Often, body mass index (BMI) thresholds may be used to determine surgical candidacy in gender-affirming chest masculinization, but evidence for using these as surgical criteria has not been established. We sought to analyze a national cohort of patients undergoing mastectomy for gender affirmation to assess the risk of postoperative complications among different BMI categories. The National Surgical Quality Improvement Program database (from 2010 to 2020) was queried to identify all encounters of mastectomy for gender affirmation. Cases were stratified by BMI categories and 30-day postoperative medical and surgical complications were compared. A total of 10,775 patients were queried. The overall proportions of medical complications remained low for all groups. Incremental increases in the proportions of readmission, return to the operating room, wound infection, and wound dehiscence were observed with each increase in BMI category (p=0.001). A multivariate regression model controlling for age, diabetes, American Society of Anesthesiologists (ASA) class, and operative time demonstrated a statistically significant increase in odds ratio (OR) for complications in the obesity II (OR 1.59, p<0.001) and obesity III (OR 1.85, p<0.001) cohorts. Age (OR 1.08, p<0.001), diabetes (OR 1.4, p=0.016), and increased operative time (OR 1.22, p<0.001) were independently associated with an increase in odds of surgical complications. While the obesity II and III cohorts experienced increased odds of complications, the authors suggest that these complications are not prohibitive. In the setting of comprehensive informed consent, obesity alone should not act as a contraindication to surgery in suitable candidates.

Purpose: The study compared physician-based outpatient mental health care follow-up between transgender and gender diverse (TGD) individuals and the general population who had a mental health-related emergency department (ED) visit or hospitalization. Methods: This retrospective population-based cohort study used linked health administrative data to examine all adult psychiatric patients discharged from an ED visit (ED cohort) or hospitalization (hospitalization cohort) between 2012 and 2018 in Ontario, Canada. TGD individuals were identified and their data linked with health administrative data. The primary outcome was the proportion of individuals with any outpatient physician visit for mental health reasons within 30 days of the index discharge. Multivariable logistic regression analyses examined follow-up outcomes, including by diagnostic category, with adjustment for sociodemographic and clinical factors. Results: There were 728 TGD and 581,708 general population individuals with a mental health-related ED visit, while 454 TGD and 217,507 general population individuals had a psychiatric hospitalization. TGD individuals had higher 30-day post-ED follow-up (adjusted risk ratio [aRR] =1.21; 95% confidence interval [CI]: 1.02–1.42), particularly with a psychiatrist (aRR = 1.27; 95% CI: 1.07–1.52) and for those with an anxiety and related disorder diagnosis (aRR = 1.63; 95% CI: 1.23–2.15). Meanwhile, TGD individuals had lower 30-day follow-up posthospitalization (aRR = 0.80; 95% CI: 0.66–0.98) after adjusting for covariates. Conclusions: TGD individuals have greater rates of post-ED mental health follow-up, particularly with a psychiatrist, but lower rates of follow-up after a hospitalization. The higher follow-up after ED visits likely reflects greater clinical need. Lower follow-up after hospitalization is concerning given the risk of adverse outcomes and requires further research.

Borderline personality disorder (BPD) is a severe form of psychopathology associated with a host of negative outcomes. Some literature suggests elevated prevalence among transgender and gender diverse (TGD) samples. Elevated BPD prevalence among TGD populations could be due to factors other than BPD-specific psychopathology. Studies of TGD samples typically omit assessment of BPD, making it difficult to understand elevated BPD diagnosis. The current study explored (1) differences in BPD diagnosis among TGD patients versus cisgender patients, (2) if differences were explained by BPD-specific pathology, and (3) if BPD diagnostic disparities existed based on assessment modality. Data from TGD (n=74) and cisgender heterosexual (n=920) patients who presented for treatment at one partial hospitalization program from 2014 to 2019 were compared to investigate differences in the frequency of BPD diagnosis. A larger proportion of TGD patients were diagnosed with BPD than cisgender patients (odds ratio [OR]=4.05, p<0.001). The disparity in diagnosis persisted even after controlling for BPD-specific personality pathology (OR=2.98, p<0.001). BPD diagnostic disparity occurred when assessed using structured (OR=4.78, p<0.001) and unstructured (OR=3.61, p<0.001) interview methods. There was no disparity, however, when BPD was diagnosed using an algorithm based on BPD-specific personality pathology purported to underlie the diagnosis. Clinical providers appear inclined to assign a BPD diagnosis to TGD patients that may not correspond with group differences in underlying personality pathology. That some BPD symptoms might be more likely in TGD samples, future research can examine criterion-level biases in BPD diagnosis among TGD individuals.

Using a community-engaged approach, we adapted a human immunodeficiency virus (HIV) prevention smartphone app, Transpire, to meet the HIV and sexually transmitted infection (STI) prevention needs of transgender men and other transmasculine people. We conducted a pilot study to assess the feasibility and acceptability of the app among participants in two cities in the southeastern United States. Participants were recruited online and through community partners. Eligible and consenting participants used the Transpire app for 3 months and completed surveys at the beginning and end of the follow-up period. Transpire gave participants access to HIV and STI prevention information; the ability to order HIV and STI at-home self-test kits, condoms, and lube; and mental health and substance use resources. The primary feasibility outcome was the System Usability Scale (SUS), which measures the usability of technology-based products. Sixty participants were enrolled. Most were 18-24 years old (n=33, 55%) and identified as non-Hispanic white (n=46, 77%). The mean SUS score was 72.4, which meets established criteria for acceptability. Fifteen (32%) participants conducted an HIV test during the 3-month follow-up period and 2 (4%) initiated pre-exposure prophylaxis. Following a community-engaged adaptation process, the Transpire app was found to be acceptable in a pilot study conducted among transmasculine participants. These pilot data indicate that app-based interventions have the potential to increase awareness of and access to sexual health resources for transmasculine people. Additional studies will be needed to assess the efficacy of Transpire or similar apps to improve sexual health outcomes.

This study aimed to explore the use of serum free testosterone concentrations in transmasculine patients as a more reliable indicator of gender-affirming testosterone therapy than total testosterone concentration. Total testosterone values, recommended by current guidelines, may be impacted by obesity. In addition, this study aimed to characterize the impact of testosterone concentrations on hematocrit and the risk of polycythemia. A retrospective study was conducted of transmasculine patients seen at Boston Children's Hospital Gender Multispecialty Service from 2007 to 2020. Sixty-eight birth-assigned female adolescents who were receiving gender-affirming testosterone therapy and had total and free testosterone concentrations were included. The aims were to determine the fidelity of total and free testosterone concentrations with body mass index (BMI) and to characterize the association of testosterone concentrations with erythrocytosis. Of 68 subjects, 23% were overweight and 40% had obesity. Compared with the group with a healthy BMI, patients with obesity had significantly lower total testosterone concentrations. Free testosterone concentrations did not vary based on BMI category. BMI z-score was inversely correlated with total testosterone, sex hormone-binding globulin, and albumin concentrations but not with free testosterone concentrations. Four percent of subjects developed erythrocytosis (e.g., hematocrit >50%). Neither BMI nor testosterone concentrations were correlated with hematocrit. Free testosterone concentrations are an adjunctive tool in the monitoring of gender-affirming testosterone therapy. In addition, the development of erythrocytosis is independent of serum testosterone concentration and warrants further study to understand factors that may predispose patients to developing secondary polycythemia.

Transgender HealthAhead of Print Letter to the Editor: Extending the Reach of Peer-Led Support Groups via TelehealthMoira A. Kyweluk, Katie S. Greeley, and Jerrica KirkleyMoira A. Kyweluk*Address correspondence to: Moira A. Kyweluk, PhD, MPH, Plume Health, 303 S. Broadway #200-357, Denver, CO 80209, USA, E-mail Address: [email protected]Plume Health, Denver, Colorado, USA.Third Space Research, Philadelphia, Pennsylvania, USA.Search for more papers by this author, Katie S. GreeleyPlume Health, Denver, Colorado, USA.Search for more papers by this author, and Jerrica KirkleyPlume Health, Denver, Colorado, USA.Search for more papers by this authorPublished Online:22 Feb 2024https://doi.org/10.1089/trgh.2022.0136AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View article"Letter to the Editor: Extending the Reach of Peer-Led Support Groups via Telehealth." Transgender Health, , pp. FiguresReferencesRelatedDetails Volume 0Issue 0 InformationCopyright 2024, Mary Ann Liebert, Inc., publishersTo cite this article:Moira A. Kyweluk, Katie S. Greeley, and Jerrica Kirkley.Letter to the Editor: Extending the Reach of Peer-Led Support Groups via Telehealth.Transgender Health.ahead of printhttp://doi.org/10.1089/trgh.2022.0136Online Ahead of Print:February 22, 2024 Topicse-health and telehealth care PDF download

Many transmasculine patients undergo gender-affirming mastectomy and hysterectomy. Conflicting evidence exists whether these procedures may be safely combined. The purpose of this study is to compare post-operative complications between transmasculine patients who underwent mastectomy alone versus mastectomy in combination with hysterectomy. Retrospective chart review was performed on patients who underwent mastectomy between January 2020 and September 2022 (n=227). Patients were separated into two groups based on whether they had mastectomy alone (n=187) versus in combination with hysterectomy (n=40). Outcomes included operation time, length of inpatient hospital stay, chest wall complication, and revision rate and gynecologic complication rate. Independent t-tests, Pearson-chi square analyses, and Fischer's exact tests were used to compare outcomes between the groups. Overall rate of chest wall complications was 8.8%. Combination of mastectomy with hysterectomy within the same day significantly increased operation time (311 vs. 166 min, p<0.001), admission time (0.23 vs. 0.02 days, p<0.001), and rate of chest wall complications (17.5% vs. 6.9%, odds ratio [OR]=2.84 95% confidence interval [CI]: 1.05-7.65), particularly infection (7.5% vs. 1.1%, OR=7.50 95% CI: 1.21-46.46). There was no difference in hematoma or seroma formation, dehiscence, partial or complete nipple loss, or revision rates between groups. Gynecologic complication rate was 2.5% (n=1). Combining mastectomy and hysterectomy is not a benign undertaking as it is associated with increased risk of post-operative chest wall infection. Multidisciplinary surgical teams treating transmasculine patients should choose a surgical plan that optimizes patient outcomes.

Injectable estrogens are options for gender-affirming hormone therapy per guidelines, which suggest intramuscular dosages of 5-30 mg every 2 weeks or 2-10 mg weekly with estradiol cypionate or valerate interchangeably. Data among transgender and gender-diverse patients are limited due to local unavailability and concerns around laboratory assay variability and estradiol (E2) level fluctuation. We note a concerning trend where patients are prescribed high-dose injections based on the guidelines leading to serum E2 levels well above the range recommended in the same guidelines. Our review indicates that 5 mg weekly or lower should be prescribed when initiating injectable estrogens to avoid supraphysiologic E2 levels.

The sociopolitical context in which transgender and gender-diverse (TGD) people live has significant effects on mental health. We examined whether perceptions of context (TGD people's perceptions of how TGD people were viewed) differed across four United States (U.S.) states and associations with mental health and identity pride, the mediational effects of minority stressors, and potential buffering effects of resilience. TGD individuals in Oregon, Michigan, Nebraska, and Tennessee (n=158; ages 19-70, mean=33.06) completed questionnaires assessing their perceptions of how TGD people were viewed in their local area and in the U.S., as well as scales assessing minority stressors, pride, resilience, and mental health. Data were collected during Fall 2019 to Spring 2020. Oregon participants viewed perceptions in their state the most positively, with no state-level differences in terms of broader U.S. perceptions. Tennessee participants experienced more expectations of rejection; however, there were no differences across the states in other minority stress variables, identity pride, resilience, or mental health. Participants who viewed their area as having more negative views of TGD people reported higher levels of discrimination, expectations of negative events, internalized stigma, and anxiety, as well as less pride. The effects of perceptions of local context on mental health were partially explained by enacted stigma and internalized stigma. Resilience did not buffer the effects of perceptions of the local context on mental health or pride. Context is important to shaping exposure to minority stressors and mental health, potentially through increasing enacted and internalized stigma.