Transsexual Patients Research Articles

Pitch-raising surgery in fourteen male-to-female transsexuals.

To evaluate the indications and results of pitch-raising surgery in male-to-female transsexual patients. Retrospective study of male-to-female transsexual patients who underwent pitch-raising surgery between 1994 and 2001 at a single institution. The 14 patients had inadequate improvements after speech therapy alone. After anterior commissure advancement (n = 2), cricothyroid approximation (n = 9), or both (n = 3), results were evaluated subjectively by the patients and speech therapists and objectively by electroglottographic measurement of fundamental frequencies (usual, maximal, and minimal), postoperative gain in usual fundamental frequency, and the percentage of irregularities. Cricothyropexy disruption occurred in two patients. Median follow-up was 6.5 months. Subjective success rates were 78.5% and 71.5% according to the patients and speech therapists, respectively. Usual, maximal, and minimal frequencies increased significantly; median postoperative gain in usual fundamental frequency was 11 Hz. Three of the four patients with a poor objective result continued to smoke after surgery. Pitch-raising surgery induces subjective and objective improvements but should be reserved for patients in whom speech therapy is not sufficiently effective.

DISSOCIATIVE DISORDERS AND TRAUMATIC CHILDHOOD EXPERIENCES IN TRANSSEXUALS

In this first prevalence study of dissociative symptoms and different forms of childhood experiences among transsexuals, 41 transsexuals and 115 psychiatric inpatients were compared by means of the Interview for Dissociative Disorders (SCID-D-R), the Dissociative Experiences Scale (DES), and the Childhood Trauma Questionnaire (CTQ). The total score for the dissociative symptoms revealed no significant differences between the transsexuals and the psychiatric inpatients. However, the higher DES score among transsexuals compared with a normal population was found to be due largely to one item. A surprisingly high prevalence of emotional maltreatment was recorded. The results suggest that both the DES and the SCID-D-R have limited validity as instruments for screening and diagnosing dissociative disorders in transsexuals. Psychiatrists should be mindful of the possible existence of dissociative disorders in transsexual patients. Further investigations are needed to clarify the effects of traumatic childhood experiences on sexual identity in transsexuals and to throw more light on the phenomenological correlation between transsexualism and dissociative identity, using taxometric analyses.

Surgical therapy in transsexual patients: A multi-disciplinary approach

Surgical therapy in transsexual patients: A multi-disciplinary approach

Service provision for gender dysphoria

Sir: I read with interest the paper by Murjan, Shepherd and Ferguson ( [ Psychiatric Bulletin June 2002, 26 , 210-212][1]). In their assessment of services provided to transsexual patients, the authors relied on the 5th edition of the Harry Benjamin International Gender Dysphoria Association

Gender identity disorders as a secondary symptom of psychosis

In The Netherlands it has recently become possible for transsexual patients to receive hormonal treatment from the onset of puberty to prevent pubertal development. From 16 years of age onwards, gender adjustment can be initiated by administration of hormones of the opposite sex. Surgical treatment can be offered once the patient reaches 18 years of age. Although such treatment will only be initiated with reticence and after a long phase of intense diagnostic screening, the question arises whether a clear differentiation can be made between pure gender identity disorders and secondary transsexual feelings that are part of an ongoing psychopathological development, such as schizophrenia. The potential diagnostic confusion is illustrated by a case history of a male schizophrenic patient. This patient had been treated hormonally for transsexualism for years before acute psychotic decompensation occurred. Neuroleptic treatment of the psychosis rapidly reduced the psych‐otic symptoms. In retrospect, the patient regards his transsexual period as a ‘mistake’. Delusions about one's physical appearance and the urge to drastically change the way one looks appear to be relatively common in patients suffering from schizophrenia.

Termination of a fe/male transsexual patient's analysis: An example of general validity

The author describes the termination of an analysis, which, while relating to the particular case of a male‐to‐female transsexual patient, may be relevant to all analysts, particularly those whose patients need to integrate disavowed and split‐off parts of themselves. The patient had undergone sex‐change surgery at the age of 20. Having lived as a woman thereafter, she had asked for analysis some twenty years later. The author, who discussed the first three years of that analysis in an earlier paper, as well as her hesitation about undertaking it, considers that its termination after seven years illustrates not only the specific problems posed by transsexuals but also the general ones presented by ‘heterogeneous patients’. To the best of her knowledge, this is the first published case history of a transsexual patient who has undergone surgery. In the author's view, the patient has acquired a new sense of internal unity based on a notion of sex differentiation in which mutual respect between the sexes has replaced confusion and mutual hate, and her quality of life has improved. On the general level, this termination shows how the reduction of paranoid‐schizoid anxieties and the reintegration of split‐off parts of the personality lead, as the depressive position is worked through, to a better toleration of internal contradictions, a new sense of cohesion of the self and a diminution of the fear of madness.

Timing of FSH-stimulation and follicular development in cryopreserved human ovarian grafts

Cryopreserved human primordial follicles grafted into immunodeficient hosts are susceptible to gonadotrophic stimulation but the optimal interval between grafting and stimulation has not been determined. The effect of stimulation with FSH at different time intervals after grafting was therefore investigated. Cryopreserved human ovarian cortical grafts from an androgen pre-treated female-to-male transsexual patient were transplanted into four groups of four non-obese, diabetic severe combined immune deficiency (NOD-SCID) mice. Ten, 12, 14 and 17 weeks after grafting, stimulation was started with daily intra-peritoneal injections of 5 IU of recombinant FSH for 14 days. Grafts were recovered and serially sectioned for counting the number of follicles and determining the different stages of development. Significantly more primary and secondary follicles were found in all stimulated groups compared with the non-stimulated control. This progression from the primordial to growing primary and secondary stages was most significant in the 14 weeks interval group. Formation of antral follicles was scarce and was only noticed in the 10 and 17 week groups. Cystic follicles and follicles with structural oocyte abnormalities were encountered in each group. Whether this phenomenon is related to the hormonal state of the tissue donor or to the cryopreservation and transplantation procedures is the subject of further investigation. It is concluded that the interval between grafting of ovarian tissue and the start of gonadotrophic stimulation may be important for an optimal follicular development after grafting.

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.

Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients.

To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results. From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds. Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse. Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.

Sparing a testis during vaginoplasty in male-to-female transsexuals: does it benefit our patients?

Testosterone and its metabolite dihydrotestosterone are the libido hormones for the male, vital to sex drive and sexual function. Fear of loss of libido and orgasm is the main reason to retain at least one testis in male-to-female transsexuals during vaginoplasty. We report on four South American transsexual patients in whom we resected a remaining testis to illustrate the superfluity of retaining it. Because there are multiple reasons for castration, we advise that bilateral orchidectomy be performed in the course of sex reassignment surgery for male-to-female transsexuals.

Gender reassignment and assisted reproduction: present and future reproductive options for transsexual people.

Transsexual people who want transition to their desired gender have to undergo hormonal and surgical treatments, which lead to irreversible loss of their reproductive potential. This paper argues that transsexual people should be offered the same options as any person that risks losing their germ cells because of treatment for a malignant disease. Indeed, transsexual women (male-to-female transsexual patients) may be given the option to store spermatozoa before they start hormonal therapy, so that their gametes may be used in future relationships. This may be especially important for the many transsexual women who identify as lesbians after their transition. Conversely, transsexual men (female-to-male transsexual patients) may be offered storage of oocytes or ovarian tissue, possibly obtained at the time of their oophorectomy. Current technology offers transsexual people the possibility to obtain children who are genetically their own in their future relationships and the option of gamete banking should therefore be discussed before starting hormonal and surgical reassignment treatment. This is particularly important for transsexual people who are diagnosed and treated at a young age.

Gender reassignment surgery and the gynecological patient

With the increasing number of open transsexuals in the population and the advances in reconstructive surgical techniques, gender reassignment surgery has been increasing since the 1960s. Secondary to the increase in patients undergoing gender reassignment surgery, the practicing gynecologist is more likely to encounter a transsexual patient. A 49-year-old, nulligravid, white female presented to the gynecology clinic for her annual gynecological exam. Her past surgical history was significant for male to female gender reassignment surgery in 1991. Her hormonal medications included levothyroxine and estrogen. She described a strong family history of breast cancer for which she was being followed in our institutional Breast Watch Clinic. On physical examination, findings were notable for surgically constructed female external genitalia and a neovagina. The rectal exam was normal and failed to demonstrate any prostate pathology. It is important for the experienced gynecologist to be familiar with transsexualism, the reconstructive surgery involved, the surgical complications, and gender identity support groups and clinics available to these patients. Transsexuals should be treated to the extent possible like other female gynecological patients, while care is taken not to overlook underlying or preexisting medical conditions, including conditions unique to the prior and new genders.

Value of spiral CT in patients with cricothyroid approximation.

Cricothyroid approximation raises the vocal pitch by simulating contraction of the cricothyroid muscle with sutures. The aim of this study was to determine the role of spiral CT in patients scheduled for cricothyroid approximation. 29 transsexual patients were examined with spiral CT prior to and after laryngoplastic surgery. CT findings were correlated with phonographic findings in all patients. The average reduction of the cricothyroid distance was 6 mm (range 2-10 mm). Vocal pitch elevation was greatest in patients with the largest reduction of the cricothyroid distance. CT accurately determines the cricothyroid distance prior to and after surgery and is an ideal method for follow-up, especially in post-operative reversion towards a lower pitch. In addition, CT provides important data in determining the most appropriate extent and site of intracordal intervention to achieve a desired pitch elevation.

Spiral computed tomography before and after cricothyroid approximation.

Cricothyroid approximation raises the vocal pitch by simulating the contraction of the cricothyroid muscle with sutures. The aim of this study was to determine the role of spiral computed tomography (CT) in patients scheduled for cricothyroid approximation. Twenty-nine transsexual patients were examined with spiral CT before and after laryngoplastic surgery. Computed tomography findings were correlated with phoniatric findings in all patients. The average reduction of the cricothyroid distance was 6 mm (range 2-10 mm). The vocal pitch elevation was more remarkable in the patient group with greater reduction of the cricothyroid distance. Computed tomography accurately determines the cricothyroid distance before and after surgery and is an ideal method for follow-up purposes, especially when there is a postoperative reversion towards a lower pitch. In addition, CT provides important data as to the most appropriate extent and site of intracordal intervention to be done for a desired pitch elevation.

Surgical conversion of genitalia in transsexual patients.

To describe the techniques and outcome of genital and urethral reconstructive surgery during gender conversion as part of the treatment of transsexuals. From 1992 to 1999, 82 patients were surgically converted after previous sexual and hormonal therapy. Using the male genital tissue to create new female genitalia, and vice versa, 30 male and 52 female transsexuals were converted. For male-to-female transsexuals, the technique of penile skin inversion was used 29 times and sigmoidocolpoplasty five times (in one patient primarily and in four patients to correct inadequate neovaginal size after penile skin inversion). In female-to-male transsexuals, 28 meta-idoioplasties and seven neophalloplasties were performed using the groin skin-flap technique, with 42 breast reductions also included as a part of the therapy. Surgical gender reassignment of the male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis, with the potential to void while standing. The morphological proportions of each patient vary, and the different shapes and sizes of the tissues can be used for plastic operations. Thus the modelling of each individual genital in transsexuals can be considered 'original'.

Long-term outcome of augmentation mammaplasty in male-to-female transsexuals: a questionnaire survey of 107 patients

A retrospective survey of long-term postoperative male-to-female transsexual patients has been performed to evaluate how well augmentation mammaplasty addresses their needs. One hundred and seven (65%) out of 164 anonymous questionnaires sent to the patients were evaluated. Average clinical follow-up of these patients was 4.8 years, whereas the average time lapse between mammaplasty and filling out of the questionnaire was 5.5 years (range, 16 months-17 years). The age of the subjects at the time of this survey ranged from 22 to 76 years (average, 41 years). Seventeen of the 107 patients had undergone further augmentation mammaplasty, on average 57 months after the initial mammaplasty. The average size of implanted prostheses was 258 ml (range, 130- 450 ml). Eighty patients (75%) indicated satisfaction with the final outcome of the mammaplasty. The median postoperative cup size in this group was B (range of postoperative bra size, 30B-40D). The remaining 27 patients (25%) were unhappy with the results of mammaplasty. The median postoperative cup size in the 18 patients who still felt their breasts to be too small was also B (range of bra size, 30B-48E). The average size of current prostheses in these 18 patients was 261 ml. For a male-to-female transsexual patient to appreciate the outcome of augmentation mammaplasty, the surgeon should tolerate and address this patient's urge for a distinctly feminine breast configuration.

Clinical Update: Medical Care of Transsexual Patients

Transsexual patients often have difficulty finding care because many physicians are not comfortable prescribing appropriate hormone regimens. Management of hormones for transsexual patients is not difficult, and these medications are safer than many therapies routinely prescribed by the primary care physician. The diagnosis of gender identity disorder (GID) must be established by an experienced mental health professional prior to consideration for hormonal management. Medical evaluation includes a thorough medical history, social history, family history, physical examination, and basic laboratory screening. If there are no medical contraindications, a variety of regimens for the male-to-female transsexual may be initiated, with initial close follow-up for medical and psychological well-being. There is less variation in female-to-male management with testosterone, but initial frequent follow-up is equally important. This review is intended to teach primary care providers how to initiate and maintain hormone regimens for transsexual patients and describe medical issues unique to transsexual patients.

Laser-assisted voice adjustment (LAVA) in transsexual patients

Laser-assisted voice adjustment (LAVA) in transsexual patients

The reported sex and surgery satisfactions of 28 postoperative male-to-female transsexual patients.

From 1980 to July 1997 sixty-one male-to-female gender transformation surgeries were performed at our university center by one author (A.M.). Data were collected from patients who had surgery up to 1994 (n = 47) to obtain a minimum follow-up of 3 years; 28 patients were contacted. A mail questionnaire was supplemented by personal interviews with 11 patients and telephone interviews with remaining patients to obtain and clarify additional information. Physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery. General satisfaction was expressed over the quality of cosmetic (normal appearing genitalia) and functional (ability to perceive orgasm) results. Follow-up showed satisfied who believed they had normal appearing genitalia and the ability to experience orgasm. Most patients were able to return to their jobs and live a more satisfactory social and personal life. One significant outcome was the importance of proper preparation of patients for surgery and especially the need for additional postoperative psychotherapy. None of the patients regretted having had surgery. However, some were, to a degree, disappointed because of difficulties experienced postoperatively in adjusting satisfactorily as women both in their relationships with men and in living their lives generally as women. Findings of this study make a strong case for making a change in the Harry Benjamin Standards of Care to include a period of postoperative psychotherapy.

Results of long-term follow-up of transsexual patients

From 69 transsexual patients (48 men, 21 women) having consulted the Basel University Psychiatric Outpatient-Department between 1970 and 1990, 13 men-to-woman- and 4 woman-to-man-transsexuals could be examined in a follow-up (5-20 years after the operation). The social conditions and the quality of life of the 13 men-to-woman-transsexuals had significantly deteriorated: 9 of the 13 depend on life annuity or on social welfare assistance. The patients live socially very isolated. Eight of them report almost not being able to experience sexual pleasure, 10 suffer from anxieties, depression or addictions. Three regret having demanded the operation and two have passed a second operation for restoration of the original state. The 4 woman-to-man-transsexuals showed slightly better results: 2 of them are fully professionally active and live in constant personal relationships of several years of duration. The 2 others, however, suffer from depression and problems of addiction and give the impression of affective lability. The results lead to the following conclusions: 1. the criteria of indication for the operation of the transsexuals should be observed thoroughly, especially the psychotherapeutic accompaniment before the operation during at least 1 year; 2. the question of emotional stability, of frustration tolerance and of the danger of an outbreak of psychosis are to be examined carefully; 3. the professional and social integration before and after the operation is of central importance.