Androgenetic alopecia in transgender and gender diverse populations: A review of therapeutics

Androgenetic alopecia (AGA) management is a significant clinical and therapeutic challenge for transgender and gender-diverse (TGD) patients. Although gender-affirming hormone therapies affect hair growth, there is little research about AGA in TGD populations. After reviewing the literature on approved treatments, off-label medication usages, and procedures for treating AGA, we present treatment options for AGA in TGD patients. The first-line treatments for any TGD patient include topical minoxidil 5% applied to the scalp once or twice daily, finasteride 1 mg oral daily, and/or low-level laser light therapy. Spironolactone 200 mg daily is also first-line for transfeminine patients. Second-line options include daily oral minoxidil dosed at 1.25 or 2.5 mg for transfeminine and transmasculine patients, respectively. Topical finasteride 0.25% monotherapy or in combination with minoxidil 2% solution are second-line options for transmasculine and transfeminine patients, respectively. Other second-line treatments for any TGD patient include oral dutasteride 0.5 mg daily, platelet-rich plasma, or hair restoration procedures. After 6-12 months of treatment, AGA severity and treatment progress should be assessed via scales not based on sex; eg, the Basic and Specific Classification or the Bouhanna scales. Dermatologists should coordinate care with the patient's primary gender-affirming clinician(s) so that shared knowledge of all medications exists across the care team.

Spectrum of Histologic Findings in Orchiectomy Specimens of Patients Seeking Male to Female Physical Adaptation

Context. Hormonal therapy followed by orchiectomy is of the standard of care in management of gender identity disorder in patients seeking male to female transition. The orchiectomy specimens from these patients are routinely subjected to histopathologic evaluation. We discuss the spectrum of histopathologic findings, incidental findings, and cost analysis of processing these specimens. Design. Orchiectomy specimens from patients seeking male to female transition received at our institution from January 2019 to June 2021 were included in the study. Data including patient age, history of hormonal therapy, testicular weight, histopathologic findings, number of tissue sections, and processing cost were collected. Results. A total of 79 specimens were identified. Mean patient age was 36.7 ± 14.5 years. Mean testicular weight was 28.0 ± 8.3 g (right) and 27.8 ± 9.1 g (left). Histologic evaluation showed diminished or absent spermatogenesis in 100% and fibrosis of seminiferous tubules in 96% of specimens. Benign, incidental findings, none of which altered patient management were present in 6 specimens (8%). For most specimens, 3 sections per testis were submitted. This resulted in a mean of 5.8 ± 1.1 tissue sections submitted per specimen. Conclusions. Orchiectomy specimens from patients with gender dysphoria always demonstrate hormone-therapy effects albeit with varying degree. The chances of discovering any incidental finding of clinical significance are negligible. Diligent gross inspection and minimal tissue sampling with additional sampling reserved for gross abnormalities can adequately document the histologic findings in a cost-effective manner.

Androgenetic alopecia incidence in transgender and gender diverse populations: A retrospective comparative cohort study

BACKGROUND

Androgenetic alopecia (AGA) is a significant challenge for many transgender and gender diverse (TGD) patients, but the rate of AGA among TGD patients receiving gender-affirming hormone therapy (GAHT) compared to cisgender patients has not yet been studied on a large scale.

OBJECTIVE

We examined the incidence of AGA among TGD patients receiving GAHT compared to cisgender patients.

METHODS

Retrospective cohort study using electronic health records from 37,826 patients seen at Fenway Health between August 1, 2014, and August 1, 2020. Crude and adjusted incidence rate ratios (aIRR) for AGA were calculated using Poisson regression.

RESULTS

TGD patients receiving masculinizing GAHT had aIRR 2.50, 95% CI 1.71-3.65 and 1.30, 95% CI 0.91-1.86 compared to cisgender women and cisgender men, respectively. The rate of AGA for TGD patients receiving feminizing GAHT was not significantly different compared to cisgender men but was significantly increased compared to cisgender women (aIRR 1.91, 95% CI 1.25-2.92).

LIMITATIONS

Inability to determine causation and limited generalizability.

CONCLUSION

TGD patients receiving masculinizing GAHT have 2.5 times the rate of AGA compared to cisgender women, whereas TGD patients on feminizing GAHT did not have a significantly increased rate of AGA compared to cisgender men.

Gender Dysphoria Versus Acute Psychosis: Can One Properly Diagnose Gender Dysphoria Solely During Acute Psychosis?

Description Gender dysphoria occurs when a discrepancy between one's sex assigned at birth and one's gender identity causes distress or impairment in function, which can lead ultimately to seeking treatment in the forms of psychotherapy, hormonal therapy, and/or gender-affirming surgery. Clinical care guidelines also recommend pharmacological treatment of psychiatric comorbidities if indicated. A review of the current literature demonstrates comorbidity between gender dysphoria and psychosis, including cases of gender dysphoria with schizophrenia and the occurrence of gender dysphoria symptoms during manic or psychotic episodes. The existing literature has yet to specifically examine gender dysphoria amongst individuals with schizoaffective disorder. The authors present the first documented case of a clear pattern of gender identity variations coinciding solely with psychotic episodes during schizoaffective disorder, bipolar type. The authors postulate that gender dysphoria can co-occur with other psychiatric disorders or may correspond only during acute psychosis. The distinction is critical to make to ensure accurate diagnoses regarding whether gender dysphoria is a symptom only during an acute psychotic illness, or if there is a longer-standing concern as to the patient's gender identity and assignment. This distinction then also informs how to make the most appropriate treatment recommendations. The authors address the significance of understanding each patient's individual circumstances and deem this paramount to advancing transgender and gender non-binary health equity at every level of medical attention, focusing specifically on proper physician training and direct patient care.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

A Follow-Up Study of Boys With Gender Identity Disorder

This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.

[CLINICAL OUTCOMES OF GENDER AFFIRMING SURGERY FOR GENDER DYSPHORIA/INCONGRUENCE: A SINGLE-INSTITUTE EXPERIENCE]

(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence. (Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes. (Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m² or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery. (Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.

[TransIdentity - Identity Development Among Adolescent Trans*people]

TransIdentity - Identity Development Among Adolescent Trans*people Identity development is one of the most important developmental tasks of adolescence. Adolescents whose gender identity does not correspond to the gender assigned at birth (trangender people) are also faced with this challenge, as are cis-gender adolescents of the same age. This study is the first to examine the personality function of identity in transgender adolescents. Based on the self report of a population of 69 adolescents from the outpatient unit for gender dysphoria the extent of identity diffusion measured by AIDA (Assessment of Identity Development in Adolescence) was compared with the values of the normative sample consisting of German-speaking pupils. Both the overall construct of identity diffusion and the areas of continuity and coherence showed average values in the examined young people, which speaks against pathological identity development. Nevertheless, identity diffusion was found in over a third (36 %). Most notably the aspect of stabilising relationships and roles was above average, which suggests that positive role identification from the areas of culture, family and body-self is present to a lesser extent than in the norm sample. The identity-stabilizing feeling of social anchoring appears to be impaired in the young transidents studied.

Between a Rock and a Hard Place - Gender Dysphoria and Comorbid Depression in a Young, Low-Income, Pakistani Transgender Man

Gender dysphoria (GD) describes an incongruence between a person's assigned and expressed gender and the distress associated with it. The management of GD ideally involves a team of healthcare professionals, including psychiatrists, endocrinologists, and surgeons, and may include one or more of the following - psychotherapy, hormone therapy, and gender reassignment surgeries. While Pakistan still has a sizeable population of the traditional 'khwaja siras' or 'hijras,' many young transgender Pakistanis are now adopting global transgender identities and seeking sex-reassignment procedures from a state-run healthcare system, which still heavily discriminates against them. In spite of the passage of a new law protecting the fundamental human rights of transgendered Pakistanis, they continue to be oppressed and deprived of education, employment, and healthcare. This case report describes one such young transman from a low-income Pakistani household, who, owing to the legal red tape, family pressure, religious disapproval, and hefty hospital expenses, is left with only two options - to undergo unsafe, unstandardized procedures at the hands of quacks or live the rest of his life trapped in the wrong body. There is a dire need for a wide-scale awareness campaign to educate and sensitize the general public about transgender rights. Medical students must also be exposed to transgender patients during their medical school training in order to familiarize them with the special medical needs of transgender individuals.

Paranoia in patients with gender dysphoria: A clinical exploration

BACKGROUND

Gender identity disorder (GID) is a distressing disorder characterized by a persistent unhappiness with one's own gender and a desire to be of the opposite gender as well as seeking sex reassignment surgery for the same. The aim of the study was to assess the Minnesota Multiphasic Personality Inventory (MMPI) profiles in patients with GID and compare with healthy normal population and also examine differences in the profiles based on original gender of the patients.

MATERIALS AND METHODS

A total of 56 patients with GID that fulfilled the Diagnostic and Statistical Manual of Mental Disorders 5 criteria for the same were participants of the study, and there were 54 control participants. They were administered the MMPI, and the scores across various scales were statistically analyzed.

RESULTS

It was seen that apart from masculinity feminity (Mf) scale, other scales such as Paranoia (Pa, P < 0.01), Schizophrenia (Sc, P = 0.01), and Psychopathic deviate (Pd, P < 0.01) were also elevated in many patients. Male patients seeking surgery to become female showed higher scores on Pa and Sc scales than female patients. On detailed inquiry, it was found that there was no evidence of psychosis clinically, and in fact, their paranoia was reality based.

CONCLUSION

MMPI profiles in patients with GID needs to interpreted with caution and clinicians must keep in mind that elevated Pa and Sc scales on the MMPI in these patients need not indicate a psychotic profile.

Gender dysphoria symptoms in schizophrenia

Gender dysphoria in individuals with schizophrenia may result from the delusionally changed gender identity or appear regardless of psychotic process. Distinguishing between these situations is not only a diagnostic challenge, but also affects the therapeutic decisionmaking. The review of the literature shows that different delusional beliefs regarding belonging to another gender, anatomy or changes within the genitals affect about one-fourth of patients with schizophrenia. Contemporary classifications of disorders are moving towards the elimination of psychotic disorders as a disqualifying criterion in diagnosing gender dysphoria. It is also established that schizophrenia may change the picture of gender dysphoria, e.g., by giving meaning and delusional interpretations of the fact of the incompatibility of phenotypic sex with the sense of gender. At the same time, before making a therapeutic decision (especially aimed at gender reassignment), it is necessary to exclude the psychotic background of the desire for gender reassignment. In case of co-occurrence of both disorders, it is crucial to evaluate the chronology and dynamics of the individual symptoms, their constancy (prolonged observation), patient's criticism and response to antipsychotic treatment.

Descriptive Study of Gender Dysphoria in Japanese Individuals with Male-to-Female Gender Identity Disorder

We focus on Japanese individuals with gender identity disorder (GID), especially male-to-female (MTF) GID, who have experienced difficulty in adapting to social life. We clarify what gender dysphoria is, and we examine methods of intervention. Semi-structured interviews were conducted with 11 individuals with MTF-GID from August 2015 to April 2017. We categorized the subjects'experiences regarding dysphoria into the 'Onset of gender dysphoria,' 'Experience of feeling gender dysphoria,' and 'Changes due to receiving medical care.' The subjects reported experiencing great pain and distress because they did not fully understand that they were experiencing dysphoria and could not align their gender identity and their self-identity. All subjects described their experiences of dysphoria as negative. Additionally, all said that the dysphoria was alleviated by a medical intervention such as visiting a gender clinic, receiving a diagnosis and treatment, and changing their physical sex to the sex congruent with their gender identity. The provision of information at the gender clinic and the physical changes achieved by medical intervention exerted a positive effect both mentally and socially on the subjects, who suffered various physical, mental and social problems.

Transgender Associations and Possible Etiology: A Literature Review

Transgender or gender dysphoria has been defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as distress resulting from the incongruence between one's experienced gender and one's assigned gender, along with a persistent and strong desire to be of another gender, and accompanied by clinically significant distress. Adolescents referred for evaluation often want hormonal therapy and several among them also express a desire for gender reassignment surgery. Furthermore, evidence shows that adolescents and adults with gender dysphoria without a sex development disorder, before gender reassignments, are at increased risk for suicide. For this review, a search of the English language scientific literature was conducted using the PubMed database. This summary discusses the associations and comorbidities of gender dysphoria and reiterates the evidence that its etiology is multifactorial. Transsexualism involves prenatal neuroanatomical changes, has a psychiatric association, and is found to be more prevalent in conjunction with schizophrenia and autism spectrum disorders. Childhood adversities and neglect are also linked to having a transgender identity. Moreover, the evidence favors a genetic predisposition. Likewise, there seems to be a growing concern with regards to the relationship between endocrine disruptors and transsexuals as well as other gender minority populations. More research needs to be done to understand the exact pathways.

Review of the Transgender Literature: Where Do We Go from Here?

Purpose: The “transgender tipping point” has brought transgender social and health issues to the forefront of American culture. However, medical professionals have been lagging in academic research with a transgender-specific focus resulting in significant knowledge gaps in dealing with the care of our transgender patients. The aim of this article is to analyze all published Medline-available transgender-specific articles, identify these knowledge gaps, and direct future research to where it is most needed.

Methods: We surveyed all Medline-available articles up to June 2016 using a combination of medical subject headings and keywords in titles and abstracts. Articles meeting inclusion criteria were reviewed, categorized, and analyzed for content and study design.

Results: In our review of the literature, we identified 2405 articles published from January 1950 to June 2016 that focused on transgender health, primarily in the fields of surgery, mental health, and endocrinology.

Conclusion: Significant knowledge gaps were found across the subspecialties, and there was a lack of prospective robust research and representation of transgender-specific data in the core medical journals. More data and research are needed to bridge the knowledge gaps that currently exist and improve the care of the transgender community.

Outcome and preferences in male-to-female subjects with gender dysphoria: Experience from Eastern India

CONTEXT

Gender dysphoria (GD) is an increasingly recognized medical condition in India, and little scientific data on treatment outcomes are available.

AIMS

Our objective is to study the therapeutic options including psychotherapy, hormone, and surgical treatments used for alleviating GD in male-to-female (MTF) transgender subjects in Eastern India.

SUBJECTS AND METHODS

This is a retrospective study of treatment preferences and outcome in 55 MTF transgender subjects who were presented to the endocrine clinic.

STATISTICAL ANALYSIS USED

Descriptive statistical analysis is carried out in the present study, and Microsoft Word and Excel are used to generate graphs and tables.

RESULTS

The mean follow-up was 1.9 years and 14 subjects (25.5%) were lost to follow-up after a single or 2-3 contact sessions. Rest 41 subjects (74.5%) desiring treatment had regular counseling and medical monitoring. All 41 subjects were dressing to present herself as female and all of them were receiving cross-sex hormone therapy either estrogen only (68%), or drospirenone in combination with estrogen (12%) or gonadotropin-releasing hormone agonist (GnRH) in combination with estrogens (19.5%). Most of the subjects preferred estrogen therapy as it was most affordable and only a small number of subjects preferred drospirenone or GnRH agonist because of cost and availability. 23.6% subjects underwent esthetic breast augmentation surgery and 25.5% underwent orchiectomy and/or vaginoplasty. Three subjects presented with prior breast augmentation surgery and nine subjects presented with prior orchiectomy without vaginoplasty, depicting a high prevalence of poorly supervised surgeries.

CONCLUSIONS

Standards of care documents provide clinical guidance for health professionals about the optimal management of transsexual people. The lack of information among health professionals about proper and protocolwise management leads to suboptimal physical, social, and sexual results.

Gender dysphoria and autism spectrum disorder: A narrative review

The current literature shows growing evidence of a link between gender dysphoria (GD) and autism spectrum disorder (ASD). This study reviews the available clinical and empirical data. A systematic search of the literature was conducted using the following databases: PubMed, Web of Science, PsycINFO and Scopus; utilizing different combinations of the following search terms: autism, autism spectrum disorder (ASD), Asperger's disorder (AD), co-morbidity, gender dysphoria (GD), gender identity disorder (GID), transgenderism and transsexualism. In total, 25 articles and reports were selected and discussed. Information was grouped by found co-occurrence rates, underlying hypotheses and implications for diagnosis and treatment. GD and ASD were found to co-occur frequently - sometimes characterized by atypical presentation of GD, which makes a correct diagnosis and determination of treatment options for GD difficult. Despite these challenges there are several case reports describing gender affirming treatment of co-occurring GD in adolescents and adults with ASD. Various underlying hypotheses for the link between GD and ASD were suggested, but almost all of them lack evidence.

Minnesota Multiphasic Personality Inventory-2 Profiles of Patients with Gender Identity Disorder Requesting Sex Reassignment Surgery

BACKGROUND

Gender identity disorder (GID) is a distressing disorder characterized by a persistent unhappiness with one's own sex and a desire to be of the opposite sex as well as seeking sex reassignment surgery for the same. The aim of the study was to assess the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) profiles in patients with GID and examine differences in the profiles based on original gender of the patients.

METHODOLOGY

Twenty-seven patients with GID that fulfilled the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision criteria for the same were participants of the study. They were administered the MMPI-2 and the scores across various scales were statistically analyzed. Before analysis, the sample was divided into groups according to gender, i.e., male-to-female and female-to-male patients who were requesting sex reassignment surgery.

RESULTS

No significant elevation of scores on any of the scales was noted in keeping with the fact that patients with GID usually demonstrate minimal psychopathology. All patients showed elevation on at least one subscale other than the masculinity-femininity subscale. No differences across gender were noted indicating that gender was probably not a determinant of psychopathology in GID.

CONCLUSIONS

MMPI-2 profiles in patients with GID failed to reveal major psychopathology though the MMPI still remains a useful tool in the assessment of this population.

Outcome and preferences in female-to-male subjects with gender dysphoria: Experience from Eastern India

CONTEXT

Awareness of gender dysphoria (GD) and its treatment is increasing. There is paucity of scientific data from India regarding the therapeutic options being used for alleviating GD, which includes psychotherapy, hormone, and surgical treatments.

AIM

To study the therapeutic options including psychotherapy, hormone, and surgical treatments used for alleviating GD.

SETTINGS AND DESIGN

This is a retrospective study of treatment preferences and outcome in 18 female-to-male (FTM) transgender subjects who presented to the endocrine clinic.

RESULTS

The mean follow-up was 1.6 years and only one subject was lost to follow-up after a single visit. All subjects desiring treatment had regular counseling and medical monitoring. All FTM subjects were cross-dressing. Seventeen (94.4%) FTM subjects were receiving cross-sex hormone therapy, in the form of testosterone only (61.1%) or gonadotropin-releasing hormone (GnRH) agonist in combination with testosterone (11.1%) or medroxyprogesterone acetate (MPA) depot in combination with testosterone (22.2%). FTM subjects preferred testosterone or testosterone plus MPA; very few could afford GnRH therapy. Testosterone esters injection was preferred by most (72.2%) subjects as it was most affordable while 22.2% chose 3 monthly injections of testosterone undecanoate for convenience and better symptomatic improvement, but it was more expensive. None preferred testosterone gels because of cost and availability concerns. About 33.3% of our subjects underwent mastectomy, 38.9% had hysterectomy with bilateral salpingo-oophorectomy, and only one subject underwent phalloplasty. About 16.7% of FTM subjects presented with prior mastectomy depicting a high prevalence of unsupervised or poorly supervised surgeries not following protocol wise approach.

CONCLUSION

Notwithstanding of advances in Standards of Care in the Western world, there is lack of awareness and acceptance in the FTM subjects, about proper and timely protocol-wise management options leading to suboptimal physical, social, and sexual results.

Ophthalmic Disparities in Transgender Patients

Transgender individuals experience unique challenges with regards to discrimination and access to health care. Further, their unique health-care needs and challenges lead to greater rates of morbidity. This article seeks to review the unique biology of transgender patients and the effects of cross-sex hormone therapy on ophthalmic and non-ophthalmic pathology. Attention is given to topics in neuro-ophthalmology, oculoplastics, and retinal disease.

Gender Dysphoria in Adults

Gender dysphoria (GD), a term that denotes persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder in the Diagnostic and Statistical Manual of Mental Disorders in 2013. Subtypes of GD in adults, defined by sexual orientation and age of onset, have been described; these display different developmental trajectories and prognoses. Prevalence studies conclude that fewer than 1 in 10,000 adult natal males and 1 in 30,000 adult natal females experience GD, but such estimates vary widely. GD in adults is associated with an elevated prevalence of comorbid psychopathology, especially mood disorders, anxiety disorders, and suicidality. Causal mechanisms in GD are incompletely understood, but genetic, neurodevelopmental, and psychosocial factors probably all contribute. Treatment of GD in adults, although largely standardized, is likely to evolve in response to the increasing diversity of persons seeking treatment, demands for greater client autonomy, and improved understanding of the benefits and limitations of current treatment modalities.

SEX REASSIGNMENT SURGERY WITH LAPAROSCOPIC SIGMOID COLON VAGINOPLASTY IN A MALE TO FEMALE TRANSSEXUAL: A CASE REPORT

We herein report and discuss our first experience about a sex reassignment surgery (SRS) with laparoscopic sigmoid colon vaginoplasty for a 40s male to female gender identity disorder. SRS for this subject included bilateral orchiectomy, penectomy, clitoroplasty, vaginoplasty, and vulvoplasty. About 20 cm of the sigmoid colon was harvested laparoscopicaly for the neovagina. Total operating time was about 9 hours, and the estimated blood loss was 900 ml without transfusion. There was no trouble during the postoperative course, and a sufficient length of vagina has been maintained.

Long-term follow-up of individuals undergoing sex reassignment surgery: Psychiatric morbidity and mortality

BACKGROUND

There is a lack of long-term register-based follow-up studies of sex-reassigned individuals concerning mortality and psychiatric morbidity. Accordingly, the present study investigated both mortality and psychiatric morbidity using a sample of individuals with transsexualism which comprised 98% (n = 104) of all individuals in Denmark.

AIMS

(1) To investigate psychiatric morbidity before and after sex reassignment surgery (SRS) among Danish individuals who underwent SRS during the period of 1978-2010. (2) To investigate mortality among Danish individuals who underwent SRS during the period of 1978-2010.

METHOD

Psychiatric morbidity and mortality were identified by data from the Danish Psychiatric Central Research Register and the Cause of Death Register through a retrospective register study of 104 sex-reassigned individuals.

RESULTS

Overall, 27.9% of the sample were registered with psychiatric morbidity before SRS and 22.1% after SRS (p = not significant). A total of 6.7% of the sample were registered with psychiatric morbidity both before and after SRS. Significantly more psychiatric diagnoses were found before SRS for those assigned as female at birth. Ten individuals were registered as deceased post-SRS with an average age of death of 53.5 years.

CONCLUSIONS

No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM) save for the total number of psychiatric diagnoses where FtM held a significantly higher number of psychiatric diagnoses overall. Despite the over-representation of psychiatric diagnoses both pre- and post-SRS the study found that only a relatively limited number of individuals had received diagnoses both prior to and after SRS. This suggests that generally SRS may reduce psychological morbidity for some individuals while increasing it for others.

Presentation of gender dysphoria: A perspective from Eastern India

CONTEXT

There is paucity of scientific data from India on gender identity disorders (GIDs) or gender dysphoria (GD).

AIMS

To study the clinical, biochemical profile, personality characteristics and family support of GID subjects.

SETTINGS AND DESIGN

A retrospective and cross-sectional study at an endocrine referral center in Kolkata in Eastern India between 2010 and 2015.

SUBJECTS AND METHODS

Seventy-three GID subjects who presented to the center were included in the study. Clinical, biochemical profile, personality characteristics (cross-dressing), and family support were investigated. The protocol was presented to the Ethics Committee who felt that given the retrospective nature of the study, informed consent could be dispensed with. GD was diagnosed by Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).

STATISTICAL ANALYSIS USED

Unpaired t-test has been used to find the significance of study parameters between two groups of patients. Chi-square/Fisher Exact test has been used to find the significance of study parameters on categorical scale between two groups.

RESULTS

Out of the total 73 patients, 55 (75.34%) patients were male-to-female and remaining 18 (24.66%) were female-to-male. Around 11% of GD subjects practiced cross-dressing. In spite of median age of onset of GD was 9 years, the mean age of GD at presentation was quite late at 25.77 ± 6.25 years due to lack of social and informative support. It is difficult for transgender to express their sexual identity in family or in society as only 10.96% of our GD subjects had family support, leading to delayed presentation and delayed endocrine consultation. This delayed endocrine consultation have accounted for a significant proportion of GD subjects having unplanned and ill-timed castration (16.36%) or mastectomy (16.67%) even by nonmedically qualified person (66.7% of castrated subjects). All GD subjects had normal thyroid stimulating hormone, testosterone, estradiol, and karyotype concordant with their biological sex. No significant differences were demonstrated between any of the studied parameters namely age at presentation, onset-age of GD, hormone profile, family support, and cross-dressing preferences.

CONCLUSIONS

Social taboo and lack of informative, family support leads to delayed medical consultation and have accounted for complexities in presentation indicating a huge need of awareness programs in our country. Social and informative support can be improved by awareness programs, which might lead to an early endocrine evaluation and proper treatment with improved outcomes.

[Legal aspects and the treatment procedure of gender dysphoria in Hungary]

The legal process of gender transition in Hungary had previously been more developed as in most European countries, as the law enabled transsexual people to change their name and gender before or without a medical treatment, which was unique at the time. Over the years, however, lots of European countries developed legal frameworks and accepted international standards of care for the treatment of gender dysphoria that Hungary did not follow. Currently in Hungary there is no consistent legal framework of gender transition, there is no official regulation or guidelines regarding gender transition process, no institution with the obligation to accommodate the process, and there is no nominated specialist in the state health care system whose remit included dealing with transsexual patients. The information on gender transition options both to the professionals and to the patients is limited and incoherent. This paper reviews the legal aspects and clinical management process of gender dysphoria in Hungary. Some issues regarding the Hungarian practice and possible solutions based on examples from the United Kingdom are addressed within the paper.

White matter microstructure in transsexuals and controls investigated by diffusion tensor imaging

Biological causes underpinning the well known gender dimorphisms in human behavior, cognition, and emotion have received increased attention in recent years. The advent of diffusion-weighted magnetic resonance imaging has permitted the investigation of the white matter microstructure in unprecedented detail. Here, we aimed to study the potential influences of biological sex, gender identity, sex hormones, and sexual orientation on white matter microstructure by investigating transsexuals and healthy controls using diffusion tensor imaging (DTI). Twenty-three female-to-male (FtM) and 21 male-to-female (MtF) transsexuals, as well as 23 female (FC) and 22 male (MC) controls underwent DTI at 3 tesla. Fractional anisotropy, axial, radial, and mean diffusivity were calculated using tract-based spatial statistics (TBSS) and fiber tractography. Results showed widespread significant differences in mean diffusivity between groups in almost all white matter tracts. FCs had highest mean diffusivities, followed by FtM transsexuals with lower values, MtF transsexuals with further reduced values, and MCs with lowest values. Investigating axial and radial diffusivities showed that a transition in axial diffusivity accounted for mean diffusivity results. No significant differences in fractional anisotropy maps were found between groups. Plasma testosterone levels were strongly correlated with mean, axial, and radial diffusivities. However, controlling for individual estradiol, testosterone, or progesterone plasma levels or for subjects' sexual orientation did not change group differences. Our data harmonize with the hypothesis that fiber tract development is influenced by the hormonal environment during late prenatal and early postnatal brain development.

Gender Dysphoria and Co-Occurring Autism Spectrum Disorders: Review, Case Examples, and Treatment Considerations

PURPOSE

Transgender and gender nonconforming people who fulfill diagnostic criteria for autism spectrum disorders (ASDs) often present to mental health providers with concerns that are distinct from those without ASDs. Gender Dysphoria (GD) and ASDs have been proposed to share etiologic mechanisms and there is evidence that ASDs may be more common in transgender and gender nonconforming people. We explore the impact of ASD characteristics on individual gender identity, expression, and the process of psychotherapy.

METHOD

The authors present two case studies of high-functioning individuals with ASD and GD diagnoses.

RESULTS

The limited ability to articulate an inner experience, deficits in Theory of Mind (ToM), along with the intolerance of ambiguity as a manifestation of the cognitive rigidity characteristic of ASDs, may present special difficulties to gender identity formation and consolidation and create challenges in psychotherapy.

CONCLUSIONS

The authors suggest that ASDs do not preclude gender transition and that individuals with high-functioning ASDs are capable of making informed decisions regarding their medical care and life choices. The authors also consider possible challenges and suggest techniques for assisting such clients in exploring their gender identities.

Management challenges in a case of gender identity disorder

Gender identity disorder (GID) is a complex disorder and can be defined as a group of disorders whose common feature is a strong and persistent preference for living as a person of the other sex. It is associated with significant impairment in social, occupational, interpersonal, and other areas of functioning. We describe the case of an adolescent, biologically male who was brought to our outpatient department primarily with symptoms of adjustment disorder with GID and the management provided. The role of a psychiatrist in the management, ethical and legal issues involved is also discussed.

Gender dysphoria - prevalence and co-morbidities in an irish adult population

INTRODUCTION

Gender dysphoria (GD) is a condition in which there is a marked incongruence between an individual's psychological perception of his/her sex and their biological phenotype. Gender identity disorder was officially renamed "gender dysphoria" in the DSM-V in 2013. The prevalence and demographics of GD vary according to geographical location and has not been well-documented in Ireland.

METHODS

We retrospectively reviewed medical records of 218 patients with suspected or confirmed GD referred to our endocrine service for consideration of hormonal therapy (HT) between 2005 and early 2014. We documented their demographics, clinical characteristics, and treatment during the study period.

RESULTS

The prevalence of GD in the Irish population was 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM), similar to reported figures in Western Europe. 159 of the patients were MTF and 59 were FTM, accounting for 72.9% and 27.1% of the cohort, respectively. The rate of referral has increased year-on-year, with 55 patients referred in 2013 versus 6 in 2005. Mean ages were 32.6 years (MTF) and 32.2 years (FTM). 22 of the patients were married and 41 had children, with 2 others having pregnant partners. 37.6% were referred by a psychologist, with the remainder evenly divided between GPs and psychiatric services. There were low rates of coexistent medical illness although psychiatric conditions were more prevalent, depression being a factor in 34.4% of patients. 5.9% of patients did not attend a mental health professional. 74.3% are currently on HT, and 9.17% have had gender reassignment surgery (GRS). Regret following hormonal or surgical treatment was in line with other Western European countries (1.83%).

CONCLUSION

The incidence of diagnosis and referral of GD in Ireland is increasing. This brings with it multiple social, health, and financial implications. Clear and accessible treatment pathways supported by mental health professionals is essential.

Treatment of anorexia nervosa in the context of transsexuality: a case report

Males comprise a minority of patients with eating disorders (ED). However, men who have sex with men, males with gender identity disorder, and transsexual (TS) males are at increased risk for ED. Little has been published about the unique treatment needs of TS patients with ED. A 19-year-old male-to-female TS patient presented with restrictive eating, purging, and weight loss. History revealed that her ED ideation and behaviors were strongly intertwined with her gender identity. She was admitted and during her hospitalization both her ED and TS status were addressed medically. Physicians treating patients with ED should be aware of patients' gender identities and the ways in which gender identity may impact management and recovery. When appropriate, providers should consider addressing medical treatment toward gender transition concurrently with treatment for ED to facilitate medical stabilization and weight restoration in the manner most consistent with the patient's identified gender.

Care of the transgender patient: the role of the gynecologist

Gender dysphoria refers to distress that is caused by a sense of incongruity between an individual's self-identified gender and natal sex. Diagnosis is made in accordance with the Diagnostic and Statistical Manual of Mental Disorders and treatment first involves psychiatric therapy, which can help determine a patient's true goals in regards to achieving gender identity. Patients who wish to transition to the opposite sex must undergo a supervised real-life test and often are treated with hormonal therapy to develop physical characteristics consistent with their gender identity. Sex reassignment surgery is an option for patients who wish to transition completely. Transpatients face many barriers when it comes to basic health needs including education, housing, and health care. This is a result of long-standing marginalization and discrimination against this community. Because of these barriers, many patients do not receive the proper health care that they need. Additionally, because of certain high-risk behaviors as well as long-term hormonal therapy, transpatients have different routine health care needs that should be addressed in the primary care setting. Gynecologists play an important role in caring for transgender patients and should be knowledgeable about the general principles of transgender health.

Self-perception in a clinical sample of gender variant children

BACKGROUND

Gender variance (GV) in childhood has a negative impact on the self-concept of children in the general population and can lead to mental health problems and even suicidal ideation in adulthood. This study explored the self-concept of clinically referred gender variant children and examined potential risk factors.

METHOD

The Self-Perception Profile for Children was administered to 147 children, who were referred to a gender identity clinic. Their parents completed the Child Behaviour Checklist and the Gender Identity Questionnaire to assess the degree of GV.

RESULTS

The referred children were at risk of developing a negative self-concept; more specifically gender variant girls had low scores on 'global self-worth', 'physical appearance' and 'behavioural conduct' compared to Dutch norms for girls. Gender variant boys had low scores on 'global self-worth', 'scholastic competence', 'athletic competence' and 'physical appearance' compared to Dutch norms for boys. Within the group of referred children, sex differences, but no age effects, were found. The referred girls felt more competent than the referred boys on 'athletic competence' and 'scholastic functioning'. For both boys and girls poor peer relations had a significant negative relationship with self-concept and more GV was related to a lower global self-worth.

CONCLUSIONS

Clinically referred gender variant children seemed vulnerable to developing a negative self-concept. Poor peer relations and extreme GV might be mediating variables. Interventions might focus on enhancing acceptance of the environment and improving social skills of gender variant children.

Lay theories of gender identity disorder

This study examined lay theories regarding gender identity disorder (GID). Pilot interviews were completed with participants (n = 10) regarding their views on possible causes and treatments of GID. Participants (mainly young British people and students; n = 124) then completed a questionnaire that was based on the interviews and a review of the salient literature on lay theories. As hypothesized, participants believed most in biomedical causes and treatments of GID. Factor analysis (with varimax rotation) identified 4 factors in relation to causes of GID: upbringing and personal factors, pregnancy and brain abnormalities, environmental factors, and biomedical causes. Five factors that were identified in relation to the cure/treatment of GID were psychological assistance and personal factors, extreme medical and behavioral changes, alternative therapies, external factors, and medical treatments. The results indicated that participants neither agreed nor strongly disagreed about causes and cures regarding GID, but that these beliefs were logically related. Limitations, particularly of sampling, were considered.

Sibling sex ratio and birth order in early-onset gender dysphoric adolescents

Several sibship-related variables have been studied extensively in sexual orientation research, especially in men. Sibling sex ratio refers to the ratio of brothers to sisters in the aggregate sibships of a group of probands. Birth order refers to the probands' position (e.g., first-born, middle-born, last-born) within their sibships. Fraternal birth order refers to their position among male siblings only. Such research was extended in this study to a large group of early-onset gender dysphoric adolescents. The probands comprised 94 male-to-female and 95 female-to-male gender dysphoric adolescents. The overwhelming majority of these were homosexual or probably prehomosexual. The control group consisted of 875 boys and 914 girls from the TRAILS study. The sibling sex ratio of the gender dysphoric boys was very high (241 brothers per 100 sisters) compared with the expected ratio (106:100). The excess of brothers was more extreme among the probands' older siblings (300:100) than among their younger siblings (195:100). Between-groups comparisons showed that the gender dysphoric boys had significantly more older brothers, and significantly fewer older sisters and younger sisters, than did the control boys. In contrast, the only notable finding for the female groups was that the gender dysphoric girls had significantly fewer total siblings than did the control girls. The results for the male probands were consistent with prior speculations that a high fraternal birth order (i.e., an excess of older brothers) is found in all homosexual male groups, but an elevated sibling sex ratio (usually caused by an additional, smaller excess of younger brothers) is characteristic of gender dysphoric homosexual males. The mechanisms underlying these phenomena remain unknown.

The eunuchs of India: An endocrine eye opener

There are established guidelines for the endocrine and overall treatment of transsexual persons. These guidelines provide information about the optimal endocrine management of male-to-female and female-to-male transsexual persons. India has a large community of eunuchs, also known as hijras, who are men with gender identity disorders. While this community has been studied from a social and medical point of new, no endocrine work has been done in them. This exploratory article tries to discuss the endocrine status, health, and management of the eunuchs.

Puberty suppression in a gender-dysphoric adolescent: a 22-year follow-up

Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13 years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22 years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.

A further assessment of Blanchard's typology of homosexual versus non-homosexual or autogynephilic gender dysphoria

In a series of important but now highly controversial articles, Blanchard examined associations of sexual orientation and transvestic fetishism among male-to-female (MTF) transgender persons in Toronto, Canada. Transvestic fetishism was rare among the homosexuals but prevalent among the non-homosexuals. Subtypes of non-homosexual MTFs (heterosexual, bisexual, and asexual) were consistently high with regard to transvestic fetishism. Non-linear associations of a continuous measurement of sexual attraction to women (gynephilia) and transvestic fetishism were interpreted in terms of an etiological hypothesis in which transvestic fetishism interferes with the early development of heterosexuality. Blanchard concluded that homosexual versus non-homosexual sexual orientation is a dominant and etiologically significant axis for evaluating and understanding this population. We further assessed these findings among 571 MTFs from the New York City metropolitan area. Using the Life Chart Interview, multiple measurements of transvestic fetishism were obtained and classified as lifetime, lifecourse persistent, adolescent limited, and adult onset. Large (but not deterministic) differences in lifetime, lifecourse persistent, and adolescent limited transvestic fetishism were found between the homosexuals and non-homosexuals. Contrary to Blanchard, differences in transvestic fetishism were observed across subtypes of the non-homosexuals, and linear (not curvilinear) associations were found along a continuous measurement of gynephilia and transvestic fetishism. Age and ethnicity, in addition to sexual orientation, were found to be statistically significant predictors of transvestic fetishism. The clinical, etiological, and sociopolitical implications of these findings are discussed.

Autism spectrum disorders in gender dysphoric children and adolescents

Only case reports have described the co-occurrence of gender identity disorder (GID) and autism spectrum disorders (ASD). This study examined this co-occurrence using a systematic approach. Children and adolescents (115 boys and 89 girls, mean age 10.8, SD = 3.58) referred to a gender identity clinic received a standardized assessment during which a GID diagnosis was made and ASD suspected cases were identified. The Dutch version of the Diagnostic Interview for Social and Communication Disorders (10th rev., DISCO-10) was administered to ascertain ASD classifications. The incidence of ASD in this sample of children and adolescents was 7.8% (n = 16). Clinicians should be aware of co-occurring ASD and GID and the challenges it generates in clinical management.

From mental disorder to iatrogenic hypogonadism: dilemmas in conceptualizing gender identity variants as psychiatric conditions

The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

Peer group status of gender dysphoric children: a sociometric study

In this sociometric study, we aimed to investigate the social position of gender-referred children in a naturalistic environment. We used a peer nomination technique to examine their social position in the class and we specifically examined bullying and victimization of gender dysphoric children. A total of 28 children (14 boys and 14 girls), referred to a gender identity clinic, and their classmates (n = 495) were included (M age, 10.5 years). Results showed that the gender-referred children had a peer network of children of the opposite sex. Gender-referred boys had more nominations on peer acceptance from female classmates and less from male classmates as compared to other male classmates. Gender-referred girls were more accepted by male than by female classmates and these girls had significantly more male friends and less female friends. Male classmates rejected gender-referred boys more than other boys, whereas female classmates did not reject the gender-referred girls. For bullying and victimization, we did not find any significant differences between the gender-referred boys and their male classmates nor between the gender-referred girls and their female classmates. In sum, at elementary school age, the relationships of gender dysphoric children with opposite-sex children appeared to be better than with same-sex children. The social position of gender-referred boys was less favorable than that of gender-referred girls. However, the gender-referred children were not more often bullied than other children, despite their gender nonconforming behavior.

Androgen receptor repeat length polymorphism associated with male-to-female transsexualism

BACKGROUND

There is a likely genetic component to transsexualism, and genes involved in sex steroidogenesis are good candidates. We explored the specific hypothesis that male-to-female transsexualism is associated with gene variants responsible for undermasculinization and/or feminization. Specifically, we assessed the role of disease-associated repeat length polymorphisms in the androgen receptor (AR), estrogen receptor beta (ERbeta), and aromatase (CYP19) genes.

METHODS

Subject-control analysis included 112 male-to-female transsexuals and 258 non-transsexual males. Associations and interactions were investigated between CAG repeat length in the AR gene, CA repeat length in the ERbeta gene, and TTTA repeat length in the CYP19 gene and male-to-female transsexualism.

RESULTS

A significant association was identified between transsexualism and the AR allele, with transsexuals having longer AR repeat lengths than non-transsexual male control subjects (p=.04). No associations for transsexualism were evident in repeat lengths for CYP19 or ERbeta genes. Individuals were then classified as short or long for each gene polymorphism on the basis of control median polymorphism lengths in order to further elucidate possible combined effects. No interaction associations between the three genes and transsexualism were identified.

CONCLUSIONS

This study provides evidence that male gender identity might be partly mediated through the androgen receptor.

Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies

INTRODUCTION

Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric comorbidity. Their clinical course is highly variable. There is controversy at present over theoretical explanations of the causes of GID and over treatment approaches, particularly with respect to early hormonal intervention strategies.

METHODS

This review is based on a selective Medline literature search, existing national and international guidelines, and the results of a discussion among experts from multiple relevant disciplines.

RESULTS

As there have been no large studies to date on the course of GID, and, in particular, no studies focusing on causal factors for GID, the evidence level for the various etiological models that have been proposed is generally low. Most models of these disorders assume that they result from a complex biopsychosocial interaction. Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism. The current state of research on this subject does not allow any valid diagnostic parameters to be identified with which one could reliably predict whether the manifestations of GID will persist, i.e., whether transsexualism will develop with certainty or, at least, a high degree of probability.

CONCLUSIONS

The types of modulating influences that are known from the fields of developmental psychology and family dynamics have therapeutic implications for GID. As children with GID only rarely go on to have permanent transsexualism, irreversible physical interventions are clearly not indicated until after the individual's psychosexual development ist complete. The identity-creating experiences of this phase of development should not be restricted by the use of LHRH analogues that prevent puberty.

The controversy surrounding "The man who would be queen": a case history of the politics of science, identity, and sex in the Internet age

In 2003, psychology professor and sex researcher J. Michael Bailey published a book entitled The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism. The book's portrayal of male-to-female (MTF) transsexualism, based on a theory developed by sexologist Ray Blanchard, outraged some transgender activists. They believed the book to be typical of much of the biomedical literature on transsexuality-oppressive in both tone and claims, insulting to their senses of self, and damaging to their public identities. Some saw the book as especially dangerous because it claimed to be based on rigorous science, was published by an imprint of the National Academy of Sciences, and argued that MTF sex changes are motivated primarily by erotic interests and not by the problem of having the gender identity common to one sex in the body of the other. Dissatisfied with the option of merely criticizing the book, a small number of transwomen (particularly Lynn Conway, Andrea James, and Deirdre McCloskey) worked to try to ruin Bailey. Using published and unpublished sources as well as original interviews, this essay traces the history of the backlash against Bailey and his book. It also provides a thorough exegesis of the book's treatment of transsexuality and includes a comprehensive investigation of the merit of the charges made against Bailey that he had behaved unethically, immorally, and illegally in the production of his book. The essay closes with an epilogue that explores what has happened since 2003 to the central ideas and major players in the controversy.

Secondary gender identity disorder - a case report

An eighteen year old Christian male, diagnosed as Bipolar Affective Disorder, 2nd manic episode with mood congruent psychotic features presented during the episode with the explicit wish for sex reassignment surgery. He even claimed to be married to a local man. With effective management of the manic episode, his wish for sex reassignment surgery has completely subsided. This report discusses the literature regarding secondary gender identity disorder occurring in psychotic conditions and further implications of the same.

Behavior therapy for transsexualism

Transsexualism is a rare disorder, and there is little literature available on its treatment. A case is presented of transsexualism with homosexual orientation in a 24 year old male. Since the disorder appeared to have behavioral antecedents, it was treated with a behavior therapy package comprising relaxation, aversion therapy with aversion relief, modelling, hypnosis, orgasmic reconditioning, behavioral counselling and sex education. Therapy resulted in normalization of gender identity, but the homosexual orientation persisted.