¿Cómo se está estudiando la co-ocurrencia entre trastorno del espectro autista y disforia de género en la población adolescente? / How is the co-occurrence between autism spectrum disorder and gender dysphoria being studied in the adolescent population?

En los últimos años aumentaron las investigaciones sobre co-ocurrencia de trastorno del espectro autista (TEA) y disforia de género (DG) secundario a la necesidad de una mayor comprensión de este fenómeno clínico emergente. Objetivos: Caracterizar los estudios en torno a la co-ocurrencia entre TEA y DG en adolescentes. Metodología: Se realizó una revisión sistemática bibliográfica. Se seleccionaron los estudios que mencionaron esta correlación e incluyeron población adolescente. Resultados: La búsqueda inicial arrojó un total de 97 publicaciones. Finalmente, de acuerdo a los criterios de elegibilidad, se incluyeron 35 artículos. Existen escasos estudios enfocados sólo en adolescentes, amplios rangos de prevalencia de esta relación y heterogeneidad en los instrumentos utilizados. Conclusiones: Al evaluar individuos con DG se debiese llevar a cabo un screening de TEA, y viceversa, para no pasar por alto esta co-ocurrencia. Cabe destacar que quienes presentan TEA tienen particularidades relacionadas con el pensamiento y planificación a futuro que hay que considerar al momento de realizar cualquier tipo de tratamiento afirmativo irreversible, enmarcado dentro de un proceso terapéutico multidimensional. Palabras claves: Adolescentes, Disforia de género, Trastorno de Espectro Autista (TEA), Condición de Espectro Autista (CEA), Autismo.

Research on co-occurrence of autism spectrum disorder (ASD) and gender dysphoria (GD) increased in recent years driven by the need for greater understanding of this emerging clinical phenomenon. Objective. To characterize studies on the co-occurrence of ASD and GD in adolescents. Methodology. A systematic literature review was conducted. Studies mentioning this correlation and including adolescent population were selected. Results. The initial search showed a total of 97 publications. 35 articles were included in the review that met the eligibility criteria. There are few studies focused only on adolescents, there is a wide range of prevalence of this relationship and heterogeneity in the instruments used. Conclusions. When evaluating individuals with GD, an ASD screening should be conducted,and vice versa, to avoid overlooking this cooccurrence. It is important to note that those with ASD have particularities related to cognitive development that need to be considered when undergoing any type of irreversible affirmative treatment, within a multidimensional therapeutic process. Keywords. Adolescents, Gender dysphoria, Autism Spectrum Disorder (ASD), Autism.

Relationship between Smoking and Vocal Self-perception of Trans Women

Objective: To verify the relationship between smoking, age, schooling, and the vocal self-perception of trans women. Methods: Cross-sectional observational quantitative study conducted with 24 trans women over 18 years old, living in their affirmed gender for a minimum of 6 months. Data collection involved selected questions from the translated and authorized Portuguese version of the Trans Woman Voice Questionnaire (TWVQ) and information regarding age, education, occupation, and smoking status. All variables were analyzed descriptively, and the association with smoking was assessed using Pearson's Chi-square, Fisher's Exact, Student's T, and Mann-Whitney tests, with a significance level of 5%. Results: The mean age of trans women was 28.2 +/- 6.5 years (range: 21 - 48). Most participants (41.6%) had completed their high school education and pursued diverse careers. Regarding smoking habits, 58.3% of women were either current smokers or had smoked at least 100 cigarettes in their lifetime. A statistically significant association was found between smoking and age (p = 0.001), with smokers having a lower average age (24.9 years) compared to nonsmokers (32.9 years). However, no statistical significance was observed between smoking, education, and self-perception of vocal femininity. Only 9 (37.5%) trans women perceived their voices as feminine, while 17 (70.7%) desired a more feminine-sounding voice. Limitation: The limited sample size in this study may have constrained the ability to detect significant differences between the analyzed groups using statistical tests. Conclusion: The smoking prevalence was notably high among younger trans women. However, there was no statistically significant difference in vocal self-perception between those who smoked and those who did not. The majority of trans women expressed a desire for their voices to sound more feminine, particularly among smokers.

Objetivo: Verificar la relación entre el tabaquismo, edad, escolaridad y la autopercepción vocal de mujeres trans. Métodos: Estudio observacional transversal cuantitativo realizado con 24 mujeres trans mayores de 18 años, que viven en su género afirmado durante 6 meses. Para la recolección de datos se utilizaron preguntas seleccionadas de la versión portuguesa traducida y autorizada del Trans Woman Voice Questionnaire (TWVQ) y datos sobre edad, educación, ocupación y tabaquismo. Todas las variables se analizaron descriptivamente y la asociación con el tabaquismo se realizó mediante las pruebas Chi-cuadrado de Pearson, Exacta de Fisher, T de Student y Mann Whitney, con un nivel de significación del 5%. Resultados: La edad promedio de las mujeres trans fue de 28,2 +/- 6,5 (rango 21 - 48). La mayoría de las participantes (41,6%) había terminado la escuela secundaria con carreras muy diversas. Respecto al tabaquismo, el 58,3% de las mujeres fuman actualmente o han fumado al menos 100 cigarrillos en su vida. Hubo una asociación estadísticamente significativa entre el tabaquismo y la edad (p = 0,001), en la que la edad promedio entre los fumadores (24,9 años) fue menor que la de los no fumadores (32,9 años). No hubo significación estadística entre el tabaquismo, la educación y la autopercepción vocal. Solo 9 (37,5%) mujeres trans actualmente consideran su voz femenina y 17 (70,7%) dijeron que la voz ideal podría sonar más femenina. Limitación: La pequeña casuística puede haber limitado la identificación de diferencias entre los grupos analizados a través de pruebas estadísticas. Conclusión: El tabaquismo fue alto entre las mujeres trans, especialmente las más jóvenes. La autopercepción vocal no fue estadísticamente diferente entre los grupos de fumadores y no fumadores. La mayoría de las mujeres trans dijeron que sus voces podrían sonar más femeninas, especialmente las fumadoras.

Need for gender affirming clinics-a case report on gender dysphoria in India

Evidence suggests that individuals with gender dysphoria/gender incongruence often experience a disproportionately high burden of disease, including in the domains of mental, sexual and reproductive health. Very few of the Lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ) population seek medical or surgical treatments, others do not speak up for their condition because of the societal taboo and suffer from illnesses which fully impact the potential and well-being of the individual. We present a case of a 24-year old boy who never got treated for gender dysphoria and was ignored by the family, was made fun of by the society and ended up having Paranoid disorder secondary to gender dysphoria. This clearly indicates the need specialist health care professionals who can identify the individual for proper treatment and connect him to support groups, who can guide and educate the family and the society on the need to accept the individual in a way in which he wants to be accepted.

Care of the transgender population: are the Indian gynaecology residents sufficiently trained?

Background: Over the past few years awareness on gender dysphoria has risen but accessing healthcare as a transgender person (TGP) is still challenging. Deficits in training of residents may contribute to disparities impacting their health. Hence, the pressing priority is to understand the unique need of the TGP and be equipped to offer them competent care. The aim of the current study was to assess the comfort, knowledge and training of the Obstetrics and Gynaecology residents in Tamil Nadu with regard to transgender healthcare.Methods: This was a cross sectional survey sent as a Google Form electronically to 100 residents who had recently completed their residency in obstetrics and gynecology in Tamil Nadu. The questions were designed to assess their knowledge and experience in the care of transgender population. Microsoft Excel software was used to analyze the resultsResults: The response rate for the survey was 67%. Among them, 47.1% of the residents were unaware of the current recommendations for Gender Reassignment Surgery. The expertise related to transition of people with gender dysphoria and the hormonal regimen wanted for them were lacking. While half of the residents realized their lack of competency in caring for TGP, 98.5% were ready for under going further training to improve their knowledge.Conclusions: It was observed that the residents did not have enough training and competency to adequately care for the TGP though they are ready to upskill their knowledge. Hence, efforts should be made to incorporate training modules for TGP care in Indian OBG residency curriculum and train the upcoming residents to offer quality care to all.

Gender identity disorder: role of the gynecologist

Gender dysphoria refers to distress that is caused by a sense of incongruity between an individual's self-identified gender and natal sex. Over 1.4 million adults are identified as transgender. Transpatients face many barriers when it comes to basic health needs including education, housing, and health care. Because of these barriers, many patients do not receive proper health care that they need. Additionally, because of certain high-risk behaviours as well as long-term hormonal therapy, transpatients have different routine health care needs that should be addressed in the primary care setting. Diagnosis is made in accordance with the diagnostic and statistical manual of mental disorders and treatment first involves psychiatric therapy, which can help determine a patient's true goals in regards to achieving gender identity. Patients who wish to undergo transition to the opposite sex must undergo a supervised real-life test and often are treated with hormonal therapy to develop physical characteristics consistent with their gender identity. Many of these individuals have undergone, or plan to undergo, gender-affirming surgery. While not all gender-affirming surgeries are provided by obstetricians and gynecologists (OBGYNs). It is a multi-disciplinary team which involves psychiatrist, endocrinologist, gynecologist and plastic surgeon. OBGYNs are uniquely skilled to perform certain gender-affirming surgeries such as hysterectomies, bilateral oophorectomies. In this case report we discuss the medical and surgical options available for the transgender population. In addition, it also highlights the role of gynecologists in having care for this population, and should be knowledgeable about the general principles of transgender health.

Consideraciones en población transgénero respecto a la infección por VIH, terapia antiretroviral, profilaxis preexposición (PreP) e interacción con tratamiento de reafirmación de género / Considerations in the transgender population regarding HIV infection, antiretroviral therapy, pre-exposure prophylaxis (PreP) and interaction with gender reaffirmation treatment

Resumen La infección por VIH es una epidemia global (prevalencia de 0,8%). En Latinoamérica, Chile, Brasil y Uruguay son los países con mayores índices. Entre las más afectadas están la población transgénero (OR 48,8 respecto a la población general). Múltiples factores bio-psico-sociales explican estas cifras. Bajo uso del preservativo, la idea de reafirmación de género, el temor a ser reemplazadas(os) por personas cisgéneros, presencia de comercio sexual, entre otros, influyen en las mayores tasas de infección. Se han implementado medidas de prevención del VIH, pero pocas dirigidas en específico a personas transgénero. La profilaxis preexposición (PreP) parece ser una nueva alternativa de prevención en este grupo, y la integración de las unidades de apoyo en la reafirmación de género con las unidades que entregan PreP, podrían aumentar su adherencia y cobertura. En las personas transgénero con infección por VIH existe baja adherencia a terapia antirretroviral (TARV), en parte por priorización del tratamiento hormonal y miedo a que la TARV altere su proceso de hormonización. Los pocos datos existentes muestran que la hormonización no se afecta con la mayoría de la TARV, pero algunos tratamientos hormonales podrían disminuir las concentraciones plasmáticas y tisulares de ciertos antirretrovirales. Faltan estudios que evalúen la interacción entre antirretrovirales y tratamiento hormonal de reafirmación de género.

Abstract HIV infection is a global epidemic, with a prevalence of 0.8%. In Latin America, Chile, Brazil and Uruguay are the countries with the highest rates. The transgender population is the most affected (OR of 48.8 compared to the general population). Multiple bio-psycho-social factors explain these issues. The low use of condoms for pressure from the partner, the idea of reaffirmation of gender, the fear to be replaced by a cisgender person, the presence of commercial sex, among others, influence the highest rates of infection. HIV prevention measures have been implemented, but few specifically targeted at transgender people. Pre-exposure prophylaxis (PreP) seems to be a new prevention alternative in this group, and the integration of support units in gender reaffirmation with units that deliver PreP could increase their adherence and coverage. In HIV (+) transgender people there is low adherence to antiretroviral therapy (ART), in part due to the prioritization of hormonal treatment and the fear that ART will alter their hormonalization process. The few data that exist show that hormonalization is not affected by ART, but that some hormonal treatments could lower the levels of certain antiretrovirals. More studies must be done to evaluate the interaction between antiretrovirals and gender affirming hormone therapy.

Characteristics of a Population with Gender Incongruence Assisted at a Specialized Outpatient Service in the City of Ribeirão Preto / Características de uma população com incongruência de gênero assistida em ambulatório especializado em Ribeirão Preto

Abstract Objective To identify the age when individuals first perceive gender incongruence (GI) and to compare sociodemographic data of female-to-male (FtM) and male-tofemale (MtF) transgender individuals assisted at an outpatient service. Methods The present cross-sectional study was conducted through a review of the medical records of individuals diagnosed with GI at a single specialized outpatient service in the city of Ribeirão Preto, state of São Paulo, Brazil. Results A total of 193 medical records from 2010 to 2018 were evaluated, and 109 (56.5%) patients had GI since childhood. The FtM transgender individuals perceived GI in childhood more often than the MtF transgender individuals (odds ratio [OR]: 2.06, 95% confidence interval [95%CI]: 1.11-3.81) Unattended hormone use was highest among the MtF group (69.6% versus 32.3%; OR: 4.78, 95%CI: 2.53-9.03). All of the individuals who were engaged in prostitution or were diagnosed with a sexuallytransmitted infection, including HIV, were in the MtF group. Conclusion Despite the more prevalent perception of GI in childhood among the FtM group, social issues were more prevalent among the MtF group, which may be the result of social marginalization.

Resumo Objetivo Identificar o período da vida emque indivíduos indentificaram pela primeira vez sua incongruência de gênero (IG), e comparar os dados sociodemográficos de homens e mulheres transgêneros (trans) atendidos em um ambulatório. Métodos Estudo transversal realizado por meio de revisão dos prontuários de pessoas com IG em ambulatório especializado de Ribeirão Preto, São Paulo, Brasil. Resultados Foram avaliados 193 prontuários de 2010 a 2018, e 109 (56.5%) pacientes apresentavamIG desde a infância. Homens trans perceberam a IG na infância com mais frequência do que as mulheres trans (razão de probabilidades [RP]: 2.06, intervalo de confiança de 95% [IC95%]: 1.11-3.81). O uso de hormônio sem supervisão foi maior entre as mulheres trans (69.6% versus 32.3%; RP: 4.78; IC95%: 2.53-9.03). Todos as pessoas que estavam inseridas na prostituição ou que apresentavam algum diagnóstico de infecção sexualmente transmissível, incluindo o HIV, eram mulherestrans. Conclusão Apesar da percepção mais prevalente da IG na infância entre homens trans, os agravos sociais foram mais prevalentes entre as mulheres trans, o que pode ser resultado da marginalização social.

Comparison of the anti-androgen effects of cyproterone acetate and spironolactone on male-to-female transsexuals / 中华医学美学美容杂志

Objective:To compare the anti-androgenic effect of cyproterone acetate (CPA) and spironolactone (SPL) on male-to-female transsexuals.Methods:From January 2012 to September 2021, 185 male-to-female transsexuals (95 using CPA and 90 using SPL) who visited the Peking University Third Hospital and under stable medication for ≥3 months were enrolled, aged 16 to 40 (23±5) years. General information and laboratory indicators of the last visit were collected for a cross-sectional study.Results:The median doses of antiandrogens in the CPA group and SPL group were 25 mg/d and 80 mg/d, respectively. And the median dose of oral estradiol valerate in both groups was 2 mg/d. Testosterone level in the CPA group was significantly lower than the SPL group [0.7 (0.7-1.5) nmol/L vs. 13.2(6.7-18.4) nmol/L, U= 6 970.500, P<0.001]. The CPA group also had better subjective effects on testicular atrophy, erection decrease, body hair decrease, skin softening and figure feminization (all P<0.05). The prolactin level of CPA group was significantly higher than that of SPL group [21.5 (12.6-30.1) ng/ml vs. 11.9 (7.7-20.0) ng/ml, U= 2 053.500, P<0.001]. Conclusions:CPA has a more significant effect on lowering testosterone levels than SPL, and is better than SPL in terms of testicular atrophy, erection decrease, body hair decrease, skin softening and figure feminization, albeit with a potentially higher risk of hyperprolactinemia.

Interview and treatment of a case with gender dysphoria / 四川精神卫生

This paper interviewed a case of patient with gender dysphoria via a bio-psycho-social approach. The client， a 21-year-old college student of male sex， had been into female dressing since the age of ten. As an adult， he became increasingly convinced that he should become a woman and began taking hormone therapy in secret and on an irregular basis. He felt himself trapped in a cycle of anxiety and distress， due to the concerns about the side effects of hormone therapy， and the practical problems regarding the impact on his academic and career arrangements， as well as the ways to explain himself to his parents. Through a remote psychiatric consultation， therapists provided targeted interventions based on the bio-psycho-social model.

Gender Dysphoria Publication Trends: A Bibliometric Analysis between 1900 and 2018 / Tendencias de publicación sobre disforia de género: Un análisis bibliométrico entre 1900 y 2018

Objective Research on gender dysphoria (GD) has been growing over the last decades with increasing interest in understanding and characterizing the causal relationships between psychological, genetics, hormonal, and sociocultural factors. Changes and acceptance of this condition as non-pathologic have led to significant changes in general perspective and its management over time. Our objective is to carry out a bibliometric analysis to know the publication trends and quality of evidence related to gender dysphoria. Methods A systematic search and critical review of the literature was carried out between January 1900 and December 2018 to perform a bibliometric analysis. Research was done in the following databases: OVID, PubMed, EMBASE, Scopus, Web of Science and Google Scholar. The medical subject headings (MeSh) terms used were: gender dysphoria; and surgery and psychology. The results were plotted using the VOSviewer version 1.6.8. Statistical analyses were performed with the IBM SPSS, Version 25.0. Results A total of 1,239 manuscripts were identified, out of which 1,041 were selected. The average number of cited times per year per manuscript is 1.84 (interquartile range [IQR] 0-2.33). The average impact index was 47.8 (IQR 20-111.6). The median of total citations per manuscript was 3 (IQR 0-33.1), and the highest number of citations per manuscript was 484. Most publications focus on the psychological aspects of GD, and there is a significant amount of manuscripts related to social and anthropological issues. Most articles have a low level of scientific evidence. Conclusion There is a great amount of published literature on GD; however, there is a significant level of disagreement in many respects on this topic. Regarding surgical gender-affirmation, there is a lack of information supported by high level of evidence to uphold the emerging expansion of medical practices.

Objetivo La investigación sobre la disforia de género (DG) ha crecido en las últimas décadas con un interés creciente por comprender y caracterizar las relaciones causales entre factores psicológicos, genéticos, hormonales y socioculturales. La aceptación de esta condición como no patológica ha llevado a cambios significativos en la perspectiva general y su manejo a lo largo del tiempo. Nuestro objetivo es realizar un análisis bibliométrico para evaluar las tendencias de publicación y la calidad de evidencias relacionadas con la disforia de género. Métodos Se realizó una búsqueda sistemática y revisión crítica de la literatura entre enero de 1900 y diciembre de 2018 para hacer un análisis bibliométrico. Se utilizaron los criterios de los Ítems de Informe Preferido para Revisiones Sistemáticas y Metaanálisis (Preferred Reporting Items for Systematic Reviews and Meta-analysis, PRISMA, en inglés), y la investigación se realizó en las siguientes bases de datos: OVID, PubMed, EMBASE, Scopus, Web of Science y Google Scholar. Los términos de encabezados de temas médicos (medical subject headings, MeSh, en inglés) utilizados fueron: disforia de género; y cirugía y psicología. Los resultados se trazaron utilizando VOSviewer, versión 1.6.8. Los análisis estadísticos se realizaron con el IBM SPSS, versión 25.0. Resultados Se identificaron un total de 1.239 manuscritos, y se seleccionaron 1.041. El número promedio de citas por año por manuscrito fue de 1,84 (rango intercuartil [RIC]: 0­2,33). El índice de impacto promedio fue de 47,8 (RIC: 20­111,6). La mediana del total de citas por manuscrito fue de 3 (RIC: 0­33.1), y el mayor número de citas por manuscrito fue de 484. La mayoría de las publicaciones se centran en los aspectos psicológicos de la DG, y hay una cantidad significativa de manuscritos relacionados con temas sociales y antropológicos. La mayoría de los artículos tienen un bajo nivel de evidencia científica. Conclusión Existe una gran cantidad de literatura publicada sobre disforia de género; sin embargo, existe un nivel significativo de desacuerdo en muchos aspectos sobre este tema. Con respecto a la afirmación quirúrgica, hace falta información respaldada por un alto nivel de evidencia que argumente la expansión emergente de las prácticas médicas.

Chest binding and respiratory complaints in transgender men / Uso de binder e queixas respiratórias em homens transexuais

Abstract Introduction: Chest binders are an important resource for building masculinity in transgender men without mastectomy, although they can cause respiratory and thoracic damage if misused. Objective: To analyze the association between chest binding and chest complaints in transgender men. Methods: This was a quantitative cross-sectional study conducted at the Trans Space of the Hospital das Clínicas de Pernambuco and the LGBTQI Patrícia Gomes outpatient clinic of the Lessa de Andrade polyclinic in Recife (Pernambuco State, northeastern Brazil). Sixty transgender men aged >18 years were included, and data on sociodemographics, general health, chest binding, and respiratory complaints in the thoracic region were collected. Descriptive analysis was performed, and prevalence ratios (PR) were estimated with a confidence interval (CI) of 95% to associate between binder use and complaints in the chest region. Results: The average was 27.25 years, of which 81.7% did not undergo mastectomy and 53.3% used chest binders. The use of chest binders was significantly associated with complaints in the chest region (PR = 2.73), difficulty breathing (PR = 2.27), and chest pain (PR = 1.82). Conclusion: This study demonstrated a higher prevalence of complaints in the chest and respiratory region in transgender men who use chest binders. This reinforces the need to broaden the view on the health of this population. Gender construction strategies are essential for the quality of life and mental health of transgender men, and binders are an important ally in this process.

Resumo Introdução: O uso de binder é um importante recurso para a construção da masculinidade nos homens transexuais não mastectomizados, contudo, pode acarretar danos respiratórios e torácicos se usado de forma inadequada. Objetivo: Analisar a associação entre o uso de binder e as queixas torácicas em homens transexuais. Métodos: Estudo transversal quantitativo realizado no Espaço Trans do Hospital das Clínicas de Pernambuco e no ambulatório LGBTQI Patrícia Gomes da Policlínica Lessa de Andrade, em Recife, PE. Foram incluídos 60 homens transexuais, com idade acima de 18 anos, e foram coletadas informações sociodemográficas, de saúde geral, uso de binder e queixas na região torácica. Foi realizada a análise descritiva e estimadas as razões de prevalência (RP) com intervalo de confiança (IC) de 95% para a associação entre o uso de binder e queixas na região do tórax. Resultados: A média foi de 27,25 anos; destes, 81,7% não realizaram mastectomia e 53,3% faziam uso de binder. O uso de binder teve associação significativa com queixas na região do tórax (RP = 2,73), dificuldade para respirar (RP = 2,27) e dor no tórax (RP = 1,82). Conclusão: Este estudo demonstrou que há prevalência maior de queixas na região do tórax e queixas respiratórias nos homens transexuais que fazem uso de binder. Isto reforça a necessidade de ampliar o olhar sobre a saúde dessa população. Estratégias de construção de gênero são essenciais para a qualidade de vida e saúde mental de homens transexuais, sendo o uso de binder um importante aliado neste processo.

Disforia de género y condición del espectro autista: una revisión sobre su relación / Gender disphory and autistic spectrum condition: a review on their relationship

Las temáticas referentes a la identidad de género han ganado amplia atención en las últimas décadas. Desde las primeras descripciones clásicas del autismo, ha existido interés en el estudio del proceso identitario en dicha población. En este contexto, la comprensión del desarrollo psicosexual de niños, niñas y adolescentes (NNA) con condición del espectro autista (CEA) ha cobrado relevancia dada la evidencia sugerente de una relación entre CEA y diversidad de género incluida disforia de género (DG). Este documento pretende realizar una revisión del tema desde una perspectiva del desarrollo.

Issues related to gender identity have gained wide attention in recent decades. Since the first classical descriptions of autism, there has been interest in the study of the identity process in this population. In this context, the understanding of the psychosexual development of boys, girls and adolescents (NNA) with autism spectrum condition (ASC) has gained relevance given the suggestive evidence of a relationship between ASC and gender diversity (including gender dysphoria (GD) This document aims to carry out a review of the subject from a developmental perspective.

Gender Dysphoria in the Pediatric Population: Initial Experience of a Transdisciplinary Group / Disforia de género en la población pediátrica: experiencia inicial de un grupo transdisciplinario

Introduction Although there is an increasing experience in the management of transgender individuals, this has not been thoroughly explored in children. The need to establish a comprehensive and transdisciplinary management is of critical importance. In order to solve this issue, we want to report the results of a cohort of individuals with gender dysphoria (GD) seen by our transdisciplinary group from a social and clinical and health access perspective. Methods A 10-year retrospective case series of all patients that had been seen by our transdisciplinary team was reviewed. The main demographic characteristics were described, as well as impact variables in terms of diagnosis and treatment of these individuals. A social description of each individual was described. Frequency, distribution, and central tendency measures were evaluated for data presentation. IBM SPSS Statistics for Windows, version 24.0 (IBM Corp, Armonk, NY) software was used. Results Four cases of GD were included. Three had male to female dysphoria and one female to male. The median reported age of GD awareness was 6 years old (between 4 and 8 years old), and the median time between GD awareness and the 1st medical evaluation was 7 years for all individuals. The median age at gender role expression was 12 years old (between 10 and 14 years old). All patients had already assumed their experienced gender role before the 1st evaluation by our group. The median age at the 1st evaluation by our group was 13 years old (between 10 and 16 years old); three of the patients were evaluated after initiation of puberty. In the present study, individuals with GD demonstrated having health care access barriers for their transition process. Referral times are high, and individuals with GD are cared after pubertal development, which is related to suboptimal outcomes. The spectrum of GD is broad, and management must be individualized according to expectations. Conclusion Individuals with GD face multiple access barriers that limit their possibility of being seen by a transdisciplinary team. This reflects in longer waiting times that negatively impact medical management. Gender dysphoria is a wide spectrum, and individuals should be evaluated individually by a transdisciplinary team.

Introducción En las ultimas décadas se ha ganado más experiencia en el manejo de individuos con disforia de genero (DG). Sin embargo, en la población pediátrica esto aun no se ha explorado completamente. La necesidad de ofrecer un manejo cuidadoso y transdisciplinario es de gran importancia. El objetivo de este estudio es presentar la experiencia de nuestro grupo transdisciplinario (GT) en el abordaje de pacientes con DG desde el punto de vista medico y social. Materiales y métodos Se realizó un análisis descriptivo de los casos de DG en menores de 18 años tratados en los últimos 10 años por el GT de Desórdenes del Desarrollo e Identidad Sexual. Se usaron medidas de frecuencia y tendencia central para la presentación de datos mediante el programa SPSS, versión 24.0. Se realizó un análisis descriptivo de las variables: familia y dinámica social; evaluación psiquiátrica; expectativas; barreras de acceso; y abordaje del GT. Resultados Se presentan cuatro casos de DG, tres hombre-mujer y uno mujer-hombre. La edad a la primera sensación de disforia (PSD) fue en promedio 5,7 años, y el tiempo medio entre la PSD y la primera evaluación médica (PEM) fue de 6,25 años. La edad promedio a la primera evaluación por el grupo (PEG) fue de 13,25 años; 3 individuos tenían pubertad avanzada y 1, incipiente. Dos individuos habían recibido atención médica antes de la PEG. Se identificó que, al momento de la valoración por el grupo, los individuos contaban con el apoyo de sus familiares, y el entorno escolar era cada vez más incluyente; en ninguno se identificó enfermedad psiquiátrica, y a todos se indicó acompañamiento por psicoterapia. La expectativa con el proceso fue heterogénea con respecto a procedimientos quirúrgicos, manejos hormonales y rol de género, dependiendo de las características físicas que generaban disforia (caracteres sexuales secundarios, genitales). Las barreras de acceso fueron el desconocimiento de los especialistas en primeras valoraciones y las administrativas. La decisión del grupo con respecto al manejo hormonal y quirúrgico, así como acompañamiento psicológico se individualizó para cada paciente. Conclusiones Los individuos con DG presentan barreras de acceso a soporte médico para su proceso de transición. Los tiempos de atención son prolongados; por ende, son atendidos después de desarrollar la pubertad, lo cual se relaciona con desenlaces subóptimos. El espectro de la DG es amplio y se debe individualizar el manejo según las expectativas.

Identidad de género y salud mental / Gender identity and mental health

Resumen Este artículo tiene como objetivo revisar las implicaciones de la identidad de género en la construcción psíquica y la salud mental, sin pretender ser una revisión exhaustiva, dada la complejidad del tema. Se realiza un recorrido por las definiciones conceptuales de la identidad de género, pasando por algunos modelos explicativos de la misma, como una forma de comprender esta experiencia. Además, se abordará la realidad transgénero como factor de estrés psicosocial y, desde una perspectiva clínica, sus repercusiones psíquicas, enfatizando la diferenciación de las identidades trans con la entidad diagnóstica llamada disforia de género. Finalmente, se caracterizará la disforia de género, con énfasis en el malestar subjetivo secundario a la discordancia de género, sus relaciones con otros diagnósticos psiquiátricos, sus repercusiones psicosociales y las barreras de atención médica que este grupo de personas experimenta.

This article aims to review the implications of gender identity in psychic construction and mental health, without intending to be an exhaustive review, given the complexity of this issue. A tour of the conceptual definitions of gender identity is made, going through some explanatory models of it, as a way to understand this experience. Also, transgender reality as a psychosocial stress factor will be addressed and, from a clinical perspective, its psychic repercussions, emphasizing the differentiation of trans identities with the diagnostic entity called gender dysphoria. Finally, gender dysphoria will be characterized, focusing on the subjective disconfort secondary to gender discordance, its relationships with other psychiatric diagnoses, its psychosocial repercussions and the health care barriers that this group of people experiences.

Gender dysphoria: prejudice from childhood to adulthood, but no impact on inflammation. A cross-sectional controlled study

Abstract Introduction Gender dysphoria (GD) is characterized by a marked incongruence between experienced gender and one's gender assigned at birth. Transsexual individuals present a higher prevalence of psychiatric disorders when compared to non-transsexual populations, and it has been proposed that minority stress, i.e., discrimination or prejudice, has a relevant impact on these outcomes. Transsexuals also show increased chances of having experienced maltreatment during childhood. Interleukin (IL)-1β, IL-6, IL-10 and tumor necrosis factor-alpha (TNF-α) are inflammatory cytokines that regulate our immune system. Imbalanced levels in such cytokines are linked to history of childhood maltreatment and psychiatric disorders. We compared differences in IL-1β, IL-6, IL-10 and TNF-α levels and exposure to traumatic events in childhood and adulthood in individuals with and without GD (DSM-5). Methods Cross-sectional controlled study comparing 34 transsexual women and 31 non-transsexual men. They underwent a thorough structured interview, assessing sociodemographic information, mood and anxiety symptoms, childhood maltreatment, explicit discrimination and suicidal ideation. Inflammatory cytokine levels (IL-1β, IL-6, IL-10 and TNF-α) were measured by multiplex immunoassay. Results Individuals with GD experienced more discrimination (p = 0.002) and childhood maltreatment (p = 0.046) than non-transsexual men. Higher suicidal ideation (p < 0.001) and previous suicide attempt (p = 0.001) rates were observed in transsexual women. However, no differences were observed in the levels of any cytokine. Conclusions These results suggest that transsexual women are more exposed to stressful events from childhood to adulthood than non-transsexual men and that GD per se does not play a role in inflammatory markers.

Vaginoplasty tips and tricks

ABSTRACT Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

Childhood transgenderity under the perspective of elementary school teachers / A transgeneridade infantil sob a ótica de professores de ensino fundamental / Transgeneridad infantil desde la perspectiva de los profesores de primaria

Objective: to analyze teachers' conceptions about transgenderity in childhood and to identify the possibilities and limits of working with these children in the school context. Method: a qualitative research study, carried out with 23 teachers from two municipal elementary schools. Semi-structured interviews were used to produce empirical material. As an analytical resource, the content analysis technique, thematic modality, was used. Results: six thematic categories emerged in the set of empirical material: There is transgenderity in childhood; The construction of gender identity and roles in childhood; The experience of trans children in the school context; Trans children: How to deal with?; Discussing the differences in the classroom: Is this the way?; and Dilemmas of school and family interaction. It was found that the gender dichotomy is reinforced in the classroom, causing tensions and stereotyped divisions for male and female roles. Various forms of violence have been reproduced by classmates and teachers, who, due to lack of knowledge or to unpreparedness, reinforce concepts and attitudes that lead to the maintenance of exclusion. Conclusion: the schools find it difficult to promote the inclusion of trans children. It is necessary to create strategies aimed at raising awareness and training the professionals who make up the school environment, especially teachers in the initial grades.

Objetivo: analisar as concepções de professores sobre a transgeneridade na infância e identificar as possibilidades e os limites de trabalho com essas crianças no contexto escolar. Método: pesquisa qualitativa, realizada com 23 professores de duas escolas municipais de ensino fundamental. Para produção do material empírico, empregaram-se entrevistas semiestruturadas. Como recurso analítico recorreu-se à técnica de análise de conteúdo, modalidade temática. Resultados: no conjunto do material empírico, emergiram seis categorias temáticas: Transgeneridade na infância existe; A construção de identidade e papéis de gênero na infância; A vivência de crianças trans no contexto escolar; Crianças trans: como lidar?; Discutir as diferenças em sala de aula: é o caminho?; Dilemas da interação escola e família. Constatou-se que a dicotomia de gênero é reforçada na sala de aula, ocasionando tensões e divisões estereotipadas para os papéis masculino e feminino. Diversas formas de violência vêm sendo reproduzidas por coleguinhas e professores, que por falta de conhecimento ou despreparo reforçam concepções e atitudes que levam à manutenção da exclusão. Conclusão: as escolas têm dificuldades para promover a inclusão de crianças trans. Faz-se necessária a criação de estratégias voltadas para a sensibilização e capacitação dos profissionais que compõem o ambiente escolar, sobretudo os professores das séries iniciais.

Objetivo: analizar las concepciones de los docentes sobre la transgeneridad en la infancia e identificar las posibilidades y límites de trabajar con estos niños en el contexto escolar. Método: investigación cualitativa, realizada con 23 profesores de dos escuelas primarias municipales. Para la producción de material empírico se utilizaron entrevistas semiestructuradas. Como recurso analítico se utilizó la técnica de análisis de contenido, modalidad temática. Resultados: de todo el material empírico surgieron seis categorías temáticas: La transgeneridad en la infancia existe; Construcción de roles de identidad y género en la infancia; Experiencia de los niños trans en el contexto escolar; Niños trans: ¿cómo tratarlos? Discutir las diferencias en el aula: ¿es el camino?; Dilemas de la interacción escuela y familia. Se verificó que la dicotomía de género se refuerza en el aula, provocando tensiones y divisiones estereotipadas para los roles masculino y femenino. Compañeros y profesores vienen reproduciendo diversas formas de violencia, por desconocimiento o falta de preparación refuerzan conceptos y actitudes que sostienen la exclusión. Conclusión: las escuelas tienen dificultades para promover la inclusión de niños trans. Es necesario crear estrategias dirigidas a sensibilizar y capacitar a los profesionales que integran el entorno escolar, especialmente a los docentes en los grados iniciales.

Quality of life after gender reassignment surgery in transwomen

Background: Gender dysphoria is a condition in which there is discrepancy between a person's gender identity and that person's sex assigned at birth. Gender reassignment surgery (GRS) has an important role in alleviating the distress caused by gender dysphoria and it is medically necessary. The literature on quality of life (QoL) of transgenders post-GRS is limited in India.Methods: This is a prospective study on transgender women who volunteered to undergo male to female (MtF) GRS from March 2015 to August 2017. The demographic details and the surgical complications were registered. The Quality of life using the WHOQOL-BREF questionnaire was measured both before and a year after the surgery. The data were compared and presented.Results: A total of 62 GRS were performed during the study period. In that, 43 patients are literate (69.35%) and only 31.93% are employed in a socially respectable position. Our study shows significant improvement in physical, psychological and social health domains after the Surgery. Highest improvement was observed in the psychological health domain. There were no major complications observed in our study group.Conclusions: The surgical management improved the QOL in the first three domains of WHOQOL-BREF instrument namely physical health, psychological health and social relationship. Among these three domains, there is a significant improvement in psychological health. Hence, GRS has an important role in relieving the psychological distress caused by gender dysphoria and significantly improves the quality of life postoperatively.

Disforia de género en el adulto con enfermedad coronaria. Reporte de caso y revisión de la literatura / Adult Gender Dysphoria with Coronary Disease. Case Report and Literature Review

RESUMEN Introducción: La disforia de género (DG) hace referencia a una marcada incongruencia entre la identidad de género y el sexo biológico, que genera un malestar clínico de al menos 6 meses de duración. Métodos: Reporte de caso y revisión no sistemática de la literatura. Presentación del caso: Mujer transgénero de 56 años, con historia de enfermedad coronaria y un segundo evento tromboembólico posterior a la automedicación de terapia hormonal. Después del tratamiento agudo de su afección cardiovascular, solicitó tratamiento para su DG. Discusión: La DG requiere un tratamiento multidisciplinario. La THC es el pilar del tratamiento. Se ha documentado que el uso de presentaciones orales de estrógenos puede aumentar el riesgo de eventos tromboembólicos en pacientes mayores de 40 años, principalmente cuando tienen factores de riesgo cardiovascular. Conclusiones: Se debe ofrecer un tratamiento integral a todas las personas con DG para aliviar el malestar psicológico, disminuir la comorbilidad psiquiátrica y mejorar su calidad de vida. Hasta el momento hay poca evidencia científica respecto a la THC en mujeres transgénero mayores de 40años, por lo que se recomienda una vigilancia multidisciplinaria, estrecha y rigurosa, en especial cuando hay riesgo cardiovascular.

ABSTRACT Introduction: Gender dysphoria (GD) refers to a marked incongruity between gender identity and biological sex. GD generates a significant clinical discomfort for at least six months. Methods: Case report and non-systematic literature review. Case presentation: A 56-year-old male-to-female patient, who had a history of coronary disease and a second thromboembolic event after hormone therapy (self-medicated). Once she had received acute management for the cardiovascular disease, she consulted for her GD. Discussion: GD requires multidisciplinary management. Cross-sex hormonal therapy is considered the main treatment. It has been documented that oral oestrogen preparations may increase the risk of thromboembolic events in patients over the age of 40, especially when they have cardiovascular risk factors. Conclusions: Comprehensive treatment should be offered to everyone who has GD, to relieve psychological distress, decrease psychiatric comorbidity and improve quality of life. To date, there is little scientific evidence regarding cross-sex hormonal therapy in transgender women over the age of 40; we therefore recommend multidisciplinary, close and rigorous monitoring, in particular when they have cardiovascular risk.