References 7: Hormone treatment helps

Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real?

This study evaluated dissociative symptomatology, childhood trauma and body uneasiness in 118 individuals with gender dysphoria, also evaluating dissociative symptoms in follow-up assessments after sex reassignment procedures were performed. We used both clinical interviews (Dissociative Disorders Interview Schedule) and self-reported scales (Dissociative Experiences Scale). A dissociative disorder of any kind seemed to be greatly prevalent (29.6 %). Moreover, individuals with gender dysphoria had a high prevalence of lifetime major depressive episode (45.8 %), suicide attempts (21.2 %) and childhood trauma (45.8 %), and all these conditions were more frequent in patients who fulfilled diagnostic criteria for any kind of dissociative disorder. Finally, when treated, patients reported lower dissociative symptoms. Results confirmed previous research about distress in gender dysphoria and improved mental health due to sex reassignment procedures. However, it resulted to be difficult to ascertain dissociation in the context of gender dysphoria, because of the similarities between the two conditions and the possible limited application of clinical instruments which do not provide an adequate differential diagnosis. Therefore, because the body uneasiness is common to dissociative experiences and gender dysphoria, the question is whether dissociation is to be seen not as an expression of pathological dissociative experiences but as a genuine feature of gender dysphoria.

Author/-s:       Marco Colizzi; Rosalia Costa; Orlando Todarello

Publication:     Psychiatry Research, 2015

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Gender dysphoria in children and adolescents – treatment guidelines and follow-up study

Treatment guidelines for transidentity in children and adolescents are presently under discussion. We present an overview of the various treatment modalities. Further, follow-up data on children and adolescents referred for gender-identity problems are presented. Of the 84 patients seen for the first time more than 3 years before follow-up, 37 mailed in the completed questionnaires. In addition, 33 patients agreed to answer some short follow-up questions. We assessed steps of treatment, gender role, psychopathology, and psychotherapy. We compared differences in psychopathology in patients with vs. without gender role change and in patients with intense vs. less intense psychotherapy. A total of 22 patients had completely changed gender role, and some had started hormonal treatment und sex reassignment surgery. Most patients were satisfied with the treatment results. All patients showed less psychopathology on follow-up, independent of role change or intensity of psychotherapy. In general, the patients reported little psychopathology. Our follow-up results support the present treatment approach. In patients with little psychopathology, low-frequency supportive treatment appears sufficient to obtain safe judgement on hormonal of surgical treatment.

Author/-s:       Bernd Meyenburg; Anne Kröger; Rebecca Neugebauer

Publication:     Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie, 2015

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Gender dysphoria in children and adolescents: a review of recent research

Purpose of review: With the advent of medical treatments such as puberty suppression and cross-sex hormones in gender dysphoric minors, there has been a debate around questions of gender identity and brain development. This review aimed to identify recent empirical studies that addressed this controversial topic.

Recent findings: Epidemiological data from several countries indicate that gender dysphoria in children and adolescents is far more common than initially anticipated. This is in line with the currently observed steady increase in referrals to gender clinics. Minors with gender dysphoria are a vulnerable population as they may face a high psychopathological burden. Recently published data on the long-term outcome of puberty suppression and subsequent hormonal and surgical treatment indicate that young people with gender dysphoria may benefit substantially with regard to psychosocial outcomes. Brain development studied by neuroimaging methods seems not to be disturbed by puberty suppression.

Summary: The first reports about long-term outcome in adolescents having undergone puberty suppression have shown promising results. However, in a substantial part of gender dysphoric minors, puberty suppression is not indicated so far because of psychiatric comorbidity and long-term follow-up data from these patients are still scarce.

Author/-s:       Johannes Fuss; Matthias Auer; Peer Briken

Publication:     Current Opinion in Psychiatry, 2015

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Long-Term Follow-Up of Adults with Gender Identity Disorder

The aim of this study was to re-examine individuals with gender identity disorder after as long a period of time as possible. To meet the inclusion criterion, the legal recognition of participants’ gender change via a legal name change had to date back at least 10 years. The sample comprised 71 participants (35 MtF and 36 FtM). The follow-up period was 10–24 years with a mean of 13.8 years (SD = 2.78). Instruments included a combination of qualitative and quantitative methods: Clinical interviews were conducted with the participants, and they completed a follow-up questionnaire as well as several standardized questionnaires they had already filled in when they first made contact with the clinic. Positive and desired changes were determined by all of the instruments: Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation. Despite these positive results, the treatment of transsexualism is far from being perfect.

Author/-s:       Ulrike Ruppin, Friedemann Pfäfflin

Publication:     Archives of Sexual Behavior, 2015

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Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report

Transsexual (TS) individuals seem to display an increased risk in having eating disorders. Several case reports describe TS individuals with anorexia nervosa (AN). In order to understand better the impact of gender dysphoria (GD) and hormonal/surgical treatments on the occurrence and course of eating disorders in TS patients long term follow-up studies are needed. We present here a 41-year-old female-to-male TS patient suffering from AN. History revealed that pathological eating habits could strongly be associated with her GD. Hormonal and surgical treatments resulted in substantial improvement in the given eating disorder. The impact of GD on the development and treatment of eating disorder is discussed in this report.

Author/-s:       Şenol Turan; Cana Aksoy Poyraz; Alaattin Duran

Publication:     Eating Behaviors, 2015

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Beyond the guidelines: challenges, controversies, and unanswered questions.

Transgender and gender-nonconforming youth have unique medical and psychosocial needs that frequently go unmet. For youth who wish to have their physical appearance congruent with their gender identity, treatment guidelines are available that advocate the use of gonadotropin-releasing hormone (GnRH) analogues (puberty blockers) and cross-sex hormone regimens. Although medical transition was once considered highly controversial, there is a mounting body of evidence that providing a supportive and affirming environment, as well as appropriate medical intervention, results in improved health outcomes. Primary care pediatricians may be unaware of current guidelines and consequently the need for treatment and/or timely referrals. Transgender youth often face other hurdles to initiation of therapy, including refusal of care and harassment in medical settings, denial of coverage by insurance plans, and the high cost of puberty blockers. Because transgender youth younger than 18 years depend on their families for medical decision making, they may be unable to access necessary medical treatment when parents do not support their transition plan. Medical transition impacts many aspects of the medical system, such as insurance coverage, billing, electronic health records, and preventive health care maintenance. These issues may become more apparent with the implementation of the Affordable Care Act (ACA) and increased use of electronic records and clinical decision support. The implementation of the ACA may also present new opportunities and protections for transgender individuals. Primary pediatricians are often the first providers families and youth reach out to for advice, and they can assist families with negotiating these complex medical, legal, social, and economic challenges and optimizing access to safe and appropriate health care services.

Author/-s:       A. Radix; M. Silva

Publication:     Pediatric annals, 2014

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Cross-Sex Hormonal Treatment and Body Uneasiness in Individuals with Gender Dysphoria

Introduction: Cross-sex hormonal treatment (CHT) used for gender dysphoria (GD) could by itself affect well-being without the use of genital surgery; however, to date, there is a paucity of studies investigating the effects of CHT alone.

Aims: This study aimed to assess differences in body uneasiness and psychiatric symptoms between GD clients taking CHT and those not taking hormones (no CHT). A second aim was to assess whether length of CHT treatment and daily dose provided an explanation for levels of body uneasiness and psychiatric symptoms.

Methods: A consecutive series of 125 subjects meeting the criteria for GD who not had genital reassignment surgery were considered.

Main outcome measures: Subjects were asked to complete the Body Uneasiness Test (BUT) to explore different areas of body-related psychopathology and the Symptom Checklist-90 Revised (SCL-90-R) to measure psychological state. In addition, data on daily hormone dose and length of hormonal treatment (androgens, estrogens, and/or antiandrogens) were collected through an analysis of medical records.

Results: Among the male-to-female (MtF) individuals, those using CHT reported less body uneasiness compared with individuals in the no-CHT group. No significant differences were observed between CHT and no-CHT groups in the female-to-male (FtM) sample. Also, no significant differences in SCL score were observed with regard to gender (MtF vs. FtM), hormone treatment (CHT vs. no-CHT), or the interaction of these two variables. Moreover, a two-step hierarchical regression showed that cumulative dose of estradiol (daily dose of estradiol times days of treatment) and cumulative dose of androgen blockers (daily dose of androgen blockers times days of treatment) predicted BUT score even after controlling for age, gender role, cosmetic surgery, and BMI.

Conclusions: The differences observed between MtF and FtM individuals suggest that body-related uneasiness associated with GD may be effectively diminished with the administration of CHT even without the use of genital surgery for MtF clients. A discussion is provided on the importance of controlling both length and daily dose of treatment for the most effective impact on body uneasiness.

Author/-s:       Alessandra D. Fisher; Giovanni Castellini; Elisa Bandini; Helen Casale; Egidia Fanni; Laura Benni; Naika Ferruccio; Maria Cristina Meriggiola; Chiara Manieri; Anna Gualerzi; Emmanuele Jannini; Alessandro Oppo; Valdo Ricca; Mario Maggi; Alessandra H. Rellini

Publication:     The Journal of Sexual Medicine, 2014

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Disorders of gender identity: what to do and who should do it?

Transsexualism is not usually indicative of psychopathology. In carefully selected individuals, with multidisciplinary support, a change of social gender role and cross-sex hormone treatment greatly improves the psychological and social state. Sustained improvement merits gender reassignment surgery. The key is early referral with subsequent primary care cooperation in the treatment plan.

Author/-s:       James Barrett

Publication:     The British Journal of Psychiatry, 2014

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Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder

Introduction: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors.

Aims: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors.

Methods: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 (SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05.

Main Outcome Measures: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt.

Results: A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre- and postoperative assessments.

Conclusions: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Author/-s:       Gunter Heylens; Charlotte Verroken; Sanne de Cock; Guy T’Sjoen; Griet de Cuypere

Publication:     The Journal of Sexual Medicine, 2014

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Effects of Testosterone Treatment and Chest Reconstruction Surgery on Mental Health and Sexuality in Female-To-Male Transgender People

Objectives: This study examined the effects of testosterone treatment with or without chest reconstruction surgery (CRS) on mental health in female-to-male transgender people (FTMs).

Methods: More than 200 FTMs completed a written survey including quantitative scales to measure symptoms of anxiety and depression, feelings of anger, and body dissatisfaction, as well as qualitative questions assessing shifts in sexuality after the initiation of testosterone. Fifty-seven percent of participants were taking testosterone and 40% had undergone CRS.

Results: Cross-sectional analysis using a between-subjects multivariate analysis of variance showed that participants who were receiving testosterone endorsed fewer symptoms of anxiety and depression as well as less anger than the untreated group. Participants who had CRS in addition to testosterone reported less body dissatisfaction than both the testosterone-only or the untreated groups. Furthermore, participants who were injecting testosterone on a weekly basis showed significantly less anger compared with those injecting every other week. In qualitative reports, more than 50% of participants described increased sexual attraction to nontransgender men after taking testosterone.

Conclusions: Results indicate that testosterone treatment in FTMs is associated with a positive effect on mental health on measures of depression, anxiety, and anger, while CRS appears to be more important for the alleviation of body dissatisfaction. The findings have particular relevance for counselors and health care providers serving FTM and gender-variant people considering medical gender transition.

Author/-s:       Samuel A. Davis; Stacey L. Colton Meier

Publication:     International Journal of Sexual Health, 2014

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Effects of Three Different Testosterone Formulations in Female-to-Male Transsexual Persons

Introduction: Gender dysphoria is characterized by a strong discomfort with the gender assigned at birth and the urge to live as a member of the opposite gender. The acquisition of phenotypic features of the desired gender requires the use of cross-sex hormones. Female-to-male (FtM) transsexual persons are treated with testosterone to induce virilization.

Aim: The aim of the study was to assess the effects of three different testosterone formulations on body weight and composition and metabolic and bone parameters.

Methods: Forty-five FtM transsexuals were randomly assigned to receive testoviron depot (i.m.: 100 mg/10 days; n = 15), testosterone gel (50 mg/die; n = 15), and testosterone undecanoate (i.m.: 1,000 mg every 6 weeks for the first 6 weeks and then every 12 weeks, n = 15). FtM individuals were studied before, at week 30, and at week 54 of testosterone treatment.

Main Outcome Measures: Anthropometric, metabolic, bone, hematological, and biochemical parameters were evaluated at baseline and after 12 months of treatment.

Results: Lean body mass significantly increased and fat mass decreased in all groups. No modifications were reported in fasting insulin and insulin sensitivity index. High-density plasma lipoprotein levels declined significantly and low-density lipoprotein concentrations increased significantly in the three groups. The activated partial thromboplastin time and factor I did not change while prothrombin time significantly increased in all groups. At week 54, all subjects were amenorrheic and time to amenorrhea did not differ between the three groups. Current general life satisfaction was increased in all subjects after 1 year of treatment.

Conclusions: One-year testosterone administration in FtM transsexuals appears to be very safe with no differences among the testosterone formulations used. Our study is preliminary, and the detection of subtle or long-term differences in the effects of the three formulations may require further larger and longer term studies in this and other populations.

Author/-s:       Carla Pelusi; Antonietta Costantino; Valentina Martelli; Martina Lambertini; Alberto Bazzocchi; Federico Ponti; Giuseppe Battista; Stefano Venturoli; Maria C. Meriggiola

Publication:     The Journal of Sexual medicine, 2014

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Gender Dysphoria and Children

The age at which gender dysphoria can be diagnosed with enough certainty to justify medical intervention is controversial. The aim of this article is to explore current literature as it relates to the gender reassignment process and diagnostic indicators supporting an appropriate age for intervention. The timing of diagnosis and treatment of gender dysphoria remains the center of debate between the long-term effects of early intervention versus delay of treatment. Limited research is available on gender dysphoria treatment protocols for children. However, preliminary studies suggest that early intervention improves the quality of life in individuals who are transgender. Ongoing research suggests that it may be possible to confirm gender dysphoria at an earlier age.

Author/-s:       Chance Nicholson; Teena M. McGuinness

Publication:     Journal of psychosocial nursing and mental health services, 2014

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Gonadal Suppressive and Cross-Sex Hormone Therapy for Gender Dysphoria in Adolescents and Adults

Individuals with gender dysphoria experience distress associated with incongruence between their biologic sex and their identified gender. Gender dysphoric natal males receive treatment with antiandrogens and estrogens to become feminized (transsexual females), whereas natal females with gender dysphoria receive treatment with androgens to become masculinized (transsexual males). Because of the permanence associated with cross-sex hormone therapy (CSHT), adolescents diagnosed with gender dysphoria receive gonadotropin-releasing hormone analogs to suppress puberty. High rates of depression and suicide are linked to social marginalization and barriers to care. Behavior, emotional problems, depressive symptoms, and global functioning improve in adolescents receiving puberty suppression therapy. Gender dysphoria, psychological symptoms, quality of life, and sexual function improve in adults who receive CSHT. Within the first 6 months of CSHT, changes in transsexual females include breast growth, decreased testicular volume, and decreased spontaneous erections, and changes in transsexual males include cessation of menses, breast atrophy, clitoral enlargement, and voice deepening. Both transsexual females and males experience changes in body fat redistribution, muscle mass, and hair growth. Desired effects from CSHT can take between 3 and 5 years; however, effects that occur during puberty, such as voice deepening and skeletal structure changes, cannot be reversed with CSHT. Decreased sexual desire is a greater concern in transsexual females than in transsexual males, with testosterone concentrations linked to sexual desire in both. Regarding CSHT safety, bone mineral density is preserved with adequate hormone supplementation, but long-term fracture risk has not been studied. The transition away from high-dose traditional regimens is tied to a lower risk of venous thromboembolism and cardiovascular disease, but data quality is poor. Breast cancer has been reported in both transsexual males and females, but preliminary data suggest that CSHT does not increase the risk. Cancer screenings for individuals of both natal and transitioned sexes should occur as recommended. More long-term studies are needed to ensure that CSHT regimens with the best outcomes can continue to be prescribed for the transsexual population.

Author/-s:       Katherine P. Smith; Christina M. Madison; Nikki M. Milne

Publication:     Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 2014

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Management of female-to-male transgender persons: medical and surgical management, life expectancy.

Purpose of review: Hormonal treatment of transgender people is becoming a normal part of medicine, though numbers of subjects remain small because of low prevalence. Information on treatment is scattered and this review brings together the latest information on treatment goals and potential side-effects of androgen treatment of female-to-male transsexual subjects.

Recent findings: Androgen treatment of female-to-male transsexuals is usually uneventful, with a good patient compliance. Goals of hormonal treatment are elimination of secondary sex characteristics of the female sex and induction of those of the male sex. Completion takes approximately 2 years. Hormonal treatment is eventually followed by surgical ablation of breasts and removal of uterus and ovaries. Phalloplasty may be considered. Concerns are the sequelae of hypogonadism following surgery, such as loss of bone mass. Contrary to earlier expectations, there is no increase in cardiovascular disease. (Hormone-related) cancers are rare, but vaginal, cervical, endometrial carcinomas have been reported. Cancers of the breasts are of greater concern and have been found in residual mammary tissue after breast ablation. So far, androgen treatment has not raised major safety concerns. Regrets about changing sex have not been reported.

Summary: Testosterone treatment of female-to-male transsexuals is effective and well tolerated.

Author/-s:       Louis J. G. Gooren

Publication:     Current Opinion in Endocrinology, Diabetes, and Obesity, 2014

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Medical treatment in gender dysphoric adolescents endorsed by SIAMS–SIE–SIEDP–ONIG

Purpose: Despite international guidelines being available, not all gender clinics are able to face gender dysphoric (GD) youth population needs specifically. This is particularly true in Italy. Centers offering specialized support are relatively few and a commonly accepted Italian approach to GD youth has still not been defined. The aim of the present Position Statement is to develop and adhere to Italian guidelines for treatment of GD adolescents, in line with the “Dutch Approach”, the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH) guidelines.

Methods: An in-depth brainstorming on the application of International guidelines in the Italian context was performed by several dedicated professionals.

Results: A staged approach, combining psychological support as well as medical intervention is suggested. In the first phase, individuals requesting medical help will undergo a psycho-diagnostic procedure to assess GD; for eligible adolescents, pubertal suppression should be made available (extended diagnostic phase). Finally, from the age of 16 years, cross-sex hormonal therapy can be added, and from the age of 18 years, surgical sex reassignment can eventually be performed.

Conclusions: The current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behavior, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.

Author/-s:       Alessandra D. Fisher; J. Ristori; Elisa Bandini; S. Giordano; M. Mosconi; E. A. Jannini; N. A. Greggio; A. Godano; C. Manieri; C. Meriggiola; V. Ricca; D. Dettore; M. Maggi

Publication:     Journal of Endocrinological Investigation, 2014

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Medical Treatment of Subjects with Gender Identity Disorder: The Experience in an Italian Public Health Center

Hormonal treatment is the main element during the transition program for transpeople. The aim of this paper is to describe the care and treatment of subjects, highlighting both the endocrine-metabolic effects of the hormonal therapy and the quality of life during the first year of cross-sex therapy in an Italian gender team. We studied 83 subjects (56 male-to-female [MtF], 27 female-to-male [FtM]) with hematological and hormonal evaluations every 3 months during the first year of hormonal therapy. MtF persons were treated with 17βestradiol and antiandrogens (cyproterone acetate, spironolactone, dutasteride); FtM persons were treated with transdermal or intramuscular testosterone. The WHO Quality of Life questionnaire was administered at the beginning and 1 year later. Hormonal changes paralleled phenotype modifications with wide variability. Most of both MtF and FtM subjects reported a statistically significant improvement in body image (p < 0.05). In particular, MtF subjects reported a statistically significant improvement in the quality of their sexual life and in the general quality of life (p < 0.05) 1 year after treatment initiation. Cross-sex therapy seems to be free of major risks in healthy subjects under clinical supervision during the first year. Selected subjects show an optimal adaptation to hormone-induced neuropsychological modifications and satisfaction regarding general and sexual life.

Author/-s:       Chiara Manieri; Elena Castellano; Chiara Crespi; Cataldo Di Bisceglie; Carlotta Dell’Aquila; Anna Gualerzi;  Mariateresa Molo

Publication:     International Journal of Transgenderism, 2014

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Morbidity in a Multisite Retrospective Study of Cross-Sex Hormone-Treated Transgender Persons

Morbidity in cross-sex hormone-treated transgender people

A multisite retrospective cohort study (6 US and 9 European centers).

We studied retrospectively the data on health of trangender subjects (N > 2000) followed for at least 1 year when starting with or already on cross-sex hormone treatment.

Results: Our data show a large co-morbidity at the start of hormone treatment: in particular >20 % depression and thyroid disease in 2 %. Other comorbidity is very variable and appears not different from data on morbidity with simular age. Few deaths were reported. HIV positivity was observed in 3 % as expected in Men having Sex with Men (MSM).

Hormone treatment varied in male-to-female transgender persons (MtF): various estrogen preparationa in different ways of administration: patch, gel, oral and intramuscular. Cyproterone acetate (CPA) in Europe and spirolonactone (ALD) were used as anti-androgens. In FtM: testosterone intramuscular short- and longacting and gel, were prescribed in >90 %. Very few side effects were reported. The main serious side effect, venous thrombo-embolism (VTE) was observed in 1 % and related to estrogen use. In FtM: acne, muscle problems and weight increase were the main side effects.

Conclusion: Our data show a very reassuring picture of side effects with cross-sex hormone treatment. Our observations are biased because we have no data on those who were lost after few visits (lost to follow up) and those who went to other clinics ("shoppers"). Nevertheless our data confirm the reassuring data from studies with smaller numbers published in the last 10 years.

Author/-s:       Henk Asscheman; Guy G. T’Sjoen; Louis J. G. Gooren

Publication:     Presentation at ICE/ENDO 2014, The Endocrine Society

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This study was also reported in the media, see “Largest Study to Date: Transgender Hormone Treatment Safe” in the Medscape medical news: One of the reported findings was that at entry into the study “the most common comorbidity in both groups was depression, with a 24.9 % incidence in MTF subjects and 13.6 % in FTM”. After treatment, 2.4 % of the male-to-female subjects and 1.4 % of the female-to-male subjects still reported depression.

Psychological status as Measured by the MMPI in Japanese Clients with Gender Identity Disorder

Objective: We aimed to investigate the psychological status of gender identity disorder (GID) clients related to treatment phase and completion of real-life experience (RLE) using the Minnesota Multiphasic Personality Inventory (MMPI) retrospectively, and provide data that can be used to facilitate appropriate psychological support during treatment.

Methods: At a GID clinic, 261 male-to-female (MtF) and 138 female-to-male (FtM) clients completed the MMPI. Participants comprised three groups based on treatment status: no treatment, treatment with oral/injected hormones, or sex reassignment surgery.

Results: The mean T-score on MMPI clinical scales was higher than the average (T = 50) in GID clients (FtM = 55.3; MtF = 64.2). In addition, T-scores for MtF clients were significantly higher than those for FtM clients on 8 of the 10 clinical scales (p < 0.01). As treatment status progressed, the T-scores for 7 scales, excluding Masculinity/Femininity, Hypomania, and Social Introversion, approached those for non-GID individuals. In FtM clients who had hormonal treatment, there was increased psychological stability in those who were open about GID treatment and had completed their RLE.

Conclusion: These findings suggest that the psychological status of GID clients is more similar to non-GID individuals as treatment and RLE progress.

Author/-s:       Takaharu Hori; Hitomi Ninomiya; Tetsufumi Kanazawa; Shinya Kinoshita; Shota Ouchi; Yasuo Kawabata; Hiroshi Okada; Jun Koh; Hiroshi Yoneda

Publication:     Bulletin of the Osaka Medical College, 2014

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Sexual Quality of Life in Gender-Dysphoric Adults before Genital Sex Reassignment Surgery

Introduction: Although there is literature on sexuality in gender dysphoria, few studies have been done prior to genital sex reassignment surgery (SRS).

Aims: To evaluate the perception of sexual QoL in gender-dysphoric patients before genital SRS and the possible factors associated to this perception.

Methods: The final sample consisted of 67 male-to-female and 36 female-to-male gender-dysphoric adults consecutively attended in a gender unit who had not undergone genital SRS; 39.8 % was receiving cross-sex hormonal treatment, and 30.1 % had undergone breast augmentation or reduction. Sexual QoL was assessed using the sexual activity facet of the World Health Organization Quality of Life (WHOQOL)-100. Sociodemographic (age, gender, partner relationship) and clinical data (being on hormonal treatment and having undergone any breast surgery) were recorded from the clinical records. Depressive symptoms were assessed using the negative feelings facet of the WHOQOL-100. Personality was assessed using the Revised NEO-Five Factor Inventory.

Main Outcome Measures: Sexual QoL, negative feelings, hormonal treatment, partner relationship, personality.

Results: The mean score of the sexual facet was 10.01 (standard deviation = 4.09). More than 50 % of patients rated their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied,” around a quarter rated it as “good/satisfied” or “very good/very satisfied,” and the rest had a neutral perception. Three variables were significantly associated with a better sexual QoL: less negative feelings (β = −0.356; P < 0.001), being on hormonal treatment (β = 0.216; P = 0.018), and having a partner (β = 0.206; P = 0.022). Age, sex, having undergone some breast surgery, and personality factors were not associated with their perception.

Conclusion: This study indicates that before genital SRS, about half of gender-dysphoric subjects perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied.” Moreover, receiving hormonal treatment, low negative feelings, and having a partner are related to a better subjective perception of sexual QoL.

Author/-s:       Constanza Bartolucci; Esther Gómez‐Gil; Manel Salamero; Isabel Esteva; Leire Zubiaurre; Angel L. Montejo; Francisca Molero; Antonio Guillamón

Publication:     Journal of Sexual Medicine, 2014

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Testosterone Treatment and MMPI-2 Improvement in Transgender Men: A Prospective Controlled Study.

Objective: Most transgender men desire to receive testosterone treatment in order to masculinize their bodies. In this study, we aimed to investigate the short-term effects of testosterone treatment on psychological functioning in transgender men. This is the 1st controlled prospective follow-up study to examine such effects.

Method: We examined a sample of transgender men (n = 48) and nontransgender male (n = 53) and female (n = 62) matched controls (mean age = 26.6 years; 74% White). We asked participants to complete the Minnesota Multiphasic Personality Inventory (2nd ed., or MMPI-2; Butcher, Graham, Tellegen, Dahlstrom, & Kaemmer, 2001) to assess psychological functioning at baseline and at the acute posttreatment follow-up (3 months after testosterone initiation). Regression models tested (a) Gender × Time interaction effects comparing divergent mean response profiles across measurements by gender identity; (b) changes in psychological functioning scores for acute postintervention measurements, adjusting for baseline measures, comparing transgender men with their matched nontransgender male and female controls and adjusting for baseline scores; and (c) changes in meeting clinical psychopathological thresholds.

Results: Statistically significant changes in MMPI-2 scale scores were found at 3-month follow-up after initiating testosterone treatment relative to baseline for transgender men compared with female controls (female template): reductions in Hypochondria (p < .05), Depression (p < .05), Hysteria (p < .05), and Paranoia (p < .01); and increases in Masculinity-Femininity scores (p < .01). Gender × Time interaction effects were found for Hysteria (p < .05) and Paranoia (p < .01) relative to female controls (female template) and for Hypochondria (p < .05), Depression (p < .01), Hysteria (p < .01), Psychopathic Deviate (p < .05), Paranoia (p < .01), Psychasthenia (p < .01), and Schizophrenia (p < .01) compared with male controls (male template). In addition, the proportion of transgender men presenting with co-occurring psychopathology significantly decreased from baseline compared with 3-month follow-up relative to controls (p < .05).

Conclusions: Findings suggest that testosterone treatment resulted in increased levels of psychological functioning on multiple domains in transgender men relative to nontransgender controls. These findings differed in comparisons of transgender men with female controls using the female template and with male controls using the male template. No iatrogenic effects of testosterone were found. These findings suggest a direct positive effect of 3 months of testosterone treatment on psychological functioning in transgender men.

Author/-s:       C. L. Keo-Meier; L. I. Herman; S. L. Reisner; S. T. Pardo; C. Sharp; J. C. Babcock

Publication:     Journal of consulting and clinical psychology, 2014

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The peripubertal gender-dysphoric child: puberty suppression and treatment paradigms.

Gender-nonconforming youth are emerging at increasingly younger ages, and those experiencing gender dysphoria are seeking medical care at, or sometimes even before, the onset of puberty. Youth with gender dysphoria are at high risk for depression, anxiety, isolation, self-harm, and suicidality at the onset of a puberty that feels wrong. Medical providers would benefit from understanding interventions that help gender-nonconforming children and youth thrive. The use of gonadotropin-releasing hormone (GnRH) agonists to block the onset of an undesired puberty in youth with gender dysphoria is a relatively new practice, particularly in the United States. These medications shut down the hypothalamic-pituitary-gonadal axis (HPG), and the production of either testosterone or estrogen is temporarily halted. Puberty blocking allows a young person to explore gender and participate more fully in the mental health therapy process without being consumed by the fear of an impending developmental process that will result in the acquisition of undesired secondary sexual characteristics. GnRH agonists have been used safely for decades in children with other medical conditions, including central precocious puberty. Potential side effects of GnRH agonists include diminished bone density, injection site problems, emotional instability, and weight gain. Preliminary data have shown GnRH agonists to be very helpful in improving behavioral and overall functioning outcomes. Puberty suppression should ideally begin in the first stages of pubertal development and can be given via intramuscular or subcutaneous injections, or via an implant that is inserted in the upper arm. Monitoring to assure suppression of the HPG axis should occur regularly. Gender-nonconforming youth who remain gender dysphoric can go on to receive cross-sex hormones for phenotypic gender transition when they are older. GnRH agonists have changed the landscape of medical intervention for youth with gender dysphoria and are rapidly becoming the standard of practice.

Author/-s:       J. Olson; R. Garofalo

Publication:     Pediatric annals, 2014

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Trans people's experiences of mental health and gender identity services: A UK study

Drawing on survey data from a national (UK) study of trans people and mental health, the study presented here reports on the experiences of trans people in two health care settings: mental health services and gender identity clinics. An analysis of the (primarily qualitative) data indicates that in these settings practitioners tend to be poorly informed about trans issues and the realities of trans people's lives. The key observations of this study are that untreated gender dysphoria (due to delays or refusals of treatment), unnecessary and intrusive questioning/tests, prejudicial attitudes by service providers, and restrictive treatment pathways, all contribute to minority stress which is detrimental to the mental health and wellbeing of trans people.

Author/-s:       Sonja J. Ellis; Louis Bailey; Jay McNeil

Publication:     Journal of Gay & Lesbian Mental Health, 2014

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Transsexual patients’ psychiatric comorbidity and positive effect of cross-sex hormonal treatment on mental health: Results from a longitudinal study

The aim of the present study was to evaluate the presence of psychiatric diseases/symptoms in transsexual patients and to compare psychiatric distress related to the hormonal intervention in a one year follow-up assessment. We investigated 118 patients before starting the hormonal therapy and after about 12 months. We used the SCID-I to determine major mental disorders and functional impairment. We used the Zung Self-Rating Anxiety Scale (SAS) and the Zung Self-Rating Depression Scale (SDS) for evaluating self-reported anxiety and depression. We used the Symptom Checklist 90-R (SCL-90-R) for assessing self-reported global psychological symptoms. Seventeen patients (14%) had a DSM-IV-TR axis I psychiatric comorbidity. At enrollment the mean SAS score was above the normal range. The mean SDS and SCL-90-R scores were on the normal range except for SCL-90-R anxiety subscale. When treated, patients reported lower SAS, SDS and SCL-90-R scores, with statistically significant differences. Psychiatric distress and functional impairment were present in a significantly higher percentage of patients before starting the hormonal treatment than after 12 months (50% vs. 17% for anxiety; 42% vs. 23% for depression; 24% vs. 11% for psychological symptoms; 23% vs. 10% for functional impairment). The results revealed that the majority of transsexual patients have no psychiatric comorbidity, suggesting that transsexualism is not necessarily associated with severe comorbid psychiatric findings. The condition, however, seemed to be associated with subthreshold anxiety/depression, psychological symptoms and functional impairment. Moreover, treated patients reported less psychiatric distress. Therefore, hormonal treatment seemed to have a positive effect on transsexual patients' mental health.

Author/-s:       Marco Colizzi; Rosalia Costa; Orlando Todarello

Publication:     Psychoneuroendocrinology, 2014

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Transsexualität – Gender-Dysphorie

In the recent past the international perspective on the phenomenon of transsexuality has drastically changed and is now referred to as gender dysphoria in various forms of expression. The necessity for treatment refers to an improvement of dysphoria and must therefore be viewed very individually. The most extremely expressed form of gender dysphoria is transsexuality. Somatic treatment steps in the sense of opposite gender hormone treatment and gender change operations are in such cases those therapeutic steps which can achieve an improvement in the quality of life of persons affected. After a diagnosis has been made and the indications for these treatment steps have been established by psychiatrists, psychologists and psychotherapists, medical specialists from diverse disciplines as well as gynecologists and endocrinologists become involved in the treatment process. Interdisciplinary cooperation with other specialist disciplines, such as urology and plastic surgery is important and makes sense. This article presents a brief review of some new aspects of gender dysphoria and the treatment of transsexuality.

Author/-s:       Ulrike Kaufmann

Publication:     Der Gynäkologe, 2014

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Values and preferences of transgender people: a qualitative study

Summary box (hormone treatment): […] Supportive factors and enablers: The outcomes of hormone treatment were described as supporting psychological well-being and self-actualization. […]

Summary box (gender-affirming surgery): – Major psychological distress was reported by those wishing to undergo surgery but unable to do so. – Great relief and improvement to well-being was reported by those able to undergo surgery. […]

Author/-s:       Mira Schneiders

Publication:     World Health Organisation, 2014

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Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment

Background: In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.

Methods: A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.

Results: After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.

Conclusions: A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.

Author/-s:       Annelou L. C. de Vries; Jenifer K. McGuire; Thomas D. Steensma; Eva C. F. Wagenaar; Theo A. H. Doreleijers; Peggy T. Cohen-Kettenis

Publication:     Pediatrics, 2014

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This article is summarised and commented on in “Paediatrics: Transgender medicine—long-term outcomes from ‘the Dutch model’” by Daniel E. Shumer and Norman P. Spack in Nature Reviews Urology, 2014 (

A prospective study on sexual function and mood in female-to-male transsexuals during testosterone administration and after sex reassignment surgery

Testosterone administration in female-to-male transsexual subjects aims to develop and maintain the characteristics of the desired sex. Very little data exists on its effects on sexuality of female-to-male transsexuals. The aim of this study was to evaluate sexual function and mood of female-to-male transsexuals from their first visit, throughout testosterone administration and after sex reassignment surgery. Participants were 50 female-to-male transsexual subjects who completed questionnaires assessing sexual parameters and mood. The authors measured reproductive hormones and hematological parameters. The results suggest a positive effect of testosterone treatment on sexual function and mood in female-to-male transsexual subjects.

Author/-s:       A. Costantino; S. Cerpolini; S. Alvisi; P. G. Morselli; S. Venturoli; M. C. Meriggiola

Publication:     Journal of sex & marital therapy, 2013

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Determinants of quality of life in Spanish transsexuals attending a gender unit before genital sex reassignment surgery

Purpose: To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL.

Methods: A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire).

Results: Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor.

Conclusions: Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Author/-s:       Esther Gómez-Gil; Leire Zubiaurre-Elorza; Isabel Esteva de Antonio; Antonio Guillamon; Manel Salamero

Publication:     Quality of Life Research, 2013

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Endocrine treatment of transsexual persons: extensive personal experience.

Objective: The Endocrine Society's recently published clinical practice guidelines for the treatment of transsexual persons acknowledged the need for further information on transsexual health. We report here the experience of one provider with the endocrine treatment of transsexual persons over the past 2 decades.

Methods: Data on demographics, clinical response to treatment, and psychosocial status were collected on all transsexual persons receiving cross-sex hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.

Results: Through 2009, a total 192 male-to-female (MTF) and 50 female-to-male (FTM) transsexual persons were seen. These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability. Mental health and psychiatric problems were inversely correlated with age at presentation. The prevalence of sex reassignment surgery was low (31% for MTF). The number of persons seeking treatment has increased substantially in recent years. Cross-sex hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.

Conclusion: Transsexual persons seeking hormonal therapy are being seen with increasing frequency. The dysphoria present in many transsexual persons is associated with significant mood disorders that interfere with successful careers. Starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes. However, significant barriers exist, such as insufficient insurance coverage, which limit comprehensive care.

Author/-s:       M. C. Leinung; M. F. Urizar; N. Patel; S. C. Sood

Publication:     Endocrine Practice, 2013

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Hormonal Therapy Is Associated With Better Self-esteem, Mood, and Quality of Life in Transsexuals

Few studies have assessed the role of cross-sex hormones on psychological outcomes during the period of hormonal therapy preceding sex reassignment surgery in transsexuals. The objective of this study was to assess the relationship between hormonal therapy, self-esteem, depression, quality of life (QoL), and global functioning. This study incorporated a cross-sectional design. The inclusion criteria were diagnosis of gender identity disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision) and inclusion in a standardized sex reassignment procedure. The outcome measures were self-esteem (Social Self-Esteem Inventory), mood (Beck Depression Inventory), QoL (Subjective Quality of Life Analysis), and global functioning (Global Assessment of Functioning). Sixty-seven consecutive individuals agreed to participate. Seventy-three percent received hormonal therapy. Hormonal therapy was an independent factor in greater self-esteem, less severe depression symptoms, and greater “psychological-like” dimensions of QoL. These findings should provide pertinent information for health care providers who consider this period as a crucial part of the global sex reassignment procedure.

Author/-s:       Audrey Gorin-Lazard; Karine Baumstarck; L. Boyer; A. Maquigneau; J. C. Penochet; D. Pringuey; F. Albarel; I. Morange; M. Bonierbale; C. Lançon; P. Auquier

Publication:     The Journal of Nervous and Mental Disease, 2013

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Hormonal therapy satisfaction is associated with better quality of life in transsexual persons

Introduction: Quality of life in transsexual persons after transition is among the most important outcome factors.

Methods: A specialist center cross-sectional study in 193 transsexual women and 128 transsexual men (mean age 42.5 years) after on average 7.4 years of cross-sex hormone therapy and 6.6 years since sex reassignment surgery (SRS), compared to an age-and gender matched control population (1 to 3 matching). Self-reported physical and mental health using the Dutch version of the SF-12 Health survey. Medical history and postsurgical outcome were addressed by a new-developed questionnaire.

Results: Compared to age-matched control men and women, transsexual women scored worse both on physical and mental functioning (all P values < 0.001). Transsexual men reported equal degree of physical functioning compared to control women, but scored worse than control men. Mental well-being in transsexual men was poorer in comparison with control men and women (all P values < 0.001). In the total sample, age was negatively correlated with physical functioning, whereas educational level was positively associated. Patients with the lowest income quartile had worse physical and mental functioning compared to the others. Participants who lived with a partner had a better mental well-being. In transsexual men, having children was positively associated with mental-well being; in transsexual women the opposite was observed. Experiences of complications of phalloplasty, erection prosthesis or vaginoplasty were not associated with quality of life scores. However, satisfaction with these procedures was positively related to mental well-being. Likewise, both in transsexual men and women satisfaction with hormonal therapy was positively associated with mental and physical functioning (both P < 0.001).

Conclusion: Results of the current study indicate transsexual men and women after long-term cross-sex hormone treatment and SRS report worse mental well being compared to a control population. QOL in transsexual persons showed a strong association with treatment satisfaction, social and economical determinants.

Author/-s:       Katrien Wierckx; Lieselot Geerts; Edward Anseeuw; Joz Motmans; Els Elaut; Gunter Heylens; Griet de Cuypere; Guy T’Sjoen

Publication:     Endocrine Abstracts, 2013

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Hormonal treatment reduces psychobiological distress in gender identity disorder, independently of the attachment style

Introduction: Gender identity disorder may be a stressful situation. Hormonal treatment seemed to improve the general health as it reduces psychological and social distress. The attachment style seemed to regulate distress in insecure individuals as they are more exposed to hypothalamic-pituitary-adrenal system dysregulation and subjective stress.

Aim: The objectives of the study were to evaluate the presence of psychobiological distress and insecure attachment in transsexuals and to study their stress levels with reference to the hormonal treatment and the attachment pattern.

Methods: We investigated 70 transsexual patients. We measured the cortisol levels and the perceived stress before starting the hormonal therapy and after about 12 months. We studied the representation of attachment in transsexuals by a backward investigation in the relations between them and their caregivers.

Main outcome measures: We used blood samples for assessing cortisol awakening response (CAR); we used the Perceived Stress Scale for evaluating self-reported perceived stress and the Adult Attachment Interview to determine attachment styles.

Results: At enrollment, transsexuals reported elevated CAR; their values were out of normal. They expressed higher perceived stress and more attachment insecurity, with respect to normative sample data. When treated with hormone therapy, transsexuals reported significantly lower CAR (P < 0.001), falling within the normal range for cortisol levels. Treated transsexuals showed also lower perceived stress (P < 0.001), with levels similar to normative samples. The insecure attachment styles were associated with higher CAR and perceived stress in untreated transsexuals (P < 0.01). Treated transsexuals did not expressed significant differences in CAR and perceived stress by attachment.

Conclusion: Our results suggested that untreated patients suffer from a higher degree of stress and that attachment insecurity negatively impacts the stress management. Initiating the hormonal treatment seemed to have a positive effect in reducing stress levels, whatever the attachment style may be.

Author/-s:       Marco Colizzi; Rosalia Costa; Valeria Pace; Orlando Todarello

Publication:     The Journal of Sexual Medicine, 2013

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Speaking from the Margins – Trans Mental Health and Wellbeing in Ireland

Conclusions – Impact of Transition on Mental Health: The key finding to emerge from this study was the significance of gender transition in improving mental health and wellbeing. Seventy-five percent of the respondents felt that their mental health had improved since transitioning. Ninety-two percent were more satisfied with their bodies and 84 % more satisfied with their lives since transitioning. Both social and physical changes of gender were shown to have a substantially positive impact on trans people’s self-esteem, happiness and quality of life. Crucial here was the importance of being able to socially transition towards their felt gender identity and having that identity recognised by others. Alongside and interacting with this was the positive role played by hormonal and surgical interventions, which enabled necessary physical and psychosocial changes to be made. Such changes reduced instances of gender dysphoria and negative body image and, in turn, served to increase confidence, satisfaction and overall wellbeing.

Hormone usage had an extremely high success rate, with 90 % of users feeling more satisfied with their lives and 87 % feeling more satisfied with their bodies since initiating hormonal therapy. In relation to surgical procedures, 90 % of those who had undergone genital surgery reported feeling more satisfied with their bodies, and 83 % were more satisfied with their bodies after undergoing other surgical procedures such as breast augmentation or chest reconstruction. Of those who had made physical changes via hormones or surgery, 92 % reported having no regrets. However, participants highlighted the importance of having the right hormonal balance and receiving post-surgical care and support. Those waiting for surgical procedures or to start hormones highlighted the negative impact that delays had on their mental health.

Rates of self-harming, suicidal thoughts and suicide attempts were high, with 44 % of respondents having self-harmed, 78 % thinking about suicide and 40 % of those having attempted suicide at some point over the life course. However, gender transition was shown to drastically reduce rates of self-harm and suicidal ideation within this group. Of those who had completed transition, 76 % reported having self-harmed more prior to transition, but none of the participants had self-harmed more after transition. In addition, 81 % thought about or attempted suicide more before transitioning, but this amount was reduced to 4 % after transition among those who had already transitioned.

Whilst transition has been shown to significantly reduce rates of self-harm and suicidal ideation, it follows that those who would like to transition but who are unable to or who are experiencing significant delays or set-backs within the health care system will be at risk of increased self-harm and suicidal behaviour. Six percent of respondents reported currently selfharming at the time of completing the survey; 28 % had thought about taking their life in the last week; and one person said they were planning to commit suicide soon or in the near future. Trans-related reasons for participants’ self-harm and suicidal ideation included gender dysphoria, not having their gender recognised, social stigma, frustrations with treatment delays, lack of access to treatment, worry that they would never ‘fully’ or ‘successfully’ transition, having their identity misunderstood by health professionals and not feeling supported by gender identity specialists.

Author/-s:       Jay McNeil; Louis Bailey; Sonja Ellis; Maeve Regan

Publication:     Report by the Transgender Equality Network Ireland (TENI), 2013

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Transsexual conditions need to be assessed for a psychological, hormonal and surgical evaluation. A multidisciplinary consent is required to perform hormonal and surgical treatment.

Method: A critical overview has been performed (PubMed) and the main guidelines have been summarised.

Results: Hormonal treatments include suppression of the naturally secreted hormone and the administration of hormone of the desired sex. The main comorbidity is thrombo-embolic complications for patients under oestogene therapy. The main surgical treatment for female to male (FtM) surgery are: periareolar mastectomy if possible, hysterectomy, ovariectomy and vaginectomy and phallic reconstruction including metaidioplasty and forearm or suprapubic phalloplasty dependant of patient's wishes. The main treatments for male to female (MtF) surgery are: prosthesis mammoplasty and vaginoplasty and for some facial feminisation. The results in term of global satisfaction are high despite a relatively high rate of complications as well.

Conclusion: Results in terms of well-being and psychological improvement justify this treatment despite its relatively high morbidity.

Author/-s:       N. Morel Journel; J. E. Terrier; F. Courtois; S. Droupy; Audrey Gorin-Lazard

Publication:     Progres en Urologie, 2013

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Clinical management of gender dysphoria in children and adolescents: the Dutch approach

The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth’s functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent cross-sex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.

Author/-s:       A. L. de Vries; Peggy T. Cohen-Kettenis

Publication:     Journal of homosexuality, 2012

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Hormone-treated transsexuals report less social distress, anxiety and depression

Introduction: The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals.

Methods: We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety.

Results: The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F=4.362, p=0.038; F=14.589, p=0.001; F=9.523, p=0.002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61 % vs. 33 % and 31 % vs. 8 % respectively).

Conclusions: The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Author/-s:       Esther Gómez-Gil; Leire Zubiaurre-Elorza; Isabel Esteva; Antonio Guillamon; Teresa Godás; M. Cruz Almaraz; Irene Halperin; Manel Salamero

Publication:     Psychoneuroendocrinology, 2012

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Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study.

Introduction: Although the impact of sex reassignment surgery on the self-reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce.

Aims: The objectives of this study were to assess the relationship between hormonal therapy and the self-reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross-sex hormone therapy as well as between transsexuals and the general population (French age- and sex-matched controls).

Methods: This study incorporated a cross-sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM-IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre-sex reassignment surgery.

Main Outcome Measure: QoL was assessed using the Short Form 36 (SF-36).

Results: The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty-four (72.1 %) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF-36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals' QoL, independently of hormonal status, did not differ from the French age- and sex-matched controls except for two subscales of the SF-36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls).

Conclusion: The present study suggests a positive effect of hormone therapy on transsexuals’ QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design.

Author/-s:       Audrey Gorin-Lazard; Karine Baumstarck; Laurent Boyer; Aurélie Maquigneau; Stéphanie Gebleux; Jean-Claude Penochet; Dominique Pringuey; Frédérique Albarel; Isabelle Morange; Anderson Loundou; Julie Berbis; Pascal Auquier; Christophe Lançon; Mireille Bonierbale

Publication:     The Journal of Sexual Medicine, 2012

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Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study

Introduction: Puberty suppression by means of gonadotropin-releasing hormone analogues (GnRHa) is used for young transsexuals between 12 and 16 years of age. The purpose of this intervention is to relieve the suffering caused by the development of secondary sex characteristics and to provide time to make a balanced decision regarding actual gender reassignment.

Aim: To compare psychological functioning and gender dysphoria before and after puberty suppression in gender dysphoric adolescents.

Methods: Of the first 70 eligible candidates who received puberty suppression between 2000 and 2008, psychological functioning and gender dysphoria were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment.

Main outcome measures: Behavioral and emotional problems (Child Behavior Checklist and the Youth-Self Report), depressive symptoms (Beck Depression Inventory), anxiety and anger (the Spielberger Trait Anxiety and Anger Scales), general functioning (the clinician's rated Children's Global Assessment Scale), gender dysphoria (the Utrecht Gender Dysphoria Scale), and body satisfaction (the Body Image Scale) were assessed.

Results: Behavioral and emotional problems and depressive symptoms decreased, while general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1. No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.

Conclusion: Puberty suppression may be considered a valuable contribution in the clinical management of gender dysphoria in adolescents.

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

Publication:     The journal of sexual medicine, 2011

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The Effects of Hormonal Gender Affirmation Treatment on Mental Health in Female-to-Male Transsexuals

Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 2003). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.

Author/-s:       Stacey L. Colton Meier; Kara M. Fitzgerald; Seth T. Pardo; Julia Babcock

Publication:     Journal of Gay & Lesbian Mental Health, 2011

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Treatment of adolescents with gender dysphoria in the Netherlands

In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.

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

Publication:     Child and adolescent psychiatric clinics of North America, 2011

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Gender Dysphoria in Adolescents – Mental Health and Treatment Evaluation

Summary: There is increasing evidence that biological, psychological and social factors all play a role in typical gender identity development. In contrast, our understanding of gender variant development and GID remains limited.

In chapter two, we present a review of studies on the psychosexual outcome in individuals with disorders of sex development (DSD) which provides some insight into the complex relationship between biological and psychosocial factors. A high percentage of affected individuals in these studies did suffer from gender dysphoria. However, these percentages varied substantially among the different DSD groups, ranging from 0 to 67%, indicating that many individuals with DSD exhibit no gender identity problems. Clearly, a distinction should be made between gender role behavior and gender identity. Whereas there are empirical findings suggesting that biological factors, especially prenatal sex hormones, influence the development of gender role behavior, there is less evidence that biological factors affect gender identity development. Hence, the findings suggest that both biological and psychosocial factors play a role in gender variant develop ment similar to the role they play in typical gender identity develop ment. In addition, the studies on individuals with DSD indicate that patients who chose to make a gender change often did so in adolescence or young adulthood.

In chapter three psychological (dys-) functioning of adolescents with GID was compared to that of adults with GID. Age adapted versions of the same instrument, the Minnesota Multiphasic Personality Inventory (MMPI-2 or MMPI-A, respectively) were administered to adults and adolescents eligible for medical intervention (cross-sex hormones and puberty suppression, respectively). Most notable, psychological functioning of adolescents was more favorable compared to adults. Whereas 73% of the adults showed problem behavior in the clinical range on two or more clinical scales, in the adolescents this was only 32%. Further findings were that, contrary to what is found in some studies (for a review, see Lawrence, Murad) no differences in psychological functioning were found in the adult transsexuals with regard to sexual orientation (sexually attracted to natal or non-natal gender). All adolescents were sexually attracted to their natal gender. Gender differences emerged as well: adult female-to-males (FtMs) functioned significantly better than adult male-to-females (MtFs) on three clinical scales. However, adolescent FtMs functioned significantly better than adolescent MtFs on only one clinical scale and the reverse was true on two clinical scales.
The salient finding in this study was the poorer psychological functioning of adult applicants for sex reassignment compared to adolescent applicants. This may reflect a better psychological functioning of early-onset GID as opposed to late-onset (after puberty) GID. However, it also suggests that it is easier to make a gender role change around the start of puberty than in adulthood.

In chapter four the co-occurrence of autism spectrum disorders (ASD) and GID was examined in children and adolescents (115 boys and 89 girls, mean age 10.8) referred to a gender identity clinic. During the standardized assessment, a GID diagnosis was made and suspected ASD 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 the combined sample of children and adolescents was 7.8% (n=16), in the 108 assessed children 6.4% (n=7) and in the 96 assessed adolescents 9.4% (n=9). The incidence of ASD was higher in in children and adolescents with a GID-NOS (gender identity disorder not otherwise specified) diagnosis than in youth fulfilling the complete GID criteria (in children 6.5% (n=5) versus 1.9% (n=1) and in adolescents 37.5% (n=3) versus 13% (n=6) respectively). The mean IQ of the children with ASD (M=82.0) was significantly lower compared to the mean IQ of the children without ASD (M=103.9). Adolescents with ASD (M=15.4 years) were significantly older than adolescents without ASD (M=13.8 years).

The observed incidence of 7.8% ASD in the combined sample of 204 children and adolescents referred to a gender identity clinic is approximately ten times higher than the prevalence of 0.6 %–1 % of ASD in the general population. This confirms the clinical impression that ASD occurs more frequently in gender dysphoric individuals than expected by chance. The cases described in the current study illustrate the clinical management issues that arise in youth with co-occurring GID and ASD. In all, the diagnostic procedure was extended to disentangle whether the gender dysphoria evolved from a general feeling of being ‘different’ or a ‘core’ cross-gender identity. Concerning gender reassignment, ASD does not have to be a strict exclusion criterion. However, to provide individuals with co-occurring gender dysphoria and ASD with proper care remains a challenge.

In chapter five, a study on psychiatric comorbidity in adolescents with GID was presented. To ascertain DSM-IV diagnoses, the Diagnostic Interview Schedule for Children (DISC) was administered to parents of 105 gender dysphoric adolescents (mean age at assessment 14.6 years, 53 natal males and 52 natal females). Of the 105 adolescents, 32.4% had at least one concurrent psychiatric disorder, and 15.2% had two or more comorbid diagnoses. Anxiety disorders occurred in 21%, mood disorders in 12.4% and disruptive disorders in 11.4% of the adolescents. Compared with natal females, natal males suffered more often from mood disorders (20.8% versus 3.8%) and social anxiety disorder (15.1% versus 3.8%). Adolescents were divided into an immediately eligible group, when the diagnostic procedure took less than 1.5 years and a delayed eligible group, when their diagnostic procedure took 1.5 years or more. The rate for oppositional defiant disorder and the rate for three or more comorbid diagnoses was higher in delayed eligible adolescents with GID (15.4% versus 3.2% and 7.4% versus 0%, respectively) compared with immediately eligible adolescents, their age was older (15.6 years versus 14.1 years) and their intelligence was lower (TIQ=91.6 versus 99.2).
We concluded that the majority of gender dysphoric adolescents do not have co-occurring psychiatric problems, despite their increased suffering from the incongruence between experienced and assigned gender after puberty had started. However, subgroups of adolescents do show comorbid psychiatric problems. Natal males seem to need more clinical attention than natal females. Contrary to our expectation, psychiatric comorbidity by itself was only minimally associated with eligibility for medical inter-ventions. Other factors, like age, intelligence and family circumstances, seem to be of importance too.

In chapter six, the effects of puberty suppression on psychological functioning and gender dysphoria were evaluated, shortly before cross-sex hormone treatment was initiated, in adolescents with GID who had received GnRHa to suppress puberty. The first 70 eligible candidates who received puberty suppression between 2000 and 2008 were assessed twice: at T0, when attending the gender identity clinic, before the start of GnRHa; and at T1, shortly before the start of cross-sex hormone treatment. Behavioral and emotional problems, depressive symptoms, anxiety and anger, general functioning, gender dysphoria and body satisfaction were assessed. Behavioral and emotional problems and depressive symptoms decreased whereas general functioning improved significantly during puberty suppression. Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both genders, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1.

By relieving the acute distress accompanying the gender dysphoria, puberty suppression seemed to have offered these youths the possibility of healthy psychological development.

Long term outcome of young adults after their gender reassignment surgery who had been treated with puberty suppression during adolescence was assessed in chapter seven. For this study, we investigated gender dysphoria, treatment satisfaction, current life situation and school or employment career, sexual functioning and quality of life. Twenty-seven young adults (11 FtMs and 16 MtFs) were assessed twice: first, shortly after their attendance at the gender identity clinic (pre-treatment, mean age 13.5 (SD 1.8)) and second, at least one year after their GRS (post-treatment, mean age 20.9 (SD 1.0)). Gender dysphoria resolved and participants were predominantly satisfied with their bodies and treatment. Concerning relationships with family and peers, and professional and educational careers, they had made important age appropriate developmental transitions. Although, compared to their peers in the general Dutch population, participants showed less experience with various sexual behaviors, the number of experiences had increased after gender reassignment surgery. Many young adults (78%) had been involved in romantic relationships. Quality of life appeared to be better compared with scores from 21-30 year old participants from a survey on the psychometric properties of the WHOQOL-Bref. Pre-treatment intelligence and poor peer relations correlated negatively with post-treatment quality of life. These findings suggest that clinical management including puberty suppression, enabled these formerly gender dysphoric adolescents to make important age appropriate developmental transitions, contributing to a satisfactory qualify of life. A subgroup of adolescents, however, showing a poorer quality of life post-treatment, deserves special clinical attention.

Author/-s:       Annelou L. C. de Vries

Publication:     Dissertation, Vrije Universiteit Amsterdam, 2010

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Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes

Objective: To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes.

Methods: We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95 % confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I2 statistic.

Results: We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80 % of individuals with GID reported significant improvement in gender dysphoria (95 % CI = 68–89 %; 8 studies; I2 = 82 %); 78 % reported significant improvement in psychological symptoms (95 % CI = 56–94 %; 7 studies; I2 = 86 %); 80 % reported significant improvement in quality of life (95 % CI = 72–88 %; 16 studies; I2 = 78 %); and 72 % reported significant improvement in sexual function (95 % CI = 60–81 %; 15 studies; I2 = 78 %).

Conclusions: Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.

Author/-s:       Mohammad Hassan Murad; Mohamed B. Elamin; Magaly Zumaeta Garcia; Rebecca J. Mullan; Ayman Murad; Patricia J. Erwin; Victor M. Montori

Publication:     Clinical Endocrinology, 2010

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This study also found a reduction in suicidality from 30 % pre-treatment to 8 % post-treatment.

Etiological aspects, therapy regimes, side effects and treatment satisfaction of transsexual patients

Background: Transsexual patients are characterized by biologically normal genotypes and phenotypes which are combined with the conviction of belonging to the opposite sex. This conviction goes along with a desire for gender reassignment, which involves psychological, hormonal and surgical treatment. Limited data on the various aspects of transsexualism exists at present.

Objective: This study aimed at evaluating etiological aspects of transsexualism, the efficacy and safety of the therapeutical procedures, and the role of patients’ satisfaction with the treatment.

Methods: Questionnaires evaluating medical history, therapy side effects and therapy satisfaction, including standardized questionnaires on sleep and psychopathology have been developed and sent to all 439 transsexual patients that are currently treated at the Max-Planck-Institut of Psychiatry in Munich.

Results: Ninety-five patients returned the questionnaire and their responses were analysed. Out of 95, 37 were FMT (average age 32 years; average age at diagnosis 25 years) and 58 were MFT (average age 48 years; average age at diagnosis 39 years). We found neither a high rate of gender identity disorders in the family histories of our patient sample nor a high rate of intake of medications by the mothers or other complications during pregnancy. Ninety-eight percent of the patients received psychotherapy, 94.7 % benefited from HT and 69.5 % had undergone surgery at the time of the study. The patients followed different HT regimes: FMT received testosterone in transdermal and/or intramuscular applications; MFT received transdermal, oral or intramuscular estrogens and cyproterone acetate in different combinations. Frequent side effects reported by FMT were acne, aggressivity and alopecia. In the group of MFT, depression, muscle mass decrease and libido decrease were frequently found. Both groups experienced a significant weight increase following HT (mean increase 10.8 ± 6.6 kg in FMT and 8.7 ± 9.8 kg in MFT). Nevertheless, in comparison with an age-matched control group, we did not see higher prevalences of lifelong cardiovascular, endocrine or tumoral comorbidities. Both groups reported a high overall satisfaction with all therapies (MFT mean value for HT: 75.6 ± 24.8 on a scale of 0=worst to 100=best possible satisfaction. FMT mean value: 88.4 ± 13.3).

Conclusion: We conclude that the therapy for transsexual patients seems to be safe with high levels of satisfaction reported by the patients. Further studies should be conducted in order to clarify the etiological aspects of transsexualism and to evaluate the long term consequences of the HT in comparison with each other (head-to-head studies).

Author/-s:       María Ángeles Bazarra-Castro

Publication:     Dissertation, Medical Faculty, Ludwig-Maximilians-Universität, München, 2009

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The Treatment of Adolescent Transsexuals: Changing Insights

Introduction: Treatment of individuals with gender identity disorder (GID) has in medicine nearly always met with a great deal of skepticism. Professionals largely follow the Standards of Care of the World Professional Association for Transgender Health. For adolescents, specific guidelines have also been issued by the British Royal College of Psychiatrists.

Aim: To describe the stepwise changes in treatment policy which, in recent years, have been made by the team of the Gender Identity Clinic at the VU University Medical Center in Amsterdam, The Netherlands.

Methods: The first step taken to treat adolescents was that, after careful evaluation, (cross-sex hormone) treatment could start between the ages of 16 and 18 years. A further step was the suppression of puberty by means of gonadotropin-releasing hormone analogs in 12–16 year olds; the latter serves also as a diagnostic tool. Very recently, other clinics in Europe and North America have followed this policy.

Results: The first results from the Amsterdam clinic show that this policy is promising.

Conclusions: Professionals who take responsibility for these youth and are willing to help should yet be fully aware of the impact of their interventions. In this article, the pros and cons of the various approaches to youngsters with GID are presented, hopefully inciting a sound scientific discussion of the issue.

Author/-s:       Peggy T. Cohen-Kettenis; Henriette A. Delemarre-van de Waal; Louis J. G. Gooren

Publication:     The Journal of Sexual Medicine, 2008

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Experiences of Transwomen with Hormone Therapy

This article describes the experiences of 12 transwomen on hormone treatment, ranging in age from 30 to 63. Findings from interviews revealed seven prominent themes: transitioning before hormone treatment, starting on hormones, matching expectations with reality, tracking changes, relationships with health professionals, reflections on gender identity, and impact of hormones. Participants tended to be highly curious about the impact of hormone therapy, and most tracked bodily and psychological changes closely. Despite problematic side effects experienced by most (including periods of depression), an overall mental health benefit was evident, with transwomen feeling relieved about reducing the impact of testosterone and the stress of presenting as men, while being able to openly explore dimensions of being female. While some transwomen expressed awareness of how social influences and ideas about gender played a part in their reactions to hormone treatment, most thought and acted in accordance with the biomedical premise that bodies and identities can be created and recreated through technical physiological manipulation. Hormone therapy was seen as the critical step in committing to, and consolidating gender transition.

Author/-s:       Richard Wassersug; Ross E. Gray; Angela Barbara; Rupert Raj; Christina Sinding

Publication:     Sexualities, 2007

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The evolution of the operated transsexual people

The objective of the present article is the evaluation of the scientific literature on the evolution of operated transsexual people and the consequences of the hormonal and surgical treatments. It seems crystal clear that both treatments produce much more positive effects than expected by the physicians and the psychologists in the past. Together with an appropriated follow-up and a correct assessment of the psychological vulnerability, these elements make acceptable the demand of sex change. Studies on the "psychological risk profile" are necessary to evaluate the factors of further adaptability and also to propose preventive steps at the beginning of the hormonal and surgical treatment.

Author/-s:       M. Bonierbale; A. Michel; C. Lançon

Publication:     Vertex: revista argentina de psiquiatriá, 2006

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Endocrine intervention for transsexuals

Regrets: Real regret in people who have undergone palliative treatment for transsexualism is rare (< 0.5 %) and, rather than misdiagnosis, usually relates to unfavourable life circumstances such as early marriage, adverse social situation and lack of support (Landen et al., 1998a), poor adaptive skills, late start of treatment and limited intelligence (van Kesteren et al., 1997; Smith et al., 2001). A history of a previously unsuccessful long-term homosexual relationship or sexual abuse in childhood also seems to increase the risk that inappropriate treatment will be demanded (Reid, 2002). Peer pressures within the transsexual community may also push vulnerable male-to-female transsexuals toward surgery to distinguish themselves from transvestites – heterosexual males for whom periodic cross-dressing induces sexual arousal (Frohwirth et al., 1987).

With respect to the quality of surgical outcome, in an unpublished survey of around 200 male-to-female transsexuals carried out by ‘Press for Change’, even those who reported poor outcomes of gender reassignment surgery did not regret their decision to undergo the procedure as the structural reconfiguration rather than the quality of change is one of the desired endpoints, perhaps reinforced by misunderstood anatomy and well-intentioned reassurances (Claire McNab, editor of ‘Press for Change’, personal communication; McNab, 2002). Satisfaction with sexual activity in both male-to-female and female-to-male transsexuals tends to increase markedly with cross-sex hormone treatment and gender-reassignment surgery even if sexual functioning may be technically imperfect (Lief & Hubschman, 1993).

Summary and conclusions: In summary, transsexuals have persistent cross-gender identities, usually without any predisposing factors. Self-diagnosis is confirmed by psychological assessment, which includes a trial period living in the chosen gender before consideration of hormonal treatment and surgery. The choice of cross-sex hormone treatment is generally straightforward and complications, principally venous thromboembolism in male-to-female and potentially osteoporosis in female-to-male, are highly amenable to treatment. Although more evidence would be welcome, adequately treated gender dysphoria is likely to be safer than the untreated condition, which is associated with an enhanced risk of depression and suicide. Reassuringly, few transsexuals regret undergoing treatment.

Doubts about the integrity of transgender individuals and the authenticity of gender dysphoria as a diagnosis, lack of approbation from peers and perhaps personal phobias may lead some members of the medical profession to withhold treatment or prescribe inadequate doses of cross-sex hormones on perceived safety grounds. Transsexual individuals require long-term assistance to optimize cross-sex hormone treatment and should not be subject to discrimination when they seek health care. The perception within some parts of the transgender community that the nonpsychiatric medical profession are not interested in their plight should be laid to rest.

Author/-s:       Andy Levy; Anna Crown; Russell Reid

Publication:     Clinical Endocrinology, 2003

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Surgical therapy in transsexual patients: a multi-disciplinary approach.

A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentally: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker. Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.

Author/-s:       S. Monstrey; P. Hoebeke; M. Dhont; G. de Cuypere; R. Rubens; M. Moerman; M. Hamdi; K. van Landuyt; P. Blondeel

Publication:     Acta chirurgica Belgica, 2001

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Mortality and morbidity in transsexual subjects treated with cross-sex hormones

Objective: The optimum steroid hormone treatment regimes for transsexual subjects has not yet been established. We have investigated the mortality and morbidity figures in a large group of transsexual subjects receiving cross-sex hormone treatment.

Design: A retrospective, descriptive study in a university teaching hospital.

Subjects: Eight hundred and sixteen male-to-female (M    F) and 293 female-to-male (F    M) transsexuals.

Interventions: Subjects had been treated with cross-sex hormones for a total of 10 152 patient-years.

Outcome measures: Standardized mortality and incidence ratios were calculated from the general Dutch population (age- and gender-adjusted) and were also compared to side effects of cross-sex hormones in transsexuals reported in the literature.

Results: In both the M    F and F    M transsexuals, total mortality was not higher than in the general population and, largely, the observed mortality could not be related to hormone treatment. Venous thromboembolism was the major complication in M    F transsexuals treated with oral oestrogens and anti-androgens, but fewer cases were observed since the introduction of transdermal oestradiol in the treatment of transsexuals over 40 years of age. No cases of breast carcinoma but one case of prostatic carcinoma were encountered in our population. No serious morbidity was observed which could be related to androgen treatment in the F    M transsexuals.

Conclusion: Mortality in male-to-female and female-to-male transsexuals is not increased during cross-sex hormone treatment. Transdermal oestradiol administration is recommended in male-to-female transsexuals, particularly in the population over 40 years in whom a high incidence of venous thromboembolism was observed with oral oestrogens. It seems that in view of the deep psychological needs of transsexuals to undergo sex reassignment, our treatment schedule of cross-sex hormone administration is acceptably safe.

Author/-s:       Paul J. M. van Kesteren; Henk Asscheman; Jos A. J. Megens; Louis J. G. Gooren

Publication:     Clinical Endocrinology, 1997

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The transsexualism syndrome: clinical aspects and therapeutic prospects

The prevalence rate of transsexualism varies from 1 to 50,000, to 1 to 100,000. Although it remains an infrequent affliction, transsexualism generates usually major suffering and may be responsible of many complications like suicide, self-mutilations, affective disorders and social disabilities. Since the first descriptions of Esquirol in the nineteenth, the medical community has always been questioned on medical, legal, social or ethical aspects of transsexualism. The aetiology of the trouble is still unknown. In the absence of biological marker, the syndrome of transsexualism can be defined only with clinical criteria. The main differential diagnosis are sexual ambiguities and psychotic disorders. For the specialists, satisfying the patients’ demand of a surgical and social reassignment still remains the only way to improve their clinical condition and avoid the onset of many dramatic complications. Without any treatment, the evolution of the trouble is chronic, without remission. Longitudinal studies of transsexual patients with a five year follow-up demonstrated subjective improvement in two thirds of the patients and don't find either higher rates of suicides nor psychotic decompensations after surgery and hormonotherapy. Clinical and neuropsychological studies of sexually differentiated cognitive abilities of transsexual patients, before and after hormonotherapy, could allow us in improving the understanding of sexual differences of the brain.

Author/-s:       T. Gallarda; I. Amado; S. Coussinoux; M. F. Poirier; B. Cordier; J. P. Olié

Publication:     L'Encephale, 1997

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The Feasibility of Endocrine Interventions in Juvenile Transsexuals

Conclusion: Teenagers with gender problems come to the attention of the psychomedical profession. Reversible hormonal treatment of juvenile transsexuals is breaking new ground, but the accounts of their impossible and distressing situation are realistic. Professionals dealing with this category cannot ignore their plight. Modern endocrinology can help to create a frame where in the juvenile transsexual and the therapist can work on the problem under less pressure of time rendering the gender problem more amenable to the right type of treatment.

Author/-s:       Louis Gooren; Henriette Delamarre-van de Waal

Publication:     Journal of Psychology & Human Sexuality, 1996

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