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A Framework for Categorizing Bottom Dysphoria in Transgender and Nonbinary Patients
Hunter R. Myers, BA1, Neeki Parsa, BA1, Urszula Kowalik, MD2
1Larner College of Medicine, Burlington, VT, USA, 2University of Vermont Medical Center, Burlington, VT, USA

BACKGROUND
Currently, Gender Dysphoria is defined in the DSM-5 as a marked incongruence between one’s experienced/expressed gender and natal gender. Manifestations of gender dysphoria are described as various desires or feelings of incongruence regarding primary and/or secondary sex characteristics. New patient centered methods of dosing hormone therapy have emerged to address dysphoria around specific secondary sex characteristics (e.g. micro doses of testosterone for minimal secondary sex characteristic development). A similar pattern has emerged in the field of Genital Gender-Affirming Surgery (GGAS), with efforts to tailor interventions to specific patient concerns instead of a one-size-fits-all method. Despite this shift in interventions, there is currently no framework or lexicon for evaluating specific manifestations of genital, or “bottom” gender dysphoria. Many models for evaluating gender dysphoria are assessment based, which seeks to evaluate the legitimacy of a patient’s gender dysphoria, as opposed to the characteristics of their gender dysphoria. Instead, this proposed model takes a categorization approach, with the hope of better elucidating and addressing patients’ treatment goals. The aim of this project is to first introduce a lexicon for specific bottom dysphorias, then develop a framework for categorizing manifestations of bottom dysphoria, and lastly to introduce non-surgical treatment options for bottom dysphoria that are established in transgender and nonbinary communities but have yet to be adopted into the medical sphere.
METHODS
An extensive literature review in PubMed across the fields of medical education, patient interaction, urological clinical encounters relating to gender and sex minorities, and patient-reported satisfaction following GGAS was conducted. This search used multiple search hedges including, among others, the following MeSH terms: gender dysphoria, gender identity disorder, transgender, gender affirming surgery, gender reassignment, sex reassignment, transexual, trans men, trans women, health services for transgender persons, transvestism, gender change. In conjunction with clinical literature, popular sites for discourse about bottom dysphoria were also reviewed, including groups on Reddit and Facebook, as well as comment sections on well-trafficked YouTube and community resources.
RESULTS

Specific Bottom Dysphoria ManifestationsPotential Non-surgical Treatment Options
Urological DysphoriaDistress, feelings of incongruence, or desire to be able to sit or stand to pee.Stand-to-pee (STP) devices
Genital DysphoriaDistress, feelings of incongruence, or desire for genitalia in congruence with a different gender.Packer or gaff.
Sexual DysphoriaDistress, feelings of incongruence, or desire to have sex in a manner that is congruent with a different gender.Sexual prosthetics including vaginal prosthetics, penetrative prosthetics, and 3-in-1s (packer + STP + sexual prosthetics).
Ejaculatory DysphoriaDistress and/or feelings of incongruence around ejaculation; distress and/or feelings of incongruence around not ejaculation, or the desire to experience ejaculation.Certain sexual prosthetics allow for ejaculation.

CONCLUSION
Individual practitioners may take a patient-centered approach to bottom dysphoria to elucidate surgical goals, however there is currently no widespread method of categorizing bottom dysphorias with which to strategize treatment plan. While many patients experience a combination of several bottom dysphorias, this itemized approach can help incorporate non-surgical treatment options into the clinical sphere, either as dysphoria relief without further intervention or as a hold-over measure while confronting long wait-times for GGAS. Potential limitations introduced by using online community resources include sampling bias, social desirability bias, survivorship bias, and often an unknown or unverifiable sample size. However, these resources offered a high-utility gestalt and insight into current practices and thought patterns in the transgender community that are often overlooked in the clinical realm. With this additional context, the researchers were well-disposed to devise a tool with both clinical relevance and cultural accessibility.
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