Liver function in transgender persons:Challenges in the COVID-19 era

Transgender persons constitute a non-negligible percentage of the general population.Physical gender-transitioning in trans persons is mainly achieved with hormonal cross-sex therapy and sex reassignment surgeries that aim to align bodily appearance with gender identity.Hormonal treatment acts via suppressing the secretion of the endogenous sex hormones and replacing them with the hormones of the desired sex.The administration of testosterone is the typical masculinizing treatment in trans men,whilst trans women are routinely treated with estradiol agents in combination with anti-androgens or gonadotrophinreleasing hormone agonists if testes are present.Exogenous androgenic steroids,estradiol agents,and anti-androgens have been implicated in a series of hepatotoxic effects.Thus,liver integrity is a major concern with the long-term administration of cross-sex therapy.Hepatic tissue is susceptible to coronavirus disease 19(COVID-19)through various pathophysiological mechanisms.Special consideration should be paid to minimize the risk of hepatic damage from the potential cumulative effect of COVID-19 and gender-affirming treatment in transgender patients.Appropriate care is significant,with continuous laboratory monitoring,clinical observation and,if needed,specific treatment,especially in severe cases of infection and in persons with additional liver pathologies.The pandemic can be an opportunity to provide equal access to care for all and increase the resilience of the transgender population.

Cancer screening and management in the transgender population:Review of literature and special considerations for gender affirmation surgery

BACKGROUND Literature focused on cancer screening and management is lacking in the transgender population.AIM To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming(TGNC)patients.METHODS We performed a systematic search of PubMed on January 5th,2022,with the following terms:“TGNC”,OR“transgender”,OR“gender non-conforming”,OR“gender nonbinary”AND“cancer screening”,AND“breast cancer”,AND“cervical cancer”,AND“uterine cancer”,AND“ovarian cancer”,AND“prostate cancer”,AND“testicular cancer”,AND“surveillance”,AND“follow-up”,AND“management”.70 unique publications were used.The findings are discussed under“Screening”and“Management”categories.RESULTS Screening:Current cancer screening recommendations default to cis-gender protocols.However,long-term genderaffirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection.The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer.Management:Prior to undergoing Gender Affirmation Surgery(GAS),discussion should address cancer screening and management in the organs remaining in situ.Cancer treatment in this population requires consideration for chemotherapy,radiation,surgery and/or reconstruction.Modification of hormone therapy is decided on a case-by-case basis.The use of prophylactic vs aesthetic techniques in surgery is still debated.CONCLUSION When assessing transgender individuals for GAS,a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential.Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social,medical,surgical and gender affirming surgery related specifications.Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes.A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS.Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address.We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature.Further research is required to ensure more comprehensive and individualized care for this population.

A Rare Case of 83-Year-Old Transgender Female: Can Thyroid Hormone Deficiency Be Involved in Transgenderism and Gender Dysphoria?

In the current report, we describe an 83-year-old biological male who self- identified as a female by legally changing his first and middle names to female ones and whose death certificate states his sex as a female. The medical history of this individual indicated complete penectomy without further specification. Postmortem physical examination revealed an absence of penis with a large scrotum, transposed urethral orifice, and small testes. The histological analysis of the testes identified abnormal epithelium in the seminiferous tubules that lacked germ and Sertoli cells as well as the interstitium without Leydig cells present. The exome sequencing of the individual’s DNA using the Next Generation Sequencing (NGS) Illumina platform revealed no genetic variants associated with either penile or urethral cancer that could have explained the complete penectomy, but pointed toward a potentially impaired production of T3 and T4 thyroid hormones which could account for the observed testicular malformation. Overall, the data obtained raise an important question as to whether the thyroid hormone axis could be an important part of the hormonal architecture supporting male sexual behavior.

Psychosexual Assessment of Transgender Individuals during the Sex Reassignment Process: Sexual Desire, Activity, and Satisfaction

A group of 39 Transgender subjects, 17 Female to Male (FtM) and 22 Male to Female (MtF), have been evaluated about their sexual desire, activity, and satisfaction during the period before and after Sex Reassignment by Surgery (SRS). Visual Analogue Scale from 0 to 10 has been used to assess sexual desire and satisfaction, number of sexual partners and number of sexual intercourses/ month have been evaluated to assess sexual activity. Moreover, after the surgery, the Sexual Desire Inventory-2 (SDI-2) was administered to patients and related to testosterone (total or free) levels. In FtM, after hysterectomy and bilateral ovariectomy, mean value of sexual desire (VAS 0 - 10) was 7.5 before beginning testosterone therapy, this value increased after six months of therapy and after one year. Just before SRS the value decreased, but increased to 8.42 after SRS. In the same patients the values (VAS 0 - 10) on sexual satisfaction were respectively 6.5, 6.9, 7.1, 6.5 and 7. Mean number of partners was 4, with 7.07 mean frequency of sexual intercourse/month, before starting therapy (after hysterectomy). During hormonal therapy (testosterone), No. of partners was 2.46 and 8.96 intercourses/month, while after SRS the partners were 1.25 and intercouses/month 7.91. MtF patients reported a sexual desire (VAS 0 - 10) before therapy of 7, this remained almost constant after 6 months, decreases after 12 months and just before surgery, and finally increased to 7.76 after SRS. For sexual satisfaction mean values of VAS were respectively: 6.1, 6.2, 6.3, 6, and 6.8. Regarding sexual activity, MtF report 3.81 mean No. of partners and 9.27 intercouses/month before the beginning of hormonal therapy, 1.36 partners and 4.36 intercourses after therapy, and 1.3 partners and 4.54 intercourses after SRS.

Effects of gender-affirming hormone therapy on insulin resistance and body composition in transgender individuals: A systematic review

BACKGROUND Transgender individuals receiving masculinising or feminising gender-affirming hormone therapy with testosterone or estradiol respectively,are at increased risk of adverse cardiovascular outcomes,including myocardial infarction and stroke.This may be related to the effects of testosterone or estradiol therapy on body composition,fat distribution,and insulin resistance but the effect of genderaffirming hormone therapy on these cardiovascular risk factors has not been extensively examined.AIM To evaluate the impact of gender-affirming hormone therapy on body composition and insulin resistance in transgender individuals,to guide clinicians in minimising cardiovascular risk.METHODS We performed a review of the literature based on PRISMA guidelines.MEDLINE,Embase and PsycINFO databases were searched for studies examining body composition,insulin resistance or body fat distribution in transgender individuals aged over 18 years on established gender-affirming hormone therapy.Studies were selected for full-text analysis if they investigated transgender individuals on any type of gender-affirming hormone therapy and reported effects on lean mass,fat mass or insulin resistance.RESULTS The search strategy identified 221 studies.After exclusion of studies that did not meet inclusion criteria,26 were included(2 cross-sectional,21 prospectiveuncontrolled and 3 prospective-controlled).Evidence in transgender men suggests that testosterone therapy increases lean mass,decreases fat mass and has no impact on insulin resistance.Evidence in transgender women suggests that feminising hormone therapy(estradiol,with or without anti-androgen agents)decreases lean mass,increases fat mass,and may worsen insulin resistance.Changes to body composition were consistent across almost all studies:Transgender men on testosterone gained lean mass and lost fat mass,and transgender women on oestrogen experienced the reverse.No study directly contradicted these trends,though several small studies of short duration reported no changes.Results for insulin resistance are less consistent and uncertain.There is a paucity of prospective controlled research,and existing prospective evidence is limited by small sample sizes,short follow up periods,and young cohorts of participants.CONCLUSION Further research is required to further characterise the impact of genderaffirming hormone therapy on body composition and insulin resistance in the medium-long term.Until further evidence is available,clinicians should aim to minimise risk by monitoring cardiovascular risk markers regularly in their patients and encouraging healthy lifestyle modifications.

Correlates of HIV infection among transgender women in two Chinese cities

Background:In an era when HIV transmission has been on the rise among men who have sex with men(MSM),transgender women may play a considerable role in China’s current HIV epidemic as a potential“bridge”of HIV transmission between homosexual and heterosexual populations.We sought to understand the risk behaviours and factors associated with HIV infection among transgender women in two cities in China.Methods:From January to December 2016,we recruited transgender women with the help of community-based organizations(CBOs)through a wide range of methods,including snowball sampling.After recruitment,we asked participants to fill out a structured questionnaire including questions about socio-demographics,sexual behaviours,condom use,substance use and uptake of health care services.HIV infection status was determined by using two different rapid testing reagents.Results:Among 498 subjects enrolled in this study,233 were from Shanghai and 265 were from Tianjin.The median age was 30 years(range:18-68;IQR:24-33).Of them,337(67.7%)preferred feminine dress,13(2.6%)had undergone transsexual operation and 68(13.7%)had used hormones for transition purposes.Nearly half(45.6%)reported having regular partners,and 351(70.5%)had casual partners.Regarding condom use,81.5%reported not always using condoms with stable partners,and 70.9%reported not using condoms with casual partners.Twentyfive(5.0%)had a history of buying sex and fifty-one(10.2%)had a history of selling sex in the past three months.A total of 200(40.2%)participants had used at least one kind of controlled substance in the past six months.The most commonly used substances were amyl nitrates(rush popper)(99.5%)and 5-MeO-DiPT(20.0%).Among rush popper users,170(85.4%)reported always having sex while on the drug,and 177(88.9%)reported increased sexual pleasure after using the drug.The HIV infection risk factors identified in our study were being located in Shanghai(aOR=9.35,95%CI=3.89-22.49),selling sex in the past three months(aOR=3.44,95%CI=1.31-9.01),and substance use in the past six months(aOR=5.71,95%CI=2.63-12.41).Conclusions:Transgender women bear a high HIV burden in the two Chinese cities.Those involved in commercial sex tended to have inconsistent condom use,leading to high risk of HIV infection.Substance use was an independent risk factor of HIV infection by increasing sexual activities and unprotected sex,which indicated an aggravated and complex situation with possible interacting syndemic factors that could cumulatively facilitate sexual risk behaviours and HIV infection in transgender women.There is an urgent need for innovative and appropriate HIV prevention programmes targeting this unique population.Efforts should be made to provide them with tailored services including persuasive communication on consistent condom use,substance use counselling and related referral services,all with the goal of reducing HIV epidemic among transgender women.

HIV incidenee and risk factors among transgender women and cisgender men who have sex with men in two cities of China:a prospective cohort study

Background:HIV epidemic among men who have sex with men(MSM)remains a major public health concern in China.Despite a growing body of research on transgender women worldwide,little is known about Chinese transgender women within MSM.We sought to estimate HIV incidence and distinguish risk factors of HIV acquisition among them from that among cisgener(non-transgender)MSM(cis-MSM).Methods:We conducted an open cohort study among Chinese MSM,including those who were identifed as transgender in Shanghai and Tianjin.Participants were initially recruited by local community-based organizations from January to June,2016,and were followed up approximately every 6 months until June 2018.At each visit,a structured questionnaire was used to gather information on demographics,sexual risk behaviors,and HIV status.HIV incidence was calculated as the number of seroconversions divided by total number of person-years of follow-up among HIV-negatives at baseline.Risk factors of HIV acquisition were assessed by univariate and multivariate Cox regression models with time-dependent variables.Results:A total of 1056 participants contributed 1260.53 person-years(PYs)of follow-up,33 HIV seroconversions occurred during the follow-up period,yielding an estimated HIV incidence of 2.62(95%CI 1.80–3.68)per 100 PYs.HIV incidence among transgender women was 4.42 per 100 PYs,which was signifcantly higher than that of 1.35 per 100 PYs among cis-MSM,demonstrating a threefold higher odds of HIV infection than cis-MSM.For transgender women,those lived locally≤2 years(adjusted hazard ratio[aHR]=1.76,95%CI 1.13–2.76)and unprotected anal sex last time(aHR=4.22,95%CI 1.82–9.79)were more likely to acquire HIV.For cis-MSM,factors associated with HIV acquisition were frequency of anal sex≥3 times in past one month(aHR=4.19,95%CI 1.06–16.47)and unprotected anal sex last time(aHR=5.33,95%CI 1.52–18.73).Conclusions:Compared to cis-MSM,transgender women were at higher risk of HIV acquisition,highlighting an urgent need of tailored prevention.Future HIV program should consider to include them to ensure that this population in China are not left behind.

Identity,stigma,and HIV risk among transgender women:a qualitative study in Jiangsu Province,China

Background:Transgender women have multiple disparities globally,including social rejection and stigma,HIV infection and untreated mental health problems.However,few data on transgender women are available in China.Therefore,this study aimed to explore transgender women's experiences on gender identity,disclosure,discrimination,transgender-specific medical care,and perceptions of HIV and sexually transmitted infections(STI)risk in China.Methods:A qualitative study was conducted in Nanjing and Suzhou city,China in 2018.Key informant interviews(n=14)and focus group discussions(n=2)with diverse transgender women were implemented.Text was transcribed and translated,and Dedoose™software was used for coding,analysis and interpretation by the research team.Results:Chinese transgender women share experiences with transgender women worldwide,including a long and challenging identity search,stigma and discrimination,poor access to trans-specific services and unmet needs for mental health care.Features unique to them include terms used for self-identification,culturally-shaped expectations for reproduction,and ideals of placing the familial and societal welfare over personal fulfillment.Social networks of this population appear sparse,scattered,and underground.Familial rejection was experienced by nearly all respondents.Perceptions of HIV and STI risk and history of HIV testing were notably low.Conclusions:Transgender women in China face high social rejection and discrimination along with unmet need for various types of healthcare.Scaling up transgender-specific services including gender-affirming medical care,mental health care and HIV/STI prevention are warranted to address the social,medical and mental health of transgender women in China.

Increased Cortical Thickness in Male-to-Female Transsexualism

Background: The degree to which one identifies as male or female has a profound impact on one’s life. Yet, there is a limited understanding of what contributes to this important characteristic termed gender identity. In order to reveal factors influencing gender identity, studies have focused on people who report strong feelings of being the opposite sex, such as male-to-female (MTF) transsexuals. Method: To investigate potential neuroanatomical variations associated with transsexualism, we compared the regional thickness of the cerebral cortex between 24 MTF transsexuals who had not yet been treated with cross-sex hormones and 24 age-matched control males. Results: Results revealed thicker cortices in MTF transsexuals, both within regions of the left hemisphere (i.e., frontal and orbito-frontal cortex, central sulcus, perisylvian regions, paracentral gyrus) and right hemisphere (i.e., pre-/post-central gyrus, parietal cortex, temporal cortex, precuneus, fusiform, lingual, and orbito-frontal gyrus). Conclusion: These findings provide further evidence that brain anatomy is associated with gender identity, where measures in MTF transsexuals appear to be shifted away from gender-congruent men.

Prevalence of HIV in a Tertiary Care Centre in Delhi: A Five-Year ICTC Based Study

Objective: The purpose of this study is to estimate the prevalence of HIV infection among the clients attending ICTC, LHMC of New Delhi, for a period of five years, i.e., from 2008 to 2012. Material & Method: A total of 25,413 clients attended ICTC, LHMC from the year 2008 to 2012. Serum samples were collected after taking informed consent and pre-test counseling. In India for all ICTCs, NACO (National AIDS Control Organization), a national guidelines has been followed for HIV testing, reporting and release of results with post test counseling. Results: Out of the total 25,413 clients tested for HIV infection, 963 (3.78%) were found to be HIV-1 seropositive. Seropositivity was higher in male clients i.e. 625 (64.4%) than female i.e. 336 (34.8%) followed by transgender (TG), i.e., 2 (0.2%). Heterosexual route of transmission was the major route seen in 676 clients (70.1%). Maximum HIV seropositivity was in the age group of 25 - 34 years (35.4%). No HIV-2 case was found among the studied population. Conclusion: HIV prevalence of 3.78% among the clients attending ICTC, LHMC, New Delhi, puts light on the burden on HIV in this part of the country and suggests the need for the scaling up of focused prevention efforts in high-risk groups.

Impact of gender-affirming hormone therapy on the development of COVID-19 infections and associated complications:A systematic review

BACKGROUND Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)can produce a wide range of clinical manifestations from asymptomatic to life-threatening.Various researchers have worked to elucidate the pathogenic mechanisms underlying these variable presentations.Differences in individual responses to systemic inflammation and coagulopathy appear to be modulated by several factors,including sex steroid hormones.Transgender men or non-binary individuals who undergo gender-affirming hormone therapy(GAHT)are a unique population of interest for exploring the androgen-mediated coronavirus disease 2019(COVID-19)hypothesis.As the search for reliable and effective COVID-19 treatments continues,understanding the risks and benefits of GAHT may mitigate COVID-19 related morbidity and mortality in this patient population.AIM To investigate the potential role of GAHT in the development of COVID-19 infections and complications.METHODS This systematic review implemented an algorithmic approach using PRISMA guidelines.PubMed,Scopus,Google Scholar top 100 results,and archives of Plastic and Reconstructive Surgery was on January 12,2022 using the key words“gender”AND“hormone”AND“therapy”AND“COVID-19”as well as associated terms.Non-English articles,articles published prior to 2019(prior to COVID-19),and manuscripts in the form of reviews,commentaries,or letters were excluded.References of the selected publications were screened as well.RESULTS The database search resulted in the final inclusion of 14 studies related to GAHT COVID-19.Of the included studies,only two studies directly involved and reported on COVID-19 in transgender patients.Several clinical trials looked at the relationship between testosterone,estrogen,and progesterone in COVID-19 infected cis-gender men and women.It has been proposed that androgens may facilitate initial COVID-19 infection,however,once this occurs,testosterone may have a protective effect.Multiple clinical studies have shown that low baseline testosterone levels in men with COVID-19 are associated with worsening outcomes.The role of female sex hormones,including estrogen and progesterone have also been proposed as potential protective factors in COVID-19 infection.This was exemplified in multiple studies investigating different outcomes in pre-and post-menopausal women as well as those taking hormone replacement therapy.Two studies related specifically to transgender patients and GAHT found that estrogen and progesterone could help protect men against COVID-19,and that testosterone hormone therapy may increase the risk of contracting COVID-19.CONCLUSION Few studies were found related to the role of GAHT in COVID-19 infections.Additional research is necessary to enhance our understanding of this relationship and provide better care for transgender patients.

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 genderaffirming 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 hypothalamicpituitary-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.

A Retrospective Study on the Prevalence of HIV among Patients Attending a Tertiary Care Hospital of Northeast India

Objective: The main objective of this study is to evaluate the prevalence of HIV infection among the clients attending ICTC, Gauhati Medical College & Hospital, Guwahati, for a period of seven years, i.e., from April 2008 to March 2015. Material & Method: A total of 40,983 clients attended ICTC, Gauhati Medical College & Hospital from the year 2008 to 2015. Serum samples were collected after taking informed consent and pre-test counseling. In India for all ICTCs, NACO (National AIDS Control Organization), a national guidelines has been followed for HIV testing, reporting and release of results with post test counseling. Results: Of the total 40,983 clients tested for HIV infection, 1919 (4.68%) were found to be HIV seropositive. Seropositivity was higher in male clients i.e. 1314 (68.47%) than female i.e. 604 (31.47%) followed by transgender (TG), i.e., 1 (0.0005%). Heterosexual route of transmission was the major route seen in 1666 clients (86.81%). Maximum HIV seropositivity was in the age group of 45 - 49 years (43.62%). Conclusion: HIV prevalence of 4.68 % among the clients attending ICTC, Gauhati Medical College & Hospital, Guwahati, puts the spotlight on the HIV burden in this part of the country and suggests the need for the scaling up of focused prevention efforts in high-risk groups.

Chemsex and its risk factors associated with human immunodeficiency virus among men who have sex with men in Hong Kong

We were intrigued by Hanum et al,who published a study on the prevalence of human immunodeficiency virus(HIV)in homosexual,bisexual,and other men who have sex with men at sexual health clinics in England and the relationship between baseline variables and future HIV occurrence.Chemically-enhanced sexual experience(chemsex)is becoming a global phenomenon.There are increasing medical and academic concerns about chemsex,where substances are used to boost sexual satisfaction,which is prevalent in groups,especially among homosexuals.Lesbians,gays,bisexuals,transgenders,and queers have become increasingly visible,valued,and committed community.However,chemsex requires urgent attention.

Health-related attitudes and risk factors for sexually transmitted infections of Chinese women who have sex with women

Background Previous studies have shown evidence of health-related risk behaviors among women who have sex with women （WSW）, such as sex with men, multiple bisexual partners, and drug use. Women who have sex with women have also been known to avoid routine physical examinations and conceal their same-sex history from physicians, which can affect their ability to receive an accurate diagnosis and treatment. No previous research has targeted women who have sex with women in China. We sought to describe women who have sex with women in China and explore risk factors for their reproductive tract infections （RTI）/sexually transmitted infections （STI）. Methods Participants were recruited through outreach in venues and online for a cross-sectional study. Data were collected using interviews and laboratory tests. Results We recruited 224 women who have sex with women. In the year preceding their participation in the study, 92% （206/224） of women reported sexual relations with women. The RTI rates were： gonorrhea （15.8%）, chlamydia （3.5%）, syphilis （0.5%）, bacterial vaginosis （14.4%）, hepatitis B virus （HBV） （0.9%）, hepatitis C virus （HCV） （0.5%）, and candidiasis （6.9%）. No HIV or herpes simplex virus （HSV） positive cases were detected. Factors associated with gonorrhea infection were non-Beijing local residency （odds ratio （OR）=2.1, 95% confidence interval （C/）： 1.2-3.8） and genital-genital contact （OR=3.1, 95% CI： 1.3-7.2）; factors associated with curable STI （excluding bacterial vaginosis, candidiasis, HBV and HCV） were non-Beijing local residency （OR=1.9; 95% CI： 1.2-3.0） and bleeding during or after sex （OR=18.1; 95% CI： 5.2-62.6）; and the factor associated with RTI （including all the infections tested） was bleeding during or after sex （OR=37.8, 95% CI： 11.2-127.4）. Conclusions Behaviors that may cause RTI/STI exist among Chinese women who have sex with women. Researchers should consider these behaviors when planninq correspondin.q prevention and interventions.

UNCOVERING:THE ECONOMIC BENEFITS OF LGBT WORKPLACE INCLUSION

Lesbian,gay,bisexual,and transgender(LGBT)people constitute approximately five percent of the population,but workplace discrimination based on sexual orientation and gender identity remains troublingly commonplace.This article summarizes a large and growing body of social science research demonstrating the economic benefits of LGBT inclusion(and the costs of LGBT exclusion)in the workplace.It concludes with recommendations for(1)future research,stressing the need for more China-specific studies,which would inform policymaking and theoretical understanding of diversity and inclusion practices on business performance,(2)improving employer LGBT-inclusion policies,and(3)strengthening state protection of the equal employment rights of LGBT people.

Using data from‘visible’populations to estimate the size and importance of‘hidden’populations in an epidemic:A modelling technique

We used reported behavioural data from cisgender men who have sex with men and transgender women(MSM/TGW)in Bangalore,mainly collected from‘hot-spot’locations that attract MSM/TGW,to illustrate a technique to deal with potential issues with the representativeness of this sample.A deterministic dynamic model of HIV transmission was developed,incorporating three subgroups of MSM/TGW,grouped according to their reported predominant sexual role(insertive,receptive or versatile).Using mathematical modelling and data triangulation for‘balancing’numbers of partners and role preferences,we compared three different approaches to determine if our technique could be useful for inferring characteristics of a more‘hidden’insertive MSM subpopulation,and explored their potential importance for the HIV epidemic.Projections for 2009 across all three approaches suggest that HIV prevalence among insertive MSM was likely to be less than half that recorded in the surveys(4.5e6.5%versus 13.1%),but that the relative size of this subgroup was over four times larger(61e69%of all MSM/TGW versus 15%).We infer that the insertive MSM accounted for 10e20%of all prevalent HIV infections among urban males aged 15e49.Mathematical modelling can be used with data on‘visible’MSM/TGW to provide insights into the characteristics of‘hidden’MSM.A greater understanding of the sexual behaviour of all MSM/TGW is important for effective HIV programming.More broadly,a hidden subgroup with a lower infectious disease prevalence than more visible subgroups,has the potential to contain more infections,if the hidden subgroup is considerably larger in size.

A narrative review of outcomes following metoidioplasty:complications and satisfaction

Metoidioplasty consists of lengthening and straightening the hormonally hypertrophied clitoris.The goals of the procedure include masculinizing the external genitalia and enabling standing micturition.Metoidioplasty may be performed as a stand-alone procedure or an interval procedure prior to phalloplasty.While most often performed with urethral lengthening,metoidioplasty may also be performed as a“simple release”(i.e.,without urethral lengthening).Secondary procedures typically include scrotoplasty and placement of testicular implants.While satisfaction with this procedure is high,complications can occur.Complications are commonly categorized as either urologic(i.e.,strictures and fistula)or wound healing(i.e.,wound disruption,infection,bleeding,etc.).This narrative review discusses postoperative outcomes,including both satisfaction and complications.Published data on complications include fistula and stricture rates from 0%-50% and 0%-63%,respectively.Overall satisfaction with appearance ranges from 48%-100%,and patient ability to void while standing ranges from 67%-100%.Metoidioplasty is a safe and effective procedure for transgender men.Further research regarding surgical techniques and outcomes will help reduce complications and improve overall patient satisfaction.

Ehlers-Danlos syndrome:prevalence and outcomes in gender affirming surgery-a single institution experience

Aim:Patients with Ehlers-Danlos Syndrome(EDS)are considered to have an increased risk for wound healing complications.Surgeons may therefore be hesitant to offer elective surgeries,including gender-affirming surgeries(GAS),to EDS patients.At our center,we frequently encountered patients presenting for GAS evaluation with the co-existing diagnosis of EDS.This study aims to establish the prevalence of EDS diagnosis in our GAS patients and compare their post-operative complications to patients without EDS diagnosis.Methods:This is a single-institution retrospective case-control study on all patients who underwent GAS from 2016-2020.Data include EDS diagnosis,demographics,operation,and complications(including minor wound healing issues).Results:Of 1363 patients presenting for GAS,36(2.6%)had EDS diagnoses and were matched with 108 control patients.Major complications requiring surgical intervention in the OR occurred in 6 patients(4.2%),(2.8% EDS vs.5.4%controls;P=0.63),while 8.3% of EDS and 14% of controls required minor interventions(P=0.38).The rate of wound healing issues of any severity was 28% in EDS vs.47% in control groups(P=0.04).Conclusion:The prevalence of EDS diagnosis in our patient population is 132 times the highest reported prevalence in the general population.Wound healing issues and the need for additional post-operative interventions in the group with EDS diagnosis were not significantly different from the control group.Our findings suggest that patients with a diagnosis of EDS undergoing GAS have comparable outcomes to patients without EDS.Concerns for post-operative complications should not be a barrier to offering GAS to patients presenting with an EDS diagnosis.

Established and experimental techniques to improve phalloplasty outcomes/optimization of a hypercomplex surgery

An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria.Phalloplasty is the most complex of these surgeries,and this complexity creates a wide range of potential complications.Some of the most common complications and therefore,targets for improvement in outcomes,concern neourethral fistula/stricture,efficacy of reinnervation of the phalloplasty flap,postoperative flap monitoring,and donor site morbidity.In the setting of no established"gold standard",this review seeks to describe the components and staging of phalloplasty,with an emphasis on established and experimental solutions to the most common and vexing problems.