Gonzalez, Cesar

Abstract Paruresis (shy bladder syndrome) is difficulty voiding in public or shared restrooms because of the actual or anticipated presence of others, affecting 2.8% to 6.6% of the general population. Although 59% of transgender persons avoid public restrooms, often for reasons distinct from paruresis, to our knowledge its assessment and treatment in this population remain undocumented. A 53-year-old transgender woman with Klinefelter syndrome (47,XXY) and paruresis since age 5 was referred for treatment. Over the first 14 visits (about 9 months), she received a cognitive-behavioral, schema-informed, and minority-stress-informed protocol integrating psychoeducation, imagery rescripting, cognitive restructuring, breath-holding, and graduated in vivo exposure with paradoxical intention, then supportive psychotherapy. On the Shy Bladder Scale (SBS), she achieved reliable and clinically significant change by Visit 8 (43 to 31, meeting a clinician-defined goal of ≤ 33; RCI = 3.60, p < .05) and her SBS decreased to 8 by Visit 24 in a supportive phase; the reliable-change statistic being defensible only over short intervals, later changes are described by clinical-range and goal status. At 10-year follow-up, the SBS was 18, still below the treatment goal, with minimal depressive and mild anxiety symptoms and improved well-being (PHQ-9 = 4; GAD-7 = 6; WHO-5 = 80%).

Introduction: Transgender and gender diverse individuals may choose to provide their infants with human milk. Lactating transgender men may experience gender dysphoria and desire to initiate or reinitiate gender-affirming testosterone therapy. However, there is limited safety data regarding use of testosterone during lactation. Main Issue: A 30-year-old G2P2 transgender man with gender dysphoria sought to initiate gender-affirming testosterone therapy while lactating. Management: Subcutaneous testosterone was self-administered beginning at 13 months post-partum. We prospectively collected data on circulating testosterone concentrations in parent serum, milk, and infant serum over 5 months until the infant self-weaned. The infant was monitored for growth and development at routine pediatric outpatient appointments. Parent serum testosterone concentrations rose with the initiation of testosterone therapy, reaching therapeutic concentrations by Day 14. Milk testosterone concentrations also increased with a maximum concentration of 35.9 ng/dl when the lactating parent was on a dose of 80 mg subcutaneous testosterone cypionate weekly. The calculated milk/plasma ratio remained under 1.0 and the calculated relative infant dose remained under 1%. The infant had no observable side effects, and his serum testosterone concentrations remained undetectable throughout the study period. Conclusion: This is the first study with data regarding human milk and infant serum testosterone concentrations during the initiation of gender-affirming testosterone therapy in a lactating individual. This evidence can help families and clinicians with decisions regarding lactation and testosterone use.