Monthly Archives: July 2014

Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study – Review, Part I

This is a fascinating study of a group of children with gender dysphoria. The authors interviewed them as teenagers when some of them had lost their gender dysphoria and some of them had not.

Most children diagnosed with gender dysphoria do not go on to transition; their gender dysphoria goes away. Gender dysphoria faded at puberty for 84% of the children in previous follow-up studies.*

In this study, the authors identified 53 Dutch speaking teenagers that their clinic had diagnosed with gender identity disorder before age 12.** Among these 53 teenagers, 55% had reapplied to the clinic for transition while 45% had not. The authors do not address the question of why their patients were more likely to still have gender dysphoria than in past studies.***

The authors interviewed only 25 of the 53 teenagers; 14 teenagers who applied for sex reassignment (7 male and 7 female) and 11 who did not (6 male and 5 female). They say that:

All adolescents were approached, orally or in writing, to participate in the study. Based on the principle of saturation in information (Glaser & Strauss, 1967), 25 adolescents were interviewed.

This limits the conclusions that can be drawn from the data, however, this is a qualitative study. It uses interviews to explore the development of gender dysphoria in these teenagers. This allows the authors to find directions for future research.****

Based on their interviews with the teenagers the authors found:

1. There were no differences in childhood behavior between the group that lost their gender dysphoria and the group that did not.

2. Both groups identified as the other gender as children, but when they were interviewed as teenagers, they explained it differently.

3. Both groups were uncomfortable with their bodies as children, but they explained it differently as teenagers.

4. The teenagers who requested transition were all attracted to people of their natal sex while the teenagers who no longer had gender dysphoria were mostly attracted to the opposite sex.

5. The years 10-13 were critical in the children’s development; this was when they either lost their gender dysphoria or became more dysphoric.

6. Important factors related to the development of adolescent feelings about gender were: changes in the social environment, the physical development of their bodies at puberty, and falling in love and discovering their sexual orientation.

7. For some of the girls whose gender dysphoria had faded, it was hard to transition back because they had worn boys’ clothing and been perceived as boys.

8. One of the teenagers they interviewed felt half female, half male. He did not want to transition.

The authors of the study conclude:

“Based on the significance most adolescents attribute to the period between 10 and 13, we suggest that clinicians should concentrate clearly on what happens in this phase of development.

It is recommended to specifically address the adolescents’ feelings regarding the factors that came up as relevant in our interviews (i.e. the effects of the changing social environment, the response to anticipated or actual puberty, and the emerging romantic/sexual feelings and sexual partner choice), before any medical steps are taken (e.g. to suppress further pubertal development).

As for the clinical management of children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our finding that some girls, who were almost (but not even entirely) living as boys in their childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredicatability of their child’s pychosexual outcome.

They may help their child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse. This attitude may guide them through uncertain years without the risk of creating the difficulties that would occur if a transitioned child wants to return to his/her original gender role.”

(Paragraphs and bold added by George Davis.)

Short version: Children should probably not transition socially before age 10. Parents and teachers should understand that the children may lose their gender dysphoria.

Therapists should work carefully with children who have gender dysphoria in the years between 10 and 13. Before giving them puberty blockers therapists should address the teenagers’ feelings about changing social relationships, puberty, and sexual development.

End of Part I of the Review of this study.

Original Article:

Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study by Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT in Clin Child Psychol Psychiatry. 2011 Oct;16(4):499-516

*The studies the authors cite followed a total of 246 children; only 39 of them had gender dysphoria after puberty, thus the overall persistence rate for the dysphoria was 16%. The persistence rate varied among the different studies from 2% to 27% (i.e. 73%-98% of the children stopped having gender dysphoria).

**The teenagers in the study were chosen from a total of 198 children who applied to their clinic between 2000-2007. The rest of the children did not meet the criteria for the study, although the authors don’t say if this was due to not being a teenager at the time of the study, not being diagnosed with GID, or not speaking Dutch.

***A few possibilities would be: a difference in the therapy given to the children (some therapies might be more effective than others), cultural differences in the countries where the studies were done (some cultures might make it harder to be gender non-conforming while others might make it easier to transition), a difference in the diagnostic methods (perhaps this clinic did a better job of diagnosing gender dysphoria), cultural differences in different eras, environmental differences in different eras (perhaps hormones are affecting children more now), or something about the way this study chose the 53 teenagers (this seems unlikely).

****A more serious question is that the authors do not say if they heard back from all of the teenagers they contacted. They cannot be sure that all of the teenagers who did not request further treatment were no longer dysphoric if they did not speak to them. This does not effect the results of their interviews, but it is an important issue.

Bilateral Non-arteritic Ischemic Optic Neuropathy in a Transsexual Woman Using Excessive Estrogen Dosage – Review

This is a study of a trans woman who went blind, probably because she gave herself an overdose of estrogen which caused her to have a stroke. In addition to losing her sight, she is no longer able to take any estrogen.

The main conclusion from this study is follow your doctor’s advice when it comes to taking hormones.

The article goes into a detailed discussion of the individual case and their diagnosis and treatment of the trans woman. The patient was in her early 50s and had been diagnosed with gender dysphoria. Her doctor had already started her on androgen blockers.

The trans woman had a history of type 2 diabetes, hypertension, obesity, and smoking. She was taking metformine 850 mg BID, glimepride 3 mg OD, and insulin therapy (NPH 12 Units OD.

These factors suggested that hormone therapy would be risky for her. The doctors put her on a low dose of transdermal estrogens and encouraged her to adopt a more healthy lifestyle.

The patient was doing well at losing weight and quitting smoking. Her hypertension persisted and she was given lisinopril 20 mg OD for it.

However, she was not doing well emotionally and was admitted to the Department of Psychiatry for several months for depression and “personality problems.” (I’m not sure what that last bit means.) The patient had been diagnosed previously with “mixed personality disorder with mainly cluster B traits” in addition to her gender dysphoria.

After 10 months of hormone therapy, the patient lost sight in one eye; six months later she lost some of her vision in the other eye. At this time they discovered that her estrogen levels were very high. The patient admitted that she had overdosed herself because she was impatient for feminization.

The authors conclude:

Both oral contraceptives in premenopausal and hormone replacement therapy in postmenopausal women are known to increase the risk for cardiovascular diseases, including cerebrovascular diseases (Sare, Gray, & Bath, 2008). Other cardiovascular risk factors, such as smoking, hypercholesterolemia, hypertension, and type 2 diabetes, play an even more important role (Lindenstrøm, Boysen, & Nyboe, 1993). It is advised that cardiovascular risk factors should be monitored and treated in transsexual persons before initiation of cross-sex hormone treatment (Hembree et al.,2009); however, no recommendations are available on a dosage reduction in sex hormone treatment in patients with cardiovascular risk factors.

In conclusion, we presented a case of bilateral non-arteretic anterior ischemic optic neuropathy possible associated to excessive estrogen therapy in a transsexual woman with co-morbidities. It is highly likely that these high estradiol levels were related to the cerebrovascular thrombosis and also played a role in development of the bilateral sequential NA-ION.

The authors suggest that cardiovascular risk factors should be monitored and treated before starting cross-sex hormone therapy. This is, of course, good advice.

However, the problem here was that the patient went against her doctor’s orders and overdosed on hormones. I would add a few conclusions to theirs:

1. Patients should follow their doctors orders when it comes to hormone doses.

2. Doctors should be aware that some patients may be extremely distressed and behave irrationally. They should clearly explain how long feminization takes and just as importantly, provide supportive therapy throughout the process.

3. Doctors and patients must work together as a team. Both doctors and patients have a role to play in creating that team. Patients must cooperate and be honest; doctors must earn the trust of patients.

4. We need more research on the safety of hormones and dosages for people who are older and/or in bad health.

5. We need more research on how to help someone with gender dysphoria who is unable to take hormones or who must take them at a low dosage.

Bold added by George Davis.

Orignal Article:

Bilateral Non-arteritic Ischemic Optic Neuropathy in a Transsexual Woman Using Excessive Estrogen Dosage by Wierckx K, De Zaeytijd J, Elaut E, Heylens G, T’Sjoen G. in Arch Sex Behav. 2014 Feb;43(2):407-9. doi: 10.1007/s10508-013-0187-9. Epub 2013 Sep 21.

The Role of Nasal Feminization Rhinoplasty in Male-to-Female Gender Reassignment – Review

This is a good article on nose surgery in facial feminization. The authors performed nose surgery on 12 transgender patients between 1998 and 2004. Measurements after the operation showed that the noses were more feminine. Eleven of the patients were very satisfied. One patient was unhappy with the results and had revision surgery. “Five patients stated at the 1-year visit that their nasal procedure had had one of the greatest impacts on their overall perception of themselves as female.”

Care needs to be taken to make sure the nose works after the surgery.

Although the basic techniques of nasal feminization surgery are not inherently different from rhinoplasty in general, the extensive tissue reductions often required potentially put the patient at risk of nasal valve insufficiency. Particular attention, therefore, must be paid to the preservation of nasal function. In our series, the nasal valve mechanism needed to be reconstructed in 4 patients, and there were no instances of nasal valve insufficiency in the postoperative period and at 1-year follow-up.

The authors discuss the differences between male and female noses and the surgical techniques they used to feminize the nose.

An interesting aspect of the study was that the patients chose not to do one particular procedure that would have made their noses more feminine. Just because a feature is more typically found in females does not mean that a trans woman wants to have it.

Independent observers evaluated photos of the noses and profiles before and after surgery. They found that surgery created a more feminine profile in all cases, based on measurements of the photographs.

The study does a good job of posing before and after pictures the same way, in fact, the hair in the before picture is slightly more feminine. You can clearly see that the nose is smaller.

As in other studies, it would be good to have information on whether the new nose helped the trans women to pass and whether any of them could pass before the surgery.

The study was done in the United Kingdom; the authors explain that before being diagnosed with transsexualism, the patient must live and dress as a woman for two years and have consulted a psychiatrist. The diagnosis is needed for gender reassignment surgery. Thus, the trans women in this study would have had considerable experience presenting as a woman before they had the surgery.

As in many studies, the authors are the people who did the surgery and who therefore may be biased in favor of believing it worked; however, they used independent observers to evaluate the appearance of the nose.

Overall, a good study, although the sample size is small. Future studies should address the question of whether nasal surgery helps trans women to pass and whether it improves their well-being and quality of life.

Original Article:

The Role of Nasal Feminization Rhinoplasty in Male-to-Female Gender Reassignment by S. A. Reza Nouraei, Prem Randhawa, Peter J. Andrews, Hesham A. Saleh in Arch Facial Plast Surg. 2007 Sep-Oct;9(5):318-20.

Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results – Review

This is an abstract that has been published online before the print version. I cannot find the full article yet.

This is a study of facial feminization of the forehead done on 172 patients over a four year period (2008-2012). It describes surgical techniques. They analyzed the results in terms of how the foreheads had changed. They also surveyed the patients on their satisfaction. The results are not actually given in the abstract.

The study seems to have been done by the people who did the surgery.

More later.

Original Abstract:

Facial Feminization Surgery: The Forehead. Surgical Techniques and Analysis of Results by Capitán L, Simon D, Kaye K, Tenorio T, in Plast Reconstr Surg. 2014 Jun 18. [Epub ahead of print].

Physical Appearance and Voice in Male-To-Female Transsexuals

This is an interesting study of the importance of physical appearance versus voice for passing. The authors used two panels to rate the “femaleness” of male-to-female transsexuals. They rated audio tapes, video tapes, and videos without sound.

The judges were randomly divided into two groups. “Each group of judges rated half of the subjects from the auditory-only mode and the audiovisual mode, and half of the subjects from the visual-only mode and the audiovisual mode.” This controlled for possible order or sequence effects.

The panelists did not know that they were listening to or looking at trans women.

The study found that overall the video alone was most likely to be rated female, the video with sound was next most likely, and the sound alone was least likely to be rated female.

Thus, appearance and voice work together when figuring out someone’s gender. To put it another way, a feminine appearance can make a voice sound more feminine.

There were, however, a few individuals who were rated more feminine without the visual appearance. For them, a feminine voice helped counteract a less-feminine appearance.

The study also found that in the auditory only mode of presentation, the average fundamental frequency of the voice was correlated with a female rating. The voice itself makes a difference.

It would have been good to have had the panels rate some cis women’s voices and photos for comparison.

This is a well-designed study that supports the conclusions the authors make. It underlines the importance of working on multiple factors for passing.

The authors of the study conclude:

One implication of this finding is, at any rate, that the success of vocal training in male-to-female transsexuals is not solely dependent on vocal characteristics, and that any assessment of the success of voice training should take into account the possible contribution of a client’s physical appearance. Whether or not the increase of fundamental frequency in a particular male-to-female transsexual is sufficient is probably also determined by the acceptability of the client’s physical appearance. With a physical appearance that rates high for femaleness an individual with a less female voice may nonetheless be accepted as a woman. Conversely, a female voice does not automatically guarantee that an individual will be accepted as a woman if physical appearance is not acceptable. As acceptability of physical appearance can influence perception of femaleness of the voice, speech pathologists involved in gender teams may consider devoting special attention to training clients with respect to physical markers of femaleness such as in clothing and makeup. Since physical appearance can apparently positively influence listeners’ judgment of the femaleness of the voice, extra attention to physical appearance seems worthwhile, particularly in those cases where efforts to alter an individual’s voice proved less successful and where other procedures (voice change surgery) are not an option.

Original Article:

Physical Appearance and Voice in Male-To-Female Transsexuals by John Van Borsel, Griet De Cuypere, Hilde Van den Berghe in J Voice. 2001 Dec;15(4):570-5.

Bold added by George Davis.

Patient Views of Facial Feminization Surgery

This first article is a good discussion of the experience of getting facial feminization surgery (FFS) from the point of view of a patient. She describes the process of choosing the surgeon and the procedures she wanted as well as dealing with family and friends. Olivia is extremely happy about the surgery and doesn’t mind the pain involved in recovery.

The pictures in the article aren’t labelled before and after, but Olivia looks great in all of them. She was passing successfully before the surgery.

The article was written a little under two months after the surgery; it would be good to read a follow-up from her.

I Had Facial Feminization Surgery by Olivia.


This next piece is a detailed diary of FFS in 1999 by Dr. Ousterhout. It includes many graphic pictures of post-surgery recovery.

Lynn’s FFS Diary

This is another diary with graphic pictures of recovery from 2000.

Madeline’s Facial Feminization Surgery

Despite the pain involved in recovery, Lynn and Madeline were both happy with their surgeries.

Lynn was already passing successfully before the surgery and had lived as a woman for many years without anyone knowing her history. Madeline transitioned after her surgery, so it is impossible to know if she could have passed without surgery.


This last article is a good set of guidelines for planning FFS. The author also discusses the process she went through in choosing a surgeon and surgeries to be done. She was not happy with the results and wants to help others avoid making the same mistakes.

The 7 Rules of Having FFS

The author of this article also wrote about regret after FFS. Both of these pieces were written shortly after the surgery; it would be good to read a follow-up piece.

One of the key things that seems to have gone wrong in the process here was not taking enough time before getting the surgery.

There is a reluctance to blame doctors and therapists in a situation like this last one that is troubling. Patients looking for FFS have strong feelings of gender dysphoria. Doctors and therapists need to work to help the patients figure out what they really need and want. Because surgeons make a great deal of money from FFS, there may be a need for a third party to advise the patient as well.

I would advise anyone seeking FFS to get counseling from someone who is not a surgeon. Patients might also want to bring a friend to consultations with a surgeon, particularly if they are having a hard time communicating their wishes.

Quality of life of individuals with and without facial feminization surgery or gender reassignment surgery – Review

This study is seriously flawed and overstates its conclusion that surgery is associated with improved mental-health related quality of life for trans women.

The authors of the study surveyed 247 trans women. They administered a questionnaire made from three surveys. The first part asked about the person’s age and their transition, the second part asked six questions related to their face, and the third part was the San Francisco 36-question health questionnaire (SF36v2).

The authors found that:

1. Trans women who had had any form of surgery had mental health outcomes equal to the general female population; trans women who had not had any surgery had mental health outcomes that were worse than the general population. It did not make any difference what type of surgery they had; FFS, gender reassignment surgery, or both.

2. All the trans women in their study had better physical health than the general female population.

3. Trans women who had had FFS had significantly higher scores on the six question Facial Feminization Survey than trans women who had not had FFS.

The biggest hole in this study (and you could drive a truck through it) is that the trans women who had had surgery were significantly different from the trans women who had not had surgery. The differences were important and relevant to the study’s results.

a) 95% of the surgery group were also taking hormones while only 66% of the non-surgery group were taking hormones.* It may be that the hormones and not the surgeries were responsible for the improved well-being.

b) 54% of the surgery group had transitioned more than five years ago while only 24% of the non-surgery group had transitioned more than five years ago.* It may be that being further along in transition was responsible for the improved well-being. There are many reasons this could be true including more time for family adjustment, having had more therapy, or knowing more about how to present as a woman.

It could also be that some people find that transition does not help them in the first few years of transition and drop out; this might mean that the group of people who are further along in transition does not include as many people who have difficulties with transition.

c) Facial feminization surgery and gender reassignment surgery are expensive and are usually paid for by individuals in the United States. It may be that the surgery group was significantly richer than the non-surgery group.

The finding that trans women had better physical health than the general female population is a baffling one. It suggests that the group of trans women who answered the survey were significantly different from the general population.

The finding also raises the question of whether you would expect the trans women who answered this survey to have a better mental health related quality of life than the general public.

Which brings us to the problems with the sample. The size of the sample in this study is a good one: 247 people, 100 who had surgery, 147 who did not. The sample may not be representative, however.

Participants were recruited from people who had received care from an FFS surgeon or clinic and people who were involved in transgender support groups or organizations. Most of the surveys were given online, but a paper version was given at a transgender health conference. People who have seen a surgeon are more likely to be well-off; FFS costs mentioned on one forum ranged from $23,000  to $64,000. The low end of the spectrum was for surgery abroad.

If the trans women answering the survey were in fact richer than the general public, it would explain why they had better physical health than most women. It might also mean that they should have had a better mental health quality of life than most women.

The authors do not discuss the order of the questions in the survey, but there may be another potential problem in the survey, depending on how it was done. Asking people questions about themselves can influence how they do on a test. It might be that asking people if they have had surgery or how long they have been on hormones affects their mood. Patients who want to have surgery but have not yet had it might feel sad or less confident. This might affect answers to questions about things like how happy they were in the last week. It matters if the demographic questions were at the end or the beginning.

Similarly, the questions about the face and its femininity might affect the mood of someone who wants FFS but cannot afford it.**

What about the results for the Facial Feminization Survey?

The authors say that one limitation of the survey is that it has not been tested in previous investigations. It was adapted from a survey originally designed for pre- and post-operative evaluations of the same patient. It is also a fairly brief questionnaire with only six items.

On the other hand, the questions are highly relevant ones that look at feelings about your face and how those feelings affect your life. It looks like a reasonable measurement tool.

Unfortunately, the data for this part of the survey has the same problem as the quality of life section. There are important and fairly large differences between the FFS group and the non-FFS group.

The study combines the groups that had FFS or FFS and gender reassignment surgery into one group and then combines the gender reassignment surgery only group with the non-surgery group. Because the non-surgery group is larger and includes so many more people who are not on hormones and/or are early in their transition, the non-FFS group ends up with more people who are not on hormones and/or are earlier in their transition.

So 93% of the people who had FFS were also on hormones while only 71% of the people who had not had FFS were taking hormones.* This is still a large difference and raises the question of whether trans women on hormones are happier with their faces – or just happier in general. (For any-surgery versus no-surgery the numbers are 95% vs. 66%.)

In addition, 47% of the people who had FFS had transitioned more than five years ago compared to only 32% of the people who had not had FFS.* (For any-surgery versus no-surgery the numbers are 54% vs. 24%.)

Finally, 100% of the people who had FFS had had surgery while only 17% of the non-FFS group had had surgery. It could be that any type of surgery improved mental health and therefore feelings about the face. More likely, being able to afford any type of surgery could be associated with having more money. The FFS group might be richer than the non-FFS group.

So we can’t be sure whether the FFS group felt better about their face due to FFS, hormones, or length of time since they started their transition. There might also be some other important difference that made them happier with their faces such as having a larger income.

Another concern about the study is that this seems to have been a middle-aged group of people. The mean age for the no surgery group was 46. For the FFS only group, the mean age was 51, for the gender reassignment surgery only group the mean age was 50, and for the group who had had both types of surgeries, the mean age was 49. This sample does not seem to be representative of all trans women, although it is unclear how this would affect the results.

As in many studies of FFS, one of the authors of the study is an expert in facial feminization surgery. This may mean he has a bias in favor of believing that it works.

What can we conclude from this study?

We need more research in this area!

Despite everything, this research is an important first step. We have no other studies that attempt to quantify the effects of facial feminization surgery. As doctors have said in many other studies, we need this data,

This study could have been greatly improved if the authors had controlled for hormonal status and length of time since the beginning of transition. Perhaps they can still use the data to do this.

It would also have helped if the authors had asked questions about income, education, and occupation and controlled for these important variables.

As it is, we can not conclude anything about the benefits of facial feminization surgery from this study.

The study provides some support for the idea that something about transition is beneficial to trans women. Even here, though, there is still a possibility that another factor like income was the important one.

We need someone, ideally someone with a background in psychological research, to re-do this study or one like it using a better sampling technique and controlling for important factors.

Original Article:

Quality of life of individuals with and without facial feminization
surgery or gender reassignment surgery by Tiffiny A. Ainsworth, Jeffrey H. Spiegel in Qual Life Res (2010) 19:1019–1024. 


*These numbers and other percentages were calculated by George Davis based on data tables provided in the study.

** The Facial Feminization Survey was adapted from an FFS outcomes evaluation form. The original form includes questions specifically related to whether or not the patient wants FFS or other surgery. I am assuming these questions were not used in the survey for this study; however, if they were, they might significantly affect the mood of people who want surgery but have not had it. This would be in addition to any possible effect from asking people how they felt about their face.