Giuseppina Rametti d,f , Beatriz Carrillo b , Esther Gómez-Gil c , Carme Junque b,f , Santiago Segovia a , Ángel Gomez e , Antonio Guillamon a,*

ABSTRACT

Background: Some gray and white matter regions of the brain are sexually dimorphic. The best MRI technique for identifying subtle differences in white matter is diffusion tensor imaging (DTI). The purpose of this paper is to investigate whether white matter patterns in female to male (FtM) transsexuals before commencing cross-sex hormone treatment are more similar to that of their biological sex or to that of their gender identity. Method: DTI was performed in 18 FtM transsexuals and 24 male and 19 female heterosexual controls scanned with a 3 T Trio Tim Magneton. Fractional anisotropy (FA) was performed on white matter fibers of the whole brain, which was spatially analyzed using Tract-Based Spatial Statistics. Results: In controls, males have significantly higher FA values than females in the medial and posterior parts of the right superior longitudinal fasciculus (SLF), the forceps minor, and the corticospinal tract. Compared to control females, FtM showed higher FA values in posterior part of the right SLF, the forceps minor and corticospinal tract. Compared to control males, FtM showed only lower FA values in the corticospinal tract. Conclusions: Our results show that the white matter microstructure pattern in untreated FtM transsexuals is closer to the pattern of subjects who share their gender identity (males) than those who share their biological sex (females). Our results provide evidence for an inherent difference in the brain structure of FtM transsexuals.

White matter microstructure in female to male transsexuals before cross-sex hormonal treatment. A diffusion tensor imaging study

Giuseppina Rametti d,f , Beatriz Carrillo b , Esther Gómez-Gil c , Carme Junque b,f , Leire Zubiarre-Elorza b , Santiago Segovia a , Ángel Gomez e , Antonio Guillamon a,*

ABSTRACT

Background: Diffusion tensor imaging (DTI) has been shown to be sensitive in detecting white matter differences between sexes. Before cross-sex hormone treatment female to male transsexuals (FtM) differ from females but not from males in several brain fibers. The purpose of this paper is to investigate whether white matter patterns in male to female (MtF) transsexuals before commencing cross-sex hormone treatment are also more similar to those of their biological sex or whether they are more similar to those of their gender identity. Method: DTI was performed in 18 MtF transsexuals and 19 male and 19 female controls scanned with a 3 T Trio Tim Magneton. Fractional anisotropy (FA) was performed on white matter of the whole brain, which was spatially analyzed using Tract-Based Spatial Statistics. Results: MtF transsexuals differed from both male and female controls bilaterally in the superior longitudinal fasciculus, the right anterior cingulum, the right forceps minor, and the right corticospinal tract. Conclusions: Our results show that the white matter microstructure pattern in untreated MtF transsexuals falls halfway between the pattern of male and female controls. The nature of these differences suggests that some fasciculi do not complete the masculinization process in MtF transsexuals during brain development.

The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI study

Giuseppina Rametti d,f , Beatriz Carrillo a , Esther Go´mez-Gil c , Carme Junque b,f , Leire Zubiaurre-Elorza b,f , Santiago Segovia a , A´ngel Gomez e , Kazmer Karadi g , Antonio Guillamon a, *

ABSTRACT

Diffusion tensor imaging (DTI) can sensitively detect white matter sex differences and the effects of pharmacological treatments. Before cross-sex hormone treatment, the white matter microstructure ofseveral brain bundlesin female-to-male transsexuals (FtMs) differsfrom those in females but not from that in males. The purpose of this study was to investigate whether cross-sex hormone treatment (androgenization) affects the brain white matter microstructure. Using a Siemens 3 T Trio Tim Magneton, DTI was performed twice, before and during cross-sex hormonal treatment with testosterone in 15 FtMs scanned. Fractional anisotropy (FA) was analyzed on white matter of the whole brain, and the latter was spatially analyzed using Tract-Based Spatial Statistics. Before each scan the subjects were assessed for serum testosterone, sex hormone binding globulin level (SHBG), and their free testosterone index. After at least seven months of cross-gender hormonal treatment, FA values increased in the right superior longitudinal fasciculus (SLF) and the right corticospinal tract (CST) in FtMs compared to their pretreatment values. Hierarchical regression analyses showed that the increments in the FA values in the SLF and CST are predicted by the free testosterone index before hormonal treatment. All these observations suggest that testosterone treatment changes white matter microstructure in FtMs.

Effects of androgenization on the white matter microstructure of female-to-male transsexuals. A diffusion tensor imaging study

Jessica Hamzelou

ABSTRACT

Differences in the brain’s white matter that clash with a person’s genetic sex may hold the key to identifying transsexual people before puberty. Doctors could use this information to make a case for delaying puberty to improve the success of a sex change later.

Transsexual differences caught on brain scan fra 2011

Ditte Slabbekoorn, Stephanie H.M. Van Goozen, Louis J.G. Gooren, Peggy T. Cohen-Kettenis

ABSTRACT

The aim of the study was to investigate whether cross-sex hormone treatment in transsexuals affected the intensity of negative and positive emotions in general, and aggressive and sexual feelings in particular. With respect to emotional behavior, changes in non-verbal expressiveness and anger readiness were examined in 47 female-to-male transsexuals (FtMs) and 54 male-to-female transsexuals (MtFs). We were also interested in finding out whether, in FtMs, the rapidly changing testosterone levels in the two-week cycle testosterone treatment had predictable effects on moods, the development of male physical characteristics and sexuality.

Keywords: sex hormones, transsexuals, emotionality, sexuality, aggression.

Effects of Cross-Sex Hormone Treatment on Emotionality in Transsexuals

Wylie C. Hembree,1 Peggy T. Cohen-Kettenis,2 Louis Gooren,3 Sabine E. Hannema,4 Walter J. Meyer,5 M. Hassan Murad,6 Stephen M. Rosenthal,7 Joshua D. Safer,8 Vin Tangpricha,9 and Guy G. T’Sjoen10

ABSTRACT

Objective:

To update the “Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2009. Participants: The participants include an Endocrine Society–appointed task force of nine experts, a methodologist, and a medical writer.

Evidence:

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. Consensus

Process:

Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.

Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline

Andreas Hahn1 , Georg S. Kranz1 , Ronald Sladky2 , Ulrike Kaufmann3 , Sebastian Ganger1 , Allan Hummer2 , Rene Seiger1 , Marie Spies1 , Thomas Vanicek1 , Dietmar Winkler1 , Siegfried Kasper1 , Christian Windischberger2 , Dick F. Swaab4 , Rupert Lanzenberger1

ABSTRACT

The sex steroid hormone testosterone exhibits a substantial influence on behavior and cognition via the modulation of underlying brain structures and function. Testosterone plays a particular role in language function, showing associations with vocabulary and sexually dimorphic gray matter regions [1]. However, the majority of studies are limited to cross-sectional investigations or single hormone applications due to ethical reasons. Here, we assessed the influence of continuous high-dose testosterone treatment on brain structure and function in female-to-male (FtM) transsexuals before and after start of hormone therapy.

Neuronal plasticity of language-related brain regions induced by long-term testosterone treatment

Dr. Courtney Finlayson

E-bok

Offering current guidelines on the relatively new practice of puberty suppression for gender-dysphoric adolescents, Pubertal Suppression in Transgender Youth provides a succinct, easy-to-digest overview of this timely topic. This concise, clinically-focused resource by Dr. Courtney Finlayson covers all relevant topics, from a brief history of medical care of transgender youth to emerging developments in the field.

Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study.

Chew D¹, Anderson J², Williams K^1,3,4, May T^1,3,4,5, Pang K^6,3

ABSTRACT

CONTEXT:

Hormonal interventions are being increasingly used to treat young people with gender dysphoria, but their effects in this population have not been systematically reviewed before.

OBJECTIVE:

To review evidence for the physical, psychosocial, and cognitive effects of gonadotropin-releasing hormone analogs (GnRHa), gender-affirming hormones, antiandrogens, and progestins on transgender adolescents.

DATA SOURCES:

We searched Medline, Embase, and PubMed databases from January 1, 1946, to June 10, 2017.

STUDY SELECTION:

We selected primary studies in which researchers examined the hormonal treatment of transgender adolescents and assessed their psychosocial, cognitive, and/or physical effects.

DATA EXTRACTION:

Two authors independently screened studies for inclusion and extracted data from eligible articles using a standardized recording form.

RESULTS:

Thirteen studies met our inclusion criteria, in which researchers examined GnRHas (n = 9), estrogen (n = 3), testosterone (n = 5), antiandrogen (cyproterone acetate) (n = 1), and progestin (lynestrenol) (n = 1). Most treatments successfully achieved their intended physical effects, with GnRHas and cyproterone acetate suppressing sex hormones and estrogen or testosterone causing feminization or masculinization of secondary sex characteristics. GnRHa treatment was associated with improvement across multiple measures of psychological functioning but not gender dysphoria itself, whereas the psychosocial effects of gender-affirming hormones in transgender youth have not yet been adequately assessed.

LIMITATIONS:

There are few studies in this field and they have all been observational.

CONCLUSIONS:

Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking. Future research to address these knowledge gaps and improve understanding of the long-term effects of these treatments is required.

Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review.

Lieke Josephina Jeanne Johanna Vrouenraets, M.Sc. a,*, A. Miranda Fredriks, M.D., Ph.D. a , Sabine E. Hannema, M.D., Ph.D. b , Peggy T. Cohen-Kettenis, Ph.D. c , and Martine C. de Vries, M.D., Ph.D. b

ABSTRACT

Keywords:

Gender dysphoria, Puberty suppression, Adolescents, Ethics, Qualitative study, Interviews, Questionnaires, Worldwide

Early Medical Treatment of Children and Adolescents With Gender Dysphoria- An Empirical Ethical Study

Martin den Heijer professor of endocrinology 1 2, Alex Bakker transgender man with 20 years of experience taking hormonal treatment, Louis Gooren emeritus professor in transgender medicine 2

ABSTRACT

Long term hormonal treatment for transgender people

Noor Beckwith,1,2 Sari L. Reisner,2–5 Shayne Zaslow,3,6 Kenneth H. Mayer,2,3,7 and Alex S. Keuroghlian1–3,*

ABSTRACT

Factors Associated with Gender-Affirming Surgery and Age of Hormone Therapy Initiation Among Transgender Adults

Sari L. Reisner, ScD, MA,^1,2 Ralph Vetters, MD, MPH,³ M Leclerc, MPH,⁴ Shayne Zaslow, MA, MS,²Sarah Wolfrum, MPH,² Daniel Shumer, MD,⁵ and Matthew J. Mimiaga, ScD, MPH^1,2,6

ABSTRACT

Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study

ABSTRACT

Transgender women: Evaluation and management

Jordan D. Frey, M.D. Grace Poudrier, B.A. Michael V. Chiodo, M.D. Alexes Hazen, M.D.

ABSTRACT

Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery (alternatively, gender reassignment surgery, sexual reassignment surgery, or gender-affirming surgery). This review presents a robust overview of genital reconstruction in the female-to-male transgender patient—an operation that, historically, was seldom performed and has remained less surgically feasible than its counterpart (male-to-female genital reconstruction).

However, as the visibility and public awareness of the trans community continues to increase, the demand for plastic surgeons equipped to perform these reconstructions is rising. The “ideal” neophallus is aesthetic, maintains tactile and erogenous sensibility, permits sexual function and standing urination, and possesses minimal donor-site and operative morbidity. This article reviews current techniques for surgical construction, including metoidioplasty and phalloplasty, with both pedicled and free flaps. Emphasis is placed on the variety of techniques available for constructing a functional neophallus and neourethra. Preparative procedures (such as vaginectomy, hysterectomy, and oophorectomy) and adjunctive reconstructive procedures (including scrotoplasty and genital prosthesis insertion) are also discussed. (Plast. Reconstr. Surg. 139: 728, 2017.)

An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature.46

Stan Monstrey, M.D., Ph.D. Gennaro Selvaggi, M.D. Peter Ceulemans, M.D. Koen Van Landuyt, M.D. Cameron Bowman, M.D. Phillip Blondeel, M.D., Ph.D. Moustapha Hamdi, M.D. Griet De Cuypere, M.D.

ABSTRACT

: In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy.

Methods:

A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure.

Results:

The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating.

Conclusions:

Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated. (Plast. Reconstr. Surg. 121: 849, 2008.)

Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm

Ralph R. Chesson, MD, c David A. Gilbert, MD, a Gerald H. Jordan, MD, b Steven M. Schlossberg, MD, b Gerald T. Ramsey, PhD, and Deborah M. Gilbert, RN ~ Norfolk, Virginia

ABSTRACT

OBJECTIVE:

Transsexual surgery is an unique area of rarely performed surgery. This study examines factors that have significance in the prevention of major morbidity in this unusual surgery. The role of the gynecologist in the psychologic, endocrine, and operative management is presented.

STUDY DESIGN:

Initial operations were complicated by fistulas at the urethra-to-phallus anastomosis site. After reviewing these complications, we modified our approach to include a two-stage procedure allowing for healing before microsurgery and sparing of the anterior vag!nal wall during vaginal hysterectomy and colpocleisis. By sparing the anterior vaginal wall, we were able to better extend the urethra for later phallus attachment.

RESULTS;

Using the two-stage procedure at colpocleisis allowed a significant reduction in the fistula rate. (p = 0.0087) with the effective elimination-fistulas, the use of stiffeners during phalloplasty for better functional results is possible.

CONCLUSION:

Extending the urethra during colpocteisis allows for better healing and significantly decreased fistula formation. Proper blood supply for microvascular surgery and adequate tissue for the anastomosis site contribute to better results. (Am J Obstet Gynecol 1996;175:1443-50.)

Key words:

Transsexual surgery, colpocleisis, anterior vaginal wall extension, phalloplasty

The role of colpocleisis transsexual phalloplasty with urethral lengthening in

Albert Leriche, Marc-Olivier Timsit, Nicolas Morel-Journel, André Bouillot, Diala Dembele and Alain Ruffion Department of Urology, Henry Gabrielle Hospital, University of Lyon I, Lyon, France

ABSTRACT

OBJECTIVE

To assess the long-term outcome of forearm free-flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in femaleto-male transsexuals is a surgical challenge.

PATIENTS AND METHODS

We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free-flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction.

RESULTS

The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy.

CONCLUSION

Our study shows that phalloplasty with a forearm free-flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.

KEYWORDS transsexualism, gender identity, surgical flap, penis surgery, urethra surgery, penile prosthesis

Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism

E-bok

This issue of Clinics in Plastic Surgery, guest edited by Loren Schechter and Bauback Safa, is devoted to Gender Confirmation Surgery. Articles in this issue include: Multidisciplinary Care and The Standards of Care for Transgender and Gender Non-conforming Individuals; Primary Care of Transgender and Gender Non-conforming Individuals; Mental Health Evaluation for Transgender and Gender Non-conforming Individuals; Hormonal Management for Transfeminine Individuals; Hormonal Management for Transmasculine Individuals; Facial Feminization; Breast and Body Contouring for Transgender and Gender Non-conforming Individuals; Penile inversion; Intestinal Vaginoplasty; Vaginoplasty Complications; Chest Surgery for Transgender and Gender Non-conforming Individuals; Metoidioplasty; Introduction to Phalloplasty; Radial Forearm; AnteroLateral Thigh flap (ALT); Penile Prostheses; Flap-related Complications; Urologic Complications; and Sexual Health after Surgery.

Gender Confirmation Surgery, An Issue of Clinics in Plastic Surgery, E-Book (The Clinics: Surgery)

M. Doornaert 1, P. Hoebeke 2, P. Ceulemans 1, G. T ’ Sjoen 3, G. Heylens 4, S. Monstrey 1

ABSTRACT

Background:

Many methods and many free or pedicled flaps have been used in phalloplasty. None of these techniques is able to completely fulfill the well described goals in penile reconstruction. Still, the radial forearm flap is currently the most frequently used fl ap and thus universally considered the gold standard.

Patients and Methods:

Since 1992, we have performed the largest series of 316 radial forearm phalloplasties to date performed by a single surgical team. From these extensive data we critically evaluate how this current supposed gold standard can meet the requirements of an ideal penile reconstruction.

Results:

We assessed outcome parameters such as number of procedures to achieve complete functional result, aesthetic outcome, tactile and erogenous sensation, voiding, donor site morbidity, scrotoplasty and sexual intercourse.

Conclusion:

While currently no controlled randomized prospective studies are available to prove the radial forearm flap is truly the gold standard in penile reconstruction, we believe that our retrospective data support the radial forearm phalloplasty as a very reliable technique for the creation of a normal looking penis and scrotum. While full functionality is achieved through a minimum of 2 procedures, the patients are always able to void standing, and in most cases to experience sexual satisfaction. The relative disadvantages of this technique are the residual scar on the forearm donor site, the rather high number of initial urinary fistulas, the potential for long-term urological complications and the need for a stiff ener or erection prosthesis. From our experience, we strongly feel that a structured multi-disciplinary cooperation between the reconstructive-plastic surgeon and the urologist is an absolute requisite to obtain the best possible technical results.

Penile Reconstruction with the Radial Forearm Flap: An Update

Stan Monstrey, M.D., Ph.D. Piet Hoebeke, M.D., Ph.D. Gennaro Selvaggi, M.D. Peter Ceulemans, M.D. Koen Van Landuyt, M.D., Ph.D. Phillip Blondeel, M.D., Ph.D. Moustapha Hamdi, M.D., Ph.D. Nathalie Roche, M.D. Steven Weyers, M.D. Griet De Cuypere, M.D. Ghent, Belgium

ABSTRACT

Background:

The ideal goals in penile reconstruction are well described, but the multitude of flaps used for phalloplasty only demonstrates that none of these techniques is considered ideal. Still, the radial forearm flap is the most frequently used flap and universally considered as the standard technique.

Methods:

In this article, the authors describe the largest series to date of 287 radial forearm phalloplasties performed by the same surgical team. Many different outcome parameters have been described separately in previously published articles, but the main purpose of this review is to critically evaluate to what degree this supposed standard technique has been able to meet the ideal goals in penile reconstruction.

Results:

Outcome parameters such as number of procedures, complications, aesthetic outcome, tactile and erogenous sensation, voiding, donor-site morbidity, scrotoplasty, and sexual intercourse are assessed.

Conclusions:

In the absence of prospective randomized studies, it is not possible to prove whether the radial forearm flap truly is the standard technique in penile reconstruction. However, this large study demonstrates that the radial forearm phalloplasty is a very reliable technique for the creation, mostly in two stages, of a normal-appearing penis and scrotum, always allowing the patient to void while standing and in most cases also to experience sexual satisfaction. The relative disadvantages of this technique are the rather high number of initial fistulas, the residual scar on the forearm, and the potential long-term urologic complications. Despite the lack of actual data to support this statement, the authors feel strongly that a multidisciplinary approach with close cooperation between the reconstructive/plastic surgeon and the urologist is an absolute requisite for obtaining the best possible results. (Plast. Reconstr. Surg. 124: 510, 2009.)

Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?

Shane D. Morrison, M.D., M.S. Afaaf Shakir, B.S. Krishna S. Vyas, M.D., M.H.S. Johanna Kirby, B.S. Curtis N. Crane, M.D. Gordon K. Lee, M.D. Seattle, Wash.; Palo Alto and San Francisco, Calif.; and Lexington, Ky.

ABSTRACT

Background:

Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes.

Methods:

A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected.

Results:

A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.

Conclusions:

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients. (Plast. Reconstr. Surg. 138: 594, 2016.)

Phalloplasty: A Review of Techniques and Outcomes

Gennaro Selvaggi, MD,* Stan Monstrey, MD, PhD,* Peter Ceulemans, MD,* Guy T’Sjoen, MD,‡ Griet De Cuypere, MD,§ and Piet Hoebeke, MD, PhD†

ABSTRACT

Background:

Tactile and erogenous sensitivity in reconstructed genitals is one of the goals in sex reassignment surgery. Since November 1993 until April 2003, a total of 105 phalloplasties with the radial forearm free flap and 127 vaginoclitoridoplasties with the inverted penoscrotal skin flap and the dorsal glans pedicled flap have been performed at Ghent University Hospital. The specific surgical tricks used to preserve genital and tactile sensitivity are presented. In phalloplasty, the dorsal hood of the clitoris is incorporated into the neoscrotum; the clitoris is transposed, buried, and fixed directly below the reconstructed phallic shaft; and the medial and lateral antebrachial nerves are coapted to the inguinal nerve and to one of the 2 dorsal nerves of the clitoris. In vaginoplasty, the clitoris is reconstructed from a part of the glans penis inclusive of a part of the corona, the inner side of the prepuce is used to reconstruct the labia minora, and the penile shaft is inverted to line the vaginal cavity.

Material and Methods:

A long-term sensitivity evaluation (performed by the Semmes-Weinstein monofilament and the Vibration tests) of 27 reconstructed phalli and 30 clitorises has been performed.

Results:

The average pressure and vibratory thresholds values for the phallus tip were, respectively, 11.1 g/mm2 and 3
m. These values have been compared with the ones of the forearm (donor site). The average pressure and vibratory thresholds values for the clitoris were, respectively, 11.1 g/mm2 and 0.5
m. These values have been compared with the ones of the normal male glans, taken from the literature. We also asked the examined patients if they experienced orgasm after surgery, during any sexual practice (ie, we considered only patients who attempted to have orgasm): all female-to-male and 85% of the male-to-female patients reported orgasm.

Conclusion:

With our techniques, the reconstructed genitalia obtain tactile and erogenous sensitivity. To obtain a good tactile sensitivity in the reconstructed phallus, we believe that the coaptation of the cutaneous nerves of the flap with the ilioinguinalis nerve and with one of the 2 nerves of the clitoris is essential in obtaining this result. To obtain orgasm after phalloplasty, we believe that preservation of the clitoris beneath the reconstructed phallus and some preservation of the clitoris hood are essential. To obtain orgasm after a vaginoplasty, the reconstruction of the clitoris from the neurovascular pedicled glans flap is essential.

Key Words:

transsexualism, phalloplasty, vaginoplasty, sensitivity, gender dysphoria, sex reass

Genital Sensitivity After Sex Reassignment Surgery in Transsexual Patients

John F. Strang, Haley Meagher, Lauren Kenworthy, Annelou L. C. de Vries, Edgardo Menvielle, Scott Leibowitz, Aron Janssen, Peggy Cohen-Kettenis, Daniel E. Shumer, Laura Edwards-Leeper, Richard R. Pleak, Norman Spack, Dan H. Karasic, Herbert Schreier, Anouk Balleur, Amy Tishelman, Diane Ehrensaft, Leslie Rodnan, Emily S. Kuschner, Francie Mandel, Antonia Caretto, Hal C. Lewis & Laura G. Anthony

Sammendrag

Bakgrunn for tema: For å produsere stemmelyd trengs luft fra lungene, et fungerende strupehode og resonansrom. Stemmen brukes for å uttrykke seg i kommunikasjon med andre, og vi kan oppfatte det lingvistiske budskapet til avsenderen gjennom talespråket; – men vi kan også oppfatte paralingvistisk informasjon som alder og kjønn. Oppfattelsen av kjønn, og hva som forstås som kjønn, kan sies å være både biologisk og sosialt betinget. Personer med kjønnsinkongruens opplever et manglende samsvar mellom det biologiske kjønnet de fikk tildelt ved fødsel og det sosiale kjønnet de identifiserer seg som. Prosjektet søker å finne ut av hvordan personer med kjønnsinkongruens som har gjennomgått kjønnsbekreftende behandling, tenker omkring egen stemme og stemmebruk.

AaseFinch-Sped4090 logoped

Annika Johansson • Elisabet Sundbom • Torvald Ho¨jerback • Owe Bodlund

ABSTRACT

This follow-up study evaluated the outcome of sex reassignment as viewed by both clinicians and patients, with an additional focus on the outcome based on sex and subgroups. Of a total of 60 patients approved for sex reassignment, 42 (25 male-to-female [MF] and 17 female-to-male [FM]) transsexuals completed a follow-up assessment after 5 or more years in the process or 2 or more years after completed sex reassignment surgery. Twenty-six (62%) patients had an early onset and 16 (38%) patients had a late onset; 29 (69%) patients had a homosexual sexual orientation and 13 (31%) patients had a non-homosexual sexual orientation (relative to biological sex). At index and follow-up, a semi-structured interview was conducted. At followup, 32 patients had completed sex reassignment surgery, five were still in process, and five—following their own decision—had abstained from genital surgery. No one regretted their reassignment. The clinicians rated the global outcome as favorable in 62% of the cases, compared to 95% according to the patients themselves, with no differences between the subgroups. Based on the follow-up interview, more than 90% were stable or improved as regards work situation, partner relations, and sex life, but 5–15% were dissatisfied with the hormonal treatment, results of surgery, total sex reassignment procedure, or their present general health. Most outcome measures were rated positive and substantially equal for MF and FM. Late-onset transsexuals differed from those with early onset in some respects: these were mainly MF (88 vs. 42%), older when applying for sex reassignment (42 vs. 28 years),

Johansson 2010

Kim Alexander Tønseth kim.tonseth@rikshospitalet.no Therese Bjark Plastikkirurgisk avdeling Oslo universitetssykehus, Rikshospitalet 0027 Oslo Gunnar Kratz Plastikkirurgisk avdeling Universitetssjukhuset Linköping Sverige Annika Gross Rolf Kirschner Kvinneklinikken Thomas Schreiner Medisinsk klinikk Trond H. Diseth Barneklinikken Ira Haraldsen Gender identity disorder (GID) seksjonen Nevroklinikken Oslo universitetssykehus, Rikshospitalet

ABSTRACT

Bakgrunn.

Oslo universitetssykehus, Rikshospitalet har siden 1979 hatt landsfunksjon for behandling av pasienter med transseksualisme. På årsbasis henvises 50–70 pasienter til utredning, hvorav rundt 20 pasienter blir diagnostisert som transseksuelle. Årlig henvises omtrent 15 pasienter av dem som oppfyller kriterier for transseksualisme, og som er blitt endokrinologisk behandlet, til kirurgisk intervensjon. I denne artikkelen beskrives diagnose og behandling av transseksualisme, med hovedvekt på kirurgi.

Materiale og metode.

Artikkelen er basert på ikke-systematisk litteraturgjennomgang og egne kliniske og vitenskapelige erfaringer.

Resultater.

Etter minimum ett års psykiatrisk utredning og diagnostikk, og ett års påfølgende hormonell behandling, vurderes pasientene i forhold til kjønnskorrigerende kirurgi. Hos pasienter som konverteres fra mann til kvinne, vurderes brystforstørrende kirurgi hvis ikke hormonbehandling alene har gitt tilfredsstillende resultat. I tillegg er det aktuelt med genital kirurgi hvor testikler og svamplegemene fjernes, og hvor neovagina og neoklitoris konstrueres. For pasienter som konverteres fra kvinne til mann, er det aktuelt å gjøre brystreduserende inngrep, hysterektomi og salpingo-ooforektomi samt neopeniskonstruksjon. Ved god respons på hormonbehandling kan klitoris rettes ut og konstrueres til en neopenis med ereksjonsmulighet (metoidioplastikk). Alternativt gjøres falloplastikk med bruk av lokalt vev fra lysken eller frie mikrovaskulære lapper.

Fortolkning.

Kjønnskorrigerende kirurgi ved transseksualisme omfatter hovedsakelig konverterende operasjoner på bryst og genitalia.

Kjønnskorrigerende kirurgi Rikshospitalet 2010Pdf

ABSTRACT

Ekspertgruppa ble oppnevnt av Helsedirektoratet i desember 2013 for å gjennomgå nåværende vilkår for å endre juridisk kjønnsstatus i Norge, samt vurdere behovene for og foreslå endringer i dagens pasient- og behandlingstilbud til personer som opplever kjønnsdysfori. Bakgrunnen for dette var oppdrag gitt av Helse- og omsorgsdepartementet i oktober 2013. Dagens vilkår for å få endret juridisk kjønnsstatus er at vedkommende først må gjennomgå kjønnsbekreftende medisinsk behandling som inkluderer kastrasjon. Offentlig behandlingstilbud av hormonell og/eller kirurgisk art, gis kun til personer som er gitt diagnosen F64.0 Transseksualisme ved Nasjonal behandlingstjeneste for transseksualisme (NBTS), Oslo universitetssykehus. Utover dette er det ikke i dag tilrettelagt for at det gis behandling i offentlig regi andre steder.

Rett til rett kjønn Ferdig rapport 090415

Trond H. Diseth

trond.diseth@rikshospitalet.no

ABSTRACT

Bakgrunn.

Årlig fødes 10–12 barn i Norge med alvorlig genital misdannelse hvor kjønnet ikke kan fastsettes ved fødsel. Tilstanden betegnes Forstyrrelser i kjønnsutviklingen (DSD). Alvorlig underviriliserte gutter (46,XY DSD) representerer den største utfordringen, hvor valg av kjønn tradisjonelt har vært jente.

Materiale og metode.

Artikkelen bygger på et grundig ikke-systematisk søk i PubMed samt egen klinisk erfaring. Resultater og fortolkning. I de siste ti år er det i økende grad stilt spørsmål ved det faglige grunnlaget for kjønnsvalg ved uklart kjønn. Avgjørende for den tradisjonelle behandlingsprotokoll har vært postulatet om at barn med forstyrrelser i kjønnsutviklingen vil utvikle seg til et valgt kjønn uansett årsak, såfremt ytre genitalia ble «normalisert» før toårsalderen, svarende til det valgte kjønn. Da viktigheten av falloslegemets størrelse og funksjonalitet for senere mannlig kjønnsidentitet og kjønnsrolleatferd ble understreket, ble de fleste alvorlig underviriliserte 46,XY DSD-barn operert til jenter. Ny kunnskap om mulig prenatal genetisk og hormonell påvirkning av fosterets hjerne for senere psykoseksuell utvikling, fører til at fagmiljøet nå utvikler nye behandlingsprotokoller. Eksakt diagnose av bakenforliggende tilstand for best mulig å predikere barnets fremtidige kjønnsidentitet, bør være fundamentet for kjønnsvalg

Studie Trond Diset 2008

Dogu Aydin, MD, Liv Johanne Buk, MD, Søren Partoft, MD, Christian Bonde, MD, Michael Vestergaard Thomsen, MD, and Tina Tos, MD

ABSTRACT

Introduction:

Gender dysphoria is a mismatch between a person’s biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty).

Aims:

To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period.

Methods:

Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported. Main Outcome Measures: Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery.

Results:

One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period.

Conclusion:

Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period. J Sex Med 2016;-:1e6.

Copyright
2016, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Key Words: Gender Dysphoria;

sugery in Denmark 1994 2015

John F. Strang, Haley Meagher, Lauren Kenworthy, Annelou L. C. de Vries, Edgardo Menvielle, Scott Leibowitz, Aron Janssen, Peggy Cohen-Kettenis, Daniel E. Shumer, Laura Edwards-Leeper, Richard R. Pleak, Norman Spack, Dan H. Karasic, Herbert Schreier, Anouk Balleur, Amy Tishelman, Diane Ehrensaft, Leslie Rodnan, Emily S. Kuschner, Francie Mandel, Antonia Caretto, Hal C. Lewis & Laura G. Anthony

ABSTRACT

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD.

There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements.

The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment;

guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/ blurring of treatment and assessment.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

Derek Glidden1 , Walter Pierre Bouman 1 , Bethany Alice Jones1,2 and Jon Arcelus 1,3

ABSTRACT

Introduction.

There is a growing clinical recognition that a significant proportion of patients with Gender Dysphoria, have concurrent Autism Spectrum Disorder (ASD). Aim. The purpose of this review is to systematically appraise the current literature regarding the co-occurrence of Gender Dysphoria and ASD.

Methods

. A systematic literature search using Medline/Pubmed, PsycINFO and Embase were conducted from 1966 to July 2015.

Main Outcome Measures.

A total of 58 articles were generated from the search. Nineteen of these publications met the inclusion criteria. Results. The literature investigating ASD in children and adolescents with Gender Dysphoria have found a higher prevalence rate of ASD compared to the general population. There is a limited amount of research in adults. Only one study showed that adults attending services for Gender Dysphoria had increased ASD scores. Another study showed a higher proportion of atypical gender identity in adults with ASD.

Conclusions.

Although the research is limited, especially with adults, there is an increasing amount of evidence that suggests a co-occurrence between Gender Dysphoria and ASD. Further research is vital for educational and clinical purposes.

Systematic_Review_ASD_and_GD_submission_29Sept_Final

Annelou L. C. de Vries • Ilse L. J. Noens • Peggy T. Cohen-Kettenis • Ina A. van Berckelaer-Onnes • Theo A. Doreleijers

ABSTRACT

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.

Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents