Tag Archives: United Kingdom

Orgasm after Vaginoplasty

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

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

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

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

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

SOME RECENT STUDIES OF ORGASM AFTER GRS

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

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

18% were never able to achieve orgasm by masturbation.

15% were rarely able to orgasm with masturbation.

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

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

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

14% of the trans women complained of anorgasmia

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

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

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

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

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

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

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

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

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

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

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

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

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

18% said they never achieve orgasm

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

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

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

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

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

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

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

and

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

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

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

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

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

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

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

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

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

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

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

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

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

8% did not consider vaginal sex pleasurable.

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

About Orgasms

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

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

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

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

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

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

Comparing the Studies

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

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

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

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

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

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

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

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

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

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

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

 

 

 

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

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

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

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

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.

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.

 

Review – Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases

Two more case histories of trans women (born male) with eating disorders, this time from the United Kingdom.

There are many more case studies of trans women (born male) with eating disorders than trans men (born female). This may mean that trans women are more likely to have eating disorders than trans men.

Alternatively, it might mean that therapists are more likely to write case studies about trans women with eating disorders.* It may be that therapists are more surprised to find patients who were born male with eating disorders because eating disorders are rare in males. It might also be that therapists are interested in trans women with eating disorders because these cases support the theory that femininity and female socialization contribute to eating disorders.

We need more research on the prevalence of eating disorders among people with gender dysphoria.

Back to the case reports. As with other cases, each one is a little different from all the others.

In the first case the patient had a long-standing eating disorder that was clearly linked to her gender dysphoria. She also had had a difficult childhood and was depressed. The patient had to be hospitalized twice for her eating disorder, but was eventually able to maintain a normal weight. She was referred to a gender identity clinic.

The second patient described anorexia as “providing an escape from emotional pain, confusion, and dissatisfaction with [her] life,” although she also wanted a more feminine physique. She eventually suggested that she could not resolve her eating disorder and depression until she dealt with her gender dysphoria. She was referred to a clinic and transitioned.

This is where it gets confusing. After surgery, she felt complete and normal and her mood stabilized. In terms of the eating disorder:

Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m²), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small.

The authors believe that she is doing well. However, a BMI under 16 is dangerously thin and her BMI is only 16.2.  Furthermore, she weighed 20 pounds more when she started treatment for her eating disorder than she did after transition.

Her gender dysphoria has been resolved, but I am not sure about her eating disorder. A BMI below 17.5 may be a sign of anorexia. You cannot diagnose anorexia without more information, but her low weight is a red flag.

So, we have two more cases where an eating disorder was linked to gender dysphoria. In one case, the patient was treated for her eating disorder in the hospital and was eventually able to maintain a normal weight. In the other case, the patient decided she needed to deal with her gender dysphoria in order to cure her eating disorder; it is unclear if this approach worked.

There are three cases of trans women who transitioned and still had eating disorders, described in this study and this study. In one case, the trans woman had an eating disorder as a teenager and it returned years later after she had sex reassignment surgery.

In this study and this one, the young patients’ eating disorders were treated without transition. However, in this study the use of blockers helped a young trans woman recover from her eating disorder. Finally, this trans man’s eating disorder was cured by transition.

These are, of course, case studies so we can not draw broad conclusions from them. Case studies bring home the individual nature of each patient’s history.

More details about Patient 1:

The first patient had a long-standing eating disorder.

“His** symptoms included a desire to be thin, distorted body image, fear of fatness, self-induced vomiting, and laxative abuse. He attributed his desire for thinness to a wish to attain a more feminine physique. The onset of his eating disorder was associated with the development of depressive symptoms, which he attributed to the fact that he could not be a woman.”

Her eating disorder was very severe with marked dietary restriction, frequent vomiting, extreme laxative use, and exercising. Her BMI was 17.0 kg/m². She was involved in internet chat rooms related to eating disorders. She was depressed, she lacked energy, she couldn’t sleep, and she couldn’t concentrate.

Her eating disorder did not begin when she decided to live as a woman as it did for the patients in this studythis studythis study, and one of the patients in this study. However, it seems to have begun at the same time as depression related to her gender, so her eating disorder is closely linked to her gender dysphoria.

She had had a difficult childhood and could not remember much of it.

“…as a child he had felt isolated from his family and peers and was shown little affection by his mother. His mother had wanted a daughter and he felt that he might have received more affection as a girl. His father, who was described as stern and authoritarian, died when he was 15 years old.”

She had been bullied at school.

She “took the female role in play” as a child and had cross-dressed starting at age 6 or 7. “During adolescence and early adulthood, he attempted to prove his masculinity by drinking heavily and becoming involved in football-related violence. However, he never felt comfortable with a male identity. He subsequently developed strong religious beliefs, which conflicted with his wish to be female and resulted in powerful feelings of guilt. These beliefs also prevented him from contemplating gender reassignment surgery. He has had one short-term heterosexual relationship. His sexual fantasies are directed towards men but take the form of being treated like a woman rather than being clearly homosexual.”

The patient requested hospitalization for her eating disorder. She gained weight well, but she began to self-harm and think about suicide.

Her treatment involved therapy that seemed to help her.

“Within individual psychotherapy, he explored issues of masculinity and maternal neglect. He appeared to experience the hospital as providing the nurturing that he had lacked as a child. It became clear that his motivation for weight loss reflected a need for a sense of internal control and clarity in the face of a confused identity. In addition, he felt that he was attempting to starve the masculine part of himself.”

She reached a normal weight, but when she left the hospital, she relapsed and had to be readmitted.

However, at the time of the case report, she was maintaining a normal weight and had been referred to a gender clinic.

The treatment of her eating disorder included therapy around her childhood trauma and her gender issues. Transition was not part of the treatment for her eating disorder, however, it may be that the referral helped her to maintain her normal weight. The timing of the events is unclear from the article.

More details on Patient 2:

The second patient had been restricting her eating for the past 13 years, since she was 28. She had “a marked preoccupation with shape, including a desire to have a more feminine physique.” Her BMI was 18.8 kg/m², which would be just within the range for normal weight.

She had had a happy and caring home life and was close to her parents who she still lived with.

However, “from the time he started school, Patient 2 felt that he did not fit into the male gender. At school, he was bullied for being passive and sensitive. He had no friends and felt he had more in common with girls than boys. He had difficulty with some subjects at school. As an adult, he was diagnosed as dyslexic but this was not recognized in childhood. He completed a qualification in electronic engineering and worked for many years as an engineer. He denied sexual feelings of any sort and has never had a sexual relationship.”

She had been referred for psychological problems seven years ago and had raised the issue of her gender dysphoria then. She was given anti-depressants, but felt that her gender issues had been ignored.

Her eating disorder did not begin when she decided to live as a woman as it did in some other cases. However, she may have been trying to look more feminine.

She began outpatient counseling for her eating disorder.

“He described AN as providing anorexia as a an escape from emotional pain, confusion, and dissatisfaction with his life. He eventually expressed his belief that his AN and depression would not resolve until his concerns regarding gender identity were addressed. He was subsequently referred to a gender identity clinic.”

As I said above, this is where it gets confusing. She transitioned and was happier, but she was even more underweight than when she began treatment. Has she truly recovered from her eating disorder or not?

“After living as a female for 2 years, he underwent gender reassignment surgery. Since the surgery, she describes herself as feeling complete and normal. Her self-confidence has increased and she feels more at ease with herself. Her mood has stabilized. Although she remains underweight (weight 52.4 kg, BMI 16.2 kg/m² ), she now feels more satisfied with her body shape. Her only current concern in terms of body image is that her breasts are too small. She has completed professional training in counseling and adult education in the female role. Although she feels the need to be in a relationship, she has no desire for a sexual relationship.”

Comparing the Two Cases

The authors conclude by comparing the two patients. In both cases the desire for thinness was associated with wanting to look feminine. In addition both patients had educational differences.

However, in the first case, “significant emotional deprivation” as a child may have made her problems more severe and harder to treat.

“This difference seems to have been reflected in the clinical presentation and response to treatment. Patient 2 was able to make good use of outpatient psychotherapy and subsequently showed a good response to gender reassignment surgery. Patient 1, by contrast, had a complicated clinical course and required inpatient treatment on two occasions. In his case, GID was associated with disturbed early relationships and a global disturbance of identity which was not restricted to gender.

We suggest that GID in Patient 1 may have had its origins in early psychological development. We speculate that, in his case, the issue of gender identify may have served to express more complex issues of personal identity. GID, like AN, may have provided the patient with a sense of structure in a chaotic internal world. Patient 2, however, may be thought of as having a more ‘‘biologic’’ form of GID, which accounts for the successful response to gender reassignment surgery. Furthermore, the lack of major personality disturbance in her case enabled her to be treated as an outpatient.”

The author conclude by suggesting that clinicians look at issues of gender identity whenever they have male patients with eating disorders.

 

Original Source:

Anorexia Nervosa and Gender Identity Disorder in Biologic Males: A Report of Two Cases by Winston AP, Acharya S, Chaudhuri S, Fellowes L. in Int J Eat Disord. 2004 Jul;36(1):109-13.

 

*For more on the difficulties of using case studies for research, see my review of Gender Identity Disorder in Twins: A Review of the Case Report Literature.

** The authors of the article refer to the trans women as “he” until they transition.

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reviews of case studies include a number of other problems.

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

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

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

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

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

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

They found no cases where both twins had gender dysphoria.

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

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

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

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

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

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

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

What was the data, then?

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

They found:

FtMs with identical twins

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

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

FtMs with fraternal twins

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

MtFs with identical twins

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

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

MtFs with fraternal twins

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

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

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

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

The authors of the review conclude:

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

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

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

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

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

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

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

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

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

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

Original Review:

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

 

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

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

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

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

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

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

Study of Gay Brothers Suggests Genetic Basis of Male Homosexuality – Discovery Magazine Article

An interesting and important piece from Discovery magazine.

“Are people born gay or is it a choice? A new study of gay brothers, the largest to date, adds more scientific evidence that there’s a genetic basis for homosexuality.

A genetic analysis of over 409 pairs of gay brothers found that two areas of the human genome, a portion of the X chromosome and a portion of chromosome 8, were associated with the men’s sexual orientation. The findings gel with a smaller study conducted in 1993 that implicated the same area of the X chromosome.”

You can read the rest of the article at Discovery magazine.

So why is this important for research on gender dysphoria?

1) If sexual orientation is influenced by genes, then researchers looking for genes related to gender identity need to control for sexual orientation.

Trans men (born female) are usually attracted to women and about half of trans women (born male) are attracted to men, so they might share genes with cis lesbians or gay men.

Future studies of genes and gender dysphoria need to include cis gay men and lesbians in the control groups.

2) The genes that may be involved in male homosexual orientation were found on the X chromosome and chromosome 8. The researchers looked at the whole genome for 409 pairs of homosexual brothers.

Studies of genes for gender dysphoria have focused on genes known to be related to sex hormones and the X and Y chromosomes (read more in Genes and Gender Dysphoria). This makes sense if you are looking at behavior that is related to sex differences, but perhaps the genes are somewhere else.

So far, researchers have had not luck finding genes related to gender dysphoria in trans women and only some luck finding genes related to gender dysphoria in trans men. Perhaps the genes for gender dysphoria and the mechanism involved are not what we expect.

A whole genome scan for genes related to gender dysphoria would be a great study for someone to do.