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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?

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A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions – Review of Case Study

This is a case study of a trans man (born female) with many serious mental health problems, including an eating disorder. He was a survivor of childhood sexual abuse and the trauma seems to have been at the root of his problems.

He had “an eating disorder with restriction and purging, substance dependence, gender dysphoria, panic disorder without agoraphobia, PTSD, dissociative disorder, learning disorder, sleep disorder, mood disorder, borderline personality disorder, and pain disorder.”

This case study does not make any connections between his eating disorder and his gender dypshoria. Given the abuse and the multiple comorbidities, it is unlikely that the gender dysphoria caused the eating disorders.

The authors suggest that both the eating disorder and the gender dysphoria were caused by the early trauma.

“the underlying foundation of these multiple diagnoses is the presence of early developmental trauma to the emotion regulation system — which manifests as physical and emotional pain with impulsive and maladaptive attempts to engage in behaviors to meet personal needs, including safety. Zanarini and colleagues performed a study examining Axis I comorbidity in patients with BPD [borderline personality disorder] and identified high rates of comorbid PTSD. They also observed that meeting criteria for multiple Axis I disorders predicted meeting criteria for BPD.”

Treatment focused on the most severe issues first; suicidal thoughts and behaviors, then purging behaviors, urges towards substance abuse, self-harm, self-care, and interpersonal behavior. The patient was treated with dialectical behavior therapy.

Medical transition came later and was not part of the recovery from the eating disorder. However, at the time the patient entered therapy, he had already taken a male name and was dressing and living as a male.

This case study has some similarities to the case of a teenage girl* who developed gender dysphoria while being treated for an eating disorder. The teenage girl was also a survivor of childhood sexual abuse with multiple mental health problems: anxiety, depression, an eating disorder, excessive exercise, and OCD-type rituals related to germs (spraying her body with Lysol and excessive hand-washing). In addition, she had a past history of PTSD, OCD, self-harm, and suicidal thoughts.

These two cases suggest that in some cases, gender dysphoria is not the main cause of an eating disorder. Rather, trauma causes multiple mental health issues.

There are two more case studies of transgender people with eating disorders who were survivors of child abuse. They suggest different possible conclusions, however.

A trans woman whose eating disorder began when she started to live as a woman. Her goal was to have a more feminine shape. Transition and hormones did not cure the eating disorder, however. She had been physically and sexually abused as a child.

A trans woman whose identical twin also had an eating disorder. Both twins were feminine in behavior from a young age and both were sexually attracted to men. Both survived an abusive father who threatened them with assault and death. However, one was a trans woman and one was a gay man.

In the first case, the eating disorder seems to be closely connected to the gender dysphoria since it started when she began to live as a woman. She clearly describes wanting to look more female. The abuse may have affected her, but gender dysphoria was also a factor.

In the second case, the eating disorder seems to have been caused by a combination of genes and environment, since both twins had anorexia but only one had gender dysphoria.

We’re left with the possibility that the answer is different in different cases. Sometimes severe childhood trauma may cause multiple mental health problems that include an eating disorder. Sometimes a combination of gender dysphoria and early childhood trauma may contribute to an eating disorder. And sometimes the same genes and environment will produce two people with similar eating disorders but different gender identities.

Of course, these are only four case studies. We can’t draw conclusions from them about all transgender people with eating disorders. Most of the case histories I have found don’t mention child abuse. Many of them suggest connections between gender dysphoria and eating disorders.

What we can see from these cases, however, is that for some transgender people with eating disorders, gender dysphoria is not the main or only cause of their eating disorder. Therapists should keep this in mind when treating transgender patients for eating disorders.

And, as always, we need more research.

Original Source (full text):

A 25-Year-Old Affirmed Male with Multiple Comorbid Conditions by Katharine J. Nelson, MD; S. Charles Schulz, MD in Psychiatric Annals, February 2012 – Volume 42 – Issue 2: 48-51.

UPSETTING MATERIAL ABOUT ABUSE BELOW

A few additional details of the case history:

The article provides an interesting discussion of diagnosing and treating a patient. The full text is available online without cost, but here are a few details of the case:

The trauma the trans man survived involved “repeated episodes of sexual violence perpetrated from age 4 to 9 years old by a childhood friend’s father in the neighborhood.”

“The patient believed he had suffered multiple head injuries related to physical violence and asphyxiation in the context of sexual trauma, but was unclear if he had lost consciousness because of head injury or because of psychological dissociation during these events.”

He had “a history of heavy chemical use, starting with first use of alcohol at age 7, which continued through age 23. He also used diet pills starting at age 14, followed by heavy use of cannabis at age 15, and cocaine and other narcotics, including pills and heroin, at age 18 years.”

The patient had severe pelvic floor dysfunction which caused him a great deal of pain. It took him a while to get this diagnosed correctly.

“The patient was born and raised as a female, but in retrospect realized he did not fully identify with either the male or female gender. In the previous 2 years, he had decided to openly adopt a male gender, name, and manner of dress. He had the intention of pursuing hormone therapy and, eventually, chest reconstruction.”

Treatment and afterwards:

“Suicidal thoughts and behaviors were identified as the highest-priority target; after 6 months, these thoughts and behaviors had resolved. The patient was engaged in therapy and did not require significant emphasis on therapy interfering behaviors; therefore, quality-of-life interfering behaviors could be targeted, including purging behaviors, urges to use substances, self-injury, self-care, and interpersonally effective behaviors with friends, family, and other medical professionals. He graduated phase 1 of DBT therapy and proceeded to phase 2 to continue working on healthy emotional experiencing and management of trauma sequelae.

The patient graduated college with a high grade point average and went on to pursue master’s level education. He underwent sex hormone treatment and chest reconstruction.

He developed additional medical comorbidities, including insulin resistance and adrenal insufficiency. These medical conditions necessitated moving back in with his parents, resulting in significant familial conflict. The patient’s therapist made a referral for family therapy through our department, which was coordinated among treatment providers. The patient is enthusiastic about the progress made in treatment and states he often wonders if he would be still be alive without the intervention he received. Over the course of 3 years, his medications were all tapered to discontinuation, with the exception of prazocin 10 mg at bedtime for nightmares, ramelteon 8 mg for sleep, and clonazepam 1 mg three times a day, which was continued to assist with pelvic musculature functioning.”

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

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

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

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

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

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

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

The patient had not continued counseling after surgery.

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

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

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

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

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

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

On the other hand,

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

Urgent needs have to be taken care of first.

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

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

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

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

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

We need to keep track of eating disorders after transition.

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

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

Not everyone needs the same treatment for gender dysphoria.

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

Comparing eating disorders in transgender teens and adults

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

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

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

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

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

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

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

Original Source:

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

 

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

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

 

More details from the case study:

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

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

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

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

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

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

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

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

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

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

More details on interviewing patients about gender

The authors offer these sample approaches:

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

Sample intake form from:

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

Sample approach for an interview from:

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

Review: Treatment of anorexia nervosa in the context of transsexuality: A case report

This is a depressing study. The main conclusion I get from it is that we need a better health care system.

The patient in this case is a 19 year-old American trans woman (born male) who developed a severe eating disorder when she decided to dress and live as a woman.

She became malnourished and ill and was hospitalized. During her treatment, she became upset as she gained weight and was afraid she would look masculine. She said she would be willing to gain a healthy amount if it would be on her hips and breasts.

When her testosterone levels returned to normal, hair began growing on her face and legs again. The patient began to exercise secretly and stopped gaining weight.

The hospital discussed gender transition with her, including the risks of treatment. She agreed to try hormone blockers and was given a three month dose of leuprolide. She was also given the androgen blocker spironolactone. After this, the patient progressed well and gained enough weight to leave the hospital.

During follow-up, the patient continued to gain weight until she began working. She lost weight while working, but was able to stabilize her weight with the help of a dietitian.

The patient was referred to an endocrinologist and a center for transgender youth for estrogen therapy and gender transition. She lost her health insurance coverage and could not afford to follow-up with transition.

Short-term hormone therapy helped this trans woman to recover from an eating disorder that made her seriously ill, but it’s unclear what will happen to her without health insurance.

It is important to remember that this is just a case study. This is only one individual; the relationship between eating disorders and gender dysphoria is complicated. We can only come to limited conclusions from any one person’s story.

I will be reviewing more case studies of eating disorders and gender dysphoria. At this point, the main conclusion I can draw is that each case is individual.

The hormone treatment in this case was not the standard cross-sex hormone treatment for people with gender dysphoria. We can not, therefore, draw conclusions about the standard hormonal treatment for trans women.

In addition, the hormone treatment the patient received in this case would not work for everyone. Leuprolide can decrease bone density which may be a problem for malnourished patients with eating disorders. In this case the doctors decided that it would be only used for a short time and the benefits outweighed the risks.

The doctors speculate about the possibility that the androgen blockers caused the patient to gain weight under the skin rather than at the belly and that this may have made her look more feminine.

It is also possible that leuprolide itself had an effect on the eating disorder. Leuprolide is a puberty blocker and eating disorders develop at puberty; perhaps when you block puberty, you block something that causes disordered eating. For example, estrogen may play a role in eating disorders and leuprolide blocks estrogen as well as testosterone.

The bottom line is that this trans woman developed a life-threatening eating disorder when she decided to live as a woman. During recovery she was distressed by the idea of looking more masculine as she regained a healthy weight. Puberty blockers and androgen blockers helped her to regain a healthy weight. Her weight was stable at follow-up, but she lost her health insurance and it is unclear what will happen to her.

More from the authors’ discussion of the case:

“Because her identity as TS [transsexual] and desire to appear more feminine were inextricable from her disordered eating, we felt that her recovery from her ED [eating disorder] would be aided by supporting her gender transition. After consulting the Endocrine Society Guidelines on Treatment of Transsexual Persons and discussing treatment possibilities with experts in transsexual youth, medical treatment options included cross-hormone (i.e., estrogen) therapy (which would also suppress testosterone release) and/or suppression of testosterone with GnRH agonists with or without the use of spironolactone as an antiandrogen agent. Treatment with cross-hormone therapy requires close follow-up with an endocrinologist familiar with this treatment; the children’s hospital to which DS was admitted is not a site experienced in cross-hormone therapy for transsexual youth. For this reason, GnRH agonist therapy with spironolactone was chosen to suppress testosterone at the level of the pituitary and delay resurgence of testosterone-related changes until the patient could access appropriate TS medical care and follow-up.

To our knowledge, there are no studies describing the patterns of weight gain in TS patients who receive antiandrogens in comparison to those who do not. However, studies of antiandrogen use for other medical conditions have shown that patients receiving antiandrogens tend to gain subcutaneous adiposity, as opposed to primarily intra-abdominal adiposity gained by patients not on antiandrogens. One could theorize that this subcutaneous pattern of weight gain would be more tolerable to MtF transsexual patients who strive for a more feminine appearance, which would support the use of GnRH agonists in these patients. This is an interesting area for future inquiry.

Possible adverse effects of GnRH agonists include decrease in bone density. This is of particular concern in malnourished patients, as malnutrition alone can adversely affect bone density. This potential drawback of GnRH therapy for DS was discussed at length as a team, and it was determined that the benefits of GnRH use outweighed the risks for two primary reasons: (1) the expected duration of GnRH therapy was brief, as it was being used as a bridge to initiation of cross-hormone therapy; and (2) suppression of DS’s testosterone level would likely facilitate her willingness to achieve weight restoration. In studies of malnourished patients with low bone density, weight restoration is the most important factor in improving bone density. Spironolactone was added to DS’s therapy regimen for additional anti-androgen effects. This medical plan enabled DS to continue to improve her nutritional status while avoiding the unwanted increase in testosterone and consequent physical changes.”

Original Source:

Treatment of anorexia nervosa in the context of transsexuality: A case report by Ewan LA, Middleman AB, Feldmann J. in Int J Eat Disord. 2014 Jan;47(1):112-5.

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

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

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

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

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

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

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

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

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

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

They make recommendations for treatment in cases like these:

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

The authors conclude by saying:

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

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

The first patient was five years old.

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

The second patient was three and a half years old.

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

More Details about the Patients

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

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

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

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

More Details about the Patients’ Treatments

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

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

 

Original Source:

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

 

 

 

 

The development of gender identity in the autistic child – Extremely Brief Review

A 1981 study of autistic children found that gender identity was related to “mental age, chronological age, communication skills, physical skills, social skills, self-help skills and academic/cognitive skills.”

The study looked at 30 children and gave them the Michigan Gender Identity Test. The goal was to see if they could demonstrate a sense of gender identity.

This study is not available online, however, I was able to get some more information on it from another study (Case study: cross-gender preoccupations with two male children with autism.)

According to Williams et al., Abelson’s study indicated that “the establishment of gender identity in children with autism (as demonstrated by recognizing one’s own self as a boy or a girl) appeared to be dependent on mental age and cognitive abilities, and was correlated with the establishment of other social and self-help skills. Abelson expressed some optimism that many children with autism have the ability to recognize themselves as boys and girls, and thus form effective ties with the identified group, which leads to more acceptable social interaction patterns.”

Original Source:

The development of gender identity in the autistic child by Abelson AG in Child Care Health Dev. 1981 Nov-Dec;7(6):347-56.

Transgender History by Susan Stryker – book recommendation

This is a great book. Read it.

Don’t you wish you could have turned in a book report like that? Sweet and simple.

This blog is about science, but I’ve decided to throw in some occasional book recommendations. I’ll be quoting Stryker’s history from time to time as well.

Meanwhile, other people have already written thorough reviews: C. Riley Snorton at the University of Pennsylvania, A Gender Variance Who’s Who, or plain old GoodReads.

You can buy Transgender History by Susan Stryker:

from Seal Press (support women’s publishing)

from Barnes and Noble (support brick and mortar stores)

from Amazon (support books)