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BACKGROUND In women with vaginal hypoplasia, such as in Mayer–Rokitansky–Küster–Hauser syndrome (MRKH) and in Complete Androgen Insensitivity Syndrome (CAIS), surgical vaginoplasty and non-surgical self-dilation treatments are available to lengthen the vagina and facilitate sexual intercourse, but the best treatment remains controversial. Vaginal dilation has been recommended as a first-line treatment, because of its less invasive character and high success rate. However, the exploration of factors associated with compliance and long-term outcome is incomplete, including whether psychological counselling needs to be embedded in treatment to maximize efficacy. It is not known if failed vaginal dilation therapy jeopardizes further surgical success outcomes, especially because in a number of these procedures ongoing vaginal dilation is required. In addition, if surgery is needed, there is a lack of evidence to inform physicians regarding the optimum surgical technique to use. Also, it is unclear whether maintenance dilation therapy in case of sexual inactivity is crucial to ensure functional success. METHODS In view of this ongoing debate, we performed a search of all published literature (English language only) restricted to the management of vaginal hypoplasia in patients with MRKH or CAIS from 1898 to March 2013 using Pubmed, Cochrane Library and Web of Science. Of the 6700 articles initially identified, a total of 190 studies are analysed. More specifically, by establishing the risk/efficacy profile (vaginal capacity, complications and long-term durability in terms of sexual function) of the different surgical and non-surgical reconstruction techniques, we evaluate if vaginal dilation proposed as the first-line technique is justified based on the evidence. RESULTS When anatomical success was defined as a length of ≥7 cm and functional success as coitus, all vaginoplasty techniques yielded significantly higher success rates (>90 versus 75% after vaginal dilation), irrespective of underlying diagnosis or start vaginal length. When functional success was defined as ‘satisfaction with sex’, including non-genital sex, differences disappeared. Failed dilation therapy does not preclude anatomical (nor functional) success if vaginoplasty afterwards is necessary. Traction vaginoplasty seems to have the highest anatomical (99%) and functional success rates (96%), whereas both split- and full-thickness skin graft procedures and intestinal procedures have the lowest successful outcomes (83–95%). Overall, complication rates were significantly lower within the vaginal dilation groups when compared with the different vaginoplasty techniques. Although no randomized control data exist regarding maintenance dilation, the available evidence suggests that continued dilation is needed to maintain patency in periods of coital inactivity. Despite the expectancy that the probability of further positive outcomes is maximized with psychological counselling, this could not be confirmed. CONCLUSIONS As the medical literature lacks high-quality comparative outcome studies and prospective, longitudinal studies are scarce, no evidence-based treatment guidelines can be provided. However, because of the physically low complication rate and an overall success chance of 75%, vaginal dilation as first choice treatment seems to be justified. Overall, the laparoscopic Vecchietti procedure, becoming more and more available in specialized centres, is considered an appropriate surgical option in patients who are poorly compliant and failed dilation therapy, or for those who do not want to start with vaginal dilation therapy. Future approaches need to raise a wider range of psychosexually oriented questions, elucidate the relationship between vaginal depth and ... [ABSTRACT FROM AUTHOR]

Introduction The term micropenis encompasses a range of congenital and acquired conditions that result in an abnormally short penis. Small penis size may persist into adulthood, becoming a major cause of dissatisfaction. Aim To review the literature pertaining to the effects of hormonal and surgical treatment on psychosexual functioning and quality of life ( QoL) in individuals with micropenis who were raised male. Main Outcome Measures Long-term psychosexual and QoL outcomes after hormonal and surgical treatment, including phalloplasty. Methods Pub Med search for relevant publications (1955-2012) on the role of hormonal and surgical treatment in sexual QoL in adult men with micropenis. Results Multiple variations in the etiology of micropenis make it difficult to draw firm conclusions that fit all of the patients within this disparate population. However, the literature review supports the conclusions that (i) male gender assignment is preferable for most 46, XY infants with congenital micropenis because of the likelihood of male gender development and genitosexual function; (ii) small penis size persisting into adulthood and dissatisfaction with genital appearance jeopardize sexual QoL; (iii) there is no known intervention, apart from phalloplasty, to guarantee that the penis will become normal in size; (iv) early data suggest that the phalloplasty technique considered the gold standard for gender reassignment in the transgender population can also be transferred to 46, XY patients with micropenis; (v) psychological support should be an integral part of management in order to alleviate the distress and impairment of QoL experienced by these individuals. Conclusions Further publication of series with large numbers and longer follow-up is needed. Specific outcome kits should be designed to measure more precisely patients' degrees of satisfaction with cosmetic, anatomical, and functional variables. Only if health-care professionals fully appreciate the impact of this condition can optimal care be provided. Callens N, De Cuypere G, Van Hoecke E, T'Sjoen G, Monstrey S, Cools M, and Hoebeke P. Sexual quality of life after hormonal and surgical treatment, including phalloplasty, in men with micropenis: A review. J Sex Med 2013;10:2890-2903. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. In patients with disorders of sex development requiring creation of a neovagina, a number of techniques are available, including surgical vaginoplasty and self-dilation therapy. Vaginal dilation therapy has been recommended as a first-line treatment because of its less invasive character and high success rate. However, no data exist on long-term psychosexual functioning after vaginal dilation as compared with that after vaginal surgery. Aims. The aim of this study is to compare the psychosexual and anatomical outcome of women with congenital vaginal hypoplasia followed in the same clinical setting after vaginoplasty with that after vaginal dilation. Methods. The sexual quality of life of 35 women at least 2 years after vaginoplasty (N = 15), vaginal dilation therapy (N = 8), or coital dilation/no treatment (N = 12) was investigated and compared with the Dutch test validation population (as control). Main Outcome Measures. Psychosexual functioning was assessed with the Female Sexual Function Index, the Female Sexual Distress Scale-Revised, and a semi-structured interview. A gynecological examination was performed to determine the anatomical outcome after both vaginal treatment regimens. Results. After either treatment, 26% of these women had a shortened vaginal length of less than 6.6 cm, i.e., more than two standard deviations below the published mean value (9.6 ± 1.5 cm). Irrespective of the treatment, 47% of the patients had (a) sexual dysfunction(s) and experienced sexual distress. However, after vaginoplasty, patients reported significantly more problems with lubrication ( P = 0.025) than after self-dilation therapy. Conclusion. Both psychological and physical factors are predisposing for sexual difficulties. To optimize psychosexual comfort, the clinical management of women with vaginal hypoplasia needs to be multidisciplinary and individually tailored. With high success rates reported, vaginal dilation should remain the cornerstone of treatment. Callens N, De Cuypere G, Wolffenbuttel KP, Beerendonk CCM, van der Zwan YG, van den Berg M, Monstrey S, Van Kuyk ME, De Sutter P, Belgian-Dutch Study Group on DSD, Dessens AB, and Cools M. Long-term psychosexual and anatomical outcome after vaginal dilation or vaginoplasty: A comparative study. J Sex Med 2012;9:1859-1868. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables. Aim. To review the current literature on case studies of twins concordant or discordant for GID. Methods. A systematic, comprehensive literature review. Results. Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference ( P = 0.005). Of the seven opposite-sex twins, all were discordant for GID. Conclusions. These findings suggest a role for genetic factors in the development of GID. Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, and T'Sjoen G. Gender identity disorder in twins: A review of the case report literature. J Sex Med 2012;9:751-757. [ABSTRACT FROM AUTHOR]

Karyotyping is often performed in transsexual individuals. Quantification and characterization of karyotype findings and abnormalities in transsexual persons. Karyotypes were listed both in male-to-female and in female-to-male transsexual persons. The data were collected through a retrospective study. Karyotypes of 368 transsexual individuals (251 male-to-female, 117 female-to-male) are described. Normal findings were found in 97.55%. Prevalence of abnormal karyotypes was 3.19% among male-to-female, and 0.85% among female-to-male transsexuals. Nine karyotypes showed variations; Klinefelter syndrome was confirmed in three persons, whereas others displayed autosomal aberrations. Karyotyping is only of very limited information in the transsexual population. [ABSTRACT FROM AUTHOR]

Introduction Sex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross-sex hormone therapy and sex reassignment surgery on sexual desire in trans persons. Aim This study aims to explore associations between sex reassignment therapy ( SRT) and sexual desire in a large cohort of trans persons. Methods A cross-sectional single specialized center study including 214 trans women (male-to-female trans persons) and 138 trans men (female-to-male trans persons). Main Outcome Measures Questionnaires assessing demographics, medical history, frequency of sexual desire, hypoactive sexual desire disorder ( HSDD), and treatment satisfaction. Results In retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy-three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it ( P = 0.03). In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD ( P = 0.02). Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD ( P = 0.02). Conclusion HSDD was more prevalent in trans women compared with trans men. The majority of trans women reported a decrease in sexual desire after SRT, whereas the opposite was observed in trans men. Our results show a significant sexual impact of surgical interventions and both hormonal and surgical treatment satisfaction on the sexual desire in trans persons. Wierckx K, Elaut E, Van Hoorde B, Heylens G, De Cuypere G, Monstrey S, Weyers S, Hoebeke P, and T'Sjoen G. Sexual desire in trans persons: Associations with sex reassignment treatment. J Sex Med 2014;11:107-118. [ABSTRACT FROM AUTHOR]

Introduction At the start of gender reassignment therapy, persons with a gender identity disorder ( GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. Aims The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. Methods This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 ( SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery ( SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. Main Outcome Measures The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. Results A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments ( P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy ( P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre- and postoperative assessments. Conclusions A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy. Heylens G, Verroken C, De Cock S, T'Sjoen G, and De Cuypere G. Reassignment therapy on psychopathology: A prospective study of persons with a gender identity disorder. J Sex Med 2014;11:119-126. [ABSTRACT FROM AUTHOR]

Introduction Data on self-perceived genital anatomy and sensitivity should be part of the long-term follow-up of genitoplasty procedures. However, no normative data, based on a large sample, exist to date. Aims Validation of the Self-Assessment of Genital Anatomy and Sexual Function, Female version (SAGAS-F) questionnaire within a Belgian, Dutch-speaking female population. Methods Seven hundred forty-nine women with no history of genital surgery (aged 18-69 years, median 25 years) completed an Internet-based survey of whom 21 women underwent a gynecological examination as to correlate self-reported genital sensitivity assessed in an experimental setting. Main Outcome Measures The SAGAS-F enables women to rate the sexual pleasure, discomfort, intensity of orgasm, and effort required for achieving orgasm in specified areas around the clitoris and within the vagina, as well as genital appearance. The latter was similarly evaluated by an experienced gynecologist, and women were asked to functionally rate the anatomical areas pointed out with a vaginal swab. Results Sexual pleasure and orgasm were strongest, and effort to attain orgasm and discomfort was lowest when stimulating the clitoris and sides of the clitoris ( P < 0.05). Vaginal sensitivity increased with increasing vaginal depth, but overall orgasmic sensitivity was lower as compared with the clitoris. Functional scores on the SAGAS-F and during gynecological examination corresponded highly on most anatomical areas ( P < 0.05). Gynecologist's ratings corresponded highly with the women's ratings for vaginal size (90%) but not for clitoral size (48%). Conclusions Replication of the original pilot study results support the validity of the questionnaire. The SAGAS-F discriminates reasonably well between various genital areas in terms of erotic sensitivity. The clitoris itself appeared to be the most sensitive, consistent with maximum nerve density in this area. Surgery to the clitoris could disrupt neurological pathways and compromise erotic sensation and pleasure. Bronselaer G, Callens N, De Sutter P, De Cuypere G, T'Sjoen G, Cools M, and Hoebeke P. Self-assessment of genital anatomy and sexual function in women (SAGAS-F): Validation within a Belgian, Dutch-speaking population. J Sex Med 2013;10:3006-3018. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction. Although sexual health after genital surgery is an important outcome factor for many transsexual persons, little attention has been attributed to this subject. Aims. To provide data on quality of life and sexual health after sex reassignment surgery (SRS) in transsexual men. Methods. A single-center, cross-sectional study in 49 transsexual men (mean age 37 years) after long-term testosterone therapy and on average 8 years after SRS. Ninety-four percent of the participants had phalloplasty. Main Outcome Measures. Self-reported physical and mental health using the Dutch version of the Short Form-36 Health Survey; sexual functioning before and after SRS using a newly constructed specific questionnaire. Results. Compared with a Dutch reference population of community-dwelling men, transsexual men scored well on self-perceived physical and mental health. The majority reported having been sexually active before hormone treatment, with more than a quarter having been vaginally penetrated frequently before starting hormone therapy. There was a tendency toward less vaginal involvement during hormone therapy and before SRS. Most participants reported an increase in frequency of masturbation, sexual arousal, and ability to achieve orgasm after testosterone treatment and SRS. Almost all participants were able to achieve orgasm during masturbation and sexual intercourse, and the majority reported a change in orgasmic feelings toward a more powerful and shorter orgasm. Surgical satisfaction was high, despite a relatively high complication rate. Conclusion. Results of the current study indicate transsexual men generally have a good quality of life and experience satisfactory sexual function after SRS. Wierckx K, Van Caenegem E, Elaut E, Dedecker D, Van de Peer F, Toye K, Weyers S, Hoebeke P, Monstrey S, De Cuypere G, and T'Sjoen G. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med **;**:**-**. [ABSTRACT FROM AUTHOR]

With regard to transsexual developments, onset age (OA) appears to be the starting point of different psychosexual pathways. To explore differences between transsexual adults with an early vs. late OA. Data 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. Transsexual 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. The 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). OA 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. [ABSTRACT FROM AUTHOR]

Studies involving patients with gender identity disorder (GID) are inconsistent with regard to outcomes and often difficult to compare because of the vague descriptions of the diagnostic process. A multisite study is needed to scrutinize the utility and generality of different aspects of the diagnostic criteria for GID. To investigate the way in which the diagnosis-specific Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criteria for GID were used to reach a psychiatric diagnosis in four European countries: the Netherlands (Amsterdam), Norway (Oslo), Germany (Hamburg), and Belgium (Ghent). The main goal was to compare item (symptom) characteristics across countries. The current study included all new applicants to the four GID clinics who were seen between January 2007 and March 2009, were at least 16 years of age at their first visit, and had completed the diagnostic assessment (N = 214, mean age = 32 ± 12.2 years). Mokken scale analysis, a form of Nonparametric Item Response Theory (NIRT) was performed. Operationalization and quantification of the core criteria A and B resulted in a 23-item score sheet that was filled out by the participating clinicians after they had made a diagnosis. We found that, when ordering the 23 items according to their means for each country separately, the rank ordering was similar among the four countries for 21 of the items. Furthermore, only one scale emerged, which combined criteria A and B when all data were analyzed together. Our results indicate that patients' symptoms were interpreted in a similar fashion in all four countries. However, we did not find support for the treatment of A and B as two separate criteria. We recommend the use of NIRT in future studies, especially in studies with small sample sizes and/or with data that show a poor fit to parametric IRT models. [ABSTRACT FROM AUTHOR]

Introduction. Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. Aim. To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Methods. Fifty transsexual women who had undergone SRS ≥6 months earlier were recruited. Main Outcome Measures. Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Results. Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Conclusions. Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain. Weyers S, Elaut E, De Sutter P, Gerris J, T'Sjoen G, Heylens G, De Cuypere G, and Verstraelen H. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med 2009;6:752–760. [ABSTRACT FROM AUTHOR]