Tag Archives: 2014

Orgasm after Vaginoplasty

Orgasm and sexual pleasure are important goals of gender reassignment surgery (GRS). Most trans women report being able to orgasm after penile-inversion vaginoplasty with clitoroplasty using the glans penis.* However, some are not able to orgasm and some report difficulty orgasming.

Two large studies found that 18% of trans women were not able to orgasm by masturbation after surgery. In one of the studies an additional 30% of the women had difficulty orgasming from masturbation.

The number of women who couldn’t orgasm went down to 14% or 15% when they included all sexual activities.

Other recent studies** have found numbers of anorgasmic women ranging from 0% to 52%, although most results were close to 18%.

It is clear that a significant percentage of trans women are not able to orgasm after this type of vaginoplasty, but it is not clear exactly how many.

SOME RECENT STUDIES OF ORGASM AFTER GRS

There were five studies where the women had clearly been sexually active:

Lawrence, 2005 – anonymous questionnaires from 232 trans women, 227 answered the question on orgasm by masturbation:

18% were never able to achieve orgasm by masturbation.

15% were rarely able to orgasm with masturbation.

15% were able to orgasm less than half the time by masturbation.

However, it seems that only 15% were completely unable to orgasm. “About 85% of participants who responded to questions about orgasm were orgasmic in some manner after SRS [GRS].” 

Imbimbo et al., 2009 – 139 trans women (93 questionnaires at clinic, 46 phone interviews):

14% of the trans women complained of anorgasmia

18% of the trans women were never able to orgasm by masturbation (out of 33 women who masturbated)

33% of the trans women were never able to orgasm by vaginal intercourse and 25% seldom orgasmed this way (out of 60 women having vaginal intercourse)

22% of the trans women were never able to orgasm by anal sex and 13% seldom did (out of 75 women having anal sex)

56 women had oral sex, but the study gives no numbers for orgasm.

Buncamper et al., 2015 – 49 trans women completed questionnaires:

10% had not had orgasm after surgery, although they had tried.

Selvaggi et al., 2007 – 30 trans women were personally interviewed by a team of experts:***

15% had not experienced orgasm after surgery during any sexual practice.

Giraldo et al., 2004  – 16 trans women were given structured interviews at follow-up visits:

0% had problems – all the women reported the ability to achieve orgasm

Note: This study is about a modification to the technique for creating a clitoris.

There is one study where 18% of the women never orgasmed after surgery, but it is not clear if they were sexually active or not:

Hess et al., 2014 – 119 trans women completed anonymous questionnaires, 91 answered the question “How easy it is for you to achieve orgasm?”:

18% said they never achieve orgasm

19% said it was rarely easy for them to achieve orgasm

The other studies above asked about sexual activity or gave the women an option to say the question did not apply or they had not tried. This one did not.

On the other hand, some people did not answer the question, so perhaps women who were not sexually active skipped the question on orgasm.

There are three studies that only give brief information on how many women could orgasm; it is not clear what is going on with the rest of the women.

Perovic et al., 2000 – 89 trans women were interviewed:

It looks like 18% had not experienced orgasm during vaginal sex, but it is possible that some of the women were not sexually active.

“Information on sensitivity and orgasm was obtained by interviewing the patients; the sensitivity was reportedly good in 83, while 73 patients had experienced orgasm.”

and

“If the penile skin is insufficient, the creation of the vagina depends on the urethral flap, which also provides moisture and sensitivity to the neovagina. The results of the interviews showed that orgasm was mainly dependent on the urethral flap.”

Goddard et al., 2007 – 70 trans women were interviewed by a telephone questionnaire; 64 of them had had a clitoroplasty:

It looks like 52% of the women with clitorises were not able to achieve clitoral orgasm, but again it is not clear if they were sexually active.

“Clitoral sensation was reported by 64 patients who had a neoclitoris formed and 31 (48%) were able to achieve clitoral orgasm.”

14% of the women complained of “uncomfortable clitoral sensation.”****

Wagner et al. (2010), – 50 trans women completed a questionnaire:

It looks like between 17% and 30% were not able to achieve clitoral orgasm.

“Of the 50 patients, 35 (70%) reported achieving clitoral orgasm” but

“90% of the patients were satisfied with the esthetic results and 84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm.” 

If we look only at the group having regular intercourse, 17% of them are not having clitoral orgasms. But were the women not having intercourse masturbating and unable to orgasm? If so, they were also sexually active and the 30% number is the relevant one.

The study gives very little information on the questionnaire and results, but it seems surprising that 83% of the women were having clitoral orgasms from sexual intercourse; that is not typical in cis women.

A final study asked about pleasurable sexual intercourse, not orgasm:

Salvador et al., 2012 – 52 trans women participated in the study. It is unclear how they were surveyed, but based on this earlier study, it could have been a combination of a questionnaire and interview.

8% did not consider vaginal sex pleasurable.

However, only one woman said sexual intercourse was unsatisfactory (2%) while 10% of the women said it was average; presumably some of the women who said it was average also said it was pleasurable and some did not.

About Orgasms

Freud believed that women had vaginal and clitoral orgasms; unfortunately he also believed that vaginal orgasms were superior and mature women should give up clitoral orgasms. In the 1960s Masters and Johnson showed the physiological basis for clitoral orgasms in the lab; they argued that orgasms during intercourse were also clitoral orgasms, just harder to achieve. More recently, some sexologists have shown that some women have G-spot orgasms during intercourse, although not all experts believe in them.

For most women it is easiest to have an orgasm from masturbation or clitoral stimulation. Most women are not able to have clitoral orgasms during vaginal intercourse without additional clitoral stimulation. Some women experience other types of orgasms during vaginal intercourse.

Although trans women’s biology is somewhat different from cis women’s, their clitorises are formed from the most sensitive area of the penis. Therefore, we might expect trans women to have orgasms most easily from masturbation of the clitoris; the study by Imbimbo et al. that compares different sexual activities supports this hypothesis.

It also makes sense that when we look at orgasms from all sexual activities, we find more trans women are able to orgasm than when we look at just clitoral orgasms; some trans women may be having G-spot orgasms involving their prostate gland.

Interestingly, Imbimbo et al. found that it was easier for trans women to have orgasms from anal sex than vaginal sex (65% of the women often had orgasm from anal sex, 35% seldom or never did; 42% of the women always or often had orgasm from vaginal sex and 58% seldom or never did). Furthermore, more of the trans women were having anal sex than vaginal sex (54% versus 43%). Perhaps they had more experience with anal sex before surgery or perhaps anal sex worked better for some women.

Studies that simply ask about orgasm without talking about what type of orgasm or sexual activity is involved do not give enough information about what is happening. Future studies that include this information would make it easier to compare the results and to improve outcomes.

Comparing the Studies

It is difficult to compare the results of the studies. The studies are of surgery at different clinics around the world; the work is being done by different surgeons and may involve variations in technique. Some of the surgeries are more recent than others as well.

In addition, the studies use different methodologies to collect data and they do not ask the same questions. Some are focused on clitoral orgasms, others talk about orgasm during intercourse, some studies talk about masturbation, and some are vague about what they mean by orgasm.

As is common in follow-up studies, almost all of the studies had a significant drop-out rate; not everyone who had the surgery participated in the study. This could create a bias in either direction – people who regret the surgery might be too depressed to respond to the clinic or people who were dissatisfied might be more motivated to participate in the study.

The method of the study could also introduce biases; people may be more likely to tell the truth in an anonymous survey than in an interview. On the other hand, interviews may allow for follow-up questions and clarifications.

With only 10 studies that are so different it is impossible to come to any definitive conclusions about orgasm after GRS. I like to believe that Goddard et al.’s numbers of anorgasmic women are so high because some of them were sexually inactive or because their study included women 9-96 months after surgery. It could also be something to do with their surgical technique. After all Perovic’s et al.’s study also included women 0.25-6 years after surgery and some of them may have been sexually inactive, but their numbers were much better.

I suspect that the reason all of Giraldo et al.’s patients were orgasmic is that their sample size is so small, but again, it could be that they have a superior technique.

It might be that Buncamper et al. had better numbers than most of the studies because their patients had surgery more recently with improved techniques, but it might also be because their study was smaller.

With so few studies, I could find no clear pattern based on when people had surgery, how data was collected, or follow-up time after surgery. For further information on the studies, see this appendix.

What is clear is that we need more research on patients who are not able to orgasm after surgery. Are some people more at risk than others? Does the surgical technique make a difference? What role does aftercare play?

Is being non-orgasmic just a possible complication of the surgery? If so, how common is it?

And most important, what can be done to enable all trans women to be able to orgasm after surgery?

 

 

 

*I did not find data on orgasm after intestinal vaginoplasty. According to this 2014 review of studies, most studies of intestinal vaginoplasty did not look at sexual function; for those that did the review reports a score for sexuality rather than information on orgasms.

** I have excluded studies published before 1994 and studies where all of the surgeries were performed before 1994. The studies by Imbimbo et al. and Selvaggi et al. may include some participants who had surgery before 1994.

*** The exact number of the participants is unclear because this study is one of a pair using the same participants. The other study by de Cuypere et al. did in-depth interviews with 32 trans women while this one focused on testing the sensitivity of the genitals for 30 trans women. Unfortunately, the de Cuypere study reports data in terms of how many women “Never-sometimes” had orgasm so their data is not comparable to other studies. (They found that 34% of the women never-sometimes had orgasm during masturbation and 50% never-sometimes had orgasm during sexual intercourse.)

**** Goddard also reports that despite problems, “no patient elected to have their clitoris removed.” Is the man mad?

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Anorexia nervosa and gender dysphoria in two adolescents – Review of a case study

This is a case history of two Canadian teenagers with severe eating disorders. Both teens had had other psychiatric problems, and in one case the problems were quite severe.

Both teens developed gender dysphoria as time went on. In both cases, they were treated successfully for their disordered eating without being treated for gender dysphoria.

It is not clear exactly what the relationship is between the eating disorders and the gender dysphoria in these two cases.

It is important to remember that this is a case study of two people. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

Case 1

The first patient identified as a very feminine gay male when he entered therapy. He was out to his friends and family and they were accepting of his sexual orientation. He was in a monogamous gay relationship.

The patient was 16 and for the past three years he had had “vomiting, food restriction, and body image distortion, perceiving his body to be overweight.” These problems became so severe that he was admitted to a hospital program.

He had insomnia, depression, problems concentrating, and a low energy level. In the past he had been diagnosed with anxiety. He had cut himself in middle school. His family’s history included substance abuse, depression, and bipolar disorder.

The patient had had body image issues since he was six. He “wanted to stay small, feminine, petite, lean, and thin. He reported that he also disliked his ‘wide torso and broad shoulders’ and wished his face shape was more round to be more in keeping with a feminine ideal.”

However, he did not wish to transition to be a woman. He did not want to physically be a female and was not upset about being a male. Rather he wanted to appear feminine and “assume the female role in a relationship.”*

After his hospital stay, the patient entered an out-patient therapy program that “focused on body and self-acceptance, along with enhancing self-efficacy. The family was involved in order to support his eating, and to accept his sexuality and gender identity.”

With this support “he was able to maintain his weight and left his relationship with his male partner who was emotionally abusive.”

Then, after about a year of treatment, the patient said he wanted to transition to living as a female. He did not want surgery, just blockers and hormones. At that point he had already regained a healthy weight and was not restricting his food. He was referred to a gender transition clinic at his request.

Because he was turning 18, his treatment at the pediatric eating disorder clinic ended.**

Case 2

The second patient was a 13 year old girl with a past history of obsessive-compulsive disorder (OCD), generalized anxiety disorder, and post-traumatic stress disorder from sexual abuse by her father. She had also self-harmed and considered suicide. Her family’s history included depression.

At the time she came to the clinic she had anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). She was taking fluoxetine and olanzapine.

She had been hospitalized twice before for her eating disorder and had a “two year history of food restriction, a rigid eating schedule, and body image preoccupation…She described becoming distressed after eating foods she considered were unhealthy, which prompted her to forgo these foods entirely. She also reported excessive exercise due to a desire to be muscular.”

The patient refused therapy, but came in for medical visits and to see the psychiatrist. She had trouble eating more, so they asked her mother to help, but after six months the mother suggested residential treatment and the daughter agreed. The patient’s fluoxetine dose was increased.

The patient began to talk about wanting to be a boy. She also thought that sex was gross. She wanted to stay at a low weight in order to prevent breast growth and menstruation. Therapists raised the question of her trauma and how it might affect her feelings, but she did not want to discuss it.

“Mother was not accepting of the patient’s desire to be a boy and therapy with the psychiatrist was focused on mother taking a more neutral stance.”

After a year, and after she had been fully weight-restored for several months, she began to dress as a boy and use a boy’s name. She hated her breasts and sometimes hit them or thought about cutting out the fat, but she did not want to have surgery. She said that she no longer had eating problems, her only problem was wanting to be a boy. She wanted to take puberty blockers. Her mother was not in agreement and the girl dropped out of treatment.

Gender dysphoria and eating disorders in these case studies

It is difficult to figure out what these case studies mean. Rather than gender dysphoria causing an eating disorder, these patients seem to have developed gender dysphoria over time while recovering from eating disorders.

The authors suggest that as the patients regained weight, their bodies changed and this made the gender dysphoria intensify. I find this unconvincing.

In the first case, the patient was concerned about his wide shoulders and angular face; gaining weight would not have changed his shoulders or made his face more angular.

More importantly, the patient was clear at the beginning of treatment that he was a man and was not distressed by being male. Saying that he wanted to transition to a female but not have surgery was not a question of symptoms intensifying or becoming more prominent. It was a dramatic change – he went from not having gender dysphoria to having it.

In the second case, it seems likely that surviving childhood sexual abuse caused the patient’s disgust with sex and hatred of her breasts, as well as her depression, anxiety, and habit of spraying her body with Lysol.*** Both the eating disorder and the gender dysphoria could be interpreted as ways of dealing with these feelings.

Why or how exactly the patients developed gender dysphoria during this time is unclear. This question is an important area for future research.

The relationship between gender dysphoria and eating disorders is unclear in these two cases, but it looks like the eating disorders were not caused by the gender dysphoria. In the first case, the patient had the distorted perception that he was overweight; this is a symptom of anorexia rather than gender dysphoria. In the second case, the patient had been sexually abused as a child and had many psychiatric disorders, including OCD. Her eating disorder could be explained by a combination of trauma and genetic factors.

What is clear is that in these two cases, the patients were successfully treated for eating disorders before any gender issues were addressed.

Stay tuned for more case histories related to eating disorders and gender dysphoria.

Original Source:

Anorexia nervosa and gender dysphoria in two adolescents by Couturier J, Pindiprolu B, Findlay S, Johnson N in Int J Eat Disord. 2015 Jan;48(1):151-5.

 

* No, I don’t know what that means either.

** I can’t figure out the math here. He was 16, but after 11 months he said he wanted to be a girl. Then they say he left their program because he was turning 18 and had been having therapy continuously for 18 months.

*** No doubt there were genetic and hormonal factors as well, but I think it’s fair to point to the abuse as a cause.

Review: Treatment of anorexia nervosa in the context of transsexuality: A case report

This is a depressing study. The main conclusion I get from it is that we need a better health care system.

The patient in this case is a 19 year-old American trans woman (born male) who developed a severe eating disorder when she decided to dress and live as a woman.

She became malnourished and ill and was hospitalized. During her treatment, she became upset as she gained weight and was afraid she would look masculine. She said she would be willing to gain a healthy amount if it would be on her hips and breasts.

When her testosterone levels returned to normal, hair began growing on her face and legs again. The patient began to exercise secretly and stopped gaining weight.

The hospital discussed gender transition with her, including the risks of treatment. She agreed to try hormone blockers and was given a three month dose of leuprolide. She was also given the androgen blocker spironolactone. After this, the patient progressed well and gained enough weight to leave the hospital.

During follow-up, the patient continued to gain weight until she began working. She lost weight while working, but was able to stabilize her weight with the help of a dietitian.

The patient was referred to an endocrinologist and a center for transgender youth for estrogen therapy and gender transition. She lost her health insurance coverage and could not afford to follow-up with transition.

Short-term hormone therapy helped this trans woman to recover from an eating disorder that made her seriously ill, but it’s unclear what will happen to her without health insurance.

It is important to remember that this is just a case study. This is only one individual; the relationship between eating disorders and gender dysphoria is complicated. We can only come to limited conclusions from any one person’s story.

I will be reviewing more case studies of eating disorders and gender dysphoria. At this point, the main conclusion I can draw is that each case is individual.

The hormone treatment in this case was not the standard cross-sex hormone treatment for people with gender dysphoria. We can not, therefore, draw conclusions about the standard hormonal treatment for trans women.

In addition, the hormone treatment the patient received in this case would not work for everyone. Leuprolide can decrease bone density which may be a problem for malnourished patients with eating disorders. In this case the doctors decided that it would be only used for a short time and the benefits outweighed the risks.

The doctors speculate about the possibility that the androgen blockers caused the patient to gain weight under the skin rather than at the belly and that this may have made her look more feminine.

It is also possible that leuprolide itself had an effect on the eating disorder. Leuprolide is a puberty blocker and eating disorders develop at puberty; perhaps when you block puberty, you block something that causes disordered eating. For example, estrogen may play a role in eating disorders and leuprolide blocks estrogen as well as testosterone.

The bottom line is that this trans woman developed a life-threatening eating disorder when she decided to live as a woman. During recovery she was distressed by the idea of looking more masculine as she regained a healthy weight. Puberty blockers and androgen blockers helped her to regain a healthy weight. Her weight was stable at follow-up, but she lost her health insurance and it is unclear what will happen to her.

More from the authors’ discussion of the case:

“Because her identity as TS [transsexual] and desire to appear more feminine were inextricable from her disordered eating, we felt that her recovery from her ED [eating disorder] would be aided by supporting her gender transition. After consulting the Endocrine Society Guidelines on Treatment of Transsexual Persons and discussing treatment possibilities with experts in transsexual youth, medical treatment options included cross-hormone (i.e., estrogen) therapy (which would also suppress testosterone release) and/or suppression of testosterone with GnRH agonists with or without the use of spironolactone as an antiandrogen agent. Treatment with cross-hormone therapy requires close follow-up with an endocrinologist familiar with this treatment; the children’s hospital to which DS was admitted is not a site experienced in cross-hormone therapy for transsexual youth. For this reason, GnRH agonist therapy with spironolactone was chosen to suppress testosterone at the level of the pituitary and delay resurgence of testosterone-related changes until the patient could access appropriate TS medical care and follow-up.

To our knowledge, there are no studies describing the patterns of weight gain in TS patients who receive antiandrogens in comparison to those who do not. However, studies of antiandrogen use for other medical conditions have shown that patients receiving antiandrogens tend to gain subcutaneous adiposity, as opposed to primarily intra-abdominal adiposity gained by patients not on antiandrogens. One could theorize that this subcutaneous pattern of weight gain would be more tolerable to MtF transsexual patients who strive for a more feminine appearance, which would support the use of GnRH agonists in these patients. This is an interesting area for future inquiry.

Possible adverse effects of GnRH agonists include decrease in bone density. This is of particular concern in malnourished patients, as malnutrition alone can adversely affect bone density. This potential drawback of GnRH therapy for DS was discussed at length as a team, and it was determined that the benefits of GnRH use outweighed the risks for two primary reasons: (1) the expected duration of GnRH therapy was brief, as it was being used as a bridge to initiation of cross-hormone therapy; and (2) suppression of DS’s testosterone level would likely facilitate her willingness to achieve weight restoration. In studies of malnourished patients with low bone density, weight restoration is the most important factor in improving bone density. Spironolactone was added to DS’s therapy regimen for additional anti-androgen effects. This medical plan enabled DS to continue to improve her nutritional status while avoiding the unwanted increase in testosterone and consequent physical changes.”

Original Source:

Treatment of anorexia nervosa in the context of transsexuality: A case report by Ewan LA, Middleman AB, Feldmann J. in Int J Eat Disord. 2014 Jan;47(1):112-5.

Review of Clinical Management of Youth with Gender Dysphoria in Vancouver – Part I – Demographics

This article is a report on health care provided to youth with gender dysphoria at a clinic in British Colombia, Canada. I’m going to focus on just the demographics in this post and do another post later.

QUICK OVERVIEW

The clinic saw a dramatic increase in the number of their teenage patients from 2006-2011. This is similar to other clinics serving teenagers with gender dysphoria.

Most of their patients were trans men (born female). This is similar to the current situation at other clinics for teenagers, but different from the past at other clinics. It is also different from most European clinics for adults.

Their patients had other psychiatric diagnoses including mood disorders, anxiety disorders, and eating disorders. The patients in this study had more psychiatric problems than teenagers studied at a clinic in the Netherlands.

7% of their patients had an autism spectrum disorder. This is similar to the results of a Dutch study of children and teens with gender dsyphoria.

Suicide attempts are a serious problem among their patients. 12% of their patients had attempted suicide before coming to the clinic; 5% attempted suicide after their first visit to the clinic. The decrease is encouraging, but clearly we need to do more to help patients during and after transition.

Some of their patients had to be hospitalized for psychiatric problems. 12% of their patients had been hospitalized before coming to the clinic, but only 1% were hospitalized after the first visit.  Again, we need to be sure to provide support during and after transition.

THE INCREASE IN TEENAGE PATIENTS

The clinic has seen a fairly dramatic increase in the number of teenage patients from 2006-2011. They went from fewer than 5 cases/year before 2006 to nearly 30 cases in 2011.

0

Number of new patients with gender dysphoria seen in 1998-2011. MtF, black bars; FtM, hatched rectangles.

This parallels what has happened at a similar clinic in Toronto, Canada and a clinic in the Netherlands.

Unlike the other two studies, the majority of the patients at this clinic were always trans men (born female). In fact, before 2006 almost all of the patients were trans men. After 2006, the number of trans women patients (born male) began to increase. However, trans men still made up 54% of all the patients they saw between January 1998-December 2011.

This is different from the pattern found in the clinics in Toronto and Amsterdam. In those two clinics the patients were mostly trans women before 2006, but after 2006 they were mostly trans men.

It’s hard to know what these numbers mean because we don’t know how common gender dysphoria is among teenagers.

“The prevalence of adolescent-onset gender dysphoria is not known, and there are limited accurate assessments of prevalence of transgenderism in adults in North America. However, the prevalence of adults seeking hormonal or surgical treatment for gender dysphoria is reported to be 1:11 900 to 1:30 400 in the Netherlands.”

Does this increase reflect an increase in the number of teenagers with gender dysphoria? If so, why are the numbers increasing?

Alternatively, is this increase due to people with gender dsyphoria seeking physical transition at a younger age?

Statistics on most European clinics have shown many more trans women transitioning than trans men (the pattern is reversed in Japan and Poland). Now the statistics on Canadian and Dutch teenagers show more trans men transitioning than trans women.

Are there more trans men than in the past? If so, why?

Or are trans men transitioning at a younger age than trans women? But then why did the other two clinics treat more teenage trans women than teenage trans men in the past?

BASIC DEMOGRAPHICS OF THE PATIENTS IN THIS STUDY

The clinic at British Colombia Children’s Hospital saw 84 youth with a diagnosis of gender dysphoria from January, 1998 to December, 2011.

45 of the patients were trans men, 37 were trans women, and 2 were males who weren’t sure of their gender identity.

Two of the trans women had disorders of sex development – one had Klinefelter syndrome (XXY chromosomes) and one had mild partial androgen insensitivity syndrome (i.e. her body made androgens, but they didn’t fully affect her).

The median age at the first visit was 16.8, the range in ages was from 11.4 to 22.5.

At the first clinic visit, most patients were in school grades 8-10 (32%) or grades 11-12 (48%); 12% were in grades 5-7, and the remaining 8% were in college/university or no longer attending school.*

PSYCHIATRIC COMORBIDITIES

Diagnoses made by a mental health professional:**

35% of the patients had a mood disorder (20 trans men, 7 trans women and probably the two males with uncertain gender identity)

24% had an anxiety disorder (15 trans men, 4 trans women and probably one male with an uncertain gender identity)

10% had ADHD (2 trans men, 6 trans women)

7% had an autism spectrum disorder (2 trans men, 4 trans women)

5% had an eating disorder (2 trans men, 2 trans women)

7% of their patients had a substance abuse problem (2 trans men, 4 trans women)

26% of their patients had two or more mental health diagnoses (12 trans men, 9 trans women) and probably one male with an uncertain gender identity.

Suicide attempts:

10 of the teenagers attempted suicide before coming to the clinic (12%). 6 of them were trans men and 2 were trans women. Perhaps the other two were the two males who weren’t sure of their gender identity.

4 of the patients attempted suicide after the first visit to the clinic (5%). Three of them were trans men and one was a trans woman.

Psychiatric hospitalizations:

12% of the patients had been hospitalized for a psychiatric condition before coming to the clinic – seven trans men and three trans women.

One trans man was hospitalized for a psychiatric condition after the first visit to the clinic (1%).

Conditions requiring hospitalization included posttraumatic stress disorder, depression, substance abuse, behavioral issues, psychosis, and anxiety.

Mood, puberty blockers, and hormones:

One trans woman and one trans man discontinued the use of a puberty blocker after they developed emotional lability (7% of the patients who took the puberty blocker). The trans man also had mood swings.***

One trans man had significant mood swings as a side effect of testosterone treatment. (3% of the patients who took testosterone.)

Two trans men temporarily stopped testosterone treatment due to psychiatric conditions – one was depressed and one had an eating disorder. (5% of the patients who took testosterone.)

One trans man temporarily stopped testosterone treatment due to distress over hair loss. (3% of the patients who took testosterone.)

Gender differences:

Trans men were significantly more likely to have depression or anxiety disorders than trans women. 44% of trans men had mood disorders compared to 19% of trans women. 33% of trans men had anxiety disorders compared to 11% of trans women.

There were no significant gender differences in other mental health issues.

27% of trans men had two or more psychiatric diagnoses compared to 24% of trans women. This seems surprising given that trans men were more likely to have mood and anxiety disorders.

The most important issue is the number of suicide attempts.

Why were there four suicide attempts after the first visit to the clinic?

Were the suicide attempts related to the two patients who developed emotional lability on blockers? or the trans man who developed mood swings after taking testosterone?

Were they related to the trans man who stopped taking hormones due to depression? Was he the same person as the trans man who developed mood swings on testosterone?

What about the trans man who stopped his hormones due to an eating disorder?

When were the suicide attempts? Were they before the patients got blockers or hormones? Did they happen after stopping hormones for any reason? Or were the patients already on hormones or blockers?

Could they have been prevented by more therapeutic support before treatment? during treatment?

Is there a way to identify which patients are at risk for suicide attempts during or after treatment?

It is encouraging to see that there were fewer suicide attempts after the first visit to the clinic than before, but it is not enough. We need to do more.

We also need more data on the decrease in the number of suicide attempts after coming to the clinic. Was it statistically significant? Was the time period before the first visit to the clinic equal to the time period after the first visit to the clinic?

Psychiatric comorbidities comparison

Compared to a clinic in the Netherlands, these patients were more likely to have mood disorders (35% vs. 12%), but about as likely to have anxiety disorders (24% vs 21%).

5% of the Vancouver patients had an eating disorder while none of the patients in the Dutch study did.

7% of the patients in this study had a substance abuse problem while only 1% of the patients in the Dutch study did.

26% of the patients in this study had two or more psychiatric diagnoses. In comparison, only 15% of the teenagers in the Dutch study had two or more psychiatric disorders.

Finally, the Dutch study found that trans women were at higher risk for having a mood disorder or social phobia while this study found that trans men were at higher risk for mood and anxiety disorders.

Why is the psychiatric comorbidity higher in the Vancouver patients?

The authors of the report suggest that it might be because the average age of their group was higher than the average age in the Dutch study – 16.6 year vs 14.6 years. It might simply be that older teenagers have had more time to develop mental health issues.

They also suggest that there could be differences in diagnostic criteria. Both groups seem to have been using DSM-IV diagnoses, but the Vancouver data was based on clinic notes while the Dutch data was based on interviewing parents. It may be that parents underestimate their children’s problems. For example, they might not realize that their teenager has a substance abuse problem or an eating disorder.

In addition, the Vancouver study includes all 84 patients their clinic saw between 1998-2011. In contrast the Dutch group invited 166 parents to participate in their study, but only 105 parents did so. It is possible that the 61 parents who did not participate had children with more problems, although the authors suggest that the inconvenience of travelling to the center was the main issue.

Finally, the Dutch group has 17 teenagers who were referred to the clinic but dropped out after just one session, “mostly because it had become evident that gender dysphoria was not the main problem.” These patients might have had more psychological comorbidity than others.

It is hard to compare this to the Vancouver clinic, however, because the Vancouver clinic’s focus is on endocrine care. 93% of the patients they saw had already been diagnosed with gender dysphoria by a mental health professional. Were there teenagers in Canada who discovered that gender dysphoria was not the main problem and did not go on to the clinic? If so we would expect the two clinics to have similar rates or psychological comorbidity. If not, we might expect a higher rate of comorbidity in Canada.

A final possibility is that the Canadian teenagers with gender dysphoria simply have more psychological problems than Dutch teenagers with gender dysphoria. Perhaps they experience more bullying and violence. Perhaps they had less supportive parents.

As usual, we need more studies. Why are the numbers of teenagers at clinics for gender dysphoria increasing? What is the prevalence of gender dysphoria among teenagers? How common are psychological comorbidities? Are trans men or trans women more at risk for depression and anxiety? What can we do to prevent suicide attempts after treatment begins? How can we better support patients with gender dysphoria during and after transition?

Original Source:

Clinical Management of Youth with Gender Dysphoria in Vancouver by Khatchadourian K, Amed S, Metzger DL in J Pediatr. 2014 Apr;164(4):906-1.

 

*This would suggest that 48% of the students were 16-17 years old, 32% were 13-15, 12% were 11-12, and 8% were 18-22.5.

** The table indicates that these were diagnoses made by a psychiatrist or psychologist. There were other diagnoses the authors didn’t include in the table: 1 patient with trichotillomania, 2 with borderline personality disorder, 1 with psychosis not otherwise specified, 1 with adjustment disorder, 2 with tic disorders, and 1 with oppositional-defiant disorder. I am not sure why these diagnoses weren’t included; perhaps they weren’t made by mental health professionals.

***The blockers being used were gonadotropin-releasing hormone analog or GnRHa.

Gender dysphoria in adolescents: difficulties in treatment – Extremely Brief Review

This is a review of an abstract; the original article is in German and I don’t have access to it.

“In many children and adolescents with gender dysphoria only minor or no psychopathology is found.”

However, 43% of the patients seen at the Frankfort University Gender Identity Clinic for children and adolescences have serious mental health issues.

This creates problems in treatment.

The article then discusses four sample cases to show some of the difficulties.

In two cases, “major psychopathology made decision for reassignment very difficult.”

In two other cases, the patients were “not able to follow recommended treatment steps, in these patients diagnostic doubts arose.”

it’s impossible to know what this means without knowing more about the study and about other gender identity clinics.

Clearly, however, there is a need for more research. Why did this gender clinic see so many children and teens with serious psychopathology? What about other gender clinics? How does this compare to the past? How many patients are we talking about? What were the mental health issues? Did any of the patients have autism spectrum disorders?

Original Source:

“Gender dysphoria in adolescents: difficulties in treatment” by Meyenburg B in Prax Kinderpsychol Kinderpsychiatr. 2014;63(6):510-22.

Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic – Brief Review

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

Demographic data on trans kids and teens is generally lacking, but there seems to be an increase in diagnoses of gender dysphoria.

“Given the increasing demand for counselling in gender dysphoria in childhood in Germany, there is a definite need for empirical data on characteristics and developmental trajectories of this clinical group.”

This study looked at the patients at one clinic and found that there were significant differences between the girls and boys with gender dysphoria. They suggest that the two groups will need “different awareness and individual treatment approaches.”

Between 2006 and 2010, the Hamburg Gender Identity Clinic saw 45 “gender variant” children and teens. 40 of these patients were diagnosed with gender identity disorder (88.9%).

Differences reported between girls and boys with gender dysphoria:

The girls were older than the boys on average.

A higher percentage of the girls were referred to the clinic at the beginning of adolescence (over 12 years old), although more girls reported an early onset of gender dysphoria.

More of the girls talked about their “(same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions.”

More of the girls reported self-mutilation in the past or present.

More of the girls reported suicidal thoughts and/or attempts.

The referral rate of girls with gender identity disorder was higher than the rate for boys. They give the ratio 1:1.5. (I am not sure what this means; this is a translation of an abstract.)

Original Source:

“Characteristics of children and adolescents with gender dysphoria referred to the Hamburg Gender Identity Clinic” by Becker I, Gjergji-Lama V, Romer G, Möller B. in Prax Kinderpsychol Kinderpsychiatr. 2014;63(6):486-509.

Most Autistic People Have Normal Brain Anatomy – Neuroskeptic | DiscoverMagazine.com

Neurosceptic has a good article up about an important new study of brain structure and autism.

The study found very few differences between the brain anatomy of people with autism and people without it. It was a large study and calls into question earlier studies that found differences.

A troubling finding was that when they made the sample size smaller, they found more differences.

Since brain studies of gender identity involve small samples, this raises an important question: are we seeing real differences, or would they disappear with a larger study like this one?

There are some questions for this new study of autism, of course. A few points from the blog and comments:

There may still be other differences in the brain, either smaller brain structures or differences in function.

It could be that there is more than one type of autism and they look different in brain scans.

The study only looked at people with autism who were high-functioning; perhaps that made a difference.

Anyhow, enjoy Neurosceptic’s article:

Most Autistic People Have Normal Brain Anatomy – Neuroskeptic | DiscoverMagazine.com.