Timo O. Nieder

Age of Onset and Sexual Orientation in Transsexual Males and Females

INTRODUCTIONnWith regard to transsexual developments, onset age (OA) appears to be the starting point of different psychosexual pathways.nnnAIMnTo explore differences between transsexual adults with an early vs. late OA.nnnMETHODSnData were collected within the European Network for the Investigation of Gender Incongruence using the Dutch Biographic Questionnaire on Transsexualism (Biografische Vragenlijst voor Transseksuelen) and a self-constructed score sheet according to the DSM-IV-TR (Diagnostic and Statistical Manual, Fourth Edition, Text Revision) criteria of Gender Identity Disorder (GID) and Gender Identity Disorder in Childhood (GIDC). One hundred seventy participants were included in the analyses.nnnMAIN OUTCOME MEASURESnTranssexual adults who, in addition to their GID diagnosis, also fulfilled criteria A and B of GIDC (a strong cross-gender identification,persistent discomfort about her or his assigned sex) retrospectively were considered as having an early onset (EO). Those who fulfilled neither criteria A nor B of GIDC were considered as having a late onset (LO). Participants who only fulfilled criterion A or B of GIDC were considered a residual (RES) group.nnnRESULTSnThe majority of female to males (FtMs) appeared to have an early OA (EO = 60 [77.9%] compared to LO = 10 [13%] and to RES = 7 [9.1%]). Within male to females (MtFs), percentages of EO and LO developments were more similar (EO = 36 [38.7%], LO = 45 [48.4%], RES = 12 [12.9%]). FtMs presented to gender clinics at an earlier age than MtFs (28.04 to 36.75). The number of EO vs. LO transsexual adults differed from country to country (Belgium, Germany, the Netherlands, Norway).nnnCONCLUSIONnOA has a discriminative value for transsexual developments and it would appear that retrospective diagnosis of GIDC criteria is a valid method of assessment. Differences in OA and sex ratio exist between European countries.

Body Image in Young Gender Dysphoric Adults: A European Multi-Center Study.

The alteration of sex-specific body features and the establishment of a satisfactory body image are known to be particularly relevant for individuals with Gender Dysphoria (GD). The aim of the study was to first develop new scales and examine the psychometric properties of the Hamburg Body Drawing Scale (Appelt & Strauß 1988). For the second part of this study, the satisfaction with different body features in young GD adults before cross-sex treatment were compared to female and male controls. Data collection took place within the context of the European Network for the Investigation of Gender Incongruence (ENIGI) including 135 female-to-male (FtMs) and 115 male-to-female (MtFs) young GD adults and 235 female and 379 male age-adjusted controls. The five female and six male body feature subscales revealed good internal consistency. The ENIGI sample reported less satisfaction with overall appearance (dxa0=xa00.30) and with all of their body features than controls, but no subgroup differences for sexual orientation (FtM and MtF) and Age of Onset (FtM) were found. Body dissatisfaction was higher with regard to sex-specific body features (largest effect sizes of dxa0=xa03.21 for Genitalia in FtMs and dxa0=xa02.85 for Androgen-responsive features and genitalia in MtFs) than with those that appeared less related to the natal sex (dxa0=xa00.64 for Facial features in FtMs and dxa0=xa00.59 for Body shape in MtFs). Not only medical body modifying interventions, but also psychosocial guidance with regard to body image might be helpful for GD individuals before transitioning.

Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults

This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.

Tertium non datur – either/or reactions to transsexualism amongst health care professionals: the situation past and present, and its relevance to the future

According to the principle of the excluded third (tertium non datur) the gender binary divides our social life into two options only: male or female. Similarly, either/or reactions also seem to be applied by people dealing professionally with issues of transsexualism, transgenderism or related statuses. For instance, the history of transsexualism is characterised by attempts to classify transsexual people hierarchically and descriptively. The primary intention was to discriminate between different types of transsexualism to prescribe hormonal and surgical treatment for ‘real’ transsexual people and to recommend psychotherapy aiming at relieving gender dysphoria for all the others. In this regard, from the early beginnings sexologists have argued about the origins of transsexualism, because the type of origin – the professionals assumed – legitimises a specific kind of treatment, for example psychotherapy for psychological issues and somatic cross-sex treatment for biological issues. Consequently, psychoanalysts and biologically orientated professionals have debated at great lengths about state-of-the-art treatment for transsexual people. Furthermore, to pass as a ‘real’ transsexual, most of the people concerned presented themselves in a very schematic way. The main focus of this article is the long-standing history of either/or reactions in health care professionals dealing with issues of transsexualism and related states. In addition, it elaborates on the iatrogenic influence on the behaviour of transsexual people of the biases of health care professionals. Finally, in highlighting perspectives of recent trans theory, conclusions important for the debate of current issues are drawn and ideas for the future of care are developed.

Sexual Behavior of Gender-Dysphoric Individuals Before Gender-Confirming Interventions: A European Multicenter Study

A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.

Yes and yes again: are standards of care which require two referrals for genital reconstructive surgery ethical?

The commonly used Standards of Care for people with gender dysphoria, including those of the World Professional Association for Transgender Health and The Royal College of Psychiatrists in the United Kingdom, as well as those standards used in many other countries, usually require that two signatures of approval from qualified mental health professionals be provided before genital reconstructive surgery (GRS) – sometimes called sexual reassignment surgery or gender confirmation surgery – is undertaken. This is different from surgeries which are similarly irreversible and remove reproductive capacity carried out on cisgender people. This paper explores the trans-specific issues from a standpoint of medical ethics and argues that, provided sufficient safeguards are in place, including assessment within a multidisciplinary team, a nuanced approach utilising a single signature may instead be appropriate.

German Medical Students' Interest in and Knowledge about Human Sexuality in 1972 and 2012

INTRODUCTIONnDuring the 1970s, a growing number of medical schools began to recognize the importance of medical education concerning human sexuality. Currently, most medical schools provide at least some instruction in human sexuality.nnnAIMnIn light of this development, the present study aimed to compare the interest in and knowledge about human sexuality of medical students from two different time periods.nnnMETHODSnThe answers to a self-constructed questionnaire of 236 students in 1972 were compared with those of 259 students in 2012. Students were asked whether they were interested in education regarding human sexuality and which specific topics they felt should be included in the medical curriculum. The students knowledge in the following domains was assessed: sexual development, sexual behavior, sexual physiology and psychology, and sexual medicine.nnnMAIN OUTCOME MEASURESnThe two cohorts were compared with regard to those specific sexuality-related topics in which the students were most and least interested in. Furthermore, the number of correct responses to the knowledge questions was compared.nnnRESULTSnWhile in 1972, 99.2% of the students were interested in medical education about human sexuality, in 2012, 80.3% showed an interest. The connection of disorders from different medical disciplines with sexuality was rated as most interesting by both the students from 1972 and 2012. Medical students from 2012 gave 50.3% correct answers to the knowledge questions, whereas students from 1972 correctly answered 46.3% of the questions.nnnCONCLUSIONSnAlthough interest in education concerning human sexuality has decreased, the majority of students view it as an important topic. Nevertheless, medical students still lack knowledge about important aspects of human sexuality (e.g., psychosexual development and relative safety of different contraceptives). Therefore, more time should be dedicated to education concerning human sexuality and its cultural, societal, and health aspects in particular.

Intimate Partnerships and Sexual Health in Gender-Dysphoric Individuals Before the Start of Medical Treatment

ABSTRACT Objectives: This study focuses on sexual health aspects in partnered gender-dysphoric individuals at the start of medical treatment by examining their partnership constellations, sexual experiences, and reports of psychological problems. Methods: As part of the cross-national European Network for the Investigation of Gender Incongruence Study, 168 adult male-to-females (MFs) and female-to-males (FMs; MF:FM sex ratio = 1:1.2) were surveyed by means of self-administered questionnaires prior to any gender-confirming hormonal and surgical interventions. Results: MFs were often found to have androphilic (female) partners (sexually oriented toward males), noncomplementary with their female gender identity. In contrast, FMs frequently had androphilic (female) partners, complementary with their male gender identity and sexual orientations toward females. Conclusions: In both genders, complementary partnership constellations were associated with more avoidance of sexual experiences and more negative sexual experiences.

High impact of sleeping problems on quality of life in transgender individuals: A cross-sectional multicenter study.

Introduction Studies in the general population suggest that determinants of QoL are often sex-dependent. Sex-dependent analyses of QoL in transgender populations have not been performed so far. Aim To identify sex-specific and potentially modifiable determinants of QoL in transgender patients Methods In this cross-sectional multicentre study including 82 transwomen (TW) and 72 transmen (TM) at different treatment stages, we investigated potential determinants for QoL focusing on the impact of mood (BDI, STAI-X), sleep quality (PSQI), chronic pain (GPQ), body image (FBeK) and social support (SSS). Main outcome measure Health-related quality of life measured with the Short Form (36) Health Survey (SF-36). Results The age-adjusted SF-36 total score and its subscales did not significantly differ between TM and TW. Using a multivariate regression analysis approach, we identified common but also sex-dependent determinants for QoL (Adjusted R2 = 0.228; 0.650 respectively). Accounting for general characteristics such as age, BMI and treatment status, sleep quality according to the PSQI was an independent and strong determinant of QoL in both sexes (β = -0.451, p = 0.003 TM; β = -0.320; p = 0.0029 TW). Chronic pain was a significant independent predictor of QoL in TM (β = -0.298; p = 0.042) but not in TW. In contrast, anxiety (β = -0.451; p< 0.001) being unemployed (β = -0.206; p = 0.020) and insecurity about the own appearance (FBeK) (β = -0.261; p = 0.01) were independent predictors of QoL in TW. The rate of those reporting high sleep disturbances (PSQI ≥5) was high with 79.2% in TW and 81.2% in TM. Accordingly, age-adjusted QoL was also significantly lower in those reporting poor sleep in both sexes. Conclusions Sleep strongly affected QoL in both genders, while other factors, like pain and body image, seem to be gender specific in transgender individuals.

Sexual orientation of trans adults is not linked to outcome of transition-related health care, but worth asking.

Abstract Since the beginning of contemporary transition-related care at the outset of the 20th century, sexual orientation has ben considered to be closely connected with gender identity and the developmental trajectories of trans people. Specifically, health professionals have regarded the anticipated post-transitional heterosexual behaviour of trans adults as predictive of a good outcome of cross-sex hormones and gender-confirming surgeries. This article reviews the current literature according to the question of whether the sexual orientation of trans people is linked to outcome measures following transition-related interventions. A comprehensive review was undertaken using the Medline database, searching for empirical studies published between 2010 and 2015. Out of a total of 474 studies, only 10 studies reported a follow-up of trans adults and assessed sexual orientation in the study protocol at all. Sexual orientation was predominantly assessed as homosexual versus non-homosexual related to sex assigned at birth. Only one 1 of 10 follow-up studies found a significant association according to the outcome between groups differentiated by sexual orientation. Empirically there is no link between sexual orientation and outcome of transition-related health care for trans adults. In order to provide comprehensive health care, we recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions; however, this knowledge should not drive, but simply inform, such comprehensive care.