Guy T’Sjoen

Non-binary or genderqueer genders

Abstract Some people have a gender which is neither male nor female and may identify as both male and female at one time, as different genders at different times, as no gender at all, or dispute the very idea of only two genders. The umbrella terms for such genders are ‘genderqueer’ or ‘non-binary’ genders. Such gender identities outside of the binary of female and male are increasingly being recognized in legal, medical and psychological systems and diagnostic classifications in line with the emerging presence and advocacy of these groups of people. Population-based studies show a small percentage – but a sizable proportion in terms of raw numbers – of people who identify as non-binary. While such genders have been extant historically and globally, they remain marginalized, and as such – while not being disorders or pathological in themselves – people with such genders remain at risk of victimization and of minority or marginalization stress as a result of discrimination. This paper therefore reviews the limited literature on this field and considers ways in which (mental) health professionals may assist the people with genderqueer and non-binary gender identities and/or expressions they may see in their practice. Treatment options and associated risks are discussed.

Male gender identity in complete androgen insensitivity syndrome.

Women and girls with complete androgen insensitivity syndrome (CAIS) invariably have a female typical core gender identity. In this case report, we describe the first case of male gender identity in a CAIS individual raised female leading to complete sex reassignment involving both androgen treatment and phalloplasty. CAIS was diagnosed at age 17, based on an unambiguously female phenotype, a 46,XY karyotype, and a 2660delT androgen receptor (AR) gene mutation, leading to a premature stop in codon 807. Bilateral gonadectomy was performed but a short period of estrogen treatment induced a negative emotional reaction and treatment was stopped. Since the age of 3, childhood-onset cross gender behavior had been noticed. After a period of psychotherapy, persisting male gender identity was confirmed. There was no psychiatric co-morbidity and there was an excellent real life experience. Testosterone substitution was started, however without inducing any of the desired secondary male characteristics. A subcutaneous mastectomy was performed and the patient received phalloplasty by left forearm free flap and scrotoplasty. Testosterone treatment was continued, without inducing virilization, and bone density remained normal. The patient qualifies as female-to-male transsexual and was treated according to the Standards of Care by the World Professional Association for Transgender Health with good outcome. However, we do not believe that female sex of rearing as a standard procedure should be questioned in CAIS. Our case challenges the role of a functional AR pathway in the development of male gender identity.

Sperm freezing in transsexual women.

Gender Identity Disorder (GID) is a condition in which a person experiences discrepancy between the sex assigned atbirth and the gender they identify with. Transsexualism is considered the most extreme form of GID and is characterized by the desire to live and be treated as a member of the opposite gender. The prevalence of male-to-female transsexualism in Belgium is estimated at 1 per 12,900 males (De Cuypere et al., 2007). The treatment consists of cross-sex hormone therapy and sex reassignment surgery in accordance with the Standards of Care of the World Professional Association for Transgender Health (WPATH) (7th Version) (www.wpath.org). At the center in Ghent, male-to-female transsexual persons, denoted as transsexual women, are treated in a multidisciplinary approach, including cross-sex hormone therapy and sex reassignment surgery for most. Hormone therapy with anti-androgens and estrogens is used in the majority of transsexual women. After at least 1 year of hormonal therapy, sex reassignment surgery can be offered, which includes orchidectomy andpenectomy in combinationwith vaginoplasty (Selvaggiet al., 2005).Bothhormonalandsurgical interventionsnegativelyaffect the male reproductive system. Hormonal therapy itself leads to decreased spermatogenesis and eventually to azoospermia (Lubbert, Leo-Rossberg, & Hammerstein, 1992; Schulze, 1988). Currently, it is unknown whether spermatogenesis will restore after prolonged estrogen treatment or not (Hembree et al., 2009). Sex reassignment surgery, on the other hand, results in an irreversible loss of natural reproductive capacity in transsexual women. Current reproductive techniques can offer adult transsexual women the possibility of having genetically related children (De Sutter, 2001). They can store their sperm for long-term cryopreservation before undergoing hormonal therapy for future use in assisted reproductive techniques (ART). Sexual orientation of transsexual women may influence the future plans for using the frozen sperm. If transsexual women have a female partner, they can procure children through intrauterine insemination, in vitro fertilization or intracytoplasmic sperm injection, based upon the sperm quality after thawing. Reproductive options for transsexual women with a male partner are more difficult as they need oocyte donation as well as a surrogate mother. Reproductive needs and rights of transsexual persons have already been recognized for over 15 years (Lawrence, Shaffer, Snow, Chase, & Headlam, 1996) and since 2001 the WPATH Standards of Care contains a paragraph that addresses the need to discuss reproductive issues with transsexual persons, prior to starting hormonal treatment (Meyer et al., 2001). Also, the new WPATH Standards of Care (Seventh version) (2011) as well as the Clinical Practice Guidelines of the Endocrine Society (Hembree et al., 2009) clearly state that transsexual persons should be encouraged to consider fertility issues before starting cross-gender hormonal treatment. On the other hand, research on this topic is still scarce. In the past 10 years, only two studies have investigated the opinions of transsexual persons themselves concerning this topic (De Sutter, Kira, Verschoor, & Hotimsky, 2002; Wierckx et al., 2012) and few have addressed reproductive difficulties (e.g., access to ART in transsexual patients) (AlvarezK. Wierckx (&) G. T’Sjoen Department of Endocrinology, University Hospital Ghent, De Pintelaan 185, 9000 Ghent, Belgium e-mail: Katrien.Wierckx@ugent.be

Fertility options in transgender people.

Abstract Hormonal and surgical treatments for transgender people have a devastating effect on the possibility for these patients to reproduce. Additionally, transgender people tend to start sex reassignment treatment at a young age, when reproductive wishes are not yet clearly defined nor fulfilled. The most recent Standards of Care of the World Professional Association for Transgender Health recommend clearly informing patients regarding their future reproductive options prior to initiation of treatment. This review gives an overview of the current knowledge and state-of-the-art techniques in the field of fertility preservation for transgender people. Where genital reconstructive surgery definitely results in sterility, hormone therapy on the other hand also has an important, but partially reversible impact on fertility. The current fertility preservation options for trans men are embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. For trans women, sperm cryopreservation, surgical sperm extraction and testicular tissue cryopreservation are possible. Although certain fertility preservation techniques could be applicable in a standardized manner based on clear biological criteria, the technique that eventually will be performed should be the preferred choice of the patient after extended explanation of all possible options.

Cross-sex hormone treatment in male-to-female transsexual persons reduces serum brain-derived neurotrophic factor (BDNF).

Serum levels of brain-derived neurotrophic factor (BDNF) are reduced in male-to-female transsexual persons (MtF) compared to male controls. It was hypothesized before that this might reflect either an involvement of BDNF in a biomechanism of transsexualism or to be the result of persistent social stress due to the condition. Here, we demonstrate that 12 month of cross-sex hormone treatment reduces serum BDNF levels in male-to-female transsexual persons independent of anthropometric measures. Participants were acquired through the European Network for the Investigation of Gender Incongruence (ENIGI). Reduced serum BDNF in MtF thus seems to be a result of hormonal treatment rather than a consequence or risk factor of transsexualism.

Gender Dysphoria and Gender Incongruence: An evolving inter-disciplinary field.

The number of people with gender dysphoria and gender incongruence who seek assessment, support and treatment at gender identity clinic services has increased substantially over the years in Europe...

Contribution of androgen receptor sensitivity to the relation between testosterone and sexual desire: An exploration in male-to-female transsexuals

Background: Low sexual desire is present in 1/3 of male-to-female transsexuals (post-operative male-to-female transsexual persons on estrogen replacement). Several studies report lower endogenous testosterone (T) levels in this group compared to community dwelling women. However, no relationship between T and sexual desire has been found in male-to-female transsexuals. Considering its role in androgen sensitivity, cytosine-adenine-guanine (CAG) trinucleotide repeat sequence in the androgen receptor (AR) might modify the relationship between T levels and sexual desire in male-to-female transsexuals. Aim: This study aims to assess the potential contribution of the number of CAG repeats in the association between T and sexual desire in male-to-female transsexuals. Material, subjects, and methods: Thirty-four post-operative male-to-female transsexuals participated in a cross-sectional study. The Sexual Desire Inventory, a questionnaire measuring sexual desire, was completed. Serum levels of total (TT) and free T (FT), DHEA-S, SHBG, and LH were measured in morning blood samples. AR gene CAG repeat length was determined by automated DNA fragment analysis of exon 1 of the AR gene. Results: The CAG repeat length ranged from 14 to 28 with a median of 21. CAG polymorphism was correlated with FT (r=0.389; p=0.023) but not with TT (r=0.191; p=0.280). The observed interaction between TT and CAG was significant only for solitary sexual desire (p=0.002). The interaction of CAG repeats and FT on sexual desire failed to reach significance. Conclusions: We could not establish that CAG repeat length is a consistent modulating factor in the relationship between TT or FT and sexual desire in male-to-female transsexuals.

Transgender Research in the 21st Century: A Selective Critical Review From a Neurocognitive Perspective

Gender dysphoria describes the psychological distress caused by identifying with the sex opposite to the one assigned at birth. In recent years, much progress has been made in characterizing the needs of transgender persons wishing to transition to their preferred gender, thus helping to optimize care. This critical review of the literature examines their common mental health issues, several individual risk factors for psychiatric comorbidity, and current research on the underlying neurobiology. Prevalence rates of persons identifying as transgender and seeking help with transition have been rising steeply since 2000 across Western countries; the current U.S. estimate is 0.6%. Anxiety and depression are frequently observed both before and after transition, although there is some decrease afterward. Recent research has identified autistic traits in some transgender persons. Forty percent of transgender persons endorse suicidality, and the rate of self-injurious behavior and suicide are markedly higher than in the general population. Individual factors contributing to mental health in transgender persons include community attitudes, societal acceptance, and posttransition physical attractiveness. Neurobiologically, whereas structural MRI data are thus far inconsistent, functional MRI evidence in trans persons suggests changes in some brain areas concerned with olfaction and voice perception consistent with sexual identification, but here too, a definitive picture has yet to emerge. Mental health clinicians, together with other health specialists, have an increasing role in the assessment and treatment of gender dysphoria in transgender individuals.

Circulating androgens correlate with resting-state MRI in transgender men

Despite mounting evidence regarding the underlying neurobiology in transgender persons, information regarding resting-state activity, particularly after hormonal treatment, is lacking. The present study examined differences between transgender persons on long-term cross-sex hormone therapy and comparisons on two measures of local functional connectivity, intensity of spontaneous resting-state activity (low frequency fluctuations, LFF) and local synchronization of specific brain areas (regional homogeneity, ReHo). Nineteen transgender women (TW, male-to-female), 19 transgender men (TM, female-to-male), 21 non-transgender men (NTM) and 20 non-transgender women (NTW) underwent a resting-state MRI scan. The results showed differences between transgender persons and non-transgender comparisons on both LFF and ReHo measures in the frontal cortex, medial temporal lobe, and cerebellum. More interestingly, circulating androgens correlated for TM in the cerebellum and regions of the frontal cortex, an effect that was associated with treatment duration in the cerebellum. By comparison, no associations were found for TW with estrogens. These data provide first evidence for a potential masculinization of local functional connectivity in hormonally-treated transgender men.

Social Science Theories on Adolescent Risk-Taking: The Relevance of Behavioral Inhibition and Activation.

The major social science theories on adolescent risk-taking—strain, social control, and differential association theories—have received substantial empirical support. The relationships between variables central to these theories and individual differences in temperament related to risk-taking, however, have not been adequately studied. In a sample of adolescents, this study examines how behavioral inhibition and activation relate to variables central to social control, strain, and differential association theories and how interactions between behavioral inhibition and activation and these theories predict aggressive and nonaggressive forms of risk-taking. The results of this study suggest that (a) BIS (behavioral inhibition system) and BAS (behavioral approach system) are related to strain, social control, and differential associations; (b) the effects of these social science and personality variables are, at least partially, additive; and (c) significant interactions exist between BIS/BAS and social control and differential association. Combining social science and personality concepts therefore could advance the understanding of differences in risk-taking.