Incidence and sex ratio of transsexualism in Sweden

Oral health status among transgender young adults: a cross-sectional study

BACKGROUND

Transgender and gender nonconforming (TGNC) people are a marginalized set of the population that continues to experience health care inequalities. This study aimed to assess oral health parameters including Candida growth and intensity among TGNC adults.

METHODS

This cross-sectional study recruited two subgroups: 40 transgender and 40 control adults. Consented participants were interviewed and clinically examined. Data using the WHO oral health assessment forms were obtained. Samples for Candida growth and intensity analysis were collected from the dorsum surface of the tongue.

RESULTS

27.5% of the transgender group was HIV seropositive. Oral nicotine stomatitis and leukoplakia are reported to be the most prevalent intra-oral lesions showing a prevalence of 27.5% and 20%, respectively. The dental and periodontal health parameters of the transgender group were worse than those of the control group. The intensity of Candida colonies was significantly higher in the test group (p = 0.014).

CONCLUSION

Poor oral health and significant oral mucosal disorders were reported in transgender adults that have shown a higher rate of behavioral risk factors such as tobacco and alcohol consumption. Further longitudinal studies in different world regions are warranted to understand the barriers to good oral health in transgender adults and how to implement effective prevention and management strategies.

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.

Online Patient Resources for Gender Affirmation Surgery: An Analysis of Readability

BACKGROUND

Gender affirmation surgery is an important treatment for patient with gender dysphoria. It consists of a series of complex procedures, and well-informed patients have been shown to have better outcomes. However, there are no published data regarding the readability of currently available online patient recourses for gender affirmation surgery. This study aims at identifying the most popular online resources and evaluating the readability of these documents in the context of average literacy within the United States.

METHODS

An online search with the terms "gender affirmation surgery," "gender reassignment surgery," "top surgery," and "bottom surgery" was performed. Location, cookies, and user account information was disabled before each search to avoid bias in the results. Readability assessment was performed using the 10 commonly used readability scales.

RESULTS

The overall mean readability level was 13.4. The mean reading level was 14 (range, 7.6-17.0) for the search term "gender affirmation surgery," 14.2 (range, 11.9-16.7) for the search term "gender reassignment surgery," 13 (range, 8.9-17.5) for the search term "top surgery," and 12.6 (range, 7.1-15.0) for the search term "bottom surgery." There was no statistically significant difference between the search terms.

CONCLUSIONS

Our findings demonstrate that the articles most commonly seen by patients who perform an Internet search for information on gender reassignment surgery are more difficult than the recommended readability level.

Quality of Life before and after Andro-Gynoid and Gynoandroid Conversion Surgery

Our study intended to assess if surgery could be able to improve transsexuals’ QoL (quality of life); 16 subjects were asked to fill in a test form to verify quality of life before and after andro-gynoid conversion surgery.

Other individuals were studied as follows: 18 MtoF (andro-gynoid) subjects awaiting surgery; 16 MtoF subjects who had been operated on more than one year before; 13 FtoM (gynoandroid) individuals waiting for surgery; 4 FtoM subjects after surgery.

The “Quality of Life Enjoyment and Satisfaction Questionnaire - Q-LES-Q” (Endicott 1993) was drawn up: this is a self-report questionnaire which assesses the degree of enjoyment and satisfaction experienced by subjects in various areas of daily functioning. Outcomes confirmed the assumption of origin.

Gender dysphoria - prevalence and co-morbidities in an irish adult population

INTRODUCTION

Gender dysphoria (GD) is a condition in which there is a marked incongruence between an individual's psychological perception of his/her sex and their biological phenotype. Gender identity disorder was officially renamed "gender dysphoria" in the DSM-V in 2013. The prevalence and demographics of GD vary according to geographical location and has not been well-documented in Ireland.

METHODS

We retrospectively reviewed medical records of 218 patients with suspected or confirmed GD referred to our endocrine service for consideration of hormonal therapy (HT) between 2005 and early 2014. We documented their demographics, clinical characteristics, and treatment during the study period.

RESULTS

The prevalence of GD in the Irish population was 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM), similar to reported figures in Western Europe. 159 of the patients were MTF and 59 were FTM, accounting for 72.9% and 27.1% of the cohort, respectively. The rate of referral has increased year-on-year, with 55 patients referred in 2013 versus 6 in 2005. Mean ages were 32.6 years (MTF) and 32.2 years (FTM). 22 of the patients were married and 41 had children, with 2 others having pregnant partners. 37.6% were referred by a psychologist, with the remainder evenly divided between GPs and psychiatric services. There were low rates of coexistent medical illness although psychiatric conditions were more prevalent, depression being a factor in 34.4% of patients. 5.9% of patients did not attend a mental health professional. 74.3% are currently on HT, and 9.17% have had gender reassignment surgery (GRS). Regret following hormonal or surgical treatment was in line with other Western European countries (1.83%).

CONCLUSION

The incidence of diagnosis and referral of GD in Ireland is increasing. This brings with it multiple social, health, and financial implications. Clear and accessible treatment pathways supported by mental health professionals is essential.

Factors predicting psychiatric co-morbidity in gender-dysphoric adults

Persons with gender identity disorder (GID) often suffer from psychiatric co-morbidity, and it is an important prognostic factor for long-term psychosocial adjustment in GID. However, previous research has not addressed the risk factors of psychiatric co-morbidity. In this study, we tried to clarify the risk factors among individuals with GID in Japan. A total of 326 consecutive GID persons were evaluated independently by two senior psychiatrists at the GID clinic using personal clinical interviews and results of examinations. The prevalence of current psychiatric co-morbidity was 17.8% of the total sample. School refusal was significantly associated with psychiatric co-morbidity. Sexual attraction to neither males nor females among GID persons and sexual attraction to females among male-to-female (MtF) GID persons were also significantly related to psychiatric co-morbidity. This is the first report to demonstrate a close relationship between patterns of sexual orientation and psychiatric co-morbidity among GID persons. We should pay more attention to psychiatric co-morbidity, especially among GID persons with non-homosexual sexual orientations.

School refusal by patients with gender identity disorder

OBJECTIVE

The accumulating evidence suggests that school refusal behavior is associated with severe negative outcomes. However, previous research has not addressed school refusal by patients with gender identity disorder (GID). In this study, we tried to clarify the prevalence of school refusal among GID patients and the relationship of school refusal to demographic characteristics.

METHODS

A total of 579 consecutive Japanese GID patients at the outpatient GID Clinic of Okayama University Hospital between April 1997 and October 2005 were evaluated.

RESULTS

The prevalence of school refusal was 29.2% of the total sample. School refusal was more frequent among GID patients with divorced parents than those with intact families. Multiple logistic regression analysis showed that younger age at consultation and divorce of parents were significantly associated with school refusal among the male-to-female GID patients.

CONCLUSION

The rate of school refusal among GID patients is high, and school refusal is closely related with a low level of education and current unemployment. We should pay more attention to GID patients of school age to prevent their school refusal, which results in low educational achievement.

Female-to-male transgender chest reconstruction: a large consecutive, single-surgeon experience

INTRODUCTION

Chest reconstruction in the female-to-male transgender individual is not a common procedure due to the low prevalence of intractable gender dysphoria. It means that few surgeons acquire sufficient expertise and many UK patients find themselves travelling abroad to centres such as Singapore, Amsterdam and the United States.

PATIENTS AND METHODS

This study retrospectively evaluated 100 consecutive patients of a single surgeon over a 3-year period with prime outcome measures including surgical technique, complications, surgical revision and patient-reported satisfaction, using a simple, 1-5 linear analogue scoring system.

RESULTS

The median age was 28 years with a median excision of 345 g per breast. Complications occurred in 11 patients, five of which required surgical haematoma evacuation. Chi(2) analysis failed to show a correlation between testosterone supplementation and haemorrhagic sequelae (p>0.1). To date, 16 patients have undergone supplementary surgery, predominantly axillary dog-ear revision. Overall patient-reported satisfaction was 4.25.

CONCLUSIONS

Whilst only a part of the process in gender transitioning, chest reconstruction is important as it is frequently the initial surgical procedure and enables the large-breasted to live in their chosen role much more easily. Historically associated with high rates of both complication and revision surgery, this study demonstrates that both may be appreciably lower and associated with high levels of patient satisfaction so that there is a realistic, high-quality option for British patients who might otherwise feel the need to travel abroad for their surgery.

Suicidal ideation among patients with gender identity disorder

In this study, we tried to clarify the prevalence of suicidal ideation and self-mutilation including suicide attempts among patients with gender identity disorder (GID) and the relationship of those behaviors to demographic characteristics. A total of 500 consecutive Japanese GID patients without any other psychiatric comorbidity were evaluated at the outpatient GID Clinic of Okayama University Hospital. The lifetime rate of suicidal ideation was 72.0% of the total sample. There were no significant differences in the prevalence of suicidal ideation among groups divided by sex, age, age at onset or education. The lifetime prevalence of self-mutilation including suicide attempts was 31.8% of the total sample. Low level of education was significantly related to self-mutilation among both male-to-female and female-to-male GID patients. Younger age at onset was a significant factor affecting self-mutilation only among MTF GID patients. A lack of strategies to cope with severe distress among persons with lower education might induce a high frequency of self-mutilation including suicidal attempt. GID patients with a low level education might be at high risk of self-mutilation and should be watched with special attention to self-mutilation.

Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden

CONTEXT

The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment.

OBJECTIVE

To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons.

DESIGN

A population-based matched cohort study.

SETTING

Sweden, 1973-2003.

PARTICIPANTS

All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively.

MAIN OUTCOME MEASURES

Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]).

RESULTS

The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.

CONCLUSIONS

Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.

Psychiatric comorbidity among patients with gender identity disorder

AIMS

Psychiatric comorbidity and mental instability seem to be important unfavorable prognostic factors for long-term psychosocial adjustment in gender identity disorder (GID). However, psychiatric comorbidity in patients with GID has rarely been assessed. In this study, we investigated the psychiatric comorbidity and life events of patients with GID in Japan.

METHODS

A total of 603 consecutive patients were evaluated independently by at least two senior psychiatrists at the GID clinic using clinical information and results of examinations.

RESULTS

Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).

CONCLUSIONS

Comparison with previous reports on the psychiatric comorbidity among GID patients revealed that the majority of GID patients had no psychiatric comorbidity. GID is a diagnostic entity in its own right, not necessarily associated with severe comorbid psychological findings.

Stress-coping strategies of patients with gender identity disorder

AIMS

Previous research has not addressed gender differences in coping strategies among patients with gender identity disorder (GID). Nor has the relationship of coping strategies to other demographic characteristics ever been clarified in GID. In this study, we tried to clarify the relationship between stress-coping strategies and demographic characteristics among patients with GID.

METHODS

The coping strategies of 344 patients with GID [227 female-to-male (FTM) and 117 male-to-female (MTF)] were assessed using the Japanese version of the Ways of Coping Questionnaires, Lazarus Stress-coping Inventory.

RESULTS

Comparison of the stress-coping inventory between MTF and FTM GID patients revealed that FTM GID patients were significantly more reliant on positive reappraisal strategies in stressful situations than MTF GID patients (P = 0.007).

CONCLUSIONS

The difference in the usage of positive reappraisal strategies between MTF and FTM type GID patients was not explained by other demographic characteristics, and we suppose that the gender difference in GID patients might influence the usage of positive reappraisal strategies. The ratio of FTM GID patients might be higher at our center because MTF GID patients can obtain vaginoplasty easily, whereas phalloplasty surgery for FTM GID patients is performed at only a few centers, including our clinic, in Japan. As a result, more FTM GID patients come to our clinic with a clear intention to undergo sexual rearrangement surgery, which might influence the gender difference in using positive reappraisal.

Clinical characteristics of patients with gender identity disorder at a Japanese gender identity disorder clinic

The aim of this study was to examine the clinical characteristics of patients with gender identity disorder (GID) at a GID clinic in Japan. A total of 603 consecutive patients were evaluated at the GID clinic using clinical information and results of physical and neurological examinations. Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Four patients were excluded for transvestic fetishism, eight for homosexuality, five for schizophrenia, three for personality disorders, and four for other psychiatric disorders. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Almost all FTM-type GID patients started to feel discomfort with their sex before puberty and were sexually attracted to females. The proportion of FTM patients who had experienced marriage as a female was very low, and very few had children. Therefore, FTM-type GID patients seem to be highly homogeneous. On the other hand, various patterns of age at onset and sexual attraction existed among MTF patients. Among the MTF-type GID patients, 28.3% had married as males and 18.7% had sired children. Thus, MTF-type GID patients seem to be more heterogeneous.

Sex steroid-related genes and male-to-female transsexualism

Transsexualism is characterised by lifelong discomfort with the assigned sex and a strong identification with the opposite sex. The cause of transsexualism is unknown, but it has been suggested that an aberration in the early sexual differentiation of various brain structures may be involved. Animal experiments have revealed that the sexual differentiation of the brain is mainly due to an influence of testosterone, acting both via androgen receptors (ARs) and--after aromatase-catalyzed conversion to estradiol--via estrogen receptors (ERs). The present study examined the possible importance of three polymorphisms and their pairwise interactions for the development of male-to-female transsexualism: a CAG repeat sequence in the first exon of the AR gene, a tetra nucleotide repeat polymorphism in intron 4 of the aromatase gene, and a CA repeat polymorphism in intron 5 of the ERbeta gene. Subjects were 29 Caucasian male-to-female transsexuals and 229 healthy male controls. Transsexuals differed from controls with respect to the mean length of the ERbeta repeat polymorphism, but not with respect to the length of the other two studied polymorphisms. However, binary logistic regression analysis revealed significant partial effects for all three polymorphisms, as well as for the interaction between the AR and aromatase gene polymorphisms, on the risk of developing transsexualism. Given the small number of transsexuals in the study, the results should be interpreted with the utmost caution. Further study of the putative role of these and other sex steroid-related genes for the development of transsexualism may, however, be worthwhile.

Sex differences in the hypothalamus in the different stages of human life

Quite a number of structural and functional sex differences have been reported in the human hypothalamus and adjacent structures that may be related to not only reproduction, sexual orientation and gender identity, but also to the often pronounced sex differences in prevalence of psychiatric and neurological diseases. One of the recent focuses of interest in this respect is the possible beneficial effect of sex hormones on cognition in Alzheimer patients. The immunocytochemical localization of estrogen receptors (ER) alpha, beta and androgen receptors has shown that there are indeed numerous targets for sex hormones in the adult human brain. Observations in the infundibular nucleus have, however, indicated that in this brain area the hyperactivity resulting from a lack of estrogens in the menopause seems to protect females against Alzheimer changes, in contrast to males. It is thus quite possible that estrogen replacement therapy may, in these brain areas, lead to inhibition of neuronal metabolism and thus to the same proportion of Alzheimer changes as are observed in men. Knowledge about the functional sex differences in the brain and the effect of sex hormones on neuronal metabolism may thus provide clues not only for the possible beneficial effects of these hormones (e.g., on cognition or hypertension), but also on possible central side effects of estrogen replacement therapy.

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.

Correcting deficiencies in HIV/AIDS care for transgendered individuals

Studies suggest that transgendered individuals are at high risk for acquiring HIV through injection drug use and sexual risk behaviors. Beginning efforts are being directed to identify the unique needs and concerns of these individuals and to develop culturally sensitive programs that will be successful in recruiting and retaining these individuals in drug abuse and HIV treatment services. These efforts include examining the available and needed services from the perspectives of both the transgendered community and health care professionals. This article reviews the phenomenon of transgenderism and the social context that places these individuals at risk for HIV. Additionally, this article proposes some guidelines for those who are in positions responsible for designing, evaluating, and implementing existing health care services to transgendered populations.

Factors predictive of regret in sex reassignment

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Clinical characteristics of a total cohort of female and male applicants for sex reassignment: a descriptive study

The objective of this study was to compare the features of female-to-male transsexuals (F-M) with those of male-to-female transsexuals (M-F) in the cohort of all applicants for sex reassignment over a 20-year period. In an observational, cross-sectional design the cohort was retrospectively identified, consisting of all 233 subjects who applied for sex reassignment in Sweden during the period 1972-1992. The cohort was subdivided into the groups M-F (n=134) and F-M (n=99), and the two groups were compared. M-F were older when applying for sex reassignment surgery than F-M, and more often had a history of marriage and children than their F-M counterparts. M-F also had more heterosexual experience. F-M, on the other hand, more frequently exhibited cross-gender behaviour in childhood than did M-F transsexuals. The present and previous studies strongly support the view that transsexualism manifests itself differently in males and females. Various models for understanding these differences are discussed.