Transsexualism in Germany: empirical data on epidemiology and application of the German Transsexuals' Act during its first ten years

Hyperspectral Imaging Detects Clitoral Vascular Issues in Gender-Affirming Surgery

The aim of this study was to assess the efficacy of hyperspectral imaging (HSI) as an intraoperative perfusion imaging modality during gender affirmation surgery (GAS). The hypothesis posited that HSI could quantify perfusion to the clitoral complex, thereby enabling the prediction of either uneventful wound healing or the occurrence of necrosis. In this non-randomised prospective clinical study, we enrolled 30 patients who underwent GAS in the form of vaginoplasty with the preparation of a clitoral complex from 2020 to 2024 and compared patients' characteristics as well as HSI data regarding clitoris necrosis. Individuals demonstrating uneventful wound healing pertaining to the clitoral complex were designated as Group A. Patients with complete necrosis of the neo-clitoris were assigned to Group B. Patient characteristics were collected and subsequently a comparative analysis carried out. No significant difference in patient characteristics was observed between the two groups. Necrosis occurred when both StO2 and NIR PI parameters fell below 40%. For the simultaneous occurrence of StO2 and NIR PI of 40% or less, a sensitivity of 92% and specificity of 72% was calculated. Intraoperatively, the onset of necrosis in the clitoral complex can be reliably predicted with the assistance of HSI.

Characteristics of the pediatric population with gender incongruence attending specialized care in Cali, Colombia: an observational, descriptive and retrospective study

BACKGROUND

Gender incongruence can often manifest itself from early childhood [Olson KR, Gülgöz S. Child Dev Perspect. 2018;12:93-7. https://doi.org/10.1111/cdep.12268 ] with a significant psychological impact, altering social and school dynamics without the appropriate care.[Tordoff DM, et al. JAMA Netw Open. 2022;5(2): e220978. https://doi.org/10.1001/jamanetworkopen.2022.0978 ] Early identification and gender-affirming care are essential to reduce adverse mental health outcomes, such as depression and self-harm [Tordoff DM, et al. JAMA Netw Open. 2022;5(2): e220978. https://doi.org/10.1001/jamanetworkopen.2022.0978 ]..This study aims to analyze characteristics and to estimate relative frequencies of gender incongruence in a population of children and adolescents receiving gender-affirming care at a high-complexity university hospital located in the third largest city in Colombia.

METHODS

This was a retrospective descriptive study of patients under 18 with gender incongruence that received gender-affirming care between January 2018 and June 2022 at Fundacion Valle del Lili in Cali, Colombia. Sociodemographic and clinical characteristics of 43 patients were assessed, as well as the relative frequencies of gender incongruence. Data analysis was performed with the statistical package STATA®. To determine significant differences between the characteristics of the patients who participated in the study, the Mann‒Whitney U test was performed for numerical variables with non-parametric distribution, while either Pearson's Chi-2 test or Fisher's exact test was performed for categorical variables.

RESULTS

For every ten individuals assigned female at birth, who manifested gender incongruence, there were eight assigned male at birth. The median age of onset of gender incongruence was ten years (IQR: 5-13 years), and the median time elapsed between the reported onset of gender incongruence and the first consultation with a multidisciplinary gender-affirming team was three years (IQR: 1-10 years). The frequency of transgender identity was notable in participants with ages between 15 and 17 years. Depressive symptoms, anxiety, and psychotropic drug use were significantly higher in individuals assigned female at birth. Among 25 individuals assigned female at birth who participated in this study, 60% self-recognized as transgender men.18 individuals assigned male at birth, 67% self-recognized as transgender women. The most frequent treatment was a referral to mental health services (46.51%).

CONCLUSION

Based on the cohort of our study, we can conclude that patients consult for gender-affirming treatment 3 years after the onset of gender incongruence. Anxiety and depression were higher in individuals assigned female at birth. Additionally, they presented at a later stage of sexual maturation, reducing the possibility of using puberty blockers.

Tissue Engineering Neovagina for Vaginoplasty in Mayer-Rokitansky-Küster-Hauser Syndrome and Gender Dysphoria Patients: A Systematic Review

Background: Vaginoplasty is a surgical solution to multiple disorders, including Mayer-Rokitansky-Küster-Hauser syndrome and male-to-female gender dysphoria. Using nonvaginal tissues for these reconstructions is associated with many complications, and autologous vaginal tissue may not be sufficient. The potential of tissue engineering for vaginoplasty was studied through a systematic bibliography search. Cell types, biomaterials, and signaling factors were analyzed by investigating advantages, disadvantages, complications, and research quantity. Search Methods: A systematic search was performed in Medline, EMBASE, Web of Science, and Scopus until March 8, 2022. Term combinations for tissue engineering, guided tissue regeneration, regenerative medicine, and tissue scaffold were applied, together with vaginoplasty and neovagina. The snowball method was performed on references and a Google Scholar search on the first 200 hits. Original research articles on human and/or animal subjects that met the inclusion (reconstruction of vaginal tissue and tissue engineering method) and no exclusion criteria (not available as full text; written in foreign language; nonoriginal study article; genital surgery other than neovaginal reconstruction; and vaginal reconstruction with autologous or allogenic tissue without tissue engineering or scaffold) were assessed. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist, the Newcastle-Ottawa Scale, and the Gold Standard Publication Checklist were used to evaluate article quality and bias. Outcomes: A total of 31 out of 1569 articles were included. Data extraction was based on cell origin and type, biomaterial nature and composition, host species, number of hosts and controls, neovaginal size, replacement fraction, and signaling factors. An overview of used tissue engineering methods for neovaginal formation was created, showing high variance of cell types, biomaterials, and signaling factors and the same topics were rarely covered multiple times. Autologous vaginal cells and extracellular matrix-based biomaterials showed preferential properties, and stem cells carry potential. However, quality confirmation of orthotopic cell-seeded acellular vaginal matrix by clinical trials is needed as well as exploration of signaling factors for vaginoplasty. Impact statement General article quality was weak to sufficient due to unreported cofounders and incomplete animal study descriptions. Article quality and heterogenicity made identification of optimal cell types, biomaterials, or signaling factors unreliable. However, trends showed that autologous cells prevent complications and compatibility issues such as healthy cell destruction, whereas stem cells prevent cross talk (interference of signaling pathways by signals from other cell types) and rejection (but need confirmation testing beyond animal trials). Natural (orthotopic) extracellular matrix biomaterials have great preferential properties that encourage future research, and signaling factors for vascularization are important for tissue engineering of full-sized neovagina.

52 Jahre Erfahrungen mit Transidentität

Der Autor gibt einen Überblick über seine 52-jährigen Erfahrungen mit transidenten Personen. Vieles hat sich im Sinne der Entpathologisierung in Diagnostik und Begleitung von transidenten Personen verändert. Nach wie vor sind transidente Personen jedoch in unserer cisheteronormativen Gesellschaft Diskriminierungen ausgesetzt und, mit zunehmender Sichtbarkeit, vermehrt Ziel von Hass und Gewalt. Insgesamt bewegt sich der Diskurs zwischen Psychotherapeut:innen und transidenten Personen stärker als früher „auf Augenhöhe“. Dennoch sind transidente Personen nach wie vor in vielfältiger Weise abhängig von Fachleuten, wenn es um die Bewilligung juristischer und körperlicher Transitionsschritte geht. In den letzten Jahren sind zwei Themen besonders aktuell geworden: die vermehrte Zahl von transidenten Kindern und Jugendlichen und das Thema Nonbinarität, obwohl beide bereits in den 1970er- und 1980er-Jahren von erwachsenen transidenten Personen erwähnt worden sind. Die Psychoanalyse hat sich erst seit Beginn des 21. Jahrhunderts, vor allem unter dem Einfluss der Queer Theory, ernsthaft mit der Transidentität auseinandergesetzt und hat sich in Richtung Entpathologisierung entwickelt. Dennoch sind transidente Kolleg:innen unter den psychoanalytischen Ausbildungskandidat:innen nach wie vor deutlich unterrepräsentiert.

Increasing normality-persisting barriers: Current socio-demographic characteristics of 350 individuals diagnosed with gender dysphoria

INTRODUCTION

The number of individuals requesting medical treatment for gender dysphoria has increased significantly within the past years. Our purpose was to examine current biographic and socio-demographic characteristics and aspects of legal gender reassignment.

DESIGN

Medical files from n = 350 individuals of a German Endocrine outpatient clinic were collected from 2009 to 2017 and analysed retrospectively.

RESULTS

Ratio of transwomen to transmen equates to 1:1.89 with a remarkable increase of transmen by the year 2013, showing a reversal of gender distribution compared with previous studies for the first time. Use of illegal substances or self-initiated hormone therapy was rare (4.6 and 2.1%). Satisfaction with gender-affirming hormone therapy was significantly higher in transmen than in transwomen (100% vs 96.2%, P = .005). Use of antidepressants declined significantly after onset of hormone treatment in transmen (13% vs 7%; P = .007). The number of individuals with a graduation diploma was only about half as high as in the general population (14.3% vs 27.3%), whereas unemployment rate was more than twice as high (14% vs 6.9%). Median latency between application for legal gender reassignment and definitive court decision was 9 months.

CONCLUSIONS

Our data provide possible indications for a decline of psychosocial burden in individuals diagnosed with gender dysphoria over the last years. However, affected individuals are still limited in their occupational and financial opportunities as well as by a complex and expensive procedure of legal gender reassignment in Germany.

Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review

Accurate estimates of the number and proportion of transgender and gender nonconforming people in a population are necessary for developing data-based policy and for planning and funding of health care delivery and research. The wide range of estimates reported in the literature is attributable primarily to differences in definitions. Other sources of variability include diverse cultural and geographic settings and important secular trends. The transgender and gender nonconforming population is undergoing rapid changes in size and demographic characteristics. More accurate and precise estimates will be available when population censuses collect data on sex assigned at birth and gender identity.

Endocrinology of Transgender Medicine

Gender-affirming treatment of transgender people requires a multidisciplinary approach in which endocrinologists play a crucial role. The aim of this paper is to review recent data on hormonal treatment of this population and its effect on physical, psychological, and mental health. The Endocrine Society guidelines for transgender women include estrogens in combination with androgen-lowering medications. Feminizing treatment with estrogens and antiandrogens has desired physical changes, such as enhanced breast growth, reduction of facial and body hair growth, and fat redistribution in a female pattern. Possible side effects should be discussed with patients, particularly those at risk for venous thromboembolism. The Endocrine Society guidelines for transgender men include testosterone therapy for virilization with deepening of the voice, cessation of menses, and increases of muscle mass and facial and body hair. Owing to the lack of evidence, treatment of gender nonbinary people should be individualized. Young people may receive pubertal suspension, consisting of GnRH analogs, later followed by sex steroids. Options for fertility preservation should be discussed before any hormonal intervention. Morbidity and cardiovascular risk with cross-sex hormones is unchanged among transgender men and unclear among transgender women. Sex steroid-related malignancies can occur but are rare. Mental health problems such as depression and anxiety have been found to reduce considerably following hormonal treatment. Future studies should aim to explore the long-term outcome of hormonal treatment in transgender people and provide evidence as to the effect of gender-affirming treatment in the nonbinary population.

Sperm cryopreservation of transgender individuals: trends and findings in the past decade

OBJECTIVES

Awareness and acceptance of transgenderism have increased in the last two decades. There is limited literature regarding the incidence and semen characteristics of transwomen banking spermatozoa. We sought to assess the incidence of sperm cryopreservation of transgender individuals compared with the cisgender population in the last 10 years. Semen parameters were also compared between the two groups.

MATERIALS AND METHODS

We performed a retrospective analysis of sperm cryopreservation performed at a single center from 2006 through 2016. Using available data on indications for banking and prior hormonal therapy status, we isolated healthy transgender and cisgender cohorts for semen parameter comparison. Linear regression was used to compare the incidence trends. Semen parameters were compared using the generalized estimating equations method. The rates of semen parameter abnormality of each group were compared using chi-square test. Semen parameter abnormalities were defined using WHO 2010 reference values.

RESULTS

We analyzed 194 transgender samples and 2327 cisgender samples for a total of 84 unique transgender sperm bankers and 1398 unique cisgender sperm bankers. The number of transgender sperm bankers increased relative to cisgender sperm bankers from 2006 to 2016. Following exclusion of cisgender sperm bankers with health issues that might impact semen quality and transgender sperm bankers with known prior hormonal therapy, we compared the semen parameters of 141 healthy cisgender sperm bankers and 78 healthy transgender sperm bankers. The transgender sperm bankers demonstrated lower sperm concentration, total motile sperm count, and post-thaw sperm parameters. The transgender sperm bankers also demonstrated a higher incidence of oligozoospermia.

CONCLUSIONS

This is the largest report to date on the incidence of transgender sperm cryopreservation and comparison of semen characteristics with cisgender sperm bankers. The data reveal an increased incidence of transgender sperm banking as well as poorer semen parameters of transgender individuals compared with cisgender controls.

[Gender confirming surgery : Female-to-male and male-to-female]

BACKGROUND

Gender confirming surgery (GCS) represents a new and interdisciplinary urological field of activity.

OBJECTIVES

Based on more than 20 years of experience, the development of interdisciplinary strategies in the surgical management of male-to-female (MtF) and female-to-male (FtM) transgenders is summarized.

MATERIALS AND METHODS

The current national and international literature, as well as the surgical experience of the authors in the field of GCS, were evaluated, and aspects relevant for urologists are presented in a comprehensive review.

RESULTS

Since 1990 more than 1200 primary GCS in MtF transgenders and more than 230 primary GCS in FtM transgenders have been performed in the authors' institutions. Presuming an incidence of at least 1:20,000 for patients with gender dysphoria (GD) in the general population, the overall number of patients is limited. The complex surgical procedures should be realized in an interdisciplinary team, trained and specialized in this field of surgery, given the high rate of complications and secondary procedures with MtF GCS.

CONCLUSION

Postoperative satisfaction rates of FtM and MtF transgenders at over 80% are satisfactory. During the last few decades, surgical procedures have been widely standardized. In the field of penile reconstruction, the free forearm lap represents the preferred method, while several surgical alternatives arise from the current literature in this field.

Prevalence, Incidence, and Sex Ratio of Transsexualism in the Autonomous Region of Madrid (Spain) According to Healthcare Demand

In recent years, different studies have provided estimates of the prevalence of transsexualism with very diverse results. The purpose of this study was to ascertain the prevalence, incidence, and sex ratio of transsexualism in the autonomous region of Madrid (Spain). A total of 1234 patients who attended from 2007 to the end of 2015 in the only Gender Identity Unit (GIU) in Madrid were analyzed. Sixty-three patients were excluded for various reasons; thus, 1171 could be included: 803 male-to-female (MtF) and 368 female-to-male (FtM) transsexual patients. Transsexualism was diagnosed based on the ICD-10, World Health Organization, 1992, and/or gender identity disorder based on the DSM-IV-TR, American Psychiatric Association, 2000. The demographic statistics were calculated on the basis of the population over 15 years old of Madrid. Based on healthcare demand, the prevalence of transsexualism was 22.1 in 100,000 inhabitants: 31.2 for MtF and 12.9 for FtM, making the MtF/FtM ratio approximately 2.2:1. The incidence rate was 2.5 in 100,000 inhabitants, representing an annual average of 130 demands. Although transsexualism occurs in all countries with different rates of prevalence, in our area, this prevalence was higher than reported from other European countries. We believe that two main circumstances might influence this high prevalence: the easy accessibility and the absence of a waiting list to the GIU, and the permissive social and legal climate and openness of Spain, especially in Madrid.

Genetic and Environmental Influences on Traits of Gender Identity Disorder: A Study of Japanese Twins Across Developmental Stages

The present study examined: (1) gender and age differences of mean gender identity disorder (GID) trait scores in Japanese twins; (2) the validity of the prenatal hormone transfer theory, which predicts that, in dizygotic (DZ) twin pairs, twins with an opposite-gender co-twin more frequently exhibit GID traits than twins with a same-gender co-twin; and (3) the magnitude of genetic and environmental influences on GID traits as a function of age and gender. Data from 1450 male twin pairs, 1882 female twin pairs, and 1022 DZ male-female pairs ranging from 3 to 26 years of age were analyzed. To quantify individual variances in GID traits, each participant completed four questionnaire items based on criteria for GID from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Our most important findings were: (1) Japanese females exhibited GID traits more frequently than males and Japanese children exhibited GID traits less frequently than adolescents and adults (among females, the prevalence was 1.6 % in children, 10 % in adolescents, and 12 % in adults; among males, the prevalence was 0.5, 2, and 3 %, respectively); (2) the data did not support the prenatal hormone transfer theory for GID traits; and (3) a large part of the variance for GID traits in children was accounted for by familial factors; however, the magnitude was found to be greater in children than in adolescents or adults, particularly among females. This study suggests that although the prevalence is likely to increase, familial effects are likely to decrease as individuals age.

Prevalence of Transgender Depends on the "Case" Definition: A Systematic Review

INTRODUCTION

A systematic review and meta-analysis was conducted to evaluate how various definitions of transgender affect prevalence estimates.

AIMS

To evaluate the epidemiology of transgender and examine how various definitions of transgender affect prevalence estimates and to compare findings across studies that used different methodologies, in different countries, and over different periods.

METHODS

PubMed, EMBASE, and Medline were searched to identify studies reporting prevalence estimates of transgender in a population. All studies were grouped based on the case definition applied to the numerator. Summary estimates were derived using a random-effects model for total prevalence of transgender and for male-to-female and female-to-male subgroups. Overall and stratum-specific meta-prevalence estimates (mPs) and 95% confidence intervals (CIs) were accompanied by tests for heterogeneity and meta-regressions to assess sources of heterogeneity.

MAIN OUTCOME MEASURES

The main outcome measure was population prevalence of transgender. Secondary outcomes included gender-specific prevalence estimates for male-to-female and female to male subgroups.

RESULTS

Thirty-two studies met the inclusion criteria for systematic review. Of those, 27 studies provided necessary data for a meta-analysis. Overall mP estimates per 100,000 population were 9.2 (95% CI = 4.9-13.6) for surgical or hormonal gender affirmation therapy and 6.8 (95% CI = 4.6-9.1) for transgender-related diagnoses. Of studies assessing self-reported transgender identity, the mP was 871 (95% CI = 519-1,224); however, this result was influenced by a single outlier study. After removal of that study, the mP changed to 355 (95% CI = 144-566). Significant heterogeneity was observed in most analyses.

CONCLUSION

The empirical literature on the prevalence of transgender highlights the importance of adhering to specific case definitions because the results can range by orders of magnitude. Standardized and routine collection of data on transgender status and gender identity is recommended.

Gender Dysphoria in Adults

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater client autonomy, and improved understanding of the benefits and limitations of current treatment modalities.

Sociodemographic Study of Danish Individuals Diagnosed with Transsexualism

Introduction

Male-to-female (MtF) and female-to-male (FtM) individuals with transsexualism (International Classification of Diseases-10) may differ in core clinical and sociodemographic variables such as age, sexual orientation, marriage and parenthood, school, educational level, and employment. Assessing and understanding the implication of such differences may be a key to developing appropriate and effective treatment and intervention strategies for this group. However, research in the area remains sparse and is often on small populations, making the generalization of results from current studies on individuals diagnosed with transsexualism difficult.

Aims

(i) To describe and assess key sociodemographic and treatment-related differences between MtF and FtM individuals in a Danish population of individuals diagnosed with transsexualism; (ii) to assess possible implications of such difference, if any, for clinical treatment initiatives for individuals diagnosed with transsexualism.

Methods

Follow-up of 108 individuals who had permission to undergo sex reassignment surgery (SRS, meaning castration and genital plastic surgery) over a 30-year period from 1978 to 2008 through the Gender Identity Unit in Copenhagen, Denmark. The individuals were identified through Social Security numbers. Clinical and sociodemographic data from medical records were collected.

Results

The sex ratio was 1.16:1 (MtF : FtM). Mean age at first referral was 26.9 (standard deviation [SD] 8.8) years for FtM and 30.2 (SD 9.7) for MtF individuals. Compared with MtF, FtM had a significantly lower onset age (before 12 years of age) and lower age when permission for SRS was granted. Further, FtM individuals were significantly more often gynephilic (sexually attracted to females) during research period and less likely to start self-initiated hormonal sex reassignment (SR) (treatment with cross-sex hormones). The MtF and FtM groups did not differ in years of school, educational level, employment, or engagement in marriage and cohabitation.

Conclusions

As approximately half of MtF started cross-sex hormonal SR without attending a gender unit, future treatment needs to focus on this group of MtF individuals in order to accommodate the medical risks of self-initiated hormonal treatment.Earlier intervention with adolescents appears necessary since three-quarters of FtM individuals before age 12 had problems with their assigned sex. For both MtF and FtM, we found problems in areas of school, education, and employment and recommend further help in these core areas.

Sociodemographic Characteristics of Trans Persons in Belgium: A Secondary Data Analysis of Medical, State, and Social Data

By performing secondary data analyses of existing medical, social, and state data, this study examined the sociodemographic profile of trans persons in Belgium and gains knowledge on those who are functionally invisible in traditional epidemiological studies or clinical samples. Based on medical interventions, post-operative transsexual persons were selected from a social survey data set, to compare their sociodemographic profile with available data on legal sex changes from the Belgian National Register and with published data on clinical samples of post-operative transsexual persons. Furthermore, based on self-chosen gender identity categories in the social survey data, transsexual participants were compared with the transgender participants (those people feeling neither female nor male, or both female and male, or otherwise). The sociodemographic data on the post-operative transsexual persons from the three datasets appeared to be very similar. Based on identity categories, the data on transsexual and transgender persons from the social survey showed differences in marital status and employment. Transsexual persons were significantly more often divorced than transgender persons. Both groups differed significantly in employment status. Information about transgender people (or the "in-between" group) is too often lacking from studies but can be obtained when identity instead of medical criteria are used in research.

Systematic Review and Meta-Analysis of Prevalence Studies in Transsexualism

Background

Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data.

Methods

Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed.

Results

The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years.

Conclusions

The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.

Satisfaction with male-to-female gender reassignment surgery

BACKGROUND

The frequency of gender identity disorder is hard to determine; the number of gender reassignment operations and of court proceedings in accordance with the German Law on Transsexuality almost certainly do not fully reflect the underlying reality. There have been only a few studies on patient satisfaction with male-to-female gender reassignment surgery.

METHODS

254 consecutive patients who had undergone male-to-female gender reassignment surgery at Essen University Hospital's Department of Urology retrospectively filled out a questionnaire about their subjective postoperative satisfaction.

RESULTS

119 (46.9% ) of the patients filled out and returned the questionnaires, at a mean of 5.05 years after surgery (standard deviation 1.61 years, range 1-7 years). 90.2% said their expectations for life as a woman were fulfilled postoperatively. 85.4% saw themselves as women. 61.2% were satisfied, and 26.2% very satisfied, with their outward appearance as a woman; 37.6% were satisfied, and 34.4% very satisfied, with the functional outcome. 65.7% said they were satisfied with their life as it is now.

CONCLUSION

The very high rates of subjective satisfaction and the surgical outcomes indicate that gender reassignment surgery is beneficial. These findings must be interpreted with caution, however, because fewer than half of the questionnaires were returned.

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.

Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder

Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.

Status of sex reassignment surgery for gender identity disorder in Japan

An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as gender identity disorder. In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called male-to-female and female-to-male gender identity disorder, respectively. Although the precise pathogenesis of gender identity disorder remains unclear, the prevalence of gender identity disorder is quite high, with the rates calculated for male-to-female to be 1:25,000 and female-to-male to be 1:12,000 in Hokkaido, Japan. The diagnosis and treatment of gender identity disorder in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition. Although gender identity disorder was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and sex reassignment surgery are considered. However, there are very few institutions that routinely carry out sex reassignment surgery in Japan, even though it is mandatory for changing sex on the census register at the present time. Sex reassignment surgery for male-to-female and female-to-male patients includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty, and hysterectomy, ovariectomy, metoidioplasty and phalloplasty, respectively. To provide accurate information about physical treatment for patients with gender identity disorder, even urologists who are not actively involved in the diagnosis and treatment of gender identity disorder should understand the fundamental aspects and contemporary problems of gender identity disorder.

Legal Aspects of Gender Reassignment Surgery in Turkey

The gender reassignment process has ethical, social and legal dimensions. However, European Union countries have recommended certain principles for such reassignment. The lack of special legislation regulating legal conditions and effects of gender reassignment creates a difficult situation for transsexuals. A new civil law was implemented in 2001 in Turkey recognising gender identity reassignment which has set new standards for procedures. According to the law, court permission is compulsory for gender reassignment surgery. Courts require expert analyses in a health council report which must include a psychiatric examination of the individual, who must also be permanently unreproductive as defined by the law. Although the new Civil Law arranges new standards for gender reassignment surgery procedures, there are several problems in reassigning the civil status of transsexuals in Turkey.

Correlates of gender dysphoria in Taiwanese university students

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

Transgender People in Australia and New Zealand: Health, Well-being and Access to Health Services

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

Sociodemographic, clinical, and psychiatric characteristics of transsexuals from Spain

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

Continuing Medical Education: Gender Identity Disorders: Diagnostic and Surgical Aspects (CME)

Transsexualism is defined as a strong and persistent cross-gender identification with the patient's persistent discomfort with his or her sex and a sense of inappropriateness in the gender role of that sex (Diagnostic and Statistical Manual of Mental Disorders, fourth revision, text revision [DSM-IV-TR]). The disturbance is not concurrent with a physical intersex condition and causes clinical distress or impairment in social, occupational, or other important areas of functioning. The trained mental health professional is obliged to find out if the patient fulfills the criteria of an irreversible gender transposition and if he or she will benefit from medical (hormonal and surgical) sex-reassignment treatment. If a patient has absolved 12 months of real-life experience and at least 6 months of continuous hormonal treatment, the indication for surgical sex reassignment may be given. Genital sex-reassignment in male-to-female transsexuals includes vaginoplasty, preferably by inversion of penoscrotal skin flaps, clitoroplasty, and vulvoplasty. The operation may be performed in one or two sessions. In contrast to genital reassignment in male-to-female patients, no operative standards are available in female-to-male subjects. Recently, neophallus creation from sensate free forearm flaps has emerged as the most promising approach for those patients who want to have a neophallus. Other alternatives such as metoidoioplasty or neophallus reconstruction from regional flaps exist, but are also accompanied by multiple possible complications and re-interventions. Best results are to be expected when using multidisciplinary teams of plastic surgeons, urologists, gynecologists, and experts in sexual medicine in large volume centers.

Do transsexuals have micturition disorders?

OBJECTIVE

Transsexualism occurs with an estimated prevalence of 2.4:100,000 male-to-female (MTF) and 1:100,000 female-to-male (FTM) transsexuals. As sex reassignment surgery involves surgery of the urethra and transsexuals are substituted life-long with the cross gender hormones there could possibly arise micturition disorders. Aim of the study was to determine if transsexuals have an increased risk of micturition disorders and if so which.

STUDY DESIGN

Between January and July 2003 we examined 25 transsexuals whereof 18 were MTF and 7 were FTM transsexuals using King's Health Questionnaire, visual analogue scale for patient's well being, perineal and transabdominal ultrasound, urine dipstick and uroflow measurement.

RESULTS

17 out of 25 patients considered themselves very happy. In MTF transsexuals, a diverted stream, overactive bladder and stress urinary incontinence was a common problem. Prostate volume was small with 20 g and palpation did not confirm and solid or suspicious lesions. None of the patients had significant residual urine but MTF transsexuals had a reduced urinary flow. We could not detect a current urinary tract infections in any of the patients.

CONCLUSION

Transsexuals have an increased risk for the development of micturition disorders including stress urinary incontinence and overactive bladder compared to age-matched control groups and should be counselled preoperatively. Reasons for the development of incontinence might be surgery including pudendal nerve damage, hormonal reasons and ageing.

Prevalence and demography of transsexualism in Belgium

AIM

The Belgian medical world has acknowledged the diagnosis of transsexualism and accepted Sex Reassignment Surgery (SRS) as one of the steps in the treatment of choice since 1985. This prevalence and demographic study analyses data on all Belgian individuals who have undergone SRS since that year.

METHODS

All (188) plastic surgeons as well as all gender teams (Antwerp, Bruges, Ghent, and Liège) in Belgium were sent demographic questionnaires to be completed for each of their transsexual patients.

RESULTS

The results show an overall prevalence of 1:12,900 for male-to-female and 1:33,800 for female-to-male transsexuals in Belgium. In Wallonia (the French-speaking region of Belgium) the prevalence is significantly lower than in Flanders (the Dutch-speaking region) and in Brussels (the bilingual capital region). In the total Belgian population the male/female sex ratio is 2.43:1, again with a substantial difference between Wallonia on the one hand and Flanders on the other.

DISCUSSION AND CONCLUSION

While in Flanders and in Brussels the prevalence is comparable to that in other Western European countries, in Wallonia it is markedly lower. Transsexualism in Wallonia appears to be socially less acceptable: persons suffering from gender dysphoria in that part of Belgium encounter more problems accessing gender clinics and receiving treatment.

Regret after sex reassignment surgery in a male-to-female transsexual: a long-term follow-up

This case report describes a four-decade presentation of a non-homosexual gender dysphoric male patient. The case material was collected from two main sources. One of the authors had weekly therapy sessions with the patient over a period of 2 years almost 15 years after sex reassignment surgery. Information was also gained from the patient's medical records covering the period from the early 1960s to the early 1990s. Over the years, the patient fulfilled the criteria for different diagnoses: overanxious reaction of childhood, fetishism and transvestism during adolescence, and transsexualism during adolescence and early adulthood. The purpose of this report was to shed light on aspects of regret, its manifestation in a male-to-female transsexual with psychiatric co-morbidity, and to show the complexity of the process of adjustment when regret is involved. The present case is an argument for a strict interpretation of the Standards of Care provided by the Harry Benjamin International Gender Dysphoria Association in terms of evaluating patients' mental health, apart from the evaluation of the gender identity disorder, and the patients' subsequent need for treatment interventions.

Dissociative disorders and traumatic childhood experiences in transsexuals

In this first prevalence study of dissociative symptoms and different forms of childhood experiences among transsexuals, 41 transsexuals and 115 psychiatric inpatients were compared by means of the Interview for Dissociative Disorders (SCID-D-R), the Dissociative Experiences Scale (DES), and the Childhood Trauma Questionnaire (CTQ). The total score for the dissociative symptoms revealed no significant differences between the transsexuals and the psychiatric inpatients. However, the higher DES score among transsexuals compared with a normal population was found to be due largely to one item. A surprisingly high prevalence of emotional maltreatment was recorded. The results suggest that both the DES and the SCID-D-R have limited validity as instruments for screening and diagnosing dissociative disorders in transsexuals. Psychiatrists should be mindful of the possible existence of dissociative disorders in transsexual patients. Further investigations are needed to clarify the effects of traumatic childhood experiences on sexual identity in transsexuals and to throw more light on the phenomenological correlation between transsexualism and dissociative identity, using taxometric analyses.

Building culturally sensitive substance use prevention and treatment programs for transgendered populations

Studies show that transgendered individuals are at high risk for substance use problems. It is important to identify the unique needs and concerns of these individuals and culturally sensitive programs that will be successful in recruiting and retaining these individuals in drug abuse treatment services. This involves incorporating the needs of services from the perspectives of both the transgendered community and health-care professionals. It is the purpose of this article to discuss transgenderism as well as the substance use problems and difficulties within substance use treatment that transgendered men and women may face. This article presents guidelines for the design and evaluation of health-care services to transgendered populations.