On gender dysphoria

Gender identity refers to an innate and deeply felt psychological identification as a female, male, or some other non-binary gender. Gender identity may be congruent or incongruent with the sex assigned at birth. Gender dysphoria refers to the discomfort or distress that gender incongruence may cause. If the distress is clinically significant, the individual may need gender-affirming treatment. The literature is sparse with respect to the etiology, prevalence, and long-term outcomes. The overall aim of this thesis is to further our understanding of gender dysphoria regarding neurobiological characteristics, epidemiology, and health following gender-affirming treatment. Study I explored the hypothesis that cerebral activation in hormone-naïve transgender women (assigned males at birth) on exposure to odorous steroids would be in line with their gender identity, and thus similar to cisgender women but different to cisgender men. Gender dysphoric transgender women demonstrated a cerebral activation pattern that corresponded predominately to that of cisgender females, but also some cisgender male characteristics. Study II described the prevalence and changes in incidence of applications for change of legal gender and applications to reverse the procedure during 1960- 2010. The incidence of gender dysphoria increased three times for individuals assigned male at birth, and two and half time times for individuals assigned female at birth. The increase accelerated after 2001. The rate of reversal applications was 2.2% with a significant decline over the study period. Study III explored long-term mortality and psychiatric morbidity after sex reassignment in a nation-wide cohort study (1973-2003). The overall mortality rate was higher in individuals who had undergone legal and medical transition compared with the general population for the whole period, but not for the period 1989-2003. Probands had more psychiatric inpatient care and suicide attempts compared with controls for the whole period as well as the period 1989-2003 (with the exception of suicide attempts). This study cannot determine the effectiveness of gender-affirming medical intervention, but the results highlight the need for better health care following gender transition. Study IV examined outcomes following legal and surgical gender transition, mean (SD) follow-up time 7.2 (7.3) years, by means of individual interviews with 16 men (assigned female at birth) and 49 women (assigned male at birth). The vast majority of the participants felt gender congruent and global clinically improved, but the prevalence of psychiatric morbidity and suicide attempts was high. Childhood adversities and adult stressful life events were common. Being born abroad, childhood adversities, and not being accepted by others in assigned gender predicted current psychiatric morbidity

The 2011 WPATH Standards of Care and Penile Reconstruction in Female-to-Male Transsexual Individuals

The World Professional Association for Transgender Health (WPATH) currently publishes the Standards of Care (SOC), to provide clinical guidelines for health care of transsexual, transgender and gender non-conforming persons in order to maximize health and well-being by revealing gender dysphoria. An updated version (7th version, 2011) of the WPATH SOC is currently available. Differences between the 6th and the 7th versions of the SOC are shown; the SOC relevant to penile reconstruction in female-to-male (FtM) persons are emphasized, and we analyze how the 2011 WPATH SOC is influencing the daily practice of physicians involved in performing a penile reconstruction procedure for these patients. Depending by an individual's goals and expectations, the most appropriate surgical technique should be performed: the clinic performing penile reconstruction should be able to offer the whole range of techniques, such as: metoidioplasty, pedicle and free flaps phalloplasty procedures. The goals that physicians and health care institutions should achieve in the next years, in order to improve the care of female-to-male persons, consist in: informing in details the individuals applying for penile reconstruction about all the implications; referring specific individuals to centers capable to deliver a particular surgical technique; implementing the surgery with the most updated refinements

Impulsivity in Compulsive Sexual Behavior Disorder and Pedophilic Disorder

Background and aims: Impulsivity is regarded as a risk factor for sexual crime reoffending, and a suggested core feature in Compulsive Sexual Behavior Disorder. The aim of this study was to explore clinical (e.g. neurodevelopmental disorders), behavioral and neurocognitive dimensions of impulsivity in disorders of problematic sexuality, and the possible correlation between sexual compulsivity and impulsivity. Methods: Men with Compulsive Sexual Behavior Disorder (n = 20), and Pedophilic Disorder (n = 55), enrolled in two separate drug trials in a specialized Swedish sexual medicine outpatient clinic, as well as healthy male controls (n = 57) were assessed with the Hypersexual Behavior Inventory (HBI) for sexual compulsivity, and with the Barratt Impulsiveness Scale (BIS) and Connors' Continuous Performance Test-II (CPT-II) for impulsivity. Psychiatric comorbidity information was extracted from interviews and patient case files. Results: Approximately a quarter of the clinical groups had Attention-Deficit/Hyperactivity Disorder (ADHD) or Autism Spectrum Disorder. Both clinical groups reported more compulsive sexuality (r = 0.73-0.75) and attentional impulsivity (r = 0.36-0.38) than controls (P < 0.05). Based on results on univariate correlation analysis, BIS attentional score, ADHD, and Commissions T-score from CPT-II were entered in a multiple linear regression model, which accounted for 15% of the variance in HBI score (P < 0.0001). BIS attentional score was the only independent positive predictor of HBI (P = 0.001). Discussion: Self-rated attentional impulsivity is an important associated factor of compulsive sexuality, even after controlling for ADHD. Psychiatric comorbidity and compulsive sexuality are common in Pedophilic Disorder. Conclusion: Neurodevelopmental disorders and attentional impulsivity - including suitable interventions - should be further investigated in both disorders

Vibrator-Assisted Start-Stop Exercises Improve Premature Ejaculation Symptoms: A Randomized Controlled Trial

Premature ejaculation (PE) is associated with decreased quality of life, lower confidence and self-esteem, and higher levels of depression, anxiety, and interpersonal difficulties. Here we investigated the effectiveness of vibrator-assisted start–stop exercises for treatment of PE, and whether the treatment effect could be enhanced by an additional psychobehavioral intervention. Fifty participants with a mean age of 41.7 years were included and randomized into two treatment groups and a waiting list control group. Participants were instructed to perform start–stop exercises while stimulating the penis with a purpose-made vibrator, 3 times a week for 6 weeks. Additionally, participants in one of the treatment groups received additional psychoeducation and performed mindfulness meditation-based body scan exercises three times a week. Data were gathered through online questionnaires before and after treatment, as well as 3 and 6 months after treatment. The interventions reduced PE symptoms with large effect sizes (partial η2 = .20 across the three groups, d [95% CI] = 1.05 [.27, 1.82] and 1.07 [.32, 1.82] for treatment groups compared to waiting list control group). The additional psychobehavioral intervention did not further reduce PE symptoms, but did decrease PE-associated negative symptoms such as levels of sexual distress, anxiety, and depression. No side effects were reported. Vibrator-assisted start–stop exercises can be offered as an adequate treatment option for PE.<br /

How the COVID-19 pandemic affects transgender health care in upper-middle-income and high-income countries – A worldwide, cross-sectional survey

Background Since the beginning of the COVID-19 pandemic, access to medical care was restricted for nearly all non-acute medical conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments (e.g., hormone treatment), transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic. This study aims to assess the impact of the COVID-19 pandemic on the health and health care of transgender people. Methods and findings As an ad hoc collaboration between researchers, clinicians, and 23 community organizations, we developed a web-based survey. The survey was translated into 26 languages, and participants were recruited via various social media and LGBTIQ-community sources. Recruitment started in May 2020. We assessed demographical data, physical and mental health problems (e.g., chronic physical conditions), risk factors (e.g., smoking), COVID-19 data (symptoms, contact history, knowledge and concerns about COVID-19), and the influence of the COVID-19 pandemic on access to transgender health care and health-related supplies. To identify factors associated with the experience of restrictions to transgender health care, we conducted multivariate logistic regression analysis. 5267 transgender people from 63 higher-middle income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding testing or treatment of a COVID-19 infection due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted due to the COVID-19 pandemic for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% of the participants reported at least one mental health conditions. Every third participant had suicidal thoughts, and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic. A limitation of the study is that we did not analyze data from low-income countries and access to the internet was necessary to participate. Conclusions Transgender people are assumed to suffer under the severity of the pandemic even more than the general population due to the intersections between their status as a vulnerable social group, their high amount of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender individuals, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behaviour, and suicidality

Clinicopathological findings in female‐to‐male gender‐affirming breast surgery

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/139962/1/his13299.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/139962/2/his13299_am.pd

The levels and predictors of physical activity engagement within the treatment seeking transgender population: a matched control study

Background: Physical activity has been found to alleviate mental health problems and could be beneficial for at-risk populations, such as transgender people. This study had three aims. First, to explore the amount of physical activity that treatment seeking transgender people engage in, and to compare this to matched cisgender people. Second, to determine whether there was a difference in physical activity depending on cross-sex hormone use. Third, to determine factors which predict physical activity among treatment seeking transgender people. Method: Transgender (n=360) and cisgender people (n=314) were recruited from the UK. Participants were asked to complete questionnaires about physical activity, symptoms of anxiety and depression, self-esteem, body satisfaction and transphobia. Results: Transgender people engaged in less physical activity than cisgender people. Transgender people who were on cross-sex hormones engaged in more physical activity than transgender people who were not. In transgender people on cross-sex hormones, high body satisfaction was the best statistical predictor of physical activity while high self-esteem was the best statistical predictor in people who were not. Conclusion: Transgender people are less active than cisgender people. Cross-sex hormone treatment appears to be able to indirectly increase physical activity within this population, which may be beneficial for mental well-being

Sociodemographic variables, clinical features, and the role of preassessment cross-sex hormones in older trans people

Introduction: As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available. Aims: The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology. Methods: Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology. Main Outcome Measures: Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire). Results: The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n ¼ 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained. Conclusion: The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined

Sport and transgender people: a systematic review of the literature relating to sport participation and competitive sport policies

Background Whether transgender people should be able to compete in sport in accordance with their gender identity is a widely contested question within the literature and among sport organisations, fellow competitors and spectators. Owing to concerns surrounding transgender people (especially transgender female individuals) having an athletic advantage, several sport organisations place restrictions on transgender competitors (e.g. must have undergone gender-confirming surgery). In addition, some transgender people who engage in sport, both competitively and for leisure, report discrimination and victimisation. Objective To the authors’ knowledge, there has been no systematic review of the literature pertaining to sport participation or competitive sport policies in transgender people. Therefore, this review aimed to address this gap in the literature. Method Eight research articles and 31 sport policies were reviewed. Results In relation to sport-related physical activity, this review found the lack of inclusive and comfortable environments to be the primary barrier to participation for transgender people. This review also found transgender people had a mostly negative experience in competitive sports because of the restrictions the sport’s policy placed on them. The majority of transgender competitive sport policies that were reviewed were not evidence based. Conclusion Currently, there is no direct or consistent research suggesting transgender female individuals (or male individuals) have an athletic advantage at any stage of their transition (e.g. cross-sex hormones, gender-confirming surgery) and, therefore, competitive sport policies that place restrictions on transgender people need to be considered and potentially revised

How the COVID-19 pandemic affects transgender health care - A cross-sectional online survey in 63 upper-middle-income and high-income countries

Background Due to the COVID-19 pandemic, access to medical care is restricted for nearly all non-acute conditions. Due to their status as a vulnerable social group and the inherent need for transition-related treatments, transgender people are assumed to be affected particularly severely by the restrictions caused by the COVID-19 pandemic. Methods As an ad hoc collaboration between researchers, clinicians and 23 community organizations, we developed a web-based survey in German that was translated into 26 languages. Participants were recruited via community sources, social media channels, and snowball sampling since May 2020. The present sample is based on the data collected until August 9, 2020. We assessed demographical data, health problems, risk factors, COVID-19 data (e.g., contact history), and the influence of the COVID-19 pandemic on access to transgender health care services. To identify factors associated with the experience of restrictions, we conducted multiple logistic regression analysis. Results 5267 transgender people from 63 upper-middle-income and high-income countries participated in the study. Over 50% of the participants had risk factors for a severe course of a COVID-19 infection and were at a high risk of avoiding COVID-19 treatment due to the fear of mistreatment or discrimination. Access to transgender health care services was restricted for 50% of the participants. Male sex assigned at birth and a lower monthly income were significant predictors for the experience of restrictions to health care. 35.0% reported at least one mental health condition and 3.2% have attempted suicide since the beginning of the COVID-19 pandemic. Discussion Transgender people suffer under the severity of the pandemic due to the intersections between their status as a vulnerable social group, their high number of medical risk factors, and their need for ongoing medical treatment. The COVID-19 pandemic can potentiate these vulnerabilities, add new challenges for transgender people, and, therefore, can lead to devastating consequences, like severe physical or mental health issues, self-harming behavior, and suicidality