Tag Archives: Belgium

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?

Advertisements

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder

This study found that hormone therapy reduced symptoms of psychological distress, although surgery had no further effect.

However, this conclusion is undercut by the fact that one person committed suicide during follow-up,* treatment did not reduce the prevalence of suicide attempts, and 17% of the people surveyed after treatment reported suicidal thoughts.

There are also areas where the methodology of the study could be improved.

Finally, the data on the percentages of suicide attempts is confusing. See the end of this review for details on the data.

Summary of the results:

After treatment, patients reported fewer symptoms of anxiety, depression, interpersonal sensitivity, and hostility.

Transition did not reduce the percentage of suicide attempts.

One patient committed suicide during follow-up.*

Transition did not affect patients’ psychosocial well-being, i.e. employment, relationships, number of sexual contacts, drug use, and suicide attempts.

Over 90% of patients said that they were happier and felt better about their body after treatment, but 17% reported that they had suicidal thoughts.

The improvement in psychological symptoms happens after hormone therapy. Surgery did not cause a significant change in psychopathology, although patients reported slightly more symptoms after surgery than after hormone therapy.

When asked, 57.9% of patients said that they experienced the most improvement after hormone therapy, 31.6% experienced the most improvement after surgery, and 10.5% experienced improvement just from being diagnosed.

After treatment, the average scores of psychopathology were similar to the general population.

After hormone therapy, none of the average subscale scores were different from the general population. However, after surgery, the group’s average scores for sleeping problems (p=0.033) and psychoticism (p=0.051) were higher than the general population.

These results raise some important questions.

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

Why didn’t surgery improve the mental well-being of the patients?

There were also a couple of important methodological questions that the authors did not discuss.

Combining the results of different treatments

As often happens, the study lumped together trans men (born female) and trans women (born male). The treatments for trans women and trans men involve different medications and surgeries. It is possible that androgens and estrogens have different effects on mood. Similarly, it might be that some surgeries are more beneficial to mental health than others or that some surgeries are more stressful than others.

The participants in the study were 46 trans women and 11 trans men. The authors do not discuss whether they differed in their mental health symptoms or social well-being. Nor do they give information on the gender of the people who completed the questionnaires at follow-up.

The study does not specify exactly what medications and dosages were used for the hormone therapy. They do not say exactly what surgeries the patients got.

Missing Data

As with many longitudinal studies, they did not have follow-up data on all of the participants due to incomplete questionnaires. In addition, one participant did not complete a questionnaire at the beginning of the study.

Thus, 56 people completed a questionnaire about their mental health before treatment, but only 47 people completed the questionnaire after hormone treatment. The authors then compared the average scores on the baseline questionnaires to the averages on the questionnaires after hormones.

It is possible that this would lead to a bias in the data. For example if depressed people were less likely to complete follow-up questionnaires, the average for the follow-up questionnaires would show fewer symptoms of depression than the average for the initial questionnaires.

The authors do not discuss whether the people who did not complete the questionnaires after hormone therapy were significantly different from those who did.

Leaving suicide out of the results

The person who committed suicide was not included in the study; if they had been it might have distorted the data. Presumably their responses at baseline would have increased the average score for symptoms of depression, but without a follow-up questionnaire for them, symptoms of depression would appear to go down. Leaving them out makes the results clear – symptoms of depression went down among everyone else.

At the same time, without data on the person who committed suicide during follow-up, it is not fully accurate to say that symptoms of depression went down after treatment. For at least one person it doesn’t make sense to talk about symptoms of depression going down.

Suicide during follow-up is part of the results of this study. It is relevant to the question of whether or not people felt better after transition. When someone commits suicide during a study, this needs to be part of the discussion. When did they commit suicide? Were they depressed before transition? Did they regret the surgery? Did they say they were depressed during or after transition?

Not talking about the suicide is disrespectful to the person who died. It leads to possibly false conclusions about the effects of transition. And it stops us from being able to figure out what we can do to prevent future suicides – do we need to give people more therapy before medical treatments? should some people not get surgery? do we need to give people more therapy after surgery?

Back to the questions raised by the study

What can we do to reduce suicide, suicide attempts, and suicidal thoughts in transgender people who have transitioned?

Clearly, medical transition is not enough. It does not prevent suicide, suicide attempts, or suicidal thoughts. It does not even reduce the prevalence of suicide attempts.

As far as I know, this is the only study that has followed a group of people with gender dysphoria during treatment and collected data on suicide attempts.

We need more research to figure out how to prevent suicide and suicide attempts among transgender people after transition. It might also help if we knew more about what was going on in this study.

When exactly were the suicide attempts – after hormones or after surgery? When exactly did the person commit suicide?  Does this reflect regret related to the surgery itself or something else?

Were there any gender differences in the suicide attempts?

Were there any differences in the specific treatments given to the people who attempted suicide? Were there any problems in the outcomes of the treatments?

Did the same people attempt suicide before and after transition?

Did the people who attempted suicide say they were depressed? Had they been diagnosed with mental health issues? Were they getting counseling?

Do we know of things that went wrong in the lives of the people who attempted suicide?

Do some people need more counseling and evaluation before transition? Should we adapt the hormonal doses or surgeries for different people? Do we need to give additional support after transition? Are there alternatives to transition that would better help some people deal with gender dysphoria?

At this point all we know is that we can not rely on medical transition to prevent or reduce suicide attempts among transgender people.

We need to know more.

Why didn’t the percentage of suicide attempts go down when people were reporting fewer symptoms of depression?

The results of this study are somewhat confusing. People reported that their symptoms of depression and psychological distress went down after transition. In addition, the vast majority of people who had transitioned said that they felt better – they were happier (93%), less anxious (81%), more self-confident (79%), and their body-related experience improved (98%). Only 2 people said they were more anxious and 1 less self-confident. Only 2 said that their overall mood was similar.

So why did 7 people (17.6%) report that they had suicidal thoughts? Why were there 4 suicide attempts?

Were the people who had suicidal thoughts so unhappy to start with that an improvement in their mood still left them suicidal? Perhaps they had even more suicidal thoughts before transition – but the prevalence of suicide attempts was not affected by transition.

It’s possible that the group’s average scores for depression are in the normal range while a few individuals are miserable. On the other hand, the group has an above average number of suicide attempts and suicidal thoughts. According to an Emory University website “It is estimated that 3.7% of the U.S. population (8.3 million people) had thoughts of suicide in the past year, with 1.0% of the population (2.3 million people) developing a suicide plan and 0.5% (1 million people) attempting suicide.” In this study, 17.6% of the group reported suicidal thoughts at the moment of follow-up. The suicide attempt percentage was 9.8% at follow-up.

We are looking at a group of people with elevated levels of suicidal thoughts and suicide attempts – how does that fit with questionnaires that find a normal level of symptoms of depression?

Are we seeing accurate reports of how people feel? Are people minimizing their problems when they fill out questionnaires after treatment?

The authors of the study do not discuss the apparent contradiction between suicide attempts and suicidal thoughts one the one hand and an improved mood on the other.

The authors do point out that the percentage of suicide attempts at the beginning of the study was lower than in other studies of transgender people. It may be that the participants in this study had fewer problems than most transgender people; for one thing they are a group that is able to access medical care. However, that does not answer the question of why for this particular group of people transition did not change the prevalence of suicide attempts.

We need more research into what is going on here. We need to be able to identify people who may attempt suicide or feel suicidal after transition so we can help them.

Why didn’t surgery improve the mental well-being of the patients?

We don’t know and we need more research to answer this question. However, here are a few possibilities:

Possibility #1 – Return to regular life

In their discussion, the authors suggest that there might be an initial euphoria after beginning hormones that wears off later on. In addition, after surgery, people might be “again confronted with stigma and other burdens.”

In other words, the improvement after hormone therapy is higher than the improvement will be in the end. There is still an improvement later on, but the initial level of euphoria isn’t going to last. If this is true, it would be important information for people who are transitioning so that they don’t have false expectations of what life will be like after transition is complete.

Possibility #2 – Surgery is not the best treatment for everyone

The authors also suggest that further studies should look at exploring the idea that some patients might want hormones without surgery.

It may be that surgery is not the best treatment for everyone with gender dysphoria. Perhaps some people would have been better off with just hormone therapy.

Previous studies have found that about 3% of people who have had genital surgery regret it, so we would expect one or two people out of 50 to regret their surgery. Perhaps they are depressed and this affects the group average.

Possiblity #3 – Effects of surgery

It is also possible that some people had post-surgical depression and that this affected the results.

Perhaps some people were still recovering from surgery and did not feel well (the study included people 1 to 12 months after surgery). In particular, this might lead to the increase in sleeping problems found in the study.

Perhaps some people were dealing with complications of surgery.

Perhaps the hormonal changes after surgery affected people’s moods.

Possibility #4 – People were already happy

On the other hand, perhaps by the time people get surgery, they are already happy due to counseling, hormones, and social transition.

Perhaps if people had been forced to stop with hormone therapy alone, they would have become unhappy.  As the authors point out, it may have made a difference that they knew they were going to be able to get surgery.

Possibility #5 – Surgery doesn’t affect mental health

It may simply be that surgery does not improve mental health. At this point, we do not have proof that it does.

In the end, we just don’t know.

Further studies are needed to determine if surgery is helpful and who should get it. Perhaps the authors of this study can use the data they already have to address this question.

 

* Data on this patient was not included in the study.

Original Source:

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder by Gunter Heylens, Charlotte Verroken, Sanne De Cock, Guy T’Sjoen, Griet De Cuypere in J Sex Med 2014 Jan 28;11(1):119-26. Epub 2013 Dec 28.

 

Questions about the data on suicide attempts:

The authors talk about the prevalence of suicide attempts before and after transition, but they don’t talk about the time periods they are looking at. The authors say that the prevalence of suicide attempts was unchanged, but they don’t explain when the suicide attempts took place before treatment. It makes a big difference if they are comparing three years before transition to three years afterward or if they are comparing a lifetime before transition to the average 3 year follow-up period – a follow-up that took place 1-12 months after surgery.

In addition, the actual data on suicide attempts is confusing. In Table 3, the authors list the prevalence of suicide attempts as 9.4% at presentation and 9.3% at follow-up. However, in their discussion they say the suicide attempt percentages were 10.9% initially and 9.8% at follow-up.

Looking at Table 3,  there were 5 attempts in a group of 54 people which would give a percentage of 9.26%, a number that doesn’t match either of the ones given by the authors. In addition, there were 4 attempts in a group of 42 people which would give 9.52%, another number that doesn’t match.

The percentage they gave at baseline in Table 3 seems to be 5 out of 53 people, while the percentage at follow-up seems to be 4 out of 43. Perhaps one of the 54 people didn’t answer the question on suicide attempts in the first set of questionnaires. But where does the additional person come from in the second set of questionnaires? If they are including the person who committed suicide in the suicide attempts, wouldn’t the number of people used to calculate the percentage before treatment be 54 or 55, not 53?

None of this explains why they would list different numbers in their discussion. Perhaps there were some suicide attempts by the same person that were included in one set of numbers but not the others? The table talks about the prevalence of suicide attempts while the discussion talks about the percentage.

It would have been helpful if they had clarified this.

 

 

A review of “Gender Identity Disorder in Twins: A Review of the Case Report Literature”

The data on twins suggests that there is a genetic component to gender dysphoria.

It also suggests that other factors are involved in developing gender dysphoria.

Unfortunately, the data is weak because it is mostly made up of case studies.

In addition, the data on identical twins and the data on fraternal twins were collected in different ways.

It is possible that this review overestimates the influence of genes due to the way the data was collected.

I had thought that writing this review would be quick and easy; genes are involved, but they are not the only factor. The truth is that the data is flawed and we don’t have conclusive proof yet. What we do have is a suggestion that genes are involved in gender dysphoria and a need for more research in this area.

Data on twins with gender dysphoria is hard to collect because it is rare. This review is an important one and it shows that there are good reasons to keep looking for possible genetic links to gender dysphoria. It also shows that there are good reasons to look for non-genetic factors that play a role in developing gender dysphoria.

Now you have the summary of the results, back to the study. Why does it mattter if many of the reports on identical twins came from case studies?

Using case studies means that there is a possibility of selection bias.

People may be more likely to publish interesting cases. For example, the review includes one case study where both identical twins had gender dysphoria, but only one had schizophrenia. In another case study both identical twins had anorexia, but only one had gender dysphoria. These cases are interesting, but they may not be typical.

This can become a more serious problem if therapists are more likely to be interested in cases of twins who are both trans. Alternatively, there could be a selection bias in favor of writing about identical twins where only one twin is trans. Some therapists might unconsciously look for cases of twins that fit their own theory about the cause of gender dysphoria. (Read more about case studies and selection bias here.)

The results of this review suggest that there is a selection bias that favors identical twins over fraternal twins. In other words, people write up and publish cases of identical twins more often than fraternal twins.

This is not because trans people don’t have fraternal twins; the studies that reviewed clinic records found 19 sets of fraternal same-sex twins and only 7 sets of identical twins. Only 27% of the twins in this group were identical twins. This is not surprising; fraternal twins are more common than identical twins in the general public.

The other studies, in contrast, reported on 16 sets of identical twins and only 2 sets of fraternal twins. A whopping 89% of the twins in this group were identical twins.

The key to figuring out if gender dysphoria is genetic is to compare identical twins and fraternal twins. If identical twins are more likely to both have gender dysphoria than fraternal twins, you have a good case for a genetic contribution. So if the sets of identical twins are chosen in a different way from the sets of fraternal twins, you have a problem.

In fact, for this study most of the data on identical twins is coming from case reports; there might be a selection bias involved there. Almost all of the data on fraternal twins, however, is coming from comprehensive reviews of clinic records.

Reviews of case studies include a number of other problems.

You can’t be sure people are being diagnosed in the same way; you may not be looking at the same phenomenon. This review looked at people diagnosed by different therapists in at least ten different countries.* The dates of the studies ranged from 1956 to 2011. Some of the twins were children or teens, some were adults.

There may also be cultural or environmental differences that are relevant. For example, one of the case studies is of a pair of identical twins in Iran. Both twins are trans. We know that many people feel pressured to transition in Iran; what if that is a factor in this particular case? What if in another country, only one of the twins would have transitioned?

The era of the study might also affect gender dysphoria. For example, the Belgian clinic noticed that two of the fraternal twins with gender dysphoria they found had been born after in vitro fertilization. If IVF is a factor in gender dysphoria, it will only affect later cases.**

The data in case studies is not uniform; this makes it hard to compare. For example, one study discussed birth weights while another focused on relationships with parents.

This review of studies did include three sets of twins who were found in a method that did not have a selection bias or problems with inconsistent collection of data.

1) Zucker looked at the records of 561 patients who went to a Canadian clinic for gender dysphoria between 1976 and 2011 and found 25 sets of twins. The patients were all under 12 years old.

They found no cases where both twins had gender dysphoria.

2) Heylens and De Cuypere looked at 3 sets of adult twins from the 450 patients who went to a Belgian gender clinic between 1985-2011 plus 3 sets of non-adult twins who went to the Belgian gender clinic for children and teenagers.

They found only one case where both of the twins had gender dysphoria: a set of identical twins who were female-to-male transgender (FtM).

3) Vujovic et al reviewed all the cases of gender dysphoria who were treated at a Serbian clinic between 1987 and 2006. Out of 147 people, one trans man and one trans woman had a fraternal twin. Neither of their twins had gender dysphoria.

If we exclude case studies because of possible bias, we end up with no genetic component to gender dysphoria in trans women. None of the clinics found pairs of male twins who both had gender dysphoria.

The problem with this approach is that identical twins who are both male-to-female transsexuals exist. They just didn’t show up at these three clinics. Presumably, they are very rare.

Using the clinic studies for trans men we would have one set of identical Belgian twins who both had gender dysphoria, and one set of identical Canadian twins who did not. In addition, we would have three sets of fraternal twins where only one twin had gender dysphoria. This is not enough data.

So it makes sense to look at the data from individual case studies; we just need to be cautious about interpreting it. It is possible that it would over or underestimate the genetic component to gender dysphoria.

What was the data, then?

The authors searched the literature and put their data from the three clinics together with data from 17 different case reports and studies.***

They found:

FtMs with identical twins

3 sets of identical twins who both had gender dysphoria (37.5%)

5 sets of identical twins where only one of the twins had gender dysphoria (62.5%)

FtMs with fraternal twins

5 sets of fraternal twins where only one of the twins had gender dysphoria (100%)

MtFs with identical twins

6 sets of identical twins where both twins had gender dysphoria (40%)

9 sets of identical twins where only one twin had gender dysphoria (60%)

MtFs with fraternal twins

16 sets of fraternal twins where only one twin had gender dysphoria (100%)

Based on this data, identical twins with gender dysphoria are more likely than fraternal twins or the general public to have a twin with gender dysphoria. This suggests a genetic component to gender dysphoria.

However, most of the time, only one identical twin has gender dysphoria. This suggests other factors are involved in gender dysphoria.

At this point, we have no idea what the other factors involved might be. The case reports don’t give enough information on the twins to figure it out. The information they give is inconsistent; one study reported on the age of the first period while another talked about whether or not the mother was domineering. In addition, we may be comparing apples and oranges; for example, one study looked at an adult male American Indian in 1976, another looked at 13 year old American females in 1992.

The authors of the review conclude:

“The etiology of GID is a complex process of biopsychosocial components with unexplained interactions. Twin literature on GID supports the contribution of genetic factors to the development of gender identity with a higher tendency in males than in females.****

Since sample size is still limited and genotype studies are lacking, conclusions must be drawn with caution.

Therefore, detailed registers of GID twins, preferably on MZ twins discordant for GID and DZ twins are needed, to gain more decisive information about the influence of genetic vs. environmental factors in the development of GID.

The authors of the study combine the data from studies of MtF and FtM twins for the statistical analysis. This gives them 9 pairs of identical twins where both twins had gender dysphoria (39%) and 14 pairs of identical twins where only one twin had gender dysphoria (61%). This is contrasted with 21 sets of fraternal twins where only one twin had gender dysphoria (100%). The difference is statistically significant.

This might be problematic since the mechanism that causes gender dysphoria in trans women is probably different from the mechanism that causes gender dysphoria in trans men. The genes are also probably different.

On the other hand the question here is whether or not gender dysphoria is inheirited, so perhaps this works.

Another problem is the possibility of selection bias. It looks like people are over-reporting cases involving identical twins. This might affect comparisons between identical twins and fraternal twins.

In addition, the total size of the group used in their statistical analysis is small and includes disparate groups – males and females, adults and children, people in different countries, and people living in different eras.

In the end, we’re left with weak evidence for a genetic component to gender dysphoria. We can’t prove it, but there is an excellent case for doing more studies in this area.

There is also an excellent case for future studies looking at what factors make one identical twin have gender dysphoria and one not. This seems to be the more common outcome than for both twins to have gender dysphoria.*****

Original Review:

Gender Identity Disorder in Twins: A Review of the Case Report Literature by Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T’Sjoen G in J Sex Med. 2012 Mar;9(3):751-7.

 

*Authors of the studies were from Belgium, Canada, Germany, Iran, Israel, the Netherlands, Serbia, Switzerland, the United Kingdom, and the United States. In addition, one author seemed to be from Scandinavia, possibly either Norway or Sweden.

**Using IVF means that the parents were infertile. It might be that the parents were older or that they had something wrong with their reproductive systems. It could be that the parent’s age or fertility problems affected the children rather than the IVF procedure.

***In some cases, it is hard to tell from the title if an article was a study or case report or an article on gender dysphoria that includes information on a case. Then again, the sub-title of this study is “A review of the case report literature,” so maybe they were all case reports.

**** I think the idea that there is a higher tendency in males than females is overstated. There were only 8 pairs of identical FtM twins and I doubt the 2.5% difference in the frequency of FtM versus MtF identical twin pairs who both have gender dysphoria is significant.

***** There may be selection bias in the cases of identical twins from the case reports. However, the clinic studies did find six sets of identical twins. In five of these six pairs, only one twin had gender dysphoria. Specifically, they found four pairs of identical male twins where only one twin had gender dysphoria, one pair of identical female twins where only one twin had gender dysphoria, and one pair of identical twins who were both FtM. So it looks like it is more common for only one identical twin to have gender dysphoria.

Emphases added are mine, including in the quote from the original review of the literature.

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

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

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

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

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

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

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

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

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

The authors conclude:

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

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

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

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

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

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

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

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

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

Bold added by George Davis.

Orignal Article:

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

Physical Appearance and Voice in Male-To-Female Transsexuals

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

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

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

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

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

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

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

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

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

The authors of the study conclude:

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

Original Article:

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

Bold added by George Davis.

Surgical modifications of forehead and orbital area in facial feminization – Brief Review

This is an abstract of an oral paper. They presented clinical cases and seem to have discussed surgical techniques.

Original Article:

Surgical modifications of forehead and orbital area in facial feminization by A. Lemaitre, W. Waskiewicz, S. Medin Rey, S. Duvigneaud, M. Shahla, K. Keiani in International Journal of Oral & Maxillofacial Surgery, Volume 40, Issue 10 , Page 1084, October 2011.