Female-to-male Transsexuals Research Articles

Phantom erectile penis after sex reassignment surgery

Between January 2001 and December 2007, we performed vaginoplasty as sex reassignment surgery in a total of 14 male-to-female transsexual (MTFTS) patients [1]. Several complications occurred such as partial flap necrosis, rectovaginal fistula formation and hypersensitivity of the neoclitoris. Just after the operation, some patients feel that their penises still exist, but by several weeks postoperatively, this sensation has disappeared. Herein we report a case of MTFTS in whom the sensation of a phantom erectile penis persisted for much longer.

Shame and Narcissistic Rage in Autogynephilic Transsexualism

One of the most important contributions made by Dreger’s article is her description of the extraordinary lengths to which some of Bailey’s male-to-female (MtF) transsexual opponents went in their attempts to discredit him, his book, and his ideas. By Dreger’s account, their campaign against Bailey continued for at least two years after the publication of The Man Who Would Be Queen (TMWWBQ; Bailey, 2003). Examination of the Internet sites maintained by some of Bailey’s principal transsexual opponents suggests that the campaign against him remains ongoing. The attacks, as described by Dreger, went far beyond writing scathing reviews of TMWWBQ. They included orchestration of charges of professional misconduct against Bailey, filed with Northwestern University and the Illinois Department of Professional Regulation; attempts to turn Bailey’s colleagues against him; attacks directed against Bailey’s children; and efforts to discredit or silence nearly anyone who openly supported him. Dreger’s article suggests that many of Bailey’s opponents intended not only to discredit Bailey’s book, but also to destroy its author. The duration, intensity, and sheer savagery of the campaign waged by many of Bailey’s MtF transsexual opponents is astonishing, especially given that Bailey’s book sold only about 4200 copies and probably would have received little attention, in either its print or Internet versions, were it not for the publicity that his opponents themselves created. One could imagine that Kohut (1972) was describing the campaign conducted by some of Bailey’s MtF transsexual opponents when he wrote the following:

Effect of Long-Term Administration of Cross-Sex Hormone Therapy on Serum and Urinary Uric Acid in Transsexual Persons

Transsexual persons afford a very suitable model to study the effect of sex steroids on uric acid metabolism. This was a prospective study to evaluate the uric acid levels and fractional excretion of uric acid (FEUA) in a cohort of 69 healthy transsexual persons, 22 male-to-female transsexuals (MFTs) and 47 female-to-male transsexuals (FMTs). The subjects were studied at baseline and 1 and 2 yr after starting cross-sex hormone treatment. The baseline levels of uric acid were higher in the MFT group. Compared with baseline, uric acid levels had fallen significantly after 1 yr of hormone therapy in the MFT group and had risen significantly in the FMT group. The baseline FEUA was greater in the FMT group. After 2 yr of cross-sex hormone therapy, the FEUA had increased in MFTs (P = 0.001) and fallen in FMTs (P = 0.004). In MFTs, the levels of uric acid at 2 yr were lower in those who had received higher doses of estrogens (P = 0.03), and the FEUA was higher (P = 0.04). The FEUA at 2 yr was associated with both the estrogen dose (P = 0.02) and the serum levels of estradiol-17beta (P =0.03). In MFTs, a correlation was found after 2 yr of therapy between the homeostasis model assessment of insulin resistance and the serum uric acid (r = 0.59; P = 0.01). Serum levels of uric acid and the FEUA are altered in transsexuals as a result of cross-sex hormone therapy. The results concerning the MFT group support the hypothesis that the lower levels of uric acid in women are due to estrogen-induced increases in FEUA.

Sociodemographic, Clinical, and Psychiatric Characteristics of Transsexuals from Spain

The aim of this study was to examine the characteristics of transsexuals from Spain. A total of 252 consecutive applicants for sex reassignment were evaluated using a standardized semistructured clinical interview and the Mini International Neuropsychiatric Interview (Spanish Version 5.0.0) to record demographic, clinical, and psychiatric data. Transsexualism was diagnosed in 230 patients, with a male to female (MF)/female to male (FM) ratio of 2.2:1. Transsexual patients frequently had low employment status, lived with their parents, and mainly had a sexual orientation toward same-sex partners. The most frequent psychiatric diagnoses were adjustment disorder and social phobia in both groups, and alcohol and substance-related disorders in the MF group. MF transsexuals were older than FM transsexuals when requesting sex reassignment, but did not differ in age when starting hormonal therapy (often on their own); fewer MFs were in employment requiring high educational qualification, more were non-Spanish natives, and more had previous and current histories of alcohol and substance abuse or dependence. The basic characteristics of transsexuals from Spain were similar to those of other European countries, except for the higher proportion of patients living with their parents and the higher proportion of MFs who reported same-sex sexual orientation compared with previous studies.

Prevalence of Polycystic Ovary Syndrome and Hyperandrogenemia in Female-to-Male Transsexuals

It has been postulated that the prevalence of polycystic ovary syndrome (PCOS) in female-to-male transsexuals (FMTs) is higher than normal. The aim of the study was to investigate the prevalence of PCOS and hyperandrogenemia in FMTs, compared with controls. Sixty-one FMTs were evaluated using the Rotterdam 2003 criteria and National Institutes of Health 1990 criteria for the diagnosis of PCOS, compared with 94 controls. Oligoovulation, anovulation, clinical and biochemical signs of hyperandrogenism and polycystic ovaries, and prevalence of PCOS were measured. The prevalence of PCOS was 11.5% in FMTs and 9.6% in controls (not significant) with National Institutes of Health 1990 criteria and 14.8% in FMTs and 12.8% in controls (not significant) with the Rotterdam 2003 criteria. Without adjustments and using multivariate analysis in a logistic regression model with adjustments for age, body mass index, and calculated free testosterone, the odds ratio for the prevalence of PCOS was not found to be significantly increased. However, there was a significantly higher prevalence of biochemical hyperandrogenism in FMTs. Hyperandrogenemia was associated with a moderate increase in the odds ratio for the prevalence of PCOS, at 1.08 and 1.07 (P < 0.001 and P = 0.001), for the two definitions used in this study, respectively. PCOS was not significantly increased in FMTs in comparison with controls. However, FMTs more frequently had biochemical hyperandrogenism.

Male-to-Female Transsexuals Show Sex-Atypical Hypothalamus Activation When Smelling Odorous Steroids

One working hypothesis behind transsexuality is that the normal sex differentiation of certain hypothalamic networks is altered. We tested this hypothesis by investigating the pattern of cerebral activation in 12 nonhomosexual male-to-female transsexuals (MFTRs) when smelling 4,16-androstadien-3-one (AND) and estra-1,3,5(10),16-tetraen-3-ol (EST). These steroids are reported to activate the hypothalamic networks in a sex-differentiated way. Like in female controls the hypothalamus in MFTRs activated with AND, whereas smelling of EST engaged the amygdala and piriform cortex. Male controls, on the other hand, activated the hypothalamus with EST. However, when restricting the volume of interest to the hypothalamus activation was detected in MFTR also with EST, and explorative conjunctional analysis revealed that MFTR shared a hypothalamic cluster with women when smelling AND, and with men when smelling EST. Because the EST effect was limited, MFTR differed significantly only from male controls, and only for EST-AIR and EST-AND. These data suggest a pattern of activation away from the biological sex, occupying an intermediate position with predominantly female-like features. Because our MFTRs were nonhomosexual, the results are unlikely to be an effect of sexual practice. Instead, the data implicate that transsexuality may be associated with sex-atypical physiological responses in specific hypothalamic circuits, possibly as a consequence of a variant neuronal differentiation.

Vaginoplasty with an M-shaped perineo- scrotal flap in a male-to-female transsexual.

To date, many techniques have been reported for vaginoplasty in male-to-female trans-sexual (MTFTS) patients, such as the use of a rectum transfer, a penile-scrotal flap and a reversed penile flap. However, none of these procedures is without its disadvantages. We developed a newly kind of flap for vaginoplasty, the M-shaped perineo-scrotal flap (M-shaped flap), using skin from both sides of the scrotum, shorn of hair by preoperative laser treatment. We applied this new type of flap in 7 MTFTS patients between January 2006 and January 2007. None of the flaps developed necrosis, and the patients could engage in sexual activity within 3 months of the operation. The M-shaped flap has numerous advantages: it can be elevated safely while retaining good vascularity, it provides for the construction of a sufficient deep vagina without a skin graft, the size of the flap is not influenced entirely by the length of the penis, and it utilizes skin from both sides of the scrotal area, which is usually excised.

A Common Polymorphism of the SRD5A2 Gene and Transsexualism

The relation between genetic variation of the androgen metabolism and transsexualism is unknown. In a case-control study of 100 male-to-female (MtF) transsexuals, 47 female-to-male (FtM) transsexuals, and 1670 controls, the authors assess allele and genotype frequencies of the steroid 5-alpha reductase (SRD5A2) Val89Leu polymorphism using polymerase chain reaction. Allele and genotype frequencies are not significantly different between MtF transsexuals and male controls (SRD5A2 V: 137/200 [69%] and SRD5A2 L: 63/200 [31%] vs 1065/1510 [71%] and 445/1510 [29%], respectively; P = .6; odds ratio [OR], 1.10; 95% confidence interval [CI], 0.76-1.58; SRD5A2 V/V+V/L: 92/100 [92%] and L/L 8/100 [8%] vs SRD5A2 683/755 [91%] and 72/755 [9%], respectively, P = .7; OR, 0.82; 95% CI, 0.24-2.84). Allele and genotype frequencies are also not significantly different between FtM transsexuals and female controls (SRD5A2 V: 70/94 [74%] and SRD5A2 L: 24/94 [26%] vs 1253/1830 [69%] and 573/1830 [31%], respectively; P = .3; OR, 0.75; 95% CI, 0.45-1.26; SRD5A2 V/V+V/L: 44/47 [93%] and L/L 3/47 [7%] vs 823/915 [90%] and 92/915 [10%], respectively, P = .6; OR, 0.61; 95% CI, 0.11-3.32). Of note, there is no gender-specific genotype distribution among controls. The SRD5A2 Val89Leu SNP is not associated with transsexualism, refuting SRD5A2 as a candidate gene of transsexualism.

A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism

To assess the association between transsexualism and allele and genotype frequencies of the common cytochrome P450 (CYP) 17 -34 T>C single nucleotide polymorphism (SNP). Case-control study. Academic research institution. 102 male-to-female (MtF) and 49 female-to-male (FtM) transsexuals, 756 male controls, and 915 female controls. Buccal swabs and multiplex polymerase chain reaction on a microarray system. Analysis of the CYP17 -34 T>C SNP. CYP17 -34 T>C SNP allele frequencies were statistically significantly different between FtM transsexuals and female controls (CYP17 T: 55/98 [56%] and CYP17 C: 43/98 [44%] versus CYP17 T: 1253/1826 [69%] and CYP17 C: 573/1826 [31%], respectively). In accordance, genotype distributions were also different between FtM transsexuals and female controls using a recessive genotype model (CYP17 T/T+T/C: 39/49 [80%] and C/C 10/49 [20%] vs. CYP17 T/T+T/C: 821/913 [90%] and C/C 92/913 [10%], respectively). The CYP17 -34 T>C allele and genotype distributions were not statistically significantly different between MtF transsexuals and male controls. Of note, the CYP17 -34 T>C allele distribution was gender-specific among controls (CYP17 C: males; 604 of 1512 [40%] vs. females; 573 of 1826 [31%]). The MtF transsexuals had an allele distribution equivalent to male controls, whereas FtM transsexuals did not follow the gender-specific allele distribution of female controls but rather had an allele distribution equivalent to MtF transsexuals and male controls. These data support CYP17 as a candidate gene of FtM transsexualism and indicate that loss of a female-specific CYP17 T -34C allele distribution pattern is associated with FtM transsexualism.

Becoming What We Love: autogynephilic transsexualism conceptualized as an expression of romantic love

The increasing prevalence of male-to-female (MtF) transsexualism in Western countries is largely due to the growing number of MtF transsexuals who have a history of sexual arousal with cross-dressing or cross-gender fantasy. Ray Blanchard proposed that these transsexuals have a paraphilia he called autogynephilia, which is the propensity to be sexually aroused by the thought or image of oneself as female. Autogynephilia defines a transsexual typology and provides a theory of transsexual motivation, in that Blanchard proposed that MtF transsexuals are either sexually attracted exclusively to men (homosexual) or are sexually attracted primarily to the thought or image of themselves as female (autogynephilic), and that autogynephilic transsexuals seek sex reassignment to actualize their autogynephilic desires. Despite growing professional acceptance, Blanchard's formulation is rejected by some MtF transsexuals as inconsistent with their experience. This rejection, I argue, results largely from the misconception that autogynephilia is a purely erotic phenomenon. Autogynephilia can more accurately be conceptualized as a type of sexual orientation and as a variety of romantic love, involving both erotic and affectional or attachment-based elements. This broader conception of autogynephilia addresses many of the objections to Blanchard's theory and is consistent with a variety of clinical observations concerning autogynephilic MtF transsexualism.

What Many Transgender Activists Don't Want You to Know: and why you should know it anyway

Currently the predominant cultural understanding of male-to-female transsexualism is that all male-to-female (MtF) transsexuals are, essentially, women trapped in men's bodies. This understanding has little scientific basis, however, and is inconsistent with clinical observations. Ray Blanchard has shown that there are two distinct subtypes of MtF transsexuals. Members of one subtype, homosexual transsexuals, are best understood as a type of homosexual male. The other subtype, autogynephilic transsexuals, are motivated by the erotic desire to become women. The persistence of the predominant cultural understanding, while explicable, is damaging to science and to many transsexuals.

Tratamiento hormonal de reasignación de sexo en España: nuestra experiencia en 236 casos

Introduction In recent decades, demand for gender reassignment therapy (psychological, hormonal and surgical) has significantly increased. In Spain, this type of therapy has not generally been provided in public hospitals. Consequently, endocrinologists and other health professionals have insufficient experience of this treatment and transsexuals have to resort to self therapy or to private hospitals. Patients and methods During an 8-year period (1997-2004), 236 individuals with gender identity disorder (GID) were evaluated. There were 129 male-to-female transsexuals and 107 female-tomale transsexuals, aged between 19 and 54 years (mean age 34 years), with distinct educational levels (primary education in 23%, secondary education in 41%, and higher education in 36%). All patients underwent diagnostic evaluation by a psychiatrist and received psychological support. After clinical and biochemical evaluation, 4 patients were rejected for hormone therapy due to distinct organic disorders. The remaining patients were selected for distinct hormone treatments and were followed-up every 6 months. Results During the follow-up period, hyperprolactinemia occurred in 65% of female-to-male transsexuals and liver enzyme alterations in 8%. There were no cases of thrombophlebitis. In male-to-female transsexuals, liver enzyme alterations were found in 24% and hyperprolactinemia in 13%. After 2 years of hormone therapy, 43 patients underwent complete gender reassignment surgery. There were no severe adverse effects, although 5 patients reported different degrees of sexual dissatisfaction. Conclusions GID are increasingly frequent. Consequently, to prevent the adverse effects of hormone self treatment, these disorders should be managed by the Spanish national health service, which should create specific multidisciplinary units for this purpose.

Feminine after cricothyroid approximation?

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.

Association between polycystic ovary syndrome and female-to-male transsexuality

The aim of this study is to understand the relationship between polycystic ovary syndrome (PCOS), altered hormonal characteristics and insulin resistance in female-to-male (FTM) transsexual patients. We studied 69 Japanese FTM cases, aged 17-47 years, who were seen in the Gender Identity Disorder Clinic of Sapporo Medical University Hospital between December 2003 and May 2006. The subjects had never received hormonal treatment or sex re-assignment surgery. Prior to treatment, they received physical examinations entailing measurement of anthropometric, metabolic and endocrine parameters, after which we compared the values obtained according to the presence or absence of PCOS and/or obesity. Insulin resistance was determined using the homeostasis model assessment of insulin resistance (HOMA-IR). Of the 69 participating FTM cases, 40 (58.0%) were found to have PCOS. Of the 49 for whom HOMA-IR was calculated, 15 (30.6%) also showed insulin resistance, whereas of the 59 for whom adiponectin was measured, 18 (30.5%) showed hypoadiponectinaemia. Of 69 for whom androgens were measured, 29 (39.1%) showed hyperandrogenaemia. Insulin resistance was associated with obesity but not with PCOS. In contrast, hyperandrogenaemia was associated with both PCOS and obesity. FTM transsexual patients have a high prevalence of PCOS and hyperandrogenaemia.

Corticotropin-releasing hormone neurons in the paraventricular nucleus of the human hypothalamus in subjects with normal and abnormal sex hormone status

In order to determine the role of peripheral sex hormone levels in the expression of corticotropin-releasing hormone (CRH) neurons, we investigated by means of immunocytochemistry the number of CRH neurons in the hypothalamic paraventricular nucleus (PVN) in postmortem material of young and old subjects with normal and abnormal sex hormone conditions. Clinical data and nuclear androgen receptor (AR) immunoreactivity (ir) in the hypothalamic medial mamillary nucleus (MMN) were used as an estimate for changes in circulating sex hormone levels. It was confirmed that nuclear AR-ir staining in the MMN is a good estimate for abnormal peripheral androgen levels and that the CRH neurons in the hypothalamic PVN are activated with age in male subjects. Male subjects with lower testosterone levels due to castration showed significantly fewer CRH neurons than age-matched male controls. Castrated male-to-female (MF) transsexuals with estrogen replacement showed normal numbers of CRH neurons, while one male case, which had high estrogen levels due to an estrogen-producing tumor, even showed a high number of CRH neurons in the PVN. Results of the present study suggested that the activation of CRH neurons during aging in male subjects results from factors other than changes in endogenous peripheral sex hormone levels. Since estrogens can prevent the drop of CRH cell number following castration in MF transsexuals, and more CRH neurons were found in the case of an estrogen-producing tumor, estrogen seems to play a stimulating role in the activity of CRH neurons in the PVN. The stimulatory effect of androgens on CRH neurons seems to occur via an indirect effect following aromatization into estrogens.

Clinical and Theoretical Parallels Between Desire for Limb Amputation and Gender Identity Disorder

Desire for amputation of a healthy limb has usually been regarded as a paraphilia (apotemnophilia), but some researchers propose that it may be a disorder of identity, similar to Gender Identity Disorder (GID) or transsexualism. Similarities between the desire for limb amputation and nonhomosexual male-to-female (MtF) transsexualism include profound dissatisfaction with embodiment, related paraphilias from which the conditions plausibly derive (apotemnophilia and autogynephilia), sexual arousal from simulation of the sought-after status (pretending to be an amputee and transvestism), attraction to persons with the same body type one wants to acquire, and an elevated prevalence of other paraphilic interests. K. Freund and R. Blanchard (1993) proposed that nonhomosexual MtF transsexualism represents an erotic target location error, in which men whose preferred erotic targets are women also eroticize their own feminized bodies. Desire for limb amputation may also reflect an erotic target location error, occurring in combination with an unusual erotic target preference for amputees. This model predicts that persons who desire limb amputation would almost always be attracted to amputees and would display an increased prevalence of gender identity problems, both of which have been observed. Persons who desire limb amputation and nonhomosexual MtF transsexuals often assert that their motives for wanting to change their bodies reflect issues of identity rather than sexuality, but because erotic/romantic orientations contribute significantly to identity, such distinctions may not be meaningful. Experience with nonhomosexual MtF transsexualism suggests possible directions for research and treatment for persons who desire limb amputation.

Do transsexuals have micturition disorders?

Objective Transsexualism occurs with an estimated prevalence of 2.4:100 000 male-to-female (MTF) and 1:100 000 female-to-male (FTM) transsexuals. As sex reassignment surgery involves surgery of the urethra and transsexuals are substituted life-long with the cross gender hormones there could possibly arise micturition disorders. Aim of the study was to determine if transsexuals have an increased risk of micturition disorders and if so which. Study Design Between January and July 2003 we examined 25 transsexuals whereof 18 were MTF and 7 were FTM transsexuals using King's Health Questionnaire, visual analogue scale for patient's well being, perineal and transabdominal ultrasound, urine dipstick and uroflow measurement. Results 17 out of 25 patients considered themselves very happy. In MTF transsexuals, a diverted stream, overactive bladder and stress urinary incontinence was a common problem. Prostate volume was small with 20 g and palpation did not confirm and solid or suspicious lesions. None of the patients had significant residual urine but MTF transsexuals had a reduced urinary flow. We could not detect a current urinary tract infections in any of the patients. Conclusion Transsexuals have an increased risk for the development of micturition disorders including stress urinary incontinence and overactive bladder compared to age-matched control groups and should be counselled preoperatively. Reasons for the development of incontinence might be surgery including pudendal nerve damage, hormonal reasons and ageing.

Typical female 2nd–4th finger length (2D:4D) ratios in male-to-female transsexuals—possible implications for prenatal androgen exposure

Prenatal exposure to androgens has been implicated in transsexualism but the etiology of the condition remains unclear. The ratio of the 2nd to the 4th (2D:4D) digit lengths has been suggested to be negatively correlated to prenatal androgen exposure. We wanted to assess differences in 2D:4D ratio between transsexuals and controls. Sixty-three male-to-female transsexuals (MFT), 43 female-to-male transsexuals (FMT), and 65 female and 58 male controls were included in the study. Photocopies of the palms and digits of the hands were taken of all subjects and 2D:4D ratios were measured, according to standard published procedures. Comparison between right-handed individuals revealed that the right-hand 2D:4D in MFT is higher than in control males but similar to that observed in control females. In FMT we found no differences in 2D:4D relative to control females. Our findings support a biological etiology of male-to-female transsexualism, implicating decreased prenatal androgen exposure in MFT. We have found no indication of a role of prenatal hormone exposure in female-to-male transsexualism.

Sexually dimorphic features in transsexuals – a female 2nd to 4th finger (2D/4D) ratio in male-to-female transsexuals

Transsexualism is characterised by the feeling of belonging to the wrong gender and the strong wish to achieve gender reassignment by hormonal and surgical treatment in combination with normal body appearance. It has been found that an androgen-dependent, sexually dimorphic nucleus in the hypothalamus which is involved in gender-specific behavior, the BSTc, has the size of females in male-to-female transsexuals (MFT). The ratio of digit 2 to digit 4 in the right hand (2D/4D ratio) has been shown to be sexually dimorphic with a smaller ratio in men than in women and to correlate negatively with testosterone and sperm count. Moreover, in patients with CAH, a condition characterized by elevated prenatal androgen levels, the 2D/4D ratio is lower. Since most sexually dimorphic feautures in the body are assumed to be regulated by prenatal testosterone levels, the D2/D4 ratio has been suggested to be a marker for prenatal testosterone exposure.

Autogynephilia: A Paraphilic Model of Gender Identity Disorder

SUMMARY Autogynephilia is defined as a male's propensity to be sexually aroused by the thought or image of himself as female. Autogynephilia explains the desire for sex reassignment of some male-to-female (MTF) transsexuals. It can be conceptualized as both a paraphilia and a sexual orientation. The concept of autogynephilia provides an alternative to the traditional model of transsexualism that emphasizes gender identity. Autogynephilia helps explain mid-life MTF gender transition, progression from transvestism to transsexualism, the prevalence of other paraphilias among MTF transsexuals, and late development of sexual interest in male partners. Hormone therapy and sex reassignment surgery can be effective treatments in autogynephilic transsexualism. The concept of autogynephilia can help clinicians better understand MTF transsexual clients who recognize a strong sexual component to their gender dysphoria.