Female-to-male Transsexuals Research Articles

Sex transition from female to male as a risk factor for sleep-disordered breathing

AimThe female-to-male (FtM) sex transition requires lifelong supplementation with male sex hormones, resulting in high prevalence of weight gain, fat redistribution and other metabolic changes. Although sleep-disordered breathing (SDB) data for this group of patients are very limited, increased prevalence is expected. We report a mini-series of six case reports of FtM transsexuals treated in our centre. Patients and methodsAll reported cases are consecutive patients referred to a department of respiratory diseases and tuberculosis of a university hospital from 2017 to 2022. The standard pulmonary examination was performed, followed by limited polysomnography. ResultsIn all FtM subjects, SDB was present and continuous positive airway pressure (CPAP) therapy was indicated. The sex transition process was completed in three individuals while the other three only took testosterone supplementation at the assessment time. The subjects’ age ranged from 21 to 38 years, the apnoea-hypopnea index ranged from 17.3 to 104.1, and the BMI was 33.48–43.41. The CPAP therapy was effective in five patients, with one requiring bi-level positive airway pressure therapy. One subject committed suicide before the first check-up, four patients had a good level of compliance at one-year follow-up, and one had insufficient CPAP adherence. ConclusionSDB decreases the quality of life and life expectancy of FtM individuals. Their prognosis is undoubtedly better with effective treatment. Hence, obese FtM subjects should be considered at risk and screened for SDB.

Color Doppler Sonography Assisted Subcutaneous Mastectomy with Inferior Pedicled Nipple-Areola Complex in Female-to-Male Transsexuals: A Retrospective Cohort Analysis.

The surgical goals of gender reassignment surgery of the breast in female-to male transsexuals (FMT) is the aesthetic shaping of a male thoracic wall with minimal scarring, while preserving the sensitivity of the nipple-areola complex (NAC). For large and ptotic breasts, we perform a mastectomy over an inframammary access with inferior pedicled NAC under color Doppler visualization of the perforators. This paper presents the technique, including complications and assessment of quality of life, as part of a unicentric analysis. This was a retrospective analysis of 23 patients (46 mastectomies) performed between September 2014 and September 2020. The complication rate and the number of corrective surgeries were recorded for quality assessment. A semiquantitative score was used to evaluate aesthetic outcome, nipple sensitivity, quality of life, and sexuality. A total of 46 mastectomies were performed in 23 patients. The patient survey showed high patient satisfaction. Loss of nipple sensitivity was observed after one mastectomy (2.17%). In 91.67% of cases, patients reported that their appearance reflected how they feel on the inside. In 75% of cases, patients reported feeling equal to other men. The overall complication rate was 10.87%. Shape correction due to persistent excess of volume was rare (2.17%, equivalent to one mastectomy). Subcutaneous mastectomy with inferior nipple pedicle can be performed with a high degree of safety and satisfaction in FMT. Color Doppler-guided visualization of the perforator vessels is helpful in allowing a thin pedicle preparation, thus reducing the need for secondary surgeries to optimize the shape. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

САМООЦЕНКА НА РАЗНЫХ ЭТАПАХ КОРРЕКЦИИ ПОЛА У ТРАНССЕКСУАЛОВ

Background of the work is associated with the high signifi cance of an accurate assessment of the adaptive potential of a transsexual sent for transgender transition. To date, psychological constructs that make it possible to predict this potential look unconvincing due to the blurriness of these constructs, as well as ways to evaluate them. Th e ability for adequate self-assessment is proposed as a relevant construct. Objective is to state the self-esteem of transsexuals at diff erent stages of transgender transition in comparison with non-transexuals. Methods. Th e anonymous questionnaire includes the M. Kuhn — T. McPartland test «Who am I» modifi ed by A. Th ostov, E. Rasskazova, V. Emelin (2014); «Cognitive Beliefs Inconsistency Study Method» (Rasskazova, Th ostov, Abramova, 2015); «Satisfaction with Life Scale» (Diener, Emmons, Larsen, Grin, 1985; adapted by E. Osin, D. Leontiev, 2008). ANOVA is used in the SPSS 23 program. Sample. Control group: 120 cisgender people. Main group: 151 transsexuals: Male-to-Female (MtF), Female-to-Male (FtM). Results. Well-being level of MtF in fi nal stage of transgender transition is equal to that of cisgender people, and FtM’s level is lower (F = 8.384; P < 0.01). FtM in all stages of transgender transition give higher marks of social recognition of their self-identifi cations than MtF (F = 8.996; P < 0.01). FtM rate their masculinity from the point of friends’ view higher than MtF (F = 3.413; P < 0.05). MtF transsexuals in all stages of transgender transition rate their self-identifi cations lower than FtM (F = 3.532; P < 0.05). Conclusion. FtM have an overestimation of self-esteem in terms of masculinity, social recognition. It is associated with psychological compensation of a lower level of well-being than MtF. MtF more accurately rate reality in all stages of transgender transition and do not resort to compensatory mechanisms.

"Single center experience of laparoscopic hysteroannessiectomy and histopathological outcomes in transgender men".

This article presents a retrospective descriptive analysis about female-to-male (FtM) gender-affirmation nongenital surgical procedures involving the gynecological team at the CIDIGeM (Centro Interdipartimentale Disturbi di Identità di Genere Molinette) Center in Turin. From 2004 to 2019, seventy FtM transsexual patients underwent hysteroannessiectomy: the chosen surgical technique involved a Total Laparoscopic Hysterectomy. The patients presented a median age of 30.5 years (range 21-53). No patients presented intraoperative complications, the median of surgery time was 80 min (range 40-150) and the hospital stay median was 5 days (range: 2-25). Histopathological examinations were negative for cancer in all patients except for one unknown case of grade 3 cervical intraepithelial neoplasia. Total Laparoscopic Hysterectomy is confirmed to be the method of choice in the group of FtM transsexuals: this approach has several advantages over abdominal hysterectomy, including more rapid recovery, fewer wound or abdominal wall infections; moreover, it has enabled us to preserve the vital structures needed for reconstruction of external genitalia. Cancer risk is still considered an area of priority in transgender research; thus, we underline the importance of performing a histopathological examination of the surgical specimen.

Chest Wall Masculinization in Female-to-Male Transsexuals: Our Treatment Algorithm and Life Satisfaction Questionnaire.

Esthetic masculinization of the chest wall is one of the first surgical steps in female-to-male transsexual (FTMTS) reassignment.This surgical procedure is not a simple mastectomy: it is required for removal of breast tissue with glandular resection and skin excess revision, to reduce and replace the nipple-areola complex in the right location, minimizing chest wall scars. The creation of an esthetically pleasing male chest allows the patient to live at ease in the male gender role.In this article, we present our series of 68 FTMTSs who underwent bilateral mastectomies for surgical sexual reassignment (a total of 136 mastectomies) according to our algorithm, in the period between January 2010 and December 2017. We selected 4 different operative procedures, classified as subcutaneous ("pull-through" and "concentric circular" techniques) and skin extended ("ultrathin vertical bipedicle" and free nipple graft).We achieved a total complication rate of 6.6%, less than that reported in the literature; additional procedures for esthetic improvements were performed in 14.7% of cases. The mean patient satisfaction was approximately 4.57% of a maximal value of 5 (excellent).To help surgeons in choosing the most appropriate FTMTS surgical technique and to reduce unfavorable results, we propose the use of our treatment algorithm in preoperative evaluation of the chest wall according to the breast volume, degree of glandular ptosis, and skin elasticity.

Risk Factors for Postoperative Hematoma after Chest Wall Contouring for Female-to-Male Transsexuals: A Clinical Study.

Gender dysphoria is a condition in which a discrepancy between biological sex and gender identity causes distress. Many female-to-male transsexuals (FTMTS) are uncomfortable with female breasts. Chest wall contouring surgery is effective for obtaining a male-type chest, reducing mental stress, and increasing sexual satisfaction in such cases. At the Okayama University Hospital Gender Center, we have obtained positive results using an algorithm to determine the most appropriate surgical method for chest wall contouring in FTMTS patients. However, serious complications requiring reoperation, such as hematoma, may still occur. Postoperative hematomas were found in 15 (4.18%) of 358 FTMTS patients who underwent chest contouring surgery at our hospital between 2006 and 2018. Postoperative hematoma was examined retrospectively. The median time to the onset of hematoma was 7 (6-12) h after the initial surgery. The main blood vessels causing bleeding were those in the head-side skin flap region where visual confirmation was difficult and the perforator vessels from the pectoralis major muscle. Intraoperative bleeding and the operation time had a significant impact on the onset of postoperative hematoma. This is the first retrospective study that investigated the blood vessels and other factors contributing to postoperative hematoma development after chest wall contouring.

Quality of Life After Sex Reassignment Surgery: A Systematic Review and Meta-Analysis

Context: Gender identity disorder (GID) or gender dysphoria is a disorder in which an individual identifies him/herself with the opposite sex. GID following sex reassignment surgery (SRS) is usually associated with severe distress and several limitations in the personal and social aspects of life as a transgender. Objectives: The current systematic review and meta-analysis aimed at evaluating the quality of life (QoL) after SRS in transgender individuals. Data Sources: A search was conducted in English databases, including PubMed, Scopus, PsycINFO, ScienceDirect, and Google Scholar. In addition, the reference lists of the included articles were reviewed without any time limitations. The final literature search was performed on 12 June 2017. Study Selection: All relevant cross sectional and observational studies were evaluated in the current review. The keywords included sex, gender, reassignment surgery, reassignment operation, sex change, sex reversal, transpersonal, sexual transition, gender dysphoria, transsexual, transgender, gender identity, male-to-female transsexual, female-to-male transsexual, quality of life, QoL, quality adjusted, and wellbeing. Data Extraction: After screening 941 articles, 16 studies were reviewed systematically, six of which were included in the meta-analysis. Comprehensive Meta-Analysis Software version 2 was used for all meta-analyses. Results: QoL improved after SRS in some dimensions, including bodily pain, emotional role, and mental health in male-to-female (MtF) transsexuals, and physical function and physical role in female-to-male (FtM) transsexuals. Physical role, vitality, and social function in MtF transsexuals were not significantly different from the general population. In other words, bodily pain, general health, social function, vitality, mental health, and emotional role in FtM transsexuals, as well as physical function and general health in MtF transsexuals, were lower than the general population. Conclusions: Based on the findings, SRS could improve some dimensions of QoL, including bodily pain, emotional role, and mental health in MtF transsexuals, and physical function as well as physical role in FtM transsexuals. Nevertheless, further research is necessary in this area.

Transgender Care Knowledge and Attitudes Amongst Puerto Rico's Gynecologists [18P

INTRODUCTION: Transgender refers to individuals whose gender identity and/or expression of gender differs from gender assigned at birth. Countless roadblocks prevent access to medical services due to stigmas and prejudices, lack of knowledge and experience in terms of their healthcare needs, and insensitive treatment from their providers. Even though the gynecology field is involved in care of transgender individuals, there is scarce literature and guidelines focused on their care. The aim of this study is to learn about attitudes, disposition and knowledge of transgender medical care amongst gynecologists actively practicing in Puerto Rico (PR). METHODS: After Institutional Review Board approval, gynecologists were invited to complete a survey designed to determine knowledge about transgender care, disposition, and experience treating transgender patients. The administered questionnaire was previously used in a study evaluating gynecologists from the continental United States but had yet to be done in PR. Responses were catalogued using Epi Info frequency analysis. RESULTS: Fifty-nine participants were recruited. When asked if comfortable taking care of male-to-female transsexuals (MTFT), 59% agreed. In female-to-male transsexuals (FTMT), 47% agreed. Regarding if would perform pap smears on FTMT 81% agreed, whereas 80% felt comfortable performing breast exams on MTFT. Of the respondents 49% are not familiar with hormonal regimens used for gender reassignments. 70% of respondents knew there is a Practice Bulletin on the care of the transgender patient. CONCLUSION: There is a willingness to treat transsexual patients amidst PR gynecologists but the lack of knowledge regarding population specific treatments and managements represents a limitation.

Sigma-lead Male-to-Female Gender Affirmation Surgery: Blending Cosmesis with Functionality.

Current male-to-female (MtF) sex-reassignment-surgery techniques have not been fully successful to achieve the ideal objectives. The ordeal of multiple procedures, associated complications, and suboptimal results leads to high rate of dissatisfaction. We have tried to overcome functional inadequacy and address the esthetic issues for outer genitalia and vagina with our innovative "true shape sigma-lead SRS: Kaushik's technique," which has now become the technique of choice for MtF genital SRS for our patients. Between April 2007 and April 2017, authors performed 386 sigma-lead SRS in MtF transsexuals. Results were analyzed based on complications, resurgeries, and esthetic/functional outcomes. Corrective SRS using rectosigmoid constituted 145 cases and is not a part of this study. Maximum follow-up was 7 years (average 34 months). Seventy-eight (20.2%) patients had complications, majority being minor (97.4%). Forty-four (11.4%) required resurgeries, 10 (2.6%) were corrective for introital stricture and mucosal prolapse, whereas 34 (8.8%) opted for optional minor esthetic enhancement. The overall satisfaction rate for cosmetic and functional outcomes was 4.7 out of 5. In addition to review of the literature, innovations in the technique have been explained. Kaushik's sigma-lead MtF SRS technique is a step short to become the gold standard of genital SRS because it has proven to be safe and reliable. It allows faster healing, minimal dilation, and nearly natural cosmetic results in the form of clitoris/clitoral hood, labia minora, labia majora along with self-lubricating, fully deep, and sensate neovagina with orgasmic capabilities. This is perhaps the largest reported series of rectosigmoid use in transsexuals carried out for primary vaginoplasty.

Novel surgical techniques in female to male gender confirming surgery.

The current management of female to male (FTM) gender confirmation surgery is based on the advances in neo phalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Reconstruction of the neophallus is one of the most difficult elements in surgical treatment of female transsexuals. While there is a variety of available surgical techniques, their results are not equally acceptable to all patients. The preference for a particular surgical technique mostly depends on the patient’s desires and expectations. Nevertheless, the surgeon’s duty is to fully inform the patient about all the advantages and disadvantages, as well as all complications that might occur after surgical procedure—and even to talk them out of a desired surgical technique if there are contraindications. Metoidioplasty is a technically demanding surgical procedure used in FTM transsexuals who desire a gender reassignment surgery (GRS) without undergoing a complex, multi-staged surgical creation of an adult-sized phallus. Metoidioplasty is viable in cases where the clitoris seems large enough after androgen hormonal treatment. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome of FTM transgender surgery is predictable. Various free flaps have been reported for total phalloplasty, such as radial forearm flap, latissimus dorsi flap, anterolateral tight flap, different abdominal wall flaps, free deltoid flap, scapular free flap, sensate osteocutaneous free fibula flap, tensor fasciae latae, deep epigastric artery perforator flap and dorsalis pedis flap. The fact that there are so many techniques for penile reconstruction in cases of penis absence, proves that none of the above mentioned techniques succeeded in achieving the ideal goals of penis reconstruction. We will emphasize the most commonly used surgical techniques in genital confirmation in FTM transsexuals with reference to respective eligibility criteria for each procedure.

Molecular basis of Gender Dysphoria: androgen and estrogen receptor interaction

BackgroundPolymorphisms in sex steroid receptors have been associated with transsexualism. However, published replication studies have yielded inconsistent findings, possibly because of a limited sample size and/or the heterogeneity of the transsexual population with respect to the onset of dysphoria and sexual orientation. We assessed the role of androgen receptor (AR), estrogen receptors alpha (ERα) and beta (ERβ), and aromatase (CYP19A1) in two large and homogeneous transsexual male-to-female (MtF) and female-to-male (FtM) populations. MethodsThe association of each polymorphism with transsexualism was studied with a twofold subject-control analysis: in a homogeneous population of 549 early onset androphilic MtF transsexuals versus 728 male controls, and 425 gynephilic FtMs versus 599 female controls. Associations and interactions were investigated using binary logistic regression. ResultsOur data show that specific allele and genotype combinations of ERβ, ERα and AR are implicated in the genetic basis of transsexualism, and that MtF gender development requires AR, which must be accompanied by ERβ. An inverse allele interaction between ERβ and AR is characteristic of the MtF population: when either of these polymorphisms is short, the other is long. ERβ and ERα are also associated with transsexualism in the FtM population although there was no interaction between the polymorphisms. Our data show that ERβ plays a key role in the typical brain differentiation of humans. ConclusionERβ plays a key role in human gender differentiation in males and females.

Reduced Luteinizing Hormone Induction Following Estrogen and Progesterone Priming in Female-to-Male Transsexuals.

Anatomical studies have suggested that one of the brain structures involved in gender identity is the bed nucleus of the stria terminalis, though this brain structure is probably not the only one to control gender identity. We hypothesized that, if this brain area also affected gonadotropin secretion in humans, transsexual individuals might produce different gonadotropin levels in response to exogenous stimulation. In the present study, we examined whether estrogen combined with progesterone might lead to a change in luteinizing hormone (LH) secretion in female-to-male (FTM) transsexual individuals. We studied female control subjects (n = 9), FTM transsexual subjects (n = 12), and male-to-female (MTF) transsexual subjects (n = 8). Ethinyl estradiol (50 μg/tablet) was administered orally, twice a day, for five consecutive days. After the first blood sampling, progesterone (12.5 mg) was injected intramuscularly. Plasma LH was measured with an immunoradiometric assay. The combination of estrogen and progesterone resulted in increased LH secretion in female control subjects and in MTF subjects, but this increase appeared to be attenuated in FTM transsexual subjects. In fact, the %LH response was significantly reduced in FTM subjects (P < 0.05), but not in MTF subjects (P > 0.5), compared to female control subjects. In addition, the peak time after progesterone injection was significantly delayed in FTM subjects (P < 0.05), but not in MTF subjects (P > 0.5), compared to female control subjects. We then compared subjects according to whether the combination of estrogen and progesterone had a positive (more than 200% increase) or negative (less than 200% increase) effect on LH secretion. A χ2 analysis revealed significantly different (P < 0.05) effects on LH secretion between female controls (positive n = 7, negative n = 2) and FTM transsexual subjects (positive n = 4, negative n = 8), but not between female controls and MTF transsexual subjects (positive n = 7, negative n = 1). Thus, LH secretion in response to estrogen- and progesterone priming was attenuated in FTM subjects, but not in MTF subjects, compared to control females. This finding suggested that the brain area related to gender identity in morphological studies might also be involved in the LH secretory response in humans. Thus, altered brain morphology might be correlated to altered function in FTM transsexuals.

Towards a further understanding of prenatal thyroid theory of homosexuality: Autoimmune thyroiditis, polycystic ovary syndrome, autism and low birth weight.

Research into the neurobiological origins of same-sex attraction is inconclusive. A recent theory of homosexuality posited that maternal thyroid dysfunction during pregnancy is associated with an increased rate of homosexual orientation in offspring. Relevant studies from the prenatal thyroid model perspective were reviewed, the major findings of which are as follows: i) An increased prevalence of Hashimoto’s disease in lesbian women suggests a maternal and even familial presence of the same autoimmune thyroid disease. Female-tomale transsexuals and lesbian women were also reported to have higher rates of polycystic ovary syndrome (PCOS). Over the last several years, reports suggesting a strong link between PCOS and thyroid autoimmunity have accumulated. ii) The increased risk of autism spectrum disorders (ASD) in the offspring of mothers with thyroid autoimmunity in pregnancy and the association between ASD and gender dysphoria indicate a link between maternal thyroid dysfunction and gender dysphoria/same-sex attraction in the offspring. iii) The high risk of miscarriage and retarded fetal growth in pregnancies of mothers who give birth to homosexual offspring can be explained by the impact of maternal thyroid dysfunction during pregnancy. This perspective review highlights relevant research findings and integrates them into the prenatal thyroid model of homosexuality. A better understanding of the mechanisms involved in the generation of same-sex orientation will contribute to the betterment of individual lives, as well as of society.

Subcutaneous mastectomy in female-to-male transsexuals: Optimizing perioperative and operative management in 8 years clinical experience

The incidence of complications, especially acute hematoma requiring surgical revision in female-to-male transsexuals (FTMTS), is consistently highly documented in literature with up to 33%. Since 2008 we perform subcutaneous mastectomies in FTMTS with an annually increasing number of cases. Due to an initially high hematoma revision rate in the previously published cohort (2008-2013), we implemented peri- and postoperative preventive measures and compared the results with the recent patient cohort (2014-2016). The records of 356 patients (712 mastectomies) were retrospectively reviewed. We compared the first cohort (C1, 01/2008 - 12/2013, 346 mastectomies; peri- and postoperative standard procedure and implementation of an algorithmic care path in our institution) with the recent cohort (C2, 01/2014 - 01/2016, 366 mastectomies) and introduced in C2 the following preventive measures: perioperative administration of tranexamic acid, intraoperative elevation of blood pressure to at least 120 mmHg before wound closure, bedrest and consequent wearing of compression bandage without removal 12 hours postoperatively. Comparison of complication rate, patient satisfaction and secondary revision rate was obtained in both cohorts. The mean operation time could be reduced from 103.6 minutes to 72.5 minutes (p < 0.05). The overall complication rate could be diminished from 11.8% to 5.5% (p < 0.05), the acute hematoma revision rate from 9.2% to 4.1% (p < 0.05). Secondary revisions were similar in both patient cohorts. Patient satisfaction rate was ameliorated from 88% to 93.5% "very satisfied" to "satisfied" patients. Hematoma is the most common reason for reoperation in FTMTS patients. By implementation of peri- and postoperative preventive measures and additional application of an algorithmic care path we could achieve a significant reduction of complications, particularly of the hematoma evacuation rate. During 8 years clinical and operative treatment in FTMTS we could furthermore achieve a decrease in operative time and an ameliorated patient satisfaction with the aesthetic results.

Fatty degeneration of mammary glands in female-to-male transsexuals

Subcutaneous mastectomy is an accepted procedure for surgical reassignment in female-to-male (FtM) transsexuals. However, fatty degeneration of the mammary gland (FDMG) is sometimes observed in FtM transsexuals, with implications for mastectomy outcomes. In this study, we describe the characteristics and risk factors of FDMG. A total of 48 FtM transsexual patients underwent bilateral subcutaneous mastectomies (96 subcutaneous mastectomies) at our clinics from January 2015 to February 2016. The patients were divided into FDMG and non-FDMG groups after evaluation of the cut surface of the resected mammary gland. The groups were compared in terms of age, smoking, hormonal therapy (testosterone), body mass index (BMI), breast size (top–under perimeter), distance between sternal notch and nipple–areolar complex (NAC), breast ptosis grade, weight of resected breast tissue, and complication rate. FDMG tissue specimens were examined histologically. Comparing the FDMG and non-FDMG groups, hormonal therapy was more common (91.3 vs. 72.0%, p = 0.049), BMI was higher (24.3 vs. 21.1%, p < 0.001), and distance between the sternal notch and NAC was longer (20.5 vs. 18.8%, p = 0.03). Hormonal therapy, high BMI, and long distance from the sternal notch to the NAC are risk factors for FDMG and should be considered prior to mastectomy in FtM transsexuals. Level of Evidence: Level III, risk/prognostic study

Autogynephilia and the Typology of Male-to-Female Transsexualism

Abstract. Sexual scientists have recognized for over a century that biologic males who seek sex reassignment – male-to-female (MtF) transsexuals – are not a homogeneous clinical population but comprise two or more distinct subtypes with different symptoms and developmental trajectories. The most widely used typologies of MtF transsexualism have been based on sexual orientation and have distinguished between persons who are androphilic (exclusively sexually attracted to males) and those who are nonandrophilic (sexually attracted to females, both males and females, or neither gender). In 1989, psychologist Ray Blanchard proposed that most nonandrophilic MtF transsexuals display a paraphilic sexual orientation called autogynephilia, defined as the propensity to be sexually aroused by the thought or image of oneself as a woman. Studies conducted by Blanchard and colleagues provided empirical support for this proposal, leading to the hypothesis that almost all nonandrophilic MtF transsexuals are autogynephilic, whereas almost all androphilic MtF transsexuals are not. Blanchard’s ideas received increased attention in 2003 after they were discussed in a book by psychologist J. Michael Bailey. The concept of autogynephilia subsequently became intensely controversial among researchers, clinicians, and MtF transsexuals themselves, causing widespread repercussions. This article reviews the theory of autogynephilia, the evidence supporting it, the objections raised by its critics, and the implications of the resulting controversy for research and clinical care.

Kisspeptin Expression in the Human Infundibular Nucleus in Relation to Sex, Gender Identity, and Sexual Orientation

Since the discovery of its central role in reproduction, our functional neuroanatomical knowledge of the hypothalamic kisspeptin system is predominantly based on animal studies. Although sex differences in kisspeptin expression have been shown in humans in adulthood, the developmental origin of this sex difference is unknown. Our objectives were to determine the following: 1) when during development the sex difference in kisspeptin expression in the infundibular nucleus would emerge and 2) whether this sex difference is related to sexual orientation or transsexuality. Postmortem hypothalamic tissues were collected by The Netherlands Brain Bank, and sections were stained for kisspeptin by immunohistochemistry. Hypothalami of 43 control subjects were categorized into three periods: infant/prepubertal (six girls, seven boys), adult (11 women, seven men), and elderly (six aged women, six aged men). Eight male-to-female (MTF) transsexuals, three HIV(+) heterosexual men, and five HIV(+) homosexual men were also analyzed. We estimated the total number of kisspeptin-immunoreactive neurons within the infundibular nucleus. Quantitative analysis confirmed that the human infundibular kisspeptin system exhibits a female-dominant sex difference. The number of kisspeptin neurons is significantly greater in the infant/prepubertal and elderly periods compared with the adult period. Finally, in MTF transsexuals, but not homosexual men, a female-typical kisspeptin expression was observed. These findings suggest that infundibular kisspeptin neurons are sensitive to circulating sex steroid hormones throughout life and that the sex reversal observed in MTF transsexuals might reflect, at least partially, an atypical brain sexual differentiation.

Lower Urinary Tract Symptoms in Male-to-Female Transsexuals: Short Terms Results and Proposal of a New Questionnaire.

BACKGROUND Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after male-to-female (MTF) sex reassignment surgery exist. Lower urinary tract symptoms (LUTS) manifest multiple domains of clinical symptoms. LUTS can significantly reduce patients’ quality of life (QoL) and may point to serious pathology of the urogenital tract.1 The etiologies of LUTS in aged men are well understood, and guidelines suggest that its pathogenesis is multifactorial and can include one or several diagnoses.2 Although it is known that in MTF transsexuals, urethral stenosis, infections, disorders of the urinary stream, and incontinence have been reported,3–5 little research effort has been devoted to studying all the LUTS in this patient cohort, mainly in young men. The aim of this study is to evaluate the surgical outcome in patients who underwent surgical sex reassignment (MTF), to investigate if they have an increased risk to develop micturition disorders with LUTS, and to assess their QoL including sexual concerns. METHODS We conducted an observational study in an unselected cohort of 30 adult transsexuals who underwent MTF sex reassignment surgery between 2012 and 2014, in 2 hospitals by different surgeons. We administered a new 21-question survey (before surgery and at 1, 3, 6, and 12 months follow-up) to investigate LUTS and their impact in patients’ QoL (including sexual QoL). The items we analyzed were involuntary urine leakage, urge and stress incontinence, frequency, stream alterations, straining to urinate, retention, presence of pelvic pain or discomfort (with or without the need of an analgesic therapy), and cystitis (with or without the need of an antibiotics therapy). The reliability of the new questionnaire has been compared with the results obtained by other validated questionnaires. RESULTS In our cohort, frequency, weakness of the urinary stream, urge incontinence, and nocturia are common problems. Pelvic pain has been reported in 40% of patients in the first month but decreased significantly over time (Fig. 1).Fig. 1: Frequency of LUTS: before surgery and during the follow-up at 1, 3, 6, and 12 months.Although more than half of the participants experienced one or more postoperative complications or discomfort, 19 patients (63%) were completely satisfied with their surgical outcome, 8 patients (27%) were slightly satisfied, and only 3 patients (10%) considered themselves as unhappy. CONCLUSIONS Results showed an increased risk for the development of LUTS that should lead the surgeon to investigate the relationship between these disorders and the surgical procedure. Micturition is a problem after surgery, and patients who consider sex reassignment should be informed about these side effects preoperatively. The data obtained from the test phase of the questionnaire seem to be encouraging. A comparative analysis of the responses and the scores (Fig. 2) enabled us to establish, preliminarily, that the new questionnaire may be a reliable tool for the assessment of symptoms in patients who underwent MTF sex reassignment surgery, even if further investigations are still required.Fig. 2: Correspondence between averages: LUTS score, QoL score, and patient’s satisfaction. Higher scores correspond to higher symptoms’ manifestation and higher dissatisfaction.

A very rare case of breast cancer in a female-to-male transsexual

The incidence of breast cancer in female-to-male (FTM) transsexuals who received mastectomy and sex reassignment surgery is very rare. In fact, there is only one previous medical report of such a case. We experienced a case of an FTM transsexual who developed breast cancer 12years after mastectomy and hysterectomy with bilateral salpingo-oophorectomy. Because he had been continuously receiving testosterone during the last 15years and because histopathological examination revealed positive estrogen receptor and androgen receptor expression, we suggest that exogenous testosterone may have initiated the development of breast cancer via two distinct pathways. We describe the clinical course and condition of the patient and recommend that medical personnel consider the possibility of hormone-related cancer in FTM transsexuals receiving cross-sex hormones.

Anatomical and Functional Findings in Female-to-Male Transsexuals: Testing a New Hypothesis.

MRI of functional connectivity, cortical thickness, surface area, and gray matter volume was carried out in 28 female-to-male transsexuals (FtM-TR) and 68 cis-sexual controls (34 male). FtM-TR displayed thicker mid-frontal, precuneal-parietal, and lingual cortex than both male and female controls, whereas, in regions with reported anatomical sex differences among the controls, FtM-TR followed patterns of the gender assigned at their birth. FtM-TR also displayed weaker functional connections from the pregenual anterior cingulate to the insular cortex, and the temporo parietal junction compared with both control groups. Distinct structural and functional pattern in the own-body image network may represent biological markers for the dysphoric own-body perception in transgender individuals.