Reassignment Surgery Research Articles

Concurrent Gender Dysphoria/Incongruence and Autism Spectrum Disorder, a literature review

IntroductionSeveral studies have found that ASD (Autism Spectrum Disorder) and GD (Gender Dysphoria by DSM-V)/GI (Gender Incongruence by ICD-11) tend to co-occur, and in recent years the interest and publications on this comorbidity has increased rapidly.ObjectivesTo review the prevalence of ASD in individual with a diagnosis of GD/GI.To better tailor and improve care offered in the National Health Service (NHS) Gender Identity Clinics (GICs) throughout the UK.MethodsSystematic literature review was conducted via Pub Med, MEDLINE and PsycINFO by the author, for all English-language articles published between 2018 and 2023, containing keywords as ASD, GD (Gender Dysphoria), GI (Gender Incongruence), transgender, autistic traits, autism, gender diversity, gender variance.ResultsRate of people with ASD appear to be higher in people accessing Gender Identity Clinics (GICs) than in the general population. Results from this literature review show increased prevalence of GD and GI in ASD population.ConclusionsThis comorbidity has highlighted the importance of better tailor transgender healthcare services for people with neurodevelopmental conditions and neurodiversity, to avoid delay in ASD individuals accessing care and gender affirming medical treatments. Services should strive to provide an effective and equitable service. It is also important to better identify potential barriers for ASD people in accessing gender care. Literature also shows the people with ASD have more difficulties in communicating and describing their gender narrative and to express their wishes for gender treatments. Symptoms including problems in communications and social skills, obsession and rigidity can also impact their assessment of GD/GI in gender identity services. Some studies showed that for individuals who have concurrent ASD and GD/GI, assessment in GICs may be extended to better review their wishes for gender identity and for gender affirming treatment. Further research is needed to better investigate and understand factors explaining the relationship between ASD and gender diversity. There is still limited research in the real life experiences of gender diverse and autistic people. There is also a need to improve Gender reassignment protocol nationally to better care for individual with ASD and GD/GI throughout GICs in the UK.Disclosure of InterestNone Declared

"I'm not getting paid to give you a TED talk on how my trans body works". Experiences of hysterectomy gender affirming surgery: A qualitative study.

To explore the experiences of care surrounding hysterectomy as part of gender affirming surgery. An in-depth reflexive thematic analysis from accounts by 10 out of 12 people was undertaken. Experiences were then mapped to the surgery journey as a template for developing system responsiveness. No one person's experience of the procedure was affirmed across the entire surgery journey. Transgender health literacy was central to inclusive practice as it mediated bodily autonomy being upheld. The physical care environment influenced the experience, for example, the waiting room was marginalizing (intimidating), with a gendered clinic name and toilets. Some participants took a female support person/partner so that "people looking would assume that I was there supporting her, not the other way around." Communication misalignments were evident around information provided/understood about fertility and ovarian preservation. Participants were also placed in the position of both receiving care and providing education: "I also shouldn't have to be going in there for treatment, and then being expected to educate the medical professional that's meant to be helping me… I'm not getting paid to give you a TED talk on how my trans body works." The experiences mapped across the surgery journey highlighted multiple levels of service provision development needed to foster inclusive practice, for example, from workforce education to healthcare policy. Healthcare for transgender people can be unsafe and inequitable. Increasing transgender health responsiveness across the surgery journey will facilitate better alignments in communication and uphold bodily autonomy, leading to safer and inclusive practice.

Paucity of Online Information About Gender-Affirming Surgery Fellowships in the United States.

Despite growing demand for gender-affirming surgery (GAS), there are few formal GAS fellowships in the United States. Paucity of online information about GAS fellowships may discourage potential applicants and decrease the visibility of the field. Thus, it is important to analyze the existing online information about GAS fellowships to improve fellow recruitment and patient outcomes. To identify the number of GAS fellowship websites (GASFWs) and evaluate their robustness. Second, to report the social media presence of GAS fellowships. To identify GASFWs, existing databases sponsored by plastic surgery associations and Google query were used between April and May 2023. Thirty-five independent variables based on previously published data were evaluated for presence in a bivariate fashion on GASFWs. Accounts on popular social media websites were also identified by Google query. Website and social media analysis were also done for GAS fellowships that were offered by departments/specialties other than plastic surgery. In total, only 6 GASFWs associated with plastic surgery departments were identified and analyzed. Eight nonplastic surgery GASFWs were included for analysis. Overall, both categories of GASFWs were not robust; key information such as previous fellow listing and selection criteria was often missing. Furthermore, important topics specifically related to GAS such as community engagement and programmatic building are often not found on GASFWs either. In addition, none of the fellowships had any independent Facebook, Instagram, or Twitter. To ensure patient safety and quality outcomes, it is important to promote GAS by recruiting more applicants for specialized training beyond residency. With increased Internet use, improving GASFWs and social media presence as well as considering the use of a centralized database or match system can foster the growth of the field.

(O-19) GENDER REASSIGNMENT IN TRANSGENDER MEN IN BOGOTá, COLOMBIA

Abstract Introduction In the 21st century, the transgender population begun to have greater visibility and advances within the health field in terms of gender reassignment. This transition covers four aspects which includes legal, social, surgical reassignment and hormone therapy. Although the word transgender is no longer in the disorders section, it’s still seen as a disease. For this reason, the transgender population continues to be pathologized. In Bogotá, Colombia, information on the processes that encompass gender reassignment is currently not sufficient. Objective To understand the perception of transgender men about the four aspects of the female-to-male gender reassignment currently taking place in Bogotá. Method Qualitative descriptive study with biographical/narrative design carried out using semi-structured interviews were conducted with 4 transgender men over 18 years who have completed at least one of the aspects in Bogotá. These interviews were audio recorded, transcribed and analyzed. The results were divided into 2 dimensions, which were subdivided into various categories. Results and discussion Once gender reassignment began, most transgender men opt to start with the social aspect because it allows them to present themselves to society in their desired way. After this, they continued with the legal, hormonal and surgical aspects according to each person's preference. As a result, a lack of protocols and poor follow-up of health care guidelines for adequate care of this population were evident. Financing No conflict.

„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.

Peri-surgical imaging of intersex and gender diverse youths.

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Embracing Inclusivity in Hospice Care: A Case Study in Supporting HIV Patients.

Despite the growing prevalence of human immunodeficiency virus (HIV) and acquired immunodefiency syndrome (AIDS) in the Philippines and the psychosocial challenges it engenders, there remains a dearth of research on the intersection of HIV and hospice care. Stigma and discrimination further compound the challenges of providing inclusive hospice care to HIV patients in the country. Drawing upon the results of a recently published article centered on a Veteran assigned male at birth who expressed a desire for gender reassignment while receiving end-of-life care, this paper highlights the importance of sensitivity, understanding, and affirmation in hospice settings for HIV patients in the Philippines.

Gender Self-Identification: Opinions About Transgender Women from a National Online Survey in Taiwan

Gender self-identification (transgender) is not permitted in most Asian countries. In Taiwan, individuals recognized as transgender must meet requirements mandated by the Gender Recognition Act. Currently, lifting the requirement for proof of sex-reassignment surgery is pending. The aim of this study was to survey a large sample of Taiwanese to gain a better understanding of the general population’s attitudes toward gender self-identification. A self-report survey, entitled “Opinions of Gender Self-Identification,” collected demographic information and responses (agree = 1, disagree = 0) to 14 statements about transgender women and women’s safety, personal rights, and the law; one statement discussed rights of transgender men to give birth; total scores ranged from 0 to 14. The online survey was distributed to non-government organizations across Taiwan and the Taiwanese islands and was available between April 16 and 30, 2022. Most of the 10,158 respondents were female (77.4%); ages of respondents ranged from 15 to > 65 years. The mean total score was 0.95 ± 2.27, indicating respondents strongly disagreed with support for transgender females; 91.56% disagreed with all statements. Although there were significant differences in scores between parents and non-parents, and those ≤ 35 years versus ≥ 36 years (p < .01), all strongly disagreed with gender self-identification. Given the majority of respondents were females, survey findings should be regarded with caution. Public acceptance of gender self-identification requires support from its residents. Our findings suggest that gender self-identification has not begun to approach even a moderate level of public support among survey respondents.

(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.

(001) Brain Activation Patterns Associated with Visually Evoked Sexual Arousal in Female-To-Male Transgender Individuals

Abstract Introduction Cross-sex hormones in female-to-male (FtM) transgender individuals play a crucial role in brain plasticity. Brain activity associated with sexual arousal in FtM transgenders receiving cross-sex hormones is poorly understood. Objective This study aimed to compare brain activation patterns associated with sexual arousal between FtM transgenders and premenopausal women using a 3.0 Tesla functional magnetic resonance imaging (fMRI). Methods This study included 13 FtM transgenders (mean age: 43.2±6.4 years) and 13 premenopausal women (mean age: 41.5 ± 8.3 years). The FtM transgender individuals, who have had sex-reassignment surgery, received testosterone supplementary therapy. Sexual orientation was evaluated using the Kinsey sexuality rating scale (0 = exclusively heterosexual; 6 = exclusively homosexual). Serum sex hormones were measured, including free testosterone (free-T), estradiol (E2), follicle-stimulating, and luteinizing hormones. Visual sexual stimulation began with a 30-s cross fixation (rest condition), followed by a 30-s natural documentary (neutral condition), 540-s erotic video (sexual activation condition), then a 30-s cross fixation (rest condition). The fMRI data were post-processed using SPM8 software. Results The average rating of the Kinsey scale in the FtM transgenders was 5.6 ± 0.5, indicating their sexual orientation falls within the category of homosexual. The FtM transgenders showed significant increases in the free-T levels (18.8±18.9 pg/mL vs. 0.4±0.4 pg/mL, p &amp;lt; 0.001) and significant decreases in the E2 levels (45.4±32.0 pg/mL vs. 279.2±247.3 pg/mL, p = 0.001) compared with premenopausal women. The brain areas with significantly higher activities during visual sexual stimuli in the FtM transgenders compared with premenopausal women included the superior parietal lobule, middle occipital gyrus, and superior frontal gyrus (p &amp;lt; 0.001). Conclusions This study illustrates the specific brain activation patterns associated with sexual arousal in female-to-male (FtM) transgenders. These findings could contribute to our understanding of the neural mechanisms associated with sexual arousal in relation to the levels of sexual hormones in FtM transgenders. This research was supported by grants from the National Research Foundation funded by the government (MSIT; 2022R1A2C2007809, 2021R1C1C2011748). Disclosure No.

(126) Medicolegal Considerations for Patients Undergoing Urologic Surgical Interventions and the Development of an Audio-Recording Application for use During Genital Gender-Affirming Surgical Consultation

Abstract Introduction Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results A PubMed search yielded 921 results on "medical malpractice claims" from 2013–2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010–2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020–2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure No.

(272) Evidence-Based Strategies for Preventing Lower-Limb Complications Secondary to Prolonged use of the Dorsal Lithotomy Position

Abstract Introduction Patient positioning at the time of surgery plays a critical role in determining patient outcomes. Specific to patients undergoing genital gender-affirming surgery (gGAS), these patients are required to be placed in the lithotomy position to access the pelvis and perineum for their procedures. Lower-extremity injury due to prolonged surgical time in the lithotomy position can have significant post-operative morbidity affecting patient outcomes. This risk is increased in patients undergoing gGAS procedures due to high surgical complexity and especially long operative times as compared to other surgical procedures. Careful attention must be placed on the patient’s specific position perioperatively due to potential injury risk. Prolonged stasis can cause injuries ranging from mild soft-tissue injuries which rapidly resolve, such as mild pressure injuries to bony prominences, to severe injuries including pressure ulcers, nerve injuries, rhabdomyolysis, and compartment syndrome. These complications can have lasting impact on the patient, with associated morbidity and mortality risk, and can also impact healthcare systems through additional dollars spent caring for patients who suffer these complications and their associated rehabilitation, and legal recourse on behalf of the patient who suffered these severe complications. Objective Our study aimed to describe our technique for preventing lower extremity injuries in the dorsal lithotomy position, and to evaluate our positioning-related post-operative complications and rates. Methods We describe our technique for lower-limb positioning in the dorsal lithotomy position, with an emphasis on injury prevention for patients undergoing gGAS. We assessed positioning-related outcomes and complications among patients undergoing gGAS for prolonged periods (&amp;gt;300 minutes) in the lithotomy position between January 2017 to March 2023. Results A total of 227 patients underwent 310 gGAS procedures were included in our study (156 masculinizing: 154 feminizing gGAS procedures). Mean operative time was 495.5 minutes +/- 156.5 minutes (SD) (Range 300–1095 minutes) (Table 1a). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-operatively. No (0%) patients had major or chronic complications including chronic nerve injury, pressure ulcers, rhabdomyolysis or compartment syndrome (Table 1b). Our patient positioning employs the use of ½ inch foam placed to surround the lower extremity, ensuring that all at-risk areas of compression are adequately protected when placing the patient’s leg in the Allen stirrups whilst in the lithotomy position (Figure 1). In addition, a perioperative list is also utilized with regular leg checks every 1.5–2 hours with nursing documentation and also, ensuring patients are able to move their lower extremities without any pain post-operatively (Figure 2). Conclusions Our study is the first to describe a specific technique and outline strategies for protecting the lower extremities to prevent injuries in patients undergoing prolonged surgical procedures in the lithotomy position. The low complication rates associated with our technique warrants attention to further refine this technique, and, to integrate these strategies into operating-room programs across diverse specialties. 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.

(038) Development of a Vaginal Dilator and Home Insemination Device for Cis-And Transgender People, Based on Actual Pelvic Anatomy

Abstract Introduction Genital gender-affirming surgery (gGAS) is a rapidly evolving surgical field. Specific to feminizing gGAS, one surgical option pertains to vaginoplasty with creation of a neovaginal canal. Given this canal is commonly lined with skin, peritoneum, or colon, women who undergo these procedures as part of their gender affirmation must commit to life-long self-dilation and douching to maintain canal patency and hygiene. Current commercially available dilators and douches are designed for cisgender anatomy, and are either straight, or, have an abrupt upward curve at the tip, inconsistent with neovaginal canal anatomy, which also lacks the elasticity of a cisgender woman’s vagina, making it sensitive to dilator shape, and douche nozzle length. In addition, many LGBTQ+ individuals with a uterus seek pregnancy without a male sexual partner, but few devices exist which cater to this specific population. Objective 1) To design a vaginal dilator which more accurately reflects pelvic and vaginal canal anatomy, 2) Design a novel dilator which combines dilation, douching, and depth measurement functions, and 3) Modify our new dilator-douche device for use with semen for home insemination by both cis- and transgender women, and, transgender men seeking to become pregnant. Methods A radio-opaque catheter was placed into the neovaginal canal of 12 transgender women who underwent vaginoplasty with canal creation. C-Arm fluoroscopy delineated canal curvature based on the catheter. In addition, gynecologic texts and instruments were examined to ascertain the shape of a cisgender woman’s vaginal canal. Based on these findings, a novel dilator was designed and 3-D printed. Results A smooth “S-shape” was found in the vaginal canal of both cis- and transgender women, consistent with the shape of cervical dilators. In cisgender women, the vaginal vault, which is elastic, is closer to the introitus than that of transgender women. The cervix is typically anteriorly located between 0.5 to 4cm proximal to the posterior fornix. Our vaginal dilators (Figure 1a) (five, each 8–12cm circumference) and insemination device (Figure 1b-c) (9cm circumference) reflect the same smooth S-shaped design. Our dilators have depth markings, side-wall grooves to allow air and liquid to pass, and, can be fitted with a douche-bulb to maintain hygiene. Our insemination device can accommodate a 10cc syringe and has a recessed anterior wall 0.5–4cm from the tip to deposit semen around the cervix for conception. Conclusions The design improvements shown with respect to this dilator-douche device should make dilation and douching more comfortable, improve hygiene, and, decrease the incidence of granulation tissue. Our inseminator offers a private, at-home means of achieving fertilization for both cisgender and transgender individuals. (U.S. Patent 11638808; Neovaginal and vaginal health devices) Disclosure No.

(041) What Penis Size and Glans-Shape do Cis and Trans Men and Women Prefer?

Abstract Introduction The ideal length, circumference, and appearance of the penis are important to the self-confidence and body image of most men. To date, only 2 works have assessed preferred erect (but not flaccid) penis length, and only among cis-gender women. No study has evaluated preferred aesthetics--ideal erect and flaccid penile length, or, glans-shape and size preferences among cis-gender and transgender and non-binary individuals. These preference domains are especially important with genital gender-affirming surgery (gGAS) because length and glans-shape are entirely elective and technique-based, and help define neophallus appearance. Lastly, outlining the planned glans shape on a neophallus can be technically challenging, and, to date no publications have reported offering trans men input/choices. Objective 1) To query ideal for flaccid and erect penis length across all individuals, across cis- and transgender identities; 2) Determine specific likes/dislikes among all subjects for 7 different glans-shape examples; and 3) Among men undergoing phalloplasty, creation of glans-shape stencils for use in the OR, as a means to offer patients choice, and, to ensure that the final product aligns with patient’s choice. Methods An anonymous, online survey (QualtricsTM) evaluated glans preferences among 7 realistic prosthetic penis models shown. Participants were queried about their age, sex, gender, sexual orientation, and their ideal flaccid and erect penis length. Stencils were created based on 6 penis models. Subsequently, 7 transmen-subjects were able to choose the most-preferred glans shape and the stencil was applied before glansplasty surgery (Figure 1). Glansplasty results were assessed 12-weeks post-operatively (Figure 1c;E-F). Results 74 participants took the survey, (mean age of 35.3, Range: 23–59). 43/74 (58%) self-identified as men, and 28/74 (38%) identified as men, including 7 trans men (Table 1a). Men reported a mean ideal flaccid and erect length of 4.5 and 6.3-inches, respectively, while women reported a length of 5.2 inches and 6.16-inches, respectively. Women had a wider range of responses for both ideal flaccid and erect penile length (p&amp;gt;0.05) (Table 1b). For glans-shape preference, across all groups (independent of sex or sexuality), the “most-liked” options were A and E, and “most-disliked” were B and D (Figure 2). Among the 7 transmen undergoing glansplasty, 5/7 (71%) chose glans-shape C, and 1/7 (14%) each chose glans-shapes A and E, for their own phallus. Conclusions This is the first study to survey both men and women regarding ideal erect penile length, and the first regarding ideal flaccid penile length and glans-shape preferences. Our data suggests that the ideal erect and flaccid length are longer (within 2SD) than the mean values for cis-men of 5.16-inches and 3.61-inches respectively, (Miles et al., BJUI, 2014) but there is greater variability among women’s responses. Regarding glans-shape, most preferred a more tapered, bullet-like tip for the distal glans and a less prominent glans ridge. Finally, our glansplasty stencils are easy to use, yield excellent aesthetic results, and the option to choose their own glans shape is highly appreciated by patients. Disclosure No.

Doggone fat: An analysis of the barriers to top surgery for fat trans and nonbinary people in Canada

ABSTRACT The use of BMI to determine eligibility for gender-affirming surgeries, specifically for top surgery, is not based in science. The present work analyzes current policies regarding BMI limits alongside research participants’ experiences with BMI limits when attempting to access gender-affirming surgeries, arguing that BMI use presents a major barrier for fat trans and nonbinary individuals seeking transition-related surgeries. Based on previous literature and research participants’ experiences, this work further argues that BMI limits (and the lack of transparency regarding these limits) are harmful insofar as their use may result in denials or delays for these surgeries, prescriptions for weight loss, and negatively affect the mental health of those seeking surgery. The use of BMI may be grounded more in concern about aesthetic surgical outcomes rather than concern about health. Variation in coverage in Canada for all essential parts of top surgery (specifically the lack of coverage for liposuction and its classification as cosmetic in some provinces) present economic barriers that affect fat individuals more than those who are thin or average.

Psychiatric Diagnoses and Psychotropic Drug Usage in Gender-Affirming Voice Surgery Patients

ObjectivesTo describe the burden of psychiatric illness and psychotropic medication usage among the subset of transgender patients who undergo gender affirming laryngeal surgery and describe some of the most commonly encountered conditions experienced by this population Methods: An IRB approved chart review was conducted for the eighteen patients who have undergone gender affirming laryngeal procedures from August 2019 to June 2022 performed at a single institution. Patient demographic data, treatment details, and psychiatric diagnoses and prescriptions for psychotropic medications were recorded. ResultsOf the eighteen patients who underwent gender affirming laryngeal surgery at this institution, sixteen patients underwent these operations as part of a transition from male to female gender, while two patients were transitioning from female to male gender. In this cohort, thirteen patients were diagnosed with a psychiatric comorbidity (72.2%). Of these patients, eleven were prescribed at least one psychotropic medication (61.1%). The most common psychiatric illnesses encountered in these patients were depression, anxiety, and post-traumatic stress disorder. Ten patients were diagnosed with more than one psychiatric comorbidity (55.6%). The most commonly prescribed psychotropic drugs were selective serotonin/norepinephrine reuptake inhibitors. Three patients in this cohort had a recorded history of at least one prior suicide attempt. ConclusionsMultiple studies have demonstrated increased rates of mental illness in transgender individuals, however, this is the first study to describe the burden of these conditions specifically in the subset of patients who undergo gender affirming laryngeal surgery.

The Role of Psychiatry for Transgender and Gender Diverse Adults.

Since the inclusion of gender identity disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), psychiatry and the broader medical field have made substantial alterations in their recognition of and respect for transgender and gender diverse (TGD) identities. As this recognition continues to expand, psychiatrists should be aware of both historical harm and current best care practices, especially in light of psychiatric morbidity in TGD populations relative to the general population. This article contextualizes the history of psychiatry's engagement with TGD patients and presents the gender minority stress and resilience model to frame the mental health disparities experienced by TGD people. We envision a role for psychiatry that goes beyond gatekeeping gender-affirming hormone therapy and surgeries. Instead, we should invest in equitable care across the continuum of mental health needs. We provide an overview of existing literature to help characterize psychiatric epidemiology for this population, with the goal of offering guidance on how psychiatrists can deliver responsive and high-quality care for TGD people. Some key areas of proposed clinical improvement include culturally tailoring interventions for substance use disorders, reducing medical trauma in acute psychiatric care settings, and better understanding the interplay of psychopharmacology and gender-affirming hormone therapy.

Urogenital Complications that Decrease Quality of Life in Transgender Surgery

Gender reassignment surgeries are performed not to treat a congenital or anatomical anomaly, but to treat the psychological problems of transsexuals. In fact, there is no definitive evidence showing that psychological problems in transsexuals are cured by hormonal and/or surgical treatments for gender reassignment. On the contrary, there is evidence that these psychological problems persist after medical and surgical interventions, and even increase in some transsexuals, and a new form of body dysphoria occurs in a quarter of cases. Psychological problems in transgender people are not cured by surgery, and additional surgery-related complications develop in three-quarters of the cases. The vast majority of these are urogenital complications, and more than half require reoperations. However, in a significant proportion of cases, the outcome is unsuccessful and these urogenital complications significantly reduce the quality of life of transsexuals. Data also show that the life expectancy of transsexuals who undergo surgery is shortened by an average of 25-28 years due to psychological problems, suicides, surgical complications, reoperations and diseases related to hormone use. These results have led to an increase in the number of detransitioners who regret their medical and surgical transition and want to return in recent years, and have increased ethical debates on this issue. In this article, urogenital complications that develop after transgender surgery, which reduce the quality of life and possibly play a role in regrets are summarized.

Perceptions and Understanding of Transgender Patient Care: A Survey of Practicing Laryngologists.

Transgender individuals face significant health disparities including deficiencies in physician education, knowledge, and comfort with transgender health care. As the prevalence of the transgender population increases more individuals may seek gender-affirming surgery. Herein, we present a survey study which presents data on (1) the current practice patterns, (2) the familiarity with, (3) the perception of, and (4) the future educational goals of transgender health care among laryngologists in the United States. A cross-sectional survey study of practicing laryngologists in the United States. A total of 53 laryngologists participated in the study, with 50 (94.3%) coming from an academic practice. Survey response rate was 32.3% (54/167). The number of patients cared for and surgeries performed were significantly associated with self-perceived overall competence (p < 0.001 and p < 0.001), surgical competence (p = 0.013 and p < 0.001), and comfort counseling patients on gender-affirming surgeries (p < 0.001 and p < 0.001). Most obtained training through real-world experience (n = 46, 86.8%), whereas only 11 (20.7%) had formal training in residency or fellowship. Although 37 (70%) of participants felt competent caring for transgender patients, 38 (72%) want to learn more about transgender care, and 49 (93%) support incorporating transgender care into otolaryngology residency/fellowship curricula. There is a need for an increased awareness of transgender healthcare issues to address disparities experienced by this diverse population. Many laryngologists report wanting to learn more about this developing part of our field and support incorporating transgender care into training. We attempt to spotlight the degree by which practicing laryngologists are familiar, competent, and comfortable with transgender care. 5 Laryngoscope, 134:3215-3219, 2024.