European Society for Sexual Medicine position statement 'Assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction'

Background: There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice. Aim: We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction. Methods: The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available. Outcomes: The foci of the study are assessment and hormonal aspects of trans health care. Results: As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment. Clinical Implications: This is an up-to-date ESSM position statement. Strengths & Limitations: These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited. Conclusion: This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people

İndol , kinazolin ve benzodiazepin sistemleri için yeni sentetik yöntemlerin geliştirilmesi

TÜBİTAK MAG30.11.2010İndol, altılı bir halka ile pirol halkasından oluşan bisiklik yapıya sahip heterosiklik ve aromatik bileşiktir. İndol türevleri çok geniş bir yelpezade çeşitli biyolojik aktivite gösterirler. Kinazolin halkası, benzen halkası ve pirimidin halkasının kenetlenmesi sonucu oluşmuş bir bileşiktir. Tıbbi açıdan, çeşitli alanlarda, örneğin; sıtma ve kanser hastalıklarının tedavisinde yaygın bir şekilde kullanılmaktadır. Benzodiazepinler, benzen ve iki azot atomu içeren yedili bir halkanın kenetlenmesi sonucunda oluşmuş bir bileşiktir. Piyasada 15’in üzerinde benzodiazepin türevi çeşitli psikolojik ve organik rahatsızlıkların tedavisinde ilaç olarak kullanılmaktadır. Bu bileşikler için literatürde sayısız ve çok çeşitli sentez yöntemleri mevcuttur. Bu proje kapsamında, bu bileşiklerin sentezi için, benzen ve furan halkasına bağlı diasitlerden hareket ederek ilgili diizosiyanatlar sentezlendi. Asit grupları aromatik halkaya bir veya iki metilen grubu aracılığı ile de bağlanmış olabilirler. İzosiyanat gruplarından ikisi veya biri kontrollü bir şekilde üretan veya üreye çevrildi.Üre ve/veya üretan fonksiyonel grubun diğer izosiyanat grubuna intramoleküler katılması sağlanarak yapıları aşağıda verilen aromatik halkaya kenetlenmiş yeni heterosiklik bileşiklerin sentezi gerçekleştirildi. Diasitlerin yanı sıra, heterosiklik halkanın oluşturulması için yarıesterler devreye sokuldu. Serbest asit fonksiyonel grubu, önce üretan ve/veya üreye çevrildi. Bazik şartlarda halka kapanma reaksiyonu heterosiklik halkayı oluşturdu. Diaçil azid sentezini gerçekleştiremediğimiz homoftalik asitte ise benzokromenon tipi kondenzasyon ürünlerinin oluştuğu belirlendi. Böylece bu sistemlerin sentezi için de yeni bir yöntem geliştirilmiş oldu.Indole is an aromatic heterocyclic compound, which has a bicyclic structure consisting of six-membered ring and pyrole ring. The derivatives of indoles show a variety of biological activity. Quinazoline is a compound made up of two fused six-membered simple aromatic rings, a benzene ring and a pyrimidine ring. Medicinally, it has been used in various areas especially as an anti-malarial agent and in cancer treatment. Benzodiazepines have a bicyclic structure consisting of benzene ring and a seven-membered ring having two nitrogen atoms. More than 15 different types of benzodiazepine medications exist to treat a wide array of both psychological and physical maladies based on dosage and implications. For the synthesis of these class of compounds, varies synthetic procedures have been published in the literature. In this project, for the synthesis of these compounds benzene and furan having two carboxylic acid groups have been used as the starting material and diacids were transformed into the corresponding diisocyanates. The acid functionalities may be directly attached to the aromatic or heterocyclic ring or they may be separated by one or two methylene groups. Both or one of these isocyanate groups have been converted into the corresponding urethane and/or urea derivatives. Intramolecular cyclization, by the addition of the urethane or urea derivative to the second isocyanate function opened up a new entry for the synthesis of various heterocyclic compounds their structures are given below. Furthermore, halfester were used for the construction of a heteroring. Acid functionality was transferred into urethane or urea derivatives. Ring-closure under the basic conditions gave also the heterocyclic unit. It was not possible to convert the homophthalic acid into diacylazide, however, it underwent condensation reaction and formed benzochromenone derivatives. This opened up a new entry to the synthesis of this class of compounds

Labiaplasty: Motivation, techniques, and ethics

Labiaplasty (also known as labia minora reduction) is attracting increasing attention in the media and in online forums. Controversy exists among health-care professionals on how to manage a request for this surgery. Furthermore, the indications for and outcomes of labiaplasty have not yet been systematically assessed, and long-term outcomes have not yet been reported. Labia minora hypertrophy is defined as enlargement of the labia minora; however, the natural variation of labia minora size has scarcely been studied, with only one study suggesting objective criteria. Perception of the 'normal' appearance of labia minora is influenced by culture, exposure to idealized photographs in media, health-care professionals' opinions, and family, friends, and sexual partners (although this influence has not been substantiated by research). The desire for labiaplasty is predominantly based on dissatisfaction with genital appearance and not on functional complaints. Most health-care professionals believe that women seeking labiaplasty should be referred to a psychiatrist or psychologist for consultation before surgery, although whether counselling and education are effective at alleviating dissatisfaction or a low genital self-esteem is not clear. As the nature of patient motivation for this type of surgery is often psychological, counselling and education could be useful in reducing the demand for labiaplasty. However, current studies on surgical technique and outcomes include few patients, therefore, evidence on the results of different labiaplasty techniques and patient satisfaction is inconclusive. Further research is required to assess the value of this treatment and the appropriate indications for it. Improved understanding as to why women seek this treatment is needed and whether conservative treatments (such as counselling) are effective. Furthermore, systematic assessment of the surgical and patient-reported outcomes of labiaplasty is needed to assess whether it is safe and effective. Moreover, understanding the effect of cultural trends, for example, the way in which many women in Western society see any exception to the ideal body as a problem, will be insightful

Evaluation of the Decision Aid for Genital Surgery in Transmen

Background: Multiple options of genital gender-affirming surgery are available to transmen. The transman should be able to weigh these options based on the outcomes, risks, and consequences that are most important to him. For this reason, a decision aid for genital surgery in transmen (DA-GST) was developed. It aims to support the transman in making thoughtful choices among treatment options and facilitate shared decision-making between the healthcare professionals and the transindividual. Aim: The aim of this study was to evaluate the newly developed DA-GST. Methods: This was a cross-sectional study using mixed methods. Transmen considering to undergo genital surgery were eligible to partake in the study. The questionnaires used in this study were developed by adapting the validated Dutch translation of the “Decisional Conflict Scale,” the “Measures of Informed Choice,” and the “Ottawa Preparation for Decision-Making Scale.” Qualitative interviews were conducted querying their subjective experience with the DA-GST. The data from the questionnaires were statistically analyzed, and the data from the interviews were thematically analyzed. Outcomes: The main outcome measures were decisional conflict and decisional confidence measured via self-report items and qualitative data regarding the use of the DA-GST via interviews. Results: In total, 51 transmen participated in the questionnaires study, 99 questionnaires were analyzed, and 15 interviews were conducted. Although confident in their decision, most transmen felt responsible to collect the necessary information themselves. The ability to go through the decision aid independently aided the decision-making process by providing information and highlighting their subjective priorities. Suggested additions are pictures of postoperational outcomes and personal statements from experienced transmen. Clinical Translation: The DA-GST could be implemented as an integral part of transgender health care. Clinicians could take the individual personal values into account and use it to accurately tailor their consult. This would ultimately improve the doctor-patient relationship and decrease decisional regret by enhancing effective shared decision-making. Strengths & Limitations: This mixed-method design study confirmed the use of the DA-GST while taking a broad range of decisional factors into account. Limitations include the absence of a baseline analysis and the limited power for the comparison of treatment groups. Conclusions: This study suggests that the DA-GST helped transmen feel more prepared for their personal consult with the surgeon, reduced decisional conflict, and increased their decisional confidence. Mokken SE, Özer M, van de Grift TC, et al. Evaluation of the Decision Aid for Genital Surgery in Transmen. J Sex Med 2020;17:2067–2076

Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes

Background: Penile inversion vaginoplasty is the surgical gold standard for genital gender-affirmative surgery in transgender women. However, there is an increase of attention for gender-confirming vulvoplasty (GCV), in which no neovaginal cavity is created. Aim: To describe underlying motives and surgical outcomes of GCV in transgender women. Methods: All transgender women who underwent GCV were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording underlying motives, demographics, perioperative complications, and reoperations. Outcomes: Underlying motives and perioperative complication rate. Results: In the period January 1990 to January 2020, 17 transgender women underwent GCV at our center. Most women reported that their motivation to undergo GCV was because they had no wish for postoperative neovaginal penetration (n = 10, 59%). This was due to a sexual preference toward women without the wish for neovaginal penetrative intercourse (n = 6, 35%) or due to a negative sexual experience in the past (n = 4, 24%). Some women desired vaginoplasty with neovaginal cavity creation but were ineligible for this because of their medical history (n = 4, 24%), for example, due to locoregional radiotherapy. The median clinical follow-up was 34 months (range 3-190). The postoperative course was uncomplicated in 11 (65%) women. Postoperative complications comprised the following: meatal stenosis (n = 2, for which surgical correction), remnant corpus spongiosum tissue (n = 1, for which surgical correction), minor wound dehiscence (n = 3, for which conservative management), and postoperative urinary tract infection (n = 1, successfully treated with oral antibiotics). One woman, who developed meatal stenosis, had a history of radiotherapy because of rectal carcinoma and needed 2 surgical procedures under general anesthesia to correct this. Information on self-reported satisfaction was available for 12 women. All were satisfied with the postoperative result and they graded their neovagina an 8.2 ± 0.9 out of 10. Clinical Implications: GCV may be added to the surgical repertoire of the gender surgeon. Transgender women with a desire for genital gender-affirmative surgery should be counseled on surgical options and its (dis)advantages. Strengths & Limitations: Strengths of this study comprise that it is from a high-volume center. A weakness of this study is the retrospective design. The absence of a self-reported outcome measure validated for the transgender persons is a well-known problem. Conclusion: An increase is observed in transgender women who opt for GCV; however, the absolute number undergoing this surgery remains small in our center. Postoperative complications do occur but are generally minor and treatable. van der Sluis WB, Steensma TD, Timmermans FW, et al. Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes. J Sex Med 2020;17:1566–1573

Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen

Background: As genital gender-affirming surgery (GAS) is a demanding and life-changing intervention, transmen should be able to make choices about the surgical treatment based on outcomes that are most important to them, while taking into consideration the concomitant risks involved. Aim: Develop a decision aid (DA) for genital surgery in transmen (DA-GST) that can assist both transmen and health care professionals (HCPs) in making a well-informed decision about the surgical treatment. Methods: A qualitative focus group study was performed. 5 Focus groups were organized with both HCPs and transmen. These were led by an independent professional moderator. Data collected during these focus groups were analyzed to provide content for the DA. Outcomes: To develop content for a DA-GST. Results: Data collected during the focus groups related to the treatment options, information deemed relevant by transmen, and the arguments for or against each treatment option. Collected items were divided into the following themes: outcome, quality of life, environment, sexuality, and beliefs. Clinical Implications: The tool will be useful in assisting both transmen and HCPs in the shared decision-making process regarding genital GAS by exploring which domains are most relevant for each specific individual. Strengths & Limitations: This DA was developed according to an iterative participatory design approach to fit the needs of both transmen and HCPs. Issues that transmen find important and relevant pertaining to genital GAS were translated into arguments that were incorporated in the DA-GST. The study is limited by the group that had participated. Not all arguments for or against specific surgical options may be covered by the DA-GST. Conclusion: An online DA was developed to support transmen with their decision-making process concerning all surgical options for removal of reproductive organs and genital GAS. Özer M, Pigot GL, Bouman M‐B, et al. Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen. J Sex Med 2018;XX:XXX–XXX

ESSM position statement 'Sexual wellbeing after gender affirming surgery'

Introduction: Much has been published on the surgical and functional results following Gender Affirming Surgery ('GAS') in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. Aim: To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. Methods: The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. Main Outcomes Measure: The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasureare provided for each statement separately. Results: The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. Conclusion: The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Copyright (C) 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine