The Epidemiology of Gender Dysphoria in Iran: The First Nationwide Study

Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran

BACKGROUND

Gender dysphoria, characterized by a misalignment between one's gender identity and assigned sex, propels individuals towards medical interventions like gender reassignment surgery (GRS) to harmonize their bodies with their gender. This process aims to enhance overall quality of life (QoL), functioning, and body image. Recognizing the importance of cultivating a positive body image for transgender individuals navigating societal norms, this narrative highlights the ongoing debate surrounding QoL post-GRS. In response, our study is outlined, aiming to scrutinize QoL and self-image among transgender men post-GRS, offering valuable insights into societal perceptions and psychological well-being in this context.

METHOD

This cross-sectional survey focused on transgender men aged 15 to 35 who underwent gender reassignment surgery (GRS) in 2018-2022 in Shiraz, Iran. Participants, after passing psychiatric evaluations, completed World Health Organization Quality of Life (WHOQOL-100) questionnaires pre- and at least one-year post-surgery. The scores of the Brief-WHOQOL questionnaire were evaluated in four domains of physical health, psychological health, social relationships, and environmental health.

RESULTS

A total of 60 individual who underwent GRS completed our questionnaire. The average age of the patients was 24.1 ± 3.8 years. Following GRS, the most increase was observed in the psychological factor (by 25.6%). The increase in score was statistically significant in all subgroups (P < 0.001) after operation. Urban living location had a significant association with higher increase in physical health (P < 0.010), psychological health (P = 0.005), and environmental health (P = 0.012) after GRS. In regards to physical health, the low socioeconomic group had a significantly less physical score improvement in QoL compared to the moderate group (P = 0.024) following GRS. In regards to environmental health, the high socioeconomic groups had significantly higher improvement in QoL compared to the low (P = 0.006) and moderate (P < 0.001) group after operation.

CONCLUSION

The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients hailing from low socioeconomic backgrounds and rural areas.

Occupational Preferences, Childhood Behavior, and Openness: The Role of Sex, Sexual Orientation, and Gender Identity in Iran

Previous research suggests that both same-sex attraction and the personality trait "openness" are associated with sex-atypical preferences and behaviors. Here, we examined the links between adulthood occupational preferences, childhood play behavior, and openness among Iranian cisgender gynephilic males (n = 228), cisgender ambiphilic males (n = 48), cisgender androphilic males (n = 178), transgender androphilic males (n = 58), cisgender androphilic females (n = 226), cisgender ambiphilic females (n = 94), cisgender gynephilic females (n = 31), and transgender gynephilic females (n = 121) from Iran. Cisgender and transgender same-sex attracted males and females exhibited sex-atypical occupational preferences with the latter group showing even more sex-atypicality than the former. The personality trait openness did not differ between cisgender groups. Transgender androphilic males had a significantly higher mean score for openness compared to cisgender androphilic females and transgender gynephilic females, whereas transgender gynephilic females had a significantly lower mean score compared to cisgender androphilic males. In both males and females, childhood sex-atypicality, same-sex attraction, and openness were associated with sex-atypical occupational preferences. Our findings from Iran provides cross-cultural support for interconnectedness of childhood and adulthood sex-atypicality, openness, and same-sex attraction in males and females who are cisgender and transgender.

Association of Recalled Childhood Sex-Typed Behavior with Sexual Orientation and Gender Identity in Iranian Adult Males and Females

Same-sex sexual attraction in both males and females has been associated with childhood sex-atypical behavior. Gynephilic females recall behaving in a manner that is less female-typical and more male-typical compared to cisgender androphilic females, whereas androphilic males recall behaving in a manner that is less male-typical and more female-typical compared to cisgender gynephilic males. In addition, male and female ambiphilic individuals exhibit intermediate levels of childhood sex-atypicality. In this study, we examined recalled childhood sex-typed behavior among Iranian cisgender gynephilic males (n = 236), cisgender ambiphilic males (n = 51), cisgender androphilic males (n = 191), transgender androphilic males (n = 60), cisgender androphilic females (n = 243), cisgender ambiphilic females (n = 96), cisgender gynephilic females (n = 32), and transgender gynephilic females (n = 122). Both cisgender androphilic males and cisgender gynephilic females recalled elevated childhood sex-atypicality, scoring intermediate between cisgender gynephilic males and cisgender androphilic females. Male and female ambiphilic participants scored intermediate between their other- and same-sex attracted cisgender counterparts. Transgender androphilic males exhibited hyper-feminized childhood behavior, scoring even more female-typical than cisgender androphilic females. Transgender gynephilic females recalled behaving as male-typical as cisgender gynephilic males. Consistent with previous research, our findings from Iran - a non-Western, Middle Eastern culture - provide cross-cultural support for the universality of childhood sex-atypicality as a normative developmental precursor of monosexual or ambisexual same-sex attraction in both males and females who are cisgender and transgender.

Evaluation of the Efficacy of Magnetic Resonance Imaging for Feminizing Gender Affirmation Genital Surgery: A Novel Approach

Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the postoperative anatomical changes in AMAB individuals who underwent GAS using magnetic resonance imaging (MRI) and to compare it with cis-females, thereby assessing the efficacy of the surgical technique in achieving pelvic anatomy similar to cis-females. Methodology This was a prospective observational study done in a tertiary care hospital. AMAB individuals who underwent gender affirmation genital surgery using single-stage solely penile skin inversion vaginoplasty were included after informed consent and approval by the Institutional Human Ethics Committee. Patients with complications such as deep space surgical site infection (SSI) and neo-vaginal prolapse were excluded. All the study participants were advised a vaginal self-dilatation regimen, reviewed three months after the surgery, and subjected to an MRI of the pelvis with a vaginal tutor. Parameters such as neo-vaginal depth, alpha (α) angle, rectovaginal thickness, and remnant of corpora cavernosa were measured and compared with cis-female parameters measured from images in the archives from the Department of Radiology. Result A total of 21 patients were included in the study, with a mean age of 27±4.7. Between the study group and cis-females, no significant difference was seen in vaginal depth, and cis-females had significantly higher values in other parameters. There was a significant difference between the subgroups, i.e., defaulters and non-defaulters in soft tissue parameters such as vaginal depth (p=0.001), α angle (p=0.002), and rectovaginal thickness (p=0.002) with the non-defaulter patients having higher values. Conclusion Single-stage penile skin inversion vaginoplasty is capable of producing anatomical parameters, importantly neo-vaginal depth, which is fairly comparable with cis-female, as evident in the non-defaulter subgroup patients. Proper compliance with the vaginal dilatation regimen plays a significant role in the maintenance of soft tissue pelvic anatomical parameters.

Withdrawn: Male-to-female and female-to-male transsexual siblings with pedophilic father: A case report

Sheikhmoonesi, F. (2024) "Male-to-female and female-to-male transsexual siblings with pedophilic father: A case report" Clinical Case Reports, 12: e8580. https://doi.org/10.1002/ccr3.8580 The above article, published online on March 5, 2024 in Wiley Online Library (http://wileyonlinelibrary.com), has been withdrawn by agreement between the Journal's Editor-in-Chief, Dr Charles Young, and John Wiley & Sons, Ltd. The article came under investigation following reports by multiple third parties who expressed concerns about the patient consent described, as well as concerns about the methodology and the inclusion of potentially stigmatizing content. Significantly, the author included potentially identifiable information about the patients and family which was not fully appreciated during peer review. Upon request, the author provided copies of consent forms for two of the individuals described. An investigation by the publisher found that the consent forms did not conform to the Journal's nor Wiley's guidelines. Additionally, the author did not provide a consent form for one research subject whose private details were disclosed. In summary, through an investigation by the publisher, it was determined that patient consent had not been properly obtained and that anonymity had not been properly maintained in the published article, which would risk the identification of the patients and necessitated withdrawal. The author disagrees with the withdrawal.

Attitudes and Beliefs Towards Transgender Individuals Among Residents of Mashhad, Iran in 2020

A growing number of studies show that transgender people are at higher risk for psychiatric morbidities. This increased vulnerability can result from the discrimination, violence, and other forms of stigma transgender people experience. Several studies have assessed the stigma by studying the public attitudes and beliefs towards transgender people. Using the Genderism and Transphobia Scale, we evaluated how citizens of a metropolitan city in Iran think and feel about transgender people. A total number of 1202 participants, with a mean age of 41.57 years ± 13.41 (27.4% cisgender men and 72.6% cisgender women), were recruited via a random cluster sampling. Demographic data and socioeconomic status were collected for all the participants. The findings showed a notable level of transphobia. Participants identifying as men, being single, personally acquainted with a transgender individual, possessing a higher education, and having a higher socioeconomic standing displayed significantly more positive views towards transgender people. Iranian transgender people, living under a theocratic state, experience more challenges compared to those live in Western countries. Our findings demonstrate that educational level accounted for much of the variance in transgender attitudes. Therefore, representing transgender issues in social media can educate the general population and positively change attitudes and behaviors.

Young transgender individuals' lived experiences of facing life's challenges: a qualitative study in Iran

Introduction

In recent years, several studies have addressed the challenges and psychological issues that transgender individuals face. However, only a few studies have explored the experiences of this population in Iran. Life experiences are heavily influenced by the dominant religious and cultural conditions and common beliefs in a society. The present study aimed to investigate transgender individuals' lived experiences of facing life's challenges in Iran.

Methods

This is a qualitative study with a descriptive and phenomenological design conducted from February to April 2022. Data were collected using semi-structured, in-depth interviews with 23 transgender individuals (13 AFAB and 10 AMAB). The collected data were analyzed using Colaizzi's method.

Results

Analysis of the qualitative data resulted in the emergence of three themes and 11 subthemes. The three main themes included mental health disparities (fear of having one's secret revealed, depression and despair, suicidal thoughts, and secrecy in the family), gender dysphoria (contradictory gender identity and contradictory behaviors), and stigma and insecurity (sexual abuse, social discrimination, disrupted occupational performance, a lack of support, disrepute, and disgrace).

Conclusions

The findings of the study indicated that transgender people in Iran are exposed to considerable mental health disparities. In addition to disrepute, infamy, and stigma, transgender people face sexual abuse, social discrimination, and a lack of family social support. The results of the present study can help mental health experts and the healthcare system as a whole to adjust their mental and physical health programs according to the needs and experiences of transgender people and their families. It is recommended that future research address the problems and psychological challenges that transgender people's families have to confront.

Evolution and trends in referrals to a specialist gender identity unit in Spain over 10 years (2012-2021)

BACKGROUND

International studies have reported an increase in referrals to gender identity units, a shift in the assigned sex ratio of adolescents, a decrease in the age at first visit, and a growing presence of individuals with nonbinary gender identities.

AIM

To investigate whether these trends are present in a Spanish sample of individuals referred to a gender identity unit over the last 10 years.

METHODS

We conducted a retrospective chart review of 913 consecutive referrals to a gender identity unit between 2012 and 2021 and retrieved information regarding sex assigned at birth, age at first visit, and expressed gender identity. We stratified the patients into 5 age categories: children (<12 years), adolescents (12-17 years), young adults (18-25 years), adults (26-45 years), and older adults (>45 years). The data were analyzed via descriptive and regression analyses.

OUTCOMES

Outcomes included the number of annual referrals, age at first visit, assigned sex ratio, and individuals with nonbinary gender identities.

RESULTS

The number of referrals increased 10-fold, from 18 in 2012 to 189 in 2021. The rates of increase over time were significantly more pronounced for adolescents and young adults and significantly greater for those assigned female at birth (AFAB). The age of referrals at first visit decreased, and AFAB individuals were, on average, younger than individuals assigned male at birth. The assigned sex ratio favored AFAB patients among adolescents (2.4:1) and young adults (1.75:1). Logistic regression showed that the odds of a new referral being AFAB increased by 9% per calendar year and that adolescent and young adult new referrals were significantly more likely to be AFAB. There were 21 referrals of nonbinary individuals starting in 2017, making up 6.4% of applications in 2021 and 2.9% during the last 5 years.

CLINICAL IMPLICATIONS

The evolution and trends observed in this study highlight the need for expanded resources, competent care, and careful reflection about implications for best practice.

STRENGTHS AND LIMITATIONS

This investigation involves a large sample of patients and is the first in our country to include people of all ages. However, the findings might not be generalizable to other gender identity units or the broader population of gender-diverse individuals.

CONCLUSION

Overall, our findings were consistent with previous international reports. We observed a marked increase in referrals, particularly among AFAB adolescents and young adults, a decreased age at first visit, and a growing presence of nonbinary individuals.