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Moreno JA, Manca R, Albrechet-Souza L, Nel JA, Spantidakis I, Venter Z, Juster RP. A brief historic overview of sexual and gender diversity in neuroscience: past, present, and future. Front Hum Neurosci 2024; 18:1414396. [PMID: 39351068 PMCID: PMC11440198 DOI: 10.3389/fnhum.2024.1414396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 08/14/2024] [Indexed: 10/04/2024] Open
Affiliation(s)
- Jhon Alexander Moreno
- Department of Psychology, Université de Montréal, Montreal, QC, Canada
- Centre de recherche de l'institut universitaire de gériatrie de Montréal, CIUSSS du Centre-Sud-de-l'Île-de-Montréal, Montreal, QC, Canada
- Notre-Dame Hospital, Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal (CCSMTL), Montreal, QC, Canada
| | - Riccardo Manca
- Department of Life Sciences, Brunel University London, Uxbridge, United Kingdom
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Lucas Albrechet-Souza
- Department of Cell Biology and Anatomy, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Juan A. Nel
- Department of Psychology, University of South Africa, Pretoria, South Africa
| | | | - Zindi Venter
- Department of Psychology, University of South Africa, Pretoria, South Africa
| | - Robert-Paul Juster
- Department of Psychiatry and Addiction, Université de Montréal, Montreal, QC, Canada
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Bakker J. Neurobiological characteristics associated with gender identity: Findings from neuroimaging studies in the Amsterdam cohort of children and adolescents experiencing gender incongruence. Horm Behav 2024; 164:105601. [PMID: 39029340 DOI: 10.1016/j.yhbeh.2024.105601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 07/05/2024] [Accepted: 07/05/2024] [Indexed: 07/21/2024]
Abstract
This review has been based on my invited lecture at the annual meeting of the Society for Behavioral Neuroendocrinology in 2023. Gender incongruence is defined as a marked and persistent incongruence between an individual's experienced gender and the sex assigned at birth. A prominent hypothesis on the etiology of gender incongruence proposes that it is related to an altered or less pronounced sexual differentiation of the brain. This hypothesis has primarily been based on postmortem studies of the hypothalamus in transgender individuals. To further address this hypothesis, a series of structural and functional neuroimaging studies were conducted in the Amsterdam cohort of children and adolescents experiencing gender incongruence. Additional research objectives were to determine whether any sex and gender differences are established before or after puberty, as well as whether gender affirming hormone treatment would affect brain development and function. We found some evidence in favor of the sexual differentiation hypothesis at the functional level, but this was less evident at the structural level. We also observed some specific transgender neural signatures, suggesting that they might present a unique brain phenotype rather than being shifted towards either end of the male-female spectrum. Our results further suggest that the years between childhood and mid-adolescence represent an important period in which puberty-related factors influence several neural characteristics, such as white matter development and functional connectivity patterns, in both a sex and gender identity specific way. These latter observations thus lead to the important question about the possible negative consequences of delaying puberty on neurodevelopment. To further address this question, larger-scale, longitudinal studies are required to increase our understanding of the possible neurodevelopmental impacts of delaying puberty in transgender youth.
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Affiliation(s)
- Julie Bakker
- GIGA Neurosciences, University of Liège, Belgium.
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3
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Torgerson C, Ahmadi H, Choupan J, Fan CC, Blosnich JR, Herting MM. Sex, gender diversity, and brain structure in early adolescence. Hum Brain Mapp 2024; 45:e26671. [PMID: 38590252 PMCID: PMC11002534 DOI: 10.1002/hbm.26671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 02/27/2024] [Accepted: 03/13/2024] [Indexed: 04/10/2024] Open
Abstract
There remains little consensus about the relationship between sex and brain structure, particularly in early adolescence. Moreover, few pediatric neuroimaging studies have analyzed both sex and gender as variables of interest-many of which included small sample sizes and relied on binary definitions of gender. The current study examined gender diversity with a continuous felt-gender score and categorized sex based on X and Y allele frequency in a large sample of children ages 9-11 years old (N = 7195). Then, a statistical model-building approach was employed to determine whether gender diversity and sex independently or jointly relate to brain morphology, including subcortical volume, cortical thickness, gyrification, and white matter microstructure. Additional sensitivity analyses found that male versus female differences in gyrification and white matter were largely accounted for by total brain volume, rather than sex per se. The model with sex, but not gender diversity, was the best-fitting model in 60.1% of gray matter regions and 61.9% of white matter regions after adjusting for brain volume. The proportion of variance accounted for by sex was negligible to small in all cases. While models including felt-gender explained a greater amount of variance in a few regions, the felt-gender score alone was not a significant predictor on its own for any white or gray matter regions examined. Overall, these findings demonstrate that at ages 9-11 years old, sex accounts for a small proportion of variance in brain structure, while gender diversity is not directly associated with neurostructural diversity.
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Affiliation(s)
- Carinna Torgerson
- Department of Population and Public Health SciencesUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
- Mark and Mary Stevens Neuroimaging and Informatics InstituteUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Hedyeh Ahmadi
- Department of Population and Public Health SciencesUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Jeiran Choupan
- Mark and Mary Stevens Neuroimaging and Informatics InstituteUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Chun Chieh Fan
- Center for Population Neuroscience and GeneticsLaureate Institute for Brain ResearchTulsaOklahomaUSA
- Department of Radiology, School of MedicineUniversity of CaliforniaSan DiegoCaliforniaUSA
| | - John R. Blosnich
- Suzanne Dworak‐Peck School of Social WorkUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Megan M. Herting
- Department of Population and Public Health SciencesUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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4
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Anger JT, Case LK, Baranowski AP, Berger A, Craft RM, Damitz LA, Gabriel R, Harrison T, Kaptein K, Lee S, Murphy AZ, Said E, Smith SA, Thomas DA, Valdés Hernández MDC, Trasvina V, Wesselmann U, Yaksh TL. Pain mechanisms in the transgender individual: a review. FRONTIERS IN PAIN RESEARCH 2024; 5:1241015. [PMID: 38601924 PMCID: PMC11004280 DOI: 10.3389/fpain.2024.1241015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 01/25/2024] [Indexed: 04/12/2024] Open
Abstract
Specific Aim Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research. Methods A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research. Results While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain. Conclusions While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.
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Affiliation(s)
- Jennifer T. Anger
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Laura K. Case
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Andrew P. Baranowski
- Pelvic Pain Medicine and Neuromodulation, University College Hospital Foundation Trust, University College London, London, United Kingdom
| | - Ardin Berger
- Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA, United States
| | - Rebecca M. Craft
- Department of Psychology, Washington State University, Pullman, WA, United States
| | - Lyn Ann Damitz
- Division of Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC, United States
| | - Rodney Gabriel
- Division of Regional Anesthesia, University of California San Diego, San Diego, CA, United States
| | - Tracy Harrison
- Department of OB/GYN & Reproductive Sciences, University of California San Diego, San Diego, CA, United States
| | - Kirsten Kaptein
- Division of Plastic Surgery, University of California San Diego, San Diego, CA, United States
| | - Sanghee Lee
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Anne Z. Murphy
- Neuroscience Institute, Georgia State University, Atlanta, GA, United States
| | - Engy Said
- Division of Regional Anesthesia, University of California San Diego, San Diego, CA, United States
| | - Stacey Abigail Smith
- Division of Infection Disease, The Hope Clinic of Emory University, Atlanta, GA, United States
| | - David A. Thomas
- Office of Research on Women's Health, National Institutes of Health, Bethesda, MD, United States
| | - Maria del C. Valdés Hernández
- Department of Neuroimaging Sciences, Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Victor Trasvina
- Department of Urology, University of California San Diego, San Diego, CA, United States
| | - Ursula Wesselmann
- Departments of Anesthesiology and Perioperative Medicine/Division of Pain Medicine, Neurology and Psychology, and Consortium for Neuroengineering and Brain-Computer Interfaces, The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Tony L. Yaksh
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
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Almås EM, Benestad EEP, Bolstad SH, Karlsen TI, Giami A. Gender Identity Orientation and Sexual Activity-A Survey among Transgender and Gender-Diverse (TGD) Individuals in Norway. Healthcare (Basel) 2024; 12:482. [PMID: 38391857 PMCID: PMC10888209 DOI: 10.3390/healthcare12040482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND The understanding and conceptualizing of gender and sexuality are continuously negotiated between individuals and cultures. Recently, new gender identity orientations have emerged, fighting pathologization and establishing new spaces and options for being sexually active gendered beings. OBJECTIVE To investigate variations in sexual activities across different gender identity orientations. METHOD A questionnaire used in France was adapted to the Norwegian context and implemented in this study. The participants were recruited through therapists, TGD organizations, and social media. RESULTS A total of 538 individuals responded to the questionnaire, of which 336 provided a written description of their gender identity. Based on an analysis of the degree of male gender identity orientation, the degree of female gender identity orientation, and the degree of nonbinary gender identity orientation, three clusters appeared and were used in the analyses of sexual activities and preferences. CONCLUSIONS Some findings could be attributed to lingering aspects of traditional gender roles, while others may be indicative of sexual expression stemming from societal acceptance of gender diversity and new identity orientations.
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Affiliation(s)
- Elsa Mari Almås
- Department of Psychosocial Health, University of Agder, 4604 Kristiansand, Norway
| | | | - Silje-Håvard Bolstad
- Department of Psychosocial Health, University of Agder, 4604 Kristiansand, Norway
| | - Tor-Ivar Karlsen
- Department of Psychosocial Health, University of Agder, 4604 Kristiansand, Norway
| | - Alain Giami
- INSERM (National Institute of Health and Medical Research), 94807 Paris, France
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Hunter SK, S Angadi S, Bhargava A, Harper J, Hirschberg AL, D Levine B, L Moreau K, J Nokoff N, Stachenfeld NS, Bermon S. The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine. Med Sci Sports Exerc 2023; 55:2328-2360. [PMID: 37772882 DOI: 10.1249/mss.0000000000003300] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
ABSTRACT Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.
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Affiliation(s)
- Sandra K Hunter
- Exercise Science Program, Department of Physical Therapy, and Athletic and Human Performance Center, Marquette University, Milwaukee, WI
| | | | - Aditi Bhargava
- Department of Obstetrics and Gynecology, Center for Reproductive Sciences, University of California, San Francisco, CA
| | - Joanna Harper
- Loughborough University, Loughborough, UNITED KINGDOM
| | - Angelica Lindén Hirschberg
- Department of Women's and Children's Health, Karolinska Institutet, and Department of Gynecology and Reproductive Medicine, Karolinska University Hospital, Stockholm, SWEDEN
| | - Benjamin D Levine
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital Dallas, and the Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kerrie L Moreau
- Department of Medicine, Division of Geriatric Medicine, University of Colorado Anschutz Medical Campus, and Eastern Colorado Health Care System, Geriatric Research Education and Clinical Center, Aurora, CO
| | - Natalie J Nokoff
- Department of Pediatrics, Section of Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Nina S Stachenfeld
- The John B. Pierce Laboratory and Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT
| | - Stéphane Bermon
- Health and Science Department, World Athletics, Monaco and the LAMHESS, University Côte d'Azur, Nice, FRANCE
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Fazli Khalaf Z, Liow JW, Nalliah S, Foong ALS. When Health Intersects with Gender and Sexual Diversity: Medical Students' Attitudes Towards LGBTQ Patients. JOURNAL OF HOMOSEXUALITY 2023; 70:1763-1786. [PMID: 35285780 DOI: 10.1080/00918369.2022.2042662] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A central tenet of the health professions is that of equitable access to health care. However, disparities in equitable healthcare provision continues to be a challenge in many societies due to prejudices against the LGBTQ community. This study was aimed at exploring the attitudes of medical students toward LGBTQ patients in Malaysia. A qualitative approach was adopted to seek depth of understanding of clinical year medical students' perceptions and attitudes toward LGBTQ patients. Data were collected in 2018 through individual interviews and focus group discussions with a total of 29 participants, using a semi-structured question guideline. Purposive sampling comprised representation from the three major ethnic groups in Malaysia. Thematic analysis using NVivo highlighted three main themes i.e., neutrality, in compliance with the Professional Code of Conduct; implicit biases and tolerance of an Odd Identity; explicit biases with prejudices and stereotyping. The lack of knowledge and understanding of the nature and issues of sexuality is problematic as found in this study. They are primarily biases and prejudices projected onto marginalized LGBTQ patients who must contend with multiple jeopardies in conservative societies such as in Malaysia. With some state policies framed around Islam the concern is with the belief among Malay/Islamic students for LGBTQ individuals to go through conversion 'therapies' to become cisgender and heterosexual.
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Affiliation(s)
- Zahra Fazli Khalaf
- Department of Psychology, College of Health and Human Sciences, North Carolina A&T State University, Greensboro, North Carolina, USA
| | - Jun Wei Liow
- Department of Social Work and Social Administration, The University of Hong Kong, Pokfulam, Hong Kong
| | - Sivalingam Nalliah
- School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Andrew L S Foong
- College of Health & Medicine, University of Tasmania, Hobart, Australia
- Faculty of Social Sciences, Quest International University, Perak Darul Ridzuan, Ipoh, Malaysia
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8
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Torgerson C, Ahmadi H, Choupan J, Fan CC, Blosnich JR, Herting MM. Sex, gender diversity, and brain structure in children ages 9 to 11 years old. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.28.551036. [PMID: 37546960 PMCID: PMC10402171 DOI: 10.1101/2023.07.28.551036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
There remains little consensus about the relationship between sex and brain structure, particularly in childhood. Moreover, few pediatric neuroimaging studies have analyzed both sex and gender as variables of interest - many of which included small sample sizes and relied on binary definitions of gender. The current study examined gender diversity with a continuous felt-gender score and categorized sex based on X and Y allele frequency in a large sample of children ages 9-11 years-old (N=7693). Then, a statistical model-building approach was employed to determine whether gender diversity and sex independently or jointly relate to brain morphology, including subcortical volume, cortical thickness, gyrification, and white matter microstructure. The model with sex, but not gender diversity, was the best-fitting model in 75% of gray matter regions and 79% of white matter regions examined. The addition of gender to the sex model explained significantly more variance than sex alone with regard to bilateral cerebellum volume, left precentral cortical thickness, as well as gyrification in the right superior frontal gyrus, right parahippocampal gyrus, and several regions in the left parietal lobe. For mean diffusivity in the left uncinate fasciculus, the model with sex, gender, and their interaction captured the most variance. Nonetheless, the magnitude of variance accounted for by sex was small in all cases and felt-gender score was not a significant predictor on its own for any white or gray matter regions examined. Overall, these findings demonstrate that at ages 9-11 years-old, sex accounts for a small proportion of variance in brain structure, while gender diversity is not directly associated with neurostructural diversity.
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Affiliation(s)
- Carinna Torgerson
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
- Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, CA, USA
| | - Hedyeh Ahmadi
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Jeiran Choupan
- Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, CA, USA
| | - Chun Chieh Fan
- Center for Population Neuroscience and Genetics, Laureate Institute for Brain Research, Tulsa, OK, USA
- Department of Radiology, School of Medicine, University of California, San Diego
| | - John R. Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Megan M. Herting
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
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van Heesewijk J, Steenwijk MD, Kreukels BPC, Veltman DJ, Bakker J, Burke SM. Alterations in the inferior fronto-occipital fasciculus - a specific neural correlate of gender incongruence? Psychol Med 2023; 53:3461-3470. [PMID: 35301969 PMCID: PMC10277722 DOI: 10.1017/s0033291721005547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 11/06/2021] [Accepted: 12/28/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increasing numbers of adolescents seek help for gender-identity questions. Consequently, requests for medical treatments, such as puberty suppression, are growing. However, studies investigating the neurobiological substrate of gender incongruence (when birth-assigned sex and gender identity do not align) are scarce, and knowledge about the effects of puberty suppression on the developing brain of transgender youth is limited. METHODS Here we cross-sectionally investigated sex and gender differences in regional fractional anisotropy (FA) as measured by diffusion MR imaging, and the impact of puberty on alterations in the white-matter organization of 35 treatment-naive prepubertal children and 41 adolescents with gender incongruence, receiving puberty suppression. The transgender groups were compared with 79 age-matched, treatment-naive cisgender (when sex and gender align) peers. RESULTS We found that transgender adolescents had lower FA in the bilateral inferior fronto-occipital fasciculus (IFOF), forceps major and corpus callosum than cisgender peers. In addition, average FA values of the right IFOF correlated negatively with adolescents' cumulative dosage of puberty suppressants received. Of note, prepubertal children also showed significant FA group differences in, again, the right IFOF and left cortico-spinal tract, but with the reverse pattern (transgender > cisgender) than was seen in adolescents. CONCLUSIONS Importantly, our results of lower FA (indexing less longitudinal organization, fiber coherence, and myelination) in the IFOF of gender-incongruent adolescents replicate prior findings in transgender adults, suggesting a salient neural correlate of gender incongruence. Findings highlight the complexity with which (pubertal) sex hormones impact white-matter development and add important insight into the neurobiological substrate associated with gender incongruence.
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Affiliation(s)
- Jason van Heesewijk
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
| | - Martijn D. Steenwijk
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
| | - Baudewijntje P. C. Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
| | - Dick J. Veltman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
| | - Julie Bakker
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
| | - Sarah M. Burke
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, location VUmc, De Boelelaan 1131, Amsterdam, Noord-Holland, Netherlands
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Transwoman Elite Athletes: Their Extra Percentage Relative to Female Physiology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159103. [PMID: 35897465 PMCID: PMC9331831 DOI: 10.3390/ijerph19159103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 12/03/2022]
Abstract
There is increasing debate as to whether transwoman athletes should be included in the elite female competition. Most elite sports are divided into male and female divisions because of the greater athletic performance displayed by males. Without the sex division, females would have little chance of winning because males are faster, stronger, and have greater endurance capacity. Male physiology underpins their better athletic performance including increased muscle mass and strength, stronger bones, different skeletal structure, better adapted cardiorespiratory systems, and early developmental effects on brain networks that wires males to be inherently more competitive and aggressive. Testosterone secreted before birth, postnatally, and then after puberty is the major factor that drives these physiological sex differences, and as adults, testosterone levels are ten to fifteen times higher in males than females. The non-overlapping ranges of testosterone between the sexes has led sports regulators, such as the International Olympic Committee, to use 10 nmol/L testosterone as a sole physiological parameter to divide the male and female sporting divisions. Using testosterone levels as a basis for separating female and male elite athletes is arguably flawed. Male physiology cannot be reformatted by estrogen therapy in transwoman athletes because testosterone has driven permanent effects through early life exposure. This descriptive critical review discusses the inherent male physiological advantages that lead to superior athletic performance and then addresses how estrogen therapy fails to create a female-like physiology in the male. Ultimately, the former male physiology of transwoman athletes provides them with a physiological advantage over the cis-female athlete.
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11
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Fortunato A, Giovanardi G, Innocenzi E, Mirabella M, Caviglia G, Lingiardi V, Speranza AM. Is It Autism? A Critical Commentary on the Co-Occurrence of Gender Dysphoria and Autism Spectrum Disorder. JOURNAL OF HOMOSEXUALITY 2022; 69:1204-1221. [PMID: 33852376 DOI: 10.1080/00918369.2021.1905385] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
An increasing amount of literature revealed a link between GD and ASD. Both GD and ASD are complex and heterogeneous conditions characterized by a large variety of presentations. Studies have reported that individuals with GD tend to have higher prevalence rates of autistic traits in comparison to the general population. The purpose of this commentary is to provide, through the description of a clinical case, our reading and a possible interpretation of the correlation of these two conditions in light of the several methodological limitations found in literature. We hypothesize that the traits often classified as autistic could be more accurately related to the distress and discomfort evoked by GD. The autistic traits of individuals with GD as forms of psychological defenses and coping mechanisms aimed at dealing with socio-relational and identity problems are discussed.
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Affiliation(s)
- Alexandro Fortunato
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza," University of Rome, Italy
| | - Guido Giovanardi
- Department of Psychology, University of Campania, "Luigi Vanvitelli," University of Caserta, Italy
| | - Eleonora Innocenzi
- Department of Letters and Philosophy, "Tor Vergata," University of Rome, Italy
| | - Marta Mirabella
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza," University of Rome, Italy
| | - Giorgio Caviglia
- Department of Psychology, University of Campania, "Luigi Vanvitelli," University of Caserta, Italy
| | - Vittorio Lingiardi
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza," University of Rome, Italy
| | - Anna Maria Speranza
- Department of Dynamic and Clinical Psychology, and Health Studies, "Sapienza," University of Rome, Italy
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12
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Gavazzi G, Fisher AD, Orsolini S, Bianchi A, Romani A, Giganti F, Giovannelli F, Ristori J, Mazzoli F, Maggi M, Viggiano MP, Mascalchi M. The fMRI correlates of visuo-spatial abilities: sex differences and gender dysphoria. Brain Imaging Behav 2022; 16:955-964. [PMID: 35384549 PMCID: PMC9010387 DOI: 10.1007/s11682-022-00638-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/28/2022]
Abstract
The contribution of brain regions to visuospatial abilities according to sex differences and gender identity is inconsistently described. One potential explaining factor may be the different tasks employed requiring a variable load of working memory and other cognitive resources. Here we asked to 20 cis and 20 transgender participants to undergo functional Magnetic Resonance Imaging during performance of a judgement line of orientation test that was adapted to explore the basic visuospatial processing while minimizing the working memory load. We show that V1 activation may be viewed as a brain area with enhanced activation in males, regardless of participants’ gender identity. On its turn, gender identity exclusively influences the visuospatial processing of extrastriate visual areas (V5) in women with gender dysphoria. They showed enhanced V5 activation and an increased functional connectivity between V5 and V1. Overall our neuroimaging results suggest that the basic visuospatial abilities are associated with different activations pattern of cortical visual areas depending on the sex assigned at birth and gender identity.
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Affiliation(s)
| | - Alessandra Daphne Fisher
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Stefano Orsolini
- Department of Electrical, Electronic, and Information Engineering "Guglielmo Marconi", University of Bologna, Cesena, Italy
| | - Andrea Bianchi
- Neuroradiology Unit, "Careggi" University Hospital, Florence, Italy
| | - Alessia Romani
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Fiorenza Giganti
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Via San Salvi, 12, 50135, Florence, Italy
| | - Fabio Giovannelli
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Via San Salvi, 12, 50135, Florence, Italy
| | - Jiska Ristori
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesca Mazzoli
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Mario Maggi
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Pia Viggiano
- Department of Neuroscience, Psychology, Drug Research, Child Health, University of Florence, Via San Salvi, 12, 50135, Florence, Italy.
| | - Mario Mascalchi
- "Mario Serio" Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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13
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Bakker J. The role of steroid hormones in the sexual differentiation of the human brain. J Neuroendocrinol 2022; 34:e13050. [PMID: 34708466 DOI: 10.1111/jne.13050] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/03/2021] [Accepted: 10/05/2021] [Indexed: 12/31/2022]
Abstract
Widespread sex differences in human brain structure and function have been reported. Research on animal models has demonstrated that sex differences in brain and behavior are induced by steroid hormones during specific, hormone sensitive, developmental periods. It was shown that typical male neural and behavioral characteristics develop under the influence of testosterone, mostly acting during perinatal development. By contrast, typical female neural and behavioral characteristics may actually develop under the influence of estradiol during a specific prepubertal period. This review provides an overview of our current knowledge on the role of steroid hormones in the sexual differentiation of the human brain. Both clinical and neuroimaging data obtained in patients with altered androgen levels/actions (i.e., congenital adrenal hyperplasia or complete androgen insensitivity syndrome [CAIS]), point to an important role of (prenatal) androgens in inducing typical male neural and psychosexual characteristics in humans. In contrast to rodents, there appears to be no obvious role for estrogens in masculinizing the human brain. Furthermore, data from CAIS also suggest a contribution of sex chromosome genes to the development of the human brain. The final part of this review is dedicated to a brief discussion of gender incongruence, also known as gender dysphoria, which has been associated with an altered or less pronounced sexual differentiation of the brain.
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Affiliation(s)
- Julie Bakker
- Neuroendocrinology, GIGA Neurosciences, Liège University, Liege, Belgium
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14
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Rainville JR, Lipuma T, Hodes GE. Translating the Transcriptome: Sex Differences in the Mechanisms of Depression and Stress, Revisited. Biol Psychiatry 2022; 91:25-35. [PMID: 33865609 PMCID: PMC10197090 DOI: 10.1016/j.biopsych.2021.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 12/28/2022]
Abstract
The past decade has produced a plethora of studies examining sex differences in the transcriptional profiles of stress and mood disorders. As we move forward from accepting the existence of extensive molecular sex differences in the brain to exploring the purpose of these sex differences, our approach must become more systemic and less reductionist. Earlier studies have examined specific brain regions and/or cell types. To use this knowledge to develop the next generation of personalized medicine, we need to comprehend how transcriptional changes across the brain and/or the body relate to each other. We provide an overview of the relationships between baseline and depression/stress-related transcriptional sex differences and explore contributions of preclinically identified mechanisms and their impacts on behavior.
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Affiliation(s)
- Jennifer R Rainville
- Department of Neuroscience, Virginia Polytechnic and State University, Blacksburg, Virginia
| | - Timothy Lipuma
- Department of Neuroscience, Virginia Polytechnic and State University, Blacksburg, Virginia
| | - Georgia E Hodes
- Department of Neuroscience, Virginia Polytechnic and State University, Blacksburg, Virginia.
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15
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Burgund ED. Task-domain and hemisphere-asymmetry effects in cisgender and transmale individuals. PLoS One 2021; 16:e0260542. [PMID: 34874973 PMCID: PMC8651105 DOI: 10.1371/journal.pone.0260542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 11/11/2021] [Indexed: 11/25/2022] Open
Abstract
The present research examined the extent to which transmale individuals’ functional brain organization resembles that of their assigned sex or gender identity. Cisgender-female, cisgender-male, and transmale participants, who were assigned female sex but did not have a female gender identity, were compared in terms of effects that have been observed in cisgender individuals: task-domain effects, in which males perform better than females on spatial tasks and females perform better than males on verbal tasks; and hemisphere-asymmetry effects, in which males show larger differences between the left and right hemispheres than females. In addition, the present research measured participants’ intelligence in order to control for potential moderating effects. Participants performed spatial (mental rotation) and verbal (lexical decision) tasks presented to each hemisphere using a divided-visual field paradigm, and then completed an intelligence assessment. In the mental-rotation task, cismale and transmale participants performed better than cisfemale participants, however this group difference was explained by intelligence scores, with higher scores predicting better performance. In the lexical-decision task, cismale and transmale participants exhibited a greater left-hemisphere advantage than cisfemales, and this difference was not affected by intelligence scores. Taken together, results do not support task-domain effects when intelligence is accounted for; however, they do demonstrate a hemisphere-asymmetry effect in the verbal domain that is moderated by gender identity and not assigned sex.
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Affiliation(s)
- E. Darcy Burgund
- Department of Psychology, Macalester College, Saint Paul, Minnesota, United States of America
- * E-mail:
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Zubiaurre-Elorza L, Cerdán S, Uribe C, Pérez-Laso C, Marcos A, Rodríguez del Cerro MC, Fernandez R, Pásaro E, Guillamon A. The Effects of Testosterone on the Brain of Transgender Men. ANDROGENS: CLINICAL RESEARCH AND THERAPEUTICS 2021; 2:252-260. [PMID: 35024694 PMCID: PMC8744429 DOI: 10.1089/andro.2021.0008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 01/28/2023]
Abstract
Transgender men (TM) experience an incongruence between the female sex assigned when they were born and their self-perceived male identity. Some TM seek for a gender affirming hormone treatment (GAHT) to induce a somatic transition from female to male through continuous administration of testosterone. GAHT seems to be relatively safe. However, testosterone produces structural changes in the brain as detected by quantitative magnetic resonance imaging. Mainly, it induces an increase in cortical volume and thickness and subcortical structural volume probably due to the anabolic effects. Animal models, specifically developed to test the anabolic hypothesis, suggest that testosterone and estradiol, its aromatized metabolite, participate in the control of astrocyte water trafficking, thereby controlling brain volume.
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Affiliation(s)
- Leire Zubiaurre-Elorza
- Department of Methods and Experimental Psychology, Faculty of Psychology and Education, University of Deusto, Bilbao, Spain
| | - Sebastian Cerdán
- Instituto de Investigaciones Biomédicas Alberto Sols, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Carme Uribe
- Institute of Neuroscience, University of Barcelona, Barcelona, Spain
| | - Carmen Pérez-Laso
- Departamento de Psicobiología, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Alberto Marcos
- Departamento de Psicobiología, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | | | - Rosa Fernandez
- Departamento de Psicología, Facultade de Ciencias da Educación, Universidade da Coruña, A Coruña, Spain
| | - Eduardo Pásaro
- Departamento de Psicología, Facultade de Ciencias da Educación, Universidade da Coruña, A Coruña, Spain
| | - Antonio Guillamon
- Departamento de Psicobiología, Universidad Nacional de Educación a Distancia, Madrid, Spain
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Frigerio A, Ballerini L, Valdés Hernández M. Structural, Functional, and Metabolic Brain Differences as a Function of Gender Identity or Sexual Orientation: A Systematic Review of the Human Neuroimaging Literature. ARCHIVES OF SEXUAL BEHAVIOR 2021; 50:3329-3352. [PMID: 33956296 PMCID: PMC8604863 DOI: 10.1007/s10508-021-02005-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 05/05/2023]
Abstract
This review systematically explored structural, functional, and metabolic features of the cisgender brain compared with the transgender brain before hormonal treatment and the heterosexual brain compared to the homosexual brain from the analysis of the neuroimaging literature up to 2018, and identified and discussed subsequent studies published up to March 2021. Our main aim was to help identifying neuroradiological brain features that have been related to human sexuality to contribute to the understanding of the biological elements involved in gender identity and sexual orientation. We analyzed 39 studies on gender identity and 24 on sexual orientation. Our results suggest that some neuroanatomical, neurophysiological, and neurometabolic features in transgender individuals resemble those of their experienced gender despite the majority resembling those from their natal sex. In homosexual individuals the majority resemble those of their same-sex heterosexual population rather than their opposite-sex heterosexual population. However, it is always difficult to interpret findings with noninvasive neuroimaging. Given the gross nature of these measures, it is possible that more differences too subtle to measure with available tools yet contributing to gender identity and sexual orientation could be found. Conflicting results contributed to the difficulty of identifying specific brain features which consistently differ between cisgender and transgender or between heterosexual and homosexual groups. The small number of studies, the small-to-moderate sample size of each study, and the heterogeneity of the investigations made it impossible to meta-analyze all the data extracted. Further studies are necessary to increase the understanding of the neurological substrates of human sexuality.
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Affiliation(s)
- Alberto Frigerio
- Division of Health Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
| | - Lucia Ballerini
- Division of Health Sciences, University of Edinburgh, Edinburgh, EH16 4SB, UK
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18
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Ramirez K, Fernández R, Collet S, Kiyar M, Delgado-Zayas E, Gómez-Gil E, Van Den Eynde T, T'Sjoen G, Guillamon A, Mueller SC, Pásaro E. Epigenetics Is Implicated in the Basis of Gender Incongruence: An Epigenome-Wide Association Analysis. Front Neurosci 2021; 15:701017. [PMID: 34489625 PMCID: PMC8418298 DOI: 10.3389/fnins.2021.701017] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction The main objective was to carry out a global DNA methylation analysis in a population with gender incongruence before gender-affirming hormone treatment (GAHT), in comparison to a cisgender population. Methods A global CpG (cytosine-phosphate-guanine) methylation analysis was performed on blood from 16 transgender people before GAHT vs. 16 cisgender people using the Illumina© Infinium Human Methylation 850k BeadChip, after bisulfite conversion. Changes in the DNA methylome in cisgender vs. transgender populations were analyzed with the Partek® Genomics Suite program by a 2-way ANOVA test comparing populations by group and their sex assigned at birth. Results The principal components analysis (PCA) showed that both populations (cis and trans) differ in the degree of global CpG methylation prior to GAHT. The 2-way ANOVA test showed 71,515 CpGs that passed the criterion FDR p < 0.05. Subsequently, in male assigned at birth population we found 87 CpGs that passed both criteria (FDR p < 0.05; fold change ≥ ± 2) of which 22 were located in islands. The most significant CpGs were related to genes: WDR45B, SLC6A20, NHLH1, PLEKHA5, UBALD1, SLC37A1, ARL6IP1, GRASP, and NCOA6. Regarding the female assigned at birth populations, we found 2 CpGs that passed both criteria (FDR p < 0.05; fold change ≥ ± 2), but none were located in islands. One of these CpGs, related to the MPPED2 gene, is shared by both, trans men and trans women. The enrichment analysis showed that these genes are involved in functions such as negative regulation of gene expression (GO:0010629), central nervous system development (GO:0007417), brain development (GO:0007420), ribonucleotide binding (GO:0032553), and RNA binding (GO:0003723), among others. Strengths and Limitations It is the first time that a global CpG methylation analysis has been carried out in a population with gender incongruence before GAHT. A prospective study before/during GAHT would provide a better understanding of the influence of epigenetics in this process. Conclusion The main finding of this study is that the cis and trans populations have different global CpG methylation profiles prior to GAHT. Therefore, our results suggest that epigenetics may be involved in the etiology of gender incongruence.
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Affiliation(s)
- Karla Ramirez
- Laboratory of Psychobiology, Department of Psychology, Institute Advanced Scientific Research Center (CICA), University of A Coruña, A Coruña, Spain.,Laboratory of Neurophysiology, Center for Biophysics and Biochemistry, Venezuelan Institute for Scientific Research (IVIC), Caracas, Venezuela
| | - Rosa Fernández
- Laboratory of Psychobiology, Department of Psychology, Institute Advanced Scientific Research Center (CICA), University of A Coruña, A Coruña, Spain
| | - Sarah Collet
- Department of Endocrinology, Ghent University, Ghent, Belgium
| | - Meltem Kiyar
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Enrique Delgado-Zayas
- Laboratory of Psychobiology, Department of Psychology, Institute Advanced Scientific Research Center (CICA), University of A Coruña, A Coruña, Spain
| | | | | | - Guy T'Sjoen
- Department of Endocrinology, Ghent University, Ghent, Belgium
| | - Antonio Guillamon
- Department of Psychobiology, Faculty of Psychology, National University of Distance Education (UNED), Madrid, Spain
| | - Sven C Mueller
- Department of Experimental Clinical and Health Psychology, Ghent University, Ghent, Belgium
| | - Eduardo Pásaro
- Laboratory of Psychobiology, Department of Psychology, Institute Advanced Scientific Research Center (CICA), University of A Coruña, A Coruña, Spain
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Patisaul HB. Endocrine disrupting chemicals (EDCs) and the neuroendocrine system: Beyond estrogen, androgen, and thyroid. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2021; 92:101-150. [PMID: 34452685 DOI: 10.1016/bs.apha.2021.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hundreds of anthropogenic chemicals occupy our bodies, a situation that threatens the health of present and future generations. This chapter focuses on endocrine disrupting compounds (EDCs), both naturally occurring and man-made, that affect the neuroendocrine system to adversely impact health, with an emphasis on reproductive and metabolic pathways. The neuroendocrine system is highly sexually dimorphic and essential for maintaining homeostasis and appropriately responding to the environment. Comprising both neural and endocrine components, the neuroendocrine system is hormone sensitive throughout life and touches every organ system in the body. The integrative nature of the neuroendocrine system means that EDCs can have multi-system effects. Additionally, because gonadal hormones are essential for the sex-specific organization of numerous neuroendocrine pathways, endocrine disruption of this programming can lead to permanent deficits. Included in this review is a brief history of the neuroendocrine disruption field and a thorough discussion of the most common and less well understood neuroendocrine disruption modes of action. Also provided are extensive examples of how EDCs are likely contributing to neuroendocrine disorders such as obesity, and evidence that they have the potential for multi-generational effects.
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Affiliation(s)
- Heather B Patisaul
- Department of Biological Sciences, Center for Human Health and the Environment, North Carolina State University, Raleigh, NC, United States.
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20
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Wang Y, Khorashad BS, Feusner JD, Savic I. Cortical Gyrification in Transgender Individuals. Cereb Cortex 2021; 31:3184-3193. [PMID: 33718960 PMCID: PMC8324983 DOI: 10.1093/cercor/bhaa412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 12/26/2022] Open
Abstract
Gender incongruence (GI) is characterized by a feeling of estrangement from the own body in the context of self. GI is often described in people who identify as transgender. The underlying mechanisms are unknown. Data from MRI measurements and tests of own body perception triggered us to pose a model that GI in transgender persons (TGI) could be associated with a disconnection within the brain circuits mediating the perception of own body as self. This is a departure from a previous model of sex atypical cerebral dimorphism, introducing a concept that better accords with a core feature of TGI. The present MRI study of 54 hormone naive transmen (TrM), 38 transwomen (TrW), 44 cismen and 41 ciswomen show that cortical gyrification, a metric that reflects early maturation of cerebral cortex, is significantly lower in transgender compared with cisgender participants. This reduction is limited to the occipito-parietal cortex and the sensory motor cortex, regions encoding own body image and body ownership. Moreover, the cortical gyrification correlated inversely with own body-self incongruence in these regions. These novel data suggest that GI in TGI may originate in the neurodevelopment of body image encoding regions. The results add potentially to understanding neurobiological contributors to gender identity.
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Affiliation(s)
- Yanlu Wang
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm 171 77, Sweden
- MR Physics, Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm 171 76, Sweden
| | - Behzad S Khorashad
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Jamie D Feusner
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm 171 77, Sweden
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Ivanka Savic
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm 171 77, Sweden
- Department of Neurology, University of California Los Angeles, Los Angeles, CA 90095-6975, USA
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21
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Dyachenko AV, Perekhov AY, Soldatkin VA, Bukhanovskaya OA. Gender Identity Disorders: Current Medical and Social Paradigm and the ICD-11 Innovations. CONSORTIUM PSYCHIATRICUM 2021; 2:54-61. [PMID: 39070730 PMCID: PMC11272310 DOI: 10.17816/cp68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Indexed: 11/08/2022] Open
Abstract
Introduction This article presents a review of current concepts of gender identity under normal and pathological conditions. Aim To analyse the impact of the medical and social paradigm shift for clinical practice. Results and discussion The modern academic literature devoted to gender identity disorders is characterized by a variety of terminology, a shift in emphasis from clinical judgement to a socially beneficial normocentric approach and a relatively few advanced, evidence-based research. There is also a lack of evidence for the gender theory underlying the new approach, which raises serious doubts about the validity of the medical and social paradigm revision. In the same time, the position of Russian psychiatrists remains to be more clinically oriented. Conclusion Patients who declare the desire to reassign their gender have to be assessed by psychiatrists for differential diagnosis to exclude a mental disorder. In such cases, the destigmatization of mental disorders is more critical than the depathologization of gender identity disorders.
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Bhargava A, Arnold AP, Bangasser DA, Denton KM, Gupta A, Hilliard Krause LM, Mayer EA, McCarthy M, Miller WL, Raznahan A, Verma R. Considering Sex as a Biological Variable in Basic and Clinical Studies: An Endocrine Society Scientific Statement. Endocr Rev 2021; 42:219-258. [PMID: 33704446 PMCID: PMC8348944 DOI: 10.1210/endrev/bnaa034] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Indexed: 02/08/2023]
Abstract
In May 2014, the National Institutes of Health (NIH) stated its intent to "require applicants to consider sex as a biological variable (SABV) in the design and analysis of NIH-funded research involving animals and cells." Since then, proposed research plans that include animals routinely state that both sexes/genders will be used; however, in many instances, researchers and reviewers are at a loss about the issue of sex differences. Moreover, the terms sex and gender are used interchangeably by many researchers, further complicating the issue. In addition, the sex or gender of the researcher might influence study outcomes, especially those concerning behavioral studies, in both animals and humans. The act of observation may change the outcome (the "observer effect") and any experimental manipulation, no matter how well-controlled, is subject to it. This is nowhere more applicable than in physiology and behavior. The sex of established cultured cell lines is another issue, in addition to aneuploidy; chromosomal numbers can change as cells are passaged. Additionally, culture medium contains steroids, growth hormone, and insulin that might influence expression of various genes. These issues often are not taken into account, determined, or even considered. Issues pertaining to the "sex" of cultured cells are beyond the scope of this Statement. However, we will discuss the factors that influence sex and gender in both basic research (that using animal models) and clinical research (that involving human subjects), as well as in some areas of science where sex differences are routinely studied. Sex differences in baseline physiology and associated mechanisms form the foundation for understanding sex differences in diseases pathology, treatments, and outcomes. The purpose of this Statement is to highlight lessons learned, caveats, and what to consider when evaluating data pertaining to sex differences, using 3 areas of research as examples; it is not intended to serve as a guideline for research design.
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Affiliation(s)
- Aditi Bhargava
- Center for Reproductive Sciences, San Francisco, CA, USA
- Department of Obstetrics and Gynecology, University of California, San Francisco, CA, USA
| | - Arthur P Arnold
- Department of Integrative Biology & Physiology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Debra A Bangasser
- Department of Psychology and Neuroscience Program, Temple University, Philadelphia, PA, USA
| | - Kate M Denton
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Victoria, Australia
| | - Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA, USA
| | - Lucinda M Hilliard Krause
- Cardiovascular Disease Program, Monash Biomedicine Discovery Institute and Department of Physiology, Monash University, Clayton, Victoria, Australia
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA, USA
| | - Margaret McCarthy
- Department of Pharmacology and Program in Neuroscience, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Walter L Miller
- Center for Reproductive Sciences, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | - Armin Raznahan
- Section on Developmental Neurogenomics, Human Genetics Branch, National Institutes of Mental Health, Intramural Research Program, Bethesda, MD, USA
| | - Ragini Verma
- Diffusion and Connectomics In Precision Healthcare Research (DiCIPHR) lab, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Fernández R, Ramírez K, Gómez-Gil E, Cortés-Cortés J, Mora M, Aranda G, Zayas ED, Esteva I, Almaraz MC, Guillamon A, Pásaro E. Gender-Affirming Hormone Therapy Modifies the CpG Methylation Pattern of the ESR1 Gene Promoter After Six Months of Treatment in Transmen. J Sex Med 2020; 17:1795-1806. [PMID: 32636163 DOI: 10.1016/j.jsxm.2020.05.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/25/2020] [Accepted: 05/27/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Brain sexual differentiation is a process that results from the effects of sex steroids on the developing brain. Evidence shows that epigenetics plays a main role in the formation of enduring brain sex differences and that the estrogen receptor α (ESR1) is one of the implicated genes. AIM To analyze whether the methylation of region III (RIII) of the ESR1 promoter is involved in the biological basis of gender dysphoria. METHODS We carried out a prospective study of the CpG methylation profile of RIII (-1,188 to -790 bp) of the ESR1 promoter using bisulfite genomic sequencing in a cisgender population (10 men and 10 women) and in a transgender population (10 trans men and 10 trans women), before and after 6 months of gender-affirming hormone treatment. Cisgender and transgender populations were matched by geographical origin, age, and sex. DNAs were treated with bisulfite, amplified, cloned, and sequenced. At least 10 clones per individual from independent polymerase chain reactions were sequenced. The analysis of 671 bisulfite sequences was carried out with the QUMA (QUantification tool for Methylation Analysis) program. OUTCOMES The main outcome of this study was RIII analysis using bisulfite genomic sequencing. RESULTS We found sex differences in RIII methylation profiles in cisgender and transgender populations. Cismen showed a higher methylation degree than ciswomen at CpG sites 297, 306, 509, and at the total fragment (P ≤ .003, P ≤ .026, P ≤ .001, P ≤ .006). Transmen showed a lower methylation level than trans women at sites 306, 372, and at the total fragment (P ≤ .0001, P ≤ .018, P ≤ .0107). Before the hormone treatment, transmen showed the lowest methylation level with respect to cisgender and transgender populations, whereas transwomen reached an intermediate methylation level between both the cisgender groups. After the hormone treatment, transmen showed a statistically significant methylation increase, whereas transwomen showed a non-significant methylation decrease. After the hormone treatment, the RIII methylation differences between transmen and transwomen disappeared, and both transgender groups reached an intermediate methylation level between both the cisgender groups. CLINICAL IMPLICATIONS Clinical implications in the hormonal treatment of trans people. STRENGTHS & LIMITATIONS Increasing the number of regions analyzed in the ESR1 promoter and increasing the number of tissues analyzed would provide a better understanding of the variation in the methylation pattern. CONCLUSIONS Our data showed sex differences in RIII methylation patterns in cisgender and transgender populations before the hormone treatment. Furthermore, before the hormone treatment, transwomen and transmen showed a characteristic methylation profile, different from both the cisgender groups. But the hormonal treatment modified RIII methylation in trans populations, which are now more similar to their gender. Therefore, our results suggest that the methylation of RIII could be involved in gender dysphoria. Fernández R, Ramírez K, Gómez-Gil E, et al. Gender-Affirming Hormone Therapy Modifies the CpG Methylation Pattern of the ESR1 Gene Promoter After Six Months of Treatment in Transmen. J Sex Med 2020;17:1795-1806.
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Affiliation(s)
- Rosa Fernández
- Departamento de Psicología, Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña (UDC), Campus de Elviña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), CHUAC, SERGAS, A Coruña, Spain.
| | - Karla Ramírez
- Departamento de Psicología, Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña (UDC), Campus de Elviña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), CHUAC, SERGAS, A Coruña, Spain
| | - Esther Gómez-Gil
- Unidad de Identidad de Género, Instituto de Neurociencias, Hospital Clínic, I.D.I.B.A.P.S., Barcelona, Spain
| | - Joselyn Cortés-Cortés
- Departamento de Psicología, Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña (UDC), Campus de Elviña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), CHUAC, SERGAS, A Coruña, Spain
| | - Mireia Mora
- Departmento de Endocrinología y Nutrición, Hospital Clínic, Barcelona, Spain
| | - Gloria Aranda
- Departmento de Endocrinología y Nutrición, Hospital Clínic, Barcelona, Spain
| | - Enrique Delgado Zayas
- Departamento de Psicología, Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña (UDC), Campus de Elviña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), CHUAC, SERGAS, A Coruña, Spain
| | - Isabel Esteva
- Servicio de Endocrinología y Nutrición, Unidad de Identidad de Género del Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Mari Cruz Almaraz
- Servicio de Endocrinología y Nutrición, Unidad de Identidad de Género del Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Antonio Guillamon
- Departamento de Psicobiología, Universidad Nacional de Educación a Distancia, Madrid, Spain
| | - Eduardo Pásaro
- Departamento de Psicología, Centro de Investigaciones Científicas Avanzadas (CICA), Universidade da Coruña (UDC), Campus de Elviña, A Coruña, Spain; Instituto de Investigación Biomédica de A Coruña (INIBIC), CHUAC, SERGAS, A Coruña, Spain
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Ocampo-Serna S, Gutiérrez-Segura JC, Vallejo-González S. Adult Gender Dysphoria with Coronary Disease. Case Report and Literature Review. REVISTA COLOMBIANA DE PSIQUIATRIA (ENGLISH ED.) 2020; 49:211-215. [PMID: 32888667 DOI: 10.1016/j.rcp.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 04/30/2018] [Accepted: 10/16/2018] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Gender dysphoria (GD) refers to a marked incongruity between gender identity and biological sex. GD generates a significant clinical discomfort for at least six months. METHODS Case report and non-systematic literature review. Case presentation A 56-year-old male-to-female patient, who had a history of coronary disease and a second thromboembolic event after hormone therapy (self-medicated). Once she had received acute management for the cardiovascular disease, she consulted for her GD. DISCUSSION GD requires multidisciplinary management. Cross-sex hormonal therapy is considered the main treatment. It has been documented that oral oestrogen preparations may increase the risk of thromboembolic events in patients over the age of 40, especially when they have cardiovascular risk factors. CONCLUSIONS Comprehensive treatment should be offered to everyone who has GD, to relieve psychological distress, decrease psychiatric comorbidity and improve quality of life. To date, there is little scientific evidence regarding cross-sex hormonal therapy in transgender women over the age of 40; we therefore recommend multidisciplinary, close and rigorous monitoring, in particular when they have cardiovascular risk.
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Affiliation(s)
- Sabina Ocampo-Serna
- Facultad de Ciencias de la Salud, Universidad Tecnológica de Pereira, Pereira, Colombia.
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Neural Correlates of Gender Face Perception in Transgender People. J Clin Med 2020; 9:jcm9061731. [PMID: 32503300 PMCID: PMC7356844 DOI: 10.3390/jcm9061731] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 05/26/2020] [Accepted: 06/01/2020] [Indexed: 02/06/2023] Open
Abstract
To date, MRI studies focused on brain sexual dimorphism have not explored the presence of specific neural patterns in gender dysphoria (GD) using gender discrimination tasks. Considering the central role of body image in GD, the present study aims to evaluate brain activation patterns with 3T-scanner functional MRI (fMRI) during gender face discrimination task in a sample of 20 hormone-naïve transgender and 20 cisgender individuals. Additionally, participants were asked to complete psychometric measures. The between-group analysis of average blood oxygenation level dependent (BOLD) activations of female vs. male face contrast showed a significant positive cluster in the bilateral precuneus in transmen when compared to the ciswomen. In addition. the transwomen group compared to the cismen showed higher activations also in the precuneus, as well as in the posterior cingulate gyrus, the angular gyrus and the lateral occipital cortices. Moreover, the activation of precuneus, angular gyrus, lateral occipital cortices and posterior cingulate gyrus was significantly associated with higher levels of body uneasiness. These results show for the first time the existence of a possible specific GD-neural pattern. However, it remains unclear if the differences in brain phenotype of transgender people may be the result of a sex-atypical neural development or of a lifelong experience of gender non-conformity.
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Baetens L, Dhondt K. Psychosocial challenges and hormonal treatment in gender diverse children and adolescents. A narrative review. Int J Impot Res 2020; 33:217-227. [PMID: 32366985 DOI: 10.1038/s41443-020-0291-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022]
Abstract
Gender dysphoria (GD) in children and adolescents is a condition that is characterized by an incongruence between the assigned and experienced gender. Despite the diversity in clinical presentation, literature demonstrates that GD might lead to poor mental health and high rates of co-occurring psychopathology. Due to the overlap of physical aspects as well as psychological needs in these children, a multidisciplinary approach is highly desirable. The aim of this narrative review is to give an overview of recent literature on several topics relevant in this domain. Guidelines on psychological counseling and hormonal treatment are given and challenging topics subject to controversy are explained. Furthermore, attention is drawn to the risks and protective factors in psychological functioning, including the growing evidence of a frequent co-occurrence with Autism Spectrum Disorder. Finally the psycho-sexual development in these children, the impact on fertility and fertility preservation are discussed.
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Affiliation(s)
- Laura Baetens
- General Psychiatry Department, Sint-Lucas, Bruges, Belgium, Ghent University, Ghent, Belgium
| | - Karlien Dhondt
- Dept Child & Adolescent psychiatry, Center for Gender and Sexuology, Pediatric Gender Clinic, Ghent University Hospital, Ghent, Belgium.
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Uribe C, Junque C, Gómez-Gil E, Abos A, Mueller SC, Guillamon A. Brain network interactions in transgender individuals with gender incongruence. Neuroimage 2020; 211:116613. [DOI: 10.1016/j.neuroimage.2020.116613] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/04/2020] [Indexed: 12/31/2022] Open
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Sadr M, Khorashad BS, Talaei A, Fazeli N, Hönekopp J. 2D:4D Suggests a Role of Prenatal Testosterone in Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:421-432. [PMID: 31975034 PMCID: PMC7031197 DOI: 10.1007/s10508-020-01630-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 01/03/2020] [Accepted: 01/06/2020] [Indexed: 06/10/2023]
Abstract
Gender dysphoria (GD) reflects distress caused by incongruence between one's experienced gender identity and one's natal (assigned) gender. Previous studies suggest that high levels of prenatal testosterone (T) in natal females and low levels in natal males might contribute to GD. Here, we investigated if the 2D:4D digit ratio, a biomarker of prenatal T effects, is related to GD. We first report results from a large Iranian sample, comparing 2D:4D in 104 transwomen and 89 transmen against controls of the same natal sex. We found significantly lower (less masculine) 2D:4D in transwomen compared to control men. We then conducted random-effects meta-analyses of relevant studies including our own (k = 6, N = 925 for transwomen and k = 6, N = 757 for transmen). In line with the hypothesized prenatal T effects, transwomen showed significantly feminized 2D:4D (d ≈ 0.24). Conversely, transmen showed masculinized 2D:4D (d ≈ - 0.28); however, large unaccounted heterogeneity across studies emerged, which makes this effect less meaningful. These findings support the idea that high levels of prenatal T in natal females and low levels in natal males play a part in the etiology of GD. As we discuss, this adds to the evidence demonstrating the convergent validity of 2D:4D as a marker of prenatal T effects.
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Affiliation(s)
- Mostafa Sadr
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Behzad S Khorashad
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Talaei
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Nasrin Fazeli
- Transgender Studies Centre, Psychiatry and Behavioral Sciences Research Centre, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Johannes Hönekopp
- Department of Psychology, Northumbria University, Newcastle upon Tyne, NE1 8ST, UK.
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Burke SM, van Heesewijk JO, Menks WM, Klink DT, Kreukels BPC, Cohen-Kettenis PT, Bakker J. Postnatal Effects of Sex Hormones on Click-Evoked Otoacoustic Emissions: A Study of Adolescents with Gender Dysphoria. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:455-465. [PMID: 32056039 PMCID: PMC7031217 DOI: 10.1007/s10508-020-01652-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/25/2020] [Accepted: 01/27/2020] [Indexed: 06/10/2023]
Abstract
Click-evoked otoacoustic emissions (CEOAEs) are echo-like sounds, generated by the inner ear in response to click-stimuli. A sex difference in emission strength is observed in neonates and adults, with weaker CEOAE amplitudes in males. These differences are assumed to originate from testosterone influences during prenatal male sexual differentiation and to remain stable throughout life. However, recent studies suggested activational, postnatal effects of sex hormones on CEOAEs. Adolescents diagnosed with gender dysphoria (GD) may receive gonadotropin-releasing hormone analogs (GnRHa) in order to suppress endogenous sex hormones and, therefore, pubertal maturation, followed by cross-sex hormone (CSH) treatment. Using a cross-sectional design, we examined whether hormonal interventions in adolescents diagnosed with GD (62 trans boys, assigned female at birth, self-identifying as male; 43 trans girls, assigned male at birth, self-identifying as female), affected their CEOAEs compared to age- and sex-matched controls (44 boys, 37 girls). Sex-typical differences in CEOAE amplitude were observed among cisgender controls and treatment-naïve trans boys but not in other groups with GD. Treatment-naïve trans girls tended to have more female-typical CEOAEs, suggesting hypomasculinized early sexual differentiation, in support of a prominent hypothesis on the etiology of GD. In line with the predicted suppressive effects of androgens, trans boys receiving CSH treatment, i.e., testosterone plus GnRHa, showed significantly weaker right-ear CEOAEs compared with control girls. A similar trend was seen in trans boys treated with GnRHa only. Unexpectedly, trans girls showed CEOAE masculinization with addition of estradiol. Our findings show that CEOAEs may not be used as an unequivocal measure of prenatal androgen exposure as they can be modulated postnatally by sex hormones, in the form of hormonal treatment.
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Affiliation(s)
- Sarah M Burke
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, 1081 HX, Amsterdam, The Netherlands
- Department of Developmental and Educational Psychology, Brain and Development Research Center, Leiden University, Leiden, The Netherlands
| | - Jason O van Heesewijk
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, 1081 HX, Amsterdam, The Netherlands.
| | - Willeke M Menks
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Daniel T Klink
- Department of Pediatric Endocrinology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Pediatrics and Genetics Research Unit, Division of Pediatric Endocrinology, Department of Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, 1081 HX, Amsterdam, The Netherlands
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, 1081 HX, Amsterdam, The Netherlands
| | - Julie Bakker
- GIGA Neuroscience, University of Liege, Liège, Belgium
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Peper JS, Burke SM, Wierenga LM. Sex differences and brain development during puberty and adolescence. HANDBOOK OF CLINICAL NEUROLOGY 2020; 175:25-54. [PMID: 33008529 DOI: 10.1016/b978-0-444-64123-6.00003-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Sex differences in behavior, and whether these behavioral differences are related to sex differences in brain development, has been a longstanding topic of debate. Presumably, sex differences can provide critically important leads for explaining the etiology of various illnesses that show (i) large sex differences in prevalence and (ii) have an origin before or during adolescence. The general aim of this chapter is to provide an overview of scientific studies on sex differences in normative brain and behavioral development across puberty and adolescence, including the (sex) hormone-driven transition phase of puberty. Moreover, we describe the literature on brain and behavioral development in gender dysphoria, a severe and persistent incongruence between the self-identified gender and the assigned sex at birth. From the literature it becomes clear there is evidence for a specific link between pubertal maturation and developmental changes in arousal, motivation, and emotion. However, this link is rather similar between boys and girls. Moreover, although there is substantial evidence for sex differences in mean brain structure, these have not always been linked to sex differences in behavior, cognition, or psychopathology. Furthermore, there is little evidence for sex differences in brain development and thus, studies so far have been unable to explain sex differences in cognition. Suggestions for future research and methodologic considerations are provided.
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Affiliation(s)
- Jiska S Peper
- Department of Psychology, Leiden University, Leiden, The Netherlands.
| | - Sarah M Burke
- Department of Psychology, Leiden University, Leiden, The Netherlands
| | - Lara M Wierenga
- Department of Psychology, Leiden University, Leiden, The Netherlands
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Iwamoto SJ, Defreyne J, Rothman MS, Van Schuylenbergh J, Van de Bruaene L, Motmans J, T’Sjoen G. Health considerations for transgender women and remaining unknowns: a narrative review. Ther Adv Endocrinol Metab 2019; 10:2042018819871166. [PMID: 31516689 PMCID: PMC6719479 DOI: 10.1177/2042018819871166] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 07/31/2019] [Indexed: 12/17/2022] Open
Abstract
Transgender (trans) women (TW) were assigned male at birth but have a female gender identity or gender expression. The literature on management and health outcomes of TW has grown recently with more publication of research. This has coincided with increasing awareness of gender diversity as communities around the world identify and address health disparities among trans people. In this narrative review, we aim to comprehensively summarize health considerations for TW and identify TW-related research areas that will provide answers to remaining unknowns surrounding TW's health. We cover up-to-date information on: (1) feminizing gender-affirming hormone therapy (GAHT); (2) benefits associated with GAHT, particularly quality of life, mental health, breast development and bone health; (3) potential risks associated with GAHT, including cardiovascular disease and infertility; and (4) other health considerations like HIV/AIDS, breast cancer, other tumours, voice therapy, dermatology, the brain and cognition, and aging. Although equally deserving of mention, feminizing gender-affirming surgery, paediatric and adolescent populations, and gender nonbinary individuals are beyond the scope of this review. While much of the data we discuss come from Europe, the creation of a United States transgender cohort has already contributed important retrospective data that are also summarized here. Much remains to be determined regarding health considerations for TW. Patients and providers will benefit from larger and longer prospective studies involving TW, particularly regarding the effects of aging, race and ethnicity, type of hormonal treatment (e.g. different oestrogens, anti-androgens) and routes of administration (e.g. oral, parenteral, transdermal) on all the topics we address.
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Affiliation(s)
- Sean J. Iwamoto
- University of Colorado School of Medicine, Division of Endocrinology, Metabolism and Diabetes, 12801 East 17th Avenue, Mail Stop: 8106, Aurora, CO 80045, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
- Division of Endocrinology, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program, Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
- Center for Research on Culture and Gender, Ghent University, Ghent, Belgium
| | - Guy T’Sjoen
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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Abstract
There are an estimated 1.4 million transgender adults in the United States, and lack of providers knowledgeable in transgender care is a barrier to health care. Obstetricians and Gynecologists can help increase access in part by becoming competent in gender-affirming hormone therapy. For transgender men, testosterone protocols can be extrapolated from those used for hypogonadal cisgender men. Unfortunately, there are not any high-quality, long-term prospective studies on the effectiveness and safety of different testosterone regimens specifically in transgender men, but the available data suggest that gender-affirming testosterone therapy is safe and effective with proper screening and monitoring.
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Wren B, Launer J, Reiss MJ, Swanepoel A, Music G. Can evolutionary thinking shed light on gender diversity? BJPSYCH ADVANCES 2019. [DOI: 10.1192/bja.2019.35] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
SUMMARYIssues of sexual reproduction lie at the core of evolutionary thinking, which often places an emphasis on how individuals attempt to maximise the number of successful offspring that they can produce. At first sight, it may therefore appear that individuals who opt for gender-affirming medical interventions are acting in ways that are evolutionarily disadvantageous. However, there are persuasive hypotheses that might make sense of such choices in evolutionary terms and we explore these here. It is premature to claim knowledge of the extent to which evolutionary arguments can usefully be applied to issues of gender identity, although worth reflecting on the extent to which nature tends towards diversity in matters of sex and gender. The importance of acknowledging and respecting different views in this domain, as well as recognising both the uncertainty and likely multiplicity of causal pathways, has implications for clinicians. We make some suggestions about how clinicians might best respond when faced with requests from patients in this area.LEARNING OBJECTIVESAfter reading this article you will be able to:•understand evolutionary arguments about diversity in human gender identity•identify strengths and weaknesses in evolutionary arguments applied to transgender issues•appreciate the range and diversity of gender experience and gender expression among people who present to specialist gender services, as well as the likely complexities of their reasons for requesting medical intervention.
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Manzouri A, Savic I. Possible Neurobiological Underpinnings of Homosexuality and Gender Dysphoria. Cereb Cortex 2019; 29:2084-2101. [PMID: 30084980 PMCID: PMC6677918 DOI: 10.1093/cercor/bhy090] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/13/2018] [Accepted: 04/03/2018] [Indexed: 01/13/2023] Open
Abstract
Although frequently discussed in terms of sex dimorphism, the neurobiology of sexual orientation and identity is unknown. We report multimodal magnetic resonance imaging data, including cortical thickness (Cth), subcortical volumes, and resting state functional magnetic resonance imaging, from 27 transgender women (TrW), 40 transgender men (TrM), and 80 heterosexual (40 men) and 60 homosexual cisgender controls (30 men). These data show that whereas homosexuality is linked to cerebral sex dimorphism, gender dysphoria primarily involves cerebral networks mediating self-body perception. Among the homosexual cisgender controls, weaker sex dimorphism was found in white matter connections and a partly reversed sex dimorphism in Cth. Similar patterns were detected in transgender persons compared with heterosexual cisgender controls, but the significant clusters disappeared when adding homosexual controls, and correcting for sexual orientation. Instead, both TrW and TrM displayed singular features, showing greater Cth as well as weaker structural and functional connections in the anterior cingulate-precuneus and right occipito-parietal cortex, regions known to process own body perception in the context of self.
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Affiliation(s)
- A Manzouri
- Department of Women’s and Children’s Health, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - I Savic
- Department of Women’s and Children’s Health, Karolinska Institute and University Hospital, Stockholm, Sweden
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
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Foreman M, Hare L, York K, Balakrishnan K, Sánchez FJ, Harte F, Erasmus J, Vilain E, Harley VR. Genetic Link Between Gender Dysphoria and Sex Hormone Signaling. J Clin Endocrinol Metab 2019; 104:390-396. [PMID: 30247609 DOI: 10.1210/jc.2018-01105] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022]
Abstract
CONTEXT There is a likely genetic component to gender dysphoria, but association study data have been equivocal. OBJECTIVE We explored the specific hypothesis that gender dysphoria in transgender women is associated with variants in sex hormone-signaling genes responsible for undermasculinization and/or feminization. DESIGN Subject-control analysis included 380 transgender women and 344 control male subjects. Associations and interactions were investigated between functional variants in 12 sex hormone-signaling genes and gender dysphoria in transgender women. SETTING Patients were recruited from the Monash Gender Clinic, Monash Health, Melbourne, Australia, and the University of California, Los Angeles. PATIENTS Caucasian (non-Latino) transgender women were recruited who received a diagnosis of transsexualism [Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV) or gender dysphoria (DSM-V)] pre- or postoperatively. Most were receiving hormone treatment at the time of recruitment. MAIN OUTCOME MEASURED Genomic DNA was genotyped for repeat length polymorphisms or single nucleotide polymorphisms. RESULTS A significant association was identified between gender dysphoria and ERα, SRD5A2, and STS alleles, as well as ERα and SULT2A1 genotypes. Several allele combinations were also overrepresented in transgender women, most involving AR (namely, AR-ERβ, AR-PGR, AR-COMT, CYP17-SRD5A2). Overrepresented alleles and genotypes are proposed to undermasculinize/feminize on the basis of their reported effects in other disease contexts. CONCLUSION Gender dysphoria may have an oligogenic component, with several genes involved in sex hormone-signaling contributing.
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Affiliation(s)
| | - Lauren Hare
- Hudson Institute of Research, Melbourne, Victoria, Australia
| | - Kate York
- Hudson Institute of Research, Melbourne, Victoria, Australia
| | | | | | - Fintan Harte
- Monash Gender Clinic, Monash Health, Melbourne, Victoria, Australia
| | | | - Eric Vilain
- Children's National Health System, Washington, DC
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Turban JL, Ehrensaft D. Research Review: Gender identity in youth: treatment paradigms and controversies. J Child Psychol Psychiatry 2018; 59:1228-1243. [PMID: 29071722 DOI: 10.1111/jcpp.12833] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Pediatric gender identity has gained increased attention over the past several years in the popular media, political arena, and medical literature. This article reviews terminology in this evolving field, traditional models of gender identity development and their limitations, epidemiology and natural history of cross-gender identification among children and adolescents, co-occurring conditions and behaviors, research into the biological and psychosocial determinants of cross-gender identification, and research into the options regarding and benefits of clinical approaches to gender incongruent youth. METHODS Based on a critical review of the extant literature, both theoretical and empirical, that addresses the issue of pediatric gender identity, the authors synthesized what is presently known and what is in need of further research in order to elucidate the developmental trajectory and clinical needs of gender diverse youth. RESULTS The field of pediatric gender identity has evolved substantially over the past several years. New research suggests that cross-gender identification is prevalent (approximately 1% of youth). These youth suffer disproportionately high rates of anxiety, depression, and suicidality. Although research into the etiology of cross-gender identification is limited, emerging data have shown that affirmative treatment protocols may improve the high rates of mental health difficulties seen among these patients. CONCLUSIONS The field of pediatric gender identity has evolved dramatically. Emerging data suggest that these patients' high rates of anxiety, depression, and suicidality appear to be improved with affirmative protocols, although future longitudinal data are needed.
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Affiliation(s)
- Jack L Turban
- Division of Child & Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Diane Ehrensaft
- Child and Adolescent Gender Center, University of California San Francisco, San Francisco, CA, USA
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Chipkin SR. The Reply. Am J Med 2018; 131:e393. [PMID: 29980251 DOI: 10.1016/j.amjmed.2018.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 04/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Stuart R Chipkin
- School of Public Health Sciences, University of Massachusetts, Amherst
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Fisher AD, Ristori J, Morelli G, Maggi M. The molecular mechanisms of sexual orientation and gender identity. Mol Cell Endocrinol 2018; 467:3-13. [PMID: 28847741 DOI: 10.1016/j.mce.2017.08.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/02/2017] [Accepted: 08/15/2017] [Indexed: 12/21/2022]
Abstract
Differences between males and females are widely represented in nature. There are gender differences in phenotypes, personality traits, behaviors and interests, cognitive performance, and proneness to specific diseases. The most marked difference in humans is represented by sexual orientation and core gender identity, the origins of which are still controversial and far from being understood. Debates continue on whether sexual behavior and gender identity are a result of biological (nature) or cultural (nurture) factors, with biology possibly playing a major role. The main goal of this review is to summarize the studies available to date on the biological factors involved in the development of both sexual orientation and gender identity. A systematic search of published evidence was performed using Medline (from January 1948 to June 2017). Review of the relevant literature was based on authors' expertise. Indeed, different studies have documented the possible role and interaction of neuroanatomic, hormonal and genetic factors. The sexual dimorphic brain is considered the anatomical substrate of psychosexual development, on which genes and gonadal hormones may have a shaping effect. In particular, growing evidence shows that prenatal and pubertal sex hormones permanently affect human behavior. In addition, heritability studies have demonstrated a role of genetic components. However, a convincing candidate gene has not been identified. Future studies (e.i. genome wide studies) are needed to better clarify the complex interaction between genes, anatomy and hormonal influences on psychosexual development.
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Affiliation(s)
- Alessandra D Fisher
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Jiska Ristori
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy
| | - Girolamo Morelli
- Department of Surgical, Medical, Molecular and of the Critical Area Pathology, University of Pisa, Pisa, Italy
| | - Mario Maggi
- Department of Experimental, Clinical and Biomedical Sciences, Careggi University Hospital, Florence, Italy.
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Burke SM, Manzouri AH, Dhejne C, Bergström K, Arver S, Feusner JD, Savic-Berglund I. Testosterone Effects on the Brain in Transgender Men. Cereb Cortex 2018; 28:1582-1596. [PMID: 28334217 PMCID: PMC6248653 DOI: 10.1093/cercor/bhx054] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 01/19/2017] [Accepted: 02/16/2017] [Indexed: 12/22/2022] Open
Abstract
Transgender individuals experience incongruence between their gender identity and birth-assigned sex. The resulting gender dysphoria (GD), which some gender-incongruent individuals experience, is theorized to be a consequence of atypical cerebral sexual differentiation, but support for this assertion is inconsistent. We recently found that GD is associated with disconnected networks involved in self-referential thinking and own body perception. Here, we investigate how these networks in trans men (assigned female at birth with male gender identity) are affected by testosterone. In 22 trans men, we obtained T1-weighted, diffusion-weighted, and resting-state functional magnetic resonance imaging scans before and after testosterone treatment, measuring cortical thickness (Cth), subcortical volumes, fractional anisotropy (FA), and functional connectivity. Nineteen cisgender controls (male and female) were also scanned twice. The medial prefrontal cortex (mPFC) was thicker in trans men than controls pretreatment, and remained unchanged posttreatment. Testosterone treatment resulted in increased Cth in the insular cortex, changes in cortico-cortical thickness covariation between mPFC and occipital cortex, increased FA in the fronto-occipital tract connecting these regions, and increased functional connectivity between mPFC and temporo-parietal junction, compared with controls. Concluding, in trans men testosterone treatment resulted in functional and structural changes in self-referential and own body perception areas.
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Affiliation(s)
- Sarah M Burke
- Department of Women's and Children's Health, Karolinska Institutet and
University Hospital, SE-171 76 Stockholm, Sweden
| | | | - Cecilia Dhejne
- ANOVA, Center of Expertise in Andrology, Sexual Medicine, and Transgender
Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Center for Psychiatric Research, Department of Clinical Neuroscience,
Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Karin Bergström
- Department of Women's and Children's Health, Karolinska Institutet and
University Hospital, SE-171 76 Stockholm, Sweden
| | - Stefan Arver
- ANOVA, Center of Expertise in Andrology, Sexual Medicine, and Transgender
Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Medicine/Huddinge, Karolinska Institutet, SE-141 86
Stockholm, Sweden
| | - Jamie D Feusner
- Department of Psychiatry and Biobehavioral Sciences, University of
California Los Angeles, Los Angeles, CA 90095, USA
| | - Ivanka Savic-Berglund
- Department of Women's and Children's Health, Karolinska Institutet and
University Hospital, SE-171 76 Stockholm, Sweden
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Burke SM, Manzouri AH, Savic I. Structural connections in the brain in relation to gender identity and sexual orientation. Sci Rep 2017; 7:17954. [PMID: 29263327 PMCID: PMC5738422 DOI: 10.1038/s41598-017-17352-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 11/23/2017] [Indexed: 12/22/2022] Open
Abstract
Both transgenderism and homosexuality are facets of human biology, believed to derive from different sexual differentiation of the brain. The two phenomena are, however, fundamentally unalike, despite an increased prevalence of homosexuality among transgender populations. Transgenderism is associated with strong feelings of incongruence between one's physical sex and experienced gender, not reported in homosexual persons. The present study searches to find neural correlates for the respective conditions, using fractional anisotropy (FA) as a measure of white matter connections that has consistently shown sex differences. We compared FA in 40 transgender men (female birth-assigned sex) and 27 transgender women (male birth-assigned sex), with both homosexual (29 male, 30 female) and heterosexual (40 male, 40 female) cisgender controls. Previously reported sex differences in FA were reproduced in cis-heterosexual groups, but were not found among the cis-homosexual groups. After controlling for sexual orientation, the transgender groups showed sex-typical FA-values. The only exception was the right inferior fronto-occipital tract, connecting parietal and frontal brain areas that mediate own body perception. Our findings suggest that the neuroanatomical signature of transgenderism is related to brain areas processing the perception of self and body ownership, whereas homosexuality seems to be associated with less cerebral sexual differentiation.
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Affiliation(s)
- Sarah M Burke
- Brain & Development Research Centre, Department of Developmental and Educational Psychology, Leiden University, Leiden, The Netherlands.
- Department of Women's and Children's Health, Karolinska Institute and University Hospital, Stockholm, Sweden.
| | - Amir H Manzouri
- Stressmotagningen, S:t Göransgatan 84, 112 38, Stockholm, Sweden
| | - Ivanka Savic
- Department of Women's and Children's Health, Karolinska Institute and University Hospital, Stockholm, Sweden
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Nota NM, Burke SM, den Heijer M, Soleman RS, Lambalk CB, Cohen-Kettenis PT, Veltman DJ, Kreukels BP. Brain sexual differentiation and effects of cross-sex hormone therapy in transpeople: A resting-state functional magnetic resonance study. Neurophysiol Clin 2017; 47:361-370. [DOI: 10.1016/j.neucli.2017.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 02/02/2023] Open
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Goetz TG, Mamillapalli R, Devlin MJ, Robbins AE, Majidi-Zolbin M, Taylor HS. Cross-sex testosterone therapy in ovariectomized mice: addition of low-dose estrogen preserves bone architecture. Am J Physiol Endocrinol Metab 2017; 313:E540-E551. [PMID: 28765273 PMCID: PMC5792142 DOI: 10.1152/ajpendo.00161.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 01/17/2023]
Abstract
Cross-sex hormone therapy (XHT) is widely used by transgender people to alter secondary sex characteristics to match their desired gender presentation. Here, we investigate the long-term effects of XHT on bone health using a murine model. Female mice underwent ovariectomy at either 6 or 10 wk and began weekly testosterone or vehicle injections. Dual-energy X-ray absorptiometry (DXA) was performed (20 wk) to measure bone mineral density (BMD), and microcomputed tomography was performed to compare femoral cortical and trabecular bone architecture. The 6-wk testosterone group had comparable BMD with controls by DXA but reduced bone volume fraction, trabecular number, and cortical area fraction and increased trabecular separation by microcomputed tomography. Ten-week ovariectomy/XHT maintained microarchitecture, suggesting that estrogen is critical for bone acquisition during adolescence and that late, but not early, estrogen loss can be sufficiently replaced by testosterone alone. Given these findings, we then compared effects of testosterone with effects of weekly estrogen or combined testosterone/low-dose estrogen treatment after a 6-wk ovariectomy. Estrogen treatment increased spine BMD and microarchitecture, including bone volume fraction, trabecular number, trabecular thickness, and connectivity density, and decreased trabecular separation. Combined testosterone-estrogen therapy caused similar increases in femur and spine BMD and improved architecture (increased bone volume fraction, trabecular number, trabecular thickness, and connectivity density) to estrogen therapy and were superior compared with mice treated with testosterone only. These results demonstrate estradiol is critical for bone acquisition and suggest a new cross-sex hormone therapy adding estrogens to testosterone treatments with potential future clinical implications for treating transgender youth or men with estrogen deficiency.
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Affiliation(s)
- Teddy G Goetz
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, Connecticut; and
| | - Ramanaiah Mamillapalli
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, Connecticut; and
| | - Maureen J Devlin
- Department of Anthropology, University of Michigan, Ann Arbor, Michigan
| | - Amy E Robbins
- Department of Anthropology, University of Michigan, Ann Arbor, Michigan
| | - Masoumeh Majidi-Zolbin
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, Connecticut; and
| | - Hugh S Taylor
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale School of Medicine, Yale University, New Haven, Connecticut; and
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Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2017; 102:3869-3903. [PMID: 28945902 DOI: 10.1210/jc.2017-01658] [Citation(s) in RCA: 1210] [Impact Index Per Article: 172.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/24/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009. PARTICIPANTS The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer. EVIDENCE This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines. CONCLUSION Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.
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Affiliation(s)
- Wylie C Hembree
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York 10032
| | | | - Louis Gooren
- VU University Medical Center, 1007 MB Amsterdam, Netherlands
| | | | - Walter J Meyer
- University of Texas Medical Branch, Galveston, Texas 77555
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minnesota 55905
| | - Stephen M Rosenthal
- University of California San Francisco, Benioff Children's Hospital, San Francisco, California 94143
| | - Joshua D Safer
- Boston University School of Medicine, Boston, Massachusetts 02118
| | - Vin Tangpricha
- Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, Georgia 30322
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Khorashad BS, Aghili Z, Kreukels BP, Hiradfar M, Roshan GM, Afkhamizadeh M, Abbaszadegan MR, Ghaemi N, Khazai B, Cohen-Kettenis P. Psychosexual Outcome Among Iranian Individuals With 5α-Reductase Deficiency Type 2 and Its Relationship With Parental Sexism. J Sex Med 2016; 13:1629-1641. [DOI: 10.1016/j.jsxm.2016.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 08/26/2016] [Accepted: 09/05/2016] [Indexed: 01/22/2023]
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45
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Pavlova MA. Sex and gender affect the social brain: Beyond simplicity. J Neurosci Res 2016; 95:235-250. [PMID: 27688155 DOI: 10.1002/jnr.23871] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/06/2016] [Accepted: 07/14/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Marina A. Pavlova
- Department of Biomedical Magnetic Resonance, Medical School; Eberhard Karls University of Tübingen; Tübingen Germany
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