Tag Archives: 2015

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?

Review of: Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned

Another case where gender identity is linked to an eating disorder, this time in a trans man (born female).

And, another case where transition did not cure the eating disorder.

In this case a teenager who was being treated for his eating disorder requested therapy for gender dysphoria. His weight had already been restored, although he was still getting therapy for the eating disorder.

After counseling for gender dysphoria, the patient took testosterone and openly identified as a man. His anxiety improved, he had more friends, and he had his first girlfriend. Five months later, he had a bilateral mastectomy.

Ten months after surgery, the patient returned to the eating clinic for help. He said that his relapse began after his surgery and got worse when he returned to normal activity.

It is important to note that six months after surgery, the patient’s weight was normal and he felt better about his appearance. However, his eating patterns do not seem to have been discussed.

The patient had not continued counseling after surgery.

There are not many details on the patient’s gender dysphoria in this case study, but there does seem to be a connection between his eating disorder and his gender dysphoria. The patient “disclosed to his family that he felt like ‘a boy in a girl’s body’ and later acknowledged that his eating disorder was related to a desire to get rid of feminine features—’I dislike my curves, my breasts, my hips, my face. I wish I had more defined muscles in my arms and a more angular face.'”

It is worth noting, however, that the patient had two cousins with eating disorders. Genetics and environment were probably also factors in his eating disorder.

The authors make a number of important points about this case in their discussion.

We don’t know if medical transition helps with eating disorders.

“Studies show that medical interventions, including both hormone therapy and surgery, improve gender dysphoria. Their effects on disordered eating in patients with gender dysphoria, however, are less clear.”

On the one hand, in one qualitative study, a trans man who had had breast reduction surgery said it helped with his eating issues. In addition, another study found that patients who had had gender reassignment surgery had less body uneasiness than patients who had not or patients with eating disorders. It is not clear to me that this last study is relevant to patients with both gender dysphoria and eating disorders.

On the other hand,

“In our patient, although he experienced considerable improvement in body image, anxiety, and social functioning following treatment for gender dysphoria, he experienced a relapse in eating disorder behaviors postoperatively. Other case reports in adults describe similar relapses in disordered eating following medical treatment for gender dysphoria.* These cases suggest that, while GCS and other medical interventions often reduce psychological distress related to gender dysphoria, additional therapies may be required to ensure long-term resolution of disordered eating. Eating disorders have high rates of chronicity as well as relapse, particularly during periods of stress and life change. It is therefore crucial to engage all patients with gender dysphoria, regardless of their stage in treatment, in open conversations about eating patterns, body image, and thought processes.”

Urgent needs have to be taken care of first.

Treatment for patients with both eating disorders and gender dysphoria needs to be integrated and hierarchical; life threatening issues have top priority. In other words, you may have to eat before you can transition.

“Eating disorder treatment is complex given the combination of medical, psychological, and nutritional needs. Patients with gender dysphoria also have distinct needs related to gender incongruity. Using a hierarchical approach is one method to help focus therapy and ensure that all needs receive attention when appropriate. Life-threatening issues, such as vital sign instability from nutritional insufficiency or suicidality, should have first priority. These issues frequently require hospitalization to initiate nutritional rehabilitation and psychiatric care in a monitored environment. Following medical and psychiatric stabilization, weight restoration can often continue in the outpatient setting with multidisciplinary support from physicians, therapists, dietitians, and when possible, family members. Throughout treatment, the eating disorder team should strive to create a safe environment for the patient to explore the sources of his or her disordered eating, providing the opportunity to recognize or reveal any underlying issues. For patients with known gender dysphoria, the eating disorder team can assist by affirming the patient’s gender identity, allowing him or her to explore different options for expressing that identity, and providing resources for specialized care.”

Trans men’s eating disorders may look different from the norm.

Trans men may have different goals from other patients with eating disorders; patients with anorexia typically wish to be thin. Trans men may be trying to eliminate their period or reduce their curves as in this case and in this Turkish case study. The trans man in this study did not care about his weight, but was very dissatisfied with his body. It is important that these patients’ eating disorders not be missed because they are atypical. As the authors say,

“While the goals of weight loss in MtF patients often align with those of cisgender eating disorder patients, the goals of weight loss in FtM patients often diverge from those of cisgender patients, potentially limiting the utility of current eating disorder questionnaires in this population.”

We need to keep track of eating disorders after transition.

We can’t assume that a patient with an eating disorder will be fine after they are treated for their gender dysphoria. Treatment for the eating disorder needs to be ongoing.

“While improvement in gender dysphoria may lead to some improvement in eating pathology, many patients may benefit from additional support from an eating disorder team, as found for our patient. Further research should explore the success of different types of eating disorder treatment in adolescents with gender dysphoria before, during, and after gender dysphoria treatment.”

Not everyone needs the same treatment for gender dysphoria.

“Treatment for gender dysphoria varies from person to person. For some individuals, dysphoria can be alleviated through psychotherapy alone or combined with non-medical changes in gender expression. For many, gender dysphoria requires hormone therapy, surgery, or both. Adolescents who desire medical treatment later in life can use hormonal treatments to suppress or delay puberty. The Standards of Care of the World Professional Association for Transgender Health, however, recommends delaying suppression until the adolescent has reached at least Tanner Stage 2, so that he or she has some experience of his or her assigned sex. Hormone therapy to feminize or masculinize the body can also be started during adolescence, although this therapy should only be used in patients who demonstrate long-lasting or intense gender dysphoria, as the effects are only partially reversible. Surgery, on the other hand, may only be pursued once the patient reaches the age of majority for his or her country. For our patient, hormone therapy began at age 18 years, 10 months after expressing symptoms of gender dysphoria, and mastectomy was performed at age 19 years.”

Comparing eating disorders in transgender teens and adults

The authors also discuss the timeline of this case – i.e. gender dysphoria was diagnosed after the eating disorder. They contrast this with case reports of adults where an eating disorder developed during or after “assuming a transgender identity.” They add that “the only other case report available on adolescent patients describes a similar progression [to this study], with both patients initially presenting with AN and later expressing themselves as transgender.” 

Therefore, they suggest that “disordered eating may be the presenting symptom in some adolescents with gender dysphoria, highlighting the benefit of addressing gender identity in young patients with eating disorders. Gender identity may be addressed either using an intake form or during the patient interview.” (see below)

The situation is a little more complicated. In fact, in this case study a teenager developed an eating disorder when she decided to live as a woman. In addition, this study of an adult mentions that her eating disorder began at age 15 when she decided to live as a woman.

So we have two cases of teenagers who decided to live as women and then developed eating disorders and three cases of teenagers who were diagnosed with gender dysphoria during treatment for eating disorders. We don’t have enough cases to come to any real conclusions about the development of eating disorders and gender dysphoria in teenagers.

In any case, it may be that interviewing teenagers when they enter treatment for eating disorders will not lead to a diagnosis of gender dysphoria. In this case study, one of the teenagers was clear at the beginning of treatment that he was a gay man and did not want to be a woman. His gender dysphoria developed during the treatment of his eating disorder.

As always, we need more research. So far we have case studies of 17 patients. The individual cases vary widely and it’s unclear exactly how gender dysphoria and eating disorders are linked. It does not seem that treating gender dysphoria cures eating disorders, however.

This newest case study demonstrates that transition for gender dysphoria does not cure an eating disorder. It points to a connection between the eating disorder and the desire to be a man, but it also points to a possible contribution from genetic and environmental factors.

Original Source:

Effects of treating gender dysphoria and anorexia nervosa in a transgender adolescent: Lessons learned by Strandjord SE, Ng H, Rome ES in Int J Eat Disord. 2015 Nov;48(7):942-5.

 

*In this case study, one of the trans women had an eating disorder in adolescence that returned many years later after surgery. In this case study, one of the trans women had transitioned but was still severely underweight – although the authors did not seem to think she had an eating disorder. Finally, in this case study, a trans man developed an eating disorder after surgery. He had not had an eating disorder previously.

In addition, there are a number of case studies where patients had eating disorders, although they were on hormones and had socially transitioned.

 

More details from the case study:

The patient had been seeing doctors for a couple of years before he brought up his gender issues.

At age 16 the patient was not getting his period, but his weight was normal and he said he had no body image concerns. The doctors prescribed oral contraceptives.

“The patient returned a year later with 2.3 kg of weight loss, resulting in a body mass index (BMI) of 16.9 kg/m2 (81% expected body weight for females of the same age). CS acknowledged daily exercise and a ‘desire for a different body shape,’ with a ‘more toned and muscular’ appearance. The patient denied food restriction, purging behaviors, or body image distortion and committed to increasing caloric intake to gain weight. Gender identity was not discussed and no treatment was pursued after this visit.

Five months later, CS presented with an additional 4.5 kg weight loss, resulting in a BMI of 14.9 kg/m2 (70% expected body weight). The patient then admitted to food restriction as well as a fear of gaining weight, leading to a diagnosis of anorexia nervosa (AN). The clinician did not inquire about underlying motivations for weight loss beyond general body dissatisfaction and anxiety.

There was no significant medical, psychiatric, or surgical history at the time of diagnosis. Family history included two cousins with eating disorders (specific diagnoses unknown). Socially, the patient was a high-achieving student with few peer relationships and no high-risk behaviors.”

At this point, the patient began 9 months of outpatient family-based therapy for anorexia. Four months into this treatment, he requested therapy for gender dysphoria. “He began biweekly individual psychotherapy to explore his gender identity and cognitive behavioral therapy to address ongoing anxiety.”

Ten months later he started to take testosterone and five months after that he had surgery to remove his breasts at age 19.

Medical treatment for gender dysphoria helped the patient significantly with his anxiety. He began to live as a man, expanded his peer relationships, and had his first romantic relationship with a woman.

His weight was stable for six months after surgery and he was more satisfied with his body, but the follow-up does not seem to have included any discussion of his eating (“a detailed discussion of his eating patterns and cognitions was not documented”).

He returned to the clinic four months later to deal with restrictive eating and excessive exercise. His body weight had decreased and his BMI had dropped from 19 kg/m2  to 17.9 kg/m2. He explained that “his relapse began postoperatively due to exercise restrictions and school-related stress, with his behaviors intensifying when he returned to normal activity.”

More details on interviewing patients about gender

The authors offer these sample approaches:

Sample approach on an intake form.
Use a two-step approach to identify both assigned sex and current gender identity.
Assigned sex at birth:
What sex were you assigned at birth, on your original birth certificate? (check one)
□ Male
□ Female
Current gender identity:
How do you describe yourself? (check one)
□ Male
□ Female
□ Transgender
□ Do not identify as male, female, or transgender
Sample approach in an interview.
Frame discussion with an opening statement.
“Because many people are affected by gender issues, I ask all patients if they have any concerns in this area. As with the rest of the visit, what you say will be kept strictly confidential.”
Begin discussion with a broad question(s).
“What questions or concerns do you have about gender, sexuality, or sexual orientation (who you are attracted to)?”
“How do you define your gender?”
“Have you been exploring gender?”

Sample intake form from:

Reisner SL, Conron KJ, Tardiff LA, Jarvi S, Gordon AR, Austin SB. Monitoring the health of transgender and other gender minority populations: Validity of natal sex and gender identity survey items in a U.S. national cohort of young adults. BMC Public Health2014; 14:1224. 

Sample approach for an interview from:

Makadon HJ. Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleve Clin J Med 2011; 78:220224

Review of: Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report

This is a fairly straightforward case study of a Turkish trans man (born female) with anorexia. In order to avoid menstruating, he dieted excessively and induced vomiting. He also wished to avoid looking female. This went on for 21 years, beginning when he was 19.

Once he was on hormones and menstruation stopped, the disordered eating ended. It has not returned after two years. He says he is no longer concerned with his weight since he is living as a man.

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.

In fact, there are six other case studies where physical transition did not cure an eating disorder. Two trans women with eating disorders were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. One trans woman believed that transition had cured her, but she was severely underweight, even more so than she had been before transition.

There are three case studies where surgery seems to have caused or triggered disordered eating. This trans man began binging and purging for the first time after having his breasts, uterus, and ovaries removed. One of the trans women in this study had an eating disorder in adolescence; her symptoms returned after sex reassignment surgery 20 years later. Finally, this adolescent trans man recovered from an eating disorder and transitioned; after his mastectomy, he began to relapse and ten months later he returned to the clinic for eating disorders.

In addition, there are a number of case studies where factors other than gender dysphoria played a role in an eating disorder. The most striking is this case of identical twins; both twins had anorexia, but only one had gender dysphoria. The twins shared genes and an abusive father, but one grew up to be a feminine gay man while the other was a trans woman.

Back to this case study. It is clearly different from typical cases of anorexia:

The rejection of femininity was the primary underlying motivation for loss of weight, and not the wish to look slim. She stated that her primary motive for purging was to stop menstruation and her second motivation was to get rid of female body shape; the latter motivation was so strong that she expressed that if she could look like a man if she put on weight she would eagerly try to put on some weight. Thus with this definite statement she was to be separated from the primary cognition of AN which is an intense fear of gaining weight. Her eating disorder symptoms were greatly alleviated after sex reassignment.”

More importantly, in this case, taking testosterone stopped the disordered eating.

The trans man in this story also had a sex reassignment surgery, although the study does not say what the surgery was (mastectomy, genital surgery, or hysterectomy with removal of the ovaries). He changed his name and is living as a man.

It is likely that transitioning cured him of anorexia. However, it is also possible that the testosterone itself played a role. Low testosterone is linked to eating disorders in both men and women. There is a study underway to see if taking testosterone can help women with eating disorders, but we will not know the results for a few more months.

A few other things of note:

The patient did not seek help for his eating disorder, even when he saw a psychiatrist for depression. His eating disorder only came out when he applied to change his sex on his identity card and was referred to a psychiatry clinic.

In order to be able to take hormones, the patient stopped vomiting. However, he continued to restrict his calories until he was actually on hormones.

Before treatment, the trans man ate more when he was depressed.

He had problems with his teeth due to vomiting eroding the enamel.

After finishing college, he had a serious suicide attempt.

The patient’s gender dysphoria began in childhood:

“In her early childhood A.T, felt strongly that she belonged to the male sex. She played boys’ toys and games, preferred boys for playmates, and she was interested in football. When she reached puberty the growth of her breasts and the onset of menstruation caused her to have severe stress, in order to hide her breasts she was wearing extra large size clothes and she was pretending a kyphosis-like posture. During the first year of her university education she had severe depressive symptoms connected with her gender dysphoria; she was spending the greater part of her time at home as she was uneager to dress and live like a woman.”

Original Source:

Prolonged anorexia nervosa associated with female-to-male gender dysphoria: A case report by Şenol Turan, Cana Aksoy Poyraz, Alaattin Duran in Eat Behav. 2015 Aug;18:54-6.

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood – Review of a case study

This is a follow-up case study of a Japanese boy with both Asperger’s syndrome and gender dysphoria. It is the first long-term follow-up case study we have for a child with autism and gender dysphoria.

The young man no longer had gender dysphoria at the 11-year follow-up.

This is a highly significant case study; we know that most children with gender dysphoria desist around puberty, but we have had no data on what happens to children with both autism and gender dysphoria.

We need more studies to find out how common this is for children with autism and gender dysphoria.

In addition, we need studies to look at how persistence and desistence from gender dysphoria work for children with autism. Is the developmental process different from neurotypical children? How should parents, educators, and therapists work with children who have both autism and gender dsyphoria?

As the authors say, “Careful long-term clinical observation and further studies are needed.”

More details on the boy’s gender dysphoria:

[The boy came to the clinic at age 5 for behaviors related to autism] At the age of 7, he verbalized a strong aversion to being a boy and desired to be a girl. The boy behaved as if he were a girl and preferred to play with girls. Based on his clinical symptoms that lasted more than 6 months, the comorbid diagnosis of GID was made according to ICD-10 criteria.

After entering school, he exhibited behaviors such as using stationery with Disney princesses and dressing himself in clothes with flowers. He rarely went to the bathroom because he did not want to be seen urinating in a standing position. He skipped swimming classes at school to avoid exposing his chest. Only at his home, the boy wore skirts and makeup. At school, he was bullied by classmates because of his feminine behaviors. However, as school teachers were supportive and intervened appropriately, he never refused to attend school.*”

You can also read more about his earlier gender dysphoria in this previous case study.

More details on the change at puberty:

“At the age of 11, when puberty started, he became confused and repeatedly shaved his body hair. He tried to keep his voice tone high. However, as puberty progressed his gender dysphoria gradually alleviated.

In Japan, in general, junior high school students are required to wear school uniforms based on their biological sex, typically a skirt for girls and trousers for boys. They are also requested to obey school regulations related to length of hair, though the strictness is highly school-dependent. Our patient entered a public school in his residential district and had to behave as a typical male student. As a consequence, his gender-related manifestations fell below the threshold for the diagnosis of GID as of age 16 (the time of this writing).”

Note: This is not just a question of changes in behavior – the authors also say that his gender dysphoria gradually alleviated as he went through puberty. In addition, the authors got informed written consent before publishing this study.

 

*School refusal is a significant problem for students with gender dysphoria in Japan. (Bullying seems to be a problem everywhere.)

Original Source:

Eleven-year follow up of boy with Asperger’s syndrome and comorbid gender identity disorder of childhood by Tateno M, Teo AR, Tateno Y, in Psychiatry Clin Neurosci. 2015 Oct;69(10):658.

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria – Review

This is a highly significant study showing that the population of teenagers referred for gender dysphoria is changing. It is noteworthy that this is happening in two different countries.

The sex ratio is changing:

The sex ratio of teenagers seeking help for gender dysphoria has changed at two clinics, one in Canada and one in the Netherlands.

Before 2006, more male than female teenagers sought transition at these clinics. Since 2006, they have seen more female teenagers than male teenagers.

Sex ratio for teenage patients at the Canadian Gender Identity Service:

  • 1999-2005 – 68% male, 32% female
  • 2006-2013 – 36% male, 64% female

Sex ratio for teenage patients at the Dutch Center for Expertise on Gender Dysphoria:

  • 1989-2005 – 59% male, 41% female
  • 2006-2013 – 37% male, 63% female

At the Canadian clinic, there was no change in the sex ratio of teenagers referred for psychiatric issues.* In both time periods, roughly two-thirds of their other patients were male.

According to the authors, “In adult samples [of transitioners], in almost all cases, the number of natal males either exceeds the number of natal females or the sex ratio is near parity.” Poland and Japan are exceptions; in those countries more females transition than males.

In addition, clinics for children with gender dysphoria have found that the number of males exceeds the number of females.

More teenagers are transitioning:

The number of teens of both sexes has increased over time, although the increase is larger for the female teenagers.

Increases at the Canadian clinic:

Female teenagers

  • 46 in 30 years (1976-2005)
  • 129 in 8 years (2006-2013)

Male teenagers

  • 80 in 30 years (1976-2005)
  • 73 in 8 years (2006-2013)

Increases at the Dutch clinic:

Female teenagers

  • 77 in 17 years (1989-2005)
  • 148 in 8 years (2006-2013)

Male teenagers

  • 109 in 17 years (1989-2005)
  • 86 in 8 years (2006-2013)

In other words, the Canadian clinic saw nearly nearly three times as many female teens in the past 8 years as they had seen in the previous thirty. The Dutch clinic saw nearly twice as many female teens in the past 8 years as they had seen in the previous seventeen.

Furthermore, “For many years in the Toronto clinic, the number of adolescent referrals was quite low. Between 1976 and 2003, for example, no more than five adolescents of one biological sex were assessed in a calendar year and, during this period, the number of males exceeded the number of females. Beginning in 2004, however, the number of adolescent referrals began to rise quite dramatically, which appears to be consistent with the observations of clinicians and researchers from other gender identity clinics.”

For earlier data on the increase in Canada, see this article.

Sexual orientation percentages have changed:

The Canadian clinic also looked at sexual orientation.

Sexual orientation of females:

  • 1976-2005 – 89% primarily attracted to females; 11% other
  • 2006-2013 – 64% primarily attracted to females; 36% other

Other could mean primarily attracted to males, bisexual, or asexual.

Sexual orientation of males:

  • 1976-2005 – 67% primarily attracted to males, 33% other
  • 2006-2013 – 44% primarily attracted to males, 56% other

Other could mean primarily attracted to females, bisexual, or asexual.

To put it another way, in the past most of the teenagers would have been gay if they weren’t transgender. If they transitioned, they would live their lives as straight people.

In 2006-2013 most of the male teenagers would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as lesbians.

One-third of the female teenagers in 2006-2013 would have been straight, bisexual, or asexual if they weren’t transgender. If they transition, some of them will live their lives as gay men.

What’s going on?

Why are we seeing more teenagers seeking help for gender dysphoria?

Why is the increase greater among female teens than males?

And why are we seeing a shift in the sexual orientation of these teens? Was it harder in the past to come out as transgender if you were seen as straight? Or is this a group of people who were less likely to have gender dysphoria in the past?

Has something changed in our environment that increases the number of people with gender dysphoria? What would affect more females than males? Why would it affect teenagers more than children (see this earlier article)? How would it fit with the changing percentages related to sexual orientation?

Is it just that there were always this many teenagers with gender dysphoria and now they are able to get care at an earlier age? How does that theory fit with the change in the sex ratio of teens applying to the clinic? with changes in their sexual orientation?

Clearly, we need more research to sort out these questions.

The authors speculate about possible explanations for the change in the sex ratio at their clinics.

They suggest that the general increase in patients might be due to a combination of destigmatization and more awareness of the biomedical treatments available to teens. However, they point out that this does not explain why more females would apply for treatment.

I don’t think we can know why the number of patients has increased without further research – research which is desperately needed.

The increase in the number of female patients at the Toronto clinic was not caused by a change in the severity of cases; they found that there was no significant relationship between severity of dysphoria and year assessed.

However, for male teens in Toronto, there was a weak correlation between severity of dysphoria and year assessed. “More recently assessed cases had moderately higher GD severity.” This only explained 6.7% of the variance. Therefore “it is unlikely that the recent inversion in the sex ratio can be accounted for by a substantive change in severity variation.”

On the other hand, they only have data on the severity of dysphoria starting in 2001 and the number of cases began increasing in 2004.

The change in the sex ratio was not due to females entering puberty at an earlier age; both clinics found no significant difference for the mean ages when females and males came to the clinic.

The sex ratio did not change due to the shift in sexual orientation. A logistical regression analysis did not find evidence for a sex x sexual orientation interaction.**

The authors suggest that perhaps the explanation for the change in the sex ratio is that it is harder for males to transition to a female role than for females to transition to a male one.

I find this unconvincing as this would have been true in the past when more male teenagers than females applied to their clinic. Nor would this hypothesis explain the shift in sexual orientation.

Here is their full explanation:

“Given that there is at least some overlap in the gender-variant developmental histories of early-onset individuals with GD and some gay men and lesbians, it might, therefore, be asked whether or not degree of stigmatization for gender-variant behavior might account for the recent inversion in the sex ratio of GD adolescents. It is well-known that cross-gender behavior in children is subject to more social stigma (e.g., peer rejection and peer teasing) in males than in females, in both clinic-referred adolescents with GD and in the general population[26–30]. Thus, it could be argued that it is easier for adolescent females to “come out” as transgendered than it is for adolescent males to come out as transgendered because masculine behavior is subject to less social sanction than feminine behavior. Some support for this was found in Shiffman’s [31] study of peer relations in adolescents with GD, in which adolescent males with GD reported more “social bullying” than adolescent females with GD. Given that a transgendered identity as an “identity option” has become much more visible over the past decade, it is conceivable, therefore, that such an identity option is easier for females to declare than it is for males because it does not elicit as much of a negative response. Thus, it could be argued that it is this sex difference in degree of stigmatization that accounts for the inversion in the sex ratio that we have identified in the two studies reported here. In other words, there are greater costs for a male to adopt a female gender identity in adolescence than it is for a female to adopt a male gender identity.”

A few more details about this study:

The first study looked at 328 teens (13-19) who were referred to the Toronto clinic between 1976 and 2013. The mean age at the time of referral was 16.66 years with no difference between the ages of males and females.

All of the teens met criteria for Gender Identity Disorder or Gender Identity Disorder Not Otherwise Specified. They were diagnosed using criteria in the relevant version of the DSM – this changed over time. The assessment of severity of dysphoria began in 2001.

The control group was 6,592 teens referred to their general clinic for psychiatric issues between 1999-2013. Eleven teens originally referred for psychiatric issues who were later referred to the Gender Identity Service were not included in this group.

The teens’ sexual orientation was determined by either clinical chart data or measurements on the Erotic Response and Orientation Scale and the Sexual History Questionnaire. This data was not available for five probands (aka people in this study).

The numbers for the sexual orientation of the teens at the Canadian clinic were:

1976-2005 (30 years)

  • 52 males primarily attracted to males
  • 26 males in the “other” category
  • 39 females primarily attracted to females
  • 5 in the “other” category

2006-2013 (8 years)

  • 32 males primarily attracted to males
  • 41 males in the “other” category
  • 82 females primarily attracted to females
  • 46 females in the “other” category

The clinic did not have data on the sexual orientation of five of the teenagers.

The second study looked at data on 420 teenagers (13 and up) referred to the Dutch clinic between 1989-2013.  Their mean age at the time of assessment was 16.14 and there was no significant age difference between males and females.

The second study did not include data on sexual orientation or a control group for comparison.

“The percentage of female adolescents from Amsterdam in the first time period did not differ significantly from the percentage of female adolescents from the Toronto clinic, and the percentage of female adolescents from Amsterdam in the second time period also did not differ from the percentage of female adolescents from the Toronto clinic, both χ2(1) < 1.”

This study is a follow-up to two earlier letters to the editor about changes in the teenage population at the clinic in Toronto: Is Gender Identity Disorder in Adolescents Coming out of the Closet? and Patterns of Referral to a Gender Identity Service for Children and Adolescents (1976–2011): Age, Sex Ratio, and Sexual Orientation.

The first letter discussed a rise in teenagers referred to the Canadian clinic between 2004-2007. The second letter discussed the continued increase in referrals from 2008-2011 and raises the question of a possible change in the sex ratio in 2008-2011.

Original Article:

Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria by Aitken M1, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, Spegg C, Wasserman L, Ames M, Fitzsimmons CL, Leef JH, Lishak V, Reim E, Takagi A, Vinik J, Wreford J, Cohen-Kettenis PT, de Vries AL, Kreukels BP, Zucker KJ in J Sex Med. 2015 Mar;12(3):756-63. doi: 10.1111/jsm.12817. Epub 2015 Jan 22.

* The Canadian clinic is the Gender Identity Service, within the Child, Youth, and Family Services (CYFS) at the Centre for Addiction and Mental Health in Toronto. The clinic in the Netherlands is the Center of Expertise on Gender Dysphoria at the VU University Medical Center in Amsterdam. This may explain why we have a comparison group for the Canadian patients with gender dysphoria, but not the Dutch ones.

**  “In the cohort examined in Study 1, perhaps it could be argued that, in the first time period, the greater number of biological males than biological females was an artifact of there being two prominent subtypes of GD (androphilic and nonandrophilic) in the former, whereas the latter were predominantly of only one subtype (gynephilic), but that this shifted in the second time period, with a greater number of females with a nongynephilic sexual orientation. However, the logistic regression analysis shown in Table 4 did not provide evidence for a sex × sexual orientation interaction. It only showed that a nonandrophilic or nongynephilic sexual orientation increased the odds that a proband presented in the second time period, but sexual orientation did not interact with probands’ biological sex.”

More Than Two Developmental Pathways in Children With Gender Dysphoria? – Review

There is a short but important piece about the persistence of gender dysphoria in children.

In this Dutch clinic, they found that:

70% of the children they diagnosed with gender dysphoria did not return to the clinic and transition; they “desisted” in their gender dysphoria.

95% of the children who desisted as teens did not return to the clinic as adults.

27% of the children they diagnosed with gender dysphoria transitioned as teenagers, 3% did so as adults.

Of the children who returned to the clinic before adulthood, 75% came back before they were 14 years old and 25% came back when they were between 14 and 18.

Boys were more likely to desist from their gender dysphoria than girls; 73% versus 61,5%. Conversely, more female children with gender dysphoria went on to transition; 38.5% versus 27%.

This is in line with earlier studies that have found that most children diagnosed with gender dysphoria change their minds when they are older, usually at puberty.

It also provides a follow-up to the question of whether or not the children who changed their minds still had gender dysphoria. They had access to a free medical transition, but did not return for it. It is possible that some of them may still return, but so far 95% have not.

This data also demonstrates what the authors call a third “developmental pathway” for children with gender dysphoria. This group seems to go through a “period of questioning sexual identity” as adolescents before deciding to transition as adults.

The clinic looked at the records of 150 adults who were diagnosed with gender dysphoria as children. The adults were now between 19 and 38 years old (average age = 25.9, SD 4.03). The sample was the first 150 consecutive patients the clinic had diagnosed who were now adults.

The authors discuss past studies of persistence of gender dysphoria in children. In the past, the persistence rate has been only 16% across studies, however, the diagnoses of gender dysphoria may have included some children who were simply gender non-conforming in their behavior. They suggest that in the future persistence rates may be higher as clinicians use a stricter definition of gender dysphoria.

In addition, they suggest that persistence rates might be higher if we include patients who choose to transition as adults. In this study, the persistence rate would only have been 27% if they did not include the 3% who transitioned as adults.

I would add that this data on persistence includes children who had access to puberty blockers and early transition. We need studies to determine if this affects rates of persistence and desistance.

We also need more studies of the children who did not return to the clinic and transition. Why didn’t they return? Did they completely lose their gender dysphoria? Are they happy? If they lost their gender dsyphoria, how did that happen? If they didn’t lose it, how are they dealing with it?

We have one study of children who desisted in their gender dysphoria, but we need more. (Desisting and persisting gender dysphoria after childhood.)

Finally, the authors provide an interesting discussion of the patients who did not transition as teenagers but returned to transition as adults:

“The average age of the 5 individuals who re-entered the clinic in adulthood was 24 years (range 21–37). Despite their knowledge of the availability of treatment for adolescents and the fact that treatment is covered by insurance, they did not apply for treatment during adolescence. Four (3 natal males and 1 natal female) tried to live as gay or lesbian persons for a long time, and 1 natal male had autism spectrum disorder. He reported that he needed to solve other problems in his life before he could address his GD. The others reported not having any problems with being homosexual. Yet, after having intimate and sexual experiences with same (natal) sex partners, they came to realize that living as a homosexual person did not solve their feelings of GD, and they felt increasingly drawn toward transitioning. All also mentioned that they were somewhat hesitant to start invasive treatments, such as hormone therapy and surgeries.”

and:

“It would be worthwhile to know whether the GD of these “persisters-after-interruption” differs qualitatively or quantitatively from the GD of straight persisters and whether the groups differ in other respects. For instance, has the GD in the persisters-after-interruption group actually disappeared for some years or, as the reports of our young adults suggest, did they make a more or less conscious choice not to live according to their experienced gender? Knowing more about this developmental route would be clinically useful when counseling young people with GD.”

This data was presented in a letter to the editor.

Citation:

More Than Two Developmental Pathways in Children With Gender Dysphoria? by Steensma TD, Cohen-Kettenis PT in J Am Acad Child Adolesc Psychiatry. 2015 Feb;54(2):147-8.