Introduction: Transsexual people receive cross-sex hormones as part of their treatment, potentially inducing hormone-sensitive malignancies.

Aim: To examine the occurrence of breast cancer in a large cohort of Dutch male and female transsexual persons, also evaluating whether the epidemiology accords with the natal sex or the new sex.

Main Outcome Measure: Number of people with breast cancer between 1975 and 2011.

Methods: We researched the occurrence of breast cancer among transsexual persons 18–80 years with an exposure to cross-sex hormones between 5 to >30 years. Our study included 2,307 male-to-female (MtF) transsexual persons undergoing androgen deprivation and estrogen administration (52 370 person-years of exposure), and 795 female-to-male (FtM) subjects receiving testosterone (15 974 total years of exposure).

Results: Among MtF individuals one case was encountered, as well as a probable but not proven second case. The estimated rate of 4.1 per 100 000 person-years (95% confidence interval [CI]: 0.8–13.0) was lower than expected if these two cases are regarded as female breast cancer, but within expectations if viewed as male breast cancer. In FtM subjects, who were younger and had shorter exposure to cross-sex hormones compared with the MtF group, one breast cancer case occurred. This translated into a rate of 5.9 per 100 000 person-years (95% CI: 0.5–27.4), again lower than expected for female breast cancer but within expected norms for male breast cancer.

Conclusions: The number of people studied and duration of hormone exposure are limited but it would appear that cross-sex hormone administration does not increase the risk of breast cancer development, in either MtF or FtM transsexual individuals. Breast carcinoma incidences in both groups are comparable to male breast cancers. Cross-sex hormone treatment of transsexual subjects does not seem to be associated with an increased risk of malignant breast development.

Author/-s: Louis J. G. Gooren; Michael A. A. van Trotsenburg; Erik J. Giltay; Paul J. van Diest

Publication: The Journal of Sexual Medicine, 2013

Web link: http://onlinelibrary.wiley.com/doi/10.1111/jsm.12319/abstract

Hormone treatment does not increase breast cancer risk.

Objective: The purpose of the current study was to examine facilitative and avoidant coping as mediators between distress and transition status, social support, and loss.

Method: A total of 351 transgender individuals (n = 226 transgender women and n = 125 transgender men) participated in this study. Participants completed measures on transgender identity, family history of mental health concerns, perceptions of loss, coping, depression, and anxiety.

Results: The rates of depressive symptoms (51.4% for transgender women; 48.3% for transgender men) and anxiety (40.4% for transgender women; 47.5% for transgender men) within the current study far surpass the rates of those for the general population. Structural equation modeling (SEM) was used to analyze the data-2 separate models were hypothesized, based on reports of anxiety or depression. The SEM results suggest that the processes for transgender women and transgender men are primarily similar for depression and anxiety; avoidant coping served as a mediator between transition status and both distress variables. Social support was directly related to distress variables, as well as indirectly related through avoidant coping.

Conclusion: Results suggest the need for practitioners to focus on interventions that reduce avoidant coping strategies, while simultaneously increasing social support, in order to improve mental health for transgender individuals. Individuals who are in the beginning stages of their transition will use different coping strategies than those who are in later stages; interventions should be adjusted on the basis of the transition status of transgender clients.

Author/-s: Stephanie L. Budge; J. L. Adelson; Kimberly A. Howard

Publication: Journal of consulting and clinical psychology, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23398495

Anxiety and depression are far higher in transsexuals; they need social support to improve mental health.

Objective: Sexual orientation in males and females is considered to be determined in early life and to be virtually unchangeable in the course of adulthood. In contrast some transsexuals report a change in their sexual orientation most overt following sex reassignment procedures. The reason for this phenomenon is unknown.

Methods: We asked 106 transsexual (66 MtF and 40 FtM) patients from our endocrine outpatient clinic to complete a questionnaire, retrospectively evaluating the history of their gender transition phase. A special focus was sexual orientation and prevalence and recalled time point of changes in their sexual orientation.

Results: FtM were most frequently heterosexual, according to their gender identity, while MtF more often reported to be homosexual (72.5 vs 29% and 33.8 vs 7.5% respectively; P<0.001). MtF reported change in sexual orientation in total in 32.8% of cases in contrast to FtM with only 17.5% (P=0.067). 6 MtF (21.4%) reported change in sexual orientation without any sex reassignment surgery in their history in contrast to only 2 FtM (12.5%). Of those who had undergone sex reassignment surgery, most but not all subjects had experienced changes in their sexual orientation following the surgical procedure (13 MtF (73.3%), 5 FtM (71%)). While there was no significant difference seen in terms of time interval between date of introduction of cross-sex hormone treatment and changes in sexual orientation, MtF experienced changes in sexual orientation more quickly after sex reassignment surgery in contrast to FtM (13.8 vs 1.75 years P<0.05).

Conclusion: In contrast to earlier reports, we showed that changes in sexual orientation do not solely occur in the context of sex reassignment surgery. Furthermore, there are clear differences between MtF and FtM, who especially reported a significantly longer interval from sex reassignment surgery to the change in sexual orientation.

Author/-s: Matthias Auer; Johannes Fuss; Anasthasia Athanasoulia; Guenter Stalla; Caroline Sievers

Publication: Endocrine Abstracts, 2013

Web link: http://www.endocrine-abstracts.org/ea/0032/ea0032P333.htm

Discusses the relation between changes of sexual orientation and sex reassignment surgery.

Background: Childhood abuse in the early lives of gender variant people has been under-reported, although higher psychiatric morbidity, particularly depression and suicidality, than in the general population is more widely recognised. There are increasing numbers of people seeking advice and treatment for gender dysphoria (GD) some of whose experiences of depression and childhood abuse may be additional treatment considerations.

Aim: To illuminate the issues relating to childhood abuse, depression and GD via case examples underpinned by a summary review of the relevant literature, for their combined relevance to therapeutic practice and service provision.

Methods: A review of relevant online literature was conducted and two case examples were developed subsequently to capture the core review themes from a practice perspective.

Results: Nine studies met the inclusion criteria. Gender variant children and adolescents may experience abuse by peers and teachers, as well as parents and caregivers. Emotional abuse and neglect may have more adverse consequences than more active forms of abuse.

Conclusions: This is an under-researched area, and inconsistencies of design, definition, measurement and controls were evident in the literature. While no clear association between depressive vulnerability and childhood abuse could be found, prevalence of such abuse was high. A case is made for clients with GD to have the opportunity to explore the influence and meaning of their adverse childhood experiences on their social and psychological development, and for additional training and education for practitioners.

Author/-s: Malcolm T. Firth

Publication: Counselling and Psychotherapy Research, 2014

Web link: http://www.tandfonline.com/doi/abs/10.1080/14733145.2013.845236#.VJkt7ZCdA

Trying to separate causes of distress from gender dysphoria itself.

Evidence supporting the continuity between child temperament and adult personality traits is accumulating. One important indicator of continuity is the presence of reliable gender differences in traits across the lifespan. A substantial literature demonstrates gender differences on certain adult personality traits and recent meta-analytic work on child samples suggests similar gender differences for some broad and narrow domains of temperament. However, most existing studies of children rely only on parent-report measures. The present study investigated gender differences in temperament traits assessed by laboratory observation, maternal-report, and paternal-report measures. Across three independent samples, behavioral observations, maternal-report, and paternal-report measures of temperament were collected on 463 boys and 402 girls. Across all three methods, girls demonstrated higher positive affect and fear and lower activity level than boys. For laboratory measures, girls demonstrated higher levels of sociability and lower levels of overall negative emotionality (NE), sadness, anger and impulsivity than boys. However, girls demonstrated higher levels of overall NE and sadness than boys when measured by maternal reports. Finally, girls demonstrated lower levels of sociability based on paternal reports. Results are discussed in relation to past meta-analytic work and developmental implications of the findings.

Author/-s: T. M. Olino; C. E. Durbin; D. N. Klein; E. P. Hayden; M. W. Dyson

Publication: Journal of personality, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22924826

Gender differences in personality.

This article is part of a Special Issue "Puberty and Adolescence". This article aims to provide an outline of what is currently known on trajectories, and contributing factors to gender identity development in adolescence. We give a historical overview of the concept of gender identity, and describe general identity development in adolescence, gender identity development in the general population and in gender variant youth. Possible psychosocial (such as child and parental characteristics) and biological factors (such as the effects of prenatal exposure to gonadal hormones and the role of genetics) contributing to a gender variant identity are discussed. Studies focusing on a number of psychosocial and biological factors separately, indicate that each of these factors influence gender identity formation, but little is known about the complex interplay between the factors, nor about the way individuals themselves contribute to the process. Research into normative and gender variant identity development of adolescents is clearly lagging behind. However, studies on persons with gender dysphoria and disorders of sex development, show that the period of adolescence, with its changing social environment and the onset of physical puberty, seems to be crucial for the development of a non-normative gender identity.

Author/-s: Thomas Dirk Steensma; Baudewijntje P. C. Kreukels; Annelou L. C. de Vries; Peggy T. Cohen-Kettenis

Publication: Hormones and Behavior, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23998673

Review and summary of other articles.

Data of the literature demonstrated controversial results of a correlation between transsexualism and genetic mutations.

To evaluate the hormone and gene profile of male-female (M-F) transsexual.

Thirty M-F transsexuals aged 24–39. Seventeen had already undergone sex reassignment surgery, 13 were awaiting. All subjects had been undergoing estrogen and antiandrogen therapy. We studied hormones of the hypothalamus- pituitary-testicular axis, thyroid and adrenal profile, GH basal and after GHRH stimulation, IGF-I. The gene study analyzed SRY, AR, DAX1, SOX9, AZF region of the Y chromosome.

Pre-surgery subjects had elevated PRL, reduced testosterone and gonadotropins. Post-surgery subjects showed reduced androgens, a marked increase in LH and FSH and normal PRL. Cortisol and ACTH were similar to reference values in pre- and post-surgery patients. There was a marked increase in the baseline and post-stimulation GH values in 6 of the 13 pre-surgery patients, peaking at T15. IGF-I was similar to reference values in both groups except for one post-surgery patient, whose level was below the normal range. There were no polymorphisms in the amplified gene region for SOX9, and a single nucleotide synonimous polymorphism for DAX1. No statistically significant differences were seen in the mean of CAG repeats between controls and transsexual subjects. SRY gene was present in all subjects. Qualitative analysis of the AZFa, AZFb, and AZFc regions did not reveal any microdeletions in any subject.

This gender disorder does not seem to be associated with any molecular mutations of some of the main genes involved in sexual differentiation.

Author/-s: F. Lombardo; L. Toselli; D. Grassetti; D. Paoli; P. Masciandaro; F. Valentini; A. Lenzi; L. Gandini

Publication: Journal of Endocrinological Investigation, 2013

Web link: http://www.pubfacts.com/detail/23324476/Hormone-and-genetic-study-in-male-to-female-transsexual-patients

A link between transsexualism and certain gene mutations and is not found.

Many previous studies have reported robust sex differences in olfactory perception. However, both men and women can be expected to vary in the degree to which they exhibit olfactory performance considered typical of their own or the opposite sex. Sex-atypicality is often described in terms of childhood gender nonconformity, which, however, is not a perfect correlate of non-heterosexual orientation. Here we explored intrasexual variability in psychophysical olfactory performance in a sample of 156 individuals (83 non-heterosexual) and found the lowest odor identification scores in heterosexual men. However, when childhood gender nonconformity was entered in the model along with sexual orientation, better odor identification scores were exhibited by gender-nonconforming men, and greater olfactory sensitivity by gender-conforming women, irrespective of their sexual orientation. Thus, sex-atypicality, but not sexual orientation predicts olfactory performance, and we propose that this might not be limited to olfaction, but represent a more general phenomenon.

Author/-s: Lenka Nováková; Jaroslava Varella Valentová; Jan Havlíček

Publication: PLOS one, 2013

Web link: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0080234

Gender non-conforming men are better at identifying odours (they smell better 😏).

Previous studies hypothesized a neurobiological mechanism for gender identity disorder (GID). Recently a possible role for serum brain-derived neurotrophic factor (BDNF) was suggested on the basis of reduced serum BDNF levels in male-to-female individuals. Here we review the question whether there is indeed a role of BDNF in the development of transsexualism.

Author/-s: J. Fuss; S. V. Biedermann; G. K. Stalla; M. K. Auer

Publication: Journal of psychiatric research, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/24070909

Discussion of the role of serum brain-derived neurotrophic factor (BDNF) in transsexualism.

Background: Satisfaction with breasts, sexual well-being, psychosocial well-being, and physical well-being are essential outcome factors following breast augmentation surgery in male-to-female transsexual patients. The aim of this study was to measure change in patient satisfaction with breasts and sexual, physical, and psychosocial well-being after breast augmentation in male-to-female transsexual patients.

Methods: All consecutive male-to-female transsexual patients who underwent breast augmentation between 2008 and 2012 were asked to complete the BREAST-Q Augmentation module questionnaire before surgery, at 4 months, and later after surgery. A prospective cohort study was designed and postoperative scores were compared with baseline scores. Satisfaction with breasts and sexual, physical, and psychosocial outcomes assessment was based on the BREAST-Q.

Results: Thirty-five male-to-female transsexual patients completed the questionnaires. BREAST-Q subscale median scores (satisfaction with breasts, +59 points; sexual well-being, +34 points; and psychosocial well-being, +48 points) improved significantly (p < 0.05) at 4 months postoperatively and later. No significant change was observed in physical well-being.

Conclusions: In this prospective, noncomparative, cohort study, the current results suggest that the gains in breast satisfaction, psychosocial well-being, and sexual well-being after male-to-female transsexual patients undergo breast augmentation are statistically significant and clinically meaningful to the patient at 4 months after surgery and in the long term.

Author/-s: R. Weigert; E. Frison; Q. Sessiecq; K. Al Mutairi; V. Casoli

Publication: Plastic and reconstructive surgery, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/24281571

Breast augmentation surgery helps male-to-female transsexuals.

Purpose of review: Discussion of short and long-term issues of cross-hormone treatment of transgender individuals in the light of recent literature.

Recent findings: Gender nonconformity has been depathologized and replaced by gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders version V. Safety of cross-sex hormone treatment is still a matter of debate, but the latest findings in literature are quite reassuring about short-term and long-term effects. No dramatic changes in recommendations for treatment have emerged in the past years, and for the most part, clinical work is based on Endocrine Society Clinical Guidelines published in 2009.

Summary: Most recent findings agreed on the importance of maintaining cross-sex hormone serum concentration within the physiological range, avoiding or limiting maximum peaks and troughs.Treatment must be highly individualized and transitioning patients need to be engaged in a 'clinical contract' with the physician in order to ensure compliance with prescribed treatments.Although overall mortality appears to be higher among transgender individuals, this in not attributed to hormonal treatment but to other causes mostly related to lifestyle habits.

Author/-s: M. C. Meriggiola; M. Berra

Publication: Current opinion in endocrinology, diabetes, and obesity, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/24468759

Hormone therapy seems safe.

Background: Gender variance (GV) in childhood has a negative impact on the self-concept of children in the general population and can lead to mental health problems and even suicidal ideation in adulthood. This study explored the self-concept of clinically referred gender variant children and examined potential risk factors.

Method: The Self-Perception Profile for Children was administered to 147 children, who were referred to a gender identity clinic. Their parents completed the Child Behaviour Checklist and the Gender Identity Questionnaire to assess the degree of GV.

Results: The referred children were at risk of developing a negative self-concept; more specifically gender variant girls had low scores on ‘global self-worth’, ‘physical appearance’ and ‘behavioural conduct’ compared to Dutch norms for girls. Gender variant boys had low scores on ‘global self-worth’, ‘scholastic competence’, ‘athletic competence’ and ‘physical appearance’ compared to Dutch norms for boys. Within the group of referred children, sex differences, but no age effects, were found. The referred girls felt more competent than the referred boys on ‘athletic competence’ and ‘scholastic functioning’. For both boys and girls poor peer relations had a significant negative relationship with self-concept and more GV was related to a lower global self-worth.

Conclusions: Clinically referred gender variant children seemed vulnerable to developing a negative self-concept. Poor peer relations and extreme GV might be mediating variables. Interventions might focus on enhancing acceptance of the environment and improving social skills of gender variant children.

Author/-s: Anouk Balleur-van Rijn; Thomas Dirk Steensma; Baudewijntje P. C. Kreukels; Peggy T. Cohen-Kettenis

Publication: Clinical Child Psychology and Psychiatry, 2013

Web linK: http://ccp.sagepub.com/content/18/3/464

Gender-variant children are at risk of developing a negative self-image.

Sex differences in human behavior show adaptive complementarity: Males have better motor and spatial abilities, whereas females have superior memory and social cognition skills. Studies also show sex differences in human brains but do not explain this complementarity. In this work, we modeled the structural connectome using diffusion tensor imaging in a sample of 949 youths (aged 8–22 y, 428 males and 521 females) and discovered unique sex differences in brain connectivity during the course of development. Connection-wise statistical analysis, as well as analysis of regional and global network measures, presented a comprehensive description of network characteristics. In all supratentorial regions, males had greater within-hemispheric connectivity, as well as enhanced modularity and transitivity, whereas between-hemispheric connectivity and cross-module participation predominated in females. However, this effect was reversed in the cerebellar connections. Analysis of these changes developmentally demonstrated differences in trajectory between males and females mainly in adolescence and in adulthood. Overall, the results suggest that male brains are structured to facilitate connectivity between perception and coordinated action, whereas female brains are designed to facilitate communication between analytical and intuitive processing modes.

Author/-s: Madhura Ingalhalikar; Alex Smith; Drew Parker; Theodore D. Satterthwaite; Mark A. Elliott; Kosha Ruparel; Hakon Hakonarson; Raquel E. Gur; Ruben C. Gur; Ragini Verma

Publication: Proceedings of the National Academy of Sciences of the United States of America, 2013

Web link: http://www.pnas.org/content/early/2013/11/27/1316909110

Overview of brain sex differences.

Findings of previous studies demonstrate sex-related preferences for toys in 6-month-old infants; boys prefer nonsocial or mechanical toys such as cars, whereas girls prefer social toys such as dolls. Here, we explored the innate versus learned nature of this sex-related preferences using multiple pictures of doll and real faces (of men and women) as well as pictures of toy and real objects (cars and stoves). In total, 48 4- and 5-month-old infants (24 girls and 24 boys) and 48 young adults (24 women and 24 men) saw six trials of all relevant pairs of faces and objects, with each trial containing a different exemplar of a stimulus type. The infant results showed no sex-related preferences; infants preferred faces of men and women regardless of whether they were real or doll faces. Similarly, adults did not show sex-related preferences for social versus nonsocial stimuli, but unlike infants they preferred faces of the opposite sex over objects. These results challenge claims of an innate basis for sex-related preferences for toy real stimuli and suggest that sex-related preferences result from maturational and social development that continues into adulthood.

Author/-s: P. Escudero; R. A. Robbins; S. P. Johnson

Publication: Journal of experimental child psychology, 2013

Web link: http://www.unboundmedicine.com/medline/citation/23933180/Sex_related_preferences_for_real_and_doll_faces_versus_real_and_toy_objects_in_young_infants_and_adults_

Sex related differences for toys might not be innate.

Background: Regarding the process of trans sexuality as a topic in the domain of sex study is not well-cared so far in different cultures. The present research aims to investigate the social causes expending the tendency sex change surgery among transsexual youth in province Tehran.

Methods: Descriptive and survey methods were used to analyze data collected through questionnaires. The population included 312 transsexuals referring to Welfare Organization of Tehran. A sample of 150 cases was selected through Cochrane’s sampling formula. Independent variables included culture, socio-economic status, religious values, civil-jurisprudence knowledge, and political sway. Sexual change (from male to female and vice versa) was regarded as the dependent variable. Results analyzed through the use of statistical tests and software SPSS.

Findings: Regarding the correlation coefficient obtained, the findings show that there is a significant relationship between, 1. Parental absence (female to male: 0.61) (male to female: 76), 2. Family support (female to male: 0.43) (male to female: 0.53), 3. Family satisfaction (female to male: 0.37) (male to female: 0.31), 4. Life expectancy (male to female: 0.64 ((female to male: 0.53), 5. Labeling (female to male: 0.69) (male to female: 0.73) 6. Adherence to traditional values (female to male: 0.59) (male to female: 0.70) 7. Employment (female to male: 0.59) (male to female: 0.63), 8. Income (female to male: 0.89) (male to female: 0.91), 9. Education (female to male: 0.67) (male to female: 0.55), 10. Adherence to religious beliefs and values (female to male: 0.73) (male to female: 0.66), 11. Non-existence of legal laws and acts (female to male: 0.39) (male to female: 0.26), 12. Performance of governmental organizations on one hand and tendency to sexual change on the other hand (female to male: 0.39) (male to female: 0.33).

Conclusion: The present study confirms that the most effective and important cause tendency in expenditing sex change surgery was include income level, the absence of either per both parents, stigmatizing and adherence to religious beliefs minimum cause was family satisfaction that: 1- With financial support and public insurance and development of special hospitals 2- By giving information to families, 3- For acceptance by the society, Can to help them (some of people with gender identity disorder).

Author/-s: Tavassoli Afsaneh; Hassanian Akram; Saberi Seyed Mehdi

Publication: Scientific Journal of Forensic Medicine, 2014

Web link: http://en.journals.sid.ir/ViewPaper.aspx?ID=398208

Factors that speed up the wish for surgery.

Introduction: Male to female (MtFs) and female to male (FtMs) subjects with gender identity disorder (GID) seem to differ with regard to some sociodemographic and clinical features. Currently, no descriptive studies focusing on MtFs and FtMs attending an Italian clinic are available.

Aim: To describe the sociodemographic characteristics of a GID population seeking assistance for gender transition and to assess possible differences in those features between MtFs and FtMs.

Methods: A consecutive series of 198 patients was evaluated for gender dysphoria from July 2008 to May 2011 in four dedicated centers. A total of 140 subjects (mean age 32.6 ± 9.0 years old) meeting the criteria for GID, with their informed consent and without genital reassignment surgery having already been performed, were considered (92 MtFs and 48 FtMs). Diagnosis was based on formal psychiatric classification criteria.

Main outcome measures: Medical history and sociodemographic characteristics were investigated. Subjects were asked to complete the Body Uneasiness Test (a self-rating scale exploring different areas of body-related psychopathology), Symptom Checklist-90 Revised (a self-rating scale to measure psychological state), and the Bem Sex Role Inventory (a self-rating scale to evaluate gender role). The presence of psychiatric comorbidities was evaluated using the Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (SCID I and SCID II).

Results: Several significant differences were found between MtFs and FtMs regarding lifestyle and sociodemographic factors and in psychometric test scores. No differences were found in terms of psychiatric comorbidity.

Conclusions: This is the first large study reporting the sociodemographic characteristics of a GID sample referring to Italian clinics, and it provides different profiles for MtFs and FtMs. In particular, FtMs display significantly better social functioning.

Author/-s: Alessandra Daphne Fisher, Elisa Bandini, Helen Casale, Naika Ferruccio, Maria C Meriggiola, Anna Gualerzi, Chiara Manieri, Emmanuele Jannini, Edoardo Mannucci, Matteo Monami, Niceta Stomaci, Augusto Delle Rose, Tommaso Susini, Valdo Ricca, Mario Maggi

Publication: The journal of sexual medicine, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23171237

MtF and FtM transsexuals have the same rate of suffering from mental illness. FtM transsexuals function better socially.

Objectives: We assessed the association between minority stress, mental health, and potential ameliorating factors in a large, community-based, geographically diverse sample of the US transgender population.

Methods: In 2003, we recruited through the Internet a sample of 1093 male-to-female and female-to-male transgender persons, stratified by gender. Participants completed an online survey that included standardized measures of mental health. Guided by the minority stress model, we evaluated associations between stigma and mental health and tested whether indicators of resilience (family support, peer support, identity pride) moderated these associations.

Results: Respondents had a high prevalence of clinical depression (44.1%), anxiety (33.2%), and somatization (27.5%). Social stigma was positively associated with psychological distress. Peer support (from other transgender people) moderated this relationship. We found few differences by gender identity.

Conclusions: Our findings support the minority stress model. Prevention needs to confront social structures, norms, and attitudes that produce minority stress for gender-variant people; enhance peer support; and improve access to mental health and social services that affirm transgender identity and promote resilience.

Author/-s: Walter O. Bockting; M. H. Miner; R. E. Swinburne Romine; A. Hamilton; E. Coleman

Publication: American journal of public health, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23488522

Stigma increases mental health problems in transsexuals, peer support reduces them.

A recent study indicated a suicide attempt rate of 41 % among trans (e.g., trans, transgender, transexual/transsexual, genderqueer, two-spirit) individuals. Although this rate is alarming, there is a dearth of literature regarding suicide prevention for trans individuals. A vital step in developing suicide prevention models is the identification of protective factors. It was hypothesized that social support from friends, social support from family, optimism, reasons for living, and suicide resilience, which are known to protect cis (non-trans) individuals, also protect trans individuals. A sample of self-identified trans Canadian adults (N = 133) was recruited from LGBT and trans LISTSERVs. Data were collected online using a secure survey platform. A three block hierarchical multiple regression model was used to predict suicidal behavior from protective factors. Social support from friends, social support from family, and optimism significantly and negatively predicted 33 % of variance in participants' suicidal behavior after controlling for age. Reasons for living and suicide resilience accounted for an additional 19 % of the variance in participants' suicidal behavior after controlling for age, social support from friends, social support from family, and optimism. Of the factors mentioned above, perceived social support from family, one of three suicide resilience factors (emotional stability), and one of six reasons for living (child-related concerns) significantly and negatively predicted participants' suicidal behavior. Overall, these findings can be used to inform the practices of mental health workers, medical doctors, and suicide prevention workers working with trans clients.

Author/-s: C. Moody; N. G. Smith

Publication: Archives of Sexual Behavior, 2013

Web link: http://europepmc.org/abstract/MED/23613139

Social support reduces suicides among transgender people.

Background: The primary challenge of male-to-female reassignment surgery is to create natural-appearing female genitalia with neovaginal dimensions adequate for intercourse, neoclitoris sensitivity, and minimal risk of complications. Surgical positioning is an important component of the procedure that successfully minimizes the risk of morbidity.

Objective: We modified various vaginoplasty techniques to better position the urethral neomeatus in the proper anatomic location to minimize the chance for complications and enhance aesthetic satisfaction.

Design, setting and participants: We retrospectively reviewed data stored in a prospective database for 24 consecutive patients who underwent male-to-female gender reassignment at a German university clinic between January 2007 and March 2011.

Surgical procedure: First, orchiectomy and penile disassembly are performed with the patient in the supine position. Both corpora cavernosa are resected with the patient in the lithotomy position, and neovaginal construction is accomplished with the incorporation of the penile urethra into the penile shaft skin. The glans is preserved and resized to form the neoclitoris. The assembled neovagina is inverted, inserted into the expanded rectoprostatic space, and secured to the sacrospinous ligament. Scrotal skin is tailored to create the labia.

Ooutcome measurements and statistical analysis: Complications and patient satisfaction with neovaginal depth, appearance, neoclitoral sensation, and capacity for sexual intercourse were evaluated.

Results and limitations: The mean neovaginal depth was 11 cm (range: 10-14 cm); median follow-up was 39.7 mo (range: 19–69 mo). All patients reported satisfactory vaginal functionality. One patient noted stenosis after 4 yr that was histologically confirmed as lichen sclerosus. Neoclitoral sensation was good or excellent in 97% of patients; 33% reported regular intercourse. No major complications were observed. Because this is a retrospective review to describe a complex reconstructive surgery and illustrate these techniques in the accompanying intraoperative surgery-in-motion video, no control group was undertaken.

Cconclusions: Gender reassignment can be performed with minimal complications using penile skin with incorporated penile urethra and intraoperative repositioning of the patient to achieve adequate neovaginal dimensions for intercourse and neoclitoral sensation.

Author/-s: B. Amend; J. Seibold; P. Toomey; A. Stenzl; K. D. Sievert

Publication: European urology, 2013

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23375962

Male-to-female sex reassignment leads to satisfactory functionality and minimal complications.

The present study aimed to investigate gender identity congruence via the unique social and cognitive experiences of self-identified transgender men and women. The authors proposed that ruminative tendencies and number of transgender friendships together would predict level of transgender congruence. Given the conceptualization of congruence as an indicator of healthy gender identity development, as well as the empirically supported relationship between rumination and negative outcomes such as depression and anxiety, the authors hypothesized that rumination would have a negative linear relationship with congruence. Furthermore, the research evidence indicating that transgender friendships provide support specific to the transgender experience while also buffering the negative outcomes of stigma and discrimination suggested that the number of transgender friendships would display a positive linear relationship with congruence. The concept of gender identity congruence is an emerging construct based on the limited research regarding the identities and experiences of transgender and gender variant adults. This concept detaches healthy transgender identity from stages of transition and focuses on the individual’s level of comfort with and acceptance of their own identity. The present study investigated gender identity congruence via the unique social and cognitive experiences of 502 transgender individuals. Results of a multiple linear regression analysis suggest that rumination may have a negative effect on transgender individuals' gender identity congruence whereas transgender friendships may bolster it.

Author/-s: Renae C. Mitchell; Matthew P. Halstad; Justin Delise; M. Paz Galupo

Publication: Conference paper, Association for Psychological Science 25th Annual Convention, 2013

Web link: http://www.researchgate.net/publication/264346283_Transgender_Friendships_and_Rumination_An_Examination_of_Gender_Identity_Congruence_Towson_University

Constantly thinking about gender identity is harmful, transgender friendships are good.

In the last few years, transgender and gender nonconforming people have become more visible in our society, which has sparked a marked increase in awareness, interest, and attention among psychologists. Questions have emerged about the extent to which psychologists are able to work competently with this population. This article presents a framework for understanding key clinical issues that psychologists who work with transgender and gender nonconforming individuals will likely encounter in their clinical work. This article does not address the knowledge and skills required to provide services related to gender transition, but rather to provide other psychological services that these clients may need, in light of the high levels of gender-related victimization and discrimination to which they are exposed. An adaptation of the Minority Stress Model (Meyer, 2003) is presented and translated to incorporate the unique experiences encountered by transgender and gender nonconforming individuals. In particular, we examine adverse experiences that are closely related to gender identity and expression, resulting expectations for future victimization or rejection, and internalized transphobia. The impact of Minority Stress Model factors on suicide attempts is presented as a detailed example. Mechanisms by which transgender and gender nonconforming persons develop resilience to the negative psychological effects of these adverse experiences are also discussed. Recommendations for clinicians are then made to assist psychologists in developing competence in working with this population.

Author/-s: Michael L. Hendricks; Rylan J. Testa

Publication: Professional Psychology: Research and Practice, 2012

Web link: http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2012-21304-001

Recommendations for clinicans on how to improve the impact of victimisation and and discrimination of transsexuals.

Between the two extreme ends of human sexuality - male and female - lie a poorly understood and poorly studied spectrum of ambiguously defined sexual identities that are very much a part of the human condition but defy rigid classification. "Bigender" is a recently formed sub-category of transgenderism, describing individuals who experience a blending or alternation of gender states. While recognized nominally by the APA, no scientific work to our knowledge has addressed this fascinating condition, or proposed any physiological basis for it. In addition, the alternation aspect has not been proposed as a nosological entity distinct from blending. We present descriptive data suggesting that many bigender individuals experience an involuntary switching of gender states without any amnesia for either state. In addition, similar to transsexual individuals, the majority of bigender individuals experience phantom breasts or genitalia corresponding to the non-biologic gender when they are in a trans-gender state. Finally, our survey found decreased lateralization of handedness in the bigender community. These observations suggest a biologic basis of bigenderism and lead us to propose a novel gender condition, "alternating gender incongruity" (AGI). We hypothesize that AGI may be related to an unusual degree or depth of hemispheric switching and corresponding callosal suppression of sex appropriate body maps in parietal cortex- possibly the superior parietal lobule- and its reciprocal connections with the insula and hypothalamus. This is based on two lines of reasoning. First, bigender individuals in our survey sample reported an elevated rate of bipolar disorder, which has been linked to slowed hemispheric switching. We hypothesize that tracking the nasal cycle, rate of binocular rivalry, and other markers of hemispheric switching will reveal a physiological basis for AGI individuals' subjective reports of gender switches. Switching may also trigger hormonal cascades, which we are currently exploring. Second, we base our hypotheses on ancient and modern associations between the left and right hemispheres and the male and female genders. By providing a case of sharp brain-sex shifts within individuals, we believe that the study of AGI could prove illuminating to scientific understanding of gender, body representation, and the nature of self.

Author/-s: L. K. Case; V. S. Ramachandran

Publication: Medical hypotheses, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22364652

Physiological differences in bigender people are discussed.

Androgen insensitivity syndrome in its complete form is a disorder of hormone resistance characterised by a female phenotype in an individual with an XY karyotype and testes producing age-appropriate normal concentrations of androgens. Pathogenesis is the result of mutations in the X-linked androgen receptor gene, which encodes for the ligand-activated androgen receptor—a transcription factor and member of the nuclear receptor superfamily. This Seminar describes the clinical manifestations of androgen insensitivity syndrome from infancy to adulthood, reviews the mechanism of androgen action, and shows examples of how mutations of the androgen receptor gene cause the syndrome. Management of androgen insensitivity syndrome should be undertaken by a multidisciplinary team and include gonadectomy to avoid gonad tumours in later life, appropriate sex-hormone replacement at puberty and beyond, and an emphasis on openness in disclosure.

Author/-s: Ieuan A. Hughes; John D. Davies; Trevor I. Buncha; Vickie Pasterski; Kiki Mastroyannopoulou; Jane MacDougall

Publication: The Lancet, 2012

Web link: http://www.sciencedirect.com/science/article/pii/S0140673612600713

Seminar on androgen insensitivity syndrome.

Objective: This study used functional magnetic resonance imaging (fMRI) to contrast the differential brain activation patterns in response to visual stimulation with both male and female erotic nude pictures in male-to-female (MTF) transsexuals who underwent a sex reassignment surgery.

Materials and Methods: A total of nine healthy MTF transsexuals after a sex reassignment surgery underwent fMRI on a 3.0 Tesla MR Scanner. The brain activation patterns were induced by visual stimulation with both male and female erotic nude pictures.

Results: The sex hormone levels of the postoperative MTF transsexuals were in the normal range of healthy heterosexual females. The brain areas, which were activated by viewing male nude pictures when compared with viewing female nude pictures, included predominantly the cerebellum, hippocampus, putamen, anterior cingulate gyrus, head of caudate nucleus, amygdala, midbrain, thalamus, insula, and body of caudate nucleus. On the other hand, brain activation induced by viewing female nude pictures was predominantly observed in the hypothalamus and the septal area.

Conclusion: Our findings suggest that distinct brain activation patterns associated with visual sexual arousal in postoperative MTF transsexuals reflect their sexual orientation to males.

Author/-s: Seok-Kyun Oh; Gwang-Won Kim; Jong-Chul Yang; Seok-Kwun Kim; Heoung-Keun Kang; Gwang-Woo Jeong

Publication: Korean Journal of Radiology, 2012

Web link: http://synapse.koreamed.org/Synapse/Data/PDFData/0068KJR/kjr-13-257.pdf

Post-op MtF transsexuals have brain activation patterns similar to control females.

Objectives: Childhood gender nonconformity has been associated with poorer relationships with parents, but it is unknown if childhood gender nonconformity is associated with childhood abuse or risk of posttraumatic stress disorder (PTSD) in youth.

Methods: We examined whether gender nonconformity before age 11 years was associated with childhood sexual, physical, and psychological abuse and lifetime risk of probable PTSD by using self-report questionnaire data from the 2007 wave of the Growing Up Today Study (n = 9 864; mean age = 22.7 years), a longitudinal cohort of US youth. We further examined whether higher exposure to childhood abuse mediated possible elevated prevalence of PTSD in nonconforming children. Finally, we examined whether association of childhood gender nonconformity with PTSD was independent of sexual orientation.

Results: Exposure to childhood physical, psychological, and sexual abuse, and probable PTSD were elevated in youth in the top decile of childhood gender nonconformity compared with youth below median nonconformity. Abuse victimization disparities partly mediated PTSD disparities by gender nonconformity. Gender nonconformity predicted increased risk of lifetime probable PTSD in youth after adjustment for sexual orientation.

Conclusions: We identify gender nonconformity as an indicator of children at increased risk of abuse and probable PTSD. Pediatricians and school health providers should consider abuse screening for this vulnerable population. Further research to understand how gender nonconformity might increase risk of abuse and to develop family interventions to reduce abuse risk is needed.

Author/-s: Andrea L. Roberts; Margaret Rosario; Heather L. Corliss; Karestan C. Koenen; S. Bryn Austin

Publication: Pediatrics, 2012

Web link: http://pediatrics.aappublications.org/content/early/2012/02/15/peds.2011-1804.abstract

Gender variance increases risks for abuse, stress and trauma.

Background: There is limited data on safety aspects of hormonal treatment in transsexual patients and clinical trials are lacking. We aimed at evaluating the long-term hormonal treatment in transsexual patients.

Patients: 95 transsexuals (37 female-to-male (FMT) and 58 male-to-female transsexuals (MFT)) treated between 1996 and 2007 were compared to an age- and gender-matched primary care patient group from the DETECT-cohort (matching 1:3).

Results: Compared to age-matched control groups, we did not observe a higher prevalence of lifetime cardiovascular, endocrine or tumoural comorbidities. FMT showed a lower prevalence of endocrine diseases (FMT to females, p=0.008 and FMT to males, p=0.033). MFT showed a lower prevalence of cardiovascular diseases (MFT to females, p=0.005 and MFT to males, p<0.001) and endocrine diseases (MFT to females p<0.001 and MFT to males, p<0.001).

Conclusion: There is no indication of an increased risk associated with HT in transsexual patients in Germany.

Author/-s: María Ángeles Bazarra-Castro; Caroline Sievers; Stephany Fulda; Jens Klotsche; Lars Pieper; Hans-Ulrich Wittchen; Günter Karl Stalla

Publication: Reproductive System & Sexual Disorders, 2012

Web link: http://www.omicsonline.org/2161-038X/2161-038X-1-101.php?aid=3275

Hormone therapy is safe and even reduces some health risks.

Sex-typed behavior was assessed at age 3 using the Pre-School Activities Inventory, and at age 13 using the Multidimensional Gender Identity Scale, in 54 masculine boys, 57 masculine girls, 75 feminine boys, 65 feminine girls, 61 control boys, and 65 control girls. At age 13, girls who had been masculine at age 3 felt less similar to other girls, were less content being a girl, and had greater self-efficacy for male-typed activities than control girls, and girls who had been feminine at age 3 had greater self-efficacy for female-typed activities. Boys who had been feminine at age 3 felt less similar to other boys and had lower self-efficacy for male-typed activities than control boys at age 13, and boys who had been masculine at age 3 felt more competent in agentic roles. Thus, sex-typed behavior at age 3 predicted sex-typed behavior at age 13. It was concluded that the degree of sex-typed behavior shown by preschool children is a good indicator of their degree of sex-typed behavior following the transition to adolescence.

Author/-s: S. Golombok; J. Rust; K. Zervoulis; J. Golding; Melissa Hines

Publication: Archives of sexual behaviour, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21681691/

Sex-typed behaviour by three-year-olds is a good predictor for sex-typed behaviour at age 13.

This study provided a descriptive and quantitative comparative analysis of data from an assessment protocol for adolescents referred clinically for gender identity disorder (n = 192; 105 boys, 87 girls) or transvestic fetishism (n = 137, all boys). The protocol included information on demographics, behavior problems, and psychosexual measures. Gender identity disorder and transvestic fetishism youth had high rates of general behavior problems and poor peer relations. On the psychosexual measures, gender identity disorder patients had considerably greater cross-gender behavior and gender dysphoria than did transvestic fetishism youth and other control youth. Male gender identity disorder patients classified as having a nonhomosexual sexual orientation (in relation to birth sex) reported more indicators of transvestic fetishism than did male gender identity disorder patients classified as having a homosexual sexual orientation (in relation to birth sex). The percentage of transvestic fetishism youth and male gender identity disorder patients with a nonhomosexual sexual orientation self-reported similar degrees of behaviors pertaining to transvestic fetishism. Last, male and female gender identity disorder patients with a homosexual sexual orientation had more recalled cross-gender behavior during childhood and more concurrent cross-gender behavior and gender dysphoria than did patients with a nonhomosexual sexual orientation. The authors discuss the clinical utility of their assessment protocol.

Author/-s: Kenneth J. Zucker; S. J. Bradley; A. Owen-Anderson; S. J. Kibblewhite; H. Wood; D. Singh; K. Choi

Publication: Journal of sex & marital therapy, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22390530/

Gender-variant children have behavioural problems and poor peer relations. Gender-dysphoric children had much higher rates of cross-gender behaviour than transvestic fetishism youth and cisgender controls. Lesbian transwomen have more indicators of transvestic fetishism than heterosexual transwomen. Heterosexual transsexuals exhibit more cross-gender behaviour than homosexual transsexuals.

Diffusion tensor imaging (DTI) can sensitively detect white matter sex differences and the effects of pharmacological treatments. Before cross-sex hormone treatment, the white matter microstructure of several brain bundles in female-to-male transsexuals (FtMs) differs from those in females but not from that in males. The purpose of this study was to investigate whether cross-sex hormone treatment (androgenization) affects the brain white matter microstructure. Using a Siemens 3 T Trio Tim Magneton, DTI was performed twice, before and during cross-sex hormonal treatment with testosterone in 15 FtMs scanned. Fractional anisotropy (FA) was analyzed on white matter of the whole brain, and the latter was spatially analyzed using Tract-Based Spatial Statistics. Before each scan the subjects were assessed for serum testosterone, sex hormone binding globulin level (SHBG), and their free testosterone index. After at least seven months of cross-gender hormonal treatment, FA values increased in the right superior longitudinal fasciculus (SLF) and the right corticospinal tract (CST) in FtMs compared to their pre-treatment values. Hierarchical regression analyses showed that the increments in the FA values in the SLF and CST are predicted by the free testosterone index before hormonal treatment. All these observations suggest that testosterone treatment changes white matter microstructure in FtMs.

Author/-s: G. Rametti; B. Carrillo; Esther Gómez-Gil; Carme Junque; Leire Zubiaurre-Elorza; S. Segovia; A. Gomez; K. Karadi; Antonio Guillamon

Publication: Psychoneuroendocrinology, 2012

Web link: http://europepmc.org/abstract/MED/22260939

Hormone treatments change white matter structure in the brain.

Persons with gender identity disorder (GID) often suffer from psychiatric co-morbidity, and it is an important prognostic factor for long-term psychosocial adjustment in GID. However, previous research has not addressed the risk factors of psychiatric co-morbidity. In this study, we tried to clarify the risk factors among individuals with GID in Japan. A total of 326 consecutive GID persons were evaluated independently by two senior psychiatrists at the GID clinic using personal clinical interviews and results of examinations. The prevalence of current psychiatric co-morbidity was 17.8 % of the total sample. School refusal was significantly associated with psychiatric co-morbidity. Sexual attraction to neither males nor females among GID persons and sexual attraction to females among male-to-female (MtF) GID persons were also significantly related to psychiatric co-morbidity. This is the first report to demonstrate a close relationship between patterns of sexual orientation and psychiatric co-morbidity among GID persons. We should pay more attention to psychiatric co-morbidity, especially among GID persons with non-homosexual sexual orientations.

Author/-s: S. Terada; Y. Matsumoto; T. Sato; N. Okabe; Y. Kishimoto; Y. Uchitomi

Publicatrion: Psychiatry research, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22884214

17.8 % of gender dysphoria patients suffer from mental illness. School refusal, asexuality and gynephily are related to higher rates of mental illness.

Introduction: Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status.

Aim: First, to assess health-related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data.

Methods: One hundred forty-eight current and former transgender patients of a gender identity clinic participated in a large QOL study.

Main outcome measures: Health-related QOL was measured using the Short Form 36-Item Questionnaire.

Results: The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health-related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single.

Conclusions: Specific social indicators are important in relation to health-related QOL of transgenders in a context of qualitative and adequate medical care.

Author/-s: Joz Motmans; Petra Meier; Koen Ponnet; Guy T’Sjoen

Publication: The journal of sexual medicine, 2012

Web link: http://europepmc.org/abstract/MED/22188877

Quality-of-life measurements depending on socioeconomic factors. Good to know that the general quality of life of MtF transsexuals is similar to female controls.

Although gender differences in cognitive abilities are frequently reported, the magnitude of these differences and whether they hold practical significance in the educational outcomes of boys and girls is highly debated. Furthermore, when gender gaps in reading, mathematics and science literacy are reported they are often attributed to innate, biological differences rather than social and cultural factors. Cross-cultural evidence may contribute to this debate, and this study reports national gender differences in reading, mathematics and science literacy from 65 nations participating in the 2009 round of the Programme for International Student Assessment (PISA). Consistently across all nations, girls outperform boys in reading literacy, d = −0.44. Boys outperform girls in mathematics in the USA, d = 0.22 and across OECD nations, d = 0.13. For science literacy, while the USA showed the largest gender difference across all OECD nations, d = 0.14, gender differences across OECD nations were non-significant, and a small female advantage was found for non-OECD nations, d = −0.09. Across all three domains, these differences were more pronounced at both tails of the distribution for low- and high-achievers. Considerable cross-cultural variability was also observed, and national gender differences were correlated with gender equity measures, economic prosperity, and Hofstede’s cultural dimension of power distance. Educational and societal implications of such gender gaps are addressed, as well as the mechanisms by which gender differences in cognitive abilities are culturally mediated.

Author/-s: David Reilly

Publication: PLoS One, 2012

Web link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3393715/

Study of gender differences by culture.

Disorders of sex development (DSDs) are estimated to be prevalent in 0.1–2 % of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation—processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5–20 % of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17β-hydroxysteroid dehydrogenase 3 (17β-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63 %). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.

Author/-s: Paulo Sampaio Furtado; Felipe Moraes; Renata Lago; Luciana Oliveira Barros; Maria Betânia Toralles; Ubirajara Barroso

Publication: Nature Reviews Urology, 2012

Web link: http://www.nature.com/nrurol/journal/v9/n11/full/nrurol.2012.182.html

Association of gender dysphoria with disorders of sex development.

Using the Life Chart Interview, a validated instrument for the collection of biographical data, lifetime information about transgender experiences was collected in a community-based sample of 571 transgender women from the New York metropolitan area. Disclosures of transgender identity in different types of relationships, responses of relationship partners indicative of gender identity conflict or affirmation, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, major depression were assessed within and across five stages of the life course. Gender identity conflict/affirmation was associated with major depression within stages of the life course (contemporaneous analysis) and predictive of changes in major depression across stages of the life course (lagged analysis).

Author/-s: Larry Nuttbrock; Walter Bockting; Andrew Rosenblum; Mona Mason; Monica Macri; Jeffrey Becker

Publication: International Journal of Transgenderism, 2012

Web link: http://www.researchgate.net/publication/254366022_Gender_Identity_ConflictAffirmation_and_Major_Depression_Across_the_Life_Course_of_Transgender_Women

Major depression is associated with gender dysphoria.

Both a same-sex sexual orientation and gender nonconformity have been linked with poorer well-being; however, sexual orientation and gender nonconformity are also correlated. It is, therefore, critical to investigate their independent contributions to well-being. Based on survey responses of 230 female and 245 male high school seniors, the present study is one of the first to provide empirical data on this topic. Both childhood and adolescent gender nonconformity were negatively related to well-being. In the same analyses, neither sexual orientation nor biological sex was a significant predictor of well-being. These results suggest that gender-atypical traits may be more relevant for psychological health than a same-sex sexual orientation. Both environmental and biological influences may account for these findings.

Author/-s: G. Rieger; R. C. Savin-Williams

Publication: Archives of sexual behaviour, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21350914/

Gender non-conformity in childhood and adolescences reduces well-being, independently of gender or sexual orientation. Both environmental and biological influences may account for these findings.

The categorization of individuals as "male" or "female" is based on chromosome complement and gonadal and genital phenotype. This combined genetic-gonadal-genitals sex, here referred to as 3G-sex, is internally consistent in ≈ 99 % of humans (i.e., one has either the "female" form at all levels, or the "male" form at all levels). About 1% of the human population is identified as "intersex" because of either having an intermediate form at one or more levels, or having the "male" form at some levels and the "female" form at other levels. These two types of "intersex" reflect the facts, respectively, that the different levels of 3G-sex are not completely dimorphic nor perfectly consistent. Using 3G-sex as a model to understand sex differences in other domains (e.g., brain, behavior) leads to the erroneous assumption that sex differences in these other domains are also highly dimorphic and highly consistent. But parallel lines of research have led to the conclusion that sex differences in the brain and in behavior, cognition, personality, and other gender characteristics are for the most part not dimorphic and not internally consistent (i.e., having one brain/gender characteristic with the "male" form is not a reliable predictor for the form of other brain/gender characteristics). Therefore although only ≈ 1 % percent of humans are 3G-"intersex", when it comes to brain and gender, we all have an intersex gender (i.e., an array of masculine and feminine traits) and an intersex brain (a mosaic of "male" and "female" brain characteristics).

Author/-s: D. Joel

Publication: Biology of sex differences, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/23244600

Human sex differences are not dimorphic and not consistent.

Brain organization theory suggests that steroid hormones during fetal development permanently organize the brain for gender, including patterns of sexuality, cognition, temperament, and interests that differ by sex. This widely-accepted theory has important implications for health, ranging from medical management of infants with intersex conditions to suggested etiologies for sex differences in autism, depression, and other mental health problems. Studies of genetic females with congenital adrenal hyperplasia (CAH), in which high prenatal androgens have been linked to both atypical genitals and "masculine" patterns of gender and sexuality, are particularly important. Based on a comprehensive review of research on CAH, this article demonstrates that such studies have neglected four broad categories of variables that plausibly affect psychosexual development: (1) physiological effects of CAH, including complex disruption of steroid hormones from early development onwards; (2) intensive medical intervention and surveillance, which many women with CAH describe as traumatic; (3) direct effects of genital morphology on sexuality (versus indirect effects that "masculine" genitals may have on gender socialization); and (4) expectations of masculinization that likely affect both the development and evaluation of gender and sexuality in CAH. Complex and iterative interactions among postnatal biological variables, medical interventions, and social context provide a more plausible explanation for atypicalities in psychology and behavior that have been reported for genetic females with CAH than the conventional explanation that early androgens have "masculinized" their brains.

Author/-s: R. M. Jordan-Young

Publication: Social science & medicine, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21962724/

Speculation on social and psychological impacts on genetic women with congenital adrenal hyperplasia (CAH).

Introduction: Long-term effects and side effects of cross-sex hormone treatment in transsexual persons are not well known.

Aim: The aim of this study is to describe the effects and side effects of cross-sex hormone therapy in both transsexual men and women.

Main outcome measures: Hormone levels were measured by immunoassays. Physical health was assessed by physical examination and questionnaires on general health and specific side effects, areal bone parameters by dual energy X-ray absorptiometry.

Methods: Single center cross-sectional study in 100 transsexual persons post-sex reassignment surgery and on average 10 years on cross-sex hormone therapy.

Results: Transsexual men did not experience important side effects such as cardiovascular events, hormone-related cancers, or osteoporosis. In contrast, a quarter of the transsexual women had osteoporosis at the lumbar spine and radius. Moreover, 6% of transsexual women experienced a thromboembolic event and another 6% experienced other cardiovascular problems after on average 11.3 hormone treatment years. None of the transsexual women experienced a hormone-related cancer during treatment.

Cconclusion: Cross-sex hormone treatment appears to be safe in transsexual men. On the other hand, a substantial number of transsexual women suffered from osteoporosis at the lumbar spine and distal arm. Twelve percent of transsexual women experienced thromboembolic and/or other cardiovascular events during hormone treatment, possibly related to older age, estrogen treatment, and lifestyle factors. In order to decrease cardiovascular morbidity, more attention should be paid to decrease cardiovascular risk factors during hormone therapy management.

Author/-s: K. Wierckx; S. Mueller; S. Weyers; E. van Caenegem; G. Roef; G. Heylens; G. T’Sjoen

Publication: The journal of sexual medicine, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22906135

Review of side effects of hormone therapy.

Taxometric methods enable determination of whether the latent structure of a construct is dimensional or taxonic (nonarbitrary categories). Although sex as a biological category is taxonic, psychological gender differences have not been examined in this way. The taxometric methods of mean above minus below a cut, maximum eigenvalue, and latent mode were used to investigate whether gender is taxonic or dimensional. Behavioral measures of stereotyped hobbies and physiological characteristics (physical strength, anthropometric measurements) were examined for validation purposes, and were taxonic by sex. Psychological indicators included sexuality and mating (sexual attitudes and behaviors, mate selectivity, sociosexual orientation), interpersonal orientation (empathy, relational-interdependent self-construal), gender-related dispositions (masculinity, femininity, care orientation, unmitigated communion, fear of success, science inclination, Big Five personality), and intimacy (intimacy prototypes and stages, social provisions, intimacy with best friend). Constructs were with few exceptions dimensional, speaking to Spence’s (1993) gender identity theory. Average differences between men and women are not under dispute, but the dimensionality of gender indicates that these differences are inappropriate for diagnosing gender-typical psychological variables on the basis of sex.

Author/-s: Bobbi J. Carothers; Harry T. Reis

Publication: Journal of Personality and Social Psychology, 2012

Web link: http://www.psych.rochester.edu/people/reis_harry/assets/pdf/CarothersReis_2012.pdf

Gender differences are quantitative, not qualitative.

Physicians are obliged to provide treatment that is consistent with their commitment to avoid or minimize harm (nonmaleficence) and their commitment to do good (beneficence). Therefore, if patient's desires were contradictory to the primary aim of medicine, the doctor's calling would require him/her to thoroughly analyze the cause of the disease and provide an adequate as well as ethical treatment rather than obediently follow patient's requests. Yet, chemical and surgical sex reassignment is one of the areas where some physicians surrender to the desire of their patients instead of finding out what their real condition is and trying to manage it in a way the essence of medicine would require. The objective of this article was to provide specific pharmacovigilance search details for the evaluation of the current situation and the scientific background of the treatment of gender dysphoria and to analyze its conformity with one of the two main ethical principles of medicine - nonmaleficence. Literature retrieval was accessed through Medline (1979–2011) using the terms "gender dysphoria," "replacement hormonal therapy," and "pharmacovigilance." The article concludes that hormonal and surgical interventions have not proven to be medically justified and could be harmful, not treating the cause, but resulting in irreversible disability. Thus, these interventions contradict the principle of nonmaleficence and goals of basic therapeutics and pharmacovigilance. They are not based on clinical trials and are lacking a thorough follow-up assessment.

Author/-s: Kristina Zamarytė; Donatas Stakišaitis; Agnė Širinskienė; Andrius Narbekovas; Jonas Juškevičius

Publication: Medicina, 2012

Web link: http://europepmc.org/abstract/MED/23455896

A rare study arguing against hormonal and surgical treatment.

Research on the psychological development of persons with Disorders of Sex Development (DSD) has focused on understanding the influence of atypical sex hormone exposure during steroid-sensitive periods of prenatal brain development on the process of psychosexual differentiation (i.e., gender identity, gender role, and sexual orientation). In contrast, analysis of clinical management strategies has focused on gender assignment and the desirability and timing of genital surgery.

This review focuses on the psychological issues that confront clinicians managing the care of persons born with DSD and their families. Particular attention is paid to processes and factors that potentially mediate or moderate psychosocial and psychosexual outcomes within and across developmental stages.

Author/-s: David E. Sandberg; Melissa Gardner; Peggy T. Cohen-Kettenis

Publication: Seminars in Reproductive Medicine, 2012

Web link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687360/

A review.

Introduction: Both biological and psychosocial factors influence psychosexual development. High levels of pre- and postnatal androgens lead to more male-typical behavior. So far, the influence of androgens on gender identity and sexual orientation is unclear. Disorders of sex development (DSDs) are heterogeneous genetic conditions with different levels of prenatal androgens resulting in variations of genital development. Through DSD, the role of the different factors, especially androgen exposure, on psychosexual development can be evaluated.

Aim: The purpose of the study was to assess psychosexual development in adolescents and adults with different forms of DSD.

Methods: For the examination of psychosexual development of 66 adolescents and 110 adults with DSD, the authors used the Utrecht Gender Dysphoria Scale for adolescents, the Questionnaire of Gender Identity for adults, and a condition-specific DSD study questionnaire. Individuals were analyzed in four subgroups reflecting the karyotype, absence/presence of androgen effects, and gender of rearing.

Main Outcome Measures: Main outcome measures used were gender identity, friendships, love and sexual relationships, and sexual orientation in adolescents and adults with DSD.

Results: Individuals with DSD did not show increased gender dysphoria. However, partnership and sexuality were identified to be difficult areas of life. Both adolescents and adults with DSD reported fewer experiences regarding love or sexual relationships compared with unaffected individuals. Especially men with DSD and undervirilization and women with DSD and androgen effects less often had a love relationship. Adult women with DSD and androgen effects more frequently engaged in love and sexual relationships with individuals of the same gender compared with women without DSD.

Conclusion: Individuals with DSD experience atypical hormonal influences (higher levels of androgens in girls/women and lower levels in androgens in boys/men); however, they did not show increased gender dysphoria in this study. However, partnership and sexual relationships are difficult areas of life for adolescents and adults with DSD. We recommend that individuals with DSD should get support from a multiprofessional team with competency in assessing and counseling issues regarding relationships and sexuality. Contact to other individuals with DSD can be helpful for nonprofessional support and exchange of experiences.

Author/-s: M. Jürgensen; E. Kleinemeier; A. Lux; Thomas Dirk Steensma; Peggy T. Cohen-Kettenis; O. Hiort; U. Thyen; B. Köhler; DSD Network Working Group

Publication: The journal of sexual medicine, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22548716/

Individuals with disorders of sex development have difficulties with partnerships and sexual relationships, but do not show increased gender dysphoria in this study.

Magnetic resonance (MR) is the best way to assess the new anatomy of the pelvis after male to female (MtF) sex reassignment surgery. The aim of the study was to evaluate the radiological appearance of the small pelvis after MtF surgery and to compare it with the normal women's anatomy. Fifteen patients who underwent MtF surgery were subjected to pelvic MR at least 6 months after surgery. The anthropometric parameters of the small pelvis were measured and compared with those of ten healthy women (control group). Our personal technique (creation of the mons Veneris under the pubic skin) was performed in all patients. In patients who underwent MtF surgery, the mean neovaginal depth was slightly superior than in women (P=0.009). The length of the inferior pelvic aperture and of the inlet of pelvis was higher in the control group (P<0.005). The inclination between the axis of the neovagina and the inferior pelvis aperture, the thickness of the mons Veneris and the thickness of the rectovaginal septum were comparable between the two study groups. MR consents a detailed assessment of the new pelvic anatomy after MtF surgery. The anthropometric parameters measured in our patients were comparable with those of women.

Author/-s: E. Brunocilla; M. Soli; A. Franceschelli; R. Schiavina; M. Borghesi; G. Gentile; C. V. Pultrone; G. Martorana; M. G. Orrei; F. Colombo

Publication: International Journal of Impotence Research, 2012

Web link: http://www.nature.com/ijir/journal/v24/n5/full/ijir201218a.html

The pelvis area of male-to-female transsexuals after surgery is comparable to that of cisgender women.

Background: Sex differences in personality are believed to be comparatively small. However, research in this area has suffered from significant methodological limitations. We advance a set of guidelines for overcoming those limitations: (a) measure personality with a higher resolution than that afforded by the Big Five; (b) estimate sex differences on latent factors; and (c) assess global sex differences with multivariate effect sizes. We then apply these guidelines to a large, representative adult sample, and obtain what is presently the best estimate of global sex differences in personality.

Methodology/principal findings: Personality measures were obtained from a large US sample (N = 10 261) with the 16PF Questionnaire. Multigroup latent variable modeling was used to estimate sex differences on individual personality dimensions, which were then aggregated to yield a multivariate effect size (Mahalanobis D). We found a global effect size D = 2.71, corresponding to an overlap of only 10% between the male and female distributions. Even excluding the factor showing the largest univariate ES, the global effect size was D = 1.71 (24 % overlap). These are extremely large differences by psychological standards.

Significance: The idea that there are only minor differences between the personality profiles of males and females should be rejected as based on inadequate methodology.

Author/-s: Marco del Giudice; Tom Booth; Paul Irwing

Publication: PLOS One, 2012

Web link: http://europepmc.org/abstract/MED/22238596

Differences between men and women are larger than previously thought.

Background: During adolescence, numerous factors influence the organization of the brain. It is unclear what influence sex and puberty have on white matter microstructure, as well as the role that rapidly increasing sex steroids play.

Methods: White matter microstructure was examined in 77 adolescents (ages 10-16) using diffusion tensor imaging. Multiple regression analyses were performed to examine the relationships between fractional anisotropy (FA) and mean diffusivity (MD) and sex, puberty, and their interaction, controlling for age. Follow-up analyses determined if sex steroids predicted microstructural characteristics in sexually dimorphic and pubertal-related white matter regions, as well as in whole brain.

Results: Boys had higher FA in white matter carrying corticospinal, long-range association, and cortico-subcortical fibers, and lower MD in frontal and temporal white matter compared with girls. Pubertal development was related to higher FA in the insula, while a significant sex-by-puberty interaction was seen in superior frontal white matter. In boys, testosterone predicted white matter integrity in sexually dimorphic regions as well as whole brain FA, whereas estradiol showed a negative relationship with FA in girls.

Conclusions: Sex differences and puberty uniquely relate to white matter microstructure in adolescents, which can partially be explained by sex steroids.

Author/-s: M. M. Herting; E. C. Maxwell, C. Irvine; B. J. Nagel

Publication: Cerebral cortex, 2012

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22002939

Puberty and white matter.

This article presents empirical research findings from a subsample of 290 transgender participants in the Virginia Transgender Health Initiative Survey (THIS) who reported whether or not they had experienced hostility or insensitivity related to their gender identity or expression during high school, termed in-school gender-based victimization (GBV). The purpose of this study was to assess the impact of in-school GBV on rates of suicide attempts among transgender people. Of the 290 respondents, 44.8 % reported they had experienced in-school GBV, and 28.5 % reported a history of suicide attempt. Among those who had attempted, 32.5 % reported having made one attempt, 28.6 % reported a history of two attempts, and 39.0% reported having made three or more attempts. Participants who reported experiencing GBV were approximately four times more likely to have attempted suicide than those who did not. Among the subgroups of 147 trans women and 81 trans men, GBV was associated both with history of suicide attempt, and with a higher number of suicide attempts over the life span. Implications for policy and clinical interventions are discussed.

Author/-s: Peter Goldblum; Rylan J. Testa; Samantha Pflum; Michael L. Hendricks; Judith Bradford; Bruce Bongar

Publication: Professional Psychology: Research and Practice, 2012

Web link: http://psycnet.apa.org/journals/pro/43/5/468

A large share of transsexuals experience gender-based hostility at school. This hostility is linked to a higher occurrence of suicide attempts.

In a series of important but now highly controversial articles, Blanchard examined associations of sexual orientation and transvestic fetishism among male-to-female (MTF) transgender persons in Toronto, Canada. Transvestic fetishism was rare among the homosexuals but prevalent among the non-homosexuals. Subtypes of non-homosexual MTFs (heterosexual, bisexual, and asexual) were consistently high with regard to transvestic fetishism. Non-linear associations of a continuous measurement of sexual attraction to women (gynephilia) and transvestic fetishism were interpreted in terms of an etiological hypothesis in which transvestic fetishism interferes with the early development of heterosexuality. Blanchard concluded that homosexual versus non-homosexual sexual orientation is a dominant and etiologically significant axis for evaluating and understanding this population. We further assessed these findings among 571 MTFs from the New York City metropolitan area. Using the Life Chart Interview, multiple measurements of transvestic fetishism were obtained and classified as lifetime, lifecourse persistent, adolescent limited, and adult onset. Large (but not deterministic) differences in lifetime, lifecourse persistent, and adolescent limited transvestic fetishism were found between the homosexuals and non-homosexuals. Contrary to Blanchard, differences in transvestic fetishism were observed across subtypes of the non-homosexuals, and linear (not curvilinear) associations were found along a continuous measurement of gynephilia and transvestic fetishism. Age and ethnicity, in addition to sexual orientation, were found to be statistically significant predictors of transvestic fetishism. The clinical, etiological, and sociopolitical implications of these findings are discussed.

Author/-s: Larry Nuttbrock; Walter Bockting; Mona Mason; Sel Hwahng; Andrew Rosenblum; Monica Macri; Jeffrey Becker

Publication: Archives of Sexual Behavior, 2011

Web link: http://link.springer.com/article/10.1007%2Fs10508-009-9579-2

Some findings in line with and some against the autogynephilia theory.

Objective: Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones.

Design: A cohort study with a median follow-up of 18.5 years at a university gender clinic.

Methods: Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses.

Results: In the MtF group, total mortality was 51 % higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population.

Conclusions: The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death.

In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.

Author/-s: Henk Asscheman; Erik J. Giltay; Jos A. J. Megens; W. (Pim) de Ronde; Michael A. A. van Trotsenburg; Louis J. G. Gooren

Publication: European Journal of Endocrinology, 2011

Web link: http://www.eje.org/content/164/4/635.full

Hormone therapy seems safe.

There are transformational possibilities in the family when presented with a child who is transgender or gender nonconforming. Challenging orthodox psychoanalytic thinking that these children's gender presentations are a consequence of poor parental rearing, trauma, or attachment disruptions, it is proposed that gender nonconformity is healthy rather than pathological and that typically these children initially just show up in their families, rather than being shaped by them. Looking at the metabolism of transphobia and the transformational possibilities within the family when boys will be girls and girls will be boys, 3 family types that either support or impede their children's creative gender development are presented: the transformers, the transphobic, and the transporting, with case material to illustrate each of the family types. A psychological construct is developed to explain the feedback loop between family and child: The transgender or gender nonconforming child who transgresses binary gender norms may face culturally imbued transphobia and psychological trauma within the family while simultaneously facilitating the family's transcendence of transphobia through transformative experiences with the child as he or she transitions from the gender assigned at birth to his or her authentic and affirmed gender identity or expression.

Author/-s: Diane Ehrensaft

Publication: Psychoanalytic Psychology, 2011

Web link: http://psycnet.apa.org/?&fa=main.doiLanding&doi=10.1037/a0023828

Discussion on the interactions within the families of transsexual or gender nonconforming children.

Brain organization theory posits a cascade of physiological and behavioral changes initiated and shaped by prenatal hormones. Recently, this theory has been associated with outcomes including gendered toy preference, 2D/4D digit ratio, personality characteristics, sexual orientation, and cognitive profile (spatial, verbal, and mathematical abilities). We examine the evidence for this claim, focusing on 2D/4D and its putative role as a biomarker for organizational features that influence cognitive abilities/interests predisposing males toward mathematically and spatially intensive careers. Although massive support exists for early brain organization theory overall, there are myriad inconsistencies, alternative explanations, and outright contradictions that must be addressed while still taking the entire theory into account. Like a fractal within the larger theory, the 2D/4D hypothesis mirrors this overall support on a smaller scale while likewise suffering from inconsistencies (positive, negative, and sex-dependent correlations), alternative explanations (2D/4D related to spatial preferences rather than abilities per se), and contradictions (feminine 2D/4D in men associated with higher spatial ability). Using the debate over brain organization theory as the theoretical stage, we focus on 2D/4D evidence as an increasingly important player on this stage, a demonstrative case in point of the evidential complexities of the broader debate, and an increasingly important topic in its own right.

Author/-s: J. Valla; S. J. Ceci

Publication: Perspectives on psychological science, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/22164187

Sex differences and prenatal hormones.

Childhood maltreatment (CM) is quite common and constitutes a nonspecific risk factor for a range of different psychiatric symptoms during lifespan. It has been demonstrated that sexual minorities are at higher risk of maltreatment and abuse, and a high proportion of transsexual subjects report CM. The aim of this study is to evaluate the prevalence of reported CM in a clinical sample of patients with male-to-female Gender Identity Disorder (MtF GID), and to explore the relationship between these early life events, body image and different psychopathological and clinical variables. A consecutive series of 162 patients with male genotype was evaluated from July 2008 to May 2010. A total of 109 subjects (mean age 36±10 years) meeting the criteria for MtF GID and giving their informed consent were considered. The occurrence of CM experiences was evaluated through a face-to-face clinical interview. Patients were asked to complete the Body Uneasiness Test and Symptom Checklist-90 Revised. More than one-fourth of patients reported CM. Maltreated subjects reported a higher body dissatisfaction and display a worse lifetime mental health. The presence of reported CM in these patients has relevant psychopathological implications, and therefore should be carefully investigated.

Author/-s: E. Bandini; A. D. Fisher; V. Ricca; J. Ristori; M. C. Meriggiola; E. A. Jannini; C. Manieri; G. Corona; M. Monami; E. Fanni; A. Galleni; G. Forti; E. Mannucci; M. Maggi

Publication: International Journal of Impotence Research, 2011

Web link: http://www.nature.com/ijir/journal/v23/n6/full/ijir201139a.html

More than one quarter of male-to-female transsexuals reported childhood maltreatment.

Sex, sexual orientation and age have been shown to be important in relation to psychological functioning in transsexuals. However, only few studies to date took these factors into account and not earlier have adolescent transsexuals participated. In this study the Minnesota Multiphasic Personality Inventory (MMPI-2 or MMPI-A, respectively) was administered to 293 adults (207 male to female transsexuals (MtFs), mean age 38.04 (range 18.56–65.62) and 86 female to male transsexuals (FtMs), mean age 33.26 (range 18.95–64.30)) and 83 adolescents (43 MtFs, mean age 15.70 (range 13.16–18.70) and 40 FtMs, mean age 15.64 (range 13.05–18.56)) with a gender identity disorder (GID). Of adult MtFs, 33% were categorized as "homosexuals" and 66% as "non-homosexuals". Of adult FtMs, 77% were categorized as "homosexuals" and 33% as "non-homosexuals". Adult FtMs functioned significantly better than MtFs on three clinical scales. Contrary to what is often assumed, no differences in psychological functioning were found in the adult transsexuals with regard to sexual orientation, except on one clinical scale. Most remarkably, significantly more adults with GID scored in the clinical range on two or more clinical scales than adolescents with GID. Therefore, early medical intervention may be recommendable for adolescents with GID.

Author/-s: Annelou L. C. de Vries; Baudewijntje P. C. Kreukels; Thomas Dirk Steensma; Theo A. H. Doreleijers; Peggy T. Cohen-Kettenis

Publication: Psychiatry Research, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/20801524

FtM transsexuals have better mental health than MtF. Adolescents transsexuals have better mental health than adult transsexuals.

The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14–18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different.

Author/-s: Thomas Dirk Steensma; R. Biemond; F. de Boer; Peggy T. Cohen-Kettenis

Publication: Clinical child psychology and psychiatry, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21216800/

Gender dysphoric children who later grew out of this phase and become non-transsexual and gender dysphoric children who remain transsexual in adolescence seem to have different causes of gender dysphoria.

This paper investigates gender differences in personality traits, both at the level of the Big Five and at the sublevel of two aspects within each Big Five domain. Replicating previous findings, women reported higher Big Five Extraversion, Agreeableness, and Neuroticism scores than men. However, more extensive gender differences were found at the level of the aspects, with significant gender differences appearing in both aspects of every Big Five trait. For Extraversion, Openness, and Conscientiousness, the gender differences were found to diverge at the aspect level, rendering them either small or undetectable at the Big Five level. These findings clarify the nature of gender differences in personality and highlight the utility of measuring personality at the aspect level.

Author/-s: Y. J. Weisberg; C. G. Deyoung; J. B. Hirsh

Publication: Frontiers in psychology, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21866227/

Gender differences.

Key findings: Hundreds of dramatic findings on the impact of anti-transgender bias are presented in this report. In many cases, a series of bias-related events lead to insurmountable challenges and devastating outcomes for study participants. Several meta-findings are worth noting from the outset:

• Discrimination was pervasive throughout the entire sample, yet the combination of anti-transgender bias and persistent, structural racism was especially devastating. People of color in general fare worse than white participants across the board, with African American transgender respondents faring far worse than all others in most areas examined.

• Respondents lived in extreme poverty. Our sample was nearly four times more likely to have a household income of less than 10 000 $ per year compared to the general population.

• A staggering 41 % of respondents reported attempting suicide compared to 1.6 % of the general population, with rates rising for those who lost a job due to bias (55 %), were harassed/bullied in school (51 %), had low household income, or were the victim of physical assault (61 %) or sexual assault (64 %).

Author/-s: Jaime M. Grant; Lisa A. Mottet; Justin Tanis; Jack Harrison; Jody L. Herman; Mara Keisling

Publication: Report by the National Center for Transgender Equality and the National Gay and Lesbian Task Force, 2011

Web link: http://www.thetaskforce.org/reports_and_research/ntds

Report on discrimination.

Context: The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.

Objective: To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.

Design: A population-based matched cohort study.

Setting: Sweden, 1973–2003.

Participants: All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973–2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively.

Main outcome measures: Hazard ratios (HR) with 95 % confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).

Results: The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95 % CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95 % CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95 % CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95 % CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

Conclusions: Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Author/-s: Cecilia Dhejne; Paul Lichtenstein; Marcus Boman; Anna L. V. Johansson; Niklas Långström; Mikael Landén

Publication: PLoS One, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21364939

Transsexuals after sex reassignment are worse off than cisgendered controls. Unfortunately, no comparison to transsexuals before treatment was made.

Objective: Handedness is the most noticeable functional expression of cerebral lateralization in humans. However, its developmental process and plasticity remain elusive. It has been postulated that prenatal testosterone (pT) has an effect on human lateralization development. In the present study we examined the relationship between pT and handedness and compared the outcome to previously published data on language lateralization in the same children.

Method: pT was assessed from amniotic fluid of healthy pregnant women using radioimmunoassay. Strength and direction of handedness of the children (n = 65 [31 girls, 34 boys], mean age [years]: 6.43, range: 5.97-7.53) was assessed based on hand choice during performance of age appropriate tasks. Regression procedures and the Olkin & Siotani Z-statistic were used.

Results: Results demonstrate that higher pT exposure was related to a decrease in strength of handedness (R² = 0.11, p = 0.01). The analysis shows that pT has quite stronger explanatory power than sex by itself, although there may be an additional effect of sex independent from pT. In a subgroup of these children we recently reported that higher levels of pT are related to increased left hemisphere dominance for language. Analyses show that pT is differentially related to handedness and language lateralization in these children (Z > 2.75, p < 0.003).

Conclusions: Results imply a differential effect of pT on language lateralization and handedness. This may be explained by differential sensitivity of different areas of the corpus callosum or hemispheres for androgens, fuelling the ongoing debate about the relationship between prenatal exposure to testosterone and lateralization of brain and behavior.

Author/-s: J. M. Lust; R. H. Geuze; C. van de Beek; P. T. Cohen-Kettenis; A. Bouma; T. G. Groothuis

Publication: Neuropsychology, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21500918

Connection between prenatal testosterone on handedness and language lateralisation.

Background: The main goal in women with Mayer-Rokitansky-Küster-Hauser syndrome (vaginal agenesis) is creation of a neovagina that will satisfy the patient's desire. We evaluated sexual and psychosocial adjustment in patients who underwent rectosigmoid vaginoplasty because of vaginal agenesis.

Methods: A total of 36 women, aged 21 to 38 years (mean=26) who underwent rectosigmoid vaginoplasty from 1997 to 2006 were evaluated. Sexual and psychosocial appraisal included the Female Sexual Function Index (FSFI), Beck's Depression Inventory (BDI), and standardised questionnaires about postoperative satisfaction, social and sexual adjustment.

Results: Mean FSFI score was 28.9 (range=11.5-35.7) with a cut-off score of 26.55 for sexual dysfunction. Out of the 36 women, 10 (27, 8%) had sexual dysfunction. Mean BDI score was 7.55 (cut-off score=0-9 for non-depression). Twenty-eight women (77.8%) were without symptoms of depression, six women (BDI range=10-29) had moderate and two women had severe depression (BDI=42). There were a significant number of patients (P<0.01) with a high satisfaction score in FSFI and low BDI results. Thirty-two (88.9%) of the patients believed that surgery was done at the right time and the main postoperative support came from their family. Thirty-four (94.4%) of the patients reported satisfactory femininity, with a heterosexual orientation. Thirty patients (83. 3%) were very satisfied with the surgery, while 34 considered surgery as the best treatment.

Conclusions: The sexual function and psychosocial status of these patients should be followed long-term to estimate their quality of life.

Author/-s: L. D. Labus; M. L. Djordjevic; D. S. Stanojevic; M. R. Bizic; B. Z. Stojanovic; T. M. Cavic

Publication: Sexual health, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21851786

Vaginoplasty is also used for other conditions than gender dysphoria and seems safe.

Background: Sex-specific trajectories in white matter development during adolescence may help explain cognitive and behavioral divergences between males and females. Knowledge of sex differences in typically developing adolescents can provide a basis for interpreting sexual dimorphisms in abilities and actions.

Method: We examined 58 healthy adolescents (12-14years of age) with diffusion tensor imaging (DTI). Diffusion parameters fractional anisotropy (FA), and mean (MD), radial (RD), and axial diffusivities (AD) were subjected to whole-brain voxel-wise group comparisons using tract-based spatial statistics. Sex differences in white matter microstructure were examined in relation to pubertal development.

Results: Early adolescent females (n=29) evidenced higher FA in the right superior corona radiata, higher FA and AD in bilateral corticospinal tracts (≥164μl, p<.01), and lower MD in the right inferior longitudinal fasciculus (ILF) and left forceps major (≥164μl, p<.01) than age-matched males (n=29). Males did not show any areas of higher FA or lower MD than females, but had higher AD in the right superior longitudinal fasciculus, ILF, and forceps minor (≥ 164μl, p<.01). Pubertal stage did not account for sex disparities.

Conclusion: In early adolescence, females' motor tracts may reflect widespread changes, while males may undergo relatively more microstructural change in projection and association fibers.

Author/-s: S. Bava, V. Boucquey; D. Goldenberg; R. E. Thayer; M. Ward; J. Jacobus; S. F. Tapert

Publication: Brain research, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21172320

Sex-dimorphic changes to the brain in puberty.

Despite strong indications of elevated risk of suicidal behavior in lesbian, gay, bisexual, and transgender people, limited attention has been given to research, interventions or suicide prevention programs targeting these populations. This article is a culmination of a three-year effort by an expert panel to address the need for better understanding of suicidal behavior and suicide risk in sexual minority populations, and stimulate the development of needed prevention strategies, interventions and policy changes. This article summarizes existing research findings, and makes recommendations for addressing knowledge gaps and applying current knowledge to relevant areas of suicide prevention practice.

Author/-s: A. P. Haas; M. Eliason; V. M. Mays; R. M. Mathy: S. D. Cochran; A. R. D’Augelli; M. M. Silverman; P. W. Fisher; T. Hughes; M. Rosario; S. T. Russell; E. Malley; J. Reed; D. A. Litts; E. Haller; R. L. Sell; G. Remafedi; J. Bradford; A. L. Beautrais; G. K. Brown; G. M. Diamond; M. S. Friedman; R. Garofalo; M. S. Turner; A. Hollibaugh; P. J. Clayton

Publication: Journal of homosexuality, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21213174

Review of suicide risk.

Previous research has shown that sexual minority (i.e., nonheterosexual) individuals report increased problematic substance use involvement, compared with their sexual majority counterparts. We hypothesize that feelings of an unstable sense of self (i.e., identity disturbance) may potentially drive problematic substance use. The purpose of the current study is to examine identity disturbance among sexual minorities as a potential explanatory mechanism of increased sexual minority lifetime rates of substance dependence. Measures of identity disturbance and three indicators of sexual orientation from lifetime female (n = 16,629) and male (n = 13,553) alcohol/illicit drug users in Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were examined. Findings generally showed that the increased prevalence of alcohol dependence, illicit drug dependence, and combined alcohol/illicit drug dependence as well as a younger age of alcohol use initiation among sexual minority women was associated with elevated levels of identity disturbance. The results were consistent with a mediational role for identity disturbance in explaining the association between sexual minority status and substance dependence and were generally replicated among male sexual minority respondents. The current research suggests that identity disturbance, a predictor of substance use, may contribute to heightened risk for substance dependence among certain subgroups of sexual minority individuals.

Author/-s: A. E. Talley; R. L. Tomko; A. K. Littlefield; T. J. Trull; K. J. Sher

Publication: Psychology of addictive behaviors, 2011

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21480677

Gender identity disturbance may contribute to a higher risk for substance addictions.

There is a scarcity of literature on clinical care for transgender and gender variant populations with serious mental illness. At times, gender identity issues among individuals with serious mental illness have been labeled as delusions that should not be reinforced by providers. However, there are significant limitations to attributing gender variance among populations with mental illness solely to a psychotic process. The following case study research demonstrates the variation in gender identity issues among individuals with serious mental illness. These individuals may experience gender dysphoria exclusively in the context of acute psychosis or may have gender identity issues that are distinct from the mental illness. Denial of an individual's gender variant presentation by treatment staff may heighten distress, thus interfering with a collaborative treatment alliance while posing additional barriers to recovery from mental illness. Implications and applications for clinical training and further research will be presented in order to promote awareness and competent care of gender issues when co-occurring with mental illness.

Author/-s: Lauren Mizock; Michael Z. Fleming

Publication: Professional Psychology: Research and Practice, 2011

Web link: http://psycnet.apa.org/journals/pro/42/2/208/

Discussion of caring for transgender people with mental illnesses.

Children with disorder of sex development (DSD) may be born with ambiguous genitalia. Decision-making in relation to sex assignment has been perceived as extremely disturbing and difficult to families and health care professionals. This is mainly due to a general paucity of information about the condition and an exaggerated feeling of stigma and shame associated with genital abnormalities. This is the first study in Egypt aimed at studying the psychosexual development and gender outcome of 40 Egyptian patients with 46,XY DSD focusing on the impact of social and religious factors. The patients were subjected to history-taking, pedigree analysis, full clinical examination, and cytogenetic studies. Hormonal, radiological investigations and molecular studies were performed when possible. Accordingly, they were classified into 4 groups: (1) sex chromosome aneuploid DSD (mixed gonadal dysgenesis) and (2) disorders of gonadal development (gonadal dysgenesis); (3) androgen biosynthesis defect (5alpha-reductase deficiency, 17beta-hydroxysteroid dehydrogenase deficiency), and (4) defect in androgen action (androgen insensitivity syndrome). The psychosexual development was assessed using adapted structured questionnaire and the Bem sex role inventory for patients below and above 12 years of age, respectively. Thirty-two patients (80%) were initially assigned as females; 3 patients with gonadal dysgenesis, 1 patient with 5alpha-reductase deficiency, and 1 patient with androgen insensitivity were reassigned as male. Male reassignment also was recorded in 5 patients with 17beta-hydroxysteroid dehydrogenase deficiency and one of them showed sex reversal twice. Gender outcome of our patients is elusive; the social component has a significant impact on the gender outcome in our society, even more than religion. We recommend that in the future more and more patients should be analyzed as well. These studies should be designed to emphasize the quality of life of DSD patients.

Author/-s: S. I. Ismail; I. A. Mazen

Publication: Sexual development : genetics, molecular biology, evolution, endocrinology, embryology, and pathology of sex determination and differentiation, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/20664246

Some data about gender dysphoria in patients with disorders of sex development.

Only case reports have described the co-occurrence of gender identity disorder (GID) and autism spectrum disorders (ASD). This study examined this co-occurrence using a systematic approach. Children and adolescents (115 boys and 89 girls, mean age 10.8, SD = 3.58) referred to a gender identity clinic received a standardized assessment during which a GID diagnosis was made and ASD suspected cases were identified. The Dutch version of the Diagnostic Interview for Social and Communication Disorders (10th rev., DISCO-10) was administered to ascertain ASD classifications. The incidence of ASD in this sample of children and adolescents was 7.8 % (n = 16). Clinicians should be aware of co-occurring ASD and GID and the challenges it generates in clinical management.

Author/-s: Annelou L. C. de Vries; I. L. Noens; Peggy T. Cohen-Kettenis; I. A. van Berckelaer-Onnes; T. A. Doreleijers

Publication: Journal of autism and developmental disorders, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/20094764/

Autism spectrum disorders are more common among transsexuals.

Over the last 20 years, Ray Blanchard, Ph.D., with a variety of coauthors and collaborators, has proposed a theory that links the sexual orientation of male-to-female transsexuals with the presence or absence of autogynephilia (erotic arousal by the thought or image of “himself” as a woman). Blanchard's Autogynephilia Theory suggests that the association between sexual orientation and autogynephilia among male-to-female transsexuals is clinically important and the association is always (or almost always) present. Although the theory has been criticized by clinicians, researchers, and transsexuals themselves, it has not been critiqued in a peer-reviewed article previously. This article will attempt to fill that gap. Key studies on which the theory is based will be analyzed and alternative interpretations of the data presented. I conclude that although autogynephilia exists, the theory is flawed.

Author/-s: Charles Moser

Publication: Journal of Homosexuality, 2010

Web link: http://www.tandfonline.com/doi/abs/10.1080/00918369.2010.486241#.Uv973k2YZhE

Flaws in the autoynephilia theory are discussed.

There have been no published reports regarding the epidemiological and psychiatric features of gender dysphoria in non-clinical young adults. The current study aimed to investigate the demographics, co-occurring psychiatric symptoms, and perceived parenting style and family support in Taiwanese young adults with gender dysphoria. The sample consisted of 5010 university freshmen (male, 51.6%) with a mean age of 19.6 years (SD = 2.7) from a national university in Taiwan. The questionnaires used for this university-based survey included the Adult Self Report Inventory-4 for psychopathology (including gender dysphoria), the Parental Bonding Instrument for parenting style, and the Family APGAR for perceived family support. Results showed that gender dysphoria was more prevalent in females (7.3%) than males (1.9%). Young adults with gender dysphoria were more likely to meet a wide but specific range of co-occurring psychiatric symptoms. The most significantly associated symptoms for males were agoraphobia, hypochondriasis, manic episode, and pathological gambling, and for females dissociative disorder, hypochondriasis, and body dysmorphic disorder. Both males and females with gender dysphoria perceived significantly less support from their families and less affection/care from both parents. Findings suggest that gender dysphoria, associated with a specific range of psychopathology and family/parenting dissatisfaction (with both similar and dissimilar patterns between sexes), is not uncommon in Taiwanese university students, particularly in females. This implies the importance of attention and specific measures to offset psychiatric conditions and to promote mental well-being of this population.

Author/-s: Meng-Chuan Lai; Yen-Nan Chiu; Kenneth D. Gadow; Susan Shur-Fen Gau; Hai-Gwo Hwu

Publication: Archives of Sexual Behavior, 2010

Web link: http://link.springer.com/article/10.1007%2Fs10508-009-9570-y

Study of psychiatric symptoms associated with transsexualism. Transsexuals receive less support and affection from their families.

Objective: To summarize the available evidence on the cardiovascular effects of cross-sex steroid use in transsexuals.

Methods: We searched relevant electronic databases and sought additional references from experts. Eligible studies reported on cardiovascular events, venous thromboembolism, blood pressure and fasting serum lipids. Data were extracted in duplicate. We used the random-effects model to estimate the pooled weighted mean difference (WMD) and 95% confidence intervals (CIs).

Results: We found 16 eligible studies, mostly uncontrolled cohorts of varied follow-up durations (1471 male-to-female (MF) and 651 female-to-male (FM) individuals). In the MF individuals, cross-sex hormone use was associated with a statistically significant increase in fasting serum triglycerides without changes in the other parameters (WMD = 23.39 mg/dl; 95% CI = 4.82-41.95). In the FM individuals, there was a similar increase of triglycerides (WMD = 31.35 mg/dl; 95% CI = 7.53-55.17) and a reduction of high density lipoprotein (HDL)-cholesterol (WMD = -6.09 mg/dl; 95% CI = -11.44 to -0.73). There was a statistically significant but clinically trivial increase in systolic blood pressure (WMD = 1.74 mmHg; 95% CI = 0.21-3.27). Analyses were associated with significant heterogeneity across studies. There were very few reported cardiovascular events (deaths, strokes, myocardial infarctions or venous thromboembolism), more commonly among MF individuals.

Conclusions: Very low quality evidence, downgraded due to methodological limitations of included studies, imprecision and heterogeneity, suggests that cross-sex hormone therapies increase serum triglycerides in MF and FM and have a trivial effect on HDL-cholesterol and systolic blood pressure in FM. Data about patient important outcomes are sparse and inconclusive.

Author/-s: M. B. Elamin; M. Z. Garcia; M. H. Murad; P. J. Erwin; V. M. Montori

Publication: Clinical endocrinology, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19473174

Hormone treatment seems safe.

The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

Author/-s: Heino F. Meyer-Bahlburg

Publication: Archives of sexual behaviour, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19851856

Discussion of the medical categorisation of gender dysphoria.

Disorders of sexual development (DSD), ranging in severity from genital abnormalities to complete sex reversal, are among the most common human birth defects with incidence rates reaching almost 3 %. Although causative alterations in key genes controlling gonad development have been identified, the majority of DSD cases remain unexplained. To improve the diagnosis, we screened 116 children born with idiopathic DSD using a clinically validated array-based comparative genomic hybridization platform. 8951 controls without urogenital defects were used to compare with our cohort of affected patients. Clinically relevant imbalances were found in 21.5% of the analyzed patients. Most anomalies (74.2%) evaded detection by the routinely ordered karyotype and were scattered across the genome in gene-enriched subtelomeric loci. Among these defects, confirmed de novo duplication and deletion events were noted on 1p36.33, 9p24.3 and 19q12-q13.11 for ambiguous genitalia, 10p14 and Xq28 for cryptorchidism and 12p13 and 16p11.2 for hypospadias. These variants were significantly associated with genitourinary defects (P = 6.08×10(-12)). The causality of defects observed in 5p15.3, 9p24.3, 22q12.1 and Xq28 was supported by the presence of overlapping chromosomal rearrangements in several unrelated patients. In addition to known gonad determining genes including SRY and DMRT1, novel candidate genes such as FGFR2, KANK1, ADCY2 and ZEB2 were encompassed. The identification of risk germline rearrangements for urogenital birth defects may impact diagnosis and genetic counseling and contribute to the elucidation of the molecular mechanisms underlying the pathogenesis of human sexual development.

Author/-s: M. Tannour-Louet; S. Han; S. T. Corbett; J. F. Louet; S. Yatsenko; L. Meyers; C. A. Shaw; S. H. Kang; S. W. Cheung; D. J. Lamb

Publication: PLoS One, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/21048976

Almost 3 % of humans suffer from disorders of sex development (DSD). The majority of causes of DSD remains unexplained.

Objective: To evaluate the incidence of venous thromboembolism (VTE) in transsexual patients and the value of screening for thrombophilia in this population.

Design: Retrospective cohort study.

Setting: Academic research institution.

Patients: Two hundred fifty-one transsexuals (162 male-to-female [MtF] and 89 female-to-male [FtM] transsexuals).

Interventions: Screening for activated protein C (aPC) resistance, antithrombin III, free protein S antigen, and protein C deficiency.

Main outcome measures: Incidence of thrombophilic defects and VTE during cross-sex hormone therapy.

Results: Activated protein C resistance was detected in 18/251 patients (7.2%), and protein C deficiency was detected in one patient (0.4%). None of the patients developed VTE under cross-sex hormone therapy during a mean of 64.2 +/- 38.0 months. There was no difference in the incidence of thrombophilia comparing MtF and FtM transsexuals (8.0% [13/162] vs. 5.6% [5/89], respectively).

Conclusions: VTE during cross-sex hormone therapy is rare. General screening for thrombophilic defects in transsexual patients is not recommended. Cross-sex hormone therapy is feasible in MtF as well as in FtM patients with aPC resistance.

Author/-s: J. Ott; U. Kaufmann; E. K. Bentz; J. C. Huber; C. B. Tempfer

Publication: Fertility and sterility, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19200981

Venous thromboembolism during hormone therapy is rare.

Girls and boys differ in their preferences for toys such as dolls and trucks. These sex differences are present in infants, are seen in non-human primates, and relate, in part, to prenatal androgen exposure. This evidence of inborn influences on sex-typed toy preferences has led to suggestions that object features, such as the color or the shape of toys, may be of intrinsically different interest to males and females. We used a preferential looking task to examine preferences for different toys, colors, and shapes in 120 infants, ages 12, 18, or 24 months. Girls looked at dolls significantly more than boys did and boys looked at cars significantly more than girls did, irrespective of color, particularly when brightness was controlled. These outcomes did not vary with age. There were no significant sex differences in infants' preferences for different colors or shapes. Instead, both girls and boys preferred reddish colors over blue and rounded over angular shapes. These findings augment prior evidence of sex-typed toy preferences in infants, but suggest that color and shape do not determine these sex differences. In fact, the direction of influence could be the opposite. Girls may learn to prefer pink, for instance, because the toys that they enjoy playing with are often colored pink. Regarding within sex differences, as opposed to differences between boys and girls, both boys and girls preferred dolls to cars at age 12-months. The preference of young boys for dolls over cars suggests that older boys' avoidance of dolls may be acquired. Similarly, the sex similarities in infants' preferences for colors and shapes suggest that any subsequent sex differences in these preferences may arise from socialization or cognitive gender development rather than inborn factors.

Author/-s: V. Jadva; M. Hines; S. Golombok

Publication: Archives of sexual behaviour, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/20232129

Findings on sex-typed preferences in infants.

In this sociometric study, we aimed to investigate the social position of gender-referred children in a naturalistic environment. We used a peer nomination technique to examine their social position in the class and we specifically examined bullying and victimization of gender dysphoric children. A total of 28 children (14 boys and 14 girls), referred to a gender identity clinic, and their classmates (n = 495) were included (M age, 10.5 years). Results showed that the gender-referred children had a peer network of children of the opposite sex. Gender-referred boys had more nominations on peer acceptance from female classmates and less from male classmates as compared to other male classmates. Gender-referred girls were more accepted by male than by female classmates and these girls had significantly more male friends and less female friends. Male classmates rejected gender-referred boys more than other boys, whereas female classmates did not reject the gender-referred girls. For bullying and victimization, we did not find any significant differences between the gender-referred boys and their male classmates nor between the gender-referred girls and their female classmates. In sum, at elementary school age, the relationships of gender dysphoric children with opposite-sex children appeared to be better than with same-sex children. The social position of gender-referred boys was less favorable than that of gender-referred girls. However, the gender-referred children were not more often bullied than other children, despite their gender nonconforming behavior.

Author/-s: M. S. Wallien; R. Veenstra; Baudewijntje P. C. Kreukels; Peggy T. Cohen-Kettenis

Publication: Archives of sexual behaviour, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19639403/

Gender dysphoric children tend to have opposite-gender friends. For boys, the social position was worse than for girls.

The psychiatric impact of interpersonal abuse associated with an atypical presentation of gender was examined across the life course of 571 male-to-female (MTF) transgender persons from the New York City Metropolitan Area. Gender-related abuse (psychological and physical), suicidality, and Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) major depression were retrospectively measured across five stages of the life course using the Life Chart Interview. Among younger respondents (current age of 19–39), the impact of both types of abuse on major depression was extremely strong during adolescence and then markedly declined during later stages of life. Among older respondents (current age of 40–59), the impact of both types of abuse on major depression was strong during adolescence and then marginally declined during later stages of life. The effects of both types of abuse on suicidality were weaker but more consistently observed across the life course among both the younger and older respondents. Gender-related abuse is a major mental health problem among MTF transgender persons, particularly during adolescence. As these individuals mature, however, the consequences of this abuse appear less severe, which may represent the development of moderately effective mechanisms for coping with this abuse.

Author/-s: Larry Nuttbrock; S. Hwahng; Walter Bockting; A. Rosenblum; Mona Mason; M. Macri; J. Becker

Publication: Journal of Sex Research, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19568976

Abuse has a strong negative mental-health impact on MtF transsexuals, especially during adolescence.

Previous studies suggest organizing effects of sex hormones on brain structure during early life and puberty, yet little is known about the adult period. The aim of the present study was to elucidate the role of 17beta-estradiol, progesterone, and testosterone on cortical sex differences in grey matter volume (GM) of the adult human brain. To assess sexual dimorphism, voxel-based morphometry (VBM) was applied on structural magnetic resonance images of 34 healthy, young adult humans (17 women, 17 men, 26.6 ±5 years) using analyses of covariance. Subsequently, circulating levels of sex hormones were associated with regional GM using linear regression analyses. After adjustment for sex and total GM, significant associations of regional GM and 17beta-estradiol were observed in the left inferior frontal gyrus (beta=0.39, p=0.02). Regional GM was inversely associated with testosterone in the left inferior frontal gyrus (beta=−0.16, p=0.04), and with progesterone in the right temporal pole (beta = −0.39, p = 0.008). Our findings indicate that even in young adulthood, sex hormones exert organizing effects on regional GM. This might help to shed further light on the underlying mechanisms of both functional diversities and congruence between female and male brains.

Author/-s: A. V. Witte; M. Savli; A. Holik; S. Kasper; Rupert Lanzenberger

Publication: Neuroimage, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19796695

In young adults, hormone levels are associated with sex differences in the brain.

Sex differences in children's toy play are robust and similar across cultures. They include girls tending to play more with dolls and boys more with wheeled toys and pretend weaponry. This pattern is explained by socialization by elders and peers, male rejection of opposite-sex behavior and innate sex differences in activity preferences that are facilitated by specific toys. Evidence for biological factors is controversial but mounting. For instance, girls who have been exposed to high fetal androgen levels are known to make relatively masculine toy choices. Also, when presented with sex-stereotyped human toys, captive female monkeys play more with typically feminine toys, whereas male monkeys play more with masculine toys. In human and nonhuman primates, juvenile females demonstrate a greater interest in infants, and males in rough-and-tumble play. This sex difference in activity preferences parallels adult behavior and may contribute to differences in toy play. Here, we present the first evidence of sex differences in use of play objects in a wild primate, in chimpanzees (Pan troglodytes). We find that juveniles tend to carry sticks in a manner suggestive of rudimentary doll play and, as in children and captive monkeys, this behavior is more common in females than in males.

Author/-s: Sonya M. Kahlenberg; Richard W. Wrangham

Publication: Current Biology, 2010

Web link: http://www.cell.com/current-biology/abstract/S0960-9822(10)01449-1

Human-like gender differences can be observed in monkeys.

Using data from over 200 000 participants from 53 nations, I examined the cross-cultural consistency of sex differences for four traits: extraversion, agreeableness, neuroticism, and male-versus-female-typical occupational preferences. Across nations, men and women differed significantly on all four traits (mean ds = -0.15; -0.56; -0.41; and 1.40; respectively, with negative values indicating women scoring higher). The strongest evidence for sex differences in SDs was for extraversion (women more variable) and for agreeableness (men more variable). United Nations indices of gender equality and economic development were associated with larger sex differences in agreeableness, but not with sex differences in other traits. Gender equality and economic development were negatively associated with mean national levels of neuroticism, suggesting that economic stress was associated with higher neuroticism. Regression analyses explored the power of sex, gender equality, and their interaction to predict men's and women's 106 national trait means for each of the four traits. Only sex predicted means for all four traits, and sex predicted trait means much more strongly than did gender equality or the interaction between sex and gender equality. These results suggest that biological factors may contribute to sex differences in personality and that culture plays a negligible to small role in moderating sex differences in personality.

Author/-s: R. A. Lippa

Publication: Archives of sexual behaviour, 2010

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18712468

Gender differences across cultures.

Autogynephilia is a paraphilic model that states that all male-to-female (MtF) transsexuals who are not exclusively attracted toward men are instead sexually oriented toward the thought or image of themselves as a woman. The assertion that transsexual women are sexually motivated in their transitions challenges the standard model of transsexualism—that is, that transsexuals have a gender identity that is distinct from their sexual orientation and incongruent with their physical sex. This article provides a review of the evidence against autogynephilia and makes the case that the taxonomy and terminology associated with this theory are both misleading and unnecessarily stigmatizing.

Author/-s: Julia M. Serano

Publication: International Journal of Transgenderism, 2010

Web link: http://www.researchgate.net/publication/233166007_The_Case_Against_Autogynephilia

Review of the evidence against autogynephilia.

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to thosewhoalready had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

Author/-s: Peggy T. Cohen-Kettenis; Friedemann Pfäfflin

Publication: Archives of Sexual Behavior, 2010

Web link: http://www.cpath.ca/wp-content/uploads/2009/08/COHEN-KETTENIS.DSM_.pdf

Discussion of the medical categorisation of gender dysphoria.

The term disorders of sex development (DSD) includes congenital conditions in which development of chromosomal, gonadal or anatomical sex is atypical. Mutations in genes present in X, Y or autosomal chromosomes can cause abnormalities of testis determination or disorders of sex differentiation leading to 46,XY DSD. Detailed clinical phenotypes allow the identification of new factors that can alter the expression or function of mutated proteins helping to understand new undisclosed biochemical pathways. In this review we present an update on 46,XY DSD aetiology, diagnosis and treatment based on extensive review of the literature and our three decades of experience with these patients.

Author/-s: Berenice Bilharinho Mendonca; Sorahia Domenice; Ivo J. P. Arnhold; Elaine M. F. Costa

Publication: Clinical Endocrinology, 2009

Web link: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2265.2008.03392.x/abstract

Complete review of 46,XY disorders of sex development (DSD).

To investigate the biological mechanism of gender identity disorder (GID), five candidate sex hormone-related genes, encoding androgen receptor (AR), estrogen receptors α (ERα) and β (ERβ), aromatase (CYP19), and progesterone receptor (PGR) were analyzed by a case–control association study. Subjects were 242 transsexuals (74 male-to-female patients (MTF) and 168 female-to-male patients (FTM)), and 275 healthy age- and geographical origin-matched controls (106 males and 169 females). The distributions of CAG repeat numbers in exon 1 of AR, TA repeat numbers in the promoter region of ERα, CA repeat numbers in intron 5 of ERβ, TTTA repeat numbers in intron 4 of CYP19, and six polymorphisms (rs2008112, rs508653, V660L, H770H, rs572698 and PROGINS) of PGR were analyzed. No significant difference in allelic or genotypic distribution of any gene examined was found between MTFs and control males or between FTMs and control females. The present findings do not provide any evidence that genetic variants of sex hormone-related genes confer individual susceptibility to MTF or FTM transsexualism.

Author/-s: Hiroshi Ujike; Kyohei Otani; Mikiya Nakatsuka; Kazushi Ishii; Aiko Sasaki; Tomoko Oishi; Toshiki Sato; Yuko Okahisa; Yosuke Matsumoto; Yuzaburo Namba; Yoshihiro Kimata; Shigetoshi Kuroda

Publication: Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2009

Web link: http://www.sciencedirect.com/science/article/pii/S027858460900222X

Five sex-hormone-related genes were investigated for a relation with transsexualism; no such relation was found.

Autogynephilia, an erotic interest in the thought or image of oneself as a woman, has been described as a sexual interest of some male-to-female transsexuals (MTFs); the term has not been applied to natal women. To test the possibility that natal women also experience autogynephilia, an Autogynephilia Scale for Women (ASW) was created from items used to categorize MTFs as autogynephilic in other studies. A questionnaire that included the ASW was distributed to a sample of 51 professional women employed at an urban hospital; 29 completed questionnaires were returned for analysis. By the common definition of ever having erotic arousal to the thought or image of oneself as a woman, 93 % of the respondents would be classified as autogynephilic. Using a more rigorous definition of “frequent” arousal to multiple items, 28 % would be classified as autogynephilic. The implications of these findings are discussed concerning the sexuality of women and the meaning of autogynephilia for MTFs.

Author/-s: Charles Moser

Publication: Journal of Homosexuality, 2009

Web link: http://www.tandfonline.com/doi/full/10.1080/00918360903005212#.UrqVeE2A1hE

Non-transsexual women are found to fit the definition of the spurios autogynephilia concept.

Interest in biological substrates of sex-related variations in psychological and physiological characteristics has led to a search for biomarkers of prenatal hormone exposure that can be measured postnatally. There has been particular interest in digit ratio, the relative lengths of the second and fourth fingers (2D:4D), but its validity as a measure of prenatal androgen has not been established. We report the strongest evaluation of the value of 2D:4D as a biomarker for early androgen exposure. Individuals with 46,XY karyotype but no effective prenatal androgen exposure due to complete androgen insensitivity syndrome had digit ratios that were feminized: they were higher than those of typical men and similar to those of typical women. Nevertheless, the effect was modest in size, and there was considerable within-group variability and between-group overlap, indicating that digit ratio is not a good marker of individual differences in prenatal androgen exposure.
Data from individuals with complete androgen insensitivity show that digit ratio (2D:4D) is not a good marker of individual differences in prenatal androgen exposure.

Author/-s: Sheri A. Berenbaum; Kristina Korman Bryk; Nicole Nowak; Charmian A. Quigley; Scott Moffat

Publication: Endocrinology, 2009

Web link: http://press.endocrine.org/doi/abs/10.1210/en.2009-0774

Individuals with complete androgen insensitivity syndrome (CAIS) had a feminised digit ratio. However, digit ratio is not a good indicator for prenatal androgen exposure.

Beginning in August 2007, we committed ourselves to a clinical review the co-morbid diagnostic patterns of the last 10 patients interviewed by our Gender Identity Clinic. We found 90 % of these diverse patients had at least one other significant form of psychopathology. This finding seems to be in marked contrast to the public, forensic, and professional rhetoric of many who care for transgendered adults. Much of this rhetoric sounds remarkably certain about the long-term value of gender transition, hormones, and sex reassignment surgery in improving the lives of those with Gender Identity Disorder (GID). Such clinical certainty would have to be based on carefully established sophisticated follow-up findings. These are lacking. The psychopathologies in this series included problems of mood and anxiety regulation and adapting in the world. Two of the 10 have had persistent significant regrets about their previous transitions. In discussing management decisions, civil rights, and ethics, we planned to separately briefly present the 10 patients. However, our decision to seek patients' permission proved so upsetting to three of the first six patients that we altered the structure of this report. Our attempt to follow the ethical principle of informed consent caused us to violate the principle of nonmalfiescence. This distressing experience only illustrates, however, the disadvantage of discussing professional concepts with lay audiences. Emphasis on civil rights is not a substitute for the recognition and treatment of associated psychopathology. Gender identity specialists, unlike the media, need to be concerned about the majority of patients, not just the ones who are apparently functioning well in transition.

Author/-s: S. B. Levine; A. Solomon

Publication: Journal of Sex & Marital Therapy, 2009

Web link: http://europepmc.org/abstract/MED/19105079

A high proportion of transsexuals suffers from psychopathology, including problems of mood and anxiety regulation and adapting in the world. Some regret transition.

Testosterone, estradiol, and progesterone levels were measured in the second trimester of pregnancy in maternal serum and amniotic fluid, and related to direct observations of gender-related play behavior in 63 male and 63 female offspring at age 13 months. During a structured play session, sex differences in toy preference were found: boys played more with masculine toys than girls (d = .53) and girls played more with feminine toys than boys (d = .35). Normal within-sex variation in prenatal testosterone and estradiol levels was not significantly related to preference for masculine or feminine toys. For progesterone, an unexpected significant positive relationship was found in boys between the level in amniotic fluid and masculine toy preference. The mechanism explaining this relationship is presently not clear, and the finding may be a spurious one. The results of this study may indicate that a hormonal basis for the development of sex-typed toy preferences may manifest itself only after toddlerhood. It may also be that the effect size of this relationship is so small that it should be investigated with more sensitive measures or in larger populations.

Author/-s: C. van de Beek; S. H. van Goozen; J. K. Buitelaar, P. T. Cohen-Kettenis

Publication: Archives of sexual behavior, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18080735

Inconclusive findings about the correlation between hormones and sex-typed toy preference.

The aim of the present study is to assess the prevalence of Axis II disorders (DSM-IV-TR) in a sample of clients requesting sex reassignment surgery (SRS), consecutively admitted to a Gender Identity Disorder (GID) psychiatric unit. Fifty clients self-referred as transsexuals (34 biological males and 16 biological females; mean age = 31.74 ± 7.06 years) were assessed through the SCID-II after a preliminary evaluation to exclude current major psychiatric disorders. Prevalence of any Axis II disorder was 52 % (N = 26), with no significant differences related to biological sex. The most frequent personality disorders were Cluster B PDs (22 % of total sample), followed by Cluster C (12 %) and Cluster A PDs (2 %). A significant prevalence of NOS PD (16 %) was also found. Our data offers prevalence estimates slightly higher than those found in previous studies and does not provide evidence for any differences in the psychopathological profile and severity between MtF and FtM transsexuals.

Author/-s: F. Madeddu; A. Prunas; D. Hartmann

Publication: The Psychiatric Quarterly, 2009

Web link: http://europepmc.org/abstract/MED/19838802

Transsexuals suffer from mental health issues; MtFs and FtMs suffer at the same rate.

Objective: To evaluate quality of life and patients’ satisfaction in transsexual patients (TS) after sex reassignment operation compared with healthy controls.

Design: A case-control study.

Setting: A tertiary referral center.

Patient(s): Patients after sex reassignment operation were compared with a similar group of healthy controls in respect to quality of life and general satisfaction.

Intervention(s): For quality of life we used the King’s Health Questionnaire, which was distributed to the patients and to the control group. Visual analogue scale was used for the determination of satisfaction.

Main outcome measure(s): Main outcome measures were quality of life and satisfaction.

Result(s): Fifty-five transsexuals participated in this study. Fifty-two were male-to-female and 3 female-to-male. Quality of life as determined by the King's Health Questionnaire was significantly lower in general health, personal, physical and role limitations. Patients' satisfaction was significantly lower compared with controls. Emotions, sleep, and incontinence impact as well as symptom severity is similar to controls. Overall satisfaction was statistically significant lower in TS compared with controls.

Conclusion(s): Fifteen years after sex reassignment operation quality of life is lower in the domains general health, role limitation, physical limitation, and personal limitation.

Author/-s: Annette Kuhn; Christine Bodmer; Werner Stadlmayr; Peter Kuhn; Michael D. Mueller; Martin Birkhäuser

Publication: Fertility and sterility, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18990387

Transsexuals after sex reassignment are worse off than cisgendered controls. Unfortunately, no comparison to transsexuals before treatment was made.

The purpose of this paper is to provide an objective and independent review of all published papers providing clinical guidelines in the hormonal and medical care of patients with gender dysphoria and transsexualism and to suggest safe modern prescribing guidelines. A computerised search of the published literature was performed using the MEDLINE, EMBASE and PsycINFO databases between 1998 and 2008. In addition, textbooks relating to the subject were reviewed. There are major similarities between various international clinical centres on the practice of therapeutics and risk management on hormone treatment for transsexual people. Most of the evidence comes from observational studies and older case reports. The mainstay of hormone treatment for the male to female trans person is estrogens and either a gonadotrophin releasing hormone (GnRH) agonist or anti-androgens. The main components of that for the female to male trans-person are testosterone and a GnRH agonist. Ongoing physical monitoring is important to maximize the benefits and minimise the risks associated with the treatment. More research is necessary to improve evidence-based practice in this area and especially the potential benefit of GnRH agonists for both trans women and men.

Author/-s: Kevan Richard Wylie; Robert Jr. Fung; Claudia Boshier; Margaret Rotchell

Publication: Sexual and relationship therapy, 2009

Web link: http://www.researchgate.net/publication/233205785_Recommendations_of_endocrine_treatment_for_patients_with_gender_dysphoria

Review of papers about hormone treatment.

Design: Testosterone treatment is essential for the induction and maintenance of virilization of female-to-male (FTM) transsexuals. Aim To test the safety of a novel testosterone preparation for this purpose.

Methods: Parenteral long-acting testosterone undecanoate (TU) was administered to 17 FTM transsexuals over 36 months. Observations were made while subjects received treatment.

Results: Serum testosterone rose from 0.50+/-0.25 to 6.2+/-1.3 ng/ml at 6 months and remained stable thereafter. The testosterone profiles were largely identical with those in hypogonadal receiving TU. There were no side effects. Over the 36 months of the study, there was a small but significant decrease in plasma cholesterol (from 218+/-47 to 188+/-42 mg/dl) and low-density lipoprotein-cholesterol (from 139+/-48 to 139+/-48 mg/dl), while plasma levels of high-density lipoprotein-cholesterol and triglycerides did not change significantly. Liver enzymes did not change during treatment. There was an increase of both levels in hemoglobin (from 13.6+/-1.2 to 16.0+/-1.5 g/dl) and hematocrit (from 41+/-4 to 46+/-4) upon administration but they remained almost without exception within the physiological range. No special measures were needed. Breast and gonads/internal genitalia did not show pathological changes over the observation period.

Conclusion: This study reports that TU is suited for induction of virilization in FTM transsexuals without significant side effects over a longer term.

Author/-s: J. W. Jacobeit; L. J. Gooren; H. M. Schulte

Publication: European journal of endocrinology, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19749027

Hormone therapy is safe.

Evidence indicating that sex-linked toy preferences exist in two nonhuman primate species support the hypothesis that developmental sex differences such as those observed in children's object preferences are shaped in part by inborn factors. If so, then preferences for sex-linked toys may emerge in children before any self-awareness of gender identity and gender-congruent behavior. In order to test this hypothesis, interest in a doll and a toy truck was measured in 30 infants ranging in age from 3 to 8 months using eye-tracking technology that provides precise indicators of visual attention. Consistent with primary hypothesis, sex differences in visual interest in sex-linked toys were found, such that girls showed a visual preference (d > 1.0) for the doll over the toy truck and boys compared to girls showed a greater number of visual fixations on the truck (d = 0.78). Our findings suggest that the conceptual categories of "masculine" and "feminine" toys are preceded by sex differences in the preferences for perceptual features associated with such objects. The existence of these innate preferences for object features coupled with well-documented social influences may explain why toy preferences are one of the earliest known manifestations of sex-linked social behavior.

Author/-s: G. M. Alexander; T. Wilcox, R. Woods

Publication: Archives of sexual behaviour, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/19016318

Toy preferences seem to be innate.

Sex steroids exert important organizational effects on brain structure. Early in life, they are involved in brain sexual differentiation. During puberty, sex steroid levels increase considerably. However, to which extent sex steroid production is involved in structural brain development during human puberty remains unknown. The relationship between pubertal rises in testosterone and estradiol levels and brain structure was assessed in 37 boys and 41 girls (10-15 years). Global brain volumes were measured using volumetric-MRI. Regional gray and white matter were quantified with voxel-based morphometry (VBM), a technique which measures relative concentrations ('density') of gray and white matter after individual global differences in size and shape of brains have been removed. Results showed that, corrected for age, global gray matter volume was negatively associated with estradiol levels in girls, and positively with testosterone levels in boys. Regionally, a higher estradiol level in girls was associated with decreases within prefrontal, parietal and middle temporal areas (corrected for age), and with increases in middle frontal-, inferior temporal- and middle occipital gyri. In boys, estradiol and testosterone levels were not related to regional brain structures, nor were testosterone levels in girls. Pubertal sex steroid levels could not explain regional sex differences in regional gray matter density. Boys were significantly younger than girls, which may explain part of the results. In conclusion, in girls, with the progression of puberty, gray matter development is at least in part directly associated with increased levels of estradiol, whereas in boys, who are in a less advanced pubertal stage, such steroid-related development could not (yet) be found. We suggest that in pubertal girls, estradiol may be implicated in neuronal changes in the cerebral cortex during this important period of brain development.

Author/-s: J. S. Peper; R. M. Brouwer; H. G. Schnack; G. C. van Baal; M. van Leeuwen; S. M. van den Berg; H. A. Delemarre-van de Waal; D. I. Boomsma; R. S. Kahn; H. E. Hulshoff

Publication: Psychoneuroendocrinology, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18980810

Puberty and brain structure.

The aim of this study was to examine the characteristics of transsexuals from Spain. A total of 252 consecutive applicants for sex reassignment were evaluated using a standardized semistructured clinical interview and the Mini International Neuropsychiatric Interview (Spanish Version 5.0.0) to record demographic, clinical, and psychiatric data. Transsexualism was diagnosed in 230 patients, with a male to female (MF)/female to male (FM) ratio of 2.2:1. Transsexual patients frequently had low employment status, lived with their parents, and mainly had a sexual orientation toward same-sex partners. The most frequent psychiatric diagnoses were adjustment disorder and social phobia in both groups, and alcohol and substance-related disorders in the MF group. MF transsexuals were older than FM transsexuals when requesting sex reassignment, but did not differ in age when starting hormonal therapy (often on their own); fewer MFs were in employment requiring high educational qualification, more were non-Spanish natives, and more had previous and current histories of alcohol and substance abuse or dependence. The basic characteristics of transsexuals from Spain were similar to those of other European countries, except for the higher proportion of patients living with their parents and the higher proportion of MFs who reported same-sex sexual orientation compared with previous studies.

Author/-s: Esther Gómez-Gil; Antoni Trilla; Manel Salamero; Teresa Godás; Manuel Valdés

Publication: Archives of sexual behavior, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18288600

Demographics of transsexuals in Spain.

In mammals, the transcription factor SRY, encoded by the Y chromosome, is normally responsible for triggering the indifferent gonads to develop as testes rather than ovaries. However, testis differentiation can occur in its absence. Here we demonstrate in the mouse that a single factor, the forkhead transcriptional regulator FOXL2, is required to prevent transdifferentiation of an adult ovary to a testis. Inducible deletion of Foxl2 in adult ovarian follicles leads to immediate upregulation of testis-specific genes including the critical SRY target gene Sox9. Concordantly, reprogramming of granulosa and theca cell lineages into Sertoli-like and Leydig-like cell lineages occurs with testosterone levels comparable to those of normal XY male littermates. Our results show that maintenance of the ovarian phenotype is an active process throughout life. They might also have important medical implications for the understanding and treatment of some disorders of sexual development in children and premature menopause in women.

Author/-s: N. H. Uhlenhaut; S. Jakob; K. Anlag; T. Eisenberger; R. Sekido; J. Kress: A. C. Treier; C. Klugmann; C. Klasen; N. I. Holter; D. Riethmacher; G. Schütz; A. J. Cooney; R. Lovell-Badge; M. Treier

Publication: Cell, 2009

Web link: http://www.ncbi.nlm.nih.gov/pubmed/20005806

This study challenges a common perception that gender is determined purely by the X-chromosomes and Y-chromosomes. The FOXL2 gene lies on a non-sex chromosome that is shared by males and females. The activity of this gene is all that prevents adult ovary cells turning into cells found in testes. The discovery that gender depends, at least in part, on the competing action of genes that are shared by both sexes suggests that gender can be more easily manipulated than previously thought.

This research had its beginnings in an act of trans activism, including a campaign by a number of trans organizations advocating the need for research dealing with health, well-being and access to health services in relation to this population. This study set out to recruit the broadest possible community sample by using a range of recruitment techniques and an online survey. In total, 253 respondents completed the survey. Of these, 229 were from Australia (90.5 %) and 24 (9.5 %) were from New Zealand. Respondents rated their health on a five-point scale; the majority of the sample rated their health as ‘good’ or ‘very good’. On the SF36 scale, respondents had poorer health ratings than the general population in Australia and New Zealand. Respondents reported rates of depression much higher than those found in the general Australian population, with assigned males being twice as likely to experience depression as assigned females. Respondents who had experienced greater discrimination were more likely to report being currently depressed. Respondents were asked about their best and worst experiences with a health practitioner or health service in relation to being trans. They contrasted encounters where they felt accepted and supported by their practitioners with others where they were met with hostility.

Author/-s: Marian K. Pitts; Murray Couch; Hunter Mulcare; Samantha Croy; Anne Mitchell

Publication: Feminism & Psychology, 2009

Web link: http://fap.sagepub.com/content/19/4/475.abstract

Higher levels of depression in transsexuals are linked to discrimination.

Many individuals born with genital ambiguity and related conditions (recently recategorized as disorders of sex development [DSD]) experience gender uncertainty or gender dysphoria, and some may undergo self-initiated gender change. Whether these phenomena are sufficiently similar to the presentations of gender identity variants (GIVs) in non-DSD persons (gender identity disorder [GID] in current psychiatric terminology) to warrant the application of identical diagnostic criteria and treatment approaches is under debate. This review takes the position that the differences in phenomena, context of presentation, etiology, and treatment settings are so large that identical diagnoses and treatment approaches are not justified and may be detrimental to the individuals in need of care, although more systematic comparisons are needed for definitive conclusions. On the other hand, there is increasing overlap of DSD and non-DSD individuals with gender problems in professional care personnel, assessment methods, aspects of medical and psychosocial management, and support groups and gender activism. Thus, a comprehensive revision of the Standards of Care (SOC) needs to include pertinent material on DSD, and clinicians caring for individuals with GIV should be acquainted with the key clinical issues in both. The remainder of this article summarizes the limited information available for DSD on the issues addressed in the sixth edition of the SOC for non-DSD GIV.

Author/-s: Heino F. L. Meyer-Bahlburg

Publication: International Journal of Transgenderism, 2009

Web link: http://www.tandfonline.com/doi/abs/10.1080/15532730903439476#preview

The author advocates different diagnoses and treatments for people affected with disorders of sex development (DSD) and transsexuals.

Transgender people face many challenges in a society that is unforgiving of any system of gender that is not binary. However, there are three primary sources of data in the United States for discerning the rates and types of violence that transgender people face throughout their lives — self-report surveys and needs assessments, hot-line call and social service records, and police reports. Data from each of these sources are discussed in length, as well as some of the methodological issues for these types of data sources. All three sources indicate that violence against transgender people starts early in life, that transgender people are at risk for multiple types and incidences of violence, and that this threat lasts throughout their lives. In addition, transgender people seem to have particularly high risk for sexual violence. Future research considerations, such as improving data collection efforts, are discussed.

Author/-s: Rebecca L. Stotzer

Publication: Aggression and Violent Behavior, 2009

Web link: http://www.sciencedirect.com/science/article/pii/S1359178909000202

Transsexuals are at high risk of violence.

This study provided information on the natural histories of 25 girls with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 8.88 years; range, 3–12 years) and at follow-up (mean age, 23.24 years; range, 15–36 years) were used to evaluate gender identity and sexual orientation. At the assessment in childhood, 60% of the girls met the Diagnostic and Statistical Manual of Mental Disorders criteria for GID, and 40% were subthreshold for the diagnosis. At follow-up, 3 participants (12%) were judged to have GID or gender dysphoria. Regarding sexual orientation, 8 participants (32%) were classified as bisexual/homosexual in fantasy, and 6 (24%) were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. The rates of GID persistence and bisexual/homosexual sexual orientation were substantially higher than base rates in the general female population derived from epidemiological or survey studies. There was some evidence of a "dosage" effect, with girls who were more cross-sex typed in their childhood behavior more likely to be gender dysphoric at follow-up and more likely to have been classified as bisexual/homosexual in behavior (but not in fantasy).

Author/-s: Kelley D. Drummond; Susan J. Bradley; Michele Peterson-Badali; Kenneth J. Zucker

Publication: Developmental Psychology, 2008

Web link: http://psycnet.apa.org/journals/dev/44/1/34/

Girls showing strong cross-sex gender identification in childhood are more likely to develop gender dysphoria than others.

Context: Male-to-female (M-->F) transsexual persons undergo extreme changes in gonadal hormone concentrations, both by pharmacological and surgical interventions. Given the importance of sex steroids for developing and maintaining bone mass, bone health is a matter of concern in daily management of these patients.

Objective: To provide data on bone metabolism, geometry and volumetric bone mineral density in M-->F transsexual persons.

Design/setting/participants: Twenty-three M-->F transsexual persons, recruited from our gender dysphoria clinic and at least 3 yrs after sex reassignment surgery, together with 46 healthy age- and height-matched control men were included in this cross-sectional study.

Main outcome measures: Body composition, areal and volumetric bone parameters determined using DXA and peripheral quantitative computed tomography. Hormone levels and markers of bone metabolism assessed using immunoassays. Peak torque of biceps and quadriceps muscles and grip strength assessed using an isokinetic and hand dynamometer, respectively.

Results: M-->F transsexual persons presented lower total and regional muscle mass and lower muscle strength as compared to controls (all P<0.001). In addition, they had higher total and regional fat mass (P<0.010) and a lower level of sports-related activity index (P<0.010). Bone mineral content and areal density (aBMD) of the lumbar spine, total hip and distal radius, as well as trabecular vBMD of the distal radius was lower as compared to controls (P<0.010). At cortical sites, no differences in cortical vBMD were observed, whereas M-->F transsexual persons were characterized by smaller cortical bone size at both the radius and tibia (P<0.010). Lower levels of biochemical markers of bone formation and resorption (P<0.010) suggested decreased bone turnover.

Conclusion: M-->F transsexual persons have less lean mass and muscle strength, and higher fat mass. In addition, they present lower trabecular vBMD and aBMD at the lumbar spine, total hip and distal radius, and smaller cortical bone size as compared to matched controls. Both the lower level of sports-related physical activity as well testosterone deprivation could contribute to these findings. These results indicate that bone health should be a parameter of interest in the long-term follow-up care for M-->F transsexual persons.

Author/-s: Bruno Lapauw; Youri E. C. Taes; Steven Simoens; Eva van Caenegem; Steven Weyers; Stefan Goemaere; Kaatje Toye; Jean-Marc Kaufman; Guy T’Sjoen

Publication: Bone, 2008

Web link: http://europepmc.org/abstract/MED/18835591

After therapy, MTF transsexuals have different lean mass, muscle strength and smaller cortical bone sizes compared to male controls.

Androgens and estrogens affect the performance on certain cognitive tests, particularly those measuring verbal fluency and mental rotation. Their effects on cognition have frequently been attributed to changes in cerebral lateralization. This study tested the impact of a reversal of the sex steroid milieu on cerebral activation and lateralization during verbal and spatial tasks in transsexuals.

fMRI scans were obtained from 6 female-to-male and 8 male-to-female transsexuals at baseline and after cross-sex steroid treatment. Activation was measured during language and mental rotation tasks. Language activation increased after sex steroid treatment in both groups (F(1,12) =3.7, p=0.08), and total language activity was correlated to post-treatment estradiol levels (rho=0.54, p=0.05). Lateralization was not affected by the reversal of sex steroid milieus (F(1,12)=1.47, p=0.25). Activation during mental rotation did not increase during treatment (F(1,12)=0.54, p=0.34), but post-treatment testosterone levels correlated to total activation during mental rotation (rho=0.64, p=0.01). Findings suggest that sex steroids may influence cerebral activation, but lateralization remains stable.

Author/-s: I. E. C. Sommer; Peggy T. Cohen-Kettenis; T. van Raalten; A. J. vd Veer; L. E. Ramsey; Louis J. G. Gooren; R. S. Kahn; N. F. Ramsey

Publication: European Neuropsychopharmacology, 2008

Web link: http://www.europeanneuropsychopharmacology.com/article/S0924-977X(07)00189-7/abstract

Hormones can influence brain activation, but not lateralisation.

Introduction: Testosterone undecanoate (TU) has potential as androgen therapy for ovariectomized female to male (FtM) transsexual subjects; however, the long-term physiologic effects of TU treatment, the significance of testosterone (T), and the T metabolites dihydrotestosterone (DHT) and estradiol (E) on specific outcome parameters are currently unknown.

Aim: The aim of this study was to investigate the long-term treatment of TU with regard to bone metabolism, body composition, and lipid profile in FtM subjects, and to evaluate the relationship between observed effects and circulating levels of T, E, and DHT.

Main outcome measures: Circulating follicle-stimulating hormone, luteinizing hormone, T, E, DHT, and lipid concentrations were measured, as well as bone metabolism, body composition, and insulin resistance.

Methods: This was a 1-year, randomized treatment, open-label, uncontrolled safety study. Fifteen ovariectomized FtM subjects from an outpatient clinic were divided into three groups to receive TU 1,000 mg alone or in combination with oral administration of letrozole (L) 2.5 mg/die or dutasteride (D) 0.5 mg/die for a period of 54 weeks.

Results: TU alone and TU + D treatments were successful in terms of hormone adjustment, did not result in any adverse effects, and were well-tolerated. Bone mineral density decreased by an average of 0.9 g/cm(2) in the TU + L group, and the addition of D resulted in a failure to gain lean mass.

Conclusions: This study confirmed that TU is a successful and safe treatment for FtM subjects. These data indicate that E has an important role in bone metabolism and that DHT may play a role in muscle metabolism.

Author/-s: M. C. Meriggiola; F. Armillotta; A. Costantino; P. Altieri; F. Saad; T. Kalhorn; A. M. Perrone; T. Ghi; C. Pelusi; G. Pelusi

Publication: The journal of sexual medicine, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18624972

Hormone therapy is safe for FtM transsexuals.

Objective: To assess the risk of development of hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. Design Description of cases of transsexuals who have developed a hormone-related malignancy observed in their own clinic or reported in the literature. Recommendations for early diagnosis and prevention are presented.

Methods: Review of the literature in PubMed.

Results: In male-to-female transsexuals receiving estrogen administration, lactotroph adenomas, breast cancer, and prostate cancer have been reported. In female-to-male transsexuals receiving treatment with testosterone, a single case of breast carcinoma and several cases of ovarian cancer have been reported. So far endometrial cancer has not been encountered though it remains a potential malignant development.

Conclusions: There are so far only a few cases of hormone-related cancer in transsexuals. There may be an underreporting. The probability of a hormone-related tumor increases with the duration of exposure to cross-sex hormones and the aging of the population of transsexuals.

Author/-s: A. Mueller; L. Gooren

Publication: European journal of endocrinology, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18567667

No major evidence for tumours during hormone therapy, but data lacking.

The management of disorders of sex development (DSD) has been a problem area for years, partly because clinicians have started to see that not all of their patients grow up to be happy adults content with the gender assigned to them at birth, and partly because of the vigorous activities of patient advocacy organizations who have publicized their unhappiness and disagreement about current practices to the world at large and to politicians in particular. Results from a large number of long-term outcome studies have been published in the last decade and this paper attempts to give an overview of what we now know and what we still do not know about how to obtain a good outcome for our patients. Many studies have focused on a particular disorder and there have been more about congenital adrenal hyperplasia and complete androgen insensitivity (CAIS) than any of the other conditions, even though mixed gonadal dysgenesis is probably more common than CAIS. This is because researchers have wanted to know about the effects of hormones on the brain. There have been studies from a number of different countries, and cultural differences come to the fore in disorders affecting sex and gender. Very few studies have been done in Africa or East Asia so far. Long-term outcome should be studied in every treatment center, but there is a great need for study instruments to be developed that would be robust enough to use in a range of different cultural settings and languages. The studies show that while many patients fare well and are leading productive lives, gender dysphoria has been underestimated in the past and that gender counseling as well as sexual counseling should be part of the multi-disciplinary service available to patients with DSD. More emphasis is also needed on strategies to prevent the development of germ cell cancers. Urological problems in both males and females with DSD have been underestimated and deserve more attention.

Author/-s: G. L. Warne

Publication: Sexual development: genetics, molecular biology, evolution, endocrinology, embryology, and pathology of sex determination and differentiation, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18987501/

For patients with disorders of sex development (DSD), more focus should be on gender dysphoria, cancer and urological problems.

Context: Transsexuals receive cross-sex hormone treatment. Its short-term use appears reasonably safe. Little is known about its long-term use. This report offers some perspectives.

Setting: The setting was a university hospital serving as the national referral center for The Netherlands (16 million people).

Patients: From the start of the gender clinic in 1975 up to 2006, 2236 male-to-female and 876 female-to-male transsexuals have received cross-sex hormone treatment. In principle, subjects are followed up lifelong.

Interventions: Male-to-female transsexuals receive treatment with the antiandrogen cyproterone acetate 100 mg/d plus estrogens (previously 100 microg ethinyl estradiol, now 2-4 mg oral estradiol valerate/d or 100 microg transdermal estradiol/d). Female-to-male transsexuals receive parenteral testosterone esters 250 mg/2 wk. After 18-36 months, surgical sex reassignment including gonadectomy follows, inducing a profound hypogonadal state.

Main outcome measures: Outcome measures included morbidity and mortality data and data assessing risks of osteoporosis and cardiovascular disease.

Results: Mortality was not higher than in a comparison group. Regarding morbidity, with ethinyl estradiol, there was a 6–8 % incidence of venous thrombosis, which is no longer the case with use of other types of estrogens. Continuous use of cross-sex hormones is required to prevent osteoporosis. Androgen deprivation plus an estrogen milieu in male-to-female transsexuals has a larger deleterious effect on cardiovascular risk factors than inducing an androgenic milieu in female-to-male transsexuals, but there is so far no elevated cardiovascular morbidity/mortality. Low numbers of endocrine-related cancers have been observed in male-to-female transsexuals.

Conclusions: Cross-sex hormone treatment of transsexuals seems acceptably safe over the short and medium term, but solid clinical data are lacking.

Author/-s: L. J. Gooren; E. J. Giltay; M. C. Bunck

Publication: The Journal of clinical endocrinology and metabolism, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/17986639

Hormone treatment seems safe.

Patients with gender dysphoria (GD) suffer from a constant feeling of psychological discomfort related to their anatomical sex. Gender reassignment surgery (GRS) attempts to release this discomfort. The aim of this study was to compare the functioning of a cohort or patients with GD before and after GRS. We hypothesised that there would be an improvement in the scores of the self-administered SCL-90R following gender reassignment surgery among male-to-female people with gender dysphoria. We studied 40 patients with a DSM-IV diagnosis of Gender Identity Disorder (GID) who attended Leicester Gender Identity Clinic. We compared their functioning as measured by Symptom Check List-90R (SCL-90R) which was administered to 40 randomly selected male-to-female patients before and within six months after GRS using the same sample as control pre-and post-surgery. There was no significant change in the different sub-scales of the SCL-90R scores in patients with male-to-female GID pre- and within six months post-surgery. The results of the study showed that GRS had no significant effect on functioning as measured by SCL-90R within six months of surgery. Our study has the advantage of reducing inter-subject variability by using the same patients as their own control. This study may be limited by the duration of reassessment post-surgery. Further studies with larger sample size and using other psychosocial scales are needed to elucidate on the effectiveness of surgical intervention on psychosocial parameters in patients with GD.

Author/-s: B. Udeze; N. Abdelmawla; D. Khoosal; T. Terrya

Publication: Sexual and Relationship Therapy, 2008

Web link: http://www.tandfonline.com/doi/abs/10.1080/14681990701882077#preview

Six months after surgery, psychosocial parameters of transsexuals have not changed.

Objective: To establish the psychosexual outcome of gender-dysphoric children at 16 years or older and to examine childhood characteristics related to psychosexual outcome.

Method: We studied 77 children who had been referred in childhood to our clinic because of gender dysphoria (59 boys, 18 girls; mean age 8.4 years, age range 5-12 years). In childhood, we measured the children's cross-gender identification and discomfort with their own sex and gender roles. At follow-up 10.4 ± 3.4 years later, 54 children (mean age 18.9 years, age range 16-28 years) agreed to participate. In this group, we assessed gender dysphoria and sexual orientation.

Results: At follow-up, 30 % of the 77 participants (19 boys and 4 girls) did not respond to our recruiting letter or were not traceable; 27 % (12 boys and 9 girls) were still gender dysphoric (persistence group), and 4 3% (desistance group: 28 boys and 5 girls) were no longer gender dysphoric. Both boys and girls in the persistence group were more extremely cross-gendered in behavior and feelings and were more likely to fulfill gender identity disorder (GID) criteria in childhood than the children in the other two groups. At follow-up, nearly all male and female participants in the persistence group reported having a homosexual or bisexual sexual orientation. In the desistance group, all of the girls and half of the boys reported having a heterosexual orientation. The other half of the boys in the desistance group had a homosexual or bisexual sexual orientation.

Conclusions: Most children with gender dysphoria will not remain gender dysphoric after puberty. Children with persistent GID are characterized by more extreme gender dysphoria in childhood than children with desisting gender dysphoria. With regard to sexual orientation, the most likely outcome of childhood GID is homosexuality or bisexuality.

Author/-s: M. S. C. Wallien; Peggy T. Cohen-Kettenis

Publication: Journal of the American Academy of Child and Adolescent Psychiatry, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/18981931

Strongly gender-dysphoric children are more likely to have gender dysphoria as adults than less gender-dysphoric children. Less gender-dysphoric children have a likelihood of becoming homosexual.

Treatment of gender-identity disorders is guided by standards set forth by the World Professional Association for Transgender Health (WPATH). Although not absolute, WPATH’s eligibility criteria for hormone therapy and/or genital-reconstructive surgery include participation in psychotherapy. In addition, applicants for genital-reconstructive surgery are required to live at least one year full-time in the preferred gender role, a period referred to as the real-life experience (RLE). The rationale behind the RLE is to prepare the client as well as possible to make a fully informed decision about irreversible surgery. Psychotherapy can play an important role in planning the RLE and in developing resilience in coping with the inevitable psychosocial challenges. The tasks of the mental-health professional include assessment of gender identity and the impact of stigma on psychological adjustment; treatment of coexisting mental-health concerns; confronting internalized transphobia; giving permission to explore gender and sexuality; managing the gate-keeping role and offering support and advocacy during the RLE and beyond. Moreover, the desire to “change sex” in a binary way and the actual reality of living life as a gender variant person can be quite different; through facilitating a “coming-out” process, psychotherapy can aid in grieving the loss of the ideal to make room for a deeper level of acceptance of one’s transgender (as opposed to male or female) identity.

Author/-s: W. O. Bockting

Publication: Sexologies, 2008

Web link: http://www.sciencedirect.com/science/article/pii/S1158136008000728

Discussion of the standards for sex reassignment treatment.

We questioned whether transsexuals always require the psychotherapy demanded by the health insurance system in Germany. For this purpose, we examined 430 transsexuals who came to our facility between 1988 and 2006. At the first consultation after the history was taken, they filled out standardised questionnaires, which are needed for proper diagnosis of psychotherapeutic treatment. These questionnaires included the Complaint Questionnaire (BFB), the Behaviour Questionnaire (VFB) and the Freiburg Personality Inventory (FPI-A). It was found that two-thirds of all transsexuals do not require deeper psychotherapy. However, there was evidence of personality deficits in a subgroup of transsexuals for whom supportive psychotherapy should be recommended. The conditions under which psychotherapy and other forms of support are successful are discussed.

Author/-s: K. Seikowski

Publication: Andrologia, 2008

Web link: http://www.researchgate.net/publication/5772965_Psychotherapy_and_transsexualism

Two-thirds of transsexuals do not require psychotherapy.

Introduction: Testosterone supplementation in ovariectomized or elderly women may improve their sense of well-being and libido, muscle mass and strength, and bone mineral density. Naturally, androgens may have virilizing effects in women. It is often believed that androgens have deleterious effects on cardiovascular risks.

Aim: To obtain an inventory of the effects of administration of testosterone on female biological functions.

Methods: We reviewed here our publications on the effects of high-dose androgen administration to female-to-male transsexuals treated between 1975 and 2004 (N = 712). Annual accrual was at a steady rate of 22-30 persons. Dosages administered were far above those suited for women.

Main outcome measures: There was special focus on the potential negative effects on cardiovascular risk markers.

Results: The standard treatment was administration of testosterone esters, 250 mg/2-3 weeks, parenterally). With this dose, virilizing effects on the skin and clitoris were prominent. Spatial ability improved, while verbal fluency deteriorated. The ovaries developed polycystic characteristics. Adequate dosages of testosterone preserved bone mass in females. Androgens increased kallikreins, such as prostate-specific antigen, in female reproductive tissues. High-dose testosterone administration appeared to increase weight, visceral fat, and hematocrit, decrease high-density lipoprotein cholesterol, increase endothelin-1, increase C-reactive protein, and increase total homocysteine. But blood pressure, insulin sensitivity, fibrinolytic markers, arterial stiffness, and levels of von Willebrand factor, fibrinogen, and interleukin-6 remained largely unchanged.

Conclusions: Our studies demonstrated that, while some markers of cardiovascular risk factors showed a shift to a more negative risk profile, others were not affected. Androgen effects on cardiovascular risk markers are therefore not universally negative, and it is reasonable to assume that the latter effects will not be negative with the much lower doses suited for administration to women.

Author/-s: L. J. Gooren; E. J. Giltay

Publication: The journal of sexual medicine, 2008

Web link: http://www.ncbi.nlm.nih.gov/pubmed/17971101

Study on the risks of hormone treatment.

Blanchard's (J Nerv Ment Dis 177:616-623, 1989) theory of autogynephilia suggests that male-to-female transsexuals can be categorized into different types based on their sexuality. Little previous research has compared the sexuality of male-to-female transsexuals to biological females. The present study examined 15 aspects of sexuality among a non-clinical sample of 234 transsexuals and 127 biological females, using either an online or a paper questionnaire. The results showed that, overall, transsexuals tended to place more importance on partner's physical attractiveness and reported higher scores on Blanchard's Core Autogynephilia Scale than biological females. In addition, transsexuals classified as autogynephilic scored significantly higher on Attraction to Feminine Males, Core Autogynephilia, Autogynephilic Interpersonal Fantasy, Fetishism, Preference for Younger Partners, Interest in Uncommitted Sex, Importance of Partner Physical Attractiveness, and Attraction to Transgender Fiction than other transsexuals and biological females. In accordance with Blanchard's theory, autogynephilia measures were positively correlated to Sexual Attraction to Females among transsexuals. In contrast to Blanchard's theory, however, those transsexuals classified as autogynephilic scored higher on average on Sexual Attraction to Males than those classified as non-autogynephilic, and no transsexuals classified as autogynephilic reported asexuality.

Author/-s: Jaimie F. Veale; Dave E. Clarke; Terri C. Lomax

Publication: