References 9: Sex reassignment surgery helps

Effect of sex reassignment on mental well-being and quality of life (Sukupuolen korjauksen vaikutus psyykkiseen hyvinvointiin ja elämänlaatuun)

Transgender people find their natal sex and the corresponding gender role unpleasant and alien, and wish to be able to live in the gender role and body of the other sex. Gender dysphoria is effectively alleviated by sex reassignment treatments. Quality of life is improved among the majority of patients, and regrets are rare. Psychiatric symptoms at the initiation of the transition process, discrimination, negative attitudes, losses in relationships, and complications in somatic treatments may deteriorate the social integration and quality of life of the transgender people. Health-care professionals can ease the transition process by organizing support for transgender individuals according to the same principles as they do for other people.

Author/-s:       A. Mattila; L. Heinonen; A. Mäntymäki; N. Uusi-Mäkelä; M. Algars

Publication:     Duodecim, 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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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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Psychosocial outcome and quality of sexual life after sex reassignment surgery: An Italian multicentric study

Objective: Sex reassignment surgery (SRS) in the treatment of Gender Dysphoria has been shown to be followed by high levels of postsurgery satisfaction, improvement in quality of life and in the general psychosocial functioning of clients, both on a short and long-term perspective (Michel et al., 2002; Landén et al., 1998; Lawrence, 2003). More recent studies based on a cohort design (Dhejne et al., 2011), however, show that after surgery, transsexuals clients are still at higher risk of mortality, psychopathology and suicidal behavior than the general population. Aim of the present study is assessing long-term outcome of SRS, through a multicentric design which involved three Italian centers specialized in the treatment of gender dysphoria (Milan, Florence, Bari).

Methods: Transsexual clients who received SRS were contacted and asked to complete a comprehensive assessment (adaptation from Lawrence 2003) including: levels of satisfaction for SRS, regret after surgery, psychosocial functioning, quality of sexual life, clinical history of gender dysphoria. Also, all participants completed the Italian version of the Psychological Well-Being questionnaire (Ryff, 1995, Ruini et al., 2003). The battery was completed either online or in a paper-and-pencil format. 28 FtM and 49 MtF transsexuals persons from the three centers completed the questionnaires, from 1 to 31 years after surgery.

Results: In both samples we found high levels of satisfaction in all the areas explored (including sexual life after surgery), and levels of psychological and social well-being comparable to those of the general population.

Conclusion: Our results support previous studies suggesting that SRS not only alleviates gender dysphoria but also improves quality of life and psychosocial functioning in transsexual persons.

Author/-s:       Antonio Prunas; Diamante Hartmann; Maurizio Bini; Elisa Bandini; Alessandra Daphne Fisher; Mario Maggi; Valeria Pace; Luca Quagliarella; Orlando Todarello

Publication:     Journal of Sexual Medicine, 2015

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An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets

Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960–2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100 000/year (FM) and from 0.23 to 0.73/100 000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13 120 and for MF 1:7 750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.

Author/-s:       Cecilia Dhejne; Katarina Öberg; Stefan Arver; Mikael Landén

Publication:     Archives of Sexual Behavior, 2014

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Assessment of Self-Perception of Transsexual Persons: Pilot Study of 15 Patients

Background and Aims (Abstract): There have been few studies in the area of Self-Perception in transsexual persons, except for the population of transsexual adolescents. Bearing in mind its importance not only in the assessment of personality but also in predicting adaptive capacity, the goal of our research is based on the examination of Self-Perception of adult transsexual persons.

Method (Abstract): The study was conducted using a Rorschach test, which provides an insight into various aspects of Self-Perception.The sample consisted of 15 transsexual persons, who passed the standard diagnostic procedure.

Results (Abstract): The results suggest that transsexual persons manage to maintain Adequate Self-Esteem. Hypervigilance Index and Obsessive Style Index are negative, while the values showing a negative quality of Self-Regard and the capacity for introspection tend to increase. In the process of Self-Introspection, negative and painful emotional states are often perceived.

Conclusion (Abstract): The estimation of Self-Perception in adult transsexual persons indicates a trend of subjective perception of a personal imperfection or inadequacy. This is probably the result of experiencing discomfort for a number of years due to gender incongruence and dysphoria, in particular in persons who enter the sex reassignment procedure later in their adulthood.

5. Conclusion: Overall results of our study indicate that transsexual persons have Adequate Self-Esteem, while the Egocentricity Index is of average values as in normal adult population. They also indicate a trend toward elevated introspection, with increased attention to the physical aspects of the body; that is, in the process of Self-Inspection negative and painful emotional states are present. It means that the trend of increased number of MOR responses in relation to the studies on adolescents transsexual persons is probably the result of long-term suffering, having in mind that the people who are involved in our study had initiated the sex reassignment procedure during their mature adult age. Prolongation or entering the desired procedure relatively late results in the trend mentioned above, that is, the subjective experience of personal imperfection or inadequacy. Analysis of the results obtained may indicate that delayed entering into the sex-reassignment procedure in transsexual persons may potentiate the negative image of themselves and cause exhaustion of adaptive resources and consequently development of comorbid disorders, particularly depression and suicidal behavior.

Author/-s:       Jasmina Barišić; Marija Milosavljević; Dragana Duišin; Borjanka Batinić; Svetlana Vujović; Srdjan Milovanović

Publication:     The Scientific World Journal, 2014

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Does Sex Reassignment Surgery Induce Cerebral Modifications in MTF Transsexuals?

Despite widely accepted biological theories, the etiopathogenesis of the gender dysphoria remains largely unclear. Several studies have shown the existence of some gender-related cerebral areas. Indeed, various areas belonging to the limbic system such as stria terminalis, preoptic nucleus, and amygdala are characterized by a sexual dimorphism both in macroscopic and microscopic structures. Men and women are different in processing cognitive and emotional stimuli. A common neurophysiologic approach to assess cognitive functions is based on event-related potential (ERP) analysis, especially on the evoked component called P300. The P300 wave is a centro-parietal positive deflection in human ERP, which occurs about 300 milliseconds after stimuli's appearance and it is known as the “cognitive wave”. Few scholars have studied male to female (MTF) transsexuals through neurophysiologic studies. We designed a prospective case-control study. Fifteen MTF transsexuals, aged average 35 years and an age matched control group of 20 healthy right-handed heterosexual volunteers (10 males and 10 females) underwent an emotional ERP test. The cognitive-emotional ERPs were achieved while the subjects were watching slides extracted from the International Affective Picture System (IAPS). Sixty pictures, divided in two series with positive/neutral and negative/neutral valences were shown randomly to the subjects. The area below the P300 wave, its amplitude and latency were compared before and after sex reassignment surgery (SRS) in transsexuals and with control groups. The P300 component of control females was characterized by a larger latency, amplitude and area, comparing to the male's one, in both the pleasant and unpleasant pictures (P < 0,01). All the P300 parameters in the MTF transsexuals increased in response to positive or negative stimuli in the postoperative recordings (P < 0,01). Therefore, our ERP analysis evidenced larger amplitude of the P300 in MTF transsexuals in the postoperative recordings in response to positive and negative stimuli. A stronger response is considered a typical female gender-related feature, as evidenced both in the scientific literature and in our control analysis. This may be interpreted as a higher responsiveness to pleasant and unpleasant stimuli in MTF transsexuals with tendency to assume female cerebral features after the sex reassignment surgery. Different hypothesis can be considered to explain the cerebral modifications evidenced in our study. Indeed, the P300 postoperative modifications can be related to both a biological modification of the cerebral activity or a postoperative psychological well-being of our patients. In conclusion, according to our preliminary results, MTF transsexuals undergoing a sex reassignment surgery, as well as a genital surgical feminization, tend to assume female cerebral features. In our opinion, these results underline the beneficial effects of the SRS allowing patients to react to the genital surgery conversion with a cerebral feminization. These two effects tend to solve the typical conflict of this disorder: the discrepancy between cerebral and physical features. However, since the gender dysphoria has low incidence, this conclusion shall be validated through prospective studies with larger samples in other specialized centers.

Author/-s:       Luigi Rolle; Marco Falcone; Sergio Vighetti; Carlo Ceruti; Omidreza Sedigh; Massimiliano Timpano; Maria Teresa Molo; Lorys Castelli; Mirko Preto; Paolo Gontero; Bruno Frea

Publication:     The Journal of Sexual Medicine, 2014

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Effects of sex reassignment surgery on quality of life and mental health in transsexuals

Introduction: Gender identity disorder is an emergent and important disorder which may lead to devastating consequences and comorbidities if proper treatment approaches are not used.

Objectives: We planned showing the improvements in patients’ life in multilple domains after sex reassignment surgery (SRS).

Aims: In our research we focused on changes experienced by people who gained new gender identity with sex reassignment surgery.

Methods: We interviewed at least one year after the operation with 20 sex reassigned transsexuals (SR-T) who were once on SRS programme of Istanbul University Psychiatry Department Psychoneurosis and Psychotherapy Unit and who had confirmative rapports for surgery and we also interviewed with 50 non-sex reassigned transsexuals (NSR-T) who applied to the same unit for SRS programme.

Results: Worries about gender discrimination and gender victimization were lower, but worries of being uncovered about transgender identity were higher in SR-T group. SR-T group scored lower on Family Assessment Device, 4th and 5th items of Arizona Sexual Life Scale and total points excluding the 3rd item (item for penile erection and vaginal lubrication), but scored higher on Multi Dimensional Scale for Perceived Social Support, Coopersmith Self Esteem Scale and psychological subscale of World Health Organization Quality of Life Scale-Brief Form.

Conclusions: The SRS used in the treatment of transsexuality releases the conflict and makes the transformation on official gender and is associated with improvements in quality of life, self esteem, family support, sexual life satisfaction and interpersonal relationships and reduction in worries about gender discrimination and gender victimization.

Author/-s:       B. Ozata; S. Yüksel; H. Noyan; M. Avayu; E. Yildizhan

Publication:     European Psychiatry, 2014

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Gender-Related Victimization, Perceived Social Support, and Predictors of Depression Among Transgender Australians

This study examined mental health outcomes, gender-related victimization, perceived social support, and predictors of depression among 243 transgender Australians (n = 83 assigned female at birth, n = 160 assigned male at birth). Overall, 69 % reported at least 1 instance of victimization, 59 % endorsed depressive symptoms, and 44 % reported a previous suicide attempt. Social support emerged as the most significant predictor of depressive symptoms (p > 0.05), whereby persons endorsing higher levels of overall perceived social support tended to endorse lower levels of depressive symptoms. Second to social support, persons who endorsed having had some form of gender affirmative surgery were significantly more likely to present with lower symptoms of depression. Contrary to expectations, victimization did not reach significance as an independent risk factor of depression (p = 0.053). The pervasiveness of victimization, depression, and attempted suicide represents a major health concern and highlights the need to facilitate culturally sensitive health care provision.

Author/-s:       Crystal Boza; Kathryn Nicholson Perry

Publication:     International Journal of Transgenderism, 2014

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Intestinal Vaginoplasty Revisited: A Review of Surgical Techniques, Complications, and Sexual Function

Introduction: Vaginal (re)construction is essential for the psychological well-being of biological women with a dysfunctional vagina and male-to-female transgender women. However, the preferred method for vagina (re)construction with respect to functional as well as aesthetic outcomes is debated. Regarding intestinal vaginoplasty, despite the asserted advantages, the need for intestinal surgery and subsequent risk of diversion colitis are often-mentioned concerns. The outcomes of vaginal reconstructive surgery need to be appraised in order to improve understanding of pros and cons.

Aims: To review literature on surgical techniques and clinical outcomes of intestinal vaginoplasty.

Methods: Electronic databases and reference lists of published articles were searched for primary studies on intestinal vaginoplasty. Studies were included if these included at least five patients and had a minimal follow-up period of 1 year. No constraints were imposed with regard to patient age, indication for vaginoplasty, or applied surgical technique. Outcome measures were extracted and analyzed.

Main Outcome Measures: Main outcome measures were surgical procedure, clinical outcomes, and outcomes concerning sexual health and quality of life.

Results: Twenty-one studies on intestinal vaginoplasty were included (including 894 patients in total). All studies had a retrospective design and were of low quality. Prevalence and severity of procedure-related complications were low. The main postoperative complication was introital stenosis, necessitating surgical correction in 4.1 % of sigmoid-derived and 1.2 % of ileum-derived vaginoplasties. Neither diversion colitis nor cancer was reported. Sexual satisfaction rate was high, but standardized questionnaires were rarely used. Quality of life was not reported.

Conclusion: Based on evidence presently available, it seems that intestinal vaginoplasty is associated with low complication rates. To substantiate these findings and to obtain information about functional outcomes and quality of life, prospective studies using standardized measures and questionnaires are warranted.

Author/-s:       Mark-Bram Bouman; Michiel C. T. van Zeijl; Marlon E. Buncamper; Wilhelmus J. H. J. Meijerink; Ad A. van Bodegraven; Margriet G. Mullender

Publication:     The Journal of Sexual Medicine, 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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Psychosocial Adjustment to Sex Reassignment Surgery: A Qualitative Examination and Personal Experiences of Six Transsexual Persons in Croatia

In Croatia, transgender individuals face numerous social and medical obstacles throughout the process of transition. The aim of this study was to depict the factors contributing to the psychosocial adjustment of six transsexual individuals living in Croatia following sex reassignment surgery (SRS). A combination of quantitative and qualitative self-report methods was used. Due to the specificity of the sample, the data were collected online. Standardized questionnaires were used to assess mental health and quality of life alongside a series of open-ended questions divided into 4 themes: the decision-making process regarding SRS; social and medical support during the SRS process; experience of discrimination and stigmatizing behaviors; psychosocial adjustment after SRS. Despite the unfavorable circumstances in Croatian society, participants demonstrated stable mental, social, and professional functioning, as well as a relative resilience to minority stress. Results also reveal the role of pretransition factors such as high socioeconomic status, good premorbid functioning, and high motivation for SRS in successful psychosocial adjustment. During and after transition, participants reported experiencing good social support and satisfaction with the surgical treatment and outcomes. Any difficulties reported by participants are related to either sexual relationships or internalized transphobia. The results also demonstrate the potentially protective role that a lengthier process of transition plays in countries such as Croatia.

Author/-s:       Nataša Jokić-Begić; Anita Lauri Korajlija; Tanja Jurin

Publication:     The scientific world journal, 2014

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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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Satisfaction with male-to-female gender reassignment surgery – results of a retrospective analysis

Hintergrund: Die Häufigkeit der Geschlechtsidentitätsstörung lässt sich nur schwer erheben. Die Erfassung der Operationen und die Anzahl der Gerichtsverfahren nach dem Transsexuellengesetz bilden die Wirklichkeit nur schlecht ab. Es gibt nur wenige Studien, die untersuchen, wie zufrieden die Patientinnen mit der operativen Geschlechtsangleichung von Mann zu Frau sind.

Methode: Es wurden 254 konsekutive Patientinnen, die sich zwischen 2004 und 2010 einer geschlechtsangleichenden Operation von Mann zu Frau an der Klinik für Urologie des Universitätsklinikums Essen unterzogen hatten, retrospektiv befragt. Der Fragebogen umfasste Fragen zur postoperativen subjektiven Zufriedenheit.

Ergebnisse: Es konnten 119 Fragebögen (Rücklauf 46,9 %) nach durchschnittlich 5,05 Jahren (Standardabweichung [SD]: 1,61 Jahre, Bereich 1–7 Jahre) ausgewertet werden. Für 90,2 % der operierten Patientinnen hatten sich nach der Operation die Erwartungen an das Leben als Frau erfüllt. In der eigenen Empfindung sahen sich 85,4 % als Frauen. Mit dem äußeren Erscheinungsbild als Frau waren 61,2 % zufrieden und 26,2 % sehr zufrieden. 37,6 % waren mit dem funktionellen Ergebnis zufrieden und 34,4 % sehr zufrieden. Ferner gaben 65,7 % an, mit dem gegenwärtigen Leben zufrieden zu sein.

Schlussfolgerungen: Die sehr hohen subjektiven Zufriedenheitsraten sowie die operativen Ergebnisse legen einen Nutzen der geschlechtsangleichenden Operation nahe. Die geringe Rücklaufquote von unter 50 % erfordert eine zurückhaltende Interpretation der Ergebnisse.

Author/-s:       Jochen Hess; Roberto Rossi Neto; Leo Panic; Herbert Rübben; Wolfgang Senf

Publication:     Deutsches Ärzteblatt International, 2014

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Study of adjustment in persons suffering from gender identity disorder (Before and after sexuality change surgery)

The goal of this research is comparison of adjustment of persons suffering from gender identity disorder before and after sexuality change surgery. The sampling method was from “available” type. The assumptions were selected based on social adjustment differences of sample persons before and after sexuality change surgery. Data was gathered by a sample of 24 persons (12 persons before surgery and 12 persons after surgery) using Bell Adjustment Inventory (form adults) (1989). The findings showed that adjustment level had increased for after-surgery group than before-surgery group, but this increment was not significant. The significance level of 95 % indicates that there is a difference between before and after surgery groups.

Author/-s:       Reyhaneh Naziri Rad; Elham Arjmand

Publication:     Applied Psychology, 2014

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Suicide Risk in the UK Trans Population and the Role of Gender Transition in Decreasing Suicidal Ideation and Suicide Attempt

Purpose: This article examines suicidal ideation and suicide attempt within the UK trans population and highlights the impact of gender dysphoria, minority stress and medical delay

Design/methodology/approach: This represents a narrative analysis of qualitative sections of a survey that utilised both open and closed questions. The study drew on utilised a non-random sample (n=889), obtained via a range of UK-based support organisations and services.

Findings: The study revealed high rates of suicidal ideation (84 % lifetime prevalence) and attempted suicide (48 % lifetime prevalence) within this sample. A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors. Subsequently, gender dysphoria, confusion/denial about gender, fears around transitioning, gender reassignment treatment delays and refusals, and social stigma increased suicide risk within this sample.

Research limitations/implications: Due to the limitations of undertaking research with this population, the research is not demographically representative.

Practical implications: The study found that trans people are most at risk prior to social and/or medical transition and that trans people who require access to hormones and surgery can be left, in many cases, unsupported for dangerously long periods of time. The article highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritise timely intervention and support.

Originality/value: The first exploration of suicidal ideation and suicide attempt within the UK trans population revealing key findings pertaining to social and medical transition, crucial for policy makers, commissioners and practitioners working across Gender Identity Services and suicide prevention.

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

Publication:     Mental Health Review Journal, 2014

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The Role of Clitoral Anatomy in Female to Male Sex Reassignment Surgery

Introduction: Controversies on clitoral anatomy and its role in female sexual function still make clitoral reconstructive surgery very challenging. We evaluated the role of clitoral anatomic features in female to male sex reassignment surgery.

Material and Methods: The study included 97 female transsexuals, aged from18 to 41 years, who underwent single stagemetoidioplasty between March 2008 and January 2013. The operative technique involved vaginectomy, the release of clitoral ligaments and urethral plate, urethroplasty by combining buccalmucosa graft and genital flaps, and scrotoplasty with insertion of testicle prostheses. Postoperative questionnaire was used to evaluate aesthetic, functional, and sexual outcome.

Results: The mean followup was 30 months. The mean length of the neophallus was 7 cm, compared to mean preoperative length of the hypertrophied clitoris of 3.3 cm. Complications occurred in 27.84 % of all patients, related mostly to urethroplasty. Voiding while standing was achieved in all cases. None of the patients had problems in sexual arousal, masturbation, or orgasms.

Conclusion: Accurate knowledge of the clitoral anatomy, physiology, and neurovascular supply is crucial for a successful outcome of female to male sex reassignment surgery. Our approach appears to ensure overall satisfaction and high quality of sexual life.

Author/-s:       Vojkan Vukadinovic; Borko Stojanovic; Marko Majstorovic; Aleksandar Milosevic

Publication:     The Scientific World Journal, 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 (

Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness

Introduction: Subjects with gender identity disorder (GID) have been reported to be highly dissatisfied with their body, and it has been suggested that the body is their primary source of suffering.

Aims: To evaluate quality and intensity of body uneasiness in GID subjects, comparing them with a sample of eating disorder patients and a control group. To detect similarities and differences between subgroups of GID subjects, on the basis of genotypic sex and transitional stage.

Methods: Fifty male-to-female (MtF) GID (25 without and 25 with genital reassignment surgery performed), 50 female-to-male (FtM) GID (28 without and 22 with genital reassignment surgery performed), 88 eating disorder subjects (26 anorexia nervosa, 26 bulimia nervosa, and 36 binge eating disorder), and 107 healthy subjects were evaluated.

Main outcome measures: Subjects were studied by means of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Symptom Checklist (SCL-90), and the Body Uneasiness Test (BUT).

Results: GID and controls reported lower psychiatric comorbidity and lower SCL-90 General Severity Index (GSI) scores than eating disorder subjects. GID MtF without genital reassignment surgery showed the highest BUT values, whereas GID FtM without genital reassignment surgery and eating disorder subjects showed higher values compared with both GID MtF and FtM who underwent genital reassignment surgery and controls. Considering BUT subscales, a different pattern of body uneasiness was observed in GID and eating disorder subjects. GID MtF and FtM without genital reassignment surgery showed the highest BUT GSI/SCL-90 GSI ratio compared with all the eating disorder groups.

Conclusions: GID and eating disorders are characterized by a severe body uneasiness, which represents the core of distress in both conditions. Different dimensions of body uneasiness seem to be involved in GID subsamples, depending on reassignment stage and genotypic sex. In eating disorder subjects body uneasiness is primarily linked to general psychopathology, whereas in GID such a relationship is lacking.

Author/-s:       Elisa Bandini; Alessandra D. Fisher; G. Castellini; C. lo Sauro; L. Lelli; M. C. Meriggiola; H. Casale; L. Benni; N. Ferruccio; C. Faravelli; D. Dettore; M. Maggi; V. Ricca

Publication:     The journal of sexual medicine, 2013

Web link:

Genital Reassignment Surgery in Male-to-Female Transsexuals: Do we have Guidelines or Standards?

Background: In 2011 the WPATH (World Professional Association for Transgender Health) published the 7th version of their “Standards of Care” for diagnosis and treatment of transsexual people. In face of further recent peer-reviewed reports of experienced centres on surgical sex reassignment it should be examined whether or not genital sex reassignment in male-to-female transsexuals actually can be based on evidence-based guidelines or standards.

Results: The indication for surgery is widely standardised and evidence-based. Most critical steps of the operation are also founded on grade B recommendations. Most experienced authors rely on penoscrotal pedicled flaps for neovaginal lining. The topic of ideal reconstruction of the vulva, especially the clitoro-labial complex is still a field of debate. Due to the high frequency of further corrective surgeries which exceeds 50% in most experienced centres, some authors prefer a primary 2-step procedure for genital reassignment.

Conclusions: The indication and principal operative steps in surgical genital reassignment in male-to-female patients rely on evidence-based recommendations. By respecting these recommendations subjective success rates of over 80 % can be expected.

Author/-s:       M. H. Sohn; M. Hatzinger; K. Wirsam

Publication:     Handchirurgie, Mikrochirurgie, Plastische Chirurgie, 2013

Web link:

Langzeitkatamnese bei Transsexuellen

Excerpt of summary: […] Both in the interviews and the follow-up questionnaire all subjects reported to have never regretted the sex change. Rather, they reported a high level of well-being. More than three quarters of the subjects (78.6 %) were employed at follow-up and 60.0 % lived in a committed relationship. In relation to the surgery results, the test subjects reported moderate to high satisfaction values. With their social relationships they were likewise satisfied and were on the whole socially well integrated. In summary, the test subjects described in the interviews more positive than negative effects of the treatment. […] In relation to the treatment as a whole as well as its effectiveness for reducing gender dysphoria, the subjects gave positive reviews overall. Between the initial examination and the time of follow-up positive changes with sometimes high effect sizes emerged on numerous scales of the standardized questionnaire. The subjects had less psychosomatic complaints, fewer interpersonal problems and significantly more life satisfaction. […] In addition, a comparison of the results of the test subjects with the values ​​of the calibration samples included in the manuals of the questionnaires was done to determine the values ​​of the subjects in relation to the general population. Here, numerous differences emerged – the subjects had lower values consistently in all questionnaires ​​. This result can be interpreted as contrast to the problems that existed prior to treatment. In comparison, the current problems must appear very small. In conclusion, one can evaluate the results of this follow-up study of transsexual patients as very positive. The improvement of quality of life shown in numerous follow-up studies over short periods continues 10 years after the treatment and longer. This underlines the importance of treatment for transsexual patients.

Original: Die vorliegende Studie ist eine Langzeitnachuntersuchung transsexueller Patienten und hatte das Ziel, deren aktuelle Lebenssituation sowie die Veränderung dieser Situation seit der mindestens 10 Jahre zurückliegenden geschlechtsumwandelnden Behandlung (bestehend aus psychotherapeutischen, hormonellen und operativen Behandlungsmaßnahmen sowie rechtlichen Schritten) unter psychosozialen Gesichtspunkten zu erfassen. Dazu wurden alle ehemaligen Patienten angeschrieben, deren Erstkontakt mit der Ambulanz der Klinik für Psychosomatische Medizin und Psychotherapie des Universitätsklinikums Ulm mindestens 10 Jahre zurücklag, bei denen Transsexualismus (ICD-10: F64.0) diagnostiziert worden war und die bis einschließlich zum Jahr 2000 eine Vornamensänderung erreicht hatten. Insgesamt wurden 140 Personen angeschrieben, mit 101 von ihnen entstand ein Kontakt und 71 (35 Frauen und 36 Männer) nahmen schließlich an der Studie teil. Mit 56 Probanden konnte ein persönlicher Gesprächstermin vereinbart werden, weitere 15 Probanden nahmen auf postalischem Wege teil. Der Katamnesezeitraum, also die Zeit, die seit der Vornamensänderung vergangen war, betrug zwischen 10 und 24 Jahren, im Mittel 13,8 Jahre. Die Erhebung fand mit einer Kombination aus qualitativen und quantitativen Methoden statt: Zunächst wurden halbstrukturierte Interviews geführt, um die aktuelle Lebenssituation der Probanden sowie die positiven und negativen Auswirkungen der geschlechtsumwandelnden Behandlung auf verschiedene Lebensbereiche zu erfassen. Um die Lebenssituation der Probanden zum Katamnesezeitpunkt auch standardisiert zu erfassen, wurde zusätzlich ein eigener Katamnesefragebogen erstellt. Um die Veränderungen zwischen Erstuntersuchungs- und Katamnesezeitpunkt standardisiert erfassen zu können, wurden die Fragebogen, die die Probanden bereits beim Erstkontakt mit der Klinik ausgefüllt hatten, erneut vorgelegt. Es wurden die psychosomatische Belastung, interpersonale Probleme, Persönlichkeitsvariablen und Geschlechtsrollenstereotype der Probanden erhoben. Sowohl in den Interviews als auch im Katamnesefragebogen gaben alle Probanden an, den Geschlechtswechsel nie bereut zu haben. Vielmehr berichteten sie von einem hohen Ausmaß an Wohlbefinden. Mehr als drei Viertel der Probanden (78.6 %) waren zum Katamnesezeitpunkt erwerbstätig und 60.0% lebten in einer festen Partnerschaft. In Bezug auf die Operationsergebnisse gaben die Probanden mittlere bis hohe Zufriedenheitswerte an. Mit ihren sozialen Beziehungen zeigten sie sich ebenfalls zufrieden und waren insgesamt sozial gut eingebunden. Zusammenfassend schilderten die Probanden auch in den Interviews mehr positive als negative Wirkungen der Behandlung. Als schwierig beschrieben sie besonders die Zeit während des Geschlechtswechsels. Im beruflichen und Familien- und Freundeskreis schien sich im Verlauf des langen Katamnesezeitraums so etwas wie Normalität eingestellt zu haben. Lediglich in Bezug auf Partnerschaft und Sexualität war die Transsexualität immer noch ein Thema, mit dem die Probanden in diesen Bereichen weiterhin konfrontiert wurden. In Bezug auf die Behandlung als Ganzes sowie ihrer Wirksamkeit zur Reduktion von Geschlechtsdysphorie kamen die Probanden zu insgesamt positiven Bewertungen. Zwischen dem Erstuntersuchungs- und dem Katamnesezeitpunkt zeigten sich auf zahlreichen Skalen der standardisierten Fragebogen positive Veränderungen mit teilweise hohen Effektstärken. Die Probanden wiesen weniger psychosomatische Beschwerden, weniger interpersonale Probleme und deutlich mehr Lebenszufriedenheit auf. In Bezug auf die Geschlechtsrollenstereotype ergaben sich keine Veränderungen. Die Werte der standardisierten Fragebogen wurden auch herangezogen, um die methodische Qualität der Nachuntersuchung sicherzustellen. Zu diesem Zweck wurden zunächst Studienteilnehmer und Nicht-Teilnehmer verglichen und so die Repräsentativität der Stichprobe für die Gesamtheit der Patienten untersucht. Dabei zeigten sich nur auf wenigen Skalen Gruppenunterschiede. Zusätzlich fand ein Vergleich der Ergebnisse der Probanden mit den in den Fragebogenmanualen enthaltenen Werten von Eichstichproben statt, um die Werte der Probanden im Verhältnis zur Allgemeinbevölkerung zu interpretieren. Hier zeigten sich zahlreiche Unterschiede, wobei die Probanden durchgängig in allen Fragebogen die geringeren Werte aufwiesen. Dieses Ergebnis kann als Kontrasteffekt zu den Problemen, die vor der Behandlung bestanden, gewertet werden. Im Vergleich dazu müssen die aktuellen Probleme sehr gering erscheinen. Schlussfolgernd kann man die Ergebnisse der vorliegenden Langzeitkatamnese transsexueller Patienten als sehr positiv werten. Die in zahlreichen Nachuntersuchungen über kurze Zeiträume gezeigte Verbesserung der Lebensqualität setzt sich auch 10 Jahre nach der Behandlung und länger fort. Das unterstreicht die große Bedeutung der Behandlung für transsexuelle Patienten.

Author/-s:       Ulrike Ruppin

Publication:     Doctoral thesis in human biology, medical faculty, Universität Ulm, 2013

Web link:

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

Web link:


Unlabelled: 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

Web link:

Disordered eating and gender identity disorder: a qualitative study

The association between disordered eating and gender identity was examined in a sample of 20 (11 female-to-male, 9 male-to-female) transgender Finnish adults, aged 21–62 years. Using semi-structured interviews, participants’ own understanding of the underlying causes of their disordered eating was analyzed, as well as the effect of gender reassignment on eating behaviors and cognitions. A majority of the participants reported current or past disordered eating. Participants most frequently described strive for thinness as an attempt to suppress features of one’s biological gender, or accentuate features of one’s desired gender. Gender reassignment was primarily perceived as alleviating symptoms of disordered eating.

Author/-s:       M. Ålgars; K. Alanko; P. Santtila; N. K. Sandnabba

Publication:     Eating disorders, 2012

Web link:

Quality of life and sexual health after sex reassignment surgery in transsexual men

Introduction: Although sexual health after genital surgery is an important outcome factor for many transsexual persons, little attention has been attributed to this subject.

Aims: To provide data on quality of life and sexual health after sex reassignment surgery (SRS) in transsexual men.

Methods: A single-center, cross-sectional study in 49 transsexual men (mean age 37 years) after long-term testosterone therapy and on average 8 years after SRS. Ninety-four percent of the participants had phalloplasty.

Main outcome measures: Self-reported physical and mental health using the Dutch version of the Short Form-36 Health Survey; sexual functioning before and after SRS using a newly constructed specific questionnaire.

Results: Compared with a Dutch reference population of community-dwelling men, transsexual men scored well on self-perceived physical and mental health. The majority reported having been sexually active before hormone treatment, with more than a quarter having been vaginally penetrated frequently before starting hormone therapy. There was a tendency toward less vaginal involvement during hormone therapy and before SRS. Most participants reported an increase in frequency of masturbation, sexual arousal, and ability to achieve orgasm after testosterone treatment and SRS. Almost all participants were able to achieve orgasm during masturbation and sexual intercourse, and the majority reported a change in orgasmic feelings toward a more powerful and shorter orgasm. Surgical satisfaction was high, despite a relatively high complication rate.

Conclusion: Results of the current study indicate transsexual men generally have a good quality of life and experience satisfactory sexual function after SRS.

Author/-s:       Katrien Wierckx; Eva van Caenegem; Els Elaut; David Dedecker; Fleur van de Peer; Kaatje Toye; Steven Weyers; Piet Hoebeke; Stan Monstrey; Griet de Cuypere; Guy T’Sjoen

Publication:     The journal of sexual medicine, 2011

Web link:

Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.

Introduction: There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue.

Aim: To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence.

Methods: Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures.  Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires.

Results: Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23 %).

Conclusions: Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.

Author/-s:       M. L. Djordjevic; D. S. Stanojevic; M. R. Bizic

Publication:     The journal of sexual medicine, 2011

Web link:

Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared.

The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.

Author/-s:       Veronica Pimenoff; Friedemann Pfäfflin

Publication:     International Journal of Transgenderism, 2011

Web link:

See also Veronica Pimenoff’s doctoral thesis at:

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

Web link:

A Five-Year Follow-Up Study of Swedish Adults with Gender Identity Disorder

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69 %) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At follow-up, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years), and non-homosexually oriented (56 vs. 15%). In conclusion, almost all patients were satisfied with the sex reassignment; 86% were assessed by clinicians at follow-up as stable or improved in global functioning.

Author/-s:       Annika Johansson; Elisabet Sundbom; Torvald Höjerback; Owe Bodlund

Publication:     Archives of Sexual Behavior, 2010

Web link:

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

Web link:

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.

Komplikationen, subjektive Zufriedenheit und sexuelles Erleben nach geschlechtsangleichender Operation bei Mann-zu-Frau-Transsexualität

Original: Es liegen nur wenige aktuelle Forschungsergebnisse zu geschlechtsangleichenden Operationen vom Mann zur Frau vor. In der vorliegenden Studie wird das Ziel verfolgt, Komplikationen, subjektive Zufriedenheit und Sexualleben nach der Operation zu untersuchen. Hierzu wurden retrospektiv die Akten von 106 operierten Mann-zu-Frau-Transsexuellen ausgewertet. 52 Patientinnen füllten darüber hinaus einen Katamnesebogen mit Fragen zu unterschiedlichen Aspekten der Geschlechtsangleichung aus. Wundheilungsstörungen und Meatusstenosen sind die häufigsten leichten Komplikationen. Bei etwa 20 % der operierten Personen treten schwerere Komplikationen auf. Etwa 80  % der Patientinnen sind mit ihrer Lebenssituation nach der Operation zufrieden, mehr als 90  % mit dem Ergebnis der Operation. Hingegen sind nur 60  % der Patientinnen mit ihrem Sexualleben nach der Operation zufrieden. Etwa 75 % nehmen sexuelle Kontakte auf, eine Orgasmusfähigkeit ist bei 89  % gegeben.

Excerpt: […] About 80 % of MtF patients are satisfied with their life after surgery, more than 90 % are satisfied with the surgery. Only about 60 % of patients are satisfied with their sex life after surgery. About 75 % have sexual contacts, 89 % have the ability to orgasm.

Author/-s:       Hagen Löwenberg; Hildegard Lax; Roberto Rossi Neto; Susanne Krege

Publication:     Zeitschrift für Sexualforschung, 2010

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Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery

Objectives: To determine the self-reported quality of life of male-to-female (MTF) transgendered individuals and how this quality of life is influenced by facial feminization and gender reassignment surgery.

Methods: Facial Feminization Surgery outcomes evaluation survey and the SF-36v2 quality of life survey were administered to male-to-female transgender individuals via the Internet and on paper. A total of 247 MTF participants were enrolled in the study.

Results: Mental health-related quality of life was statistically diminished (P < 0.05) in transgendered women without surgical intervention compared to the general female population and transwomen who had gender reassignment surgery (GRS), facial feminization surgery (FFS), or both. There was no statistically significant difference in the mental health-related quality of life among transgendered women who had GRS, FFS, or both. Participants who had FFS scored statistically higher (P < 0.01) than those who did not in the FFS outcomes evaluation.

Conclusions: Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

Author/-s:       Tiffiny A. Ainsworth; Jeffrey H. Spiegel

Publication:     Quality of Life Research, 2010

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Study of quality of life for transsexuals after hormonal and surgical reassignment

Aim: The main objective of this work is to provide a more detailed assessment of the impact of surgical reassignment on the most important aspects of daily life for these patients. Our secondary objective was to establish the influence of various factors likely to have an impact on the quality of life (QoL), such as biological gender and the subject's personality.

Methods: A personality study was conducted using Eysenck Personality Inventory (EPI) so as to analyze two aspects of the personality (extraversion and neuroticism). Thirty-eight subjects who had undergone hormonal surgical reassignment were included in the study.

Results: The results show that gender reassignment surgery improves the QoL for transsexuals in several different important areas: most are satisfied of their sexual reassignment (28/30), their social (21/30) and sexual QoL (25/30) are improved. However, there are differences between male-to-female (MtF) and female-to-male (FtM) transsexuals in terms of QoL: FtM have a better social, professional, friendly lifestyles than MtF. Finally, the results of this study did not evidence any influence by certain aspects of the personality, such as extraversion and neuroticism, on the QoL for reassigned subjects.

Author/-s:       N. Parola; M. Bonierbale; A. Lemaire; V. Aghababian; A. Michel; C. Lançon

Publication:     Sexologies, 2010

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A report from a single institute’s 14-year experience in treatment of male-to-female transsexuals

Introduction: Gender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion. AIM: The aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS.

Methods: From January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire.

Main outcome measures: The questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction.

Results: Average age was 31 years old. Seventy-two percent had a high educational level, and 63 % were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4 % had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina's esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets.

Conclusions: Our patients' high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up.

Author/-s:       Ciro Imbimbo; Paolo Verze; Alessandro Palmieri; Nicola Longo; Ferdinando Fusco; Davide Arcaniolo; Vincenzo Mirone

Publication:     The Journal of Sexual Medicine, 2009

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Gay and bisexual identity development among female-to-male transsexuals in North America: emergence of a transgender sexuality.

We studied a North American sample of female-to-male (FtM) transsexuals sexually attracted to men, aiming to understand their identity and sexuality in the context of a culture of transgender empowerment. Sex-reassigned FtM transsexuals, 18 years or older and attracted to men, were recruited via an FtM community conference and listserv. Participants (N = 25) responded to open-ended questions about identity development, sexual behavior, and social support. Data were analyzed by content analysis. Scores for sexual identity, self esteem, sexual functioning, and psychological adjustment were compared to those of a comparison group (N = 76 nontransgender gay and bisexual men). Of the 25 FtMs, 15 (60%) identified as gay, 8 (32%) as bisexual, and 2 (8%) as queer. All were comfortable with their gender identity and sexual orientation. The FtM group was more bisexual than the nontransgender gay and bisexual controls. No significant group differences were found in self esteem, sexual satisfaction, or psychological adjustment. For some FtMs, sexual attractions and experiences with men affirmed their gender identity; for others, self-acceptance of a transgender identity facilitated actualization of their attractions toward men. Most were "out" as transgender among friends and family, but not on the job or within the gay community. Disclosure and acceptance of their homosexuality was limited. The sexual identity of gay and bisexual FtMs appears to mirror the developmental process for nontransgender homosexual men and women in several ways; however, participants also had experiences unique to being both transgender and gay/bisexual. This signals the emergence of a transgender sexuality.

Author/-s:       W. Bockting; A. Benner; E. Coleman

Publication:     Archives of sexual behaviour, 2009

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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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Evaluation of surgical procedures for sex reassignment: a systematic review

Objectives: To evaluate earlier reviews and literature concerning five individual surgical procedures for male-to-female (MTF) transsexism: clitoroplasty, labiaplasty, orchidectomy, penectomy and vaginoplasty. Further evaluations were made of eight surgical procedures for female-to-male (FTM) transsexism: hysterectomy, mastectomy, metoidoplasty, phalloplasty, salpingo-oophorectomy, scrotoplasty/placement of testicular prostheses, urethroplasty and vaginectomy.

Background: Increased prevalence and advances in surgical options available to patients requesting gender reassignment surgery have made this an important consideration for research. There remains a lack of systematic reviewing of the evidence, in particular, of the individual surgical options available.

Methods: Searches were undertaken in six electronic databases (Applied Social Sciences Index and Abstracts [ASSIA], Cochrane Library [Wiley Online], Embase [Ovid Online], Medline [Ovid Online], Medline in Process [Ovid Online], Psycinfo) providing coverage of the biomedical, grey literature and current research.

Results: Eighty-two published papers (38 MTF; 44 FTM) met the inclusion criteria identified across the 13 surgical procedures. For MTF transsexism there was no evidence satisfying the inclusion criteria concerning labiaplasty, penectomy or orchidectomy procedures. A large amount of evidence was available concerning vaginoplasty and clitoroplasty procedures. For FTM transsexism satisfactory outcomes were reported. Outcomes related to the ability to perform sexual intercourse, achieve orgasm and void whilst standing. Some complications were reported for both MTF and FTM procedures.

Conclusions: The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence.

Author/-s:       P. A. Sutcliffe; S. Dixon; R. L. Akehurst; A. Wilkinson; A. Shippam; S. White; R. Richards; C. M. Caddy

Publication:     Journal of plastic, reconstructive & aesthetic surgery, 2009

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Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks

Introduction: Greater acceptance of sexual minorities has enabled people with transsexualism access to adequate treatment and social integration. Gender reassignment surgery is a complex phase in the care of transsexual patients. In response to a greater volume of patients, surgical techniques have evolved and the outcome in patients with male-to-female transsexualism is now a very accurate imitation of female genitalia, enabling sexual intercourse with orgasm.

Aim: To evaluate the results of surgical reassignment of genitalia in male-to-female transsexuals.

Methods: A retrospective 3-month follow-up study of patients’ opinions following gender reassignment surgery in 129 patients having a primary procedure (eight of whom had later sigmoideocolpoplasty) and five patients undergoing reoperation following an initial unsuccessful procedure at other units. All patients were male transsexuals. The surgical techniques are described in detail.

Main outcome measures: Sexual functions and complications 3 months after surgery.

Results: All patients were satisfied with the first phase operation. Thirteen patients (9.7%) underwent successful sigmoideocolpoplasty. Main complications were as follows: rectal lesions developing during preparation of the vaginal canal (1.5%); bleeding from the stump of the shortened urethra in the first 48 hours postoperatively requiring secondary suturing (4.5%); temporary urinary retention requiring repeated insertion of urinary catheters for up to 6 days (5.2%); and healing of the suture between the perineum and the posterior aspect of the vaginal introitus healing by secondary intention (5.2%). The neoclitoris had erogenous sensitivity in 93.9% of patients and 65.3% reached orgasm in the first 3 months.

Conclusions: Surgical conversion of the genitalia is a safe and important phase of the treatment of male-to-female transsexuals.

Author/-s:       Ladislav Jarolím; Jiří Sedý; Marek Schmidt; Ondřej Nanka; René Foltán; IvanKawaciuk

Publication:     The Journal of Sexual Medicine, 2009

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Long-term assessment of the physical, mental, and sexual health among transsexual women

Introduction: Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking.

Aim: To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS.

Methods: Fifty transsexual women who had undergone SRS > or = 6 months earlier were recruited.

Main outcome measures: Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored.

Results: Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals.

Conclusions: Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.

Author/-s:       Steven Weyers; Els Elaut; Petra de Sutter; Jan Gerris; Guy T’Sjoen; Gunter Heylens; Griet de Cuypere; Hans Verstraelen

Publication:     The Journal of Sexual Medicine, 2009

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Male-to-female transsexualism. Sex reassignment surgery from a biopsychosocial perspective.

Many man-to-female-transsexuals prefer sex reassignment surgery. Surgical complications are common, most frequently a stenosis of the vagina as well as the urethral ostium. In up to 24 % of patients secondary corrective surgery is necessary. Regret and feelings of doubt can occur in up to 8 % of the cases. In the setting of an interdisciplinary team the postoperative somatic, psychological and socio-economic situation can be improved. This review is based on a Medline literature search and summarizes the pertinent literature of the last 22 years.

Author/-s:       Andreas Baranyi; Dominique Piber; Hans-Bernd Rothenhäusler

Publication:     Wiener Medizinische Wochenschrift, 2009

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Sexual functioning in transsexuals following hormone therapy and genital surgery: a review

Introduction: Sexual function following genital sexual reassignment surgery (SRS) is an important outcome for many transsexuals, affecting the choice of surgical technique, satisfaction with surgery, and quality of life. However, compared to other outcome measures, little clinical and research attention has been given to sexual functioning following SRS.

Aim: To discuss the potential impact of cross-sex hormone therapy and SRS on sexual function and to summarize the published empirical research on postsurgical sexual functioning in male-to-female (MtF) and female-to-male (FtM) transsexuals.

Methods: Cross-sex hormone therapy and SRS techniques are outlined, the potential roles of cross-sex hormone therapy and SRS on sexual function are discussed, and peer-reviewed literature published in English on postoperative sexual functioning in MtF and FtM transsexuals is reviewed.

Main outcome measures: Sexual desire, sexual arousal, and ability to achieve orgasm following SRS.

Results: Contrary to early views, transsexualism does not appear to be associated with a hyposexual condition. In MtF transsexuals, rates of hypoactive sexual desire disorder (HSDD) are similar to those found in the general female population. In FtM transsexuals, sexual desire appears unequivocally to increase following SRS. Studies with MtF transsexuals have revealed not only vasocongestion, but also the secretion of fluid during sexual arousal. Research on sexual arousal in FtM transsexuals is sorely lacking, but at least one study indicates increased arousal following SRS. The most substantial literature on sexual functioning in postoperative transsexuals pertains to orgasm, with most reports indicating moderate to high rates of orgasmic functioning in both MtF and FtM transsexuals.

Conclusions: Based on the available literature, transsexuals appear to have adequate sexual functioning and/or high rates of sexual satisfaction following SRS. Further research is required to understand fully the effects of varying types and dosages of cross-sex hormone therapies and particular SRS techniques on sexual functioning.

Author/-s:       C. Klein; B. B. Gorzalka

Publication:     The Journal of Sexual Medicine, 2009

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Transsexualism in Serbia: a twenty-year follow-up study

Introduction: Gender dysphoria occurs in all societies and cultures. The prevailing social context has a strong impact on its manifestations as well as on applications by individuals with the condition for sex reassignment treatment.

Aim: To describe a transsexual population seeking sex reassignment treatment in Serbia, part of former Yugoslavia.

Methods: Data, collated over a period of 20 years, from subjects applying for sex reassignment to the only center in Serbia, were analyzed retrospectively.

Main outcome measures: Age at the time of application, demographic data, family background, sex ratio, the prevalence of polycystic ovarian syndrome (PCOS) among female-to-male (FTM) transsexuals, and readiness to undergo surgical sex reassignment were tabulated.

Results: Applicants for sex reassignment in Serbia are relatively young. The sex ratio is close to 1:1. They often come from single-child families. More than 10 % do not wish to undergo surgical sex reassignment. The prevalence of PCOS among FTM transsexuals was higher than in the general population but considerably lower than that reported in the literature from other populations. Of those who had undergone sex reassignment, none expressed regret for their decision.

Conclusions: Although transsexualism is a universal phenomenon, the relatively young age of those applying for sex reassignment and the sex ratio of 1:1 distinguish the population in Serbia from others reported in the literature.

Author/-s:       Svetlana Vujović; P. Popovic; G. Sbutega-Milosevic; M. Djordjevic; Louis J. G. Gooren

Publication:     The journal of sexual medicine, 2009

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Body Image and Transsexualism

Background: To achieve a detailed view of the body image of transsexual patients, an assessment of perception, attitudes and experiences about one's own body is necessary. To date, research on the body image of transsexual patients has mostly covered body dissatisfaction with respect to body perception.

Sampling and methods: We investigated 23 preoperative (16 male-to-female and 7 female-to-male transsexual patients) and 22 postoperative (14 male-to-female and 8 female-to-male) transsexual patients using a validated psychological measure for body image variables.

Results: We found that preoperative transsexual patients were insecure and felt unattractive because of concerns about their body image. However, postoperative transsexual patients scored high on attractiveness and self-confidence. Furthermore, postoperative transsexual patients showed low scores for insecurity and concerns about their body.

Conclusions: Our results indicate an improvement of body image concerns for transsexual patients following standards of care for gender identity disorder. Follow-up studies are recommended to confirm the assumed positive outcome of standards of care on body image.

Author/-s:       Bernd Kraemer; Aba Delsignore; Ulrich Schnyder; Urs Hepp

Publication:     Psychopathology, 2008

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Transsexuality: living in a wrong body?

Transsexuality is a permanent feeling of uneasiness and non-affiliation to the gender in which a person was born, accompanied with a permanent striving to live and be accepted as a person of the opposite gender. The dysfunction appears in childhood and adult age. There is at least one transsexual male in 30,000 adult men and one transsexual female in 100,000 adult women. The aetiology of the dysfunction is still not elucidated, although there are hints connecting transsexuality with a non-standard hormonal activity in prenatal and short perinatal phase of development, which determines an erroneous sexual organization of the brain. Transsexuals differ with respect to biological gender and gender identity (male-to-female, female-to-male) as well as with respect to sexual orientation (homosexual and non-homosexual). For the majority of operated transsexuals the change of gender is a process which improves the quality of life and psychological health. Offering help to transsexuals is an exceptionally difficult task which demands cooperation of a mental health professional (psychiatrist, psychologist), endocrinologist and a surgeon.

Author/-s:       N. Jokić-Begić; A. B. Cikes; T. Jurin; E. Lucev; D. Markanović; S. Rucević

Publication:     Lijec̆nic̆ki vjesnik, 2008

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Feminizing genitoplasty in adult transsexuals: early and long-term surgical results

Objective: To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period.

Patients and methods: Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction.

Results: In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations.

Conclusion: This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.

Author/-s:       Jonathan C. Goddard; Richard M. Vickery; Assad Qureshi; Duncan J. Summerton; Deenesh Khoosal; Tim R. Terry

Publication:     BJU international, 2007

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Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges

In 1990 Green and Fleming concluded that sex reassignment surgery (SRS) is an effective treatment for transsexuality because it reduced gender dysphoria drastically. Since 1990, many new outcome studies have been published, raising the question as to whether the conclusion of Green and Fleming still holds. After describing terminological and conceptual developments related to the treatment of gender identity disorder (GID), follow-up studies, including both adults and adolescents, of the outcomes of SRS are reviewed. Special attention is paid to the effects of SRS on gender dysphoria, sexuality, and regret. Despite methodological shortcomings of many of the studies, we conclude that SRS is an effective treatment for transsexualism and the only treatment that has been evaluated empirically with large clinical case series.

Author/-s:       Luk Gijs; Anne Brewaeys

Publication:     Annual Review of Sex Research, 2007

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Follow-up of sex reassignment surgery in transsexuals: A Brazilian cohort

This study examined the impact of sex reassignment surgery on the satisfaction with sexual experience, partnerships, and relationship with family members in a cohort of Brazilian transsexual patients. A group of 19 patients who received sex reassignment between 2000 and 2004 (18 male-to-female, 1 female-to-male) after a two-year evaluation by a multidisciplinary team, and who agreed to participate in the study, completed a written questionnaire. Mean age at entry into the program was 31.21±8.57 years and mean schooling was 9.2±1.4 years. None of the patients reported regret for having undergone the surgery. Sexual experience was considered to have improved by 83.3% of the patients, and became more frequent for 64.7% of the patients. For 83.3% of the patients, sex was considered to be pleasurable with the neovagina/neopenis. In addition, 64.7% reported that initiating and maintaining a relationship had become easier. The number of patients with a partner increased from 52.6% to 73.7%. Family relationships improved in 26.3% of the cases, whereas 73.7% of the patients did not report a difference. None of the patients reported worse relationships with family members after sex reassignment. In conclusion, the overall impact of sex reassignment surgery on this cohort of patients was positive.

Author/-s:       Maria Inês Inês Lobato; Walter José Koff; Carlo Manenti; Débora da Fonseca Seger; Jaqueline Salvador; Maria da Graça Borges Fortes; Analídia Rodolpho Petry; Esalba Silveira; Alexandre Annes Henriques

Publication:     Archives of sexual behaviour, 2006

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Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery

Background: To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed.

Aims: The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure.

Method: From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment.

Results: On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors.

Conclusion: While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Author/-s:       Griet de Cuypere; Els Elaut; Gunter Heylens; G. van Maele; G. Selvaggi; G. T’Sjoen; R. Rubens; P. Hoebeke; S. Monstrey

Publication:     Sexologies, 2006

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This study found a reduction in the rate of suicide attempts from 29.3 % pre-treatment to 5.1 % post-treatment.

Postoperative Ergebnisse bei Transsexualität unter besonderer Berücksichtigung der Zufriedenheit – eine Nachuntersuchung

Excerpt: The degree of satisfaction was generally very high (above 90 %).

Original: Die Untersuchung beschäftigt sich mit der Zufriedenheit von transsexuellen Patienten, die geschlechtsangleichend operiert wurden (N=56; davon 33 Mann-zu-Frau-Transsexuelle und 23 Frau-zu-Mann-Transsexuelle). Hierzu wurde eine follow-up Befragung von sämtlichen Patienten (N=139) durchgeführt, die in der Klinik für Psychosomatische Medizin und Psychotherapie Essen zwischen 1989 und 2001 im Rahmen des TSG zur Vornamensänderung begutachtet worden waren. Untersuchungsinstrument war ein dafür eigens entwickelter Fragebogen. Der Rücklauf betrug 48,2 %. Die Stichprobe stellte (bezüglich des Bildungsniveaus, der beruflichen Ausbildung, der beruflichen Integration und hinsichtlich des Begutachtungsergebnisses) eine „Positiv-Auswahl“ dar. Neben der Zufriedenheit mit dem Geschlechtsrollenwechsel insgesamt wurden die Zufriedenheit mit der Psychotherapie, dem operativen Ergebnis, der Akzeptanz durch die Umgebung, der beruflichen sowie der partnerschaftlichen Entwicklung und dem sexuellen Erleben in einem fünfstufigen Bewertungssystem erfasst. Das Ausmaß der Zufriedenheit war generell sehr hoch (über 90 %). Gewisse Polarisierungen konnten für die berufliche sowie die partnerschaftliche Entwicklung herausgearbeitet werden. Von großer Bedeutung für die Gesamtzufriedenheit sind Verfahrensablauf, psychotherapeutische Begleitung, in gewissem Umfang partnerschaftliche Entwicklung und vor allem sexuelles Erleben. Von untergeordneter Bedeutung für die Zufriedenheit mit dem Geschlechtsrollenwechsel sind hingegen die Akzeptanz durch die Umgebung, die Zufriedenheit mit der beruflichen Entwicklung sowie das operative Ergebnis. Je länger die Begutachtung zur Vornamensänderung zurücklag, umso geringer war die Zufriedenheit mit dem Geschlechtsrollenwechsel. Frau-zu-Mann-Transsexuelle waren sozial besser integriert und akzeptiert. Der Grad der Erwerbstätigkeit aber auch die Häufigkeit partnerschaftlicher Beziehungen nahm bei beiden Geschlechtern im Verlauf deutlich zu. Bei beiden Geschlechtern dominierten längerfristige und dauerhafte Paarbeziehungen, was früheren Untersuchungen widerspricht, die für Mann-zu-Frau-Transsexuelle instabilere Beziehungsmuster annahmen. Die vorliegenden Ergebnisse belegen eindrucksvoll, dass das Richtlinienverfahren weitgehend angewandt wird und in seiner Mehrstufigkeit sinnvoll ist. Klarheit und Transparenz des Verfahrens erscheinen notwendig. Für den Gesamtverlauf ist eine aus Sicht der Betroffenen hilfreiche psychotherapeutische Begleitung bzw. Behandlung von großer Bedeutung und sollte mindestens bis zur geschlechtsangleichenden Operation erfolgen. Da sich viele Veränderungen im psychosozialen Bereich oftmals erst postoperativ entwickeln, erscheint das Angebot weiterer psychotherapeutischer Interventionen indiziert. Die hohe Bedeutung, die das sexuelle Erleben für die Betroffenen hat, sollte entsprechende Berücksichtigung finden sowohl bei Überlegungen zum operativen Vorgehen als auch bei psychotherapeutischen Fragestellungen.

Author/-s:       Friederike Johanne Happich

Publication:     Inaugural-Dissertation, Medizinische Fakultät, Universität Essen-Duisburg, 2006

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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 appropiated 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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Transsexuals’ life satisfaction after gender transformation operations

Background: More and more frequently, the registration of life satisfaction is being used to evaluate different medical treatments. So far, there have been only few such surveys on transsexuals (TS). Therefore, the aim of this study was to evaluate the general and the health-related life satisfaction of transsexuals after gender transformation operations.

Patients and methods: Forty patients took part in this German cross-sectional study. The Questions on Life Satisfaction Module (FLZ) and free questions on different aspects of the new gender identity were used as measuring instruments.

Results: Of the TS studied, 85–95 % were "very satisfied" or "satisfied" with the results of their gender transformation operation in respect to gender identity. The TS were significantly less satisfied (P > 0.001) in overall "general life satisfaction" than the general population. In overall FLZ scores for "health-related life satisfaction", no differences were seen.

Conclusion: These data indicate a discrepancy between subjective satisfaction with new gender identity and current life situation, and they identify problems with life satisfaction.

Author/-s:       A. Zimmermann; R. Zimmer; L. Kovacs; S. Einödshofer; P. Herschbach; G. Henrich; W. Tunner; E. Biemer; N. A. Papadopulos

Publication:     Der Chirurg, 2006

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Sexual and physical health after sex reassignment surgery

A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male) post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome. Relatively few and minor morbidities were observed in our group of patients, and they were mostly reversible with appropriate treatment. A trend toward more general health problems in male-to-females was seen, possibly explained by older age and smoking habits. Although all male-to-females, treated with estrogens continuously, had total testosterone levels within the normal female range because of estrogen effects on sex hormone binding globulin, only 32.1 % reached normal free testosterone levels. After SRS, the transsexual person's expectations were met at an emotional and social level, but less so at the physical and sexual level even though a large number of transsexuals (80 %) reported improvement of their sexuality. The female-to-males masturbated significantly more frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement, and more easily reaching orgasm was seen in the female-to-male group. The majority of participants reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported the secretion of a vaginal fluid during sexual excitation, originating from the Cowper's glands, left in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more realized (compared to those without), but pain during intercourse was more often reported.

Author/-s:       Griet de Cuypere; Guy T’Sjoen; R. Beerten, G. Selvaggi; P. de Sutter; P. Hoebeke; S. Monstrey; A. Vansteenwegen; R. Rubens

Publication:     Archives of sexual behaviour, 2005

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Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals

Background: We prospectively studied outcomes of sex reassignment, potential differences between subgroups of transsexuals, and predictors of treatment course and outcome.

Method: Altogether 325 consecutive adolescent and adult applicants for sex reassignment participated: 222 started hormone treatment, 103 did not; 188 completed and 34 dropped out of treatment. Only data of the 162 adults were used to evaluate treatment. Results between subgroups were compared to determine post-operative differences. Adults and adolescents were included to study predictors of treatment course and outcome. Results were statistically analysed with logistic regression and multiple linear regression analyses.

Results: After treatment the group was no longer gender dysphoric. The vast majority functioned quite well psychologically, socially and sexually. Two non-homosexual male-to-female transsexuals expressed regrets. Post-operatively, female-to-male and homosexual transsexuals functioned better in many respects than male-to-female and non-homosexual transsexuals. Eligibility for treatment was largely based upon gender dysphoria, psychological stability, and physical appearance. Male-to-female transsexuals with more psychopathology and cross-gender symptoms in childhood, yet less gender dysphoria at application, were more likely to drop out prematurely. Non-homosexual applicants with much psychopathology and body dissatisfaction reported the worst post-operative outcomes.

Conclusions: The results substantiate previous conclusions that sex reassignment is effective. Still, clinicians need to be alert for non-homosexual male-to-females with unfavourable psychological functioning and physical appearance and inconsistent gender dysphoria reports, as these are risk factors for dropping out and poor post-operative results. If they are considered eligible, they may require additional therapeutic guidance during or even after treatment.

Author/-s:       Yolanda Louise Susanne Smith; Stephanie H. M. van Goozen; Abraham J. Kuiper; Peggy T. Cohen-Kettenis

Publication:     Psychological Medicine, 2005

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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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Factors Associated with Satisfaction or Regret Following Male-to-Female Sex Reassignment Surgery

This study examined factors associated with satisfaction or regret following sex reassignment surgery (SRS) in 232 male-to-female transsexuals operated on between 1994 and 2000 by one surgeon using a consistent technique. Participants, all of whom were at least 1-year postoperative, completed a written questionnaire concerning their experiences and attitudes. Participants reported overwhelmingly that they were happy with their SRS results and that SRS had greatly improved the quality of their lives. None reported outright regret and only a few expressed even occasional regret. Dissatisfaction was most strongly associated with unsatisfactory physical and functional results of surgery. Most indicators of transsexual typology, such as age at surgery, previous marriage or parenthood, and sexual orientation, were not significantly associated with subjective outcomes. Compliance with minimum eligibility requirements for SRS specified by the Harry Benjamin International Gender Dysphoria Association was not associated with more favorable subjective outcomes. The physical results of SRS may be more important than preoperative factors such as transsexual typology or compliance with established treatment regimens in predicting postoperative satisfaction or regret.

Author/-s:       Anne A. Lawrence

Publication:     Archives of Sexual Behavior, 2003

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Patient Satisfaction with Sex Re-assignment Surgery in New South Wales, Australia

An evaluation of the effect of sex re-assignment surgery on a group of patients attending a private clinic in Sydney, Australia. Fifty-seven patients who underwent full male-to-female sex re-assignment surgery between 1987 and 2000 completed a satisfaction survey. Several factors that might influence the extent of satisfaction with surgical outcome were explored, including age, work status, social life, and the appearance and function of the new genitalia. Patients reported significantly improved social and personal satisfaction following surgery, compared with five years previously. The study challenges outcomes from previously reported studies with regard to the age of patients at the time of surgery, and the finding that from the patient's perspective, there is no fundamental association between a successful surgical outcome and a satisfactory post-operative life experience.

Author/-s:       Fran Collyer; Catherine Heal

Publication:     Australian Journal of Primary Health, 2002

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Postoperative Psychological Functioning of Adolescent Transsexuals: A Rorschach Study

The Rorschach Comprehensive System was used to assess postoperative psychological functioning in transsexuals who applied for sex reassignment in adolescence. We investigated a group of 22 consecutive adolescent transsexuals, who were otherwise psychologically well adapted. Nineteen subjects provided valid Rorschach protocols before and after sex reassignment. The most notable change found was an increase in X + %, reflecting a decrease in both distorted perception and idiosyncratic perception. Little support was found for the idea of major psychological deterioration for the patients as a group. Rather, the results suggest stability in psychological functioning over time. The Rorschach findings are consistent with questionnaire data from earlier studies, with the exception that the Rorschach data may point to some improvement in reality testing.

Author/-s:       Yolanda Louise Susanne Smith; Leo Cohen; Peggy T. Cohen-Kettenis

Publication:     Archives of Sexual Behavior, 2002

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Predictors and Outcomes of Treatment for Transsexuals

Prospective research supports the therapeutic effect of sex reassignment (SR) for adolescent and adult transsexuals. Data were used from 345 patients who applied for SR. Of these applicants, 232 started hormone treatment, 113 did not. The group who completed SR consisted of 196 transsexuals. Follow-up data were gathered one to five years after SR. The results of 171 treated adult transsexuals showed improvement in many areas of functioning after SR. The main symptom for which the patients had requested treatment, gender dysphoria, had disappeared after treatment, which is the primary goal of SR. Improvement was also found in satisfaction of the patients with their sex characteristics. In addition, according to observers, the appearance of the transsexuals better matched that of the desired new gender after treatment. Psychological functioning of the group had also improved after SR. Most of the transsexuals also functioned well socially, sexually, and in the new gender role. Above all, the vast majority of the group expressed no feelings of regret about their SR. However, a few individuals expressed reservations about the beneficial effects of treatment at follow-up. In particular, one male-to-female expressed strong regret and another some feelings of regret, during and after treatment. Both assigned these feelings to the adverse reactions from society. By far the least explored and most controversial domain with respect to SR is early (hormone) treatment with adolescent transsexuals. Results of the present study support the decision to refer well-functioning adolescents for early (between 16 to 18 years) hormone treatment, considering the positive outcomes of SR on several areas of postoperative functioning of this group. Within the treated adolescent group the gender dysphoria was absent after SR. The adolescents also appeared to function quite well socially and psychologically, and they were more satisfied with their sex characteristics as well after SR. Not a single adolescent expressed feelings of regret concerning the decision to undergo SR. Other findings from this thesis led us to conclude that the distinction between subtypes of transsexuals is theoretically and clinically meaningful. The differences that were found between homosexual and nonhomosexual transsexuals suggest different developmental routes for each of these subtypes. The road along which the nonhomosexual subtype evolves the gender identity conflict is most likely to be accompanied with more obstacles. Taking into account that the nonhomosexuals were found to be psychologically more vulnerable than the homosexuals, especially before treatment, they may require additional guidance during treatment. Finally, we investigated which factors at assessment could predict the course and outcomes of SR. Eligibility for SR was largely based upon the factors gender dysphoria, psychological stability, and physical appearance. Transsexuals with a nonhomosexual preference, psychological instability, and strong dissatisfaction about their appearance, at assessment, are more at risk for worse postoperative functioning and more dissatisfaction after treatment. To conclude, the current study substantiates findings from previous, mainly retrospective, studies, that SR is indeed effective. However, alleviation of the gender identity problem is not equivalent with an easy life. Yet, for most of the transsexuals who participated in this study, the strict eligibility criteria and the standard professional guidance as currently provided, appears to be sufficient to help resolve their gender identity conflict.

Author/-s:       Yolanda Louise Susanne Smith

Publication:     Dissertation, Universiteit Utrecht, 2002

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The transsexual: what about the future?

Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1 % of regrets, and a little more than 1 % of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.

Author/-s:       A. Michel; M. Ansseau; J. J. Legros; W. Pitchot; C. Mormont

Publication:     European Psychiatry, 2002

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Adolescents with Gender Identity Disorder Who Were Accepted or Rejected for Sex Reassignment Surgery: A Prospective Follow-up Study

Objective: To conduct a prospective follow-up study with 20 treated adolescent transsexuals to evaluate early sex reassignment, and with 21 nontreated and 6 delayed-treatment adolescents to evaluate the decisions not to allow them to start sex reassignment at all or at an early age.

Method: Subjects were tested on their psychological, social, and sexual functioning. Follow-up interviews were conducted from March 1995 until July 1999. Treated patients had undergone surgery 1 to 4 years before follow-up; nontreated patients were tested 1 to 7 years after application. Within the treated and the nontreated group, pre-and posttreatment data were compared. Results between the groups were also compared.

Results: Postoperatively the treated group was no longer gender-dysphoric and was psychologically and socially functioning quite well. Nobody expressed regrets concerning the decision to undergo sex reassignment. Without sex reassignment, the nontreated group showed some improvement, but they also showed a more dysfunctional psychological profile.

Conclusions: Careful diagnosis and strict criteria are necessary and sufficient to justify hormone treatment in adolescent transsexuals. Even though some of the nontreated patients may actually have gender identity disorder, the high levels of psychopathology found in this group justify the decision to not start hormone treatment too soon or too easily.

Author/-s:       Yolanda Louise Susanne Smith; Stephanie H. M. van Goozen; Peggy T. Cohen-Kettenis

Publication:     Journal of the American Academy of Child & Adolescent Psychiatry, 2001

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Done is done – and gone is gone. Sex reassignment is presently the best cure for transsexuals

Sweden was the first country to legislate on sex reassignment procedures in 1972. Patients with gender dysphoria are in Sweden referred to one of six university clinics specialised in the field; all surgery, however, is centralised to the Karolinska Hospital in Stockholm. The aetiological strivings regarding transsexualism have to date been inconclusive; however, several lines of evidence speak in favour of an early biological influence on gender identity. The vast majority of studies addressing outcome have provided convincing evidence for the benefit of sex reassignment surgery in carefully selected cases. The current article summarises the state of the art regarding work-up and treatment of transsexuals.

Author/-s:       Mikael Landén; Owe Bodlund; L. Ekselius; G. Hambert; B. Lundström

Publication:     Lakartidningen, 2001

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Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients

Objective: To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results.

Patients and methods: From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds.

Results: Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse.

Conclusion: Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Author/-s:       S. Krege; A. Bex; G. Lümmen; H. Rübben

Publication:     BJU International, 2001

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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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The case for publicly funded transsexual surgery


  • Transsexualism is recognized as a psychiatric disorder by the American Psychiatric Association and by the World Health Organization.

  • Sex reassignment surgery is the treatment of last resort for transsexuals who cannot achieve peace of mind in their original gender role.

  • There is ample evidence that sex reassignment improves transsexuals’ psychosocial adjustment, in particular, their mood and morale.

  • The overwhelming majority of patients express satisfaction with their decision to undergo sex reassignment.

  • The fact that sex reassignment surgery is a palliative treatment rather a cure is not a rationale for withholding it.

  • As an effective treatment for a specific mental disorder, sex reassignment surgery is as deserving of public funding as any other psychiatric treatment.

Author/-s:       Ray Blanchard

Publication:     Psychiatry Rounds, 2000

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New women: Sexological outcomes of male-to-female gender reassignment surgery

This research study investigated sexological outcomes of gender reassignment surgery in 17 postoperative male-to-female transsexuals (new women). Study procedures included self-report questionnaires, a structured interview, a medical history and physical examination with gynecological evaluation (the New Woman's Gynecological Index), and neovaginal blood flow assessment by photoplethysmography. The results of descriptive analysis, correlational analysis, discriminant analysis, and multiple regression analysis identifying predictors of good sexual functioning are presented. Gender reassignment was rated as successful by 94% of the new women. Two-thirds of the new women were orgasmic. The best predictors of orgasmic potential were genital sensitivity and congruence between gender identity and body. The best predictors of sexual satisfaction were the Stress Inventory total score and the genital neurosensory evaluation. The best predictors of overall success of gender reassignmerit were vaginal depth and vulvar cosmesis.

Author/-s:       Maryann Schroder; Richard A. Carroll

Publication:     Journal of Sex Education and Therapy, 1999

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Outcomes of Treatment for Gender Dysphoria

This paper reviews the empirical research on the psychosocial outcomes of treatment for gender dysphoria. Recent research has highlighted the heterogeneity of transgendered experiences. There are four possible outcomes for patients who present with the dilemma of gender dysphoria: an unresolved outcome, acceptance of one's given gender, engaging in a cross-gender role on a part-time basis, and making a full-time transition to the other gender role. Clinical work, but not empirical research, suggests that some individuals with gender dysphoria may come to accept their given gender role through psychological treatment. Many individuals find that it is psychologically sufficient to express the transgendered part of themselves through such activities as cross-dressing or gender blending. The large body of research on the outcome of gender reassignment surgery indicates that, for the majority of those who undergo this process, the outcome is positive. Predictors of a good outcome include good pre-reassignment psychological adjustment, family support, at least l year of living in the desired role, consistent use of hormones, psychological treatment, and good surgical outcomes. The outcome literature provides strong support for adherence to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association. Implications to be drawn from this research include an appreciation of the diversity of transgendered experience, the need for more research on non-reassignment resolutions to gender dysphoria, and the importance of assisting the transgendered individual to identify the resolution that best suits him or her.

Author/-s:       Richard A. Carroll

Publication:     Journal of Sex Education & Therapy, 1999

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Prediction of outcome in transsexualism by means of the Defense Mechanism Test and multivariate modeling: a pilot study.

To elaborate the predictive value of the projective method using the Defense Mechanism Test in a 5-year follow-up study of 16 transsexuals, all subjects were approved for sex reassignment surgery and had completed the baseline assessments and the 5-year follow-up evaluation. Furthermore, we intended to create an outcome model based on the test data for prior patients wherein new consecutive applicants for sex change could be tested to predict the outcome in individual cases. Outcomes after five years showed that 62 % of the transsexuals were judged as improved in a variety of areas of psychosocial functioning, 19 % were unchanged, and 19 % were worsened. Firstly, the analysis of the test data confirmed differences between the improved transsexuals and those who were not. Secondly, sex differences were found, with female-to-male transsexuals having a better outcome and being more homogeneous than their male counterparts. Thirdly, there was good correspondence in prediction of outcome between the model based on the Defense Mechanism Test and a clinical judgment made by a psychiatrist for two new applicants for sex reassignment surgery. It appears the Defense Mechanism Test has a predictive ability for patients with gender-identity disorder.

Author/-s:       Elisabet Sundbom; Owe Bodlund

Publication:     Perceptual and Motor Skills, 1999

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The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (Arnold Melman). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced postoperatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Author/-s:       Jamil Rehman; Simcha Lazer; Alexandru E. Benet; Leah C. Schaefer; Arnold Melman

Publication:     Archives of Sexual Behavior, 1999

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Transsexualism: a review of etiology, diagnosis and treatment

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Author/-s:       Peggy T. Cohen-Kettenis; Louis J. G. Gooren

Publication:     Journal of psychosomatic research, 1999

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Transsexualism. Epidemiology, phenomenology, regret after surgery, aetiology, and public attitudes

Transsexualism denotes a condition in which the gender identity-the personal sense of being a man or a woman-contradicts the bodily sex characteristics. This thesis is based on three independent surveys about transsexualism.

First, all 233 subjects applying for sex reassignment in Sweden during 1972–1992 were retrospectively examined through medical records. The incidence of applying for sex reassignment was 0.17/100 000 individuals over 15 years of age and per year. The male-to-female (M-F)/female-to-male (F-M) ratio was 1.4/1. With the exception of an incidence peak related to the legislation regulating sex reassignment in the early 1970s, the incidence has remained fairly stable since the first estimates in Sweden in the late 1960s. The M-F (n=134) and F-M (n=99) groups were phenomenologically compared. M-F transsexuals were older, and more often had a history of marriage and children than their F-M counterparts. M-F transsexuals also had more heterosexual experience. F-M transsexuals, on the other hand, more frequently reported cross-gender behaviour in childhood than did M-F transsexuals. It is concluded that transsexualism is manifested differently in males and females. The regret frequency (defined as applying for reversal to the original sex) was 3.8 %. Prognostic factors for regret were, 'a poor support from the family', and 'belonging to the secondary group of transsexuals' (denotes people who develop transsexualism only after a significant period of transvestism or homosexuality).

Second, 28 M-F transsexuals and 30 male controls were investigated. To test the hypothesis that genes coding for proteins involved in the sexual differentiation of the brain influence the susceptibility of transsexualism, we analysed (1) a tetra nucleotide polymorphism of the aromatase gene, (2) a CAG repeat sequence in the first exon of the gene coding for the androgen receptor, and (3) a CA repeat polymorphism of the estrogen receptor beta gene. Results support the notion that the gender identity is related to the sex steroid-driven sexual differentiation of the brain, and that certain genetic variants of three of the genes critically involved in this process, may enhance the susceptibility for transsexualism.

Third, a questionnaire comprising questions about attitudes towards transsexualism and transsexuals was mailed to a random national sample (n=998) of Swedish residents, 18–75 years of age. The response rate was 67 %. The results showed that a majority supports the possibility for transsexuals to undergo sex reassignment. However, 63 % thought that the individual should bear the expenses for it. In addition, a majority supported the transsexuals' right to get married in their new sex, and their right to work with children. Transsexuals' right to adopt and raise children was supported by 43 % whereas 41 % opposed this. The results indicated that those who believed that transsexualism is caused by psychological factors had a more restrictive view on transsexualism than people who held a biological view.

Author/-s:       Mikael Landén

Publication:     Doctoral Thesis, University of Gothenburg, 1999

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Factors predictive of regret in sex reassignment.

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972–1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8 % of the patients who were sex reassigned during 1972–1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Author/-s:       Mikael Landén; J. Wålinder; G. Hambert; B. Lundström

Publication:     Acta Psychiatrica Scandinavia, 1998

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Sex reassignment of adolescent transsexuals: a follow-up study

Objective: To investigate postoperative functioning of the first 22 consecutive adolescent transsexual patients of our gender clinic who underwent sex reassignment surgery.

Method: The subjects were interviewed by an independent psychologist and filled out a test battery containing questionnaires on their psychological, social, and sexual functioning. All subjects had undergone surgery no less than 1 year before the study took place. Twelve subjects had started hormone treatment between 16 and 18 years of age. The posttreatment data of each patient were compared with his or her own pretreatment data.

Results: Postoperatively the group was no longer gender-dysphoric; they scored in the normal range with respect to a number of different psychological measures and they were socially functioning quite well. Not a single subject expressed feelings of regret concerning the decision to undergo sex reassignment.

Conclusions: Starting the sex reassignment procedure before adulthood results in favorable postoperative functioning, provided that careful diagnosis takes place in a specialized gender team and that the criteria for starting the procedure early are stringent.

Author/-s:       Peggy T. Cohen-Kettenis; Stephanie H. M. van Goozen

Publication:     Journal of the American Academy of Child and Adolescent Psychiatry, 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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An epidemiological and demographic study of transsexuals in the Netherlands

This is an epidemiological and demographic study of 1285 transsexuals in the Netherlands. The data were collected from 1975 to the end of 1992. Over 95 % of the Dutch transsexuals have been treated at the study center. Between 1975 and 1984 the annual number of female-to-male transsexuals increased, stabilizing thereafter. In the male-to-female transsexuals this trend continued up to 1989, declining slightly thereafter. Over the last 5 years on average 50 (range 38–60) male-to-female transsexuals and 21 (range 14–25) female-to-male transsexuals received surgical and/or hormonal treatment yearly. The sex ratio remained stable over this period: 3 male vs. 1 female subject. The calculated prevalence of transsexualism in The Netherlands is 1:11 900 males and 1:30 400 females. Transsexuals live predominantly in urbanized areas, but those living in nonurbanized areas show an even distribution over the country. The majority of female-to-male transsexuals apply for reassignment between the ages of 20–25, seldom in middle ages. The majority of male-to-female transsexuals do so between the ages of 25–30 and middle-aged subjects are not rare. Between 77–80 % of both categories receive surgical and/or hormonal treatment. Five male-to-female transsexuals regretted sex reassignment.

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

Publication:     Archives of sexual behaviour, 1996

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Long-term outcome of sex reassignment of male transsexual patients

We report on our experience and our results with gender reassignment during the past 20 years. This study investigates the cosmetic and functional adequacy of the neovagina and also the psychological and social status in 37 surgically reassigned male-to-female transsexuals after a mean postsurgical follow-up of 7.5 years. There were 169 subjects who desired operations to adjust sex. In 58 cases the diagnosis "transsexualism" was supported by two psychosomatic and psychiatric expert opinions. We carried out 52 such operations in two stages. The mean age of the patients was 29 (18-40) years. The depth of the neovagina was approximately 12 cm, a cosmetic and physiologic result which adds greatly to the patients' satisfaction. There were no complications such as rectal or urethral fistulas. In one patient, vaginal stenosis developed after reoperation at a different institution. Three patients complained about short vaginas (6-9 cm). Correspondingly, the psychosocial status showed good improvement after surgery.

Author/-s:       K. Jarrar; E. Wolff, W. Weidner

Publication:     Der Urologe, 1996

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The outcome of sex reassignment surgery in Belgrade: 32 patients of both sexes

Several aspects of the quality of life after sex reassignment surgery in 32 transsexuals of both sexes (22 men, 10 women) were examined. The Belgrade Team for Gender Identity Disorders designed a standardized questionnaire for this purpose. The follow-up period after operation was from 6 months to 4 years, and four aspects of the quality of life were examined: attitude towards the patients' own body, relationships with other people, sexual activity, and occupational functioning. In most transsexuals, the quality of life was improved after surgery inasmuch as these four aspects are concerned. Only a few transsexuals were not satisfied with their life after surgery.

Author/-s:       Z. Rakic; V. Starcevic; J. Maric; K. Kelin

Publication:     Archives of sexual behavior, 1996

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Sex reassignment surgery. A study of 141 Dutch transsexuals.

This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male transsexuals and 105 male-to-female transsexuals in the Netherlands. Data were collected by means of structured interviews. The evaluation was made on the basis of subjective data only, that is on what the persons themselves reported on their gender identity, gender role, and physical condition. Allowing for the restrictive methodology of the (ex post facto) study, it is concluded that there is no reason to doubt the therapeutic effect of sex reassignment surgery. No specific differences were found between those who were still in medical treatment and those who had completed treatment. The findings obtained in the female-to-male transsexuals compare favourably with those obtained in male-to-female transsexuals. Finally, the conclusion is drawn that more attention ought to be paid to psychosocial guidance in addition to medical guidance.

Author/-s:       P. Snaith; M. J. Tarsh; R. Reid

Publication:     The British Journal of Psychiatry, 1993

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A controlled study of psychological and social change after surgical gender reassignment in selected male transsexuals

Of two groups of 20 patients accepted for gender reassignment surgery, one was offered early operation and therefore had had surgery by follow-up two years later, while the second was still awaiting operation at two-year follow-up. Although the groups were similar initially, significant differences between them emerged at follow-up in terms of neuroticism and social and sexual activity, with benefits being enjoyed by the operated group.

Author/-s:       C. Mate-Kole; M. Freschi; A. Robin

Publication:     The British Journal of Psychiatry, 1990

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Prediction of regrets in postoperative transsexuals.

This study investigated whether heterosexual males are more likely to regret sex reassignment surgery than homosexual males or females. Subjects were 111 postoperative transsexuals who had been surgically reassigned for at least one year, representing a follow-up rate of 84.1 %. Subjects' feelings about surgery were assessed with self-administered questionnaires. None of the 61 homosexual females or 36 homosexual males consciously regretted surgery, compared to 4 of the 14 heterosexual males: a significant difference. This finding suggests that heterosexual applicants for sex reassignment should be evaluated with particular caution, although a heterosexual preference is not an absolute contraindication for surgery.

Author/-s:       R. Blanchard; B. W. Steiner; L. H. Clemmensen; R. Dickey

Publication:     Canadian journal of psychiatry, 1989

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Sex reassignment surgery: a study of 141 Dutch transsexuals.

This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male transsexuals and 105 male-to-female transsexuals in the Netherlands. Data were collected by means of structured interviews. The evaluation was made on the basis of subjective data only, that is on what the persons themselves reported on their gender identity, gender role, and physical condition. Allowing for the restrictive methodology of the (ex post facto) study, it is concluded that there is no reason to doubt the therapeutic effect of sex reassignment surgery. No specific differences were found between those who were still in medical treatment and those who had completed treatment. The findings obtained in the female-to-male transsexuals compare favorably with those obtained in male-to-female transsexuals. Finally, the conclusion is drawn that more attention ought to be paid to psychosocial guidance in addition to medical guidance.

Author/-s:       B. Kuiper; P. Cohen-Kettenis

Publication:     Archives of sexual behaviour, 1988

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PS: This study also found a drop in suicidality (pre-treatment/post-treatment) from 19 % to 0 % from transgender men and from 24 % to 6 % for transgender women.

A study of pre- and postsurgical transsexuals: MMPI characteristics

This study examines assessment issues concerning transsexualism through the use of the Minnesota Multiphasic Personality Inventory (MMPI). The MMPI was administered to 20 transsexuals matched within sex on age and education: five presurgical male-to-females, five postsurgical male-to-females, five presurgical female-to-males, and five postsurgical female-to-males. Mean T scores for each of these four subsamples were examined in comparison to normative groups. Comparisons among the four subsamples showed significant differences in mean raw scores attributable to both sex and surgical status. The most striking of these comparisons indicated that postsurgical subjects had a higher level of psychological adjustment.

Author/-s:       M. Fleming; D. Cohen; P. Salt; D. Jones; S. Jenkins

Publication:     Archives of Sexual Behavior, 1981

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