Monthly Archives: August 2014

Effects of cross-sex hormone treatment on cortical thickness in transsexual individuals – Review of Abstract

This is an interesting study that found that taking cross-sex hormones changed the thickness of the cortex in the brain.

I have only been able to see the abstract; the study was published in May 2014 and I do not have access to it.

The study looked at 15 trans men (born female) before and after they took testosterone for at least six months. They also looked at 14 trans women (born male) before and after they took androgen blockers and estrogens for at least six months.

They found that :

“After testosterone treatment, FtMs (trans men) showed increases of CTh bilaterally in the postcentral gyrus and unilaterally in the inferior parietal, lingual, pericalcarine, and supramarginal areas of the left hemisphere and the rostral middle frontal and the cuneus region of the right hemisphere. There was a significant positive correlation between the serum testosterone and free testosterone index changes and CTh changes in parieto-temporo-occipital regions. In contrast, MtFs (trans women), after estrogens and antiandrogens treatment, showed a general decrease in CTh and subcortical volumetric measures and an increase in the volume of the ventricles.”

In other words, taking testosterone makes certain areas of your brain thicker and more testosterone changes your brain more.

Blocking testosterone and taking estrogens makes certain areas of your brain shrink. According to the abstract, this makes the ventricles get bigger – the ventricles are a network of cavities in the brain that contain cerebrospinal fluid.

We already know that there are sex differences in the thickness of the brain’s cortex, although we don’t know exactly what they mean. (You can read more about cortical thickness and what it might mean here.)

Thus study suggests that some of the sex differences we observe in the brain are related to the hormones in our bodies. Our brains are not set in stone by pre-natal exposure to hormones.

For transgender people this study shows that hormone therapy will change your brain.

It does not tell us what that will means in terms of changes in thoughts, feelings, or behaviors.

It’s also not clear if the changes in the trans women’s brains are caused by reducing the testosterone level or adding estrogen or both.

The abstract does not discuss whether the changes caused by the cross-sex hormones make the brain more “masculine” or “feminine” or neither.

It looks like this study is a follow-up to an earlier study, Cortical Thickness in Untreated Transsexuals. The earlier study found that before hormone therapy there were differences between transsexuals and control groups.

The differences the authors found in their earlier study were fairly complicated:

“We would suggest that transsexuals do not show a simple masculinization (FtMs) or feminization (MtFs) of their brains—rather, they present a complex picture in their process of sexual differentiation depending on the brain region studied and the kind of measurements taken.”

In other words, there were some ways in which trans men have brains like cis men’s and some ways in which their brains are like cis women’s while trans women have brains that are like cis women’s in some ways and like cis men’s in others.

One caveat to the pre-hormone part of the study – the authors only included people who were “erotically attracted to subjects with the same anatomical sex.” Thus, it is possible that the brain differences they observed were caused by sexual orientation, not gender identity.

Many studies of gender identity and the brain make this mistake. For example, they will compare a group of trans men who are attracted to women to a group of cis men who are attracted to women and a group of cis women who are attracted to men. It makes it impossible to be sure if any differences between the brains of trans men and cis women are due to gender identity or sexual orientation.

Studies of gender identity and the brain should include control groups of lesbians and gay men as well as straight people.

In any case, the current study shows that taking cross-sex hormones will further change the brain.

Original Article (Abstract):

Effects of cross-sex hormone treatment on cortical thickness in transsexual individuals by Zubiaurre-Elorza L, Junque C, Gómez-Gil E, Guillamon A in J Sex Med. 2014 May;11(5):1248-61.

Related blog post – Increased Cortical Thickness in Male-to-Female Transsexualism – A Review and a Hypothesis.

Comorbid childhood gender identity disorder in a boy with Asperger syndrome – Review

This is a very short article, actually published as a letter to the editor.

The authors present a case of a boy who they diagnosed with both gender dysphoria and autism. (In a later follow-up study, they found that he no longer had gender dysphoria at age 16.)

They present this case study as a counter point to the “extreme male brain” theory of autism. As they say, with the extreme male brain theory, “gender dysphoria in female subjects with Asperger syndrome (AS) could be explained logically. But a literature search yielded no boys with AS and gender identity disorder (GID). Hereby we present such a case.”

The authors diagnosed the boy with gender dysphoria based on the following criteria: feminine behaviors and speech, preferring female playmates, preference for feminine activities, lack of interest in sterotypical boy toys, liking cute characters in cartoons, always painting cute girls surrounded with hearts and flowers, dressing in girls’ clothes at home, regretting being a boy, wishing he were a girl, and saying that he would grow up to be a woman.

The child was of average intelligence and had not had delays in developing motor skills or language. However, he had “limited interactions with others, difficulty in developing peer relationships and was underresponsive in social situations. He liked making his own rules and frequently lost his temper when there were broken.” He was also preoccupied with certain colors and figures.

The authors make a distinction between gender-related symptoms in autism and gender identity disorder:

“Most of the gender-related symptoms in autistic spectrum disorder (ASD) could be related to behavioral and psychological characteristics of autism. For example, a boy with ASD might have a sense of belonging to the female sex after being bullied by male peers. Tranvestism in ASD may arise from a preoccupation with specific clothes such as a flared skirt which satisfies their tactile sensation. In their youth, ASD subjects can sometimes develop a unique confusion of identity that occasionally expands to gender-related problems. But these views do not explain the present case. For the diagnosis of GID in ASD, sufficient language abilities and sufficient follow-up time are essential. The present case fulfills these requirements.”

The authors conclude by saying that if the GID persists, they would treat the patient following international standards – i.e. he would be allowed to transition following the same protocol as anyone else.

One thing I found interesting in this article was that one of the boy’s feminine behaviors was covering his mouth with his hand when he laughed. This is something women in Japan do, but not in the West. Clearly culture plays a role in how a child expresses their gender dysphoria.

Original Article:

Comorbid childhood gender identity disorder in a boy with Asperger syndrome by Masaru Tateno md , phdYukie Tateno md, Toshikazu Saito md , phd in Psychiatry and Clinical Neurosciences Volume 62, Issue 2, page 238April 2008

Psychiatric comorbidity among patients with gender identity disorder – Partial Review

This study looked at the patients at a Japanese clinic for gender identity disorder to see if they had any other mental health issues. They did not find a high rate of autism spectrum disorders (ASDs).

This is not a review of the full study, just the information related to ASD.

Out of 579 patients that they treated, only 4 were diagnosed with Asperger’s disorder and there were no other cases of autism spectrum disorders.

In other words, less than 1% of this group had an ASD.

All of the patients with Asperger’s were born male.

This data is worth noting because it is so different from results in other countries. Are patients with autism not referred to the GID clinic in Japan? Is autism being diagnosed the same way in the different studies? Are adult patients less likely to have ASD than children and teenagers with gender dysphoria?

This data also highlights the fact the gender dysphoria and autism spectrum disorders are connected in males, not just females – in fact, in this case, they were connected only in males.

There is a theory that having an “extreme male brain” makes some girls with autism develop gender dysphoria. While that could still be true, it does not explain why males with autism would feel that they are females.

Instead of an “extreme male brain,” there might be some other mechanism that connects autism and gender dysphoria in both trans women (born male) and trans men (born female).

Another interesting aspect of the data was that they diagnosed 96% of the patients they saw with GID. Of the 24 patients who were not diagnosed with GID, half had severe psychological disorders like schizophrenia. Eight were excluded for homosexuality and four were excluded for transvestic fetishism.

I am not sure why they diagnosed such a high percentage of their patients with GID. Perhaps by the time people are referred to their clinic, they have been diagnosed by other doctors. It might also be somehow related to the definition of GID or the process of diagnosis.

I am assuming they excluded the gay patients because the patients discovered that they did not have GID and that the clinic is not excluding all gay patients. Most people with GID are attracted to people of their birth sex.

Other important results from the abstact:

“Using DSM-IV criteria, 579 patients (96.0%) were diagnosed with GID. Among the GID patients, 349 (60.3%) were the female-to-male (FTM) type, and 230 (39.7%) were the male-to-female (MTF) type. Current psychiatric comorbidity was 19.1% (44/230) among MTF patients and 12.0% (42/349) among FTM patients. The lifetime positive history of suicidal ideation and self mutilation was 76.1% and 31.7% among MTF patients, and 71.9% and 32.7% among FTM patients. Among current psychiatric diagnoses, adjustment disorder (6.7%, 38/579) and anxiety disorder (3.6%, 21/579) were relatively frequent. Mood disorder was the third most frequent (1.4%, 8/579).”

The horrifying part has been bolded. I’m putting off talking about it until another day when I can deal with it.

I’ll just add that the authors suggested that “the harsh circumstances in which most GID patients have lived in Japan might influence the high rate of suicidal ideation or self mutilation in GID patients.”

Original Article:

Psychiatric comorbidity among patients with gender identity disorder by Masahiko Hoshiai MDYosuke Matsumoto MD, PhDToshiki Sato MD, PhDMasaru Ohnishi MD, PhDNobuyuki Okabe MDYuki Kishimoto MDSeishi Terada MD, PhD, and Shigetoshi Kuroda MD, PhD in Psychiatry and Clinical Neurosciences Volume 64, Issue 5, pages 514–519, October 2010.

Comorbidity of Asperger syndrome and gender identity disorder – Review

This is a case study of a 35-year-old woman who had Asperger syndrome and gender dysphoria. The authors discuss her psychological profile in detail.

They believe that her gender dysphoria developed because she had Asperger’s syndrome.

They say:

“…we noticed over-developed logical thinking and accentuation of logical-abstract abilities, as well as an imbalance of low emotionality and a high level of instrumental, non-emotional attributes including activity, lack of emotionality and perseverance. These characteristics are generally associated with masculinity and may have led to a subjective consciousness in our patient of being male. In this regard, primary cognition and perception in AS (Asperger’s syndrome) may be interpreted as masculine attributed and pave the way to the development of the female-to-male GID (gender identity disorder). The adaptation of the male gender identity, from early life on, possibly enabled the patient to better integrate the lack of emotionality and the accentuated logical-abstract abilities. The extremely high level of masculinity can be interpreted as an additional compensatory effort to accentuate the biologically absent male side.

Taking this into account, we believe that over the years, our patient has developed GID as a consequence of adopting male emotional and cognitive traits due to AS. Following this argument, GID in this patient could be regarded as a sequel to AS.”

Although the authors think the gender dysphoria was caused by Asperger’s, they believe that because there is no treatment for Asperger’s, gender dysphoria in Asperger’s should still be treated as a “primary GID.”

The patient did well with cross-gender living and the clinic treated her for GID following international standards.

The authors refer to the theory that autism is caused by an extreme male brain and connect it to their case study.

They also refer to the “well-known exaggerated masculinity in female-to-male GID patients.”

Because of the above, the authors hypothesized that gender dysphoria could develop in a woman with Asperger’s because Asperger’s syndrome is associated with behaviors we consider masculine. Their theory fits the person in this case study. It might make sense for other trans men.

The problem with this theory, however, is that it does not explain trans women with Asperger’s.

Asperger’s syndrome is more common than would be expected among boys and men with gender dysphoria, too. There is no logical way to understand why men with extra masculine brains and behaviors would believe that they were women and want to transition.

This way of looking at the connection between Asperger’s syndrome and gender dysphoria might lead therapists to assume that a woman with Asperger’s syndrome was correct when she said she had gender dysphoria, but a man with Asperger’s syndrome was confused.

It is, of course, possible that trans men and trans women with Asperger’s syndrome want to transition for different reasons.

On the other hand, it seems simpler to think that whatever links Aspergers and gender dysphoria in men is the same thing as what links them in women.

More About the Patient from the Study:

The patient was not diagnosed with Asperger’s in her childhood, although she had some inconsistencies in her social relationships and was very interested in details and structured and geometric entities. At age 33 she asked to be examined for Aspergers; she was diagnosed with Aspergers in 2001.

The patient remembered always wanting to be a boy. She chose male playmates (although she seems to have mostly not had playmates), liked football, and acted like a tomboy. She “insisted on being a boy and refused girl’s clothing.” She had heterosexual platonic partnerships that did not work out due to her lack of social skills.

At age 34 the patient sought treatment for gender dysphoria. She was diagnosed with GID by two of the authors of the study in 2003.

The study discusses all the tests they gave her and the results. Her intelligence scores were in the upper average range with no discrepancies between verbal and performance measures. She did poorly on a test of executive function; apparently this is common in people with Asperger’s syndrome.

For a test called the Personal Attitudes Questionnaire (PAQ) she scored as less feminine and more masculine than male controls. According to the authors, “This fits the profile of patients with Asperger syndrome and is consistent with female-to-male GID.”

She also had a low score on a test of attractivity/self-confidence; the authors say this is consistent with the “body image distortions described by patients with gender identity syndrome.”

Original Article:

Comorbidity of Asperger syndrome and gender identity disorder by Kraemer B, Delsignore A, Gundelfinger R, Schnyder U, Hepp U in Eur Child Adolesc Psychiatry. 2005 Aug;14(5):292-6.

Interesting note: The patient was diagnosed with Asperger’s syndrome by the daughter of Hans Asperger.

The Kids Who Beat Autism – NYT Article

There’s a fascinating article in the NYT about children who are diagnosed with autism, but outgrow it.

The author, Ruth Padawer, discusses two studies of this phenomenon:

Intervention for optimal outcomes in children and adolescents in a history with autism,

and

Predicting young adult outcomes among more and less cognitively able individuals with autism spectrum disorders.

The experts do not know yet what caused the autism or how to cure it. They have just shown that about 10% of kids can overcome it.

Factors that increase the chance of outgrowing autism include: earlier parental concern, earlier referral to therapists, and earlier and more intense intervention. Applied Behavior Analysis (ABA) may increase the chances of a good outcome. (ABA is not appropriate therapy for gender dysphoria; there is a famous case of it being used with a gender non-conforming boy with disastrous results.)

In addition, children who start with better scores on IQ tests are more likely to do well. Presumably their autism is not as severe to start with.

The children who overcome autism may still have some symptoms, including “social awkwardness, attention deficit hyperactivity disorder, repetitive movement, mild perseverative interests and subtle difficulties in explaining cause and effect.” One of the people interviewed in the article also mentions sensory issues such as feeling that omelets are slimy or disliking the texture of paper.

However, for the group of children whose autism faded, we can’t be sure if their brains changed due to treatment, if their brains changed on their own, or if their brains were never the same as the brains of other children with autism,

Another study found that therapy could change the brain activity of children with autism.

Early Behavioral Intervention is Associated With Normalized Brain Activity in Children with Autism.

According to the New York Times, “Prior studies determined that autistic children show more brain engagement when they look at color photos of toys than at color photos of women’s faces — even if the photo is of the child’s mother. Typically developing children show the reverse, and the parts of their brain responsible for language and social interaction are more developed than those of autistic children.”

Toddlers who received “25 hours a week of a behavioral therapy designed to increase social engagement” had brain patterns like typically developing children after two years; toddler who received the regular community intervention did not.

This article is not directly related to gender dysphoria, but it is an interesting look at a condition that may be somehow linked to gender dysphoria.

Original Article:

The Kids Who Beat Autism by  Ruth Padawer in The New York Times.

Gender dysphoria in pervasive developmental disorders – Review

This article is in Japanese, so I have only seen the abstract.

In the abstract, the authors suggest that people with autism spectrum disorders (ASD) “often have identity crises which sometimes include gender dysphoria.” They speculate that when people with ASD become teenagers, they “realize their uniqueness and differences compared to others, and, as a result, they may develop confusion of identity which could be exhibited as gender identity disorder.”

They talk about a recent study that found that “amongst 204 children and adolescents who visited a GID clinic in the Netherlands, 7.8% were diagnosed with autism spectrum disorders after a careful diagnostic procedure by a multi-disciplinary team.”

The paper looks at four cases of young people with both ASD and either gender dysphoria or “related symptoms.” Their study included:

“1) a girl with PDD (pervasive developmental disorders=autism/ASD) who repeatedly asserted gender identity disorder (GID) symptoms in response to social isolation at school,

2) a junior high school boy with PDD and transvestism,

3) a boy diagnosed with Asperger’s disorder who developed a disturbance of sexual orientation, and

4) a boy with Asperger’s disorder and comorbid childhood GID.”

They believe that “Many of the clinical symptoms related to gender dysphoria might be explained by the cognitive characteristics and psychopathology of PDD.”

Without seeing more, it is hard to evaluate this study.

Nevertheless, they do not seem to have proven their case very well. Two of the four people they discuss do not sound like they have gender dysphoria.

For the other two children, it would help to know more details – did they outgrow the gender dysphoria? do they now believe that they were wrong about their gender? could they have gender dysphoria and ASD?

The authors conclude by saying that gender dysphoria has become more well-known in Japan and they are seeing more patients complaining of it.

They believe that it is important to consider an underlying diagnosis of ASD for patients with gender dysphoria; I can agree with that conclusion at least.

Original Article:

Gender dysphoria in pervasive developmental disorders by Tateno M, Ikeda H, Saito T in Seishin Shinkeigaku Zasshi. 2011;113(12):1173-83.

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder – Review

This is a March 2014 study and I am not able to read it online yet.

In the past, researchers have found that people with gender identity disorder are more likely to have autism spectrum disorders than the general public. This study came at the question from the other direction. They looked at children with autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), or a medical neurodevelopmental disorder to see if they were gender variant.

They measured gender variance by scores on the Child Behavior Checklist (CBCL) that parents had filled out. They compared the children’s scores to two control groups and the standarized scores for the CBCL.

The study found that children with ASD and ADHD were more likely to express gender variance, at least as measured by the CBCL. The children with medical neurodevelopmental disorders were not more likely to be gender variant.

This is a very intriguing, although limited, result. These children were not actually tested to see if they had gender dysphoria. What exactly does it mean that they had more gender variance than other children? Were they more likely to play with children of the opposite sex? Did they prefer toys and activities we see as suitable for the opposite sex? Did they dress differently than other children?

The big question here is whether or not these children actually wanted to be the opposite sex. If not, they did not have gender dysphoria.

Another important question is whether the children were naturally more like the other sex or just didn’t understand the socially approved gender roles, either due to ASD or to not paying attention.

On the other hand, given that children with gender dysphoria are more likely to have ASD than usual, it might be that children with ASD have more gender dysphoria than we realize.

An interesting tangent – there may be a link between ASD and ADHD. It’s not clear if they share an underlying cause or genetic predisposition or not. If there is a common cause, might it also be linked to gender dysphoria?

As usual, we need a follow-up study in this area. A useful study would look at what percentage of children, teens, and adults with ASD or ADHD have gender dysphoria.

Original Article:

Increased Gender Variance in Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder by Strang JF, Kenworthy L, Dominska A, Sokoloff J, Kenealy LE, Berl M, Walsh K, Menvielle E, Slesaransky-Poe G, Kim KE, Luong-Tran C, Meagher H, Wallace GL in Arch Sex Behav. 2014 Mar 12.