Birth order and ratio of brothers to sisters in Spanish transsexuals

Carving the Biodevelopment of Same-Sex Sexual Orientation at Its Joints

Sexual orientation is a core aspect of human experience and understanding its development is fundamental to psychology as a scientific discipline. Biological perspectives have played an important role in uncovering the processes that contribute to sexual orientation development. Research in this field has relied on a variety of populations, including community, clinical, and cross-cultural samples, and has commonly focused on female gynephilia (i.e., female sexual attraction to adult females) and male androphilia (i.e., male sexual attraction to adult males). Genetic, hormonal, and immunological processes all appear to influence sexual orientation. Consistent with biological perspectives, there are sexual orientation differences in brain development and evidence indicates that similar biological influences apply across cultures. An outstanding question in the field is whether the hypothesized biological influences are all part of the same process or represent different developmental pathways leading to same-sex sexual orientation. Some studies indicate that same-sex sexually oriented people can be divided into subgroups who likely experienced different biological influences. Consideration of gender expression in addition to sexual orientation might help delineate such subgroups. Thus, future research on the possible existence of such subgroups could prove to be valuable for uncovering the biological development of sexual orientation. Recommendations for such future research are discussed.

The fraternal birth-order effect as a statistical artefact: convergent evidence from probability calculus, simulated data, and multiverse meta-analysis

The fraternal-birth order effect (FBOE) is a research claim which states that each older brother increases the odds of homosexual orientation in men via an immunoreactivity process known as the maternal immune hypothesis. Importantly, older sisters supposedly either do not affect these odds, or affect them to a lesser extent. Consequently, the fraternal birth-order effect predicts that the association between the number of older brothers and homosexual orientation in men is greater in magnitude than any association between the number of older sisters and homosexual orientation. This difference in magnitude represents the main theoretical estimand of the FBOE. In addition, no comparable effects should be observable among homosexual vs heterosexual women. Here, we triangulate the empirical foundations of the FBOE from three distinct, informative perspectives, complementing each other: first, drawing on basic probability calculus, we deduce mathematically that the body of statistical evidence used to make inferences about the main theoretical estimand of the FBOE rests on incorrect statistical reasoning. In particular, we show that throughout the literature researchers ascribe to the false assumptions that effects of family size should be adjusted for and that this could be achieved through the use of ratio variables. Second, using a data-simulation approach, we demonstrate that by using currently recommended statistical practices, researchers are bound to frequently draw incorrect conclusions. And third, we re-examine the empirical evidence of the fraternal birth-order effect in men and women by using a novel specification-curve and multiverse approach to meta-analysis (64 male and 17 female samples, N = 2,778,998). When analyzed correctly, the specific association between the number of older brothers and homosexual orientation is small, heterogenous in magnitude, and apparently not specific to men. In addition, existing research evidence seems to be exaggerated by small-study effects.

New Data on Birth Order in Homosexual Men and Women and a Reply to Vilsmeier et al. (2021a, 2021b)

The fraternal birth order effect (FBOE) is the repeated finding that older brothers increase the odds of homosexuality in later-born males. It has been our working assumption, based on the majority of previous studies, that a similar FBOE does not occur in females. In an elaborate quantitative review posted last year to a preprint server, Vilsmeier et al. (2021a) concluded that there is no valid evidence for an FBOE in men or women. Ablaza et al. (2022) subsequently published a study of population-level data from the Netherlands with conclusions completely opposite to those of Vilsmeier et al., namely, that there is robust evidence of an FBOE in both men and women. The present research was initially undertaken to refute the assertion of Vilsmeier et al. that there is no proof of an FBOE in men and to investigate how they obtained such a discrepant conclusion. We found evidence that the discrepancy may relate to Vilsmeier et al.'s use of the large and demonstrably unreliable sample published by Frisch and Hviid (2006). After the publication by Ablaza et al., we expanded our article to address their finding of an FBOE in women. We argue that our preferred explanation of the FBOE in men-that it reflects the progressive immunization of some mothers to Y-linked antigen by each succeeding male fetus and the concomitantly increasing effects of anti-male antibody on sexual differentiation in the brain in each succeeding male fetus-could plausibly be extended to female homosexuality.

Are Sibship Characteristics Predictive of Same Sex Marriage? An Examination of Fraternal Birth Order and Female Fecundity Effects in Population-level Administrative Data from the Netherlands

Despite historical increases in the number of individuals engaging in same-sex relations and entering same-sex unions, the causes of sexual orientation remain an open question. Two biological processes that have received some degree of empirical validation are the fraternal birth-order effect (FBOE) and the female-fecundity effect (FFE). Respectively, these processes posit that having a greater number of older brothers and being part of larger sibships independently increase the odds of male homosexuality. Nevertheless, previous studies have relied on suboptimal data and methods, including underpowered and selected samples, and models that fail to fully disentangle the two processes. In addition, they have rarely analyzed samples of women. We address these limitations using high-quality, population-level linked register data from the Netherlands (n = 9,073,496). Applying a novel multivariable approach, we jointly examine the FBOE and FFE by comparing the sibship characteristics of men (n = 26,542) and women (n = 33,534) who entered a same-sex union against those who did not (n = 4,607,785 men and 4,405,635 women). Our analyses yield robust evidence of an FBOE on both male and female homosexuality, but no support for the FFE. Additionally, we find that individuals' birth order affects the probability of entering a same-sex union, regardless of the sex of older siblings.

Meta-Analyses of Fraternal and Sororal Birth Order Effects in Homosexual Pedophiles, Hebephiles, and Teleiophiles

This study investigated the relations between numbers of older brothers, numbers of older sisters, and the odds of homosexuality in later-born males, including males who are most attracted sexually to prepubescent or early pubescent children (pedohebephiles) and males who are most attracted sexually to adults (teleiophiles). The authors meta-analyzed data from 24 samples of homosexual and heterosexual men, originally reported in 18 studies, and totaling 18,213 subjects. The results confirmed that older brothers increase the odds of same-sex preference in pedohebephiles as they do in teleiophiles. They also replicated the recent finding that older sisters have a similar but weaker statistical association with the odds of homosexuality. These findings have two theoretical implications. First, the findings for older brothers and older sisters indicate some commonality in the factors that influence sexual preference in teleiophiles and those that influence sexual preference in pedohebephiles. Second, the finding for older sisters confirms a prediction stemming from the hypothesis that male fetuses stimulate maternal antibodies that increase the odds of homosexuality in later-born males. Such immunization could result from miscarried as well as full-term fetuses, and number of older sisters should correlate with number of male fetuses miscarried before gestation of the subject.

Sexual differentiation of the human hypothalamus: Relationship to gender identity and sexual orientation

Gender identity (an individual's perception of being male or female) and sexual orientation (heterosexuality, homosexuality, or bisexuality) are programmed into our brain during early development. During the intrauterine period in the second half of pregnancy, a testosterone surge masculinizes the fetal male brain. If such a testosterone surge does not occur, this will result in a feminine brain. As sexual differentiation of the brain takes place at a much later stage in development than sexual differentiation of the genitals, these two processes can be influenced independently of each other and can result in gender dysphoria. Nature produces a great variability for all aspects of sexual differentiation of the brain. Mechanisms involved in sexual differentiation of the brain include hormones, genetics, epigenetics, endocrine disruptors, immune response, and self-organization. Furthermore, structural and functional differences in the hypothalamus relating to gender dysphoria and sexual orientation are described in this review. All the genetic, postmortem, and in vivo scanning observations support the neurobiological theory about the origin of gender dysphoria, i.e., it is the sizes of brain structures, the neuron numbers, the molecular composition, functions, and connectivity of brain structures that determine our gender identity or sexual orientation. There is no evidence that one's postnatal social environment plays a crucial role in the development of gender identity or sexual orientation.

Transsexualism: A Different Viewpoint to Brain Changes

Transsexualism refers to a condition or belief which results in gender dysphoria in individuals and makes them insist that their biological gender is different from their psychological and experienced gender. Although the etiology of gender dysphoria (or transsexualism) is still unknown, different neuroimaging studies show that structural and functional changes of the brain result from this sexual incongruence. The question here is whether these reported changes form part of the etiology of transsexualism or themselves result from transsexualism culture, behaviors and lifestyle. Responding to this question can be more precise by consideration of cultural neuroscience concepts, particularly the culture–behavior–brain (CBB) loop model and the interactions between behavior, culture and brain. In this article, we first review the studies on the brain of transgender people and then we will discuss the validity of this claim based on the CBB loop model. In summary, transgender individuals experience change in lifestyle, context of beliefs and concepts and, as a result, their culture and behaviors. Given the close relationship and interaction between culture, behavior and brain, the individual’s brain adapts itself to the new condition (culture) and concepts and starts to alter its function and structure.

Gender Nonconformity and Birth Order in Relation to Anal Sex Role Among Gay Men

Androphilia is associated with an elevated number of older brothers among natal males. This association, termed the fraternal birth order effect, has been observed among gay men who exhibit marked gender nonconformity. Gender nonconformity has been linked to gay men's preferred anal sex role. The present study investigated whether these two lines of research intersect by addressing whether the fraternal birth order effect was associated with both gender nonconformity and a receptive anal sex role (243 gay men, 91 heterosexual men). Consistent with previous research, we identified the fraternal birth order effect in our sample of gay men. Also, gay men were significantly more gender-nonconforming on adulthood and recalled childhood measures compared to heterosexual men. When gay men were compared based on anal sex role (i.e., top, versatile, bottom), all groups showed significantly greater recalled childhood and adult male gender nonconformity than heterosexual men, but bottoms were most nonconforming. Only gay men with a bottom anal sex role showed evidence of a fraternal birth order effect. A sororal birth order effect was found in our sample of gay men, driven by versatiles. No significant associations were found between fraternal birth order and gender nonconformity measures. These results suggest that the fraternal birth order effect may apply to a subset of gay men who have a bottom anal sex role preference and that this subgroup is more gender-nonconforming. However, there were no significant associations between fraternal birth order and gender nonconformity at the individual level. As such, based on the present study, whether processes underpinning the fraternal birth order effect influence gender nonconformity is equivocal.

Fraternal Birth Order, Family Size, and Male Homosexuality: Meta-Analysis of Studies Spanning 25 Years

The fraternal birth order effect is the tendency for older brothers to increase the odds of homosexuality in later-born males. This study compared the strength of the effect in subjects from small versus large families and in homosexual subjects with masculine versus feminine gender identities. Meta-analyses were conducted on 30 homosexual and 30 heterosexual groups from 26 studies, totaling 7140 homosexual and 12,837 heterosexual males. The magnitude of the fraternal birth order effect was measured with a novel variable, the Older Brothers Odds Ratio, computed as (homosexuals' older brothers ÷ homosexuals' other siblings) ÷ (heterosexuals' older brothers ÷ heterosexuals' other siblings), where other siblings = older sisters + younger brothers + younger sisters. An Older Brothers Odds Ratio of 1.00 represents no effect of sexual orientation; values over 1.00 are positive evidence for the fraternal birth order effect. Evidence for the reliability of the effect was consistent. The Older Brothers Odds Ratio was significantly >1.00 in 20 instances, >1.00 although not significantly in nine instances, and nonsignificantly <1.00 in 1 instance. The pooled Older Brothers Odds Ratio for all samples was 1.47, p < .00001. Subgroups analyses showed that the magnitude of the effect was significantly greater in the 12 feminine or transgender homosexual groups than in the other 18 homosexual groups. There was no evidence that the magnitude of the effect differs according to family size.

The Prevalence of Only-Child Status Among Children and Adolescents Referred to a Gender Identity Service Versus a Clinical Comparison Group

Several studies indicate that homosexual males have a high proportion of older brothers compared to heterosexual males. Natal males with gender dysphoria who are likely to be homosexual also display this sibship pattern. Until recently, there was little evidence linking homosexuality and/or gender dysphoria in females to unique sibship characteristics. Two studies have indicated that natal female youth clinically referred for gender dysphoria are more likely to be only children (Schagen, Delemarre-van de Waal, Blanchard, & Cohen-Kettenis, 2012; VanderLaan, Blanchard, Wood, & Zucker, 2014). However, these studies did not include control groups of youth clinically referred for other reasons. Thus, it is unclear whether the increased likelihood of only-child status is specific to gender-referred natal females. This study compared only-child status among youth referred to a mental health service for gender dysphoria (778 males, 245 females) versus other reasons (783 males, 281 females). Prehomosexual gender-referred males were less likely to be only children than clinical controls. Contrary to previous findings, gender-referred females were not more likely to be only children, indicating that increased likelihood of only-child status is not specific to gender-referred females, but is characteristic of clinic-referred females more generally.

Birth order and recalled childhood gender nonconformity in Samoan men and fa'afafine

Having a greater than average number of older biological brothers is a robust correlate of male androphilia (i.e., sexual attraction and arousal to adult males). Previous investigations have sought to understand whether this fraternal birth order (FBO) effect is also systematically related to recalled indicators of childhood gender nonconformity (CGN). However, these investigations have relied on data from low-fertility Western populations in which expressions of femininity in male children are routinely stigmatized and consequently, suppressed. The present study examined the FBO effect (among other sibship characteristics) and recalled indicators of CGN in Samoa, a high-fertility population, whose members are relatively tolerant of male femininity. Indeed, Samoans identify feminine androphilic males as belonging to an alternative gender category, known locally as fa'afafine. The present study compared the sibship characteristics of 231 fa'afafine and 231 opposite-sex attracted men from Samoa, as well as how these characteristics related to recalled CGN. Results replicated the well-established FBO effect for predicting male sexual orientation, with each older brother increasing the odds of being androphilic by 21%. However, no relationship was found between the number of older brothers (or other siblings) a participant had and their recalled CGN. Although fa'afafine reported significantly more CGN than Samoan men, CGN did not mediate the FBO effect, nor did the FBO effect and CGN interact to predict male sexual orientation. These findings are consistent with previous studies suggesting that the FBO effect is associated with male sexual orientation, but not childhood female-typical gender expression among androphilic males.

BIRTH ORDER AND ANDROPHILIC MALE-TO-FEMALE TRANSSEXUALISM IN BRAZIL

Previous research has indicated that biological older brothers increase the odds of androphilia in males. This finding has been termed the fraternal birth order effect. The maternal immune hypothesis suggests that this effect reflects the progressive immunization of some mothers to male-specific antigens involved in fetal male brain masculinization. Exposure to these antigens, as a result of carrying earlier-born sons, is hypothesized to produce maternal immune responses towards later-born sons, thus leading to female-typical neural development of brain regions underlying sexual orientation. Because this hypothesis posits mechanisms that have the potential to be active in any situation where a mother gestates repeated male fetuses, a key prediction is that the fraternal birth order effect should be observable in diverse populations. The present study assessed the association between sexual orientation and birth order in androphilic male-to-female transsexuals in Brazil, a previously unexamined population. Male-to-female transsexuals who reported attraction to males were recruited from a specialty gender identity service in southern Brazil (n=118) and a comparison group of gynephilic non-transsexual men (n=143) was recruited at the same hospital. Logistic regression showed that the transsexual group had significantly more older brothers and other siblings. These effects were independent of one another and consistent with previous studies of birth order and male sexual orientation. The presence of the fraternal birth order effect in the present sample provides further evidence of the ubiquity of this effect and, therefore, lends support to the maternal immune hypothesis as an explanation of androphilic sexual orientation in some male-to-female transsexuals.

A Review of the Status of Brain Structure Research in Transsexualism

The present review focuses on the brain structure of male-to-female (MtF) and female-to-male (FtM) homosexual transsexuals before and after cross-sex hormone treatment as shown by in vivo neuroimaging techniques. Cortical thickness and diffusion tensor imaging studies suggest that the brain of MtFs presents complex mixtures of masculine, feminine, and demasculinized regions, while FtMs show feminine, masculine, and defeminized regions. Consequently, the specific brain phenotypes proposed for MtFs and FtMs differ from those of both heterosexual males and females. These phenotypes have theoretical implications for brain intersexuality, asymmetry, and body perception in transsexuals as well as for Blanchard's hypothesis on sexual orientation in homosexual MtFs. Falling within the aegis of the neurohormonal theory of sex differences, we hypothesize that cortical differences between homosexual MtFs and FtMs and male and female controls are due to differently timed cortical thinning in different regions for each group. Cross-sex hormone studies have reported marked effects of the treatment on MtF and FtM brains. Their results are used to discuss the early postmortem histological studies of the MtF brain.

Fraternal Birth Order and Extreme Right-Handedness as Predictors of Sexual Orientation and Gender Nonconformity in Men

The present study explored whether there were relationships between number of older brothers, handedness, recalled childhood gender nonconformity (CGN), and sexual orientation in men. We used data from previous British studies conducted in our laboratory (N = 1,011 heterosexual men and 921 gay men). These men had completed measures of demographic variables, number and sex of siblings, CGN, and the Edinburgh Handedness Inventory. The results did not replicate the fraternal birth order effect. However, gay men had fewer "other siblings" than heterosexual men (even after controlling for the stopping-rule and family size). In a sub-sample (425 gay men and 478 heterosexual men) with data available on both sibling sex composition and handedness scores, gay men were found to show a significantly greater likelihood of extreme right-handedness and non-right-handedness compared to heterosexual men. There were no significant effects of sibling sex composition in this sub-sample. In a further sub-sample (N = 487) with data available on sibling sex composition, handedness, and CGN, we found that men with feminine scores on CGN were more extremely right-handed and had fewer other-siblings compared to masculine scoring men. Mediation analysis revealed that handedness was associated with sexual orientation directly and also indirectly through the mediating factor of CGN. We were unable to replicate the fraternal birth order effect in our archived dataset but there was evidence for a relationship among handedness, sexual orientation, and CGN. These data help narrow down the number of possible neurodevelopmental pathways leading to variations in male sexual orientation.

Evidence against a typology: a taxometric analysis of the sexuality of male-to-female transsexuals

Previous theories and research have suggested there are two distinct types of male-to-female (MF) transsexuals and these types can be distinguished by their sexuality. Using the scales Attraction to Femininity in Males, Core Autogynephilia, Autogynephilic Interpersonal Fanasy, and Attraction to Transgender Fiction as indicator variables, taxometric analysis was applied to an online-recruited sample of 308 MF transsexuals to investigate whether such a distinction is justified. In accordance with previous research findings, MF transsexuals categorized as "nonandrophilic" scored significantly higher on Core Autogynephilia than did those categorized as "androphilic"; they also scored significantly higher on Attraction to Femininity in Males and Attraction to Transgender Fiction. Results of one of the taxometric procedures, L-Mode, gave slightly more support for a dimensional, rather than taxonic (two-type), latent structure. Results of the two other taxometric procedures, MAMBAC and MAXCOV, showed greater support for a dimensional latent structure. Although these results require replication with a more representative sample, they show little support for a taxonomy, which contradicts previous theory that has suggested MF transsexuals' sexuality is typological.

Detecting and correcting for family size differences in the study of sexual orientation and fraternal birth order

The term "fraternal birth order effect" denotes a statistical relation most commonly expressed in one of two ways: Older brothers increase the odds of homosexuality in later born males or, alternatively, homosexual men tend to have more older brothers than do heterosexual men. The demonstrability of this effect depends partly on the adequate matching of the homosexual and heterosexual study groups with respect to mean family size. If the homosexual group has too many siblings, relative to the heterosexual group, the homosexual group will tend to show the expected excess of older brothers but may also show an excess of other sibling-types (most likely older sisters); if the homosexual group has too few siblings, it will tend not to show a difference in number of older brothers but instead may show a deficiency of other sibling-types (most likely younger brothers and younger sisters). In the first part of this article, these consequences are illustrated with deliberately mismatched groups selected from archived data sets. In the second part, two slightly different methods for transforming raw sibling data are presented. These are intended to produce family-size-corrected variables for each of the four original sibling parameters (older brothers, older sisters, younger brothers, and younger sisters). Both versions are shown to render the fraternal birth order effect observable in the deliberately mismatched groups. In the third part of the article, fraternal birth order studies published in the last 5 years were surveyed for failures to find a statistically significant excess of older brothers for the homosexual group. Two such studies were found in the nine examined. In both cases, the collective findings for older sisters, younger brothers, and younger sisters suggested that the mean family size of the homosexual groups was smaller than that of the heterosexual comparison groups. Furthermore, the individual findings for the four classes of siblings resembled those for the present experimentally mismatched groups in which the mean family size of the homosexual group was significantly smaller. This illustrates the necessity of comparing groups on measures of mean family size and removing this confound in some way when those means are markedly different.

Exposure to childhood traumas ups the odds of giving birth to daughters

This study examined the likelihood of giving birth to a daughter as a function of women's exposure to four categories of stressors: childhood trauma, adult trauma, chronic stressors, and recent (adverse) life events. Hypothesis 1 stated that exposure to recent life events (near conception) and to childhood traumas would increase women's chances of having a girl baby. Hypothesis 2 stated that the relationship between stress and gender outcome is mediated by persistent posttraumatic stress disorder (PTSD) symptoms. The final sample was comprised of 225 women. The design was prospective observational. At first contact, women were retained if they were <27 weeks pregnant and met initial inclusion criteria. In interview 2, at 27-30 weeks, women were excluded for positive diagnoses of anxiety disorders besides PTSD with or without depression (Structured Clinical Interview for DSM-IV Disorders). In interview 3 (30-34 weeks), reports on stress categories (Social Stress Indicator Questionnaire) and PTSD symptoms (Post-Traumatic Checklist) were obtained. Infant gender was obtained from medical records. The relationship between stress categories and the distribution of girl/boy infants was examined with Chi Squares and logistic regression analyses. Mediation was tested with the macro PROCESS (Hayes 2012). Childhood trauma was the only stress category that increased the odds of having a girl, with an odds ratio of >3.0 for women who had been exposed to more than two such events. PTSD symptoms (partially) mediated the relationship between childhood trauma and infant gender. Findings suggest that women's exposure to childhood trauma contributes to the determination of the sex ratio at birth and that PTSD symptoms are part of the cause.

Birth order and sibling sex ratio of children and adolescents referred to a gender identity service

In adult male samples, homosexuality is associated with a preponderance of older brothers (i.e., the fraternal birth order effect). In several studies comparing gender dysphoric youth, who are likely to be homosexual in adulthood, to clinical or non-clinical control groups, the findings have been consistent with the fraternal birth order effect in males; however, less is known about unique sibship characteristics of gender dysphoric females. The current study investigated birth order and sibling sex ratio in a large sample of children and adolescents referred to the same Gender Identity Service (N = 768). Probands were classified as heterosexual males, homosexual males, or homosexual females based on clinical diagnostic information. Groups differed significantly in age and sibship size, and homosexual females were significantly more likely to be only children. Subsequent analyses controlled for age and for sibship size. Compared to heterosexual males, homosexual males had a significant preponderance of older brothers and homosexual females had a significant preponderance of older sisters. Similarly, the older sibling sex ratio of homosexual males showed a significant excess of brothers whereas that of homosexual females showed a significant excess of sisters. Like previous studies of gender dysphoric youth and adults, these findings were consistent with the fraternal birth order effect. In addition, the greater frequency of only children and elevated numbers of older sisters among the homosexual female group adds to a small literature on sibship characteristics of potential relevance to the development of gender identity and sexual orientation in females.

Gender identity disorder and schizophrenia: neurodevelopmental disorders with common causal mechanisms?

Gender identity disorder (GID), recently renamed gender dysphoria (GD), is a rare condition characterized by an incongruity between gender identity and biological sex. Clinical evidence suggests that schizophrenia occurs in patients with GID at rates higher than in the general population and that patients with GID may have schizophrenia-like personality traits. Conversely, patients with schizophrenia may experience alterations in gender identity and gender role perception. Neurobiological research, including brain imaging and studies of finger length ratio and handedness, suggests that both these disorders are associated with altered cerebral sexual dimorphism and changes in cerebral lateralization. Various mechanisms, such as Toxoplasma infection, reduced levels of brain-derived neurotrophic factor (BDNF), early childhood adversity, and links with autism spectrum disorders, may account for some of this overlap. The implications of this association for further research are discussed.

Coordination of healthcare for transsexual persons: a multidisciplinary approach

PURPOSE OF REVIEW

To describe the experience in Spain concerning the public healthcare for transsexual persons using a multidisciplinary approach and to review the relevant literature. Treatment includes social and psychological support, cross-hormone treatment, and sex reassignment surgeries. Although the recommendations of The World Professional Association for Transgender Health are used as guidelines, the application of these standards of care varies considerably, probably because of specific clinical and country factors.

RECENT FINDINGS

The sex reassignment process is complex and requires not only coordination of multiple procedures, but also lifetime follow-up of transsexual individuals. Gender units must provide high-quality services, been essential the principle of accessibility to resources together with a protocolized follow-up and anticipation of secondary effects from the clinical surgical treatment. Two recent challenges are juvenile gender dysphoria and gender variants, which increasingly consult professionals.

SUMMARY

Transsexualism affects all adaptive physical and psychosocial aspects of a person. As diagnosis is based only on the history and personal perceptions, a broad social debate exists about the need for treatment financed by the public health systems. Some countries restrict the care to transsexuals with private medical policies. Thus, coordination of care also requires participation of the family and associations, with continuous information to the health authorities, the judiciary, and the media of each country.

A possible second type of maternal-fetal immune interaction involved in both male and female homosexuality

Recent research has found that the mothers of firstborn homosexual sons produce fewer subsequent offspring than do the mothers of firstborn heterosexual sons. It was hypothesized that a subset of mothers of firstborn homosexuals may be responsible for this finding. If there is a subset of mothers whose immune reactions cause their first male fetus to be homosexual and their subsequent fetuses to die, then their immune reactions should also cause their first male fetus to have a lower birth weight. This leads to the prediction that, within the population of firstborn homosexual men, those with no younger siblings should also tend to have lower birth weights. This prediction was tested using a previously published sample of 1,445 firstborn subjects: 929 heterosexual females, 47 homosexual females, 409 heterosexual males, and 60 homosexual males. The results showed that firstborn homosexuals with no younger siblings (i.e., only children) did have lower birth weights compared with all the other subjects, but the finding applied to firstborn lesbian women as well as firstborn gay men.

Sibling sex ratio and birth order in early-onset gender dysphoric adolescents

Several sibship-related variables have been studied extensively in sexual orientation research, especially in men. Sibling sex ratio refers to the ratio of brothers to sisters in the aggregate sibships of a group of probands. Birth order refers to the probands' position (e.g., first-born, middle-born, last-born) within their sibships. Fraternal birth order refers to their position among male siblings only. Such research was extended in this study to a large group of early-onset gender dysphoric adolescents. The probands comprised 94 male-to-female and 95 female-to-male gender dysphoric adolescents. The overwhelming majority of these were homosexual or probably prehomosexual. The control group consisted of 875 boys and 914 girls from the TRAILS study. The sibling sex ratio of the gender dysphoric boys was very high (241 brothers per 100 sisters) compared with the expected ratio (106:100). The excess of brothers was more extreme among the probands' older siblings (300:100) than among their younger siblings (195:100). Between-groups comparisons showed that the gender dysphoric boys had significantly more older brothers, and significantly fewer older sisters and younger sisters, than did the control boys. In contrast, the only notable finding for the female groups was that the gender dysphoric girls had significantly fewer total siblings than did the control girls. The results for the male probands were consistent with prior speculations that a high fraternal birth order (i.e., an excess of older brothers) is found in all homosexual male groups, but an elevated sibling sex ratio (usually caused by an additional, smaller excess of younger brothers) is characteristic of gender dysphoric homosexual males. The mechanisms underlying these phenomena remain unknown.

Fertility in the mothers of firstborn homosexual and heterosexual men

This study tested the balancing selection hypothesis, that is, genes predisposing men to homosexuality escape elimination from the population because the decreased fertility of men with the heritable form of homosexuality is offset by an increased fertility among biological relatives who carry the same genetic variants. The index subjects (probands) were 40,197 firstborn heterosexual men and 4,784 firstborn homosexual men retrieved from six archival data sets, all of which had previously been used in published research. The measure of familial (specifically, parental) fertility was the proband's number of younger siblings. The results directly contradicted the prediction of the balancing selection hypothesis. In four of the six samples, the homosexual probands had significantly fewer younger siblings; in the other two samples, the means were not significantly different. It is possible that mothers who produce a homosexual son at their first delivery include a biologically distinct subpopulation of mothers of homosexual sons.

[Organization of healthcare for transsexual persons in the Spanish national health system]

OBJECTIVE

Recognition of transexuality as a clinical entity for which medical attention should be available is currently a well-established reality, but institutional care has not been uniformly instituted throughout Spain. The aim of the present study was to determine the current situation of healthcare for transexualism in the publicly-funded health service in Spain.

MATERIALS AND METHODS

A descriptive study based on data provided by the Spanish Society of Endocrinology Group on Identity and Sexual Differentiation was performed. The resources in the regions that have created specific gender units for these disorders are described.

RESULTS

Nine autonomous regions (55%) have started to provide various procedures, although only four provide genitoplastic procedures. The first region to include all sex reassignment surgeries was Andalusia (year 1999). At the same time, Madrid and Catalonia also began to provide specialized mental health care and endocrinology but did not include surgical procedures until 2007 and institutional recognition until 2008. Since 2007 other regions have incorporated healthcare for transsexual patients. Overall, 3,303 patients (a male-to female/female-to-male transsexual ratio of 1.9/1) and 864 surgical procedures have been registered in this study. The composition and proportion of working hours of specialists, as well as the kinds of treatments provided, differ widely in each region.

CONCLUSIONS

The geographical distribution of healthcare to transsexual persons and the services provided vary. Few regions offer genitoplastic procedures. The number of applicants exceeds the number estimated by the national health system.