Transsexual Patients Research Articles

1490 – Transsexualism and personality, study about 14 cases with structured assessment

Introduction Transsexualism is a rare condition, characterized by permanent conviction of belonging to opposite sex, leading to a request for hormono-surgical sex reassignment. Objectives and aims of the study The personality of transsexual patient is a matter of debate: most psychoanalysts postulate a severe personality disorder, while STOLLER's and biological hypothesis argue for of the absence of specific disturbance. Methods Fourteen transsexuals patients (9 men and 5 women), referred to the specialized multidisciplinary team of Nantes University hospital were included. All received hormone therapy, 5 patients underwent surgery. The MMPI-2 and SCID-II were used as standardized tools to assess personality. Results Using the SCID-II, frequency of personality disorders was 14.29%, showing no statistical difference compared to the general population (10%). The MMPI-2 mean T score was close to the general population 50. Moreover, man versus woman transsexuals have a degree of psychopathology significantly higher than woman versus man transsexuals. Operated versus non-operated patients showed no significant differences in the various tests. Conclusion Our results tend to relativize the unique psychopathological determinism of transsexualism, and seem to strengthen the hypothesis of biological factors involved in this problem. The prognosis is more favorable for woman versus man transsexuals.

Socio-demographic characteristics of transsexuals referred to the forensic medicine center in southwest of Iran

Background:Transsexualism or gender identity disorder affects person's gender identity.Aim:This study was to describe socio-demographic characteristics in a population of transsexuals.Materials and Methods:We studied 44 persons of both sexes with diagnostic criteria of gender identity disorder who were referred to the Legal Medicine Organization of Fars, southwest of Iran during the time period 2005-2010. The general practitioners examined the following socio-demographic characteristics and then recorded them in a semi-structured questionnaire, which was developed by the Forensic Medicine Center in Shiraz: Sex, age, educational level, place of residence, marital status, duration of treatment, and employment status.Results:A total of 44 persons (18 (40.9%) males versus 26 (59.1%) females) were referred for sex change during the study period. The sex ratio was 0.69:1. The mean age was 27.6 ± 2.9 years. The majority of patients were diploma and higher diploma education (77.3%), lived in urban areas (81.8%), were employed (56.9%), were single (93.1%), and were under six months of hormonal treatment (61.4%).Conclusions:It seems that social acceptance is lower for male to female transsexuals, since these patients have lower employment and literacy statuses. Further studies should be designed to evaluate and deeper analyze more socio-demographic, clinical, and psychiatric variables about transsexual patients.

Polymicrogyria of the Unilateral Temporal Lobe in a Transsexual Patient—Case Report

Introduction: Polymicrogyria, the appearance of irregular small and over numbered gyri on the surface of the brain, has been reported as the most frequent finding, when exists, on the temporal lobe. Case Presentation: A patient, male, age of 35, came to the regular head and brain MRI scan due to psychiatric and hormonal treatment within transsexualism. There were no data of epilepsy in a patient’s history. MRI scans were acquired with a 1.5 T Siemens Magnetom system with a standard head coil. Three-dimensional 3D RAGE, contiguous 1.0 mm slice, and 1 acquisition sequence underwent final 3D rendering and subsequent volumetry. On the definitive 3D image, we have revealed an unusual gyrisation on the left temporal lobe which had a picture of partial polymicrogyria. Conclusion: This is a unique finding, to our knowledge, of the unilateral temporal polymicrogyria in a person with transsexualism. Although polymicrogyria is mostly related to epileptifom attacks, its impact on the transsexualism appearance is opened to be examined.

The reoperation cascade after breast augmentation with implants: What the patient needs to know

Breast augmentation with implants is the most commonly performed aesthetic surgical procedure. However, the risk of complications requiring revision surgery with unsatisfactory final results is often underestimated. In a 10-year retrospective study, patients receiving implant exchange or implant removal after breast augmentation were reviewed with regards to surgical technique, implant type and position, complications and follow-up interventions. As many as 230 patients were included with a mean age of 40.23 years. A total of 192 (83.5%) had primary augmentation for aesthetic reasons, 24 (10.4%) patients were transsexuals and 14 (6.1%) were treated for malformations. The median primary implant size was 260, 224 and 327 g for aesthetic, malformation and transsexual patients, respectively. Capsular contracture was the leading cause for revision in aesthetic patients whereas size and shape were the main reasons for reoperation in transsexual and malformation patients, respectively. As many as 25% of patients required more than one revision procedure. The time between operations in aesthetic augmentation patients was significantly shorter for the second revision procedure (106.2 months vs. 11.4 months, p<0.0001). The cumulative risk for needing a second revision procedure in aesthetic patients at 12 months was 24.5%. There was no correlation between implant site, size, position or type of complication and the number of revision procedures. Our data highlight the high complication rate of revision surgery involving implant removal or replacement. We conclude that patients must be routinely informed of the high risk and arduous consequences of revision surgery, which should be stated as such in the written consent for the procedure.

Symptomatic meningioma induced by cross-sex hormone treatment in a male-to-female transsexual

Transsexualism is defined as a strong conviction of belonging to the opposite sex in individuals without any physical intersex condition. Cross-sex hormone therapy is an important component of medical treatment of transexuals but it is not exempt from adverse effects.We report a case of a meningioma in a male-to-female transsexual patient treated with estrogens and cyproterone acetate for the past 4years. He claimed recently severe headache and visual impairment. Blood tests showed normal results. A contrast-enhanced magnetic resonance imaging (MRI) scan revealed a mass in the tuberculum sellae consistent with a meningioma. Treatment was discontinued and tumor resection was performed. Histologic diagnosis confirmed strongly progesterone receptor-positive and estrogen negative meningioma. After surgery, the patient rejected the possibility of continuing with the treatment of estrogens and cyproterone, and so triptorelin (GnRH agonist) was initiated. At 1-year follow-up the patient's symptoms had ameliorated and a MRI scan revealed no recurrence of the tumor.This is the third case reported in the literature of a meningioma after treatment with estrogens and cyproterone acetate. We consider extremely important a long-term follow-up observation of male-to-female transsexual undergoing cross-sex hormone therapy in order to detect as soon as possible the adverse effects that can be derived from this therapy.

Radiological evaluation by magnetic resonance of the ‘new anatomy’ of transsexual patients undergoing male to female sex reassignment surgery

Magnetic resonance (MR) is the best way to assess the new anatomy of the pelvis after male to female (MtF) sex reassignment surgery. The aim of the study was to evaluate the radiological appearance of the small pelvis after MtF surgery and to compare it with the normal women's anatomy. Fifteen patients who underwent MtF surgery were subjected to pelvic MR at least 6 months after surgery. The anthropometric parameters of the small pelvis were measured and compared with those of ten healthy women (control group). Our personal technique (creation of the mons Veneris under the pubic skin) was performed in all patients. In patients who underwent MtF surgery, the mean neovaginal depth was slightly superior than in women (P=0.009). The length of the inferior pelvic aperture and of the inlet of pelvis was higher in the control group (P<0.005). The inclination between the axis of the neovagina and the inferior pelvis aperture, the thickness of the mons Veneris and the thickness of the rectovaginal septum were comparable between the two study groups. MR consents a detailed assessment of the new pelvic anatomy after MtF surgery. The anthropometric parameters measured in our patients were comparable with those of women.

Clinical practice guidelines for assessment and treatment of transsexualism. SEEN Identity and Sexual Differentiation Group (GIDSEEN)

Abstract Transsexual patients can only be diagnosed and treated at functional gender identity units with the provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System.

Dancing With the Unconscious: The Art of Psychoanalysis

This article examines psychoanalytic work as an art and uses the metaphor of dance between two unconscious minds to describe the rich creativity of mental life. Free association, transference/countertransference, and dreamwork are each discussed for their creative dimensions and their coupling in the cure. A compelling session with dream analysis of a transsexual patient is presented verbatim (along with the author's inner thoughts) to illustrate the art of dance that takes place between analyst and analysand.

Guías de práctica clínica para la valoración y tratamiento de la transexualidad. Grupo de Identidad y Diferenciación Sexual de la SEEN (GIDSEEN)*(anexo 1)

Transsexual patients can only be diagnosed and treated at functional gender identity Units with provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System.

Organización de la asistencia a la transexualidad en el sistema sanitario público español

ObjectiveRecognition of transexuality as a clinical entity for which medical attention should be available is currently a well-established reality, but institutional care has not been uniformly instituted throughout Spain. The aim of the present study was to determine the current situation of healthcare for transexualism in the publicly-funded health service in Spain. Materials and methodsA descriptive study based on data provided by the Spanish Society of Endocrinology Group on Identity and Sexual Differentiation was performed. The resources in the regions that have created specific gender units for these disorders are described. ResultsNine autonomous regions (55%) have started to provide various procedures, although only four provide genitoplastic procedures. The first region to include all sex reassignment surgeries was Andalusia (year 1999). At the same time, Madrid and Catalonia also began to provide specialized mental health care and endocrinology but did not include surgical procedures until 2007 and institutional recognition until 2008. Since 2007 other regions have incorporated healthcare for transsexual patients. Overall, 3,303 patients (a male-to female/female-to-male transsexual ratio of 1.9/1) and 864 surgical procedures have been registered in this study. The composition and proportion of working hours of specialists, as well as the kinds of treatments provided, differ widely in each region. ConclusionsThe geographical distribution of healthcare to transsexual persons and the services provided vary. Few regions offer genitoplastic procedures. The number of applicants exceeds the number estimated by the national health system.

Comorbidities in Transsexual Patients under Hormonal Treatment Compared to Age- And Gender-Matched Primary Care Comparison Groups

Background: There is limited data on safety aspects of hormonal treatment in transsexual patients and clinical trials are lacking. We aimed at evaluating the long-term hormonal treatment in transsexual patients. Patients: 95 transsexuals (37 female-to-male (FMT) and 58 male-to-female transsexuals (MFT)) treated between 1996 and 2007 were compared to an age- and gender-matched primary care patient group from the DETECT-cohort (matching 1:3). Results: Compared to age-matched control groups, we did not observe a higher prevalence of lifetime cardiovascular, endocrine or tumoural comorbidities. FMT showed a lower prevalence of endocrine diseases (FMT to females, p=0.008 and FMT to males, p=0.033). MFT showed a lower prevalence of cardiovascular diseases (MFT to females, p=0.005 and MFT to males, p<0.001) and endocrine diseases (MFT to females p<0.001 and MFT to males, p<0.001). Conclusion: There is no indication of an increased risk associated with HT in transsexual patients in Germany

P-1339 - Agoraphobia hemiparesis and hemihypesthesia in a transsexual patient - case report

Transsexualism is a gender identity disorder soon to be removed from the DSM criteria for mental disorders. The actual developmental/congenital origin of the disorder has yet to be established. One of the theories involves morphological and neuro-hormonal modification in the corpus callosum as a possible substrate. Diagnostic assessment of a 22 year old female - male transsexual patient with a history of agoraphobia and migraine, reporting intermittent symptoms of numbness of left side of body and cheek and headaches. Data on personal/family history was obtained and neurological examination was performed. MRI scan was acquired with a 1.5 T Siemens Magnetom system with a standard head coil. Sagittal three-dimensional 3D RAGE, contiguous 1.0 mm slices, 1 acquisition sequences were obtained. Results and discussion: Family history of anxiety disorder was confirmed. Symptoms appeared following reduction of anxiolytic medication and emotional crisis. Neurological status showed signs of left pyramid deficit. NMR scan findings showed bilateral arachnoid cysts in genu corpus callosum probably of congenital origin. Co-morbidity versus concomitant disorders of psychiatric, neurological and congenital origin were discussed.

Removal of an entrapped large metallic dilator from the sigmoid neovagina in a male-to-female transsexual using a laparoscopic approach

IntroductionTo describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20cm in length and 3.5cm in diameter) in a case of male-to-female transsexual. Presentation of the caseThe patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70min. DiscussionUp to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator. ConclusionLaparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.

P-686 - Gender transition as a risk factor for psychotic relapsecase report of ftm transsexual patient

Pre-surgery diagnostic procedures, in which psychiatric examination takes a major role, have long-lasting consequences. Through the case presentation of a diagnostically and therapeutically interesting gender dysphoric individual, the authors wish to address the necessity of continual follow up of transgerder persons even after recommendation letter for surgery. The authors in this paper give detailed data on gender history and gender transition for the 49-year-old divorced biological female with university education who lives alone. Gender transition was very slow according to his own capacities for acceptance of change. He had hystory of mild depressive non psychotic episodes periodically and severe suicid attempt at 12. In his 48 he was clinically significant depressed after metoidioplastic surgery. Afterwards he gradually developed paranoid symptomatology which progressed to psychotic level after antidepressants. Inspite discontinuation of medication paranoid features additionaly escalate. He is still preoccupated with genital complaints which has character of cognitive distorsions and at the moment not motivated for further genital transition (phalloplasty). Gender history, clinical presentation and successful living full-time as a male for thirty years confirms that presented patient meets all criteria for the Gender Identity Disorder. This case report reminds us to pay attention to some precautions and possible risk factors for reconstructive surgery reccomendation, such as: 1. Personality traits (depressive, paranoid, avoidant). 2. Former psychiatric disorder (depression, suicidal behaviors, transient psychotic features). 3. Slow transition in full expression of gender identity (important predictor of possible psychotic relapse in this case).

Human Acellular Matrix Graft of Tunica Albuginea for Penile Reconstruction

Penile curvature is one of the most common male conditions, affecting nearly 10% of men, and can impair sexual intercourse. Tunica albuginea (hTA) plays a key role in penile curvature, and reconstructive procedures may be necessary for its substitution. Although several grafts have been proposed for hTA repair, the ideal graft is not yet available. The aim of this article is to evaluate a new human tunica albuginea acellular matrix (hTAAM) as potential graft for penile reconstructive procedures. Twelve penises were obtained during sex reassignment surgeries from male-to-female transsexual patients. After dissection, hTAs were assigned into two groups according to the decellularization methods: polyethylene glycol (PEG) 1000 method following ultraviolet-C radiation, and Triton X-100 modified method. Structural analyses were assessed by hematoxilin and eosin, Masson's trichrome, Weigert's, and picrosirius-polarization staining methods. Total protein, total glycosaminoglycan (GAG), and nucleic acid (DNA and RNA) concentrations were assessed by specific biochemical analyses. Uniaxial strength tests were performed to evaluate biomechanical properties. All hTAAMs presented no nuclear or cellular remnants. Total protein concentration was significantly higher in PEG 1000 hTAAM. Despite GAG concentration decreased significantly in hTAAM, Triton X-100 hTAAM retained the highest GAG concentration (1.0 ± 0.42 µg HexUr/mg dry tissue, P > 0.05). All decellularization methods were efficacious to remove nucleic acids. The maximal break point presented no difference between hTA and hTAAM groups (P > 0.05). PEG 1000 and Triton X-100 decellularization methods provide equally successful hTAAMs, preserving original structural and biochemical properties.

Hormone-treated transsexuals report less social distress, anxiety and depression

The aim of the present study was to evaluate the presence of symptoms of current social distress, anxiety and depression in transsexuals. We investigated a group of 187 transsexual patients attending a gender identity unit; 120 had undergone hormonal sex-reassignment (SR) treatment and 67 had not. We used the Social Anxiety and Distress Scale (SADS) for assessing social anxiety and the Hospital Anxiety and Depression Scale (HADS) for evaluating current depression and anxiety. The mean SADS and HADS scores were in the normal range except for the HAD-Anxiety subscale (HAD-A) on the non-treated transsexual group. SADS, HAD-A, and HAD-Depression (HAD-D) mean scores were significantly higher among patients who had not begun cross-sex hormonal treatment compared with patients in hormonal treatment (F=4.362, p=.038; F=14.589, p=.001; F=9.523, p=.002 respectively). Similarly, current symptoms of anxiety and depression were present in a significantly higher percentage of untreated patients than in treated patients (61% vs. 33% and 31% vs. 8% respectively). The results suggest that most transsexual patients attending a gender identity unit reported subclinical levels of social distress, anxiety, and depression. Moreover, patients under cross-sex hormonal treatment displayed a lower prevalence of these symptoms than patients who had not initiated hormonal therapy. Although the findings do not conclusively demonstrate a direct positive effect of hormone treatment in transsexuals, initiating this treatment may be associated with better mental health of these patients.

Distinctive Features of Female-to-Male Transsexualism and Prevalence of Gender Identity Disorder in Japan

The prevalence of transsexualism is thought to differ among socio-geographic backgrounds, and little is known about its prevalence in Japan. Polycystic ovary syndrome (PCOS), which is known to be associated with insulin resistance and metabolic syndrome, is often seen in female-to-male (FTM) transsexual patients. Consequently, detection of PCOS is an important part of health care for these individuals. The purpose of this study was to assess the prevalence of transsexuality in Japan, as well as the incidences of PCOS and insulin resistance among Japanese FTM transsexual patients. One hundred four male-to-female (MTF) and 238 FTM Japanese transsexual patients were studied. Medical histories, including histories of menstrual cycling and hormone treatment, were taken. To exclude other diseases, such as congenital adrenal hyperplasia and hormone-secreting tumors, thorough medical assessments, including transvaginal or transrectal ultrasonography and measurement of serum hormone levels and insulin resistance indexes, were performed. The diagnosis of PCOS was based on the Rotterdam 2003 criteria. Based on demographic statistics, the prevalences of MTF and FTM transsexuality are about 3.97 and 8.20 per 100,000 people, respectively, making the MTF-to-FTM ratio about 1:2. Of the FTM transsexual patients studied, 128 had not taken hormones before their initial assessment (untreated group); the remaining 50 self-administered androgen. Among the untreated group, 32.0% were diagnosed with PCOS, 30.1% were insulin-resistant, and 31.1% showed hypoadiponectinemia. The sex ratio among Japanese transsexuals is different than among Caucasians. PCOS and insulin resistance are common findings in FTM transsexual patients at initial presentation.

Demanda de atención sanitaria en las unidades de identidad de género de Andalucía y Cataluña durante la década 2000 a 2009

Objective To evaluate the demand for public health services in two gender identity disorder units (Andalusia and Catalonia) during the period of 2000-2009. Method A descriptive and comparative study was made of the demand for health services, the demographic and clinical characteristics of the patients, and the sex reassignment surgeries performed. Results A total of 828 subjects in Andalusia and 549 in Catalonia requested clinical assistance. In both communities, the percentages of cases diagnosed of transsexualism (88 vs 89.7%), the percentages excluded in the sex reassignment program (16.7 vs 15.3%), the male/female ratio (1.6:1 vs 2.1:1), and the mean age (28 vs 29 years) were similar. A total of 284 sex-reassignment surgeries were performed in Andalusia and 50 in Catalonia. Conclusions The demand has been maintained in Andalusia and has increased in Catalonia in recent years. The basic demographic and clinical characteristics of transsexual patients were similar between both units and comparable to those of other countries.

Vaginal prolapse, pelvic floor function, and related symptoms 16 years after sex reassignment surgery in transsexuals

To evaluate the prevalence of prolapse and related bladder, bowel, and sexual problems in transsexual patients (TS) after sex reassignment surgery. A cross-sectional study. A tertiary referral center. 55 transsexuals, comprising 52 male-to-female and 3 female-to-male patients. Gynecologic examination with pelvic floor testing, measurements for pelvic organ prolapse applying International Continence Society pelvic organ prolapse (ICS-POP) staging, and the Sheffield prolapse questionnaire to assess prolapse symptoms, and bladder, bowel, and sexual function. ICS-POP score and Sheffield prolapse questionnaire. Of the 55 transsexuals who participated in this study (52 male-to-female and 3 female to male), 7.5% showed a prolapse greater than or similar to ICS-POP stage 2, and 3.8% required surgical intervention. For bladder symptoms, 47% reported voiding difficulties, 24.6% urgency, 17% urge incontinence, and 23% stress incontinence. Fecal urgency and incomplete emptying of the bowel occurred in 9.4% and 7.6% of patients, respectively. In addition, 23% reported that they were never satisfied with their sexual function. Pelvic floor symptoms may occur in transsexuals involving the bladder, bowel, and sexual function. Surgical corrective options should be determined on an individual basis as with other patients who have prolapse symptoms.

Changes in the sleep electroencephalogram (EEG) during male to female transgender therapy

Steroids, including estrogens, participate in sleep regulation. For example estrogen replacement therapy improved sleep quality in postmenopausal women. Patients, who undergo a cross-gender hormone therapy, receive high doses of estrogens. The effects of this treatment on sleep are unknown. To clarify this issue, we examined seven male to female transsexual patients (age range 31-44 years, mean±SD 35.9±4.2 years). The patients spent two nights on 2 separate occasions in our sleep laboratory. The first night of each session served for adaptation to laboratory conditions. In the second night sleep electroencephalogram [EEG] was recorded from 2300h to 0700h. The first examination was performed before and the second about 3 months after initiation of cross-gender hormone therapy with a dose of 80-100mg estrogen applied every 2 weeks. Additionally patients were treated with a starting dose of the anti-androgen cyproteronacetate of 100mg/day and after about 6 weeks with a maintenance therapy of 50mg/d in order to suppress androgenic effects. Statistical analysis was performed with the Wilcoxon rank test. Under this estrogen therapy we found a significant increase in stage 1 sleep during the whole night (at baseline [b]: 33.29±9.94min; treatment [t]: 51.57±24.26min; p<0.05) Beta activity in nonREM sleep was significantly increased (p=0.02) during hormone therapy compared to before treatment. Other sleep EEG parameters showed no significant changes. Administration of estrogen and anti-androgens in male to female transsexual patients had only a small influence on sleep EEG, with an increase in the duration of shallow sleep.