Cambios en los caracteres sexuales secundarios del paciente con disforia de género a consecuencia del tratamiento endocrino en Cuba / Changes in the secondary sexual characteristics of the patient with gender dysphoria as a result of endocrine therapy in Cuba

RESUMEN Introducción: La transexualidad es una incongruencia entre el sexo con el que se nace y el sexo al que se siente pertenecer, por tanto, estas personas desean cambios en su apariencia física que se logran mediante el tratamiento hormonal. Objetivo: Describir los cambios en los caracteres sexuales secundarios en pacientes con disforia de género en Cuba como consecuencia del tratamiento endocrino. Métodos: Se realizó un estudio de revisión de las historias clínicas en 76 pacientes atendidas por disforia de género en los últimos 15 años. Se extrajo la información relacionada con datos sociodemográficos y algunos cambios físicos, como resultado del traamiento hormonal. Para el análisis de los datos se obtuvieron distribuciones de frecuencia de las variables cualitativas, media y desviación estándar de las cuantitativas. Resultados: La mayoría de los pacientes corresponde a transexuales de hombre a mujer (THM). Al año, la mayoría de las personas ya tenían un estadio III o IV de desarrollo mamario (45,3 por ciento de estos tenían estadio III y el 32,3 por ciento estadio IV). Al año de iniciada la atención de los 58 pacientes, 41,4 por ciento tenían un patrón de vello triangular típico del sexo femenino con el que se identifican y a los 2 años ascendió al 80,5 por ciento. Al año se evaluaron 50 por ciento de todos los casos y en ese momento solo 5,1 por ciento mantenían un vello facial intenso y más de la mitad (56,8 por ciento), ya no tenían. Al inicio, la media del volumen testicular fue de 17,4 ml, a los 3 meses fue de 15,7 ml, a los 6 meses 14,3 ml y 9,7 ml al año. Conclusiones: Los pacientes con disforia de género en la mayoría de los casos logran cambios en los caracteres sexuales secundarios acordes al sexo con que se identifican(AU)

ABSTRACT Introduction: Transsexualism is an inconsistency between the sex with which someone was born and the sex he or she feels belong to; therefore, these subjects want to do changes in their physical appearance that are achieved through hormonal treatment. Objective: To describe changes in the secondary sexual characteristics in patients with gender dysphoria in Cuba as a result of endocrine therapy. Methods: A study was conducted to review the clinical records in 76 patients treated by gender dysphoria in the past 15 years. It was collected the information related to socio-demographic data and some physical changes as a result of the hormonal therapy. For data analysis were obtained frequency distributions of the qualitative variables, the mean and the standard deviation of the quantitative ones. Results: The majority of patients correspond to male to female transsexuals (THM, by its acronym in Spanish). A year after, the majority of the patients already studied had a stage III or stage IV of breast development (45.3 percent) of these had stage III and 32.3 percent had stage IV). A year after the start of the attention of the 58 patients, 41.4 percent had a pattern of triangular hair typical of the female sex which they feel identified with and after 2 years it increased to 80.5 percent. After a year, there were evaluated 50 percent of all cases and at that time only 5.1 percent maintained intense facial hair, and more than half (56.8 percent) had no facial hair. At the beginning, the mean of testicular volume was 17.4 mL, after 3 months it was 15.7 mL, after 6 months was 14.3 mL and 9.7 mL after a year. Conclusions: Patients with gender dysphoria in most cases achieve changes in the secondary sexual characteristics in accordance with the sex which they feel identified with(AU)

Etiology of Gender Identity.

This article reviews the current literature characterizing potential factors associated with the etiologies of gender identity. The PubMed database was searched for all literature that assessed key elements affecting development of gender identity. Current models attribute gender identity etiology to endogenous biology along with prenatal androgen exposure. However, no genetic loci or specific neuroanatomic regions have been consistently identified as the single explanation for transgender identity. Although environment may play a role in gender expression, there are no data to suggest an exogenous explanation for the development of gender identity.

Psychomedical care in gender identity dysphoria during adolescence. / Atención psicomédica en la disforia de identidad de género durante la adolescencia.

INTRODUCTION: In the clinical literature, the term gender dysphoria is used to define the perception of rejection that a person has to the fact of being male or female. In children and adolescents, gender identity dysphoria is a complex clinical entity. The result of entity is variable and uncertain, but in the end only a few will be transsexuals in adulthood. OBJECTIVES: METHODOLOGY: RESULTS AND CONCLUSIONS.

[Biological etiologies of transsexualism]. / Le point sur les étiologies biologiques de la transsexualité.

Transsexualism or gender dysphoria is a disorder of sexual identity of unknown etiology. At the biological level, one assumes atypical brain development during certain periods of its formation (genesis) notably during embryogenesis, as a result of altered hormonal influence and a particular genetic polymorphism. This article summarizes the research conducted to date in these three areas only, excluding psycho-social and environmental factors.

Transexualidad: una alteración cerebral que comienza a conocerse / Transsexualism: a brain disorder that begins to known

La transexualidad describe la condición de una persona cuyo sexo psicológico difiere del biológico. Las personas con trastorno de identidad de género sufren de forma persistente por esta incongruencia y buscan un cambio de la anatomía sexual, mediante tratamiento hormonal y quirúrgico. Esta revisión, desde una perspectiva ética, ofrece una visión de las correlaciones neurobiológicas estructurales y funcionales de la transexualidad y los procesos de cambio cerebrales por la administración de las hormonas del sexo deseado. Varios estudios demuestran un aumento de la conectividad funcional entre regiones de la corteza cerebral, que son huellas de la angustia psicosocial generada por la discordancia entre el sexo psicológico y el biológico. Tal angustia se puede atribuir a una imagen corporal incongruente debida a los cambios en la conectividad funcional de los componentes clave de la red de representación del cuerpo. Parte de los cambios de la conectividad suponen un mecanismo de defensa puesto que disocia la emoción sentida de la imagen corporal. Las personas transexuales presentan signos de feminización o masculinización de estructuras y procesos cerebrales con dimorfismo sexual y que durante la administración hormonal se desplazan parcialmente aún más hacia las correspondientes al sexo deseado. Estos cambios permiten una reducción de la angustia psicosocial. Sin embargo, un modelo de 'reasignación del sexo' no resuelve el problema, puesto que no se trata la alteración cerebral que lo causa. Se trata de una grave cuestión de ética médica. La liberación de los prejuicios para conocer lo que ocurre en el cerebro de los transexuales es una necesidad médica, tanto para definir lo que es y no es un tratamiento terapéutico, como para guiar las acciones legales

Transsexualism describes the condition when a person’s psychological gender differs from his or her biological sex. People with gender identity disorder suffer persistently from this incongruence and they search hormonal and surgical sex reassignment to the desired anatomical sex. This review, from an ethical perspective, intends to give an overview of structural and functional neurobiological correlations of transsexualism and their course under cross-sex hormonal administration. Several studies demonstrate an increased functional connectivity between cortex regions reaffirming psychosocial distress of psychologicalbiological sex incongruity. Such distress can be ascribed to a disharmonic body image due to changes in the functional connectivity of the key components of body representation network. These brain alterations seem to imply a strategic mechanism dissociating bodily emotions from bodily images. For a number of sexually dimorphic brain structures or processes, signs of feminization or masculinization are observable in transsexual individuals, who during hormonal administration seem to partly further adjust to characteristics of the desired sex. These changes allow a reduction of psychosocial distress. However, a model leading to a 'gender affirmation' does not solve the problem, since brain disorders causing it are not corrected. This is a serious medical ethics issue. Prejudices should be left aside. To know what happens in the brain of transsexuals is a medical need, both to define what is and what is not, and so to choose an adequate treatment, and to decide and guide legal actions

Dissociative symptoms in individuals with gender dysphoria: is the elevated prevalence real?

This study evaluated dissociative symptomatology, childhood trauma and body uneasiness in 118 individuals with gender dysphoria, also evaluating dissociative symptoms in follow-up assessments after sex reassignment procedures were performed. We used both clinical interviews (Dissociative Disorders Interview Schedule) and self-reported scales (Dissociative Experiences Scale). A dissociative disorder of any kind seemed to be greatly prevalent (29.6%). Moreover, individuals with gender dysphoria had a high prevalence of lifetime major depressive episode (45.8%), suicide attempts (21.2%) and childhood trauma (45.8%), and all these conditions were more frequent in patients who fulfilled diagnostic criteria for any kind of dissociative disorder. Finally, when treated, patients reported lower dissociative symptoms. Results confirmed previous research about distress in gender dysphoria and improved mental health due to sex reassignment procedures. However, it resulted to be difficult to ascertain dissociation in the context of gender dysphoria, because of the similarities between the two conditions and the possible limited application of clinical instruments which do not provide an adequate differential diagnosis. Therefore, because the body uneasiness is common to dissociative experiences and gender dysphoria, the question is whether dissociation is to be seen not as an expression of pathological dissociative experiences but as a genuine feature of gender dysphoria.

Finger length ratios in Serbian transsexuals.

Atypical prenatal hormone exposure could be a factor in the development of transsexualism. There is evidence that the 2nd and 4th digit ratio (2D:4D) associates negatively with prenatal testosterone and positively with estrogens. The aim was to assess the difference in 2D:4D between female to male transsexuals (FMT) and male to female transsexuals (MFT) and controls. We examined 42 MFT, 38 FMT, and 45 control males and 48 control females. Precise measurements were made by X-rays at the ventral surface of both hands from the basal crease of the digit to the tip using vernier calliper. Control male and female patients had larger 2D:4D of the right hand when compared to the left hand. Control male's left hand ratio was lower than in control female's left hand. There was no difference in 2D:4D between MFT and control males. MFT showed similar 2D:4D of the right hand with control women indicating possible influencing factor in embryogenesis and consequently finger length changes. FMT showed the lowest 2D:4D of the left hand when compared to the control males and females. Results of our study go in favour of the biological aetiology of transsexualism.

Lay theories of gender identity disorder.

This study examined lay theories regarding gender identity disorder (GID). Pilot interviews were completed with participants (n = 10) regarding their views on possible causes and treatments of GID. Participants (mainly young British people and students; n = 124) then completed a questionnaire that was based on the interviews and a review of the salient literature on lay theories. As hypothesized, participants believed most in biomedical causes and treatments of GID. Factor analysis (with varimax rotation) identified 4 factors in relation to causes of GID: upbringing and personal factors, pregnancy and brain abnormalities, environmental factors, and biomedical causes. Five factors that were identified in relation to the cure/treatment of GID were psychological assistance and personal factors, extreme medical and behavioral changes, alternative therapies, external factors, and medical treatments. The results indicated that participants neither agreed nor strongly disagreed about causes and cures regarding GID, but that these beliefs were logically related. Limitations, particularly of sampling, were considered.

[Transsexualism]. / Le transsexualisme.

UNLABELLED: Transsexual conditions need to be assessed for a psychological, hormonal and surgical evaluation. A multidisciplinary consent is required to perform hormonal and surgical treatment. METHOD: A critical overview has been performed (PubMed) and the main guidelines have been summarised. RESULTS: Hormonal treatments include suppression of the naturally secreted hormone and the administration of hormone of the desired sex. The main comorbidity is thrombo-embolic complications for patients under oestogene therapy. The main surgical treatment for female to male (FtM) surgery are: periareolar mastectomy if possible, hysterectomy, ovariectomy and vaginectomy and phallic reconstruction including metaidioplasty and forearm or suprapubic phalloplasty dependant of patient's wishes. The main treatments for male to female (MtF) surgery are: prosthesis mammoplasty and vaginoplasty and for some facial feminisation. The results in term of global satisfaction are high despite a relatively high rate of complications as well. CONCLUSION: Results in terms of well-being and psychological improvement justify this treatment despite its relatively high morbidity.

Evaluation and management of children and adolescents with gender identification and transgender disorders.

PURPOSE OF REVIEW: Gender identity development is poorly understood but impacted by central nervous system (CNS) factors, genes, gonadal hormones and receptors, genitalia, and social/environmental factors. Gender identity disorder (GID) is the diagnostic term to describe persons discontent with the sex they were assigned at birth and/or the gender roles associated with that sex. It is crucial that the diagnosis be verified as persistent, since gender confusion among those young persists among only a portion. RECENT FINDINGS: Recent publications do not yet provide an overall perspective but involve observations regarding outcome information, unusual variables, incidence of cross-gender behavior, and CNS differences related to GID and bi-gender descriptions. Approaches to therapy for GID and task force guidelines are noted. SUMMARY: Although the concept of gender identity is a relatively new paradigm and remains an area of active and exciting investigation, findings reported here provide items of information for understanding and treatment of GIDs and illustrate the need for further research.

Hypogonadism in a male-to-female transsexual with super obesity.

The global obesity epidemic is having a profound impact on the health of populations. From a reproductive standpoint, obesity has been associated with infertility and hypogonadism. We present the case of a 29-year-old male-to-female transsexual with super obesity (body mass index >50) who was found to have profound hypogonadism with total and free testosterone levels in the normal female reference range. There is virtually no literature on the hormonal sequelae of obesity in transsexual people. The patient was prescribed an aromatase inhibitor, letrozole 2.5 mg twice daily for 2 weeks, to determine the role of oestrogen in the hypogonadism. The aromatase inhibitor reduced the serum oestradiol concentration from 125 to 6.9 pm. There were dramatic corresponding rises in total testosterone (2.8 to 10.7 nm), luteinising hormone (4.1 to 20.5 mIU ml(-1) ) and follicle stimulating hormone (1.8 to 15.3 mIU ml(-1) ). This diagnostic test demonstrated the important role of oestrogen in mediating the hypogonadism. After the testing, the patient was started on oestrogen therapy after a careful discussion of the benefits versus risks of oestrogen therapy. We anticipate that similar cases of hypogonadism in male-to-female transsexuals will likely become more common in an era of increased obesity rates.

Gender dysphoria associated with disorders of sex development.

Disorders of sex development (DSDs) are estimated to be prevalent in 0.1-2% of the global population, although these figures are unlikely to adequately represent non-white patients as they are largely based on studies performed in Europe and the USA. Possible causes of DSDs include disruptions to gene expression and regulation-processes that are considered essential for the development of testes and ovaries in the embryo. Gender dysphoria generally affects between 8.5-20% of individuals with DSDs, depending on the type of DSD. Patients with simple virilizing congenital adrenal hyperplasia (CAH), as well as those with CAH and severe virilization, are less likely to have psychosexual disorders than patients with other types of DSD. Early surgery seems to be a safe option for most of these patients. Male sex assignment is an appropriate alternative in patients with Prader IV or V DSDs. Patients with 5α-reductase 2 (5α-RD2) and 17ß-hydroxysteroid dehydrogenase 3 (17ß-HSD3) deficiencies exhibit the highest rates of gender dysphoria (incidence of up to 63%). Disorders such as ovotesticular DSD and mixed gonadal dysgenesis are relatively rare and it can be difficult to conclusively evaluate patients with these conditions. For all DSDs, it is important that investigators and authors conform to the same nomenclature and definitions to ensure that data can be reliably analysed.

Clinical management of gender dysphoria in children and adolescents: 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 cross-sex 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.

A developmental, biopsychosocial model for the treatment of children with gender identity disorder.

This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto. The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provide clinical examples of how the model is used in the treatment.

The dynamic development of gender variability.

We diagram and discuss theories of gender identity development espoused by the clinical groups represented in this special issue. We contend that theories of origin relate importantly to clinical practice, and argue that the existing clinical theories are under-developed. Therefore, we develop a dynamic systems framework for gender identity development. Specifically, we suggest that critical aspects of presymbolic gender embodiment occur during infancy as part of the synchronous interplay of caregiver-infant dyads. By 18 months, a transition to symbolic representation and the beginning of an internalization of a sense of gender can be detected and consolidation is quite evident by 3 years of age. We conclude by suggesting empirical studies that could expand and test this framework. With the belief that better, more explicit developmental theory can improve clinical practice, we urge that clinicians take a dynamic developmental view of gender identity formation into account.

Thoughts on the nature of identity: how disorders of sex development inform clinical research about gender identity disorders.

Disorders of sex development (DSD), like gender dysphoria, are conditions with major effects on child sexuality and identity, as well as sexual orientation. Each may in some cases lead to change of gender from that assigned neonatally. These similarities-and the conditions' differences-provide a context for reviewing the articles in this issue about clinical approaches to children with gender dysphoria, in relation to assessment, intervention, and ethics.

Apples to committee consensus: the challenge of gender identity classification.

The debate surrounding the inclusion of gender dysphoria/gender variant behavior (GD/GV) as a psychiatric diagnosis exposes many of the fundamental shortcomings and inconsistencies of our current diagnostic classification system. Proposals raised by the authors of this special issue, including basing diagnosis on cause rather than overt behavior, reclassifying GD/GV behavior as a physical rather than mental condition, and basing diagnosis on impairment or distress, offer some solutions but have limitations themselves given the available database. In contrast to most accepted psychiatric conditions where emphasis is placed on ultimately changing internal thoughts, feelings, and behaviors, consensus treatment for most GD/GV individuals, at least from adolescence onward, focuses on modifying the external body and external environment to maximize positive outcomes. This series of articles illustrating the diversity of opinions on when and if gender incongruence should be considered pathological reflects the relative lack of scientific indicators of disease in this area, similar to many other domains of mental functioning.

Gender dysphoric/gender variant (GD/GV) children and adolescents: summarizing what we know and what we have yet to learn.

The optimal approach to treating minors with gender dysphoria/gender variance (GD/GV) is much more controversial than treating these phenomena in adults. This is because children have limited capacity to participate in decision making regarding their own treatment, and even adolescents have no legal ability to provide informed consent. Minors must, therefore, depend on parents or other caregivers to make treatment decisions on their behalf, including those that will influence the course of their lives in the long term. Presently, the highest level of evidence available for selecting among the various approaches to treatment is best characterized as "expert opinion." Yet, opinions vary widely among experts and are influenced by theoretical orientation and assumptions and beliefs regarding the origins of gender identity, as well as its perceived malleability at particular stages of development. This article outlines some of the more salient points raised by the clinicians who treat GD/GV and their discussants. This article summarizes what the editors believe is known and what has yet to be learned about minors with GD/GV, their families, their treatment, and their surrounding cultures.

Status of sex reassignment surgery for gender identity disorder in Japan.

An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as gender identity disorder. In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called male-to-female and female-to-male gender identity disorder, respectively. Although the precise pathogenesis of gender identity disorder remains unclear, the prevalence of gender identity disorder is quite high, with the rates calculated for male-to-female to be 1:25,000 and female-to-male to be 1:12,000 in Hokkaido, Japan. The diagnosis and treatment of gender identity disorder in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition. Although gender identity disorder was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and sex reassignment surgery are considered. However, there are very few institutions that routinely carry out sex reassignment surgery in Japan, even though it is mandatory for changing sex on the census register at the present time. Sex reassignment surgery for male-to-female and female-to-male patients includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty, and hysterectomy, ovariectomy, metoidioplasty and phalloplasty, respectively. To provide accurate information about physical treatment for patients with gender identity disorder, even urologists who are not actively involved in the diagnosis and treatment of gender identity disorder should understand the fundamental aspects and contemporary problems of gender identity disorder.