Du trenger ikke å være en “spesialist” for å hjelpe unge mennesker som utforsker deres kjønnsidentitet. Faktisk, etter vurderingsprosessen, er det meste av den terapeutiske inngangen gitt utenfor Nasjonal behandlingstjenester for transseksualisme, vanligvis i BUP eller DPS. Når det er mulig, ber NBTS lokale BUP eller DPS å være involvert sammen med NBTS teamet. Når dette skjer, er NBTS-klinikere alltid tilgjengelige for kontakt med bestemte tilfeller. NBTS har utviklet noen primære terapeutiske mål som vi har brukt til å veilede vårt arbeid. Klinisk arbeid med unge mennesker kan ta en rekke formater, inkludert en-til-en-sesjoner eller stadig gruppearbeid der andre unge sammen med fagfolk kan yte støtte.
Les mer under for flere ideer om hvordan du arbeider med unge og kjønn.
Lytt og vis forståelse
Utforsk sammen med den unge personen der de er når det gjelder kjønnsidentitet, hør på å forstå (heller enn å tilby umiddelbare løsninger).
En del av din rolle kan være å hjelpe den unge personen til å finne sine egne løsninger, og avveie fordelene og ulempene med valg de vurdere (for eksempel i forhold til sosialt overgang).
Møt med respekt
Opprettholde en respektfull og ikke-dømmende tilnærming til å jobbe med personen
Dette kan innebære å bruke deres foretrukne navn og pronomen, selv om andre velger å ikke gjøre det.
Kjønnsuttrykk
Hjelp dem å eksperimentere med deres kjønnsuttrykk
Er det et trygt sted personen kan prøve ut ting (når det gjelder kjole, navn, pronomen etc) uten å måtte forplikte seg til noe?
Kjønsforståelse
Diskuter kjønnsforståelse
Kjønnsidentiet er komplisert og mangfoldig, og kan forstås som et spekter i stedet for nødvendigvis å være et binært valg mellom mann eller kvinne. Hva tenker den unge personen om denne ideen? Hvilke kjønnsrollemodeller har de? Skap mer innsikt
Ikke lukke noen dører
Hjelp personen til å holde alle muligheter åpne og gi en trygg mulighet til å utforske usikkerhet og tvil.
Unges identiteter utvikler seg gjennom ungdomsår og i voksen alder, og enkelte mennesker bestemmer seg for at de ønsker å uttrykke sin kjønnsidentitet på mange forskjellige måter, noe som kan endres over tid. Å holde valgmuligheter åpne er viktig for personen skal kunne endre seg hvis de vil. Det er mange måter å være menneske på. Det finnes ingen mal eller fasit.
Familie
Jobb med familien
Gi plass til forskjellige meninger, tanker og følelser. Det er også viktig å bli lyttet til og føle omsorg. Oppfordre til åpen kommunikasjon om kjønn, på en måte som føles trygg.
Nettverk
Tenkt nettverk
Hvem kjenner personen og hvilken støtte kan de gi, om nødvendig? Utred nettverket og gjør nytte av det.
Risiko og utfordringer
Vurder risiko og tilhørende utfordringer.
Unge som stiller spørsmål om kjønnsidentitet, kan oppleve en rekke tilknyttede psykiske problemer, inkludert selvskading og selvmordstanker. Det er viktig at dette vurderes og forvaltes lokalt. Kjønnsidentitet eksisterer ikke i vakuum og det at personen søker støtte for sin kjønnsutfordring betyr ikke nødvendigvis at alle andre vanskeligheter vil bli bedre – det er ofte andre kompleksiteter som må vurderes og det vil være viktig å diskutere med person om hvordan det er best å gjøre dette.
Felles omsorg i nettverk
Etter vår erfaring har personen og fagpersoner rundt et stort utbytte når samarbeide går på tvers og det er god kommunikasjon med NBTS, BUP, DPS og andre lokale tjenestene, også skole og arbeid.
Samlet nettverksstøtte
HBRS kan om ønskelig bli med på lokale nettverksmøter, der vi kan delta i diskusjoner mellom flere organer som kan omfatte familien, skolen og andre som er involvert. Vi kan gi råd og veiledning i forhold til å møte personen på en god måte og hvordan man kan være med på å gjøre nærmiljøet til et trygt og inkluderende sted for alle.
Lokale ressurser
HBRS mener at det er viktig at det lokale hjelpeapparatet, slik som BUP, DPS og andre er innvolvert, slik at de kan vurdere risikoer som kan oppstå, slik som selvskading eller om det er risiko for selvmord.
Samtidig så må vi erkjenne at kunnskapen rundt kjønnsdysfori og kjønnsinkongruens er ikke alltid like god alle steder. Men vi ser at kunnskapsnivået er økende, og at NBTS stiller seg til disposisjon om det lokale hjelpeapparatet trenger råd og veiledning.
Nettverksmøte
Et typisk nettverksmøte vil bli holdt der hvor barnet og familien bor, og vil involvere det lokale hjelpeapparatet, som kan være representanter fra bup, skole, eller andre instanser som er aktuelle. På denne måten får vi en mulighet til å få et helhetlig bilde av eventuelle utfordringer.
Hvordan går man fram?
Henvisning og vurdering
NBTS fordrer nå at du har henvisning fra 2-linjetjenesten. Det betyr at din fastlege kan henvise deg til BUP (under 18 år) og til DPS (18 år og eldre). Du kan også ta direkte kontakt med psykologer som har store kunnskaper om kjønnsinkongruens og kjønnsdysfori. Du kan kontakte HBRS om vi har kunnskap om psykologer i ditt fylke som har en slik erfaring. HBRS samarbeider med psykologspesialist Asle Offerdal som har arbeidet med denne tematikken siden 2001.
Psykolog Offerdal holder til i samme lokale som HBRS i Oslo.
Hvis du er avhengig av å komme til en psykolog eller psykiater som har refusjonsavtale med NAV så kan du gå inn på nettsiden til den helseregionen som er aktuell for deg: Les mere på helsenorge.no
Du kan også kontakte HBRS på info@hbrs.no
Hvordan gå fram?
Henvisning og vurdering
NBTS fordrer nå at du har henvisning fra 2-linjetjenesten. Det betyr at din fastlege kan henvise deg til BUP (under 18 år) og til DPS (18 år og eldre). Du kan også ta direkte kontakt med psykologer som har store kunnskaper om kjønnsinkongruens og kjønnsdysfori. Du kan kontakte HBRS om vi har kunnskap om psykologer i ditt fylke som har en slik erfaring. HBRS samarbeider med psykologspesialist Asle Offerdal som har arbeidet med denne tematikken siden 2001.
Psykolog Offerdal holder til i samme lokale som HBRS i Oslo.
Hvis du er avhengig av å komme til en psykolog eller psykiater som har refusjonsavtale med NAV så kan du gå inn på nettsiden til den helseregionen som er aktuell for deg: Les mere på helsenorge.no
Du kan også kontakte HBRS på info@hbrs.no
Hvordan skal BUP, DPS utarbeide en henvisning til NBTS?
Utarbeidelse av henvisning
For barn og unge under 18 år:
BUP skal gjennomføre en bred barne- og ungdomspsykiatrisk utredning og så henviser BUP på indikasjon til Nasjonal behandlingstjeneste for transseksualisme barn og unge, Teamet for kjønnsidentitetsutredninger av barn og unge (KID-Teamet).
Følgende utredning av barnet/ungdommen er ønskelig fra lokal BUP før henvisning: Utviklingsanamnese inklusive familieforhold
- ASEBA (barn/ungdom, foresatte, lærer)
- Semistrukturert intervju (Kiddie-SADS, CAS)
- Utredning av kognitiv funksjon om aktuelt (WISC, pedagogisk utredning eventuelt andre observasjoner)
Utredning med tanke på sosialt samspill og autismespekterlidelse
Forskning viser det er overhyppighet av autismespekterlidelser hos pasienter med kjønnsinkongruens (opp mot 30%). Det er derfor viktig å screene for dette. Det finnes ikke mange screeningsverktøy som er reliable nok, men vi kan anbefale disse som anbefales fra «Retningslinje for utredning av ASD i Helse Sør Øst».
Henvisninger og brev til NBTS-barn og unge
NBTS barn og unge, Teamet for kjønnsidentitetsutredninger av barn og unge (KID-Teamet)
Avdeling for barn og unges psykiske helse på sykehus (S-BUP)
Barne- og ungdomsklinikken, Rikshospitalet
Oslo Universitetssykehus
Postboks 4950 Nydalen
0424 Oslo
Voksne 18 år og eldre:
Distriktspsykiatriske poliklinikk (DPS) skal gjennomføre en psykiatrisk utredning og henvise deg videre til Nasjonal behandlingstjeneste for transseksualisme (NBTS) ved Oslo universitetssykehus.
Følgende utredning er ønskelig fra DPS før henvisning til NBTS:
- Anamnese
- Semistrukturert intervju (MINI)
- SCID II
- Utredning med tanke på autismespekterlidelse (Asperger) ved klinisk mistanke.
- Utredning av kognitiv funksjon om aktuelt.
Henvisninger og brev til NBTS voksne
NBTS voksne
Psykosomatisk avdeling
Rikshospitalet
Oslo Universitetssykehus
Postboks 4950 Nydalen
0424 Oslo
Svar på henvisning
Når kan pasienten forvente det?
Pasienter som henvises til NBTS er såkalt (elektiv) helsehjelp i spesialisthelsetjenesten, skal få avklart om de har behov for og dermed rett til nødvendig helsehjelp fra spesialisthelsetjenesten og få vurdert hvilken frist de i så fall skal ha. NBTS må gjøre en rettighetsvurdering innen 10 virkedager. Det betyr at du innen 10 virkedager skal få et brev fra NBTS som avklarer om du vil bli innkalt til time.
Du skal ifølge pasient- og brukerrettighetsloven ha fått svar på henvisningsbrev senest 10 virkedager etter at brevet er mottatt på NBTS. Dersom du og din lege/psykolog ikke har fått svar innen 10 virkedager kan din lege/psykolog kontakte NBTS og purre på svar. Les mere om pasient- og brukerrettighetsloven på lovdata.no
Første time på NBTS
Hva kan pasienten forvente?
Den første timen blir brukt til informasjon om videre utredning og behandling. Det må også beregnes at pasienten må fylle ut en del skjemaer.
Utredning
Hva består utredningen av og hvor lenge varer den?
Det er vanskelig å si noe sikkert om hvor ofte pasiente vil bli innkalt til time. Men man kan regne med minst 4 – 6 samtaler i løpet av det første året, diagnostiske samtaler. Disse utføres av leger, psykologer og sykepleier. Utredningen er individuell og vil derfor ta ulik tid. Men utredningen skal vanligvis ikke ta mere enn 1 år.
Tidsperspektiv
Hvor lenge varer utredningen og behandlingen?
Utredning og behandling er individuell og vil derfor kunne ta ulik tid. Det vil også være preget av hvor mange operasjoner man ønsker. Men man må påregne 3 – 5 år fra første time på NBTS. I noen tilfeller kan det også ta lengre tid før man er ferdig med alle operasjoner. Hver time hos lege, psykolog og sykepleier varer i omtrent 45 minutter, hvis ikke nærmere spesifisert i innkallingsbrevet. Hvis det er ønskelig med flere timer samme dag eller to dager vil NBTS vil informere pasienten om dette skriftlig, og tilpasse det etter behov med en pasienthotell-overnatting hvis pasienten kommer fra en annen region i Norge.
Hvis du ikke finner svar på dine spørsmål vedrørende behandlingen i dette hefte eller på HBRS sin hjemmeside, så kan du sende spørsmål til info@hbrs.no
Forskning
Desisting and persisting gender dysphoria after childhood Steensma 2011
Thomas D. Steensma, Roeline Biemond, Fijgie de Boer and Peggy T. Cohen-Kettenis
Abstract
The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14-18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different.
Desisting and persisting gender dysphoria after childhood Steensma 2011
A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children
Julia Temple Newhook, Jake Pyne, Kelley Winters, Stephen Feder, Cindy Holmes, Jemma Tosh, Mari-Lynne Sinnott, Ally Jamieson & Sarah Pickett
Abstract
Background: It has been widely suggested that over 80% of transgender children will come to identify as cisgender (i.e., desist) as they mature, with the assumption that for this 80%, the trans identity was a temporary “phase.” This statistic is used as the scientific rationale for discouraging social transition for pre-pubertal children. This article is a critical commentary on the limitations of this research and a caution against using these studies to develop care recommendations for gender-nonconforming children.
Methods: A critical review methodology is employed to systematically interpret four frequently-cited studies that sought to document identity outcomes for gender-nonconforming children (often referred to as “desistance” research).
Results: Methodological, theoretical, ethical, and interpretive concerns regarding four “desistance” studies are presented. The authors clarify the historical and clinical contexts within which these studies were conducted to deconstruct assumptions in interpretations of the results. The discussion makes distinctions between the specific evidence provided by these studies versus the assumptions that have shaped recommendations for care. The affirmative model is presented as a way to move away from the question of, “How should children’s gender identities develop over time?” toward a more useful question: “How should children best be supported as their gender identity develops?”
Conclusion: The tethering of childhood gender diversity to the framework of “desistance” or “persistence” has stifled advancements in our understanding of children’s gender in all its complexity. These follow-up studies fall short in helping us understand what children need. As work begins on the 8th version of the Standards of Care by the World Professional Association for Transgender Health, we call for a more inclusive conceptual framework that takes children’s voices seriously. Listening to children’s experiences will enable a more comprehensive understanding of the needs of gender-nonconforming children and provide guidance to scientific and lay communities.
A critical commentary on follow-up studies and desistance NEWHOOK.IJT.2018
A critical commentary on “A critical commentary on follow-up studies and “desistence” theories about transgender and gender non-conforming children”
Thomas D. Steensma & Peggy T. Cohen-Kettenis
Abstract
The article entitled “A critical commentary on follow-up studies and “desistence” theories about transgender and gender non-conforming children” by Temple Newhook et al. (2018) is a plea to abandon longitudinal studies on the development of gender variant children as they do not respect children’s autonomy. A few relatively recent studies are criticized and it is concluded that conducting longitudinal psychosexual outcome studies and acknowledging the children’s feelings are contradictory. We agree that the longitudinal studies currently available have their limitations. We do, however, strongly disagree with the authors that studies on gender variant children’s development should be abandoned and that our studies do not take children’s needs and voices seriously or are unethical
A FOLLOW-UP STUDY OF BOYS WITH GENDER IDENTITY DISORDER
Devita Singh
Abstract
This study provided information on the long term psychosexual and psychiatric outcomes of 139 boys with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 7.49 years; range, 3–12 years) and at follow-up (mean age, 20.58 years; range, 13–39 years) were used to evaluate gender identity and sexual orientation outcome. At follow-up, 17 participants (12.2%) were judged to have persistent gender dysphoria. Regarding sexual orientation, 82 (63.6%) participants were classified as bisexual/ homosexual in fantasy and 51 (47.2%) participants were classified as bisexual/homosexual in behavior. The remaining participants were classified as either heterosexual or asexual. With gender identity and sexual orientation combined, the most common long-term outcome was desistence of GID with a bisexual/homosexual sexual orientation followed by desistence of GID with a heterosexual sexual orientation. The rates of persistent gender dysphoria and bisexual/homosexual sexual orientation were substantially higher than the base rates in the general male population.
Childhood assessment data were used to identify within-group predictors of variation in gender identity and sexual orientation outcome. Social class and severity of cross-gender behavior in childhood were significant predictors of gender identity outcome. Severity of childhood cross-gender behavior was a significant predictor of sexualorientation at follow-up. Regarding psychiatric functioning, the heterosexual desisters reported significantly less behavioral and psychiatric difficulties compared to the bisexual/homosexual persisters and, to a lesser extent, the bisexual/homosexual desisters. Clinical and theoretical implications of these follow-up data are discussed.
Kraftig ökning av könsdysfori bland barn och unga
Louise Frisén, Olle Söder, Per-Anders Rydelius,
Abstract
- Under det senaste decenniet har antalet unga med könsdysfori som söker sjukvårdens insatser för köns bekräftande åtgärder ökat kraftigt.
- En minoritet (ca 20 procent) av barn <12 år med könsdysfori kommer att ha en kvarstående önskan om könsbekräftande åtgärder.
- Majoriteten av de barn vars könsdysfori förstärks i samband med puberteten uppfyller diagnoskriterierna för transsexualism och kan behandlas med pubertets stoppande hormoner i syfte att undvika utveckling av oönskade sekundära könskarakteristika.
- Tidigt insatt behandling underlättar möjligheten att framgångsrikt passera i det önskade könet och är förknippat med betydligt bättre prognos.
Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development
Riittakerttu Kaltiala-Heino1,2*, Maria Sumia2 , Marja Työläjärvi2 and Nina Lindberg3,4
Abstract
Background:
Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.
Methods:
Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.
Results:
The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.
Conclusion:
The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
Keywords:
Transsexualism, Gender dysphoria, Sex reassignment, Adolescent development
CHILDREN WITH ATYPICAL GENDER DEVELOPMENT
Louise Newman
Gender dysphoria
is the sense of discomfort with one’s biological sex and assigned gender role − may present in children from the age of 2 years. Some children may express unhappiness at their gender and often may express the desire to change sex. This can have a significant impact on child development in a broad way and also on family functioning. Families vary in their response to a child’s cross-gendered preferences or gender questions with some showing acceptance and tolerance and others expressing anxiety and a desire to resolve the issue. There are scarce data available as to the prevalence of this condition in children and there is ongoing debate about the best clinical approach to it. The evidence base about treatment in children is limited and the ethical issues are complex.
Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study
Thomas D. Steensma, Ph.D., Jenifer K. McGuire, Ph.D., M.P.H., Baudewijntje P.C. Kreukels, Ph.D., Anneke J. Beekman, B.Sc., Peggy T. Cohen-Kettenis, Ph.D.
Abstract
Objective:
To examine the factors associated with the persistence of childhood gender dysphoria (GD), and to assess the feelings of GD, body image, and sexual orientation in adolescence.
Method:
The sample consisted of 127 adolescents (79 boys, 48 girls), who were referred for GD in childhood (<12 years of age) and followed up in adolescence. We examined childhood differences among persisters and desisters in demographics, psychological functioning, quality of peer relations and childhood GD, and adolescent reports of GD, body image, and sexual orientation. We examined contributions of childhood factors on the probability of persistence of GD into adolescence.
Results:
We found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant (age at childhood assessment) and unstudied factors (a cognitive and/or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD, and varied among natal boys and girls.
Conclusion:
Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD. J. Am. Acad. Child Adolesc. Psychiatry, 2013;52(6):582–590.
Key Words:
childhood gender dysphoria, desistence, persistence, sexual orientation, social role transitioning
Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach
ANNELOU L. C. DE VRIES, MD, PhD and PEGGY T. COHEN-KETTENIS, PhD VU University Medical Center, Amsterdam, the Netherlands
The Dutch Approach
The Dutch approach on clinical management of both prepubertal children under the age of 12 and adolescents starting at age 12 with gender dysphoria, starts with a thorough assessment of any vulnerable aspects of the youth’s functioning or circumstances and, when necessary, appropriate intervention. In children with gender dysphoria only, the general recommendation is watchful waiting and carefully observing how gender dysphoria develops in the first stages of puberty. Gender dysphoric adolescents can be considered eligible for puberty suppression and subsequent crosssex hormones when they reach the age of 16 years. Currently, withholding physical medical interventions in these cases seems more harmful to wellbeing in both adolescence and adulthood when compared to cases where physical medical interventions were provided.
KEYWORDS
gender, gender identity, gender identity disorder, gender identity disorder of childhood, gender identity disorder of adolescence, gender vari
Clinical Management of Gender Dysphoria in Children and Adolescents The Dutch Approach
Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study
Thomas D. Steensma, Roeline Biemond, Fijgje de Boer, and Peggy T. Cohen-Kettenis Department of Medical Psychology, VU University Medical Centre, Amsterdam, the Netherlands
Abstract
The aim of this qualitative study was to obtain a better understanding of the developmental trajectories of persistence and desistence of childhood gender dysphoria and the psychosexual outcome of gender dysphoric children. Twenty five adolescents (M age 15.88, range 14–18), diagnosed with a Gender Identity Disorder (DSM-IV or DSM-IV-TR) in childhood, participated in this study. Data were collected by means of biographical interviews. Adolescents with persisting gender dysphoria (persisters) and those in whom the gender dysphoria remitted (desisters) indicated that they considered the period between 10 and 13 years of age to be crucial. They reported that in this period they became increasingly aware of the persistence or desistence of their childhood gender dysphoria. Both persisters and desisters stated that the changes in their social environment, the anticipated and actual feminization or masculinization of their bodies, and the first experiences of falling in love and sexual attraction had influenced their gender related interests and behaviour, feelings of gender discomfort and gender identification. Although, both persisters and desisters reported a desire to be the other gender during childhood years, the underlying motives of their desire seemed to be different. Keywords childhood gender dysphoria, Gender Identity Disorder, gender variant, psychosexual development, sexual orientation, transgender, transsexual
Desisting and persisting gender dysphoria after childhood Steensma 2011
Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study
Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study
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
Purpose:
The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions. The aim of this study was to explicate the considerations of proponents and opponents of puberty suppression in GD to move forward the ethical debate.
Methods:
Qualitative study (semi-structured interviews and open-ended questionnaires) to identify considerations of proponents and opponents of early treatment (pediatric endocrinologists, psychologists, psychiatrists, ethicists) of 17 treatment teams worldwide.
Results:
Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-) availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived. Strikingly, the guidelines are debated both for being too liberal and for being too limiting. Nevertheless, many treatment teams using the guidelines are exploring the possibility of lowering the current age limits.
Conclusions:
As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required. 2015 Society for Adolescent Health and Medicine. All rights reserved.
Gender dysphoria in adolescents: the need for a shared assessment protocol and proposal of the AGIR protocol
Gender dysphoria in adolescents: the need for a shared assessment protocol and proposal of the AGIR protocol
D. Dèttore1,2, J. Ristori2,3, P. Antonelli2 , E. Bandini2 , A.D. Fisher2,3, S. Villani2 , A.L.C. de Vries4 , T.D. Steensma4 , P.T. Cohen-Kettenis4
Abstract
In the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam, a structured assessment and treatment protocol for adolescents with atypical gender identities is used. This multidimensional approach includes specific phases: psychological assessment, medical evaluation, possible psychotherapy, gonadotropin-releasing hormone (GnRH) analogues and cross-sex hormone therapy, which are differentiated according to age and specific requirements of each individual case. Recently, a collaborative study called AGIR (Adolescent Gender Identity Research) has been proposed by the Dutch clinic to allow international and cross-clinic comparisons with regards to referral background and psychological functioning, and to evaluate the treatment of gender dysphoric adolescents. An extensive assessment and timely treatment of adolescents with gender dysphoria seems essential to support the process of awareness and structuring of the dimensions of sexual identity, to prevent frequent associated psychopathologies and to improve quality of life by promoting more adequate psychosocial adaptation. Currently, transgender health care in Italy is characterized by isolated practitioners. Thus, it is particularly important to create specialised services that use a common protocol and that are coordinated at both the national and international levels in order to respond to the increasing number of requests in this age group.
Key words
Gender identity • Gender Dysphoria • Assessment • Intervention • Protocol • Adolescents
More Than Two Developmental Pathways in Children With Gender Dysphoria?
More Than Two Developmental Pathways in Children With Gender Dysphoria?
Thomas D. Steensma, PhD Peggy T. Cohen-Kettenis, PhD Center of Expertise on Gender Dysphoria VU University Medical Center Amsterdam t.steensma@vumc.nl
LETTER TO THE EDITOR
Current prospective studies on the development of children fulfilling diagnostic criteria of gender identity disorder according to the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR have indicated that the most common psychosexual outcome is homosexuality or heterosexuality without gender dysphoria (GD).1 Across all studies, the persistence rate of GD has been approximately 16%. What should be emphasized is that these studies did not use the fairly strict criteria of the DSM-5, and children could receive the diagnosis based only on gender-variant behavior.
More Than Two Developmental Pathways in Children Steensma 2015
‘Rapid onset’ of transgender identity ignites storm
‘Rapid onset’ of transgender identity ignites storm
Meredith Wadman
Artikkel
Critics charge a study is biased, but others say politics is inhibiting science.
A study describing “rapid onset gender dysphoria” (ROGD) in teens and young adults—a sudden unease with the gender they were assigned at birth—has infuriated transgender activists while sparking a debate about academic freedom. Critics of the paper, published last month in PLOS ONE by physician-scientist Lisa Littman of Brown University, call it a flawed study that reflects an antitransgender agenda, in part because it suggests some cases may be the result of “social contagion.” Brown and the journal have both distanced themselves from the paper, drawing charges that they surrendered to political pressure.
The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. (2018)
The myth of persistence: Response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. (2018)
Kenneth J. Zucker
Abstract
Temple Newhook et al. (2018) provide a critique of recent follow-up studies of children referred to specialized gender identity clinics, organized around rates of persistence and desistance. The critical gaze of Temple Newhook et al. examined three primary issues:
(1) the terms persistence and desistance in their own right;
(2) methodology of the follow-up studies and interpretation of the data; and
(3) ethical matters. In this response, I interrogate the critique of Temple Newhook et al. (2018).
KEYWORDS
Desistance; developmental psychiatry; DSM-5; gender dysphoria; gender identity disorder; persistence; transgender
Young Adult Psychological Outcome After Puberty
Suppression and Gender Reassignment
Young Adult Psychological Outcome After Puberty
Suppression and Gender ReassignmentAnnelou L.C. de Vries, MD, PhD,a Jenifer K. McGuire, PhD, MPH,b Thomas D. Steensma, PhD,a Eva C.F. Wagenaar, MD,a Theo A.H
Abstract
BACKGROUND:
In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.
METHODS:
A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.
RESULTS:
After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Wellbeing was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.
CONCLUSIONS:
A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults. Pediatrics 2014;134:696–704
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 , 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.
The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI 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.
Effects of androgenization on the white matter microstructure of female-to-male transsexuals. A diffusion tensor imaging 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.
Transsexualism differences caught on brain scan
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.
Effects of Cross-Sex Hormone Treatment on Emotionality in Transsexuals
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
Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline
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.
Neuronal plasticity of language-related brain regions induced by long-term testosterone treatment
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
Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study.
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.
Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review.
Chew D1, Anderson J2, Williams K1,3,4, May T1,3,4,5, Pang K6,3
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.
Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study
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
Purpose
The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions. The aim of this study was to explicate the considerations of proponents and opponents of puberty suppression in GD to move forward the ethical debate.
Methods
Qualitative study (semi-structured interviews and open-ended questionnaires) to identify considerations of proponents and opponents of early treatment (pediatric endocrinologists, psychologists, psychiatrists, ethicists) of 17 treatment teams worldwide.
Results
Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived. Strikingly, the guidelines are debated both for being too liberal and for being too limiting. Nevertheless, many treatment teams using the guidelines are exploring the possibility of lowering the current age limits.
Conclusions
As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.
Keywords:
Gender dysphoria, Puberty suppression, Adolescents, Ethics, Qualitative study, Interviews, Questionnaires, Worldwide
Long term hormonal treatment for transgender people
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
The aim of hormone treatment in transgender people is to adjust their secondary sex characteristics to be more congruent with their experienced gender. Hormone treatment for transgender people is usually initiated by specialist gender clinics, but some people start hormone treatment of their own accord without a prescription. With growing numbers of transgender people presenting to healthcare services (estimated as 9.2 per 100 0001 ), general practitioners, general endocrinologists, and other doctors will become increasingly involved in their long term care, the prescription of hormones, and consideration of potential side effects. Several guidelines are available on the start of hormonal treatment2-7; the focus of this article is the long term hormonal care for transgender people who might no longer attend a specialist clinic.
Factors Associated with Gender-Affirming Surgery and Age of Hormone Therapy Initiation Among Transgender Adults
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
Purpose:
Gender-affirming surgeries and hormone therapy are medically necessary treatments to alleviate gender dysphoria; however, significant gaps exist in the research and clinical literature on surgery utilization and age of hormone therapy initiation among transgender adults.
Methods:
We conducted a retrospective review of electronic health record data from a random sample of 201 transgender patients of ages 18–64 years who presented for primary care between July 1, 2010 and June 30, 2015 (inclusive) at an urban community health center in Boston, MA. Fifty percent in our analyses were trans masculine (TM), 50% trans feminine, and 24% reported a genderqueer/nonbinary gender identity. Regression models were fit to assess demographic, gender identity-related, sexual history, and mental health correlates of genderaffirming surgery and of age of hormone therapy initiation.
Results:
Overall, 95% of patients were prescribed hormones by their primary care provider, and the mean age of initiation of masculinizing or feminizing hormone prescriptions was 31.8 years (SD = 11.1). Younger age of initiation of hormone prescriptions was associated with being TM, being a student, identifying as straight/heterosexual, having casual sexual partners, and not having past alcohol use disorder. Approximately one-third (32%) had a documented history of gender-affirming surgery. Factors associated with increased odds of surgery were older age, higher income levels, not identifying as bisexual, and not having a current psychotherapist.
Conclusion:
This study extends our understanding of prevalence and factors associated with gender-affirming treatments among transgender adults seeking primary care. Findings can inform future interventions to expand delivery of clinical care for transgender patients. Keywords: barriers to
Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study
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, MPH1,2,6
ABSTRACT
Purpose
Transgender youth represent a vulnerable population at risk for negative mental health outcomes including depression, anxiety, self-harm, and suicidality. Limited data exists to compare the mental health of transgender adolescents and emerging adults to cisgender youth accessing community-based clinical services; the current study aimed to fill this gap.
Methods
A retrospective cohort study of electronic health record (EHR) data from 180 transgender patients age 12–29 years seen between 2002–2011 at a Boston-based community health center was performed. The 106 female-to-male (FTM) and 74 male-to-female (MTF) patients were matched on gender identity, age, visit date, and race/ethnicity to cisgender controls. Mental health outcomes were extracted and analyzed using conditional logistic regression models. Logistic regression models compared FTM to MTF youth on mental health outcomes.
Results
The sample (n=360) had a mean age of 19.6 (SD=3.0); 43% white, 33% racial/ethnic minority, and 24% race/ethnicity unknown. Compared to cisgender matched controls, transgender youth had a two- to three-fold increased risk of depression, anxiety disorder, suicidal ideation, suicide attempt, self-harm without lethal intent, and both inpatient and outpatient mental health treatment (all p<0.05). No statistically significant differences in mental health outcomes were observed comparing FTM and MTF patients, adjusting for age, race/ethnicity, and hormone use.
Conclusions
Transgender youth were found to have a disparity in negative mental health outcomes compared to cisgender youth, with equally high burden in FTM and MTF patients. Identifying gender identity differences in clinical settings and providing appropriate services and supports are important steps in addressing this disparity.
Keywords:
mental health, transgender, gender minority, adolescent, health disparit
Transgender women: Evaluation and management
ABSTRACT
The terms transgender and gender incongruence describe a situation where an individual’s gender identity differs from external sexual anatomy at birth. Health care providers should be familiar with commonly used terms (table 1). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy [1].
This topic will use the term transgender in the broadest sense to include any person with incongruence between gender identity and external sexual anatomy at birth. The evaluation and management of transgender women are discussed here. The evaluation and management of transgender men, the primary care of the transgender adult, and gender diversity in children and adolescents are reviewed separately. (See “Transgender men: Evaluation and management” and “Primary care of transgender individuals” and “Gender development and clinical presentation of gender diversity in children and adolescents” and “Management of transgender and gender-diverse children and adolescents”.)
An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature.46
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.)
Chest-Wall Contouring Surgery in Female-to-Male Transsexuals: A New Algorithm
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
The role of colpocleisis transsexual phalloplasty with urethral lengthening in
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
Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism
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
Gender Confirmation Surgery, An Issue of Clinics in Plastic Surgery, E-Book (The Clinics: Surgery)
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)
Penile Reconstruction with the Radial Forearm Flap: An Update
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
Penile Reconstruction: Is the Radial Forearm Flap Really the Standard Technique?
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?
Phalloplasty: A Review of Techniques and Outcomes
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.)
Genital Sensitivity After Sex Reassignment Surgery in Transsexual Patients
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
”Det er ufattelig deilig når andre oppfatter deg som den du faktisk er!”
I hvilken grad er stemmen og dens uttrykk viktig for kjønnsidentitet hos personer med kjønnsinkongruens?
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.
Kraftig ökning av könsdysfori bland barn och unga
Louise Frisén, Olle Söder, Per-Anders Rydelius,
Abstract
- Under det senaste decenniet har antalet unga med könsdysfori som söker sjukvårdens insatser för köns bekräftande åtgärder ökat kraftigt.
- En minoritet (ca 20 procent) av barn <12 år med könsdysfori kommer att ha en kvarstående önskan om könsbekräftande åtgärder.
- Majoriteten av de barn vars könsdysfori förstärks i samband med puberteten uppfyller diagnoskriterierna för transsexualism och kan behandlas med pubertets stoppande hormoner i syfte att undvika utveckling av oönskade sekundära könskarakteristika.
- Tidigt insatt behandling underlättar möjligheten att framgångsrikt passera i det önskade könet och är förknippat med betydligt bättre prognos.
Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development
Riittakerttu Kaltiala-Heino1,2*, Maria Sumia2 , Marja Työläjärvi2 and Nina Lindberg3,4
Abstract
Background:
Increasing numbers of adolescents present in adolescent gender identity services, desiring sex reassignment (SR). The aim of this study is to describe the adolescent applicants for legal and medical sex reassignment during the first two years of adolescent gender identity team in Finland, in terms of sociodemographic, psychiatric and gender identity related factors and adolescent development.
Methods:
Structured quantitative retrospective chart review and qualitative analysis of case files of all adolescent SR applicants who entered the assessment by the end of 2013.
Results:
The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.
Conclusion:
The findings do not fit the commonly accepted image of a gender dysphoric minor. Treatment guidelines need to consider gender dysphoria in minors in the context of severe psychopathology and developmental difficulties.
Keywords:
Transsexualism, Gender dysphoria, Sex reassignment, Adolescent development
A Five-Year Follow-Up Study of Swedish Adults with Gender Identity Disorder
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),
Kjønnskorrigerende kirurgi
ved transseksualisme
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
Rett til rett kjønn – helse til alle kjønn
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.
Barn født med uklare kjønnskarakteristika
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
Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study
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;
Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in…
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.
Gender dysphoria and autism spectrum disorder: a systematic review of the literature
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.
Autism Spectrum Disorders in Gender Dysphoric Children and Adolescents
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
Vi har har en elev som vil eller har endret kjønn på skolen?
Hva gjør vi?
Som lærer så kan det være mange spørsmål og bekymringer som dukker opp når det er en elev som enten har eller skal endre kjønn eller kjønnsuttrykk.
Mange føler at de har alt for liten kunnskap om tematikken til at de skal kunne håndtere situasjonen på en slik måte så alle parter blir ivaretatt. Dette er ikke uvanlig.
HBRS kan tilby mange forskjellige tilltak for å hjelpe skolen og de ansatte til å lettere håndtere situasjonen på en god måte. Vi tilbyr samtaler med lærer, der det er rom for å stille alle spørsmål man kan sitte inne med. Vi har hørt de fleste spørsmålene før, så det er ingen feil spørsmål.
Vi kan også være behjelpelig med informasjon til elever i klassen og eventuelt andre. Dette gjør vi i samarbeid med eleven, foreldrene og skolen. Vår erfaring er at det forskjellige behov av type presentasjon fra elev til elev. Derfor vil vi ha et kartleggings møte i forkant av et eventuelt informasjonsforedrag til klassen.
Nytt navn? Juridisk kjønn?
Endring av navn og/eller juridisk kjønn?
Etter vår erfaring har personen og fagpersoner rundt et stort utbytte når samarbeide går på tvers og det er god kommunikasjon med NBTS, BUP, DPS og andre lokale tjenestene, også skole og arbeid.
Toalett, dusj og garderober?
Hvordan løser vi det, med hensyn til alle?
Når det gjelder garderobe og dusj utfordringen, så løser de aller fleste skoler det med at eleven får tilgang til en egen garderobe. Det kan være at eleven kan få benytte lærergarderoben før læreren. Eller at eleven kan gå inn i garderoben før de andre eleven. Vi vet at det også er skoler som legger kroppsøving til siste time, slik at eleven kan dusje hjemme.
Toalettet kan være utfordrende for eleven, og det kan også by på utfordringer for de andre elevene. Vi mener det er viktig å snakke med eleven og se på de ønsker eleven har, og snakke om de utfordringene som kan dukke opp. Spesielt om det er et ønske om å benytte seg av toalettene til det kjønnet eleven opplever seg som. Vi mener det også er viktig at skolen tar hensyn til alle elevene. Det kan bety at eleven må benytte seg av eventuelle unisex toaletter, og ikke toalettet til det kjønnet eleven opplever seg som. For å løse dette på best mulig måte for alle parter, så oppfordrer vi til åpenhet og en god dialog.
Hver skole har sine egne løsninger, basert på eleven og de muligheter/begrensinger skolebygget har.
Skjult eller åpen?
Vil eleven fortelle det til alle? Eller ingen?
Når det gjelder garderobe og dusj utfordringen, så løser de aller fleste skoler det med at eleven får tilgang til en egen garderobe. Det kan være at eleven kan få benytte lærergarderoben før læreren. Eller at eleven kan gå inn i garderoben før de andre eleven. Vi vet at det også er skoler som legger kroppsøving til siste time, slik at eleven kan dusje hjemme.
Toalettet kan være utfordrende for eleven, og det kan også by på utfordringer for de andre elevene. Vi mener det er viktig å snakke med eleven og se på de ønsker eleven har, og snakke om de utfordringene som kan dukke opp. Spesielt om det er et ønske om å benytte seg av toalettene til det kjønnet eleven opplever seg som. Vi mener det også er viktig at skolen tar hensyn til alle elevene. Det kan bety at eleven må benytte seg av eventuelle unisex toaletter, og ikke toalettet til det kjønnet eleven opplever seg som. For å løse dette på best mulig måte for alle parter, så oppfordrer vi til åpenhet og en god dialog.
Hver skole har sine egne løsninger, basert på eleven og de muligheter/begrensinger skolebygget har.
Tilrettelegging
Hva gjør vi?
Etter vår erfaring har personen og fagpersoner rundt et stort utbytte når samarbeide går på tvers og det er god kommunikasjon med NBTS, BUP, DPS og andre lokale tjenestene, også skole og arbeid.
Loven
Hva sier den?
Når det gjelder garderobe og dusj utfordringen, så løser de aller fleste skoler det med at eleven får tilgang til en egen garderobe. Det kan være at eleven kan få benytte lærergarderoben før læreren. Eller at eleven kan gå inn i garderoben før de andre eleven. Vi vet at det også er skoler som legger kroppsøving til siste time, slik at eleven kan dusje hjemme.
Toalettet kan være utfordrende for eleven, og det kan også by på utfordringer for de andre elevene. Vi mener det er viktig å snakke med eleven og se på de ønsker eleven har, og snakke om de utfordringene som kan dukke opp. Spesielt om det er et ønske om å benytte seg av toalettene til det kjønnet eleven opplever seg som. Vi mener det også er viktig at skolen tar hensyn til alle elevene. Det kan bety at eleven må benytte seg av eventuelle unisex toaletter, og ikke toalettet til det kjønnet eleven opplever seg som. For å løse dette på best mulig måte for alle parter, så oppfordrer vi til åpenhet og en god dialog.
Hver skole har sine egne løsninger, basert på eleven og de muligheter/begrensinger skolebygget har.
Ønsker du et hel/halvdagskurs eller et foredrag?
Sammen med en rekke fagfolk har vi utviklet et undervisningsopplegg som vi tilbyr både profesjoner, kommuner, helse- og sosial foretak og andre instanser over hele landet. Vi skreddersyr opplegget vårt slik at det passer for deg/dere.
Undervisningen er basert på kunnskapsøkning og refleksjon. Vi jobber med utgangspunkt i at det er den enkelte yrkesutøver selv som vet best hvordan han eller hun vil nærme seg tema. Vi tilbyr noen perspektiver som det så blir opp til den enkelte yrkesutøver å selv velge å bruke på den måten de kjenner seg mest komfortable med.
Foredrag/kurs er gratis, men ved lengre reiser ut av oslo, må vi få dekket reise og losji.
Arbeide terapeutisk med kjønn
Du trenger ikke å være en “spesialist” for å hjelpe unge mennesker som utforsker deres kjønnsidentitet. Faktisk, etter vurderingsprosessen, er det meste av den terapeutiske inngangen gitt utenfor Nasjonal behandlingstjenester for transseksualisme, vanligvis i BUP eller DPS. Når det er mulig, ber NBTS lokale BUP eller DPS å være involvert sammen med NBTS teamet. Når dette skjer, er NBTS-klinikere alltid tilgjengelige for kontakt med bestemte tilfeller. NBTS har utviklet noen primære terapeutiske mål som vi har brukt til å veilede vårt arbeid. Klinisk arbeid med unge mennesker kan ta en rekke formater, inkludert en-til-en-sesjoner eller stadig gruppearbeid der andre unge sammen med fagfolk kan yte støtte.
Les mer under for flere ideer om hvordan du arbeider med unge og kjønn.
Lytt og vis forståelse
Utforsk sammen med den unge personen der de er når det gjelder kjønnsidentitet, hør på å forstå (heller enn å tilby umiddelbare løsninger).
En del av din rolle kan være å hjelpe den unge personen til å finne sine egne løsninger, og avveie fordelene og ulempene med valg de vurdere (for eksempel i forhold til sosialt overgang).
Møt med respekt
Opprettholde en respektfull og ikke-dømmende tilnærming til å jobbe med personen
Dette kan innebære å bruke deres foretrukne navn og pronomen, selv om andre velger å ikke gjøre det.
Kjønnsuttrykk
Hjelp dem å eksperimentere med deres kjønnsuttrykk
Er det et trygt sted personen kan prøve ut ting (når det gjelder kjole, navn, pronomen etc) uten å måtte forplikte seg til noe?
Kjønsforståelse
Diskuter kjønnsforståelse
Kjønnsidentiet er komplisert og mangfoldig, og kan forstås som et spekter i stedet for nødvendigvis å være et binært valg mellom mann eller kvinne. Hva tenker den unge personen om denne ideen? Hvilke kjønnsrollemodeller har de? Skap mer innsikt
Ikke lukke noen dører
Hjelp personen til å holde alle muligheter åpne og gi en trygg mulighet til å utforske usikkerhet og tvil.
Unges identiteter utvikler seg gjennom ungdomsår og i voksen alder, og enkelte mennesker bestemmer seg for at de ønsker å uttrykke sin kjønnsidentitet på mange forskjellige måter, noe som kan endres over tid. Å holde valgmuligheter åpne er viktig for personen skal kunne endre seg hvis de vil. Det er mange måter å være menneske på. Det finnes ingen mal eller fasit.
Familie
Jobb med familien
Gi plass til forskjellige meninger, tanker og følelser. Det er også viktig å bli lyttet til og føle omsorg. Oppfordre til åpen kommunikasjon om kjønn, på en måte som føles trygg.
Nettverk
Tenkt nettverk
Hvem kjenner personen og hvilken støtte kan de gi, om nødvendig? Utred nettverket og gjør nytte av det.