Multidisciplinary Gender Research Articles

Abstract: Clitoroplasty and Labia Minoraplasty in Penile Inversion Vaginoplasty in Circumcised and Uncircumcised Transwomen

INTRODUCTION: Gender dysphoria, the incongruence between anatomic sex and gender identity is estimated to affect 1% of the population. Creation of a feminine vulva remains a technical challenge for surgeons, especially in circumcised patients. We present a vulvoplasty technique with creation of neoclitoris and labia minora using a dorsal glans pedicled flap with prepuce skin in uncircumcised patients or distal shaft skin in circumcised patients. METHODS: A retrospective case review was performed of all penile inversion vaginoplasties performed by senior author between 2014 and 2016. History of circumcision, use of full thickness skin grafts to lengthen vault, necrosis of labia minora, and any revisionary surgery was recorded. RESULTS: A total of 159 single stage penile inversion vaginoplasty operations were performed using the described technique from 2014–2016. All patients were evaluated by the UZ Gent multidisciplinary gender team prior to surgery and met standards of care established by WPATH. The majority, 97.5 % of patients, required FTSG to lengthen the vaginal vault. Creation of clitoral hood and labia minora was achieved in all patients with 3.2 % requiring minor aesthetic refinements for partial skin necrosis and 25.8% for labia majora refienments or dehiscence. Just one patient experienced total necrosis of the labia minora prepuce flap tissue. Average length of follow-up was 2 years. The neoclitoris is constructed from a M-shape dorsal glans flap, sutured into a dome, and inset to the distal resected corporal bodies in the anterior midline. The urethra mucosa is inset as a shield and the prepuce flap is wrapped laterally and posteriorly to construct labia minora. In circumcised patients, distal penile shaft skin is used in absence of prepuce skin and survives on random blood supply through the circumcision scar. Labia majora are fashioned from the scrotal skin. Remaining penile shaft skin is inverted to construct the introitus and vaginal apex is lined with full thickness skin graft from excess scrotal skin. Postoperative genital aesthetics were excellent. CONCLUSION: Creation of the clitoral hood and labia minora during penile inversion vaginoplasty is achievable in both circumcised and uncircumcised patients with excellent aesthetic results and low revisionary surgery rate.

Overrepresentation of Adopted Adolescents at a Hospital-Based Gender Dysphoria Clinic.

Purpose: We have noted a greater than expected prevalence of adopted children presenting to our multidisciplinary gender program for evaluation of gender dysphoria.Methods: A retrospective review of 184 patient charts was conducted to assess the prevalence of adopted children presenting to gender clinic.Results: Fifteen of 184 patients seen were living with adoptive families (8.2%). This is significantly higher than expected based on U.S. census data.Conclusion: Adopted children are referred to our gender program more than would be expected based on the percentage of adopted children in our state and the United States at large. This may be due to a true increased risk of gender dysphoria in adopted children, or could represent presentation bias. Gender programs should be prepared to provide assessments for adopted children. Further work is needed to understand the relationship between adopted status and gender development.

Mental Health Concerns and Insurance Denials Among Transgender Adolescents.

Transgender youth are at high risk for mental health morbidities. Based on treatment guidelines, puberty blockers and gender-affirming hormone therapy should be considered to alleviate distress due to discordance between an individual's assigned sex and gender identity. The goals of this study were to examine the: (1) prevalence of mental health diagnoses, self-injurious behaviors, and school victimization and (2) rates of insurance coverage for hormone therapy, among a cohort of transgender adolescents at a large pediatric gender program, to understand access to recommended therapy. An IRB-approved retrospective medical record review (2014-2016) was conducted of patients with ICD 9/10 codes for gender dysphoria referred to pediatric endocrinology within a large multidisciplinary gender program. Researchers extracted the following details: demographics, age, assigned sex, identified gender, insurance provider/coverage, mental health diagnoses, self-injurious behavior, and school victimization. Seventy-nine records (51 transgender males, 28 transgender females) met inclusion criteria (median age: 15 years, range: 9-18). Seventy-three subjects (92.4%) were diagnosed with one or more of the following conditions: depression, anxiety, post-traumatic stress disorder, eating disorders, autism spectrum disorder, and bipolar disorder. Fifty-nine (74.7%) reported suicidal ideation, 44 (55.7%) exhibited self-harm, and 24 (30.4%) had one or more suicide attempts. Forty-six (58.2%) subjects reported school victimization. Of the 27 patients prescribed gonadotropin-releasing hormone analogues, only 8 (29.6%) received insurance coverage. Transgender youth face significant barriers in accessing appropriate hormone therapy. Given the high rates of mental health concerns, self-injurious behavior, and school victimization among this vulnerable population, healthcare professionals must work alongside policy makers toward insurance coverage reform.

Genetic Analysis for the Diagnosis of Disorders of Sexual Development in Indonesia

Disorders of sex development (DSD) is defined by congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical, while in clinical practice this term means any abnormality of the external genitalia. DSD patients have been managed by a multidisciplinary gender team in our center as collaboration between Dr. Kariadi province referral hospital and Faculty of Medicine Diponegoro University. Diagnosis should be established by specific physical examination hormonal, chromosomal and DNA studies; and imaging for most of the cases depending on indication.Since 2004 the involvement of molecular and cytogenetic analysis so far can diagnosed many of the DSD cases. Most of the genetically proven cases were Congenital Adrenal hyperplasia, Androgen Insensitivity syndrome and sex chromosomal DSD that lead abnormal gonadal development. Many of them remain undiagnosed, further testing such as advanced DNA study should be carried out in collaboration with other center in overseas.The novel genes were found in some cases that contributed for the management of DSD. Information for medical professionals, patients, family members and community about the availability and necessity of DSD diagnosis should be delivered to improve DSD management and patient quality of life.

Psychiatry's Role in Supporting Healthy Development in Gender Diverse Children

Increasing numbers of transgender and gender nonconforming (TGNC) children are presenting for care in medical and behavioral health settings. Most providers have little to no training on how to assist patients, families, or medical colleagues with gender concerns. Despite a growing pool of multidisciplinary gender clinics nationwide, many communities lack competent psychiatrists to assist these children. Accessing care at gender clinics can be burdensome to families due to cost and distance. This article seeks to contribute to the competency of psychiatric providers who encounter TGNC children. Areas of focus include differences in sex and gender development, common clinical presentations, assessment for gender-related distress, and the role of psychiatry in provision of care for healthy gender development in TGNC young children and adolescents. [ Psychiatr Ann . 2016;46(6):355–360.]

Youth and Caregiver Perspectives on Barriers to Gender-Affirming Health Care for Transgender Youth

PurposeFew transgender youth eligible for gender-affirming treatments actually receive them. Multidisciplinary gender clinics improve access and care coordination but are rare. Although experts support use of pubertal blockers and cross-sex hormones for youth who meet criteria, these are uncommonly offered. This study's aim was to understand barriers that transgender youth and their caregivers face in accessing gender-affirming health care. MethodsTransgender youth (age 14–22 years) and caregivers of transgender youth were recruited from Seattle-based clinics, and readerships from a blog and support group listserv. Through individual interviews, focus groups, or an online survey, participants described their experiences accessing gender-affirming health care. We then used theoretical thematic analysis to analyze data. ResultsSixty-five participants (15 youth, 50 caregivers) described barriers spanning six themes: (1) few accessible pediatric providers are trained in gender-affirming health care; (2) lack of consistently applied protocols; (3) inconsistent use of chosen name/pronoun; (4) uncoordinated care and gatekeeping; (5) limited/delayed access to pubertal blockers and cross-sex hormones; and (6) insurance exclusions. ConclusionsThis is the first study aimed at understanding perceived barriers to care among transgender youth and their caregivers. Themed barriers to care led to the following recommendations: (1) mandatory training on gender-affirming health care and cultural humility for providers/staff; (2) development of protocols for the care of young transgender patients, as well as roadmaps for families; (3) asking and recording of chosen name/pronoun; (4) increased number of multidisciplinary gender clinics; (5) providing cross-sex hormones at an age that permits peer-congruent development; and (6) designating a navigator for transgender patients in clinics.

MMPI-2 Profile of French Transsexuals: The Role of Sociodemographic and Clinical Factors. A cross-sectional design.

The assessment of co-existing psychological and psychiatric disorders is advocated in the Standards of Care for the health of transsexual people. This study aimed to determine the psychopathological characteristics of transsexuals based on a large sample of French individuals and to identify whether these characteristics differed according to the individual’s sociodemographic or clinical characteristics. The aim of this study was to determine the psychopathological characteristics of transsexuals from a large sample of French individuals and whether these differed by sociodemographic or clinical characteristics. This cross-sectional study was conducted in a French public university hospital. The inclusion criteria were 18 years or older, diagnosis of gender dysphoria, and eligibility for a standardized sex reassignment procedure. Personality characteristics were assessed using the Minnesota Multiphasic Personality Inventory 2 (MMPI-2). A total of 108 individuals provided a valid MMPI-2 between January 2007 and December 2010. The final sample had a median age of 31 years and included 54 (50%) Female-to-Male individuals. In multivariate models, hormonal therapy status was significantly related to the scales of MMPI-2 (Psychasthenia and Masculinity/Femininity). Personality assessment can help a multidisciplinary gender dysphoria team detect potential psychopathological factors of vulnerability.

Evaluation of Asperger Syndrome in Youth Presenting to a Gender Dysphoria Clinic.

There is evolving evidence that children and adolescents with gender dysphoria have higher-than-expected rates of autism spectrum disorder (ASD), yet clinical data on ASD among youth with gender dysphoria remain limited, particularly in North America. This report aims to fill this gap. We conducted a retrospective review of patient chart data from 39 consecutive youth ages 8 to 20 years (mean age 15.8 years, natal male: n = 22, natal female: n = 17) presenting for evaluation at a multidisciplinary gender clinic in a large U.S. pediatric hospital from 2007 to 2011 to evaluate the prevalence of ASD in this patient population. Overall, 23.1% of patients (9/39) presenting with gender dysphoria had possible, likely, or very likely Asperger syndrome as measured by the Asperger Syndrome Diagnostic Scale (ASDS). These findings are consistent with growing evidence supporting increased prevalence of ASD in gender dysphoric children. To guide provision of optimal clinical care and therapeutic intervention, routine assessment of ASD is recommended in youth presenting for gender dysphoria.

Assessing patient satisfaction with a multidisciplinary gender dysphoria clinic in Melbourne.

The Gender Dysphoria Clinic in Melbourne, Australia, assessed patient outcome by focusing on patients' subjective evaluation of the healthcare services they received through the clinic. A satisfaction survey, which was previously used in two established gender clinics in the US and UK, was adapted and then administered to consecutive patients who attended the Gender Dysphoria Clinic during a 1-month period. A total of 127 surveys were available for analysis: 88% of patients reported being satisfied with the services they received. Patients' perceived level of distress reduced significantly, following their involvement with the Gender Dysphoria Clinic. Feeling understood and heard in a non-judgmental manner by a specialist in the field of gender dysphoria was the most positive aspect of service provision. The most negative aspect of the clinic was a lengthy waiting list. Although the majority of trans-and-gender-diverse patients attending the Gender Dysphoria Clinic were satisfied with the service they received, there is a need to identify strategies to facilitate timely access to the clinic.

Gender Surgery as Part of a University-Based Multidisciplinary Gender Services Team

Gender Surgery as Part of a University-Based Multidisciplinary Gender Services Team

Children and Adolescents With Gender Identity Disorder Referred to a Pediatric Medical Center

To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients. Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity. Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%). After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

Consensus in Guidelines for Evaluation of DSD by the Texas Children's Hospital Multidisciplinary Gender Medicine Team

The Gender Medicine Team (GMT), comprised of members with expertise in endocrinology, ethics, genetics, gynecology, pediatric surgery, psychology, and urology, at Texas Children's Hospital and Baylor College of Medicine formed a task force to formulate a consensus statement on practice guidelines for managing disorders of sexual differentiation (DSD) and for making sex assignments. The GMT task force reviewed published evidence and incorporated findings from clinical experience. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence presented in the literature for establishing evidence-based guidelines. The task force presents a consensus statement regarding specific diagnostic and therapeutic issues in the management of individuals who present with DSD. The consensus statement includes recommendations for (1) laboratory workup, (2) acute management, (3) sex assignment in an ethical framework that includes education and involvement of the parents, and (4) surgical management.

Long-term follow-up: psychosocial outcome of Belgian transsexuals after sex reassignment surgery

Abstract Background To establish the benefit of sex reassignment surgery (SRS) for persons with a gender identity disorder, follow-up studies comprising large numbers of operated transsexuals are still needed. Aims The authors wanted to assess how the transsexuals who had been treated by the Ghent multidisciplinary gender team since 1985, were functioning psychologically, socially and professionally after a longer period. They also explored some prognostic factors with a view to refining the procedure. Method From 107 Dutch-speaking transsexuals who had undergone SRS between 1986 and 2001, 62 (35 male-to-females and 27 female-to-males) completed various questionnaires and were personally interviewed by researchers, who had not been involved in the subjects' initial assessment or treatment. Results On the GAF (DSM-IV) scale the female-to-male transsexuals scored significantly higher than the male-to-females (85.2 versus 76.2). While no difference in psychological functioning (SCL-90) was observed between the study group and a normal population, subjects with a pre-existing psychopathology were found to have retained more psychological symptoms. The subjects proclaimed an overall positive change in their family and social life. None of them showed any regrets about the SRS. A homosexual orientation, a younger age when applying for SRS, and an attractive physical appearance were positive prognostic factors. Conclusion While sex reassignment treatment is an effective therapy for transsexuals, also in the long term, the postoperative transsexual remains a fragile person in some respects.

Surgical Therapy in Transsexual Patients: a Multi-Disciplinary Approach

A transsexual patient has the constant and persistent conviction that he or she belongs to the opposite sex, thus creating a deeply seated gender identity conflict. With psychotherapy being unsuccessful, it has been proven that in carefully selected patients, gender reassignment or adjusting the body to the mind (both with hormones and surgery) is the best way to normalize their lives. Optimal treatment of these patients requires the multidisciplinary approach of a gender team with the input of several specialties. Such a team consists of a nucleus of physicians who sees the patient more frequently: the psychiatrist, the endocrinologist, the plastic surgeon, the gynecologist and the urologist and a more peripheral group that sees the patients more incidentaly: the psychologist, the otorhinolaryngologist, the dermatologist, the speech therapist, the lawyer, the nurse and the social worker.Between 1987 and 1999, a total of 71 male-to-female (MTF) and 54 female-to-male transsexuals have undergone gender confirming surgery in our hospital. This article gives a review and an update on the different surgical procedures as well as on the outcome in our patient population. The results in this series of patients clearly demonstrate that a close cooperation of the different surgical specialties, within our multidisciplinary gender team, is the key to success in treating transsexual patients.