Transgender people: health at the margins of society.

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Evidence regarding cosmetic and medically unnecessary surgery on infants.

The Journal of Pediatric Urology has recently published several articles from the Annecy (France) Working Party on DSD. We question several of the presented findings and recommendations. In two key articles summarizing their review, the authors concluded that identified studies are not representative and suffer from methodological weaknesses, such that they "lack the necessary detail to base further recommendations". In a third article, the Working Party reported that the science supporting early surgery is "scanty", and that "no studies" support the belief that gender variant children require early genital surgery. Nevertheless, the Working Party warned that without long-term research, "if no effort is made, we will be left, in the next generation, to continue making the same judgment, based on 'experience' and 'expert opinion'". None of the studies cited in the articles support such assertions as we read them. We maintain that reviewed evidence suggests a moratorium on early surgical intervention is imperative for children with differences in sex development, and that the best ethical and scientific considerations require that gender surgery should be delayed until the child can consent. We further present evidence that UN and case law presently under way in the USA support such a moratorium.

Surviving a gender-variant childhood: the views of transgender adults on the needs of gender-variant children and their parents.

Adults with gender-variant childhoods have often lived traumatic lives because of the attitudes and limited understanding that people in their environment had of the concept of gender variance. This study explores the childhoods of transgender adults with the aim to understand their gender-related difficulties as children, in order to identify their needs and the needs of their parents at that time. The authors conducted a semi-structured survey with 110 transgender adults in order to explore their retrospective childhood experiences. Responses were analyzed through content and thematic coding. Their needs most commonly identified as children were for educated authority figures; acceptance and support to discuss their gender variance; freedom of identity expression; validation; and recognition. The needs most commonly allocated to their parents were access to information, education to increase other's awareness, peer support, and access to educated professionals.

Developmental, sexual and reproductive neuroendocrinology: historical, clinical and ethical considerations.

Different milestones have marked the development of the field of neuroendocrinology. This is an essay in which a new direction is proposed; one in which the field is marked more by a concern for ethical considerations than experimental procedures. Among the primary concerns is the need for a national registry for intersex and transsexual cases to follow how they are managed and to assess the long-term results. As in Europe, the data in the registries should be available to qualified and certified researchers and clinicians for analysis. A secondary focus is on the surgery often imposed in cases of intersex. Many current procedures have been found to have negative effects. The overall aim is to provide better management and treatment. Other topics are offered for ethical consideration.

Pornography and sex crimes in the Czech Republic.

Pornography continues to be a contentious matter with those on the one side arguing it detrimental to society while others argue it is pleasurable to many and a feature of free speech. The advent of the Internet with the ready availability of sexually explicit materials thereon particularly has seemed to raise questions of its influence. Following the effects of a new law in the Czech Republic that allowed pornography to a society previously having forbidden it allowed us to monitor the change in sex related crime that followed the change. As found in all other countries in which the phenomenon has been studied, rape and other sex crimes did not increase. Of particular note is that this country, like Denmark and Japan, had a prolonged interval during which possession of child pornography was not illegal and, like those other countries, showed a significant decrease in the incidence of child sex abuse.

Pornography, public acceptance and sex related crime: a review.

A vocal segment of the population has serious concerns about the effect of pornography in society and challenges its public use and acceptance. This manuscript reviews the major issues associated with the availability of sexually explicit material. It has been found everywhere it was scientifically investigated that as pornography has increased in availability, sex crimes have either decreased or not increased. It is further been found that sexual erotica has not only wide spread personal acceptance and use but general tolerance for its availability to adults. This attitude is seen by both men and women and not only in urban communities but also in reputed conservative ones as well. Further this finding holds nationally in the United States and in widely different countries around the world. Indeed, no country where this matter has been scientifically studied has yet been found to think pornography ought be restricted from adults. The only consistent finding is that adults prefer to have the material restricted from children's production or use.

Clinical implications of the organizational and activational effects of hormones.

Debate on the relative contributions of nature and nurture to an individual's gender patterns, sexual orientation and gender identity are reviewed as they appeared to this observer starting from the middle of the last century. Particular attention is given to the organization-activation theory in comparison to what might be called a theory of psychosexual neutrality at birth or rearing consistency theory. The organization-activation theory posits that the nervous system of a developing fetus responds to prenatal androgens so that, at a postnatal time, it will determine how sexual behavior is manifest. How organization-activation was or was not considered among different groups and under which circumstances it is considered is basically understood from the research and comments of different investigators and clinicians. The preponderance of evidence seems to indicate that the theory of organization-activation for the development of sexual behavior is certain for non-human mammals and almost certain for humans. This article also follows up on previous clinical critiques and recommendations and makes some new suggestions.

Sex, gender, and identity over the years: a changing perspective.

This article attempts to put changing terms, emphases, and views on the interrelated, but separate, concepts of sex, gender, and identity into perspective. Often, these facets of a person's life are intermingled and confused. To understand individuals whose lives are touched by any aspect of sexuality that is of interest to the medical community, knowledge of how these terms have developed and changed over the years seems of particular value. The article also tries to show the relevance of certain concepts in dealing with the specific issues of intersex. Here, medical management and ethical thinking about dealing with such conditions also have undergone change. It is probable that the terms and treatment modalities that are associated with sex- and gender-related conditions will continue to evolve as we learn more about them.

Androgen insensitivity syndrome and Klinefelter's syndrome: sex and gender considerations.

Two of the most common intersex conditions, androgen insensitivity and Klinefelter's syndrome, are described with an emphasis on aspects that are of relevance to psychiatrists. Attention is focused on commonalities and differences between these syndromes and particular attention is given to how persons who have these conditions manifest sexual and gender adjustments to their situations. Tips on counseling and medical management are offered.