Tag Archives: my kid is transgender

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients – Study Review

This is a 2010 study of the functional and cosmetic outcomes of the surgical techniques used at a German clinic. They followed 50 trans women who had surgery between May 2001 and April 2008. The surgeries were all performed by the same surgeon who had extensive surgical experience.

Before surgery, all the patients had completed a two year “real life” test and had been recommended for surgery by two independent psychiatrists. They had been on hormones for at least one year, although they stopped taking hormones a month before the surgery.

The patients were sent a questionnaire to follow-up on sexual function and patient satisfaction with the surgery. All 50 patients completed the questionnaire; the mean follow-up time was 3 years.

Outcomes of Surgery

Regrets:

One person regretted the surgery and became clinically depressed. They attempted suicide twice and had not fully recovered two years later.

The patient was 24 years old and the authors suggest that the ideal age for surgery is 30 years old. They also recommend thorough evaluation and good counseling before surgery.

This is consistent with other studies that found a regret rate after surgery of 3-4%. In a group of 50 people getting the surgery, you would expect one or two people to wish that they had not had the surgery.

The patient regretted the surgery 3 days after the operation.

Complications:

6% had bleeding after surgery

4% required operative revision due to the bleeding (two of the three who had bleeding)

10% had shrinkage of the vagina which could be corrected by a second surgical intervention

4% had a minor bulge in the anterior vaginal wall which could be easily fixed with simple excision

There were no post-operative rectocele (bulge of the rectum into the vagina) or urethrovesical fistulae.

The authors of the study say that the incidence of surgical complications was comparable to the data in the literature.

The 6% of patients with bleeding that they report is better than the 10% reported by a United Kingdom clinic in this review.

Their rate of complications is considerably better than this 2001 study at a different German hospital which reported that “Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.”

They do not report any problems with narrowing of the urethra, which is also an improvement over the 3-4% reported by the clinic in the Untied Kingdom.

They do not report any problems with pulmonary embolisms or fistualae between the rectum and vagina. These are problems that are relatively rare and you might not expect to see them in a group of only 50 people; the review from the United Kingdom reported a rate of 2 in 1000 pulmonary embolisms with 1 death. They also reported a rate of 6 in 800 rectal fistulae.

Minor complications:

6% subcuntaneous hematoma that did not require any further therapy (i.e. they had a ruptured blood vessel causing a lump or bruise under the skin)

General:

Mean operative time – 190 (160–220) minutes or 3.16 (2,66- 3.66) hours

Mean depth of the vagina – 10 (6–14) cm or 3.93 (2.36-5.51) inches

Median hospital stay – 10 (6–14) days

In comparison, the United Kingdom clinic reported an operative time of 120-150 minutes, while the 2001 German study reported a mean time of 6.3 hours with a range of 4-9 hours.

Satisfaction with results at follow-up

Appearance:

10% of the patients were dissatisfied with the appearance of their labia

90% were satisfied with the appearance of their genitals

We need more research on how to construct labia that are satisfactory for all trans women.

Depth of Vagina:

20% were dissatisfied with the depth of their vagina

80% were satisfied with the depth of their vagina

4% were still dissatisfied with their vagina after a second operation

Of the ten women who were dissatisfied with the depth of their vagina, eight had a new operation to augment the vagina. Of the women who had the second operation, two were still dissatisfied (25%). Perhaps the secondary operation could be improved.

We need to know more – why were 20% dissatisfied with the depth of their vagina? What can be done to ensure that all trans women have vaginas that are deep enough?

How deep were the vaginas at follow-up? Were there some women whose vaginas were not deep who were satisfied anyway?

Sexual Pleasure:

5% of the trans women having regular sexual intercourse experienced pain during intercourse; 84% of the trans women were having regular sexual intercourse

70% of the trans women reported achieving clitoral orgasm

The authors are not clear here, but it looks like 30% of the trans women who had this surgery are unable to achieve orgasm. This is a serious problem; they should have addressed it more fully.

Were some of the women not attempting orgasm? Did everyone answer the question?

At one point the authors say, “84% reported having regular sexual intercourse, of whom 35 had clitoral orgasm” – that would change the numbers to 35 out of 42 women which would be better (although it would still leave 17% of the sexually active women not having orgasms). On the other hand, they also say, “Of the 50 patients, 35 (70%) reported achieving clitoral orgasm.”

As it stands, it looks like a large percentage of trans women are not having orgasms after surgery. That would be a problem and worthy of more discussion in the results. The ability to orgasm is an important, vital aspect of the outcome of these surgeries.

In addition, doctors and surgeons need to address the problem of pain during intercourse. Is there something trans women can do themselves to reduce the pain? Can the surgeries be improved in this area?

From their Discussion and Conclusions:

“The incidence of surgical complications was comparable to the literature data. The most common complication (10%) in the follow-up was shrinkage of the neovagina. In all cases a second surgical correction was necessary to definitively solve the problem. In all patients vaginopexy to the sacrospinous ligament was carried out, reducing the rate of neovaginal prolapse as described in the literature.

After 3 years, 49 patients were satisfied and did not regret or had doubts about having undergone sexual reassignment surgery. The only exception was a 24-year old patient who, 3 days after the operation, regretted his decision. After that, he developed a strong depression which needed psychological therapy. Two years after surgery, the patient had still not recovered completely and had attempted suicide twice.

We agree with Rehman and Melman that the best age to undergo sexual reassignment surgery is 30 years, an age that enables patients to adjust socially and sexually, increasing the possibility to develop attractiveness and allowing the patients to mature in dealing with new life stresses. Moreover, before undergoing such surgery, it is our opinion that all patients at all ages need deep and intensive psychological examination and must be informed about all the functional and cosmetic risks associated with this operation and, above all, about the impossibility of regretting the decision and returning to their natural gender.

With improvements in surgical technique over the years, male-to-female gender-transforming surgery can assure satisfying cosmetic and functional results, with a reduced intra- and postoperative morbidity. Nevertheless the experience of the surgeon and the center remains a central important aspect for obtaining optimal results.”

The full article includes graphic pictures of surgery as well as details of their technique; you can get it at the link below.

Original Source:

Male-to-Female Transsexualism: Technique, Results and 3-Year Follow-Up in 50 Patients by Wagner S, Greco F, Hoda MR, Inferrera A, Lupo A, Hamza A, Fornara P in Urol Int. 2010;84(3):330-3.

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Review of Gender reassignment surgery: an overview

This article is a good summary of surgeries used in medical transition. It is not a study or review of studies, but it is written by two experienced surgeons from the United Kingdom. They provide some numbers related to complications and some valuable information on specific techniques.

It is important to remember that this is not a scientific study or survey; it is a report by surgeons based on their experience. The results in other clinics may be different. If you are seeking surgery, ask your doctor about their work.

The authors’ discussion of sexual pleasure and orgasm is very limited. They do not discuss patient satisfaction. They do not look at the mental health effects of surgery, either, just the physical outcomes.

As always, there are many areas where we do not yet have any studies and we don’t know the answer. We could use more studies and articles about the various techniques, their outcomes, and their complications. Any evaluation of these techniques should include patient satisfaction and sexual function.

So what are the physical outcomes and complications of various surgeries that the authors discuss?

SURGERIES FOR TRANS WOMEN

Some Complications and Risks, Vaginoplasty

Death from pulmonary embolism – 1 in 1000 among recent patients at their clinic.

Pulmonary embolism (blood clot that travels to the lungs) – 2 in 1000 among recent patients at their clinic. The length of the surgery makes blood clots a problem; this clinic works to reduce them.

“MtF surgery can be complicated by all the normal nonspecific complications of major surgery. For instance, venous thromboembolic disease is a particular problem, partly owing to the nature of the operation (pelvic surgery), the prolonged duration of the operation (5 h in some units) and the practice, which is still common, of keeping patients on bed rest for several days after the operation. In our unit, the operative time is reliably in the region of 120–150 min and patients are mobilized immediately after surgery to reduce the risk of thromboembolism. Combined with routine use of low-­molecularweight heparins and compression stockings, we have seen only two pulmonary emboli in the last 1,000 MtF surgical procedures (one of which was fatal).”

Clinically significant bleeding – At least 10%. Most of the bleeding is from the “corpus spongiosum surrounding the urethra.”

“Specific to the operation itself, the most common complication of MtF surgery is bleeding. In units with large numbers, labial hematomas are seldom seen, but do occasionally occur. Most may be managed conservatively, but they do result in an increased incidence of wound dehiscence [opening up along the incision], as observed in our institution. The principle source of postoperative hemorrhage is from the corpus spongiosum surrounding the urethra. Even with meticulous suturing, some 10% of patients will experience clinically significant bleeds. This bleeding may be reduced by leaving the postoperative pressure dressing in place for longer, but that in turn can inhibit patient mobilization and may result in increased risk of thromboembolism.”

Fistula (hole) between the rectum and vagina – 6 in 800 at their clinic in 2008 – the numbers are unknown in general and possibly “seriously under-reported.” The cause is unknown.

Fistuals frequently require further surgery and sometimes lead to the removal of the neovagina.

“When a fistula occurs, a defunctioning colostomy is usually needed. About 50% of fistulas will then close spontaneously, but in the remainder further surgery is needed. In difficult cases, removal of the neovagina may be required.”

Narrowing of the urethra – 3-4% minimum rate. This problem causes “dribbling incontinence.” The narrowing develops a few months after the operation and requires surgery. The surgery is usually effective – “although a few do go on to long-term intermittent catheterization.”

Loss of vaginal depth and width – The authors give no numbers, but believe that these complications are under-reported. The loss of depth could be due to loss of skin; in this case a new vaginoplasty is required using using tissue from the bowel. Loss of depth and width could also be caused by not following a proper dilation routine.

“Again, these complications are probably markedly under-reported, as some patients are effectively celibate or do not need much vaginal depth and width for their chosen sexual activities.”

Growth of hair in the vagina – This is caused by not removing hair either before surgery or perioperatively. There is no cure; if your surgeon is using skin from the scrotum, be sure to have the hair removed.

“Once hair growth is seen in the vault of the neovagina, little can be done to prevent its continued growth, and a number of patients will have to return at intervals for removal of hairballs.”

Overall complicate rate – Under 25%. It is not clear exactly what complications they are including in this number.

Clitoroplasty

The authors don’t give numbers on orgasms or sexual satisfaction. In their experience, the vast majority of innervated neoclitorides have sensations.

Some surgeons create additional erogenous sensation by putting the part of the glans penis left after making the clitoris between the urethra and neoclitoris.

Past techniques led to problems with urethtral fistualas and leaking pee, but the techniques have changed.

“The rate of urinary leakage from urethral fistulas was substantial with this technique and it has now been largely superseded by techniques in which the neurovascular bundle to the glans, which lies between Buck’s fascia and the corpora cavernosa, is preserved. This technique has been widely described and seems to provide good rates of sensitivity and sexual satisfaction.”

Labioplasty

Creating labia minora is challenging. The best technique to use will depend on how much skin is left from the penis; this may vary depending on the individual and the surgery. There aren’t any guidelines on how to do this.

“Overall, a balance needs to be achieved between construction of a satisfactory neovagina, and a good, realistic, cosmetic external appearance. To date, no guidelines exist that give an indication of when and how penile or scrotal skin should be used for clitoral hood or labia minora reconstruction, or the ideal penile skin length, depth of the vagina or tissue that should be used. The choice of technique for labioplasty is, therefore, largely that of the individual surgeon.”

Urethrostomy

The authors describe one technique which has a low rate of immediate complications like bleeding, but can lead to peeing upwards or narrowing of the urethra. In addition, this technique leaves in place some erectile tissue that swells during sexual arousal.

The authors prefer a different technique which creates a satisfactory direction of pee and which they believe looks better cosmetically. However it has a raised risk of bleeding.

Specifically, with the first technique they “divide the urethra in the proximal bulb and suture the urothelium direct to the skin (bringing the urethra through the anterior skin flap)” and with the second they “spatulate the urethra, and excise some or all of the corpus spongiosum posterior to the urethral meatus.”

Other Surgeries for Trans Women

The authors briefly mention breast augmentation, vocal cord and throat surgery, and facial feminization surgery.

Breast augmentation in trans women is similar to breast augmentation in cis women, but will be affected by the shape and size of the starting breast tissue and muscles.

Speech therapy is required after vocal cord surgery.

“In facial feminization, good results are achieved by shaving of the frontal bossae, the brow ridges, the mandible angles and the chin, accompanied sometimes by rhinoplasty.”

SURGERIES FOR TRANS MEN

Some Complications and Risks, Metoidioplasty

One of the advantages of a metoidioplasty is that there are few complications and recovery time is “quick.”

“The complication rate is relatively low (overall complication rate <20%)—especially when compared with more elaborate microsurgical techniques, in which complications are reported in 40% of patients.”

The disadvantages of this type of surgery are that it produces a short phallus that may not be capable of sexual penetration. Not everyone can pee standing up.

On the other hand, sexual sensations are well preserved which is a pretty important factor. The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

“…micturition in a standing position is somewhat, but not always, achievable. Despite the small size, some patients report satisfactory intercourse with female partners, and sensation is usually well preserved. Nevertheless, this approach is not well suited to individuals in whom clitoral hypertrophy is less marked, and the small size of the resultant phallus is unsatisfactory for most patients, not least because it is inadequate to show in clothing and for satisfactory sexual penetration.”

Are they trying to cause dysphoria here? I don’t think there are any numbers on what percentages of trans men prefer which form of surgery.

Some Complications and Risks, Phalloplasty

Overall complication rate – Over 40%. it is not clear exactly what complications they are including.

Microsurgical flap failure – Less than 2%.

Fistulas involving the neourethra – 25-30% in most series.

“Most fistulas will eventually close after a period of catheterization, but many require revision surgery.”

Urethral stricture formation (narrowing of the tube that carries pee out of the body) – 18%.

Postmicturition dribble (dribbling after peeing) – In one study, 79% of patients reported this problem.

Erectile function – Most phalloplasty techniques require the insertion of an inflatable prosthesis to become erect for sexual activity. “…the failure rate for penile prostheses is considerable, usually owing to infection of the device…”

We don’t know much about this yet. “Long-term results on the use of these erectile implants in FtM transsexuals is still lacking.”

There are some techniques that do not require a prosthesis, but they may have other issues.

“When a latissimus dorsi myocutaneous free flap is used, sexual intercourse is possible by contraction of the muscle, which stiffens, but shortens, the penis without requiring a prosthesis. Flaps harvested with bone (for example, fibula or osteocutaneous radial forearm flap) do not need stiffeners, but this flap type results in a permanent erection.”

Sexual sensation – For free-flap phalloplasties, “Sexual sensation with retention of ability to orgasm is usually preserved.” The authors don’t compare metoidioplasty and phalloplasty in terms of sexual pleasure for the trans man.

Different techniques – There are a few different techniques for phalloplasty, but we don’t have any studies comparing them to see which ones are best.

“To date, the gender team at Ghent University Hospital, Belgium, has published the largest series on phalloplasty (with radial forearm flap technique). The investigators demonstrated that the radial forearm flap is a reliable technique, although evidence that other techniques are similarly reliable, or even better than the radial forearm flap, is lacking.”

Mastectomy

An earlier review found few studies of mastectomies specifically for trans men. However, as the authors note here, it is important to have a surgeon experienced in mastectomies for trans men. The surgery is not the same as it is for women.

The authors give no numbers on complications but note that people often need minor revisions for cosmetic reasons.

The authors provide a few notes on techniques:

“The exact technique will depend on the volume of breast tissue, and the skin excess and elasticity. In small breasts, a satisfactory result may be achieved by subcutaneous mastectomy via a circumareolar incision, but in most patients more extensive surgery, with additional noticeable scars, is required. For very ptotic breasts, a breast amputation with free nipple– areola complex graft is indicated. Finally, the nipple itself and the diameter of the areola are often reduced. When done properly, the results may be very satisfactory, but poor technique can lead to unacceptable cosmetic results. Minor revisions to ameliorate the final cosmetic outcome are often required.”

Other Surgeries for Trans Men

For scrotal reconstruction, “As long as this advancement of the neoscrotum to the natural position in front of the legs is carried out, very satisfactory results can be obtained with no major complications.”

The authors say patients should get their uteruses and ovaries removed. They don’t provide any additional information on the procedures.

“Patients will also require hysterectomy and ovariectomy, because of the potential risk of endometrial carcinoma with protracted testosterone use, and are usually accomplished laparoscopically at the time of one of the stages of subsequent phalloplasty. The short blind-ended vagina can be left in place or removed.”

We could use more studies and articles on all of the above surgeries.

AUTHORS’ CONCLUSIONS

“Gender reassignment surgery—in which elective surgery is performed to alter an individual’s body to resemble the other sex and in doing so adapt the body to the patient’s perception and lifestyle—is one of the most challenging surgical disciplines.

In MtF surgery, the technique is largely standardized, but refinements are needed to satisfy specific patient requests, such as vaginal depth and ‘perfect’ cosmetic outcome.

In FtM surgery, the variety of techniques available demonstrates that the ideal technique has not yet been identified and, depending on a patient’s request, a different surgical approach should be used. Furthermore, very few centers have the experience of, and subsequently can offer, different techniques for FtM gender reassignment. Moreover, complications are frequent and limitations to the ideal reconstruction are present with every technique used.

The complex psychological background of the patients and their expectations further challenge gender reassignment surgeons. The cooperation of the gender team in making a diagnosis, selecting appropriate patients for surgery, and deciding timing and type of surgical procedures to be performed, is crucial in reducing patients’ regrets or minor dissatisfactions (at both physical and psychosocial functioning levels) as a result of possible complications or for not having achieved the result expected.”

Original Source:

Gender reassignment surgery: an overview by Selvaggi G, Bellringer J. in Nat Rev Urol. 2011 May;8(5):274-8.

 

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins – Review

This is a fascinating study of identical twins; one had gender dysphoria and one did not. Both twins developed anorexia.

Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both had a difficult childhood with an abusive father.

Both twins were underweight at birth and needed intensive care. Both had developmental delays.

However, one twin considered himself to be a gay man while one identified as a straight woman.

In this case study, gender dysphoria did not cause the eating disorder.

This case highlights the importance of other factors in eating disorders, including genes, hormones, and trauma.

It raises the question; how important is gender identity as a cause of eating disorders?

This case is different from other case studies where gender dysphoria seems to be intimately linked to the eating disorder.

We can’t look at these two patients and conclude that gender dysphoria never contributes to eating disorders. However, this case is a good reminder to be cautious about drawing conclusions from other case studies. Perhaps there are just some people with eating disorders who also have gender dysphoria. Or perhaps there is some other factor which causes both eating disorders and gender dysphoria.

As always, we need more studies.

More about the Patients:

Eating Disorders

Twin A was diagnosed with AN-purging subtype and Twin B was diagnosed with AN-restricting subtype.

Twin B developed an eating disorder at an earlier age, but Twin A was more underweight and had a more disturbed perception of his body. Furthermore, Twin A was hospitalized for his eating disorder and Twin B was not.

Neither twin seems to have been able to maintain a healthy weight.

At age 16 Twin A “was admitted to a children’s hospital because of AN. Later, he was hospitalized in the psychiatric inpatient unit for adolescents. At first, his eating behavior was restrictive. Then he reported intermittent vomiting (AN binge-purge). His weight decreased to 46 kg/1.79 m (body mass index [BMI] ¼ 14.3 kg/m²). His ideal weight was 44 kg according to a BMI of 13.7 kg/m² , which shows his severe disturbance in body perception. During hospitalization, his behavior was sometimes aggressive. He was emotionally unstable, depressed, and was rarely able to engage in stable relationships. Despite strict dietary rules, he achieved a maximal weight of 55 kg (BMI ¼ 17.2 kg/m²). Soon after being discharged, his weight decreased again.”

Twin B’s eating disorder began at a younger age. “In puberty, he developed severe underweight. At the age of 13, he was 42 kg/1.58 m (BMI ¼ 16.8 kg/m² ). When he was referred to our outpatient unit at the age of 18½ years [for gender dysphoria], his weight was 48 kg and his height was 1.76 m (BMI ¼ 15.5 kg/m² ). He denied deliberate dieting, binging, or purging. Although he regarded himself as too slim, he did not manage to gain weight. Further medical checkups revealed no somatic cause for his underweight. An osteodensitometry yielded an osteopenia of the spine.”

Gender Identity

Twin A was a gender non-conforming gay male:

In childhood, he preferred girls’ games and toys (Barbie dolls) and was very close to his twin brother. His sexual feelings were always for males. Although he started cross-dressing at the age of about 16 years, his gender identification was always male. He considered himself to be a homosexual.”

Twin B was a trans woman:

“As far as he could remember, he had felt he was a girl, preferring girls as playmates and had started cross-dressing at nursery school. In gymnastic lessons, he refused to change with the other boys because he was ashamed of his body. Eventually, he refused to attend sports lessons at all. When he was 9 years old, he started to grow his hair. His class mates seemed to accept him as a girl. When he started to work as a hairdresser, he tried to correspond to the male gender role and did not cross-dress. However, at his professional school and in his free time, he continued to cross-dress. His employer, who realized he was transsexual, permitted and encouraged him to cross-dress at work, which consequently allowed him to live as a young woman. Sexually, he was always attracted to men. However, in contrast to his brother, he never considered himself to be homosexual and viewed this attraction as ‘‘heterosexual.’’ Until this point, he had not engaged in sexual relationships either with men or with women.”

Twin B requested hormonal and surgical sex reassignment.

Childhood

The twins grew up together in a small Swiss city without any other siblings. Their childhood was not easy:

“[Their father] was very authoritarian. He could not accept the sexual orientation and the cross-dressing of his sons and threatened them with assault and even with death.

…In family conflicts, [their mother] took a position between her husband and her sons. At a family consultation, she appeared emotionally unstable.”

Birth 

The birth was a difficult one. Both twins were underweight and spent time in intensive care.

“the mother had been admitted to a hospital with hypertension, edema, and proteinuria at 38 weeks of gestation. The vaginal delivery was induced because of maternal preeclampsia. Twin A weighed 2.17 kg at delivery and his Apgar score was 9/9/9. Because of perinatal acidosis and hypotonia, he was kept in the incubator for 3 days. He was diagnosed with a subependymal hemorrhage with ventricular invasion. Twin B’s birth weight at delivery was 1.95 kg and his Apgar score was 7/9/9. Both twins were admitted immediately to the neonatal intensive care unit.”

Developmental Delays

They both had developmental delays:

“In early childhood, Twin A showed a developmental delay in language and motor skills and had deficits in cognitive and verbal skills. He was socially isolated and his behavior was often aggressive.”

“…Twin B had delays in language and motor development during early childhood. He showed the typical symptoms of attention deficit and hyperactivity disorder. The parents refused further assessment and treatment.”

Other

Twin A was diagnosed with borderline personality disorder and subnormal verbal intelligence.

Twin B was diagnosed with gender dysphoria.

There is no obvious pattern to any of this. Twin A was larger at birth, but had more problems right after birth. Both had developmental delays, and Twin B may have had ADHD as well. Both were feminine in their behavior, but only Twin B developed gender dysphoria. Both were sexually attracted to men. Twin B developed an eating disorder earlier, but Twin A’s eating disorder seems more severe. Twin A has borderline personality disorder and Twin B does not.

Discussion

The authors offer two possible hypotheses about the twins’ gender identity.

Perhaps the twins are on a continuum of gender non-conformity where gender dysphoria is at the extreme end.

Alternatively, perhaps gender dysphoria* in childhood is inherited, but the later development of gender identity is determined by environmental factors and psychiatric comorbidity.

“In childhood, both Twin A and Twin B showed gender atypical behavior and stereotypical feminine traits and interests. In adolescence, their sexual orientation was revealed to be homosexual. Twin A developed effeminate homosexuality with male gender identity, whereas Twin B stabilized his cross-gender identity. Although Twins A and B are concordant for GID in childhood and sexual orientation on a categorical level, they are now discordant for TS. On a more dimensional level, one could argue that Twins A and B show an opposite sex-dimorphic behavior and that they arrived at different points of a continuum. The fact that GID in childhood is a predictor for later homosexuality and TS could support the dimensional view. It could be hypothesized that GID in childhood is mainly hereditary, whereas the development of the later phenotype of the gender identification is determined by environmental factors and psychiatric comorbidity, as any difference between MZ twins provides strong evidence for the role of environmental influences.”

The authors also discuss the relationship between gender and eating disorders. However, they don’t address the fact that the two twins had different gender identities, but both had eating disorders.

Perhaps both gay men and trans women are vulnerable to eating disorders for different reasons, but perhaps genes, hormones, and environment matter more than gender identity.

“Homosexual men seem to have an increased vulnerability to eating disturbance and body dissatisfaction (Williamson & Hartley, 1998), are more dissatisfied with their weight (French, Story, Remafedi, Resnick, & Blum, 1996), and are more concerned about their attractiveness (Siever, 1994). Male AN is associated with disturbed psychosexual and gender identity development, which supports the hypothesis that males with atypical gender role behavior have an increased risk of developing an ED (Fichter & Daser, 1987). Furthermore, feminine gender traits are discussed as a specific risk factor for ED in men and women (Meyer, Blissett, & Oldfield, 2001). Although the role of sexual orientation as a risk factor for ED is well documented, there is hardly any literature about GID and ED. For men with disturbance of gender identity in addition to the aforementioned factors concerning sexual orientation, underweight could be a way to suppress their libido and the expression of their secondary sexual characteristics and, at the same time, correspond to a female ideal of attractiveness (Hepp & Milos, 2002).”

We need more research!

“Further research in eating behavior and body dissatisfaction in patients with GID could provide more insight into the role of gender identity in the development of ED and lead to a better understanding of ED as well as GID.”

 

* In this case, gender non-conformity might be a more fitting phrase. Twin A does not seem to have ever wanted to be a girl.

 

Original Source:

Gender Identity Disorder and Anorexia Nervosa in Male Monozygotic Twins by Urs Hepp, Gabriella Milos, and Hellmuth Braun-Scharm in Int J Eat Disord. 2004 Mar;35(2):239-43.

 

Review – Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report

This is the earliest (1997) case study of someone with both gender dysphoria and an eating disorder.

Eating disorders are rare in children and in males, so an eating disorder in a boy is very unusual.

The boy’s mother had “abnormal eating habits and attitudes” and had been diagnosed with anorexia while she was pregnant with him. The boy had always been small for his age and did not get enough calories due to “extreme faddiness [picky eating] and the failure of the family to eat regular meals.” He was diagnosed with gender identity disorder when he was ten.

The boy developed a severe eating disorder at age 12 after a doctor suggested that he be given hormones to induce puberty.

In his case it looks like his gender dypshoria triggered his eating disorder, but he probably had a predisposition to problems with eating.

Treatment focused on three things: building up his weight, therapy with his family, and therapy with the patient around gender issues. In addition, a teacher was involved to prevent bullying at school. The boy refused the hormone treatments to induce puberty.

The patient’s weight improved steadily until his size was normal for his age and height, but the therapists thought he might relapse in the future due to family conflict and social prejudice.

In this case what worked was a combination of therapy for both the eating disorder and the gender dysphoria, along with family issues.

As always, it is important to remember that this is a case study of just one person. So far, the main conclusion I can draw from cases studies is that each person’s story is different.

More details on the case:

The boy had been gender non-conforming since he was three and had stated that he wished to be a girl. At age 10 his weight dropped and he was referred to a psychiatrist who diagnosed him with gender identity disorder. He was being bullied at school for being gender non-conforming and developed depression, abdominal pain, and headaches.* He was also dealing with severe conflicts between his parents and an older brother with behavior problems.

At that time, therapists helped him develop coping strategies to deal with the bullying and counseled his parents. His eating, weight, and mood improved quickly.

At age 12, his weight dropped rapidly and he had cold extremities and no signs of puberty. He was living on water biscuits and low calorie orange squash (sweet fruit juice) while exercising up to five hours a day.

He was diagnosed with anorexia “in a context of long-standing eating problems and marital disharmony,” with the doctor’s recommendation of hormones to induce puberty as a “significant precipitant.”

“… he admitted feeling uncertain about hormone treatment. He wanted the comfort of acceptance by his social peer group, but felt happiest and most at ease in a feminine role. After the issue of hormone treatment was raised, B. briefly attempted to control and even deny cross-gender behaviors as if forcing himself to conform to male sex stereotypes. His behaviour soon returned to being highly effeminate. He dressed in female clothing and jewellery whenever he could, wore make-up and stylized his hair into a long pony-tail. His interests were hairdressing, fashion magazines, and knitting. At school he associated only with girls and was physically nauseated at the idea of having to play contact sports like rugby with other boys.”

Treatment included individual therapy related to his gender dysphoria:

“Individual work with B. was difficult because of his high level of denial. Over a period of time he began to focus on his dilemma between social conformity which would allow acceptance by others and his acknowledgement of his own revulsion at the idea of his developing male sexuality. In therapy he recognized that he had attempted to delay puberty by restricting his calorie intake. His anxiety about puberty related to his fear of the development of male secondary sex characteristics, the acquisition of a male sex drive, and potential loss of slimness. He was troubled and confused by homosexual and heterosexual fantasies. Exploration of these themes allowed some gradual resolution. Over a period of several months, he began to see some positive benefits from the eventual development of secondary male sex characteristics and to recognize that these changes did not necessarily preclude the continuance of cross-gender behaviour which was an undeniable part of his identity.”

A teacher at his school was also involved to “provide a contact in school who could help B. with teasing and tactfully educate other staff members about his special needs.”

His weight improved steadily and stabilized at 95 percent expected weight for his age and height.

Original Source:

Anorexia Nervosa in a Young Boy with Gender Identity Disorder of Childhood : a Case Report by E. Waters and L. Whitehead in Clin Child Psychol Psychiatry July 1997 vol. 2 no. 3 463-467.

 

*The narrative is a little confusing, but this seems to have happened before the resurgence of his eating problems at age 12.

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.

Gender identity problems in autistic children – Review of a case study

This is a case report of two Turkish boys with autism and gender dysphoria. Unlike this earlier study of two boys with autism, the boys in this study verbalized a clear desire to be a girl.

In the earlier case study, the boys had cross-gender interests, but probably did not have gender dysphoria. In this case study, however, the boys had cross-gender interests and gender dysphoria.

This study followed the boys for at least four years, so we know that the gender dysphoria was not transient.

We do not, however, know if their gender dypshoria will persist. Most children with gender dysphoria desist around the time of puberty. What happens with children with autism? Are they more or less likely to persist in their gender dysphoria? How should parents and educators handle their gender dysphoria? Is their gender dysphoria different from gender dysphoria in neurotypical children? How common is gender dysphoria among children with autism?

In the first of these two cases the patient was treated with behavior modification, encouraging separation from the mother, and establishing a bond with his father. His cross-gender behavior continued. In the second case his parents tried to establish a good bond with his father, but again, his cross-gender behaviors have continued.

The author of this study suggests that gender dyshoria in children with autism may be underreported and might be interpreted as unusual interests rather than actual gender dypshoria. At this point, however, we don’t have enough data to know if that is the case. This is a case study of only two children.

This case study does, however, show that children with autism can have genuine gender dypshoria, like the Swedish teenage girl in this case study and the Japanese boy in this one.

“This case study, which is a preliminary attempt to report the developmental pattern of cross-gender behaviour in autistic children, tries to underline that (1) diagnosis of GID in autistic individuals with a long follow-up seems possible; and (2) high functioning verbally able autistic individuals can express their gender preferences as well as other personal preferences.

Finally, this report points to the need for further study of gender identity development as well as other identity problems in individuals with high functioning autism.”

(Emphasis mine)

Original Source:

Gender identity problems in autistic children by N. M. Mukaddes in Child: Care, Health and Development Volume 28, Issue 6, pages 529–532, November 2002.

More details about the case studies:

Case 1 – 10 year old boy with autism:

“One year after the referral [for autism], when he was aged 6 years, he started to show improvements in spontaneous speech and imitative play, and displayed more interest in his peers and other people. At the same time, his mother reported some cross-gender behaviours such as wearing his mother’s dresses, putting lego bricks in his socks under his heels and pretending to have high-heel shoes. Along with the improvement in spontaneous speech and imitative behaviour, he started to state his disappointment about his gender. Sometimes, he prayed and begged God to make his penis disappear. After these verbal expressions, he shared his fantasy about his wish to become a bride, married to a man from the age of 8 years. He never shows interest in male activities, he always avoids rough-and-tumble play and prefers to play with girls. Although he has shown some improvement in his social relatedness and language, his social difficulties in terms of reciprocal relationships with peers and sustaining a conversation with others still remain. Despite the eclectic treatment approaches (behavioural modification, encouraging separation from his mother and establishing a bond between him and his father), his cross-gender behaviours show a persistent pattern.”

Case 2 – 7 year old boy with autism:

He started to use phrases at age 4 years [he was referred to the clinic at age 3 for autism], showed improvement in social relationships and sharing interests with peers at nursery school. He also started some make-believe play. At the same time, he had shown persistent attachment to his mother’s and some significant female relative’s clothes and especially liked to make skirts out of their scarves. After age 5 years, he started to ‘play house’ and ‘play mother roles’. This was the most persistent and most pervasive pattern of his play, and he pushed his therapist as well as his peers and family members to ‘play house’ with him. He avoids rough-and-tumble play and likes to share his interests with one or two of his female classmates. His parents were worried about his behaviour and tried to prevent it, but he reacted aggressively. He started to state his desire to grow up as a woman (like his mother). He gave up his attachment to some feminine objects, but still shows persistence in playing the ‘mother roles’ and expresses his desire to be a woman. Although there are some improvements in terms of social relatedness, language and the disappearance of stereotypical behaviours, his social interaction pattern is still inappropriate for his age. His parents have tried to establish good bonding between him with his father as a identification object. Despite this, his cross-gender behaviours are persistent.

Case study: cross-gender preoccupations in two male children with autism

This is a 1996 case study of two boys with autism who had cross-gender interests, but probably did not have gender dysphoria.

Both boys liked dolls, although the way they played with them was not typical. In addition, one of the boys liked to imitate the scenes of cartoons with female characters. Both boys cross-dressed and created long hair with cloth.

Neither of them played with other children of either sex. One boy ran around and screamed until the other children left and the other fought with others if they bothered him.

Neither of them expressed a dislike of being a boy or a desire to be a girl – although, on the other hand, their language was limited.

The parents of one of the boys thought they might have reinforced his interest in dolls. They had been so excited to see him using toys of any sort that they bought dolls for him.

The mother of the other boy was anxious about her son’s cross-dressing and reluctant to discuss it.

The authors suggest that for these boys the cross-dressing may represent an unusual preoccupation rather than a sign of gender identity. “This preoccupation may relate to a need for sensory input that happens to be predominantly feminine in nature (silky objects, bright and shiny substances, movement of long hair, etc.).”

The authors suggest that cases like these could lead to misdiagnosing gender dysphoria:

“These cases also point to the potential for confusion of primary gender identity disorders with preoccupations in high-functioning individuals with autism.”

They make recommendations for treatment in cases like these:

“Rather than a narrow focus on altering the preoccupation, a broad intervention addressing social, communication, and play skill development appears to be important. Thus, identifying other interests in the children to be developed in the context of social situations may aid social skill development by increasing opportunities for interactive play. Parents and others working with the children may need help in understanding the nature of feminine preoccupations in boys and in destigmatizing these interests.”

The authors conclude by saying:

It is our hypothesis that the feminine preoccupations of these children with autism may have resulted from an inherent predisposition toward unusual interests combined with the boys’ social environment. The sensory aspects of the feminine objects may have contributed to the development of these preoccupations. It seems less likely that the feminine interests are related to issues of gender roles/confusion. This report points to the need for future study of the complex interplay of environmental and neurobiologic factors affecting gender identity roles and preoccupation in autism.

More Details About the Boys’ Cross-Gender Interests and Behavior

The first patient was five years old.

“Although his parents report no truly imaginative play, M.C. will imitate the scenes from a video having to do with female cartoon characters (e.g. Cinderella, Snow White, and Ariel). He likes to hold Barbie dolls, but frequently will rip off the dolls’ heads and play with parts of the doll, particularly the hair. He enjoys bright, shiny objects. He often dresses up using female clothing and uses towels or other fabric to fashion long hair for himself. M.C. demonstrates little interest in male toys or other toys in general.”

The second patient was three and a half years old.

“His favorite toys are a Minnie Mouse doll and a Barbie doll although his play consists mostly of shaking the hair of the Barbie doll. He enjoys wearing his sister’s or mother’s clothing, including high heeled shoes, bras, and underwear. He often puts a shirt over his head and acts as if it is long hair.”

More Details about the Patients

The first patient lived with his parents and older brother. There was nothing unusual about his birth, although his later medical history included “hospitalization for dehydration/gastroenteritis and right inguinal hernia repair.”

Behaviorally, “M.C.’s speech is characterized by short sentences which are often stereotyped. He recently began requesting objects by pointing. His parents report that he is an active, impulsive, moody child with a good memory. M.C. frequently engages in perseverative motor activities. He is generally a loner. When with other children he frequently runs around and screams until the children go away.”

The second patient lived with his mother, older sister, fraternal twin, and his mother’s boyfriend. The pregnancy and birth were complicated. The patient had also had frequent upper respiratory infections and ear infections and a hospitalization for reactive airway disease and pneumonia.

In terms of his development, “although he learned the words to several songs at an early age, he did not begin using phrases until approximately 3 years of age. C.W. is described as a loner who does not play with others. He engages in perseverative activities such as opening and shutting doors as well as running his hand repeatedly through water. He watches commercials, music videos, and ‘Wheel of Fortune’ on television. He fights with others if they bother him, and screams if unable to do what he wants.”

More Details about the Patients’ Treatments

The first patient was treated with special education services after kindergarten and consultation with a school specialist in autism. His communication skills improved and his interests broadened somewhat. However, he was still interested in dolls and requested a Pocahontas doll for his birthday.

In the second case, the boy was enrolled in a school program that included special education services. His mother had a home consultation visit with a specialist in autism. He continues to cross-dress, although his mother only allows it when he comes home from school.

 

Original Source:

Case study: cross-gender preoccupations in two male children with autism by Williams PG, Allard AM, Sears L. in J Autism Dev Disord. 1996 Dec;26(6):635-42.