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Roblee C, Hamidian Jahromi A, Ferragamo B, Radix A, De Cuypere G, Green J, Dorafshar AH, Ettner R, Monstrey S, Schechter L. Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional. Plast Reconstr Surg 2023; 152:953e-961e. [PMID: 36827473 DOI: 10.1097/prs.0000000000010326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
SUMMARY Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.
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Affiliation(s)
- Cole Roblee
- From the Rosalind Franklin University of Medicine & Science
| | | | | | - Asa Radix
- Callen-Lorde Community Health Center
- Department of Medicine, New York University Langone Health
| | | | - Jamison Green
- World Professional Association for Transgender Health
| | - Amir H Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center
| | | | - Stan Monstrey
- Department of Plastic Surgery, Ghent University Hospital
| | - Loren Schechter
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center
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Knudson G, Green J, Tangpricha V, Ettner R, Bouman WP, Adrian T, Allen L, De Cuypere G, Fraser L, Hansen TM, Karasic D, Kreukels BPC, Rachlin K, Schechter L, Winter S. Identity recognition statement of the world professional association for transgender health (WPATH). Int J Transgend 2018. [DOI: 10.1080/15532739.2018.1470399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Gail Knudson
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Vin Tangpricha
- Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Tamara Adrian
- Diverlex Diversity and Equality Through the Law, Caracas, Miranda, Venezuela
| | - Luke Allen
- University of Missouri - Kansas City, Missouri, USA
| | | | - Lin Fraser
- Private Practice, San Francisco, California, USA
| | | | - Dan Karasic
- University of California, San Francisco, California, USA
| | | | | | | | - Sam Winter
- Curtin University, Bentley, Perth, Western Australia, Australia
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Abstract
Gender dysphoria describes the psychological distress caused by identifying with the sex opposite to the one assigned at birth. In recent years, much progress has been made in characterizing the needs of transgender persons wishing to transition to their preferred gender, thus helping to optimize care. This critical review of the literature examines their common mental health issues, several individual risk factors for psychiatric comorbidity, and current research on the underlying neurobiology. Prevalence rates of persons identifying as transgender and seeking help with transition have been rising steeply since 2000 across Western countries; the current U.S. estimate is 0.6%. Anxiety and depression are frequently observed both before and after transition, although there is some decrease afterward. Recent research has identified autistic traits in some transgender persons. Forty percent of transgender persons endorse suicidality, and the rate of self-injurious behavior and suicide are markedly higher than in the general population. Individual factors contributing to mental health in transgender persons include community attitudes, societal acceptance, and posttransition physical attractiveness. Neurobiologically, whereas structural MRI data are thus far inconsistent, functional MRI evidence in trans persons suggests changes in some brain areas concerned with olfaction and voice perception consistent with sexual identification, but here too, a definitive picture has yet to emerge. Mental health clinicians, together with other health specialists, have an increasing role in the assessment and treatment of gender dysphoria in transgender individuals.
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Affiliation(s)
- Sven C Mueller
- From the Department of Experimental Clinical and Health Psychology, Ghent University; and the Department of Endocrinology and the Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Griet De Cuypere
- From the Department of Experimental Clinical and Health Psychology, Ghent University; and the Department of Endocrinology and the Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Guy T'Sjoen
- From the Department of Experimental Clinical and Health Psychology, Ghent University; and the Department of Endocrinology and the Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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van de Grift TC, Elaut E, Cerwenka SC, Cohen-Kettenis PT, De Cuypere G, Richter-Appelt H, Kreukels BP. Effects of Medical Interventions on Gender Dysphoria and Body Image: A Follow-Up Study. Psychosom Med 2017; 79:815-823. [PMID: 28319558 PMCID: PMC5580378 DOI: 10.1097/psy.0000000000000465] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. METHODS Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). RESULTS At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. CONCLUSIONS Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.
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Beek TF, Cohen-Kettenis PT, Bouman WP, de Vries ALC, Steensma TD, Witcomb GL, Arcelus J, Richards C, De Cuypere G, Kreukels BPC. Gender Incongruence of Childhood: Clinical Utility and Stakeholder Agreement with the World Health Organization's Proposed ICD-11 Criteria. PLoS One 2017; 12:e0168522. [PMID: 28081569 PMCID: PMC5233419 DOI: 10.1371/journal.pone.0168522] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 12/04/2016] [Indexed: 11/18/2022] Open
Abstract
The World Health Organization (WHO) is revising the tenth version of the International Classification of Diseases and Related Health Problems (ICD-10). This includes a reconceptualization of the definition and positioning of Gender Incongruence of Childhood (GIC). This study aimed to: 1) collect the views of transgender individuals and professionals regarding the retention of the diagnosis; 2) see if the proposed GIC criteria were acceptable to transgender individuals and health care providers; 3) compare results between two countries with two different healthcare systems to see if these differences influence opinions regarding the GIC diagnosis; and 4) determine whether healthcare providers from high-income countries feel that the proposed criteria are clinically useful and easy to use. A total of 628 participants were included in the study: 284 from the Netherlands (NL; 45.2%), 8 from Flanders (Belgium; 1.3%), and 336 (53.5%) from the United Kingdom (UK). Most participants were transgender people (or their partners/relatives; TG) (n = 522), 89 participants were healthcare providers (HCPs) and 17 were both HCP and TG individuals. Participants completed an online survey developed for this study. Overall, the majority response from transgender participants (42.9%) was that if the diagnosis would be removed from the mental health chapter it should also be removed from the ICD-11 completely, while 33.6% thought it should remain in the ICD-11. Participants were generally satisfied with other aspects of the proposed ICD-11 GIC diagnosis: most TG participants (58.4%) thought the term Gender Identity Disorder should change, and most thought Gender Incongruence was an improvement (63.0%). Furthermore, most participants (76.1%) did not consider GIC to be a psychiatric disorder and placement in a separate chapter dealing with Gender and Sexual Health (the majority response in the NL and selected by 37.5% of the TG participants overall) or as a Z-code (the majority response in the UK and selected by 26.7% of the TG participants overall) would be preferable. In the UK, the majority response (35.8%) was that narrowing the GIC diagnosis was an improvement, while the NL majority response (49.5%) was that this was not an improvement. Although generally the results from HCPs were in line with the results from TG participants some differences were found. This study suggests that, although in an ideal world a diagnosis is not welcomed, several participants felt the diagnosis should not be removed. This is likely due to concerns about restricting access to reimbursed healthcare. The choice for positioning of a diagnosis of GIC within the ICD-11 was as a separate chapter dealing with symptoms and/or disorders regarding sexual and gender health. This was the overall first choice for NL participants and second choice for UK participants, after the use of a Z-code. The difference reflects that in the UK, Z-codes carry no negative implications for reimbursement of treatment costs. These findings highlight the challenges faced by the WHO in their attempt to integrate research findings from different countries, with different cultures and healthcare systems in their quest to create a manual that is globally applicable.
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Affiliation(s)
- Titia F. Beek
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail: (TFB); (BPCK)
| | - Peggy T. Cohen-Kettenis
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
| | - Walter P. Bouman
- Nottingham Centre for Gender Dysphoria, Nottingham, United Kingdom
| | - Annelou L. C. de Vries
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
- Department of Child and Adolescent Psychiatry, VU University Medical Center, Amsterdam, The Netherlands
| | - Thomas D. Steensma
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
| | - Gemma L. Witcomb
- School of Sport, Exercise, and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Jon Arcelus
- Nottingham Centre for Gender Dysphoria, Nottingham, United Kingdom
- Division of Psychiatry and Applied Psychology, Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | | | - Griet De Cuypere
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| | - Baudewijntje P. C. Kreukels
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
- Department of Medical Psychology, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail: (TFB); (BPCK)
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Winter S, De Cuypere G, Green J, Kane R, Knudson G. The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey. Arch Sex Behav 2016; 45:1605-1614. [PMID: 27492343 DOI: 10.1007/s10508-016-0811-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 04/25/2016] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Abstract
ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members' views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).
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Affiliation(s)
- Sam Winter
- Faculty of Health Science, School of Public Health, Curtin University, Bentley, Perth, WA, 6102, Australia
| | - Griet De Cuypere
- Center of Sexology and Gender, University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.
| | - Jamison Green
- Human Sexuality PhD Program, California Institute of Integral Studies, 1453 Mission Street, San Francisco, CA, 94103, USA
| | - Robert Kane
- Faculty of Health Science, School of Psychology and Speech Pathology, Curtin University, Bentley, Perth, WA, 6102, Australia
| | - Gail Knudson
- Faculty of Medicine, University of British Columbia, #201 - 1770 Fort Street, Victoria, BC, V8R 1J5, Canada
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7
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Affiliation(s)
- Griet De Cuypere
- Center of Sexology and Gender, University Hospital, Ghent 9000, Belgium.
| | - Sam Winter
- School of Public Health, Faculty of Health Science, Curtin University, Perth, WA, Australia
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Koehler A, Richter-Appelt H, Cerwenka S, Kreukels BP, Watzlawik M, Cohen-Kettenis PT, De Cuypere G, Haraldsen IRH, Nieder TO. Recalled gender-related play behavior and peer-group preferences in childhood and adolescence among adults applying for gender-affirming treatment. Sexual and Relationship Therapy 2016. [DOI: 10.1080/14681994.2016.1195908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Andreas Koehler
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hertha Richter-Appelt
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Cerwenka
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Griet De Cuypere
- Department of Sexology and Gender Problems, Ghent University Hospital, Ghent, Belgium
| | - Ira. R. H. Haraldsen
- Department of Neuropsychiatry and Psychosomatic Medicine, Rikshospitalet, Oslo, Norway
| | - Timo O. Nieder
- Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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9
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van de Grift TC, Cohen-Kettenis PT, Steensma TD, De Cuypere G, Richter-Appelt H, Haraldsen IRH, Dikmans REG, Cerwenka SC, Kreukels BPC. Body Satisfaction and Physical Appearance in Gender Dysphoria. Arch Sex Behav 2016; 45:575-85. [PMID: 26474976 PMCID: PMC4778147 DOI: 10.1007/s10508-015-0614-1] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 08/25/2015] [Accepted: 08/26/2015] [Indexed: 05/12/2023]
Abstract
Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.
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Affiliation(s)
- Tim C van de Grift
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
- Department of Plastic, Reconstructive & Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands.
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Thomas D Steensma
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Griet De Cuypere
- Center of Sexology and Gender Problems, Ghent University Hospital, Ghent, Belgium
| | - Hertha Richter-Appelt
- Department of Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ira R H Haraldsen
- Department of Neuropsychiatry and Psychosomatic Medicine, Division of Clinical Neuroscience, Rikshospitalet, Oslo, Norway
| | - Rieky E G Dikmans
- Department of Plastic, Reconstructive & Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Susanne C Cerwenka
- Department of Sex Research and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, EMGO Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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Schneider C, Cerwenka S, Nieder TO, Briken P, Cohen-Kettenis PT, De Cuypere G, Haraldsen IR, Kreukels BPC, Richter-Appelt H. Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Arch Sex Behav 2016; 45:551-8. [PMID: 26883025 DOI: 10.1007/s10508-016-0702-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 01/19/2016] [Accepted: 01/21/2016] [Indexed: 05/25/2023]
Abstract
This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.
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Affiliation(s)
- Catharina Schneider
- Department of Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Susanne Cerwenka
- Department of Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Timo O Nieder
- Department of Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Peer Briken
- Department of Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Griet De Cuypere
- Department of Sexology and Gender Problems, University Hospital Ghent, Ghent, Belgium
| | - Ira R Haraldsen
- Department of Neuropsychiatry and Psychosomatic Medicine, Rikshospitalet Oslo, Oslo, Norway
| | - Baudewijntje P C Kreukels
- Department of Medical Psychology, VU University Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Hertha Richter-Appelt
- Department of Sex Research and Forensic Psychiatry, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Colebunders B, De Cuypere G, Monstrey S. New Criteria for Sex Reassignment Surgery: WPATHStandards of Care, Version 7,Revisited. Int J Transgend 2016. [DOI: 10.1080/15532739.2015.1081086] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Callens N, Bronselaer G, De Sutter P, De Cuypere G, T'Sjoen G, Hoebeke P, Cools M. Costs of pleasure and the benefits of pain: self-perceived genital sensation, anatomy and sexual dysfunction. Sex Health 2015; 13:63-72. [PMID: 26567764 DOI: 10.1071/sh15160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 09/28/2015] [Indexed: 11/23/2022]
Abstract
UNLABELLED Background Research has highlighted the complex association between female sexual dysfunction (FSD) and distress regarding sexual activity, with decreased physical pleasure being an important mediator. The current study aims to elucidate the association between pleasurable and painful genital sensitivity and FSD, and to further investigate whether FSD may be distressing because it prevents the experience of sexual pleasure, induces pain or both. METHODS Sexually active women (n=256; median, 22 years; range, 18-49 years) completed web-based questionnaires, including the Self-Assessment of Genital Anatomy and Sexual Function, the Female Sexual Function Index and the Female Sexual Distress Scale. RESULTS Women reported their clitoris to be more sensitive than their vagina in terms of having more pleasurable responses (P<0.001), but not more painful responses (P=0.49). In women with FSD (n=36), impaired self-perceived genital sensation was found: they reported significantly less sexual pleasure and orgasm intensity, and more orgasm effort and discomfort within the clitoral and vaginal area than women without FSD (n=220) (P-value<0.05). The odds of having FSD were significantly greater in women with perceived increased discomfort in the vaginal area during stimulation (odds ratio=5.59, P=0.009, 95% confidence interval: 1.53-20.39), but not in the clitoral area. CONCLUSIONS The data provide evidence of the relevance of self-perceived genital sensitivity to sexual pleasure and overall sexual experience. Enhancing the pleasurableness of genital sensations, especially during partnered sex, could decrease the likelihood of experiencing pain and concomitant FSD.
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Affiliation(s)
- Nina Callens
- Department of Pediatrics, Division of Pediatric Endocrinology, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Guy Bronselaer
- Department of Urology, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Petra De Sutter
- Department of Obstetrics and Gynecology, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Griet De Cuypere
- Department of Sexology and Gender Problems, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Guy T'Sjoen
- Department of Sexology and Gender Problems, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Piet Hoebeke
- Department of Urology, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - Martine Cools
- Department of Pediatrics, Division of Pediatric Endocrinology, University Hospital Ghent and Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
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Van Caenegem E, Wierckx K, Elaut E, Buysse A, Dewaele A, Van Nieuwerburgh F, De Cuypere G, T'Sjoen G. Prevalence of Gender Nonconformity in Flanders, Belgium. Arch Sex Behav 2015; 44:1281-7. [PMID: 25588709 DOI: 10.1007/s10508-014-0452-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Revised: 09/27/2014] [Accepted: 10/11/2014] [Indexed: 05/12/2023]
Abstract
Gender nonconformity refers to the extent to which a person's gender identity, gender role and/or gender expression differs from the cultural norms prescribed for people of a particular sex, within a certain society and era. Most data on gender nonconformity focus on the prevalence of gender dysphoria (which also includes a distress factor) or on the number of legal sex changes. However, not every gender nonconforming individual experiences distress or applies for treatment. Population-based research on the broad spectrum of gender nonconformity is scarce and more information on the variance outside the gender binary is needed. This study aimed to examine the prevalence of gender incongruence (identifying stronger with the other sex than with the sex assigned at birth) and gender ambivalence (identifying equally with the other sex as with the sex assigned at birth) based on two population-based surveys, one of 1,832 Flemish persons and one of 2,472 sexual minority individuals in Flanders. In the general population, gender ambivalence was present in 2.2 % of male and 1.9 % of female participants, whereas gender incongruence was found in 0.7 % of men and 0.6 % of women. In sexual minority individuals, the prevalence of gender ambivalence and gender incongruence was 1.8 and 0.9 % in men and 4.1 and 2.1 % in women, respectively. With a current Flemish population of about 6 million, our results indicate a total of between 17,150 and 17,665 gender incongruent men and between 14,473 and 15,221 gender incongruent women in Flanders.
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Affiliation(s)
- Eva Van Caenegem
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
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Motmans J, Ponnet K, De Cuypere G. Sociodemographic Characteristics of Trans Persons in Belgium: A Secondary Data Analysis of Medical, State, and Social Data. Arch Sex Behav 2015; 44:1289-1299. [PMID: 25300904 DOI: 10.1007/s10508-014-0411-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Revised: 03/01/2014] [Accepted: 05/21/2014] [Indexed: 06/04/2023]
Abstract
By performing secondary data analyses of existing medical, social, and state data, this study examined the sociodemographic profile of trans persons in Belgium and gains knowledge on those who are functionally invisible in traditional epidemiological studies or clinical samples. Based on medical interventions, post-operative transsexual persons were selected from a social survey data set, to compare their sociodemographic profile with available data on legal sex changes from the Belgian National Register and with published data on clinical samples of post-operative transsexual persons. Furthermore, based on self-chosen gender identity categories in the social survey data, transsexual participants were compared with the transgender participants (those people feeling neither female nor male, or both female and male, or otherwise). The sociodemographic data on the post-operative transsexual persons from the three datasets appeared to be very similar. Based on identity categories, the data on transsexual and transgender persons from the social survey showed differences in marital status and employment. Transsexual persons were significantly more often divorced than transgender persons. Both groups differed significantly in employment status. Information about transgender people (or the "in-between" group) is too often lacking from studies but can be obtained when identity instead of medical criteria are used in research.
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Affiliation(s)
- Joz Motmans
- Policy Research Centre on Equality Politics, University of Antwerp, Lange Nieuwstraat 55, 2000, Antwerp, Belgium,
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Elaut E, Buysse A, De Sutter P, Gerris J, De Cuypere G, T'Sjoen G. Cycle-Related Changes in Mood, Sexual Desire, and Sexual Activity in Oral Contraception-Using and Nonhormonal-Contraception-Using Couples. J Sex Res 2014; 53:125-136. [PMID: 25420716 DOI: 10.1080/00224499.2014.976780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Findings on women's sexuality across the menstrual cycle are inconsistent. One relatively consistent finding is a midcycle and premenstrual peak in sexual desire in freely cycling women. Results on the cycle-related effects on sexual behavior are less clear. Large proportions of reproductive-aged women use combined oral contraception (COC), but studies on potential cycle-related shifts in sexual desire and behavior are sparse. A prospective diary study assessed sexual desire, sexual behavior, and mood in 89 heterosexual couples. Women were using one of four contraceptive methods: (1) nonhormonal contraception, (2) low-dose COC containing 20 mcg ethinylestradiol and 75 mcg gestoden or desogestrel, (3) COC containing 35 mcg ethinylestradiol and 2 mg cyproteronacetate, and (4) COC containing 30 mcg ethinylestradiol and 3 mg drospirenone. No cycle effects of sexual desire were established in the COC group, but frequency of sexual intercourse declined in the last days of active pill taking. These results were similar in both female and male partners. Negative affect did not covary with sexual desire.
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Affiliation(s)
- Els Elaut
- a Centre for Sexology and Gender Problems , Ghent University Hospital
| | - Ann Buysse
- b Department of Experimental-Clinical and Health Psychology , Ghent University
| | - Petra De Sutter
- c Department of Reproductive Medicine, Obstetrics, and Gynaecology , Ghent University Hospital
| | - Jan Gerris
- c Department of Reproductive Medicine, Obstetrics, and Gynaecology , Ghent University Hospital
| | - Griet De Cuypere
- a Centre for Sexology and Gender Problems , Ghent University Hospital
| | - Guy T'Sjoen
- a Centre for Sexology and Gender Problems , Ghent University Hospital
- d Department of Endocrinology , Ghent University Hospital
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Callens N, Weyers S, Monstrey S, Stockman S, van Hoorde B, van Hoecke E, De Cuypere G, Hoebeke P, Cools M. Vaginal dilation treatment in women with vaginal hypoplasia: a prospective one-year follow-up study. Am J Obstet Gynecol 2014; 211:228.e1-228.e12. [PMID: 24681288 DOI: 10.1016/j.ajog.2014.03.051] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/19/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Vaginal dilation treatment has been shown to be a (cost) effective first-line alternative to surgery in normalizing vaginal length and improving sexual function in women with vaginal hypoplasia. There remains, however, a need for prospective studies, with long-term assessment of multiple outcomes. STUDY DESIGN This was a prospective, single-centre observational study of 16 women with Mayer-Rokitansky-Küster-Hauser syndrome (n = 12) or 46,XY disorders of sex development (n = 4). All women underwent an outpatient vaginal dilation program supervised by a psychologist and physiotherapist. At baseline (T0), stop of treatment (T1) and 1 year follow-up (T2), semistructured interviews, and validated questionnaires assessed sexual function and distress, self-esteem, vaginal perceptions, and health-related quality of life. Gynecological examinations evaluated vaginal dimensions. RESULTS Ten women completed the program, 3 are still in the program, and dilation failed in 3 and chose vaginoplasty. Sixty-nine percent reached a normal vaginal length (≥6.5 cm) in 5.8 ± 3.3 months. Seventy percent were sexually active with pleasurable experiences at T1, 57% at T2. The significant decrease in sexual distress at T1 (P < .05) was followed by a nonsignificant increase at T2. Depressive mood symptomatology remained high at T1 and T2, related to loss of bodily integrity and fertility. The majority refused further psychological counseling. CONCLUSION Vaginal dilation treatment should remain the cornerstone of treatment in women with vaginal hypoplasia. However, the diagnosis remains to have a negative impact on emotional well-being in the long term. The role of psychological intervention as both a primary and adjuvant treatment needs clear evaluation.
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Affiliation(s)
- Nina Callens
- Department of Pediatric Endocrinology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Steven Weyers
- Department of Obstetrics and Gynecology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic Surgery, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Sabine Stockman
- Department of Urology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Birgit van Hoorde
- Department of Sexology and Gender Problems, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Eline van Hoecke
- Department of Pediatric Psychology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Griet De Cuypere
- Department of Sexology and Gender Problems, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Piet Hoebeke
- Department of Urology, Ghent University and University Hospital Ghent, Ghent, Belgium
| | - Martine Cools
- Department of Pediatric Endocrinology, Ghent University and University Hospital Ghent, Ghent, Belgium.
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Callens N, De Cuypere G, De Sutter P, Monstrey S, Weyers S, Hoebeke P, Cools M. An update on surgical and non-surgical treatments for vaginal hypoplasia. Hum Reprod Update 2014; 20:775-801. [DOI: 10.1093/humupd/dmu024] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Callens N, De Cuypere G, T’Sjoen G, Monstrey S, Lumen N, Van Laecke E, Hoebeke P, Cools M. Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study. World J Urol 2014; 33:137-43. [DOI: 10.1007/s00345-014-1283-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 03/17/2014] [Indexed: 11/29/2022] Open
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Heylens G, Elaut E, Kreukels BPC, Paap MCS, Cerwenka S, Richter-Appelt H, Cohen-Kettenis PT, Haraldsen IR, De Cuypere G. Psychiatric characteristics in transsexual individuals: multicentre study in four European countries. Br J Psychiatry 2014; 204:151-6. [PMID: 23869030 DOI: 10.1192/bjp.bp.112.121954] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results. AIMS To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder. METHOD Data were collected within the European Network for the Investigation of Gender Incongruence using the Mini International Neuropsychiatric Interview - Plus and the Structured Clinical Interview for DSM-IV Axis II Disorders (n = 305). RESULTS In 38% of the individuals with gender identity disorder a current DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and anxiety disorders. Furthermore, almost 70% had a current and lifetime diagnosis. All four countries showed a similar prevalence, except for affective and anxiety disorders, and no difference was found between individuals with early-onset and late-onset disorder. An Axis II diagnosis was found in 15% of all individuals with gender identity disorder, which is comparable to the general population. CONCLUSIONS People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.
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Affiliation(s)
- Gunter Heylens
- Gunter Heylens, MD, Els Elaut, MSc, Department of Sexology and Gender Problems, University Hospital Ghent, Belgium; Baudewijntje P. C. Kreukels, PhD, Department of Medical Psychology, VU University Hospital, Amsterdam, The Netherlands; Muirne C. S. Paap, PhD, Department of Research Methodology, Measurement and Data Analysis, Behavioural Sciences, Susanne Cerwenka, Mr.Sc, Hertha Richter-Appelt, PhD, Department of Sex Research and Forensic Psychiatry, University Medical Centre Hamburg-Eppendorf, Germany; Peggy T. Cohen-Kettenis, PhD, Department of Medical Psychology, VU University Hospital Amsterdam, The Netherlands; Ira R. Haraldsen, MD, PhD, Department of Neuropsychiatry and Psychosomatic Medicine, Rikshospitalet Oslo, Norway; Griet De Cuypere, MD, PhD, Department of Sexology and Gender Problems, University Hospital Ghent, Belgium
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Heylens G, Verroken C, De Cock S, T'Sjoen G, De Cuypere G. Effects of Different Steps in Gender Reassignment Therapy on Psychopathology: A Prospective Study of Persons with a Gender Identity Disorder. J Sex Med 2014; 11:119-26. [DOI: 10.1111/jsm.12363] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cerwenka S, Nieder TO, Cohen-Kettenis P, De Cuypere G, Haraldsen IRH, Kreukels BPC, Richter-Appelt H. Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study. J Sex Marital Ther 2014; 40:457-71. [PMID: 24846436 DOI: 10.1080/0092623x.2013.772550] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.
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Affiliation(s)
- Susanne Cerwenka
- a University Medical Center Hamburg-Eppendorf , Department of Sex Research and Forensic Psychiatry , Hamburg , Germany
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Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, Weyers S, Hoebeke P, T'Sjoen G. Sexual Desire in Trans Persons: Associations with Sex Reassignment Treatment. J Sex Med 2014; 11:107-18. [DOI: 10.1111/jsm.12365] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, Hoebeke P. Self‐Assessment of Genital Anatomy and Sexual Function within a Belgian, Dutch‐Speaking Female Population: A Validation Study. J Sex Med 2013; 10:3006-18. [DOI: 10.1111/jsm.12326] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Callens N, De Cuypere G, Van Hoecke E, T'Sjoen G, Monstrey S, Cools M, Hoebeke P. Sexual Quality of Life after Hormonal and Surgical Treatment, Including Phalloplasty, in Men with Micropenis: A Review. J Sex Med 2013; 10:2890-903. [DOI: 10.1111/jsm.12298] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Callens N, De Cuypere G, Wolffenbuttel KP, Beerendonk CC, van der Zwan YG, van den Berg M, Monstrey S, Van Kuyk ME, De Sutter P, Dessens AB, Cools M. Long‐Term Psychosexual and Anatomical Outcome after Vaginal Dilation or Vaginoplasty: A Comparative Study. J Sex Med 2012; 9:1842-51. [DOI: 10.1111/j.1743-6109.2012.02747.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T'Sjoen G. Gender identity disorder in twins: a review of the case report literature. J Sex Med 2012. [PMID: 22146048 DOI: 10.1111/j.1743-6109.2011.02567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
INTRODUCTION The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables. AIM To review the current literature on case studies of twins concordant or discordant for GID. METHODS A systematic, comprehensive literature review. RESULTS Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P=0.005). Of the seven opposite-sex twins, all were discordant for GID. CONCLUSIONS These findings suggest a role for genetic factors in the development of GID.
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Affiliation(s)
- Gunter Heylens
- Department of Sexology and Gender Problems, Ghent University Hospital, Ghent, Belgium.
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Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T'Sjoen G. Gender identity disorder in twins: a review of the case report literature. J Sex Med 2011; 9:751-7. [PMID: 22146048 DOI: 10.1111/j.1743-6109.2011.02567.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables. AIM To review the current literature on case studies of twins concordant or discordant for GID. METHODS A systematic, comprehensive literature review. RESULTS Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P=0.005). Of the seven opposite-sex twins, all were discordant for GID. CONCLUSIONS These findings suggest a role for genetic factors in the development of GID.
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Affiliation(s)
- Gunter Heylens
- Department of Sexology and Gender Problems, Ghent University Hospital, Ghent, Belgium.
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Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, Weyers S, Hoebeke P, Monstrey S, De Cuypere G, T'Sjoen G. Quality of Life and Sexual Health after Sex Reassignment Surgery in Transsexual Men. J Sex Med 2011; 8:3379-88. [DOI: 10.1111/j.1743-6109.2011.02348.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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De Cuypere G, Knudson G, Bockting W. Second Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Gender Dysphoria forDSM 5. Int J Transgend 2011. [DOI: 10.1080/15532739.2011.624047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Elaut E, Buysse A, De Sutter P, De Cuypere G, Gerris J, Deschepper E, T'Sjoen G. Relation of androgen receptor sensitivity and mood to sexual desire in hormonal contraception users. Contraception 2011; 85:470-9. [PMID: 22133661 DOI: 10.1016/j.contraception.2011.10.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 10/13/2011] [Accepted: 10/15/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Since very little research in this field is available, this study aims to assess the role of psychosexual, relationship, hormonal and genetic measures in the sexual desire of users of three hormonal contraceptive products [low-dose combined oral contraceptive (20 mcg ethinylestradiol/150 mcg desogestrel), progestin-only pill (75 mcg desogestrel) and vaginal ring (daily dose of 15 mcg ethinylestradiol/120 mcg etonogestrel)]. STUDY DESIGN Fifty-five couples were randomized over three groups in which the women consecutively used each product during 3 months. Both partners repeatedly filled out questionnaires on solitary and dyadic sexual desire (desire to behave sexually by oneself or towards a partner). Total and free testosterone, sex hormone binding globulin and a genetic marker of androgen receptor sensitivity [cytosine-adenine-guanine (CAG) repeat length] were assessed on blood samples of the female partners. RESULTS Sexual desire was higher in women with either short or long CAG repeats (solitary, p=.004; dyadic, p=.008). Desire levels were higher during vaginal ring use (solitary, p=.018; dyadic, p=.007). The woman's mood was found to impact her dyadic sexual desire (p<.001); this scale was also strongly associated with the male partner's dyadic sexual desire (p<.001). CONCLUSIONS The current study found evidence for a role of androgen receptor sensitivity and mood in the sexual desire of hormonal contraceptive users.
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Affiliation(s)
- Els Elaut
- Department of Sexology and Gender Problems, Ghent University Hospital, De Pintelaan 185, Ghent, Belgium.
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Knudson G, De Cuypere G, Bockting W. Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Transvestic Fetishism forDSM 5. Int J Transgend 2011. [DOI: 10.1080/15532739.2011.606201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Knudson G, De Cuypere G, Bockting W. Second Response of the World Professional Association for Transgender Health to the Proposed Revision of the Diagnosis of Transvestic Disorder forDSM5. Int J Transgend 2011. [DOI: 10.1080/15532739.2011.606195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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T'Sjoen G, De Cuypere G, Monstrey S, Hoebeke P, Freedman FK, Appari M, Holterhus PM, Van Borsel J, Cools M. Male gender identity in complete androgen insensitivity syndrome. Arch Sex Behav 2011; 40:635-638. [PMID: 20358272 DOI: 10.1007/s10508-010-9624-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 03/06/2010] [Accepted: 03/17/2010] [Indexed: 05/29/2023]
Abstract
Women and girls with complete androgen insensitivity syndrome (CAIS) invariably have a female typical core gender identity. In this case report, we describe the first case of male gender identity in a CAIS individual raised female leading to complete sex reassignment involving both androgen treatment and phalloplasty. CAIS was diagnosed at age 17, based on an unambiguously female phenotype, a 46,XY karyotype, and a 2660delT androgen receptor (AR) gene mutation, leading to a premature stop in codon 807. Bilateral gonadectomy was performed but a short period of estrogen treatment induced a negative emotional reaction and treatment was stopped. Since the age of 3, childhood-onset cross gender behavior had been noticed. After a period of psychotherapy, persisting male gender identity was confirmed. There was no psychiatric co-morbidity and there was an excellent real life experience. Testosterone substitution was started, however without inducing any of the desired secondary male characteristics. A subcutaneous mastectomy was performed and the patient received phalloplasty by left forearm free flap and scrotoplasty. Testosterone treatment was continued, without inducing virilization, and bone density remained normal. The patient qualifies as female-to-male transsexual and was treated according to the Standards of Care by the World Professional Association for Transgender Health with good outcome. However, we do not believe that female sex of rearing as a standard procedure should be questioned in CAIS. Our case challenges the role of a functional AR pathway in the development of male gender identity.
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Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology, Center for Sexology and Genderproblems, Ghent University Hospital, Belgium.
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Nieder TO, Herff M, Cerwenka S, Preuss WF, Cohen‐Kettenis PT, De Cuypere G, Hebold Haraldsen IR, Richter‐Appelt H. Age of Onset and Sexual Orientation in Transsexual Males and Females. J Sex Med 2011; 8:783-91. [DOI: 10.1111/j.1743-6109.2010.02142.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Inoubli A, De Cuypere G, Rubens R, Heylens G, Elaut E, Van Caenegem E, Menten B, T'Sjoen G. Karyotyping, Is It Worthwhile in Transsexualism? J Sex Med 2011; 8:475-8. [DOI: 10.1111/j.1743-6109.2010.02130.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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De Cuypere G, Knudson G, Bockting W. Response of the World Professional Association for Transgender Health to the ProposedDSM 5Criteria for Gender Incongruence. Int J Transgend 2010. [DOI: 10.1080/15532739.2010.509214] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Knudson G, De Cuypere G, Bockting W. Process Toward Consensus on Recommendations for Revision of theDSMDiagnoses of Gender Identity Disorders by the World Professional Association for Transgender Health. Int J Transgend 2010. [DOI: 10.1080/15532739.2010.509213] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Knudson G, De Cuypere G, Bockting W. Recommendations for Revision of theDSMDiagnoses of Gender Identity Disorders: Consensus Statement of the World Professional Association for Transgender Health. Int J Transgend 2010. [DOI: 10.1080/15532739.2010.509215] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Monstrey S, Vercruysse H, De Cuypere G. Is Gender Reassignment Surgery Evidence Based? Recommendation for the Seventh Version of the WPATHStandards of Care. Int J Transgend 2009. [DOI: 10.1080/15532730903383799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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De Cuypere G, Vercruysse H. Eligibility and Readiness Criteria for Sex Reassignment Surgery: Recommendations for Revision of the WPATHStandards of Care. Int J Transgend 2009. [DOI: 10.1080/15532730903383781] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Weyers S, Elaut E, De Sutter P, Gerris J, T'Sjoen G, Heylens G, De Cuypere G, Verstraelen H. Long-term Assessment of the Physical, Mental, and Sexual Health among Transsexual Women. J Sex Med 2009; 6:752-60. [DOI: 10.1111/j.1743-6109.2008.01082.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
A number of studies have evaluated the effectiveness of a cricothyroid approximation (CA) in creating a more female voice in male-to-female transsexuals (MFTs) from an acoustic perspective. An increase in pitch is of little value, however, unless it accurately indicates listeners' perceptions of gender. The purpose of this study was to further investigate the effectiveness of a CA in feminizing the voice from a perceptual perspective. Video recordings of nine MFTs, nine nontranssexual males (NTMs), and nine nontranssexual females (NTFs) were presented twice to the panel of judges in a randomized order: first auditory only (only hearing a subject's speech) and subsequently audiovisual (hearing and seeing a subject's speech). The panel of judges, 42 students (21 female, 21 male) from different disciplines, rated the participants' voices on a 100-mm visual analog scale with "very male" and "very female" as left and right extremes, respectively. The group of MFT obtained scores that were situated in between those of the NTM and the NTF, both for the auditory only and the audiovisual mode of presentation. Perception of femaleness significantly correlated with average fundamental frequency for both modes of presentation. It can be concluded that a CA approximation is a viable option to raise the voice pitch in MFTs but that this surgery alone may not be sufficient to create a voice that is perceived as a totally female.
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Affiliation(s)
- John Van Borsel
- Ghent University Hospital, Faculty of Medicine and Health Sciences, Ghent, Belgium.
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Lumen N, Monstrey S, Selvaggi G, Ceulemans P, De Cuypere G, Van Laecke E, Hoebeke P. Phalloplasty: a valuable treatment for males with penile insufficiency. Urology 2008; 71:272-6; discussion 276-7. [PMID: 18308099 DOI: 10.1016/j.urology.2007.08.066] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 06/25/2007] [Accepted: 08/10/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To apply a phalloplasty technique used in female-to-male transsexual surgery in male patients with penile insufficiency. METHODS Seven male patients (aged 15 to 42 years) were treated with phalloplasty (6 with radial forearm free flap and one with anterolateral thigh flap) between March 2004 and April 2006 (follow-up, 9 to 34 months). All patients suffered psychologically from their condition, with low self-esteem and sexual and relational dysfunction. They were evaluated by a sexologist-psychiatrist before and after surgery. Erectile implant surgery is offered approximately 1 year after the phallic reconstruction. RESULTS There were no complications concerning the flap. Two complications were reported in the early postoperative period. Two patients developed urinary complications (stricture and/or fistula). Patient satisfaction after surgery was high in 6 cases and moderate in 1 case. Psychological evaluation confirms this, especially on the self-esteem level. Four patients underwent erectile implant surgery. In 2 patients the erectile implant had to be removed. CONCLUSIONS This success has convinced us that phalloplasty is a valuable treatment for penile insufficiency. It has good results in terms of patient self-esteem and sexual well-being. This technique opens new horizons for the treatment of penile agenesis, micropenis, crippled penis, shrivelled penis, some disorders of sexual development, traumatic amputations, and cloacal exstrophy.
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Affiliation(s)
- Nicolaas Lumen
- Department of Urology, Ghent University Hospital, Ghent, Belgium.
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Elaut E, De Cuypere G, De Sutter P, Gijs L, Van Trotsenburg M, Heylens G, Kaufman JM, Rubens R, T'Sjoen G. Hypoactive sexual desire in transsexual women: prevalence and association with testosterone levels. Eur J Endocrinol 2008; 158:393-9. [PMID: 18299474 DOI: 10.1530/eje-07-0511] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE An unknown proportion of transsexual women (defined as post-operative male-to-female transsexuals on oestrogen replacement) experience hypoactive sexual desire disorder (HSDD). It has been suggested that the absence of ovarian androgen production together with oestrogen treatment-related increase in sex hormone-binding globulin (SHBG) levels could be leading to HSDD, due to low levels of biologically available testosterone. This study wishes to document the HSDD prevalence among transsexual women and the possible association to androgen levels. DESIGN Cross-sectional study. METHODS Transsexual women (n=62) and a control group of ovulating women (n=30) participated in this study. Questionnaires measuring sexual desire (sexual desire inventory) and relationship and sexual satisfaction (Maudsley Marital Questionnaire) were completed. Serum levels of total testosterone, LH and SHBG were measured in blood samples obtained at random in transsexual women and in the early follicular phase in ovulating women. RESULTS The transsexual group had lower levels of total and calculated free testosterone (both P<0.001) than the ovulating women. HSDD was reported in 34% of the transsexual and 23% of the ovulating women (P=0.30). Both groups reported similar levels of sexual desire (P=0.97). For transsexual women, no significant correlation was found between sexual desire and total (P=0.64) or free testosterone (P=0.82). In ovulating women, these correlations were significant (P=0.006, resp. P=0.003). CONCLUSIONS HSDD is reported in one-third of transsexual women. This prevalence is not substantially different from controls, despite markedly lower (free) testosterone levels, which argues against a major role of testosterone in this specific group.
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Affiliation(s)
- Els Elaut
- Department of Sexology and Gender Problems, Ghent University Hospital, Belgium
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Kins E, Hoebeke P, Heylens G, Rubens R, De Cuypere G. The female-to-male transsexual and his female partner versus the traditional couple: a comparison. J Sex Marital Ther 2008; 34:429-438. [PMID: 18770112 DOI: 10.1080/00926230802156236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
In this explorative study, nine stable relationships between female-to-male transsexuals and their biologically female partners were compared to an equal number of "traditional" heterosexual couples. The aim was to investigate any differences between these two groups on three aspects: satisfaction about the partner relationship, sexual satisfaction, and partnership sex typing. Data do not show any significant differences in relational and sexual satisfaction between the transsexuals' female partner and the women in the "traditional" couples. In contrast, the female-to-male transsexuals and their female partners were found to have adopted a more pronounced sex-typed partner relationship than the "traditional" couples.
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Affiliation(s)
- Evie Kins
- Department of Developmental Psychology, Ghent University, Ghent, Belgium.
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Selvaggi G, Monstrey S, Ceulemans P, T'Sjoen G, De Cuypere G, Hoebeke P. Genital sensitivity after sex reassignment surgery in transsexual patients. Ann Plast Surg 2007; 58:427-33. [PMID: 17413887 DOI: 10.1097/01.sap.0000238428.91834.be] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tactile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery. Since November 1993 until April 2003, a total of 105 phalloplasties with the radial forearm free flap and 127 vaginoclitoridoplasties with the inverted penoscrotal skin flap and the dorsal glans pedicled flap have been performed at Ghent University Hospital. The specific surgical tricks used to preserve genital and tactile sensitivity are presented. In phalloplasty, the dorsal hood of the clitoris is incorporated into the neoscrotum; the clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft; and the medial and lateral antebrachial nerves are coapted to the inguinal nerve and to one of the 2 dorsal nerves of the clitoris. In vaginoplasty, the clitoris is reconstructed from a part of the glans penis inclusive of a part of the corona, the inner side of the prepuce is used to reconstruct the labia minora, and the penile shaft is inverted to line the vaginal cavity. MATERIAL AND METHODS A long-term sensitivity evaluation (performed by the Semmes-Weinstein monofilament and the Vibration tests) of 27 reconstructed phalli and 30 clitorises has been performed. RESULTS The average pressure and vibratory thresholds values for the phallus tip were, respectively, 11.1 g/mm and 3 microm. These values have been compared with the ones of the forearm (donor site). The average pressure and vibratory thresholds values for the clitoris were, respectively, 11.1 g/mm and 0.5 microm. These values have been compared with the ones of the normal male glans, taken from the literature. We also asked the examined patients if they experienced orgasm after surgery, during any sexual practice (ie, we considered only patients who attempted to have orgasm): all female-to-male and 85% of the male-to-female patients reported orgasm. CONCLUSION With our techniques, the reconstructed genitalia obtain tactile and erogenous sensitivity. To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential. To obtain orgasm after a vaginoplasty, the reconstruction of the clitoris from the neurovascular pedicled glans flap is essential.
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Affiliation(s)
- Gennaro Selvaggi
- Department of Plastic Surgery, Ghent University Hospital, Gent, Belgium.
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De Cuypere G, T'Sjoen G, Beerten R, Selvaggi G, De Sutter P, Hoebeke P, Monstrey S, Vansteenwegen A, Rubens R. Sexual and physical health after sex reassignment surgery. Arch Sex Behav 2005; 34:679-90. [PMID: 16362252 DOI: 10.1007/s10508-005-7926-5] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2004] [Revised: 09/02/2004] [Accepted: 12/02/2004] [Indexed: 05/05/2023]
Abstract
A long-term follow-up study of 55 transsexual patients (32 male-to-female and 23 female-to-male) post-sex reassignment surgery (SRS) was carried out to evaluate sexual and general health outcome. Relatively few and minor morbidities were observed in our group of patients, and they were mostly reversible with appropriate treatment. A trend toward more general health problems in male-to-females was seen, possibly explained by older age and smoking habits. Although all male-to-females, treated with estrogens continuously, had total testosterone levels within the normal female range because of estrogen effects on sex hormone binding globulin, only 32.1% reached normal free testosterone levels. After SRS, the transsexual person's expectations were met at an emotional and social level, but less so at the physical and sexual level even though a large number of transsexuals (80%) reported improvement of their sexuality. The female-to-males masturbated significantly more frequently than the male-to-females, and a trend to more sexual satisfaction, more sexual excitement, and more easily reaching orgasm was seen in the female-to-male group. The majority of participants reported a change in orgasmic feeling, toward more powerful and shorter for female-to-males and more intense, smoother, and longer in male-to-females. Over two-thirds of male-to-females reported the secretion of a vaginal fluid during sexual excitation, originating from the Cowper's glands, left in place during surgery. In female-to-males with erection prosthesis, sexual expectations were more realized (compared to those without), but pain during intercourse was more often reported.
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Affiliation(s)
- Griet De Cuypere
- Department of Sexology and Gender Problems, University Hospital Ghent, Ghent, Belgium.
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Selvaggi G, Ceulemans P, De Cuypere G, VanLanduyt K, Blondeel P, Hamdi M, Bowman C, Monstrey S. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast Reconstr Surg 2005; 116:135e-145e. [PMID: 16267416 DOI: 10.1097/01.prs.0000185999.71439.06] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism. BACKGROUND Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons. METHODS The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism. RESULTS Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined. CONCLUSIONS This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.
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Affiliation(s)
- Gennaro Selvaggi
- Department of Plastic Surgery, University Hospital of Ghent, Ghent, Belgium.
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