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Gender dysphoria refers to distress that is caused by a sense of incongruity between an individual's self-identified gender and natal sex. Diagnosis is made in accordance with the Diagnostic and Statistical Manual of Mental Disorders and treatment first involves psychiatric therapy, which can help determine a patient's true goals in regards to achieving gender identity. Patients who wish to transition to the opposite sex must undergo a supervised real-life test and often are treated with hormonal therapy to develop physical characteristics consistent with their gender identity. Sex reassignment surgery is an option for patients who wish to transition completely. Transpatients face many barriers when it comes to basic health needs including education, housing, and health care. This is a result of long-standing marginalization and discrimination against this community. Because of these barriers, many patients do not receive the proper health care that they need. Additionally, because of certain high-risk behaviors as well as long-term hormonal therapy, transpatients have different routine health care needs that should be addressed in the primary care setting. Gynecologists play an important role in caring for transgender patients and should be knowledgeable about the general principles of transgender health.

Surgeons who perform sex reassignment surgeries (SRS) define their goals and evaluate their outcomes in terms of two kinds of results: aesthetic and functional. Since the neogenitals fashioned through sex reassignment surgeries do not enable reproductive function, surgeons must determine what the function of the genitals is or ought to be. A review of surgical literature demonstrates that questions of what constitute genital form and function, while putatively answered in the operating room, are not answerable in the discourses of clinical evaluation used to define them. When the genitals--the word itself derived from the Latin genitas meaning to beget--are not reproductive, the question of their function shifts away from the biological and into other registers: pleasure, intimacy, sociality. As condensed sites of meaning and meaning-making around which selves, affects, resources, anxieties and futures are organized, the genitals signify in excess of the categories of "aesthetic" and "function" that surgeons use to assess them. Not reducible to either aesthetics or function, but constitutive of them both, this excess appears in surgical texts in the form of imagined futures of social and sexual engagement and demonstrates a powerful means by which properly sexed bodies are created.

The purpose of this article is to report on the most recent findings on the current surgical treatments for sex reassignment surgery for both male-to-female and female-to-male transsexuals.For male-to-female sex reassignment surgery, researches aim to refine the inverted peno-scrotal flap surgical technique in order to increase the neovaginal length and width, prevent complications and ameliorate the cosmetic outcome.Bowel segment vaginoplasty, used mainly for secondary cases, is becoming more and more common.For female-to-male sex reassignment surgery, the radial forearm flap is the only procedure that has proved to fulfil most of the patient expectations; however, because of a high complications rate, long recovery time and a large number of the required operations, and the absence of guarantee that patients will be satisfied, the free radial forearm flap is not the best option for every patient. Alternatives such as abdominal/groin flap, thigh flap and metaidoioplasty are very much used.In order to provide the best care for transsexual patients, centres performing sex reassignment surgery should co-operate and implement both the refinements and the new techniques offered and/or requested.

Algumas definições de transexualidade incluem a questão da cirurgia de redesignação sexual como um desejo inerente aos(às) transexuais. Este estudo teve por objetivo investigar os significados atribuídos à cirurgia por quatro mulheres transexuais, destacando as concepções a respeito das mudanças que a redesignação acarreta na vida da pessoa transexual. Os dados foram colhidos mediante aplicação individual de entrevista aberta na modalidade história de vida temática. O material transcrito foi organizado sob a forma de estudos de caso e analisado com base na Teoria Queer. Os resultados sugerem que os significados atribuídos à cirurgia são polissêmicos e mutáveis ao longo do processo de desenvolvimento e que o desejo de se submeter ao procedimento não deve ser um critério definidor da transexualidade.

Objectives. We examined the extent of nonprescribed hormone use and self-performed surgeries among transgender or transsexual (trans) people in Ontario, Canada. Methods. We present original survey research from the Trans PULSE Project. A total of 433 participants were recruited from 2009 to 2010 through respondent-driven sampling. We used a case series design to characterize those currently taking nonprescribed hormones and participants who had ever self-performed sex-reassignment surgeries. Results. An estimated 43.0% (95% confidence interval = 34.9, 51.5) of trans Ontarians were currently using hormones; of these, a quarter had ever obtained hormones from nonmedical sources (e.g., friend or relative, street or strangers, Internet pharmacy, herbals or supplements). Fourteen participants (6.4%; 95% confidence interval = 0.8, 9.0) reported currently taking nonprescribed hormones. Five indicated having performed or attempted surgical procedures on themselves (orchiectomy or mastectomy). Conclusions. Past negative experiences with providers, along with limited financial resources and a lack of access to transition-related services, may contribute to nonprescribed hormone use and self-performed surgeries. Promoting training initiatives for health care providers and jurisdictional support for more accessible services may help to address trans people’s specific needs.

To evaluate the self-reported perceived quality of life (QoL) in transsexuals attending a Spanish gender identity unit before genital sex reassignment surgery, and to identify possible determinants that likely contribute to their QoL. A sample of 119 male-to-female (MF) and 74 female-to-male (FM) transsexuals were included in the study. The WHOQOL-BREF scale was used to evaluate self-reported QoL. Possible determinants included age, sex, education, employment, partnership status, undergoing cross-sex hormonal therapy, receiving at least one non-genital sex reassignment surgery, and family support (assessed with the family APGAR questionnaire). Mean scores of all QoL domains ranged from 55.44 to 63.51. Linear regression analyses revealed that undergoing cross-sex hormonal treatment, having family support, and having an occupation were associated with a better QoL for all transsexuals. FM transsexuals have higher social domain QoL scores than MF transsexuals. The model accounts for 20.6 % of the variance in the physical, 32.5 % in the psychological, 21.9 % in the social, and 20.1 % in the environment domains, and 22.9 % in the global QoL factor. Cross-sex hormonal treatment, family support, and working or studying are linked to a better self-reported QoL in transsexuals. Healthcare providers should consider these factors when planning interventions to promote the health-related QoL of transsexuals.

Cross-sex hormonal therapy and sex reassignment surgery (including gonadectomy) in transsexual persons has an impact on body composition and bone mass and size. However, it is not clear whether baseline differences in bone and body composition between transsexual persons and controls before cross-sex hormonal therapy play a role.A cross-sectional study with 25 male-to-female transsexual persons (transsexual women) before cross-gender sex steroid exposure (median age 30 years) in comparison with 25 age-matched control men and a male reference population of 941 men.Areal and volumetric bone parameters using respectively dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), body composition (DXA), grip strength (hand dynamometer), Baecke physical activity questionnaire, serum testosterone and 25-OH vitamin D.Transsexual women before cross-sex hormonal therapy presented with less muscle mass (p≤0.001) and strength (p≤0.05) and a higher prevalence of osteoporosis (16%) with a lower aBMD at the hip, femoral neck, total body (all p0.001) and lumbar spine (p=0.064) compared with control men. A thinner radial cortex (p≤0.01) and lower cortical area at the radius and tibia (both p0.05) was found in transsexual women vs. control men. Serum testosterone was comparable in all 3 groups, but 25-OH vitamin D was lower in transsexual women (p≤0.001).Transsexual women before the start of hormonal therapy appear to have lower muscle mass and strength and lower bone mass compared with control men. These baseline differences in bone mass might be related to a less active lifestyle.

Summary Introduction Sex reassignment surgery is carried out in France with the approval of a multidisciplinary team of psychiatrists, psychologists, endocrinologists and surgeons. The specialists monitor the patient for at least 2 years before any irreversible surgical decision concerning the sexual organs is taken. Objective To understand the reasons for regrets after surgery and to review our psychological and psychiatric assessment tools. Method We present here an exceptional case of an individual who wants to return to his birth sex just days after surgery. The individual concerned was born male and was monitored by the team for a period of 8 years before the decision for surgical intervention was taken. We studied the patient's file in detail including the various consultations he had with the psychiatrist of the transgender unit and with the rest of team. We also analyzed the results of psychological tests and the follow-up questionnaire. Results The use of psychological tests did not shed any light on the high risk of postoperative regret in this case. The elements of differential diagnosis were discussed but the patient was untruthful in his answers. Conclusion The scientific literature shows that the risk of regret is higher among men who have experienced a long heterosexual life, whose request for sex reassignment comes late in life, and who do not receive the support of family and friends. To this conclusion, we might add that the lack of sex life, interruption of the treatment and the absence of gender disorder in childhood seem to be significant criteria for risk of postoperative regret. In addition, in our unit, we have abandoned the use of psychological tests to assess the request of transgender patients.

Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS. Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality. Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0–10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p

For transgender women, genital adjustment surgery involves removal of the natal reproductive organs and creation of a neovagina, vulva and clitoris. We conducted a review of the medical literature in order to summarise the issues that can affect the health of the neovagina in the long term, and to make recommendations on how to manage these issues.

Untreated transgender men face serious negative health care outcomes. Effective medical, surgical, and mental health treatment ameliorates these risks. Although the research is not as robust as would be ideal, hormone treatment is effective and generally well tolerated with few serious medical risks. Surgeries carry serious risks; but for most transgender men, the benefits outweigh the risks. This review describes current evidence-based medical treatments for transgender men and provides an overview of surgical therapy to enable practitioners to discuss these options with their transgender male patients.

While trans employees have become more widely recognized in society, our understanding of their work experiences remains underdeveloped. In the current study, we investigate whether transitioning is associated with job satisfaction in England, Wales and Scotland. Using longitudinal data collected before and after sex reassignment surgery associations between job satisfaction and mental health/life satisfaction are examined for trans men and women. The estimations suggest that employees experience higher job satisfaction, mental health and life satisfaction after sex reassignment surgery than before. In addition, the estimations suggest that after sex reassignment surgery, the associations between job satisfaction and mental health/life satisfaction are stronger than before. Moreover, the estimations suggest that employees not only experience higher job satisfaction after sex reassignment surgery, but also during transitioning. The results suggest that, firms should not treat transitioning employees in a biased way, since their transition might entail positive personal and workplace advancements.

Summary Background Several therapy options exist for male-to-female (MTF) transgenders desiring sex reassignment. Surgery includes numerous different procedures. Of those, vaginoplasty is predominant and aims at providing attractive esthetics and fully functional genitals. This study aimed to present the surgical results of our modified combined vaginoplasty technique in a consecutive patient cohort. Methods We included 40 MTF transgender patients who underwent a two-stage sex reassignment surgery (SRS) in an observational prospective study between September 2012 and January 2014. Demographic characteristics, medical and surgical history, operative details, and outcomes after surgery were documented. Postoperatively, 23 patients received a pelvic examination following the standardized protocol. Results Measured vaginal depth was 11.77–14.99 cm depending on the size of the dilator used (25–40 mm). Vaginal, clitoral, and labial sensitivities were intact and favorable in all examined patients. Nineteen women (47.5%) opted for breast augmentations to achieve a feminine cosmesis, making it the most common nongenital operation. Complications were mostly minor and temporary. Severe adverse events, such as wound infections (n = 3), colon injuries (3), short (1) or narrow (1) vaginas, or partial clitoral necroses (1), were rare and immediately addressed by the surgical team. No vaginal construction was lost, and no secondary reconstructive approaches were required. Conclusion Satisfactory physical results and favorable low rates of complications endorse our combined technique for MTF SRS. These findings, however, need to be confirmed by other research groups as well. Therefore, in our opinion, MTF SRS remains an evolving area of development, whose research is aiming to establish a state-of-the-art surgical technique.

Background At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. Aim To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. Methods We use expert opinion to provide a “first of its kind” framework for training surgeons to care for transgender and gender nonconforming individuals. Outcomes We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. Results This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. Clinical Implications The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. Strengths and Limitations This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. Conclusion We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures.

Lower urinary tract symptoms (LUTS) refer to a group of medical symptoms, that affect approximately 40% of old men. It is a term used to describe a range of symptoms related to problems of the lower urinary tract (bladder, prostate and urethra). Although it is known that in MTF transsexuals, LUTS may be common problems, little research effort has been devoted to use the correct instruments fot symptoms evaluation. Is it possible to evaluate the surgical outcome and the presence of LUTS by using the existing questionnaieres?

OBJECTIVE: To investigate the role of MRI in the evaluation of both the new female anatomy and complications in male-to-female sex reassignment surgery (MtF-SRS). METHODS: 71 consecutive patients with MtF-SRS had 74 MRI [age range, 21-63 years; mean (±standard deviation) age, 36 ± 10 years; median age, 37 years]. In 47 patients, MRI was performed to rule out early post-operative complications after gender conversion (n = 40), vaginoplasty (n = 6) or remodelling of the labia majora (n = 1). In 27 patients, MRI was performed 1-20 years after MtF-SRS for late post-operative complications, pain or dysuria, inflammatory changes or poor cosmetic outcome. Three patients had MRI both before and after the operation. RESULTS: MRI allowed investigation of the new female anatomy in all cases. Soon after MtF-SRS, a small amount of blood was identified in all patients around the neoclitoris, urethral plaque and labia. Post-operative complications were clinically significant fluid collections (n = 5), labial abscesses (n = 2), severe cellulitis (n = 3), partial neovaginal prolapse (n = 3), focal necrosis and dehiscence of the vaginal wall (n = 2) and hypovascularization of the neoclitoris (n = 1). After ileal vaginoplasty, three patients developed clinically insignificant haematomas, one a large rectovaginal fistula with dehiscence of the intestinal anastomosis and bowel perforation (n = 1). In the 27 patients investigated 1-20 years after MfF-SRS, MRI demonstrated cavernosal remnants (n = 10), spared testis (n = 1) neovaginal strictures (n = 8), fistulas and abscesses (n = 3) and prolapse (n = 2). Three of these patients also had fibrotic changes. In the remaining three patients, no pathological features were identified. CONCLUSION: After genital reconfiguration, MRI allows assessment of the post-operative anatomy and of post-operative complications. Advances in knowledge: Imaging features of the new anatomy and of surgical complications after SRS are discussed and illustrated.

Objective Our purpose was to compare the life style, family and social relationships (social adaptation) and the quality of life in people with gender dysphoria with and without history of sex reassignment surgery. Method Twenty individuals (SR group) who were earlier followed in Istanbul University Psychiatry Department Psychoneurosis and Psychotherapy Unit with gender dysphoria diagnosis in order to have confirmative reports for the sex reassignment (SR) surgery were interviewed at least one year after the surgery. For comparison, 50 individuals with gender dysphoria (NSR group) who had recently applied to the same unit were interviewed. Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-I), Family Assessment Device (FAD), Multidimensional Scale for Perceived Social Support (MSPSS), World Health Organization Quality of Life Scale (WHOQOL-BREF) were administered. Results In the SR group, concerns about gender related discrimination and victimization were lower, but concerns related to the disclosure of transgender identity were higher compared to the NSR group. The SR group scored lower on FAD Affective Involvement, Problem Solving, Affective Responsiveness subscales, but scored higher on MSPSS family subscale and psychological domain of WHOQOL-BREF. Conclusion The sex reassignment surgeries (SRS) required for legal change in gender status of individuals with gender dysphoria are helpful in relieving the conflicts. SRS causes improvements in the quality of life, family support, interpersonal relationships and reduces the concerns about the gender related discrimination and victimization.

In 1976, prisoners acquired the right to medical treatment from the U.S. Supreme Court through the Eighth Amendment to the United States Constitution, which forbade, in part, cruel and unusual punishment. The following year, a Fourth Circuit Court of Appeals ruled that medical treatment included psychiatric or mental health treatment. These rulings applied to general prisoners, but not initially prisoners who suffered from gender identity disorder. Courts ruled then that gender identity disorder was not a serious mental disorder—a critical component of the right to medical care and mental health treatment. Later, a few appeals courts ruled that gender identity disorder was a serious mental disorder, triggering a prisoner’s right to medical care and mental health treatment for this disorder. Prisoners with gender identity disorder have litigated for sex realignment surgery as part of their treatment, which prison administrators have balked. The latest ruling unequivocally ordered the Massachusetts Department of Corrections to give a prisoner suffering from gender identity disorder sex reassignment surgery, but the prison system has appealed. This ruling, and previous rulings, has furthered policy towards transsexual prisoners.

Sex reassignment surgery is a therapy for gender dysphoria (gender identity disorder) standardly provided only upon a psychiatric authorization. Transgender scholars criticize this practice as unjustified medicalization and stigmatization of transsexual people. By demanding that sex reassignment surgery is not classified as therapy, they imply it should be classified as some kind of a biomedical enhancement. It is argued in this article that this reclassification is empirically and morally implausible because sex reassignment surgery is incompatible with two major views of enhancement. It is incompatible with the nontherapeutic view because it does not improve or augment, above average, any physical or mental trait or function. It is incompatible with the welfarist view because this view, contrary to the transgender scholars’s demands, is compelled to retain the standard practice of providing sex reassignment surgery in order to ensure the optimal balance between its availability, beneficence, and possible harmfulness.

We aim to describe the relationship between sexual orientation identity and medical morbidities in a large sample of male-to-female (MTF) transgender patients.We reviewed medical records of patients presenting for MTF sex reassignment surgery (SRS) by a single, high-volume surgeon from 2011 to 2015. Sexual attraction to men (heterosexual), women (lesbian), or both (bisexual) was asked of each patient. We examined 16 medical morbidities for this analysis.During the study period, 330 MTF transgender patients presented for SRS. The average age at the time of surgery was 38.9 (range 18-76). One hundred and one patients (32%) reported being heterosexual, 110 patients (34%) reported being lesbian, and 108 patients (34%) reported being bisexual. Lesbian patients presented for SRS at older ages (mean = 43 years old) compared with heterosexual patients (mean = 36 years old) and bisexual patients (mean = 37), P 0.01. No differences were found in the majority of coexisting medical morbidities by sexual orientation identity. Lesbian patients had greater odds of having a history of depression, age-adjusted odds ratio (aOR) = 2.36, 95% confidence interval (CI) 1.26-4.40, compared with heterosexual patients. Lesbian patients had higher odds of being married or partnered, aOR = 2.31, 95% CI (1.27-4.19), compared with heterosexual patients. Heterosexual patients had higher odds of having human immunodeficiency virus (HIV), aOR = 9.07, 95% CI (1.08-76.5) compared with lesbian patients.Sexual orientation identity in MTF transgender patients is variable. The majority of medical morbidities are not associated with sexual orientation identity. Although HIV and depression are common morbidities among MTF patients seeking SRS, the prevalence of these morbidities differs by sexual orientation identity, but these findings need replication. Counseling and future research initiatives in transgender care should incorporate sexual orientation identity and associated risk behavior.

Patients with gender dysphoria are offered cross-sex hormone therapy and sex reassignment surgery to achieve the transition between the sex assigned at birth and gender identity. According to international guidelines, cross-sex hormone therapy in trans-women should lead to a psychologically and physiologically healthy body with feminized serum hormone levels, resulting in suppression of spermatogenesis. However, in a recently published multi-center study, we discovered a high proportion of patients with male serum hormone levels and qualitatively intact spermatogenesis on the day of sex reassignment surgery. The objective of this study was to review the content of 11 publications that focus on the influence of cross-sex hormone therapy on testicular morphology. These publications were identified based on a PubMed search for the key words transgender/transsexual/gender dysphoria in male-to-female persons, cross-sex hormone therapy, and testicular tissues. Whereas three publications described a marked reduction of the spermatogenic level in all patients examined, eight publications reported inconsistent results. Histological analyses showed highly variable outcomes from qualitatively normal spermatogenesis and undisturbed Leydig/Sertoli cell morphology to full testicular regression with severe cellular damage and hyalinization. Explanations for these heterogeneous findings include insufficient cross-sex hormone therapy regarding dosage or duration. As complete spermatogenesis is associated with virilized serum hormone levels, these patients may face challenges especially after sex reassignment surgery in adjusting to the abruptly established hypogonadal state following removal of the testes. These findings also suggest that contraception should be discussed, and fertility preservation should be offered during/prior to cross-sex hormone therapy. There is a need for more individualized and better-controlled cross-sex hormone therapy and post-treatment regimens. Evidence-based guidelines for attending clinicians need to be established in order to deliver the most appropriate care.

An immunologic adjuvant is a substance that enhances the antigen-specific immune response preferably without triggering one on its own. Silicone, a synthetic polymer used for reconstructive and cosmetic purposes, can cause, once injected, local and/or systemic reactions and trigger manifestations of autoimmunity, occasionally leading to an overt autoimmune disease. Siliconosis, calcinosis cutis with hypercalcemia and chronic kidney disease have all been reported in association with silicone injection. Here, we describe a case of autoimmune/auto-inflammatory syndrome induced by adjuvants, calcinosis cutis and chronic kidney disease after liquid silicone multiple injections in a young man who underwent a sex reassignment surgery, followed by a review of the literature. To our knowledge, this is the first report describing the concomitance of the three clinical conditions in the same patients. The link between silicone and the immune system is not completely understood yet and requires further reports and investigations with long-term data, in order to identify the main individual and genetical risk factors predisposing to the wide spectrum of the adjuvant-induced responses.

Item does not contain fulltext OBJECTIVE: To describe our experience and results obtained in the management of neovaginal fistulas after vaginoplasty as gender reassignment surgery in transgender women. METHODS: A retrospective study was performed of 1,082 transgender women who underwent 1,037 primary and 80 revision vaginoplasty procedures between 1990 and 2015. Thirty-five women underwent both primary and later revision vaginoplasty at our institution. Patient, clinical, surgical, and outcome characteristics were reviewed. RESULTS: We treated 25 (2.3%) patients for 13 rectoneovaginal, 11 urethroneovaginal, and one pouch-neovaginal fistulas. Patients undergoing revision vaginoplasty were at higher risk of rectoneovaginal fistula development (0.8% compared with 6.3%, P

Transgender health and healthcare refer to the diagnosis, treatment, and prevention of health issues for transgender or gender-non-conforming people. Like the general population, transgender people desire access to safe, non-discriminatory, culturally sensitive, and affordable healthcare. However, although their healthcare needs are similar to that of the cisgender population, transgender people have specific physical health and psychological health needs related to their transgender identity – such as support surrounding gender transition. For the past century, Western medicine has treated transgender bodies – using gender-confirming surgery, also known as sex reassignment surgery (SRS) or gender reassignment surgery (GRS), to align trans people's primary and secondary sex characteristics with their gender identity. Transgender patients are medicalized, often diagnosed with gender dysphoria before receiving gender-confirming care such as hormones or SRS. The World Professional Association for Transgender Health (WPATH) provides “standards of care,” a set of clinical guidelines to help practitioners treat patients diagnosed with gender dysphoria. Keywords: health; LGBTQ; medical practices; sexual minorities; transgender

This essay focuses on "hermaphrodites" and the emerging profession of surgery in thirteenth- and fourteenth-century Europe. During this period, surgeons made novel claims about their authority to regulate sexual difference by surgically ''correcting" errant sexual anatomies. Their theories about sex, I argue, drew upon both ancient roots and contemporary conflicts to conceptualize sexual difference in ways that influenced Western Europe for centuries thereafter. I argue that a close examination of medieval surgical texts complicates orthodox narratives in the broader history of sex and sexuality: medieval theorists approached sex in sophisticated and varied manners that belie any simple opposition of modern and premodern paradigms. In addition, because surgical treatments of hermaphrodites in the Middle Ages prefigure in many ways the treatment of atypical sex (a condition now called, controversially, intersex or disorders/differences of sex development) in the modern world, I suggest that the writings of medieval surgeons have the potential to provide new perspectives on our current debates about surgery and sexual difference.

Transsexual patients can only be diagnosed and treated at functional gender identity units with the provision of high quality care, development of clinical practice guidelines, and interdisciplinary working groups. The therapeutic process has three mainstays: initial psychological diagnostic evaluation and psychotherapy, endocrinological evaluation and hormone therapy, and sex reassignment surgery. Cross-sex hormone therapy is essential for the anatomical and psychological transition process in duly selected patients. Hormones help optimize real-life sex identity, improve quality of life, and limit psychiatric co-morbidities often associated to lack of treatment. Development of this clinical practice guideline addresses the need for implementing a coordinated action protocol for comprehensive health care for transgender people in the National Health System.

Objective This study used functional magnetic resonance imaging (fMRI) to contrast the differential brain activation patterns in response to visual stimulation with both male and female erotic nude pictures in male-to-female (MTF) transsexuals who underwent a sex reassignment surgery. Materials and methods A total of nine healthy MTF transsexuals after a sex reassignment surgery underwent fMRI on a 3.0 Tesla MR Scanner. The brain activation patterns were induced by visual stimulation with both male and female erotic nude pictures. Results The sex hormone levels of the postoperative MTF transsexuals were in the normal range of healthy heterosexual females. The brain areas, which were activated by viewing male nude pictures when compared with viewing female nude pictures, included predominantly the cerebellum, hippocampus, putamen, anterior cingulate gyrus, head of caudate nucleus, amygdala, midbrain, thalamus, insula, and body of caudate nucleus. On the other hand, brain activation induced by viewing female nude pictures was predominantly observed in the hypothalamus and the septal area. Conclusion Our findings suggest that distinct brain activation patterns associated with visual sexual arousal in postoperative MTF transsexuals reflect their sexual orientation to males.

Introduction Studies show a positive impact of gender reassignment treatment on the quality of life (QOL) of transgender persons, but little is known about the influence of their socioeconomic status. Aim First, to assess health‐related QOL of transgender men and women and compare it with a general population sample, second, to investigate the differences between transgender men and transgender women, and third, to analyze how their levels of QOL differ according to socioeconomic and transition data. Methods One hundred forty‐eight current and former transgender patients of a gender identity clinic participated in a large QOL study. Main Outcomes Measures Health‐related QOL was measured using the Short Form 36‐Item Questionnaire. Results The QOL of transgender women did not differ significantly from the general Dutch female population, although transgender men showed reduced mental health‐related QOL compared with the general Dutch male sample. Transgender women had a lower QOL than transgender men for the subscales physical functioning and general health, but better QOL for bodily pain. Time since start of hormone use was positively associated for transgender women with subscales bodily pain and general health, and negatively associated for transgender men with the subscale role limitations due to physical health problems. There was no significant difference in QOL between the group who had undergone genital surgery or surgical breast augmentation and the group who did not have these surgeries. Transgender men with an erection prosthesis scored significantly better on the subscales vitality and (at trend level) on role limitations due to emotional problems. A series of univariate analyses revealed significantly lower QOL scores for transgender persons that were older, low educated, unemployed, had a low household income, and were single. Conclusions Specific social indicators are important in relation to health‐related QOL of transgenders in a context of qualitative and adequate medical care. Motmans J, Meier P, Ponnet K, and T'Sjoen G. Female and male transgender quality of life: Socioeconomic and medical differences. J Sex Med 2012;9:743–750.

An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as gender identity disorder. In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called male-to-female and female-to-male gender identity disorder, respectively. Although the precise pathogenesis of gender identity disorder remains unclear, the prevalence of gender identity disorder is quite high, with the rates calculated for male-to-female to be 1:25,000 and female-to-male to be 1:12,000 in Hokkaido, Japan. The diagnosis and treatment of gender identity disorder in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition. Although gender identity disorder was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and sex reassignment surgery are considered. However, there are very few institutions that routinely carry out sex reassignment surgery in Japan, even though it is mandatory for changing sex on the census register at the present time. Sex reassignment surgery for male-to-female and female-to-male patients includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty, and hysterectomy, ovariectomy, metoidioplasty and phalloplasty, respectively. To provide accurate information about physical treatment for patients with gender identity disorder, even urologists who are not actively involved in the diagnosis and treatment of gender identity disorder should understand the fundamental aspects and contemporary problems of gender identity disorder.

Introduction Although the impact of sex reassignment surgery on the self‐reported outcomes of transsexuals has been largely described, the data available regarding the impact of hormone therapy on the daily lives of these individuals are scarce. Aims The objectives of this study were to assess the relationship between hormonal therapy and the self‐reported quality of life (QoL) in transsexuals while taking into account the key confounding factors and to compare the QoL levels between transsexuals who have, vs. those who have not, undergone cross‐sex hormone therapy as well as between transsexuals and the general population (French age‐ and sex‐matched controls). Methods This study incorporated a cross‐sectional design that was conducted in three psychiatric departments of public university teaching hospitals in France. The inclusion criteria were as follows: 18 years or older, diagnosis of gender identity disorder (302.85) according to the Diagnostic and Statistical Manual, fourth edition text revision (DSM‐IV TR), inclusion in a standardized sex reassignment procedure following the agreement of a multidisciplinary team, and pre‐sex reassignment surgery. Main Outcome Measure QoL was assessed using the Short Form 36 (SF‐36). Results The mean age of the total sample was 34.7 years, and the sex ratio was 1:1. Forty‐four (72.1%) of the participants received hormonal therapy. Hormonal therapy and depression were independent predictive factors of the SF‐36 mental composite score. Hormonal therapy was significantly associated with a higher QoL, while depression was significantly associated with a lower QoL. Transsexuals' QoL, independently of hormonal status, did not differ from the French age‐ and sex‐matched controls except for two subscales of the SF‐36 questionnaire: role physical (lower scores in transsexuals) and general health (lower scores in controls). Conclusions. The present study suggests a positive effect of hormone therapy on transsexuals' QoL after accounting for confounding factors. These results will be useful for healthcare providers of transgender persons but should be confirmed with larger samples using a prospective study design. Gorin‐Lazard A, Baumstarck K, Boyer L, Maquigneau A, Gebleux S, Penochet J‐C, Pringuey D, Albarel F, Morange I, Loundou A, Berbis J, Auquier P, Lancon C, and Bonierbale M. Is hormonal therapy associated with better quality of life in transsexuals? A cross‐sectional study. J Sex Med 2012;9:531–541.

PURPOSE: The aim of this study is to thoroughly report on surgical outcomes from 332 patients who underwent male to female gender reassignment surgery (GRS). MATERIAL AND METHODS: Records from 332 patients who underwent GRS from 1995 to 2008 were reviewed. All patients were submitted to penile inversion vaginoplasty with glans-derived sensate clitoroplasty. Mean age was 36.7 years (range 19-68 years). Surgical complications were stratified in 6 main groups: genital region, urinary tract, gastrointestinal events, wound healing disorders and unspecific events. RESULTS: Progressive obstructive voiding disorder due to meatal stenosis was the main complication observed in 40% of the patients, feasibly corrected during the second setting. Stricture recurrence was found in 15%. Stricture of vaginal introitus was observed in 15% of the cases followed by 12% and 8% of vaginal stenosis and lost of vaginal depth, respectively. Rectal injury was seen in 3% and minor wound healing disorders in 33% of the subjects. CONCLUSION: Regarding male to female GRS, a review of the current literature demonstrated scarce description of complications and their treatment options. These findings motivated a review of our surgical outcomes. Results showed a great number of adverse events, although functionality preserved. Comparision of our outcomes with recent publications additionally showed that treatment options provide satisfying results. Moreover, outcomes reaffirm penile inversion vaginoplasty in combination with glans-derived sensate clitoroplasty as a safe technique. Nevertheless, discussing and improving surgical techniques in order to reduce complications and their influence on patient's quality of life is still strongly necessary and theme of our future reports.

This study compares 2 cohorts of female-to-male (FtM) transsexuals, one who transitioned between 1969 and 1987 and the other, between 2000 and 2006. Eight individuals from each group were interviewed. Results revealed that FtMs transitioning since 2000 less often seek bottom surgery, use a greater variety of terms to label their gender identity, and more often identify themselves as attracted to both men and women (and, for some, being attracted to transgender persons). Findings suggest that the experience of feeling “man enough” (achieving satisfaction with his sex and/or gender) has changed for FtMs.

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 **;**:**–**.

In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.

This article reports on the first efforts of systematically collecting national data regarding the prevalence of transsexualism and sex reassignment surgery (SRS) in Italy. The Italian Ministry of Health and the clinics offering such treatment were asked to cooperate by providing their data. Various problems were encountered in data collection, mainly due to the missing standardization of the record procedures in the clinics. The number of persons who underwent SRS, their age, nationality, the type of surgery and the sex ratio are reported. The resulting prevalence, lower than in other countries, suggests that the data is not complete. A standardization of the record procedures would make accessible full data and allow a reliable evaluation of the prevalence of transsexualism in Italy.

The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared. The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a ...

ObjectiveTo describe sexual desire in female-to-male transsexual persons post sex reassignment surgery (SRS). The associations between serum androgen levels and sexual desire are examined.DesignSingle center cross-sectional study.MethodsForty-five female-to-male transsexual persons post SRS completed a standardized questionnaire assessing sexual desire (Sexual Desire Inventory). In addition, participants were asked questions on sexual desire before starting hormone treatment and having SRS. Serum levels of testosterone, LH and sex hormone-binding globulin were measured on fasting morning serum samples.ResultsIn retrospect, 73.9% of the participants reported an increase in sexual desire after hormone treatment and SRS. Solitary sexual desire scores were significantly correlated with frequency of masturbation (r=0.835;PPPost hocanalysis revealed that female-to-male transsexual persons with elevated levels of LH, indicating suboptimal testosterone therapy, reported significantly lower solitary sexual desire levels (than those with low LH levels;P=0.007). Suppressed LH levels were also associated with having a higher need for sexual activities (P=0.009) and a higher frequency of excessive sexual desire (P=0.007).ConclusionMost female-to-male transsexual persons report on a marked increase in sexual desire after testosterone treatment and SRS. No direct associations between levels of testosterone and solitary or dyadic sexual desire were found. However, measures of sexual desire were inversely associated with LH levels.

We report a case of uterine cancer and invasive cervical cancer, detected incidentally during the female-to-male sex reassignment surgery. The management of these patients is presented. Such individuals may not be receiving regular gynecologic care appropriate to their remaining genital organs; symptoms of malignant disease may be missed.

The authors, both experienced gender therapists, engage in an interactive discussion of two cases that involve ethical dilemmas and complex psychological presentations. Three themes are discussed: (1) writing letters of recommendation for hormonal or surgical treatment when the clinical presentation involves complicating factors, (2) providing support for transgender persons who are not expressing their authentic gender and choose to remain closeted, and (3) the flexible use of the World Professional Association for Transgender Health's (WPATH's) Standards of Care. The authors each present a case and then discuss various strategies that are affirming of transgender identities.

Context. In aging men, circulating testosterone (T) declines which is associated with an increase in the levels of luteinizing hormone (LH) and follicle stimulating hormone (FSH), albeit insufficient to maintain T at its original level. It has been speculated that a higher sensitivity of the hypothalamus and/or pituitary for the feedback effect of circulating sex hormones in older men is responsible. Objective. To compare the effect of experimentally varied plasma levels of estradiol on the LH and FSH secretion in young and old castrated male-to-female transsexuals, in almost absence of T. Design, subjects, and interventions. In 10 healthy, young (mean age 37.6 +/- 6.2 years) and 11 healthy, old (mean age 68.1 +/- 7.0) male-to-female transsexuals after gonadectomy plasma estradiol levels were experimentally varied with estradiol patches (the first week 100 mu g/day patches, the second week 50 mu g/day, the third week 25 mu g/day and the fourth week no patch was applied) and plasma levels of LH and FSH were monitored after every week. Results. Mean plasma bioavailable estradiol (E2) levels in the two groups ranged between 13.6 and 104 pmol/l. LH and FSH were inversely related to peripheral estradiol levels, were lower in the old group at all time points reaching statistical significance in the last week of the study when no patch was applied and estradiol levels were extremely low. Conclusions. The results of this study do not support the hypothesis of an age related increasing sensitivity of the hypothalamo-pituitary compartment for the negative feedback of E2, but suggest a deficient feed-forward drive in older male-to-female transsexuals.

A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood, he preferred playing with girls and felt that he should have been one. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves.

Introduction: A transsexual (TXL) is an individual who seeks or has commenced a social transition from natal gender to desired gender. (1) This transition usually involves hormone treatment or sex reassignment surgery (SRS). Epidemiological characteristics of TXLs in Sri Lanka (SL) has not been studied to date. Objective: The aim of this study is to describe the epidemiological characteristics and management of TXL clinic attendees at a tertiary care clinic setting in SL. Method: This is a descriptive cross sectional study. Data was collected retrospectively from routine clinic notes on demographic and management characteristics of TXLs registered in the psychiatry clinics of Teaching Hospital Peradeniya from their incept to 31st August 2018. Data were analyzed using SPSS-17. Results: Total number of TXLs were 71 with 31% male to female (MTF) TXLs and 69% female to male (FTM) TXLs . Ratio between FTM to MTF was 2:1. Majority were Sinhala Buddhists between 31-35yrs. Unemployment was seen in 23%. A comorbid psychiatric condition was diagnosed in 20% on presentation. The clinic has increasingly drained TXLs from almost all the provinces in SL over time. Hormonal treatment was received by 65% while 25% received some SRS. Majority were distressed due to deficiencies in organizing legal documents, hormone administration and SRS. Conclusions: There is an increasing trend in help seeking by TXL individuals. Many were unable to have SRS. There is a major gap in service provision. The study creates awareness on the distribution of the TXLs in SL, their epidemiological characteristics and deficiencies in management.

Objetivo: reportar un caso de histerectomía por laparoscopia convencional en cambio de sexo female-to-male en Colombia, en un paciente diagnosticado como transexual, y realizar una revisión de la literatura respecto a las distintas alternativas de histerectomía en el contexto de esta condición.Materiales y métodos: paciente de 35 años, transexual, en tratamiento hormonal con undecanoato de testosterona, sometido a histerectomía laparoscópica como parte de reasignación de sexo, en una institución de III nivel de complejidad, con evolución posoperatoria favorable. Se realizó búsqueda en las bases de datos de Medline vía PubMed, Embase y Lilacs, con los términos MESH: “hysterectomy”, “laparoscopy”, “transsexualism”, en inglés, español y checo, sin limitación de tiempo.Resultados: la investigación incluyó 11 estudios: 3 estudios de serie de casos, 6 cohortes, 1 ensayo clínico controlado y 1 reporte de caso. La histerectomía laparoscópica es la más utilizada para la reasignación de sexo en transexuales masculinos. La histerectomía vaginal es una alternativa por considerar si se requiere musculatura abdominal para futura faloplastia.Conclusiones: la histerectomía por laparoscopia surge como una alternativa a la histerectomía vaginal en pacientes transexuales masculinos sometidos a cirugía de reasignación de sexo. Se requieren ensayos controlados aleatorizados para una mejor evaluación comparativa de las alternativas quirúrgicas disponibles.

A 22 year old Pakistani woman has petitioned the Peshawar High Court for permission to have sex reassignment surgery so that she can work publicly and support her family. Kainat Murad told The BMJ , “I want to work and earn a livelihood for my family. I have no brothers or sisters, and my parents, who cannot work, need my support.” She said …

Introduction Both estrogen and testosterone are important in maintaining bone health. It is known that those in the transsexual population undergo significant changes in their body composition and bone mass due to the hormonal changes, either from male-to-female or female-to-male after sex reassignment surgery. Objective This meta-analysis aimed to explore the bone mineral changes in transsexual female individuals before and after following either genital reassignment surgery or cross-sex hormonal therapy or both. We additionally performed a systemic review of the bone mineral change in transsexual male individuals. Method A comprehensive search of the MEDLINE and EMBASE databases was performed from inception through October 2017. The inclusion criterion was observational studies evaluating the bone mineral density change in transsexual persons. The pooled mean difference (MD) of bone mineral density (BMD) and their 95% confidence interval (CI) were calculated using a random-effects meta-analysis to compare the changes between transsexual persons and controls. The between-study heterogeneity of effect-size was quantified using the Q statistic and I2. Result Data were extracted from 5 observational studies involving 322 subjects. Pooled results from trans women compared to age-matched male controls demonstrated a statistically significant lower BMD at the lumbar spine (MD= -0.08; 95% CI: -0.14 to -0.01, p-value=0.02, I2 =87%) and hip (MD= -0.16; 95% CI: -0.20 to -0.12, p-value Conclusion To the best of our knowledge, this is the first systematic review and meta-analysis investigating the bone mineral density change in transsexual persons. We found a statistically significant decrease in BMD at hip and spine among transsexual female individuals compared to the male control groups. The result of our meta-analysis suggested that low bone mineral density could be found in transsexual female individuals.

This study surveyed 134 female-to-male transgendered individuals (FtMs) in order to obtain information about their experience of hysterectomy and oophorectomy. The survey was designed to explore motivation for undergoing surgery, access to care, surgical complications, postoperative changes, and use of standards of care. The survey was distributed at transgender conferences and online via transgender email lists and Web sites. Results demonstrated a wide range of postoperative experiences. Common motives for the surgery were to remove organs that were incongruent with the individual's identity (58%) and also concern about the potential for future medical problems associated with masculinizing hormone therapy (60%). Many sources advocate lowering testosterone after oophorectomy, yet our data reveal that virtually equal numbers of individuals increased (23%) or decreased (25%) testosterone levels postoperatively, and nearly twice as many maintained the same dose (44%). For many respondents hysterectomy and oophorectomy came before a year of living full-time in their preferred gender role (34%), before a full year on hormones (41%), or chest reconstruction (54%). This not only reflects the diversity of experience in this population but also has implications for the relevance and implementation of the Standards of Care for Gender Identity Disorders.