Anna Martha Vaitses Fontanari

WHOQOL-100 Before and After Sex Reassignment Surgery in Brazilian Male-to-Female Transsexual Individuals

INTRODUCTION The 100-item World Health Organization Quality of Life Assessment (WHOQOL-100) evaluates quality of life as a subjective and multidimensional construct. Currently, particularly in Brazil, there are controversies concerning quality of life after sex reassignment surgery (SRS). AIM To assess the impact of surgical interventions on quality of life of 47 Brazilian male-to-female transsexual individuals using the WHOQOL-100. METHODS This was a prospective cohort study using the WHOQOL-100 and sociodemographic questions for individuals diagnosed with gender identity disorder according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The protocol was used when a transsexual person entered the ambulatory clinic and at least 12 months after SRS. MAIN OUTCOME MEASURES Initially, improvement or worsening of quality of life was assessed using 6 domains and 24 facets. Subsequently, quality of life was assessed for individuals who underwent new surgical interventions and those who did not undergo these procedures 1 year after SRS. RESULTS The participants showed significant improvement after SRS in domains II (psychological) and IV (social relationships) of the WHOQOL-100. In contrast, domains I (physical health) and III (level of independence) were significantly worse after SRS. Individuals who underwent additional surgery had a decrease in quality of life reflected in domains II and IV. During statistical analysis, all results were controlled for variations in demographic characteristics, without significant results. CONCLUSION The WHOQOL-100 is an important instrument to evaluate the quality of life of male-to-female transsexuals during different stages of treatment. SRS promotes the improvement of psychological aspects and social relationships. However, even 1 year after SRS, male-to-female transsexuals continue to report problems in physical health and difficulty in recovering their independence.

BIRTH ORDER AND ANDROPHILIC MALE-TO-FEMALE TRANSSEXUALISM IN BRAZIL

Previous research has indicated that biological older brothers increase the odds of androphilia in males. This finding has been termed the fraternal birth order effect. The maternal immune hypothesis suggests that this effect reflects the progressive immunization of some mothers to male-specific antigens involved in fetal male brain masculinization. Exposure to these antigens, as a result of carrying earlier-born sons, is hypothesized to produce maternal immune responses towards later-born sons, thus leading to female-typical neural development of brain regions underlying sexual orientation. Because this hypothesis posits mechanisms that have the potential to be active in any situation where a mother gestates repeated male fetuses, a key prediction is that the fraternal birth order effect should be observable in diverse populations. The present study assessed the association between sexual orientation and birth order in androphilic male-to-female transsexuals in Brazil, a previously unexamined population. Male-to-female transsexuals who reported attraction to males were recruited from a specialty gender identity service in southern Brazil (n=118) and a comparison group of gynephilic non-transsexual men (n=143) was recruited at the same hospital. Logistic regression showed that the transsexual group had significantly more older brothers and other siblings. These effects were independent of one another and consistent with previous studies of birth order and male sexual orientation. The presence of the fraternal birth order effect in the present sample provides further evidence of the ubiquity of this effect and, therefore, lends support to the maternal immune hypothesis as an explanation of androphilic sexual orientation in some male-to-female transsexuals.

Healthcare Needs of and Access Barriers for Brazilian Transgender and Gender Diverse People

Transgender and gender diverse people (TGD) have specific healthcare needs and struggles with access barriers that should be addressed by public health systems. Our study aimed to address this topic in the Brazilian context. A hospital and web-based cross-sectional survey built with input from the medical and transgender communities was developed to assess TGD healthcare needs of and access barriers in two Brazilian states. Although services that assist this population have existed in Brazil since the 1990s, TGD have difficulty accessing these services due to discrimination, lack of information and a policy design that does not meet the needs of TGD. A history of discrimination was associated with a 6.72-fold increase in the frequency of health service avoidance [95% CI (4.5, 10.1)]. This article discusses the urgent necessity for adequate health policies and for the training of professionals regarding the needs of Brazilian TGD.

Laryngeal surgical treatment in transgender women: A systematic review and meta-analysis

To identify the effects of laryngeal surgical treatment in the voice of transgender women, especially on the fundamental frequency (f0).

Follow-up of psychological outcomes of interventions in patients diagnosed with disorders of sexual development: A systematic review.

The objective of this study was to perform a systematic review of articles that followed up the psychological outcomes of interventions in patients with disorders of sexual development. The analysis focused on the methodological quality of the studies and the assumptions on the evaluation of the intervention outcomes. The review signaled the need for better consideration about the complexity of intersexuality and for a shift from the anatomical/functional/aesthetic to the subjective outcomes related to patient’s quality of life. Furthermore, it is suggested that the interventions should be better investigated, given the lack of evidence for the necessity of early procedures.

Discordant Transsexualism in Male Monozygotic Twins: Neuroanatomical and Psychological Differences

One monozygotic male twin pair discordant for transsexualism is described. Both twins were interviewed and tested with the Wechsler Adult Intelligence Scale battery for cognitive functions and they underwent magnetic resonance imaging to measure the volumes of specific cerebral structures. Interviews with the twins and their mother indicated no unusual medical or life history events that could have had a causal role in the emergence of the disorder. Both cognitive function testing and neuroimaging detected differences between the twins that could be related to unexplained epigenetic effects and exogenous hormone usage.

Perceptual-Auditory and Acoustical Analysis of the Voices of Transgender Women

Voice is an important gender marker in the transition process as a transgender individual accepts a new gender identity. The objectives of this study were to describe and relate aspects of a perceptual-auditory analysis and the fundamental frequency (F0) of male-to-female (MtF) transsexual individuals. A case-control study was carried out with individuals aged 19-52 years who attended the Gender Identity Program of the Hospital de Clínicas of Porto Alegre. Vocal recordings from the MtF transgender and cisgender individuals (vowel /a:/ and six phrases of Consensus Auditory Perceptual Evaluation Voice [CAPE-V]) were edited and randomly coded before storage in a Dropbox folder. The voices (vowel /a:/) were analyzed by consensus on the same day by two judge speech therapists who had more than 10 years of experience in the voice area using the GRBASI perceptual-auditory vocal evaluation scale. Acoustic analysis of the voices was performed using the advanced Multi-Dimensional Voice Program software. The resonance focus and the degrees of masculinity and femininity for each voice recording were determined by listening to the CAPE-V phrases, for the same judges. There were significant differences between the groups regarding a greater frequency of subjects with F0 between 80 and 150 Hz (P = 0.003), and a greater frequency of hypernasal resonant focus (P < 0.001) in the MtF cases and greater frequency of subjects with absence of roughness (P = 0.031) in the control group. The MtF group of individuals showed altered vertical resonant focus, more masculine voices, and lower fundamental frequencies. The control group showed a significant absence of roughness.

Transsexual Voice Questionnaire for Male-to-female Brazilian Transsexual People.

OBJECTIVES The aim of the study was to verify the answers to the transsexual voice questionnaire for male-to-female transsexual (TVQMtF) people given to individuals who participated in the Gender Identity Program (PROTIG) at the Hospital de Clínicas de Porto Alegre, Brazil, in relation to some of their demographic characteristics, visual-perceptual evaluations of the face, laryngeal prominence, and auditoryperceptual judgments of voice. METHODS In this cross-sectional study, 47 transsexual women aged between 18 and 50 responded to the (TVQMtF). The demographic data and perceptual ratings were selected from the PROTIG database. RESULTS Among all participants, 55.32% had completed secondary education, and 72.34% had not undergone a sex reassignment surgery; 4.2% of subjects did not use hormones, 23.40% had undergone speech therapy, the average number of years of experience in the female role was 13.98 years, and the participants had been definitively cross-dressing for 5-34 years. Most of the participants had low scores on the (TVQMtF), and significant differences in the total score were observed in accordance with age (higher scores were observed among those <30 years and ≥40 years old) and visual-perceptual evaluations of the face (higher scores were observed in the individual evaluated with masculine face). There were no significant correlations between the total score obtained by the participants and the other demographic variables. CONCLUSIONS Although most of the participants had low scores on the (TVQMtF), some individuals were still experiencing distress due to being perceived as being of the opposite sex or were dissatisfied with their voices.

Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression

Introduction: Gender dysphoria (GD) (DMS-5) is a condition marked by increasing psychological suffering that accompanies the incongruence between ones experienced or expressed gender and ones assigned gender. Manifestation of GD can be seen early on during childhood and adolescence. During this period, the development of undesirable sexual characteristics marks an acute suffering of being opposite to the sex of birth. Pubertal suppression with gonadotropin releasing hormone analogs (GnRHa) has been proposed for these individuals as a reversible treatment for postponing the pubertal development and attenuating psychological suffering. Recently, increased interest has been observed on the impact of this treatment on brain maturation, cognition and psychological performance. Objectives: The aim of this clinical report is to review the effects of puberty suppression on the brain white matter (WM) during adolescence. WM Fractional anisotropy, voice and cognitive functions were assessed before and during the treatment. MRI scans were acquired before, and after 22 and 28 months of hormonal suppression. Methods: We performed a longitudinal evaluation of a pubertal transgender girl undergoing hormonal treatment with GnRH analog. Three longitudinal magnetic resonance imaging (MRI) scans were performed for diffusion tensor imaging (DTI), regarding Fractional Anisotropy (FA) for regions of interest analysis. In parallel, voice samples for acoustic analysis as well as executive functioning with the Wechsler Intelligence Scale (WISC-IV) were performed. Results: During the follow-up, white matter fractional anisotropy did not increase, compared to normal male puberty effects on the brain. After 22 months of pubertal suppression, operational memory dropped 9 points and remained stable after 28 months of follow-up. The fundamental frequency of voice varied during the first year; however, it remained in the female range. Conclusion: Brain white matter fractional anisotropy remained unchanged in the GD girl during pubertal suppression with GnRHa for 28 months, which may be related to the reduced serum testosterone levels and/or to the patients baseline low average cognitive performance.Global performance on the Weschler scale was slightly lower during pubertal suppression compared to baseline, predominantly due to a reduction in operational memory. Either a baseline of low average cognition or the hormonal status could play a role in cognitive performance during pubertal suppression. The voice pattern during the follow-up seemed to reflect testosterone levels under suppression by GnRHa treatment.

Reduced serum concentrations of brain-derived neurotrophic factor (BDNF) in transsexual Brazilian men

Serum BDNF levels are significantly decreased in transsexual Brazilian women when compared to cis-sexual men. Since transsexual men are also exposed to chronic social stress and have a high prevalence of associated psychopathologies, it is plausible to inquire if BDNF serum levels are altered in transsexual men as well. Therefore, our objective was to evaluate differences in BDNF serum level of transsexual men when compared to cis-sexual men and women. Our sample comprises 27 transsexual men, 31 cis-sexual women and 30 cis-sexual men recruited between 2011 and 2015. We observed that BDNF serum concentration is decreased in transsexual men comparing to cis-sexual men and women. Cross-sex hormone treatment, chronic social stress or long-term gender dysphoria (GD) could explain the variation found in BDNF serum levels.