Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

Somewhere under the rainbow: Exploring the identities and experiences of trans persons

The literature on transgender/transsexual-spectrum persons is limited. Most studies are based on the assumption that trans persons are best understood within rigid and binary definitions of gender and sexuality and tend to focus on diagnostics, medical management and risk factors. Researchers and clinicians may also assume that people who challenge cultural norms of gender and sexuality can be grouped together. Such assumptions about the specific experiences of trans persons can be harmfully incorrect. The goals of the present study were to explore the gender and sexual identities of trans persons, to investigate group differences, and to examine factors that predict better psychological and physical well-being. Participants took part in an online study and provided information about their gender and sexual identity, social support, relationship quality, and mental/physical health. Results depicted diverse gender identities and sexual orientations among trans persons and emphasized that while many challenges faced by sexual and gender minorities are similar, trans persons report unique mental and physical health outcomes. Also, greater social support and relationship quality predicted mental, but not physical, health among trans persons. These results highlight the importance of acknowledging the complexity of trans identities and the key role of social and personal support.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth'12)

PURPOSE

To report the prevalence of students according to four gender groups (i.e., those who reported being non-transgender, transgender, or not sure about their gender, and those who did not understand the transgender question), and to describe their health and well-being.

METHODS

Logistic regressions were used to examine the associations between gender groups and selected outcomes in a nationally representative high school health and well-being survey, undertaken in 2012.

RESULTS

Of the students (n = 8,166), 94.7% reported being non-transgender, 1.2% reported being transgender, 2.5% reported being not sure about their gender, and 1.7% did not understand the question. Students who reported being transgender or not sure about their gender or did not understand the question had compromised health and well-being relative to their non-transgender peers; in particular, for transgender students perceiving that a parent cared about them (odds ratio [OR], .3; 95% confidence interval [CI], .2-.4), depressive symptoms (OR, 5.7; 95% CI, 3.6-9.2), suicide attempts (OR, 5.0; 95% CI, 2.9-8.8), and school bullying (OR, 4.5; 95% CI, 2.4-8.2).

CONCLUSIONS

This is the first nationally representative survey to report the health and well-being of students who report being transgender. We found that transgender students and those reporting not being sure are a numerically small but important group. Transgender students are diverse and are represented across demographic variables, including their sexual attractions. Transgender youth face considerable health and well-being disparities. It is important to address the challenging environments these students face and to increase access to responsive services for transgender youth.

Assessment of self-perception of transsexual persons: pilot study of 15 patients

Background and Aims. 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. 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. 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. 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.

Breast imaging in the transgender patient

OBJECTIVE

Limited information exists regarding breast health in the transgender population. In this article, we review transgender terminology, barriers faced by transgender patients, current breast care screening recommendations, and normal and abnormal imaging findings in this population.

CONCLUSION

Health disparities in the transgender population continue. Educating physicians on the breast health care needs of transgender patients is important for improving their care.

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

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

Cross-gender hormone therapy in adolescents

Many transgender youth experience significant amounts of emotional distress regarding the incongruence between their internal gender identity and their physical body. Cross-gender hormonal medical treatments, as managed by a multidisciplinary medical/mental health team, assist patients in transitioning to their desired gender by aligning the physical body to match the gender identity. The World Professional Association for Transgender Health Standards of Care and the Endocrine Society's Clinical Practice Guidelines provide a basic road map for practitioners. Expectations of the youth and the concerns of the family must be addressed and the youth psychologically supported during the transition period. Issues around future fertility should be explored as well. The goal of this article is to introduce the general pediatrician to cross-gender hormone treatments, their management, monitoring laboratory tests and clinical effects, and the issues surrounding their use in adolescents.

Beyond the guidelines: challenges, controversies, and unanswered questions

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

Understanding gender variance in children and adolescents

Gender variance is an umbrella term used to describe gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender. In recent years, growing media coverage has heightened public awareness about gender variance in childhood and adolescence, and an increasing number of referrals to clinics specializing in care for gender-variant youth have been reported in the United States. Gender-variant expression, behavior, and identity may present in childhood and adolescence in a number of ways, and youth with gender variance have unique health needs. For those experiencing gender dysphoria, or distress encountered by the discordance between biological sex and gender identity, puberty is often an exceptionally challenging time. Pediatric primary care providers may be families' first resource for education and support, and they play a critical role in supporting the health of youth with gender variance by screening for psychosocial problems and health risks, referring for gender-specific mental health and medical care, and providing ongoing advocacy and support.

Defensive functioning in MtF and FtM transsexuals

In spite of the potential clinical utility of defense mechanisms in the assessment of gender identity disorder patients as candidates to sex reassignment surgery, there is paucity of research in this field. The aim of the present study is therefore to ascertain whether the defensive profile of MtF and FtM transsexuals seeking sex reassignment surgery can be defined more primitive, immature and maladaptive than that of the two control groups. We compared the defensive profiles as assessed through the REM-71 (Steiner et al., 2001) of 104 MtF transsexuals, 46 FtM transsexuals and two control groups of males and females. Our results show that MtF transsexuals present an overall more primitive defensive array than that of both control groups, while FtMs show a profile not dissimilar from that of both control groups. Our results support the hypothesis that MtF transsexuals are characterized by higher proneness to psychopathology than the general population and show a more immature level of psychological functioning than FtM transsexuals.

Sex and gender diversity among transgender persons in Ontario, Canada: results from a respondent-driven sampling survey

Recent estimates suggest that as many as 1 in 200 adults may be trans (transgender, transsexual, or transitioned). Knowledge about dimensions of sex and gender in trans populations is crucial to development of inclusive policy, practice, and research, but limited data have been available, particularly from probability samples. The Trans PULSE community-based research project surveyed trans Ontarians (n=433) in 2009-2010 using respondent-driven sampling. Frequencies were weighted by recruitment probability to produce estimates for the networked Ontario trans population. An estimated 30% of trans Ontarians were living their day-to-day lives in their birth gender, and 23% were living in their felt gender with no medical intervention. In all, 42% were using hormones, while 15% of male-to-female spectrum persons had undergone vaginoplasty and 0.4% of female-to-male spectrum persons had had phalloplasty. Of those living in their felt gender, 59% had begun to do so within the past four years. A minority of trans Ontarians reported a linear transition from one sex to another, yet such a trajectory is often assumed to be the norm. Accounting for this observed diversity, we recommend policy and practice changes to increase social inclusion and service access for trans persons, regardless of transition status.

Robotic single-site surgery for female-to-male transsexuals: preliminary experience

Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.

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.

Molecular detection of Lactobacillus species in the neovagina of male-to-female transsexual women

There is a general opinion that penile skin lined neovagina of transsexual women is not able to support the growth of lactobacilli. This study was undertaken to prove if lactobacilli strains could survive in neovagina and to characterise the most dominant Lactobacillus species. Sixty three male-to-female transsexual women without abnormal vaginal discharge, clinical signs of infection were recruited on an ongoing basis from among transsexual outpatients in an academic research institution and tertiary care centre. Neovaginal smears were taken for molecular Lactobacillus spp. profiling by denaturing gradient gel electrophoresis (PCR–DGGE). Lactobacillus species were detected from 47/63 transsexual women (75%). The 279 Lactobacillus signals detected by PCR-DGGE technique belonged to 13 different species. Lactobacilli of the L. delbrueckii group (L. gasseri, L. crispatus, L. johnsonii, L. iners, L. jensenii) were predominant. More than 90% of women harboured a combination of two or more neovaginal Lactobacillus species. In this study we report the frequent occurrence of lactobacilli from neovagina of transsexual women. Both, frequency and composition were similar to the normal lactic acid bacterial microflora in both women of reproductive age and postmenopausal women.

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

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

Culturally (in)competent? Dismantling health care barriers for sexual minority women

Lesbian and bisexual (LB) women exhibit elevated rates of a variety of behaviors (i.e., smoking, excessive caloric intake, physical inactivity, heavy alcohol consumption) that put them at risk for adverse health consequences. Furthermore, LB women experience numerous barriers to obtaining culturally competent health care. In this article we review risk behaviors and health care barriers and we discuss the role of stress as an important contributing factor in LB women's health outcomes. We suggest future research, health care delivery changes, and training improvements that will prepare social workers to effectively address the needs of their LB clients.

Fertility preservation in the transgender patient: expanding oncofertility care beyond cancer

While the field of oncofertility raised awareness about fertility concerns in oncology patients, new applications for fertility preservation are emerging, such as transgender medicine. As transgender medicine evolves, the number of individuals seeking gender reassignment hormone therapy is drastically increasing, generating a population of patients with unmet fertility needs and unknown reproductive potential. We present the first case report of a female-to-male (FtM) transgender patient to undergo oocyte cryopreservation before initiating androgen therapy. Our patient is a 17-year-old FtM transgender person undergoing gender transition throughout adolescence with an endocrinologist. The patient wished to complete androgen therapy before starting his first year of college to avoid gender ambiguity. After extensive consultation and psychological assessment, the patient was considered an appropriate candidate and proceeded with oocyte cryopreservation. He underwent baseline fertility testing followed by successful ovarian stimulation and surgical retrieval. We recommend that a discussion of reproductive health concerns and fertility preservation options be incorporated into the comprehensive care of transgender patients.

Management of juvenile gender dysphoria

PURPOSE OF REVIEW

To describe the treatment of gender dysphoria in adolescents.

RECENT FINDINGS

Careful study and evaluation of children with persistent severe gender dysphoria has led to the recommendation that puberty be suppressed at Tanner Stage II. If the dysphoria persists until age 16, treatment with sex steroids of the appropriate gender may begin at age 16 and be followed by gender-appropriate surgery.

SUMMARY

Protocols and results of treatment of early adolescents have demonstrated that the harmful effects of persistent gender dysphoria can be prevented. Pubertal suppression in early puberty not only prevents the severe distress, but also allows healthy adolescent development living in the appropriate gender.

On the quest for a biomechanism of transsexualism: is there a role for BDNF?

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

Safety of hormonal treatment in transgenders

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey

STUDY OBJECTIVE

Transgender, transsexual, or transitioned (trans) people have reported avoiding medical care because of negative experiences or fear of such experiences. The extent of trans-specific negative emergency department (ED) experiences, and of ED avoidance, has not been documented.

METHODS

The Trans PULSE Project conducted a survey of trans people in Ontario, Canada (n=433) in 2009 to 2010, using respondent-driven sampling, a tracked network-based method for studying hidden populations. Weighted frequencies and bootstrapped 95% confidence intervals (CIs) were estimated for the trans population in Ontario and for the subgroup (n=167) reporting ED use in their felt gender.

RESULTS

Four hundred eight participants completed the ED experience items. Trans people were young (34% aged 16 to 24 years and only 10% >55 years); approximately half were female-to-male and half male-to-female. Medically supervised hormones were used by 37% (95% CI 30% to 46%), and 27% (95% CI 20% to 35%) had at least 1 transition-related surgery. Past-year ED need was reported by 33% (95% CI 26% to 40%) of trans Ontarians, though only 71% (95% CI 40% to 91%) of those with self-reported need indicated that they were able to obtain care. An estimated 21% (95% CI 14% to 25%) reported ever avoiding ED care because of a perception that their trans status would negatively affect such an encounter. Trans-specific negative ED experiences were reported by 52% (95% CI 34% to 72%) of users presenting in their felt gender.

CONCLUSION

This first exploratory analysis of ED avoidance, utilization, and experiences by trans persons documented ED avoidance and possible unmet need for emergency care among trans Ontarians. Additional research, including validation of measures, is needed.

Challenges of implementing collaborative models of decision making with trans-identified patients

BACKGROUND

Factors health providers face during the doctor-patient encounter both impede and assist the development of collaborative models of treatment.

OBJECTIVE

I investigated decision making among medical and therapeutic professionals who work with trans-identified patients to understand factors that might impede or facilitate the adoption of the collaborative decision-making model in their clinical work.

DESIGN

Following a grounded theory approach, I collected and analysed data from semi-structured interviews with 10 U.S. physicians and 10 U.S. mental health professionals.

RESULTS

Doctors and therapists often desire collaboration with their patients but experience dilemmas in treating the trans-identified patients. Dilemmas include lack of formal education, little to no institutional support and inconsistent understanding and application of the main documents used by professionals treating trans-patients.

CONCLUSIONS

Providers face considerable risk in providing unconventional treatments due to the lack of institutional and academic support relating to the treatment for trans-people, and the varied interpretation and application of the diagnostic and treatment documents used in treating trans-people. To address this risk, the relationship with the patient becomes crucial. However, trust, a component required for collaboration, is thwarted when the patients feel obliged to present in ways aligned with these documents in order to receive desired treatments. When trust cannot be established, medical and mental health providers can and do delay or deny treatments, resulting in the imbalance of power between patient and provider. The documents created to assist in treatment actually thwart professional desire to work collaboratively with patients.

Being Transgender

In this interview-based study, we investigated the common social experiences and minority stressors related to being transgender. It is one of two articles that resulted from a grounded theory analysis of interviews with 17 participants who claimed a variety of transgender identities (e.g., cross-dresser, transman, transwoman, butch lesbian) and were from different regions in the United States. The interview was centered on how participants’ identities influenced their lives across different interpersonal contexts. Participants described developing a more complex understanding of gender because of the effect of their transgender status on others and the need to modify their gender presentation at times to secure their safety. In the workplace, their gender could overshadow their competence and, in the age of social media, was always at risk of becoming public. Seeking social support could be dangerous, and the process of transitioning was found to make safe spaces especially elusive. Also, open communication about sex and gender was found to be particularly important within successful intimate relationships. Our findings emphasized the tensions between a need to be respected and valued for oneself and one’s abilities with a need to mitigate the very real dangers of being visible or out as transgender in different contexts. Our research can be used to enhance health professionals’ understandings of transgender people’s life experiences, to identify salient minority stressors for further research exploration, and to advance advocacy.

Surgical outcomes and patients' satisfaction with suprapubic phalloplasty

INTRODUCTION

Many techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives.

AIM

The aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty.

METHODS

Medical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being.

MAIN OUTCOME MEASURES

Medical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables.

RESULTS

Duration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine-feminine scale (r = 0.58), attractive-unattractive scale (r = 0.69), and happy-depressed scale (r = 0.63).

CONCLUSION

Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

Sex steroids and variants of gender identity

This article summarizes for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development (DSD) or with non-DSD transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Twenty years of endocrinologic treatment in transsexualism: analyzing the role of chromosomal analysis and hormonal profiling in the diagnostic work-up

OBJECTIVE

To demonstrate that adequate pubertal history, physical examination, and a basal hormone profile is sufficient to exclude disorders of sexual development (DSD) in adult transsexuals and that chromosomal analysis could be omitted in cases of unremarkable hormonal profile and pubertal history.

DESIGN

Retrospective chart analysis.

SETTING

Endocrine outpatient clinic of a psychiatric research institute.

PATIENT(S)

A total of 475 subjects (302 male-to-female transsexuals [MtF], 173 female-to-male transsexuals [FtM]). Data from 323 (192 MtF/131 FtM) were collected for hormonal and pubertal abnormalities. Information regarding chromosomal analysis was available for 270 patients (165 MtF/105 FtM).

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Pubertal abnormalities, menstrual cycle, and hormonal irregularities in relation to chromosomal analysis conducted by karyotype or hair root analysis.

RESULT(S)

In the MtF group, 5.2% of the patients reported pubertal irregularities and 5.7% hormonal abnormalities, and in the FtM group 3.8% and 19.1%, respectively. Overall chromosomal abnormality in both groups was 1.5% (2.9% in the FtM and 0.6% in the MtF group). The aneuploidies found included one gonosomal aneuploidy (45,X[10]/47,XXX[6]/46,XX[98]), two Robertsonian translocations (45,XXder(14;22)(q10;q10)), and one Klinefelter syndrome (47,XXY) that had already been diagnosed in puberty.

CONCLUSION(S)

Our data show a low incidence of chromosomal abnormalities and thus question routine chromosomal analysis at the baseline evaluation of transsexualism, and suggest that it be considered only in cases of abnormal history or hormonal examination.

Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study

OBJECTIVE

To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.

METHOD

The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.

RESULTS

We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.

CONCLUSION

Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD.