to ascertain the efficacy and safety of progesterone in current hormonal regimens.

DHT Induces Arterial Stiffening in Female Wild Type Mice

Testosterone is the predominant sex hormone in men and is increased in women with polycystic ovarian syndrome (PCOS). PCOS patients also experience an increased risk for cardiovascular diseases including hypertension and arterial stiffness. Our previous work showed significant downregulation of the G protein‐coupled estrogen receptor (GPER) as well as the nuclear estrogen receptor ERα in cultured vascular smooth muscle cells in response to the testosterone metabolite dihydrotestosterone (DHT), which cannot be aromatized to estrogen. Therefore, we hypothesized that DHT may induce arterial stiffness in female mice via downregulation of vascular estrogen receptors. Two groups of female wildtype mice were treated with DHT via silastic capsule for 4 weeks; one group received a dose designed to mimic DHT levels in men while the other group received twice this dose. While post‐treatment systolic blood pressure was not different between the control, single dose, and double dose groups (111 ± 10, 106 ± 3, 110 ± 7, n=8 per group; P=0.22), intracarotid vascular stiffness measured via pulse wave velocity showed a more than two‐fold increase in single dose (4.3 ± 0.8 m/s) and double dose (4.8 ± 1.0 m/s) DHT treated mice when compared with non‐treated controls (1.9 ± 0.3 m/s; P<0.0001). These findings suggest that high testosterone levels in females may promote arterial stiffening and cardiovascular damage independent of changes in blood pressure. Future studies will include histological analysis of aortic sections using Masson’s trichrome to assess changes in the extracellular matrix as well as droplet digital polymerase chain reaction to assess changes in estrogen receptor expression. In conclusion, these findings of arterial stiffening in response to increased DHT levels in females are important for not only PCOS patients but also women using testosterone for fitness, gender transitioning, or reduced libido.

Under the Law: Wanted: American educator

A recent series of bills subject educators to fines, or even jail time, for conduct lawmakers find acceptable, such as assisting transgender students with gender transition, offering potentially “harmful” material in school libraries, or teaching “critical race theory.” These laws enable private citizens to sue educators who engage in these activities for damages, essentially acting as “bounty hunters” who enforce the law when the state cannot. Robert Kim discusses the precedents behind such third-party enforcement and considers whether educators’ fears of rampant litigation are overblown.

Medieval and Trans Ways of Being

Medieval and Trans Ways of Being

TRANSFORMATIVE CREATURES: THEOLOGY, GENDER DIVERSITY, AND HUMAN IDENTITY

AbstractGender transition may be figured as part of a broader creaturely process of being partners in our own becoming. Gender transition is explored through the lenses of transformation (including comparisons with theosis and with religious conversion) and neurodiversity. Humans are transformative creatures; trans and gender‐variant people, like others, have the power to curate their own identities and are on a journey toward perfection. Our nature as humans, including our sexed and gendered nature, is not over‐and‐done‐with. In this sense, our active building and shaping of our identities and body‐stories is not a rejection of a divine blueprint for human existence, nor an exercise of illegitimate human hubris, but rather a licit creaturely form of generativity.

Social and medical practices of gender transition in Russia

AIM. To examine the social and medical aspects of gender transition practices in Russia.
 MATERIAL AND METHODS. An anonymous online survey of people living in Russia whose gender experience differed from the sex marker determined at birth was conducted. The final sample consisted of 588 respondents (aged 24.016.70), of whom 69.9% (n=409) were transgender male, 23.1% (n=136) were transgender female, and 7.3% (n=43) had a different gender identity.
 RESULTS. There was a high frequency of social disadaptation among respondents (15.5% of the sample). Most respondents first reflected that their gender identity did not match their sex at birth and/or did not fit into the social framework during childhood or adolescence, with a peak at age 1114 (39.8% of the entire sample). The age at which respondents began gender transition was overwhelmingly after adulthood, with a peak at age 1825 (32.0% of the entire sample). More than half of the respondents (59.4%) who had medical body changes associated with gender transition initiated them on their own. Less than half of the respondents who were on hormone therapy (41.0%) had been monitored by an endocrinologist. The study showed a large proportion of people who already had medical body changes but had not changed sex marker on their IDs, with transgender women having the largest rate in this indicator.
 CONCLUSION. The data obtained determine the relevance of developing a system of specialized medical care for transgender people with essential destigmatizing psychotherapeutic and psychiatric care for these people, as well as emphasize the need to study the availability of medical (psychiatric) care for transgender people living in Russia.

‘This app can help you change your voice’: Authenticity and authority in mobile applications for transgender voice training

Mobile applications for transgender voice training seek to help trans people alter their speaking voices, often with the goal of alignment with one or another pole of binary gender expression (i.e., voice ‘feminization’ or ‘masculinization’). These apps offer instruction, audio tools and feedback mechanisms that allow users to record, evaluate and track their progress relative to a desired – and gendered – goal. As with digital technologies generally, however, these apps draw on and reproduce particular ideas of both the needs and capacities of imagined users and broader social and political phenomena – in this case, voice, gender expression and gender transition. In the following paper, we undertake a critical discourse analysis of five mobile voice training apps for transgender people. We find that rather than offering expansive or open-ended conceptions of gender, these apps reproduce ideals of gender as not only binary but also white, affluent and able-bodied. We also offer a critique of the apps’ characterization of transition as reifying the normative authority of clinical and technoscientific knowledge and conditioning ‘authenticity’ on an ability to conform to (racialized, classed and ableist) binary gender norms.

What Cardiothoracic Radiologists Should Know About Imaging in Transgender Patients.

Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.

The lived experience of gender dysphoria in autistic young people: a phenomenological study with young people and their parents.

Gender dysphoria is distress in relation to incongruence between an individual’s gender and sex assigned at birth. Gender clinics offer support for gender dysphoria, and there is a higher prevalence of autism in young people attending such clinics than in the general population. We aimed to investigate the lived experiences of autistic young people who have experienced gender dysphoria, and their parents, using a multi-perspectival IPA design. Young autistic people aged 13–17 years (n = 15), and their parents (n = 16), completed in-depth interviews about the young person’s experience of gender dysphoria. We analysed each individual transcript to generate individual themes, and for each of the dyads, developed themes which acknowledged the similarities and differences in parent–child perspectives. The first superordinate theme was coping with distress which had two subordinate themes; understanding difficult feelings and focus on alleviating distress with external support. This theme described how young people were overwhelmed by negative feelings which they came to understand as being about gender incongruence and looked to alleviate these feelings through a gender transition. The second superordinate theme was working out who I am which had two subordinate themes: the centrality of different identities and needs and thinking about gender. This theme described how young people and their parents focused on different needs; while young people more often focused on their gender-related needs, parents focused on autism-related needs. We conclude that young people and parents may have different perspectives and priorities when it comes to meeting the needs of autistic young people who experience gender dysphoria.

Moving Forward: Giving Voice to Partners in a Relationship With Those in Gender Transition

Moving Forward: Giving Voice to Partners in a Relationship With Those in Gender Transition

Proving authentic femininity: transnormative health narratives in television

ABSTRACT Through a rhetorical analysis of Pose, Euphoria, and Supergirl, the author explores the transnormative health narrative that evolves from these popular series. She argues that the representations simultaneously bring awareness and positive visibility to the issues facing transgender communities while reinforcing a false and harmful gender binary. By constructing health narratives from media representation, this research uses public discourse and imagery to offer a comprehensive analysis of how media informs social realities that dictate medical access. She argues that trans representations of health invite both a resilience against and an assimilation toward hegemonic dictations of gender transition and transgender identity.

P109. TEACHING AND TRAINING IN GENDER-AFFIRMING PROCEDURES IN US ACADEMIC PLASTIC SURGERY RESIDENCY PROGRAMS

PURPOSE: Over 1.4 million adults in the U.S. identify as transgender and there has been a significant increase in patients seeking surgical transition. However, the literature is void on the quantity and adequacy of surgical transition training during residency. This study aims to review the current state of gender transition education in US plastic surgery residency programs. METHODS: We performed a cross-sectional study on all accredited independent and integrated plastic surgery residency programs. Information on program curricula was collected from official program websites, and email to or telephone interview with the program coordinator. Programs were also categorized on whether they were affiliated with a “Leaders in LGBT Healthcare” center. Exposure to surgical transition was deemed to be either incidental or structured. RESULTS: One hundred and thirty programs were included in this study. Most programs provided exposure to gender-affirming surgery (n = 96, 74%), significantly fewer provided structured training (n = 37, 28% vs 74%, p <0.001). Of those who provided formal training, all provided didactic training, 86% provided clinical training (n = 32) and less than half (n = 14, 43%) provided a dedicated rotation. Programs affiliated with “Leaders in LGBT Healthcare” centers were significantly more likely to provide dedicated rotations than their non-affiliated counterparts (p=0.028). CONCLUSION: Despite the growing demand for gender transition surgery, only one in four plastic surgery residency programs have structured training in their curriculum. To better serve the transgender population, a universal structured curriculum on gender transition surgery should be created.

Requirement of Mental-health Referral Letters for Staged and Revision Genital Gender-Affirming Surgeries: An Unsanctioned Barrier to Care

ABSTRACT Introduction The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental-health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health-insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. Objective This study investigates insurance requirements for referral letters and their negative impact on care. Methods We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral-letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. Results Nearly all reviewed U.S. health-insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral-letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Conclusions Insurance companies’ requirements for referral letters impede care and contradict WPATH guidelines. We advocate that referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral-letter requirements for secondary surgeries provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients’ surgical readiness. Significant changes in mental-health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document. Disclosure No

A Novel Sacral Erector Spinae Block Reduces Opioid Use After Gender-affirming Vaginoplasty

ABSTRACT Introduction Surgeries that affirm a person's gender identity can be the ultimate end to the distress associated with the discordance between one's gender identity and sex assigned at birth. Gender-affirming vaginoplasty (GAV) is increasingly being performed as a critical component of gender transition for individuals assigned male at birth transitioning to female. As GAV becomes offered at more centers around the United States (US), it is important to understand and consider surgical outcomes that are unique to this operation without losing sight of the larger context of surgical care in the US. In this vain, it is known that post-surgery prescriptions for opioids are a catalyst for opioid addiction in nearly 1 in 16 surgery patients; furthermore, individuals with gender dysphoria are twice as likely to abuse prescription opioids. Regional anesthetic blocks have been adopted in many urologic surgeries to reduce opioid consumption both during and after surgery. The sacral erector spinae plane block (ESP) is a novel block that can block the S2-S4 pain levels in addition to some of the lumbar plexus with benefits over a neuraxial/epidural block including being a superficial block, no significant motor weakness, reduced risk of epidural hematoma, and less risk of intraoperative hemodynamic lability. Objective We sought to review complications and opioid usage after a novel sacral erector spinae plane block as an adjunct for pain control in the perioperative period in patients undergoing robotic-assisted penile inversion vaginoplasty. Methods We reviewed all charts of patients undergoing robotic-assisted penile inversion vaginoplasty or vulvoplasty at our institution. On the morning of surgery, patients were placed in a prone position and administered midazolam and fentanyl for sedation. Median sacral crests and the erector spinae muscle/plane (ESP) were identified using ultrasound guidance, and 0.2% ropivacaine was injected at the S4 and S2 sacral crest. Results A total of 13 patients received the ESP block. There were no complications either in the immediate post-block period or after surgery related to the block. Mean opioid consumption in the first 24 hours after surgery, 24-48hr, 48-72hr, 72-96hr, and 96-120 hours after surgery were 29.1, 50.9, 46.0, 36.5, and 38.7 oral morphine equivalents (OMEs), respectively. There was a significantly reduced amount of OME consumption in the 24 hours after surgery compared to the 24-48 hour period (p=0.017). Conclusions Sacral erector spinae plane block is a safe and efficacious way to reduce opioid consumption in the postoperative period after gender-affirming robotic-assisted penile inversion vaginoplasty or vulvoplasty. Disclosure No

Texas judge halts investigations targeting gender‐affirming care

A Texas state judge on March 11 issued an injunction blocking state investigations into youth health services for gender transitioning, probes that were launched after the state attorney general suggested that some of these procedures constitute child abuse. The state's recent actions had sent shock waves across a mental health provider community that considers gender‐affirming health services to be lifesaving care (see MHW, March 7).

Greek trans women selling sex, spaces and mobilities, 1960s–80s

ABSTRACT This article shows how sex work, gender identity and spatial mobilities were entangled for Greek trans women selling sex. Selling sex, particularly as trans women, exposed them to severe threats due to restrictive legislation and bias against them. Nevertheless, sex work could also be an empowering experience, facilitating their gender transitioning and helping them develop professional self-esteem. Greek trans women selling sex experienced such barriers and empowerment between the 1960s and early 1980s. Thus, contrary to the powerful argument in the history of sexuality, the late 1970s witnessed no ‘turn inwards’ for them. Selling sex as a pathway to gender transitioning was a process situated in specific spaces and facilitated by mobilities. Gender transitioning through sex work transpired in niches that trans women selling sex carved out in Athens and Salonica from the 1960s on. Simultaneously, movement across space had a complex and, sometimes, cumulative effect on sex work as a road to gender transitioning. Individuals engaging in the latter process relocated within the urban centres or from villages and provincial towns to the large cities of Greece, populating the abovementioned niches. In these niches, they exchanged information on locations outside of Greece. Subsequently, some trans women travelled to Casablanca to undergo gender-affirming surgery and/or migrated to West Berlin to sell sex. Such cross-border mobility had an ambiguous impact on the link between sex work and gender transitioning for Greek trans women, sometimes consolidating it and sometimes helping weaken it. In exploring the experience of Greek trans women in West Berlin, the article also contributes to the conjoined study of sex work, on the one hand, and migration from Greece to West Germany, on the other, which historians have hitherto primarily analysed separately from one another.

Doing Gender Transitions

In diesem Beitrag geht es um Geschlechterübergänge (Gender Transitionen) als in der Übergangsforschung bisher kaum beforschtes Thema. Der herangezogene neomaterialistische Forschungsansatz ermöglicht, dabei über eine Betrachtung als individuellen Transformationsprozess hinauszugehen. Basierend auf empirischem Material beschreibe ich die Formation transitionierender Subjekte in situierten Praktiken, unter Berücksichtigung des komplexen Zusammenwirkens von u.a. Diskursen, Körpern, Gefühlen, Gegenständen, Wissen und institutionellen Regularien. Dadurch wird deutlich, dass eine Gender Transition und transitionierende Subjekte keine singulären, sondern relationale Prozesse darstellen, die weder rein soziokulturell noch rein materiell sind. Abschließend diskutiere ich Anregungen neomaterialistischer Ansätze für die U¨bergangsforschung, insbesondere ihre Reflexivierung und Relationierung.

Prevalence and Factors Associated With Gender-Affirming Surgery Among Transgender Women & Transgender Men in a Community-Based Clinic in Metro Manila, Philippines: A Retrospective Study.

BackgroundMore information is needed about gender-affirming surgery (GAS) in the Philippines because of many self- or peer-prescribed gender-affirming procedures among transgender people.AimTo assess the desire of transgender adults for GAS, determined the prevalence, and evaluated factors associated with the desire.MethodsWe did a retrospective study of medical charts of 339 transgender men (TGM) and 186 transgender women (TGW) who attended clinical services at Victoria by LoveYourself, a transgender-led community-based clinic in Metro Manila, from March 2017 to December 2019. The medical charts were reviewed to ascertain data on gender dysphoria (GD), clinical and sociodemographic characteristics, health-seeking behaviors, and gender-affirmation-related practices, including the use of gender-affirming hormone therapy (GAHT). We also estimated the prevalence and explored factors associated with the desire for GAS using generalized linear models with a Poisson distribution, log link function, and a robust variance.Main Outcome MeasuresOur primary outcome was the self-reported desire for GAS.ResultsAlmost half were already on GAHT, of whom 93% were self-medicating. Our study's prevalence of GD is 95% and nearly 3 in 4 desire GAS. The prevalence of desiring GAS was related to the specific surgical procedure chosen. Transgender adults opting for breast surgery and genital surgeries have 8.06 [adjusted prevalence ratio, (aPR): 8.06; 95% Confidence Interval, (CI): 5.22–12.45; P value < .001] and 1.19 (aPR: 1.19; 95% CI: 1.11–1.28; P value < .001) times higher prevalence of GAS desire, respectively, compared with otherwise not opting for those procedures. Moreover, the prevalence of GAS desire was higher among patients with GD (aPR 1.09; 95% CI: 1.01–1.18; P value = .03) than individuals without GD.Clinical TranslationProviders' awareness of patients’ desires, values, and health-seeking preferences could facilitate differentiated guidance on their gender affirmation.Strengths and LimitationsThis quantitative study is the first to explore gender-affirming practices among transgender adults in the Philippines and provide significant insights into their healthcare needs. Our study focused only on TGM and TGW and did not reflect the other issues of transgender people outside of Metro Manila, Philippines. Furthermore, our retrospective study design may have missed essential predictors or factors not captured in the medical charts; hence, our study could never dismiss confounding factor bias due to unmeasured or residual confounding factors.ConclusionsThere is a high prevalence of self- and peer-led attempts from TGM and TGW to facilitate the gender transition, with the desire for GAS being significantly associated with GD and by which specific surgical procedure is chosen.Eustaquio PC, Castelo AV, Araña YS et al. Prevalence and Factors Associated With Gender-Affirming Surgery Among Transgender Women & Transgender Men in a Community-Based Clinic in Metro Manila, Philippines: A Retrospective Study. Sex Med 2022;10:100497.

To T or Not to T: The Transmasculine Singing Voice on Hormone Replacement Therapy

ABSTRACT Because testosterone-based hormone replacement therapy (HRT) naturally lowers the mean fundamental frequency range of the singer’s voice, the transmasculine voice has historically been treated as a kind of “gold standard” for gender transition—take T, wait a year and voila: a male voice. However, the process of post-pubertal hormonal changes is far more complex than it superficially appears, particularly for the voice. Research on outcomes for transitioning voices is sparse, and anecdotal narratives about poor outcomes give both professional and serious avocational singers pause. This lack of readily available evidence-based research presents a challenge both to trans singers and the voice professionals working with them: given the uncertainty of vocal outcomes, should the transmasculine singer pursue HRT? This article seeks to provide an overview of current knowledge about HRT and the transmasculine voice, contextualize existing data from a singing-voice point of view and highlight the gaps in understanding—offering insight from a transmasculine voice professional’s personal transition and professional teaching experience.

‘What’s in a name?’ The discursive construction of gender identity over time

ABSTRACT In recent years the concern with gender diversity fuelled by the rapid expansion of transgender studies highlighted multiple possibilities for constructing gender through discursive enactments. As the self-declaration of gender identity gained legitimacy, personal narratives became increasingly relevant. Verbalizing gender identity is instrumental for extending the very notion of gender as belonging to the domain of individual subjectivity and amenable to as many names as people’s non-transferable experiences allow. Drawing on 40 in-depth interviews with transgender and gender-nonconforming individuals in Portugal, the article examines the multiple terms used to self-describe and affirm gender identity over time. Reconstituted step-by-step through longitudinal lenses, each semantic journey illustrates how individuals appropriate different lexicons and self-describe at the intersection of multiple categories, resist biomedical codifications of gender transition and reinvent the terms of binary discursive regimes. Through their discursive practices, trans and gender-nonconforming individuals in the Portuguese context challenge one-dimensional readings of gender identity. While combining narrative approaches with regimes of power, the paper mobilizes Foucault’s notion of discursive formation and Bourdieu’s concept of field. ‘What’s in a name’ is more significant than Shakespeare ever imagined. The more the nexus-bodies-names-identities is disarticulated, the more individuals gain semiotic agency for self-describing their gender identities.