Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1)

[Recommendations for Primary Health Care for transgender people]

The WHO defines Primary Health Care as essential health care, based on practical, scientifically founded and socially acceptable methods and technologies, made available to all individuals and families in the community, through their full participation, and at a cost that the community and the country can bear, at each and every stage of their development, in a spirit of self-responsibility and self-determination. With the intention of fulfilling the basic objective of caring for and promoting health in all the groups that make up our current society, the need arises to focus on certain groups in which the actions of Primary Care are currently consensual or poorly protocolised, as is the case with the health care of transgender people.

Gender identity: Current concepts and gender-affirming hormone therapy

In the past five years, healthcare organisation for trans people in Spain has changed as laws intended to protect sexual and gender diversity have been put in place. As a result, endocrinologists are not only on the front lines (understood as prescribing and following up gender-affirming hormone therapy) but also coordinating multidisciplinary healthcare for these individuals. Advances in transgender medicine, the complexity of diverse trans identities and the impact of hormone therapy on quality of life and risk of middle- and long-term complications call for in-depth examination of a personalised biopsychosocial approach to trans people that requires specific training in this field of knowledge as well as updates on the concepts, terminology and drug treatments used.

Thorax masculinization in a transsexual patient: Inferior pedicle mastectomy without an inverted T scar

Transsexual individuals with gender dysphoria or gender identity disorder are rare, with a prevalence reported to range from 0.002% to 0.014%. Studies have shown that mastectomy yields significant improvements in body image and self-esteem in female-to-male transsexual patients. In patients with grade III breast ptosis, mastectomy with a nipple-areolar complex (NAC) graft is the most commonly used technique, although it has several disadvantages. In the case described herein, a bilateral mastectomy preserving the NAC in an inferior pedicle was performed. Additionally, a thin superior thoracic dermal-fat flap was preserved and eventually sutured at the previous inframammary fold, preventing an inverted T scar. This case shows the advantage of this technique for preserving the blood supply and innervation of the NAC, with a low hypopigmentation risk. Furthermore, in this technique, the patch effect does not impair the results of the NAC graft, and there is no need to use an inverted T scar that may result in thoracic feminization.

Low estrogen doses normalize testosterone and estradiol levels to the female range in transgender women

OBJECTIVE

The ideal dosage of cross-sex hormones remains unknown. The aim of this study was to evaluate the luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin levels after low-dose estrogen therapy with or without cyproterone acetate in transgender women.

METHODS

The serum hormone and biochemical profiles of 51 transgender women were evaluated before gonadectomy. Hormone therapy consisted of conjugated equine estrogen alone or combined with cyproterone acetate. The daily dose of conjugated equine estrogen was 0.625 mg in 41 subjects and 1.25 mg in 10 subjects, and the daily dose of cyproterone acetate was 50 mg in 42 subjects and 100 mg in one subject.

RESULTS

Estrogen-only therapy reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 731.5 to 18 ng/dL, 6.3 to 1.1 U/L and 9.6 to 1.5 U/L, respectively. Estrogen plus cyproterone acetate reduced the testosterone, luteinizing hormone and follicle-stimulating hormone levels from 750 to 21 ng/dL, 6.8 to 0.6 U/L and 10 to 1.0 U/L, respectively. The serum levels of luteinizing hormone, follicle-stimulating hormone, testosterone, estradiol and prolactin in the patients treated with estrogen alone and estrogen plus cyproterone acetate were not significantly different. The group receiving estrogen plus cyproterone acetate had significantly higher levels of gamma-glutamyltransferase than the group receiving estrogen alone. No significant differences in the other biochemical parameters were evident between the patients receiving estrogen alone and estrogen plus cyproterone acetate.

CONCLUSION

In our sample of transgender women, lower estrogen doses than those usually prescribed for these subjects were able to adjust the testosterone and estradiol levels to the physiological female range, thus avoiding high estrogen doses and their multiple associated side effects.

Position statement: Gender dysphoria in childhood and adolescence. Working Group on Gender Identity and Sexual Development of the Spanish Society of Endocrinology and Nutrition (GIDSEEN)

Gender dysphoria (GD) in childhood and adolescence is a complex condition where early detection and comprehensive treatment are essential to improve quality of life, decrease mental comorbidity, and improve GD. In this position statement, the Working Group on Gender Identity and Sexual Development of the Spanish Society of Endocrinology and Nutrition (GIDSEEN), consisting of specialists in Endocrinology, Psychology, Psychiatry, Pediatrics and Sociology, sets out recommendations for evaluation and treatment of GD in children and adolescents. Interdisciplinary management of GD should be carried out at specialized units (UTIGs), considering that any clinical intervention should follow the principles of scientific rigor, experience, ethical and deontological principles, and the necessary caution in front of chronic, aggressive, and irreversible treatments.

Differences in personality traits between male-to-female and female-to-male gender identity disorder subjects

The present study aimed to investigate differences in personality traits among male-to-female (MtF), female-to-male (FtM) gender identity disorder (GID) subjects and non-transsexual male (M) and female (F) controls. Subjects were 72 MtF and 187 FtM GID subjects without psychiatric comorbidities together with 184 male and 159 female non-transsexual controls. Personality traits were assessed using a short version of the Temperament and Character Inventory (TCI-125). Group comparisons were made by two-way ANOVA. Statistical significances were observed as follows: 1) lower novelty seeking in FtM than in M or MtF, 2) higher reward dependence in FtM than in M, 3) higher cooperativeness in FtM than in M or MtF, 4) the highest self-transcendence in MtF among all the groups. The highest self-transcendence in MtF subjects may reflect their vulnerable identity and constrained adaptation to society as the minority. Nevertheless, higher reward dependence and cooperativeness in FtM subjects can be related to more determined motivation for the treatments of GID and might promise better social functioning and adjustment than MtF subjects.

Effects of spray-drying on w/o/w multiple emulsions prepared from a stearic acid matrix

The goal of this study was to explore the effects of spray-drying on w/o/w double emulsions of methyltestosterone (MT) loaded in a stearic acid matrix. MT-loaded nanoparticles were formulated by a water-in-oil-in-water emulsion technique using 50, 75, and 100 mg of stearic acid, 2% and 3% w/v polyvinyl alcohol, 5% w/v lactose, and 0.2% w/v chitosan. The emulsions were immediately spray-dried based on an optimized model of inlet temperature and pump rate, and characterized for optimized responses with regard to particle size, polydispersity index, and zeta potential, for both emulsion and powder samples. Dynamic light scattering analysis shown that the nanoparticles increased in size with increasing concentrations of polyvinyl alcohol and stearic acid. Scanning electron microscopy indicated that the MT-loaded nanoparticles were spherical in shape, had a smooth surface, and were in an amorphous state, which was confirmed by differential scanning calorimetry. These MT-loaded nanoparticles are a promising candidate carrier for the delivery of MT; however, further studies are needed in order to establish the stability of the system and the cargo release profile under normal conditions of use.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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