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Norms are considered to influence expectations toward gender-related behavior. Deviations from these norms are often perceived negatively by the social environment. The objective of this study was to investigate adults diagnosed with aGender Identity Disorder(GID), their recalled play behavior, and peer preferences in childhood and adolescence. Differences between individuals who applied for transition from female to male (FtMs) and those who applied for transition from male to female (MtFs) and between age-of-onset subgroups were explored. Data collection took place as part of the European Network for the Investigation of Gender Incongruence. The sample consisted ofN= 634 participants (mean age = 30.6) diagnosed with GID according to DSM-IV-TR who were recruited between 2007 and 2012. Participants answered two questions regarding recalled play behavior and three questions on peer preferences. Nonconforming gender expression was more frequently recalled in FtMs than MtFs. Within gender groups, individuals who were categorized as early-onset recalled nonconforming gender expression more frequently than individuals who were categorized as late-onset. The results of the study are in line with previous findings indicating different phenomenological pathways in individuals applying for gender-affirming treatment that warrant attention. Factors that are considered to impact on gender-related differences in nonconforming gender expression are discussed. [ABSTRACT FROM PUBLISHER]

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. [ABSTRACT FROM AUTHOR]

This consensus statement is an executive summary of several papers resulting from a 2009 consensus process comprising nine work groups and 37 members of the World Professional Association for Transgender Health (WPATH). The purpose of this group was to put forth recommendations for the upcoming revision of the DSM with respect to the Gender Identity Disorder diagnoses. The consensus process was collaborative, interdisciplinary, and evidence based. A majority (but not all) of the participants believed that a diagnosis related to Gender Identity Disorder should remain in the DSM, and many advocated changes in name, diagnostic criteria, and placement within the DSM. The proposed name is Gender Dysphoria, and the diagnostic criteria should be distress based. Placement should be outside the chapter on Sexual Disorders and possibly within Psychiatric Disorders Related to a Medical Condition. If there were to be a diagnostic category for childhood, there should also be separate categories for adults and adolescents. A Not Otherwise Specified category should be retained, and Disorders of Sex Development should not be an exclusionary criterion for Gender Dysphoria. [ABSTRACT FROM AUTHOR]

The World Professional Association for Transgender Health (WPATH) is recognized as the leading authority in the field of transgender health, through a membership that encompasses experts in this field and transgender community representatives. WPATH therefore is in an excellent position to give input on the DSM 5 section on gender identity disorders. To streamline the ideas of the membership, the authors, all elected officers of the association, organized a consensus-building process beginning January 2009 to arrive at recommendations for removal or reform of the DSM 5 diagnoses. This article describes this process, how the various work groups were formed, and the topics covered in the work group discussions. In addition, this article reports on a face-to-face meeting held with all of the consensus participants and work groups in conjunction with the 2009 biennial conference of WPATH in Oslo, Norway, where a consensus was reached on several issues. The outcome of this face-to-face meeting was subsequently discussed during a plenary session at the conference, which many WPATH members attended. After a description of this process, we introduce the nine articles written by each of the working groups and an executive summary with a set of recommendations for the DSM 5 Work Group on Sexual and Gender Identity Disorders. [ABSTRACT FROM AUTHOR]

In a review of the literature on follow-up studies of sex reassignment surgery (SRS) with regard to regret, suicide, and prognosis, this article evaluates the eligibility and readiness criteria of the WPATH Standards of Care—Sixth Version. Because the literature shows a lack of high-quality follow-up studies on large numbers of operated transsexuals, it offers no evidence-based research above evidence Level B or Level C. Nevertheless, our review allows us to conclude that most of the eligibility criteria are evidence-based. Although psychiatric co-morbidity is consistently mentioned in the literature as a negative predictive factor, it is barely addressed in the eligibility and readiness criteria for SRS. Therefore this paper suggests some changes and a shift in emphasis in the eligibility and readiness criteria of the Standards of Care. [ABSTRACT FROM AUTHOR]

In a review of the literature on follow-up studies of sex reassignment surgery (SRS), or gender reassignment surgery (GRS), this paper evaluates the levels of evidence-based medicine in relation to the surgical therapy of patients with transsexualism or with a severe gender identity disorder (GID). The specific questions that are addressed in this article are to what degree sex reassignment surgery, in general, is effective and medically indicated for severe gender identity disorder and what are the conditions under which gender reassignment surgery may occur. Furthermore, the requirements for the surgeon performing genital reconstruction will be discussed, and, finally, levels of evidence will be evaluated for genital surgery in male-to-female and female-to-male patients. Because the literature shows a lack of randomized clinical trials or high-quality follow-up studies on large numbers of operated transsexuals, it offers no evidence based-research above evidence level B or C. Some minor recommendations can be made at the re-writing of seventh version of the Standards of Care of WPATH, but although they seem intuitively appropriate, they are more based on expert opinion without explicit critical approval from peer-reviewed literature. [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]

Abstract: Since its introduction, there has been a debate about the validity of the factorial structure of the SCL-90-R. In this study we investigate whether the lack of agreement with respect to the dimensionality can be partly explained by important variables that might differ between samples such as level of psychological distress, the variance of the SCL-90-R scores and sex. Three samples were included: a sample of severely psychiatrically disturbed patients (n=3078), a sample of persons with Gender Incongruence (GI; n=410) and a sample of depressed patients (n=223). A unidimensional pattern of findings were found for the GI sample. For the severely disturbed and depressed sample, a multidimensional pattern was found. In the depressed sample sex differences were found in dimensionality: we found a unidimensional pattern for the females, and a multidimensional one for the males. Our analyses suggest that previously reported conflicting findings with regard to the dimensional structure of the SCL-90-R may be due to at least two factors: (a) level of self-reported distress, and (b) sex. Subscale scores should be used with care in patient groups with low self-reported level of distress. [Copyright &y& Elsevier]

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]