Kevan Wylie

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

ABSTRACT The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Serving transgender people: clinical care considerations and service delivery models in transgender health

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.

Sexual dysfunction and the ageing male

Male sexuality in older age is an important issue but is not fully understood. This review aims to clarify the normal ageing process, the sexual behaviour of ageing men and the prevalence of sexual dysfunction. It identifies conditions affecting male sexuality in older age and highlights areas where more extensive research is required.

Sex education in schools is insufficient to support adolescents in the 21st century

“The twin concepts of innocence and ignorance are vehicles for adult double standard. A child is ignorant if she doesnt know what adults want her to know, but innocent if she doesnt know what adu...

Synergies in health and human rights: a call to action to improve transgender health

2015 was an unprecedented year in the recognition of transgender rights in some high-income countries. However, this recognition in the public domain has yet to translate to a concerted eff ort to support the right to health of transgender people around the world. Transgender people continue to face a range of challenges that deprive them of respect, opportunities, and dignity and have damaging eff ects on their mental and physical health and wellbeing, as shown in the Lancet Series on transgender health. These “situated vulnerabilities”, as they are called in the Series paper by Sari Reisner and colleagues, can prompt or aggravate depression, anxiety, self-harm, and suicidal behaviour among transgender people, which are exacerbated by biological risks, and social and sexual network-level risks, for HIV and other sexually transmitted infections. In their Lancet Series paper, Sam Winter and colleagues write of a “slope leading from stigma to sickness”. Moving forward, these health needs and vulnerabilities can be better addressed through improved understanding of the legal and social policies that promote harms and diminish the potential impact of health programmes. There is also a need for increased knowledge of the optimal content and models of clinical service provision, as highlighted by Kevan Wylie and colleagues’ Series paper, and of the epidemiology of communicable and non-communicable diseases in transgender people globally. Ultimately, action is needed at and across multiple levels and sectors to optimise the provision and uptake of health services for transgender people (panel). Health policies must change to improve the health of transgender people. Transgender people worldwide report problems in accessing appropriate and equitable health care—whether related to gender affi rmation, sexual and reproductive health, or more general health. Steps need to be taken to ensure that national health policies are as inclusive as possible with regard to transgender health care. Such health care, including access to feminising and masculinising hormones, should be funded on the same Synergies in health and human rights: a call to action to improve transgender health

Holding onto womanhood: a qualitative study of heterosexual women with sexual desire loss.

This article explores heterosexual womens accounts of sexual desire loss, particularly the ways in which it can affect their sense of themselves as women. In-depth interviews were conducted with 17 participants recruited through a psychosexual clinic in England, and the data analysed using a material-discursive approach. The findings showed that having sexual desire loss often challenged participants perceptions of themselves as women. Specific challenges related to dealing with isolation and `otherness, addressing their own feelings of not being `proper wives because they did not sexually satisfy their partners and maintaining a sense of sexual attractiveness in the absence of sexual desire. Participants responded to these challenges in various ways, often renegotiating their identities as women. The findings are discussed in relation to theorizing womens sexuality and their implications for health care.

Controversies in Sexual Medicine: Is Physical Examination Required Before Prescribing Hormones to Patients with Gender Dysphoria?

INTRODUCTIONnA genital examination can have psychologic effects on a patient, particularly when the source of their sexual medicine complaint is a body part. How necessary is a physical exam before prescribing hormones in cases of gender dsyphoria?nnnMETHODSnFive people with expertise and/or interest in the area of gender dysphoria and endocrinology were asked to contribute their opinions.nnnMAIN OUTCOME MEASUREnTo provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine.nnnRESULTSnOf the five experts writing on the topic, one believes that a physical examination should always be performed before prescribing hormones for gender dysphoria, one believes it is not a prerequisite, and three believe a physical examination is recommended, but is not necessary in cases where the patient objects despite an explanation of the purpose of the exam. As long as this was documented, it would not present a medicolegal problem.nnnCONCLUSIONSnIt is not clear whether or not a physical examination must be performed on all gender dsyphoric patients before prescribing hormones; however, an examination would be helpful in revealing a significant health management issue.

Are the Criteria for the ‘Real-Life Experience’ (RLE) Stage of Assessment for GID Useful to Patients and Clinicians?

ABSTRACT A clinicians recommendation for progression to gender reassignment surgery is usually supported by a successful RLE. However, the gate-keeping role of clinicians can put them at odds with the supportive position most caring professionals adopt. The RLE criteria used in a regional clinic were reviewed with a cohort of patients undergoing gender role transition. All nineteen patients were male to female trans women, with eighteen living in role all of the time and fourteen being fully aware of the RLE criteria. Eighteen found it useful to live in role full-time, with thirteen finding clinicians knowledge of their RLE very useful. Five patients experienced problems with living in role, while the majority (n = 14) reported no/not many problems. Despite this, seventeen said they would live in role all of the time, even if their behaviour was not being assessed for progression to surgery. One hundred percent of responders thought that living in role was an important part of the assessment process for gender dysphoria. Although patients found living in role valuable and important, a number of suggestions were made for improvements to the RLE criteria used by the regional clinic. These included the ability to commence hormone therapy as soon as the RLE begins, and incorporating time spent living in role whilst on the waiting list with documented real life experience.

A Benefit-Risk Assessment of Dapoxetine in the Treatment of Premature Ejaculation

Premature ejaculation (PE) is considered to be the most common sexual problem affecting men, despite the likelihood that it is under-diagnosed. It is a complex condition with many physical and psychological components, making management complicated. It is important to develop treatments for PE as it adversely affects quality of life for individuals and partners.Dapoxetine is a short-acting selective serotonin reuptake inhibitor (SSRI) that has been developed principally for the treatment of PE. It is considered more suitable for the treatment of PE than other SSRIs as it can be used as an ‘on demand’ treatment to be taken a few hours before an expected sexual encounter, reducing the possibility of adverse effects.Dapoxetine may represent a breakthrough in the treatment of PE as it is the first drug to be licensed for this indication. This review attempts to present a balanced benefit-risk assessment of dapoxetine by examining the evidence from phase III clinical trials, focusing on its efficacy in prolonging intravaginal ejaculatory latency time (IELT), patient sexual satisfaction and safety in patients with PE. The benefits and risks of other therapies that are used to treat PE off-licence are also reviewed. There has only been one study to date that directly compares dapoxetine to another therapy, paroxetine, for this indication.It was found that dapoxetine is most effective at a dose of 60 mg in increasing IELT compared with placebo. All studies have also found that dapoxetine is well tolerated as an ‘on-demand’ therapy and with continual dosing; however, there are little data regarding possible long-term adverse effects. Findings of the dapoxetine development programme demonstrated that dapoxetine is associated with vasovagal-mediated (neurocardiogenic) syncope. No other associated significant cardiovascular adverse events were identified.Further research is needed to directly compare dapoxetine with other therapies and to investigate the outcomes of dapoxetine used in conjunction with behavioural therapies, and other non-pharmaceutical therapies.

British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice.

BACKGROUNDnTestosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging.nnnAIMnTo review the available literature on TD and provide evidence-based statements for UK clinical practice.nnnMETHODSnEvidence was derived from Medline, EMBASE, and Cochrane searches on hypogonadism, testosterone (T) therapy, and cardiovascular safety from May 2005 to May 2015. Further searches continued until Mayxa02017.nnnOUTCOMESnTo provide a guideline on diagnosing and managing TD, with levels of evidence and grades of recommendation, based on a critical review of the literature and consensus of the British Society of Sexual Medicine panel.nnnRESULTSn25 statements are provided, relating to 5 key areas: screening, diagnosis, initiating T therapy, benefits and risks of T therapy, and follow-up. 7 statements are supported by level 1, 8 by level 2, 5 by level 3, and 5 by level 4 evidence.nnnCLINICAL IMPLICATIONSnTo help guide UK practitioners on effectively diagnosing and managing primary and age-related TD.nnnSTRENGTHS AND LIMITATIONSnA large amount of literature was carefully sourced and reviewed, presenting the best evidence available at the time. However, some statements provided are based on poor-quality evidence. This is a rapidly evolving area of research and recommendations are subject to change. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions and take personal values and preferences and individual circumstances into account. Many issues remain controversial, but in the meantime, clinicians need to manage patient needs and clinical expectations armed with the best clinical evidence and the multidisciplinary expert opinion available.nnnCONCLUSIONnImproving the diagnosis and management of TD in adult men should provide somatic, sexual, and psychological benefits and subsequent improvements in quality of life. Hackett G, Kirby M, Edwards D, etxa0al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. J Sex Med 2017;14:1504-1523.