Tag Archives: Trans women

Evaluation of surgical procedures for sex reassignment: a systematic review – information on specific surgeries

This is a 2007 review of research on gender reassignment surgery. The authors found that there was not enough strong research to evaluate gender reassignment surgery; you can read more about the study as a whole here. This article looks more at specific surgical procedures.

The authors of the review evaluated individual surgical procedures rather than just looking at the outcome of all gender reassignment surgeries together. This allows a better understanding of which procedures are the most effective. It also means excluding some studies that looked at more than one procedure.

The authors reviewed all the articles they could find on specific gender reassignment surgeries from 1980 onwards. The review took place in October and November 2005.

The following are some of the results they found for specific surgeries. There is not enough data to definitively evaluate particular procedures and techniques, but there is useful information on possible complications. Clearly, however, we need more research.

Surgeries for Trans Women (born male)

Clitoroplasty/neoclitoris construction – The authors reviewed three studies that used a range of surgical techniques. The results were generally good but in one study 2 out of 10 patients had necrosis of the neoclitoris; in another study three out of nine patients did not report sexual satisfaction.

“All three included papers reported successful results in terms of function and cosmetic appearance with few or no complications (e.g. urine leakage). Rehman and Melman reported that the neoclitoris had remained intact postoperatively in eight out of 10 patients and the functional and cosmetic appearance was comparable to a normal clitoris. In two patients, however, the results were not satisfactory because of necrosis of the neoclitoris.

Using the dorsal portion of the glans penis with the dorsal neurovascular pedicle for clitoroplasty, the neoclitorides in nine patients survived well, and six patients reported sexual satisfaction. However, the transpositioning of glans on the long dorsal neurovascular pedicle appears to be a procedure with high risks. Overall, several studies have reported that the neoclitoris construction can result in good preservation of light touch and sexual sensation.

Vaginoplasty/neovagina construction – The authors reviewed 32 studies. Satisfactory cosmetic and functional results were reported in many of the studies, although one found that “vaginoplasty combining inversion of the penile and scrotal skin flaps produced poor functional outcomes.” 

One study reported some severe complications.

A 2001 study from Germany reported that “major complications during, immediately and after surgery occurred in nine of the 66 patients (14%), including necrosis of the distal urethra (n = 1), necrosis of the glans (n = 3), a rectal lesion (n = 3), and severe wound infections (n = 6).”  

In addition, according to the abstract of the 2001 study, “Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft.”

At the same time, 47% of the patients in the 2001 study completed a follow-up questionnaire and almost all of them reported that they were “satisfied with the cosmetic result and capacity for orgasm.” Over half of the people who answered the follow-up questionnaire had had sexual intercourse. It is not clear if the satisfied group included the people who had had complications.

It would be good to have more information to compare to the German results. Are these rates of complications normal?

The reviewers did not find studies that met their criteria for labiaplasty, orchidectomy, or penectomy.

Surgeries for Trans Men (born female)

Hysterectomy – The authors only reviewed one study that met their criteria; it reported successful operations for two trans men. The study also reported that “a laparoscopic hysterectomy using the McCartney tube for FTM GRS was a useful procedure in overcoming difficulties encountered due to restricted vaginal access.”

Mastectomy – The authors reviewed three studies: “Colic and Colic found the use of a circumareolar approach for subcutaneous mastectomy produced flatter masculine breasts, leaving sufficient dermal vascularization for the nipple-areola complex. Of the 12 FTM patients all were very satisfied with the outcomes of surgery mainly because of the periareolar scar. It was reported, however, that two areolar necroses occurred due to perforation of the thin vascular dermal pedicle.”

Metoidioplasty – The authors reviewed two studies.

In the first, the procedure was successful for 32 patients with an average hospital stay of 11 days. One patient had a severe haematoma (solid swelling of clotted blood), but there were no other complications.

In the second study, 17 patients were satisfied with the size and appearance of their penis, but 5 people required additional augmentation phalloplasty. In two cases, the trans men developed urethral stenosis (narrowing of the urethra) and in three cases they developed fistula. The complications were related to the urethroplasty.

The reviewers add: “The metoidioplasty procedure produces a very small phallus (e.g. mean = 5.7 cm, range = 4–10 cm), hardly capable of sexual penetration, if at all. Only 10 of the 32 patients were able to void whilst standing. It should be noted that in the study by Hage et al, 18 patients combined the metoidioplasty procedure with the construction of a bifid scrotum in which testicular prostheses were implanted. Overall these two studies found metoidioplasty was an appropriate method where the clitoris seems large enough to provide a phallus and satisfies the patient.”

Phalloplasty – There is only limited data on the outcomes of phalloplasty, although two studies reported good outcomes in terms of size and stiffness and one reported good psychological outcomes.

However, there are a range of procedures and they have mixed results.

Serious complications have been reported and phalloplasty leaves a scar somewhere on the body.

One study found that creating the neourethra in two stages could reduce complications.

Another study using a suprapubic abdominal wall flap produced a good cosmetic appearance for 68% of the people; presumably 32% of the trans men had phalluses that did not look as good. A small study of using a lateral arm free flap reported good results.

“There appear to be limited data on outcome measures, including social integration, patient satisfaction and physiological function. Good operative results have been reported in terms of appropriate size and stiffness without vascular compromise and in terms of psychological outcomes. In addition to an aesthetically appealing look either while being nude (81%) or wearing a tight swim suit (91%), to void whilst standing appears to be an important goal for many FTM patients. It is important to recognize that there are a range of phalloplasty procedures available with mixed findings being reported in terms of effectiveness. Hage et al. reported several serious complications such as vesicovaginal, urethrovaginal fistulas and urinary incontinence. Furthermore, unlike the metoidioplasty procedure, free flap phalloplasty techniques produce extensive scarring to the donor site, unless techniques such as tissue expansion are used. Of the 85 FTM patients who had a phalloplasty fashioned from suprapubic abdominal wall flap that was tubed to form the phallus, Bettocchi et al. reported the cosmetic appearance of the phallus was considered good in 68% of the patients. Major complications (n = 60) were associated with the neourethra (75%), stricture formation (64%) and/or fistulae (55%). It should be noted that the complication rates found by Bettocchi et al. were significantly less (P < 0.001) when the neourethra was created in two stages. In contrast, Khouri et al. concluded by using a prefabricated lateral arm free flap technique it is possible to achieve a fully functional penis with stable long-term results and excellent patient satisfaction.”

Scrotoplasty/scrotum construction/testicular prosthesis – The authors reviewed two studies that met their criteria. “This procedure is generally accomplished by hollowing out the labia majora, inserting silicone implants, and attaching the labia to develop a single scrotal sac. Implant expulsion, rupture or dislocation is encountered in a small number of patients.”

Urethroplasty – The authors did not find any studies that met their criteria, but they reported that “A one-stage total phalloplasty and urethroplasty was associated with a significant rate of fistulas and strictures.”

The authors did not find studies that met their criteria for Salpingo-oophorectomy or vaginectomy/vaginal closure.

The authors conclude that “There is a need for good quality controlled trials based on clearly defined diagnosis and assessment criteria.”

And, “we have confirmed the findings from previous reviews that the evidence to support GRS has several limitations in terms of: (a) lack of controlled studies; (b) evidence has not collected data prospectively; (c) high loss to follow up; and (d) lack of validated assessment measures. We have extended these findings from previous reviews by providing a summary of the evidence available for each of the ‘core’ procedures for MTF and FTM transsexism. In the majority of studies a large number of persons with transsexism experience a successful outcome in terms of subjective well being, cosmesis, and sexual function. We conclude that the magnitude of benefit and harm cannot be estimated accurately using the current available evidence.”

I have included more of their discussion in my review  here.

Original Source:

Evaluation of surgical procedures for sex reassignment: a systematic review by Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy CM in J Plast Reconstr Aesthet Surg. 2009 Mar;62(3):294-306.

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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.

 

A Quote to Be Thankful for

“Now, the boys and girls up in marketing all know that advertisements and commercials don’t sell products. Advertisements and commercials sell what? Sex and gender! That’s right! And sex and gender sell what? The products? Very good! Sex, because it’s sex. And once you’ve had great sex, well, you’re going to want some more. And if you’ve never had great sex, you’ll buy anything hoping to get some. But gender—that’s another can of worms. That’s a different kettle of fish. That’s another pea in a different pod. Simply put, once you buy gender, you’ll buy anything in order to keep it. You’ll buy anything. So—the boys and girls up in marketing have come up with the ultimate marketing strategy. We’re not going to sell you any products tonight, no we’re going to sell you gender. And you want to buy it.

You want to buy gender because you want to relieve the nagging feeling that you’re not quite a man, not quite a woman.”

Doc Grinder speaking in the play Hidden: a Gender by Kate Bornstein, from Gender Outlaw, page 173.

Trans Lives Matter in San Francisco in the 1960s

“The Central City Anti-Poverty Program Office opened that fall as a result of the Tenderloin neighborhood organizing campaign. This multiservice agency included an office for the police community-relations officer to the homophile community, a police sergeant by the name of Elliott Blackstone. One afternoon shortly after the agency opened, a transgender neighborhood resident named Louise Ergestrasse came into Blackstone’s office, threw a copy of Benjamin’s The Transsexual Phenomenon on his desk, and demanded that Blackstone do something for ‘her people.’ Blackstone was willing to be educated on the matter, and he soon took a leading role in changing police treatment of transgender people.”

From Transgender History by Susan Stryker, page 75.

Review of Disordered Eating and Gender Identity Disorder: A Qualitative Study

This is a qualitative study of eating disorders and gender dysphoria. Its strength is that the authors asked transgender people themselves what they thought. Its weakness is that we can’t draw many conclusions from it, although we can use it to find questions for future research.

Limits of the Study

We can’t use it to estimate the prevalence of eating disorders among trans people. The participants were recruited for a study of body image and eating behaviors. Transgender people with eating disorders may be more likely to volunteer for such a study.

We can’t use it to collect statistics on trans people with eating disorders because the data is not uniform. Participants were asked open-ended questions, so we can’t be sure what it means when they give different answers. For example, one person talked about wanting to control his body. Did other participants agree with him and not think to mention it or did they just not care about controlling their bodies?

We can’t look at how individual eating disorders and gender dysphoria developed over time because we don’t have case histories of the participants.

The participants in the study were not formally diagnosed with eating disorders; the data on their eating is self-reported, although convincing. It is not clear from the study how many of the participants currently had symptoms of disordered eating.

On the other hand, we do have some data we can use from this study.

Data from the Study

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise.*

About half of the transgender people with an eating disorder talked about gender dysphoria causing their eating disorder and about half did not.**

Other explanations given for the eating disorder included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

Explanations related to gender could be classified as efforts to suppress gender or efforts to accentuate gender.

A few participants talked about the relationship between disordered eating and transition. Some saw hormones as positive and some saw them as negative:

Two trans men (born female) said that hormone therapy had helped them to stop caring about their weight.

Two trans women (born male) said that hormone therapy had made them gain weight. (One of the women who said this was waiting for diagnosis and hormone treatment; presumably she was self-medicating.)

One woman who was considering gender reassignment said that breast reduction surgery had helped her stop caring about her weight.***

There was no clear relationship between medical transition and current scores on subscales of the Eating Disorder Inventory-3.**** The three people with the highest total scores included:

Two trans women who had had genital surgery and were on estrogen – the surgery means that their bodies were no longer producing much testosterone; and

One trans men who was taking testosterone and waiting for a mastectomy.

You can read further details of the study below the footnotes.

Future Research

The data we can get from this study isn’t much, but it does point to some important questions for future research. Many of these are questions raised by case studies as well.

What do transgender people see as the main cause of their disordered eating? Do they see it as being about issues like control, autonomy, and stress or do they see it as being related to gender dysphoria? Or both?

Is affirming the desired gender or suppressing biological sex a more important factor in disordered eating? Do trans men and trans women give different answers to this question?

Are there differences between the group of people who see their eating disorder as being related to gender issues and those who do not? Do they have different patterns in terms of when their symptoms of disordered eating developed, what their symptoms looked like, or what happened when they transitioned?

Do people’s perceptions of what causes their disordered eating match reality? Do they have relatives with eating disorders, for example? Were there other factors in their life that might have contributed to the eating disorder? When did the eating disorder develop?

How does the relationship between the eating disorder and gender dysphoria affect recovery from the eating disorder?

When did the disordered eating begin in relation to the gender dysphoria? How did the two conditions develop over time?

Does transition increase or decrease symptoms of disordered eating? Does it have no effect?

Are the effects of transition on eating disorders different for trans men and trans women? In this study, two trans men with eating disorders felt hormone therapy helped their recovery, while two trans women said it made them gain weight.

Trans women and trans men are not getting the same treatment for gender dysphoria; how does that affect eating disorders? In this study, trans men had mastectomies while trans women had genital surgery. Mastectomies might be more important in issues related to body shape. In addition, hormone therapy would have involved completely different medications for trans men and trans women.

Do the hormones themselves play a role in eating disorders, either reducing or increasing symptoms?

Comparison to Case Studies

Prevalence of eating disorders in trans men versus trans women

In this study, slightly over half of the participants were trans men. Trans women were not more likely to have eating disorders than trans men. In contrast, the case studies are overwhelmingly of trans women with eating disorders. What is the real prevalence of eating disorders among transgender people? Is there a difference in the rates among trans men and trans women or not?

It might be that selection bias means that case studies of trans women with eating disorders are written up more frequently. Eating disorders are relatively rare among biological males and potential authors of case studies might notice them more. Conversely, it might be that trans men were more willing to volunteer for the study than trans women or that a group of trans men encouraged each other to participate.

The link between eating disorders and gender dysphoria

Some case studies suggest that factors other than gender dysphoria are central in the development of disordered eating. We have the case of the identical twins who both had anorexia, although only one was transgender. Similarly, the trans man with an eating disorder in this case study had two cousins with eating disorders and this boy’s mother had had anorexia. Then we have the case of the teenage survivor of sexual abuse with PTSD, generalized anxiety disorder, OCD, an eating disorder, and a history of self-harm. The teenager developed gender dysphoria while being treated for her eating disorder; it may be that the trauma was the most important factor in all of her problems.

On the other hand, we have five cases of trans women whose eating disorder began when they decided to live as women, reported in this case study, this one, this one, and this one. In addition, in this case study, one trans woman’s eating disorder seems to have begun at the same time as depression related to her gender.

We also have a couple of case studies where trans men say that their disordered eating was a desire to get rid of feminine features; in this case his curves, breasts, hips, and feminine face and in this case his period and feminine shape. However, in the first case, the trans man also had two cousins with eating disorders.

There is also this somewhat unusual case of an underweight boy with poor eating habits who developed severe anorexia after a doctor suggested that he take testosterone to induce puberty. Again, in this case, his mother had also had anorexia.

Intriguingly in these two cases, gender identity seemed to affect the patient’s symptoms, but not the underlying dissatisfaction with their bodies. In the first case, the patient had a fluid gender identity; when he lived as a man he tried to gain weight and muscle, when he lived as a woman he tried to lose weight. His habits were always pathological and he always hated his body. In the second case, the patient initially identified as a woman. After coming out as gay to supportive friends, he identified as a gay man; as a woman he dieted and as a man he tried to gain muscles.

Of course, since they are case studies, there could be some selection bias. People might be more likely to report cases where gender identity seemed to have affected the eating disorder – or they might be more likely to report cases that are unusual like identical twins and fluid gender identity.

This is where this study is helpful; we see that a number of transgender patients did not bring up gender issues when asked what they thought caused their eating disorders. We also see that some patients thought gender issues were important causes. And now we need another study to find out what that means.

The effect of transition on gender dysphoria

This study found one person considering transition who said that breast reduction surgery had helped her with her disordered eating,

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

In the qualitative study two trans men said that hormone therapy had helped them with their eating disorders, while two trans women said hormones had made them gain weight.

On the other hand, two trans women and a trans man who were taking hormones had relatively high scores on three subscales of the Eating Disorder Inventory-3. The two trans women had already had genital surgery (which would have included removing their gonads) while the trans man was waiting for a mastectomy.

Looking at the case studies, there were two trans women with eating disorders who were already on hormones (here and here), although one of them does not seem to have been interested in recovering from her disordered eating. There was one trans woman who believed that transition had cured her, but she was severely underweight, even more so than she had been before transition.  In addition, the patients listed above who had problems with their eating after sex reassignment surgery were also on hormones, although it could still be that hormone therapy initially helped them.

On the other hand, there was one trans man whose eating disorder was cured by taking testosterone. In addition, taking puberty blockers helped this adolescent trans woman restore her weight, although, of course, puberty blockers are not the same as hormone therapy for trans women or trans men.

In many of the case studies, patients recovered from disordered eating before they were referred to a gender clinic.

It seems clear that we can not rely on transition to cure an eating disorder and at times it may exacerbate it. Therapy for eating disorders should be aimed at the eating disorder and patients with gender dyshporia and eating disorders should have follow-up care for the eating disorder after they transition.

You can read further details of the qualitative study below the footnotes.

Original Source:

Review of Disordered Eating and Gender Identity Disorder: A Qualitative Study by Ålgars M, Alanko K, Santtila P, Sandnabba NK in Eat Disord. 2012;20(4):300-11.

 

*I count 16 people with an eating disturbance or excessive exercise, according to their Table 2. I’m not sure if this is a typo or if two people reported symptoms that were not considered severe enough to be an eating disorder.

**It is difficult to tell from the study how many people identified gender dysphoria as a cause of their eating disorder. The study talks about 5 people who were suppressing their gender and 3 people who were accentuating their gender, but the two groups overlap. They quote one person twice for both suppressing and expressing their gender. There is no list of which people talked about which possible causes for their gender dysphoria, so there could be more overlap.

Based on the quotes they include, at least seven and possibly eight people mentioned something to do with gender as a possible cause of their eating disorder. This means at least six or seven did not.

It is also possible that some of the people who mentioned gender dysphoria as a possible cause of their eating disorder also mentioned other possible causes. Or that some people did not answer the question.

*** There was also one trans woman (“Julie”) who felt that genital surgery had made her less self-conscious about her body and her weight. However, she had never had any symptoms of an eating disorder or excessive exercise. Her case does not answer the question of how eating disorders may be related to gender dysphoria, especially since there is a group of people with eating disorders and gender dysphoria who did not say that gender issues affected their eating.

****The participants were tested on the Drive for Thinness, Bulimia, and Body Dissatisfaction sub-scales of the Eating Disorder Inventory-3.

 

More Details on the Study:

Eating Disorders and Gender Dysphoria

The authors found 14 people with gender dysphoria who reported current or previous disordered eating and/or excessive exercise. Looking at their Table 2, I count 16 people with disordered eating and/or excessive exercise, but perhaps there were two cases where the symptoms were not severe enough to be considered disordered.

Of these 14 people, seven or eight mentioned gender as a cause of their eating disorder or excessive exercise (see footnote above as to why the number is unclear). This included 6 or 7 trans men and 2 trans women.

Six or seven people did not mention gender as a cause of their eating disorder or excessive exercise.

Other explanations given included self-control, feeling like an outsider, struggle for autonomy, feeling that one did not deserve to eat, psychological stress and strain, and a belief that being thin would make sexual situations easier.

“I have always wanted to feel that I can control my body.”

“I have felt like I was an outsider since I was little. I have felt inadequate, like I don’t belong to the group, and because of that any criticism about what was most essential to me, my body and how desirable I am, was a really serious thing to me.”

“At that age [eating] was really the only thing I could have an influence on.”

Explanations related to gender fell into three categories –

  • suppressing gender (“The background of that crazy weight loss was that my curves would disappear”),
  • accentuating gender (“It is easier to make a man’s body look feminine if you’re a bit thinner”), and
  • enhanced masculinity (“[After losing a lot of weight] I could buy pants at the men’s department, and they fit in a certain way, the right way, as I see it.”)

Four trans men mentioned suppressing gender, one trans man mentioned accentuating gender, and one trans man mentioned enhancing masculinity. It is possible that there is some overlap between the categories.*

One trans woman mentioned accentuating gender and one trans woman mentioned both accentuating and suppressing gender as possible causes of disordered eating.*

Eating Disorders and Transition

The authors identified sixteen people who had already begun hormone therapy and/or had surgery. In addition, one trans woman seems to have been self-medicating and one trans man had already had breast reduction surgery. Of these 18 people:

Two trans men said that said that taking testosterone had helped them recover from their eating disorder; they stopped caring about weight gain.

Two trans women said that taking hormones caused weight gain and in one case, problems with blood sugar. It is not clear exactly which medications they were talking about – estrogen and blockers or just estrogen. One of the trans women who said this was waiting to begin hormone treatment, so presumably she was self-medicating.

One woman who was considering gender reassignment said that breast reduction surgery had helped her recover from her eating disorder. She no longer cared about weight gain after the surgery.

One trans woman said that after genital surgery she felt comfortable in her body and didn’t care about any fat. However, she had never had any symptoms of disordered eating or excessive exercise, so this may not be relevant to people with eating disorders.

Current Scores on Subscales of the Eating Disorder Inventory-3 (EDI-3)

The study does not separate data on current symptoms of disordered eating and excessive exercise from data on past symptoms. However, the study participants completed three subscales from the Eating Disorder Inventory-E (EDI-3): Drive for Thinness, Bulimia, and Body Dissatisfaction.

We can not use the scores on three subscales of the EDI-3 to diagnose an eating disorder, but they may give some indication of how the participants are doing now.

Of particular concern are “Sue,” “Martha,” and “Leo.” Sue and Martha are trans women who had had genital surgery and were on hormones. Leo is a trans man who was on hormones but was waiting for a mastectomy.

Sue scored 16 on the drive for thinness scale, 17 on the bulimia scale, and 21 on body dissatisfaction. Martha scored 9 on the drive for thinnness scale, 9 on the bulimia scale, and 22 on body dissatisfaction. Leo scored 14 on the drive for thinness scale, 11 on the bulimia scale, and 34 on body dissatisfaction.  The three of them had the highest total scores compared to any of the other study participants.

Quote of the Day

“What frightened me most about the possibility of skin grafts was not my potential appearance, but rather the symbolism—my obviously stitched-together face being interpreted by others as a metaphor for the fakeness of my entire body, my gender. Whenever I shared this thought with cissexual friends, they always responded the same way, telling me that it was nonsense, that cancer-related skin grafts have nothing to do with transsexuality. And while that may be true in a logical sort of way, it seemed to me to be particularly convenient for them to say. Unlike them, I didn’t have the privilege of having my body viewed as inherently natural and congruent. My body is always betraying me, whether it was the male body that used to feel completely alien to me, or my current female state, which others view as inherently unnatural and illegitimate.”

from Excluded by Julie Serano, page 41.

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.