[Ethical issues of gender reassignment surgery]. / Enjeux éthiques de la chirurgie de réassignation sexuelle.

Gender reassignment raises complex ethical issues. It questions gender identity and the right to self-determination. Some highlight the right to access the medical care necessary to live according to one's perceived gender. Others worry about the potential rush into major medical decisions, especially among minors. The need for a medical diagnosis of gender dysphoria can be seen as pathologizing. The requirement for surgery for marital status change, while not mandatory in many places, remains controversial. The balance between informed consent and access to treatment, as well as stigma and discrimination, contribute to the complexity of ethical issues. Finally, the issues surrounding the competence of health professionals, the quality of care and the integration of individual needs make these decisions particularly sensitive from an ethical point of view.

[Facial feminization, history, evolution of objectives]. / Féminisation faciale, historique, évolution des objectifs.

The author's experience dates from 1990, during the period when he was in charge of the feminization of the facial skeleton in order to improve the social integration of male transsexual patients. Very quickly, these techniques were extended to genetic women who wanted a more feminine face. This facial skeletal surgery was then supplemented with soft tissue surgery. This skeletal and volumetric surgery has become an important contribution in the search of facial rejuvenation and beauty.

[Recommendations of the Committee of Andrology and Sexual Medicine of the AFU concerning the management of andrological and sexual medicine pathologies during the COVID-19 crisis]. / Recommandations du Comité d'andrologie et de médecine sexuelle de l'AFU concernant la prise en charge andrologique et en médecine sexuelle en contexte et en sortie de crise sanitaire liée au COVID-19.

OBJECTIVE: To assist urologists in the management of andrological and sexual medicine pathologies during the COVID-19 crisis. MATERIAL AND METHOD: Use of the formalized consensus method. RESULTS: The medical and surgical management of patients in andrology and sexual medicine must be adapted. Consultations should, as far as possible, be carried out by tele-consultation. For operative procedures, the delay between the operative decision and the date of (re)scheduling of the procedure will depend on: (1) the level of criticality of the clinical situation; (2) the type of intervention; (3) the functional and psychological repercussions, including quality of life while waiting for the procedure; (4) the notion of losing the chance of having an optimal outcome; (5) the risk of potential complications from delaying a procedure for too long; and (6) taking into account the patient's risk factors for severe forms of COVID-19. The protection of urologists from COVID-19 should be considered. Each urologist must make the best decision for the patient, taking into account the acceptable time frame and quality of life impact before surgical management, the COVID risk parameters, the technical and anesthetic feasibility and the structural possibility of the health care institution to ensure a specific dedicated pathway during the COVID-19 health crisis. CONCLUSION: The management of andrological and sexual medicine pathologies must be adapted to the COVID-19 crisis context. Some patients may require surgery, including in emergency. These recommendations are transitional and will end with the COVID-19 crisis.

[Development of the facial feminization surgery patient's satisfaction questionnaire (QESFF1): Qualitative phase]. / Élaboration d'un questionnaire de satisfaction encadrant la chirurgie de féminisation faciale chez les patientes transsexuelles male to female (QESFF1) : Phase qualitative.

OBJECTIVE: Facial feminization surgery is becoming a more frequently requested procedure in transsexual male to female patients transformation. A global way of reporting outcomes data and showing the beneficial impact of this specific procedure is necessary. The objective of this study is to develop a reliable and valid tool to report patients' outcomes after facial feminization surgery. METHODS: A systematic literature review, input from experts working with transsexual patients and patient interviews were used to develop the conceptual framework of the questionnaire. It includes the outcomes deemed important to facial feminization surgery and it was used to construct items of the questionnaire. RESULTS: There is no specific tool for measuring patients outcomes after facial feminization surgery. Ten experts and 18 patients participated to this study. The conceptual framework includes the following themes: satisfaction with facial feminine appearance; adverse effects; quality of life. The questionnaire includes fourteen separate Likert scales, with preoperative and postoperative versions. The reliability of the questionnaire is excellent with a medium Alpha score of 0.85. Facial feminization surgery is associated with high patient satisfaction in this sample (83.7±7.41). CONCLUSION: QESFF1 is a reliable questionnaire and its development follows the steps recommended by the patient-reported outcomes process. A large sample pilot test is needed to demonstrate its validity. The QESFF1 can provide physicians with the necessary tools to measure the impact of facial feminization surgery on male to female transsexual patients and also has the potential to support clinical trials.

[Female-to-male transgender chest reconstruction: A retrospective study of patient satisfaction]. / Chirurgie mammaire de réassignation vers le sexe masculin : étude rétrospective de la satisfaction des patients transsexuels après mastectomie.

BACKGROUND: Mammaplasty in gender reassignment surgery is often poorly understood, due to a lack of information about this condition and its therapy. The aim of this work was to evaluate patient satisfaction following bilateral mastectomy for female-to-male gender reassignment. METHODS: We contacted 22 patients who underwent mammaplasty for female-to-male gender reassignment between January 2012 and March 2013 in our university hospital. Patients were sent postal questionnaires. A modified Q-breast questionnaire adapted for gender reassignment surgery enabled us to objectively evaluate patient aesthetic and psychological satisfaction. An overall score superior to 320 was considered as very satisfied for the patient. RESULTS: A total of 73% of the patients answered the questionnaire. The mean score was 332/378. This score corresponded to "very satisfied" on our questionnaire. The psychological score was 54.5/60. CONCLUSION: This study showed that a real benefit was obtained in terms of patient quality of life and self-confidence. The high level of patient satisfaction confirmed that gender reassignment mastectomy is a useful and valid procedure, which enables these patients to reclaim their place in society. It can only be considered if it is within the framework of structures that ensure comprehensive and pluridisciplinary treatment for the patient.

[Facial feminization surgery - middle and inferior thirds]. / Chirurgie de féminisation du visage ­ tiers moyen et inférieur.

The authors present the surgical techniques of facial feminization of the middle third and the inferior third in the context of sexual reassignment surgery. These techniques adapted to patients 'male to female' are proposed to strong masculine facial features of patients and are based in the middle third of the remodeling of the malar region by fat grafting, reduction and/or deprojection techniques in rhinoseptoplasty and upper lip surgery. Concerning the inferior third, remodeling of the mandibular angles, genioplasty and chondrolaryngoplasty are adapted.

[Anatomical study of men's nipple areola complex]. / Étude anatomique du complexe aérolo-mamelonnaire (CAM) chez l'homme.

The surgical approach of gynecomastia, sexual reassignment surgery in female-to-male transsexuals and the increase of number of obese wishing to turn to plastic surgery led us to deepen the anatomical knowledge of the nipple areola complex (NAC) in men, poorly retailed in the literature. By inspiring us of the methodology of a Japanese study, we studied 50 healthy volunteers male, from 18 to 55 years old, from July till August 2015. We measured various distances relative to the NAC to define its vertical and horizontal position, as well as the internipple distance according to the size, to the weight and to the body mass index (BMI). At the end of the analysis, we were able to underline a lower vertical thoracic position of the NAC in the tall category of person, a more side horizontal position to the subject presenting a high BMI and a linear relation between the BMI and the internipple (Em) defined by (Em)=8.96×BMI. The surgeon's judgment and the desires of the patient are essentials basis of therapeutics decisions that could be lean on this anatomical study, which allowed to establish an idea of the cartography of the NAC in man. It will be interesting and necessary to confront it with other studies with larger scale.

[Transsexualism]. / Le transsexualisme.

UNLABELLED: Transsexual conditions need to be assessed for a psychological, hormonal and surgical evaluation. A multidisciplinary consent is required to perform hormonal and surgical treatment. METHOD: A critical overview has been performed (PubMed) and the main guidelines have been summarised. RESULTS: Hormonal treatments include suppression of the naturally secreted hormone and the administration of hormone of the desired sex. The main comorbidity is thrombo-embolic complications for patients under oestogene therapy. The main surgical treatment for female to male (FtM) surgery are: periareolar mastectomy if possible, hysterectomy, ovariectomy and vaginectomy and phallic reconstruction including metaidioplasty and forearm or suprapubic phalloplasty dependant of patient's wishes. The main treatments for male to female (MtF) surgery are: prosthesis mammoplasty and vaginoplasty and for some facial feminisation. The results in term of global satisfaction are high despite a relatively high rate of complications as well. CONCLUSION: Results in terms of well-being and psychological improvement justify this treatment despite its relatively high morbidity.

[Sociology of transidentity]. / Sociologie des transidentités.

The issues concerning trans individuals cross our contemporary concerns. They are at the heart of new visibilities in television series, at the crossroads of controversy and misunderstanding in the world of sports, in the spotlight of transphobic violence, or in the case of problems within institutions, whether medical or academic. However, increased visibility does not always mean increased understanding.

[Decision-making in gender reassignment surgery]. / La décision en chirurgie de réassignation génitale.

The prescribing of hormones and the performing of gender reassignment surgery on a healthy body are dangerous and irreversible acts. To ensure patients' safety, endocrinologists and surgeons must use the skills of experienced psychiatrists to create a differential diagnosis, evaluate any frailties and weigh up the risk-benefit ratio. Therapeutic decisions are made as part of multidisciplinary consultation meetings. A minimum two-year observation period must be respected for the treatment to be covered by social security.

Da transfobia ao racismo: experiências de transição de homens transexuais negros / From transphobia to racism: Black trans men's transition experiences / Dès la transphobie au racisme: des experiences de transition des hommes noirs / De la transfobia al racismo: vivencias de la transición de hombres transexuales negros

A visibilidade social e acadêmica de homens transexuais deu-se tardiamente em comparação com mulheres trans. Ainda mais invisíveis são as experiências de transição dos homens trans negros, que agregam a intersecção gênero-raça. Este estudo qualitativo teve por objetivo analisar como homens transexuais negros vivenciam suas experiências de transição de gênero, à luz do conceito de interseccionalidade. Participaram quatro homens que se autodeclararam transexuais e negros, de 22 a 33 anos. Foram realizadas entrevistas semiestruturadas, seguidas de análise temática. Os resultados apontam que o reconhecimento social das identidades transmasculinas advém do racismo, quando este se intersecciona com a transfobia. À medida que o sujeito passa a ser lido como homem, recebe o atributo racista de "perigoso". A baixa empregabilidade é uma das consequências perversas dessa leitura que articula dois eixos de subordinação: transgeneridade e raça. Há urgência de políticas públicas para que se interrompa esse ciclo de desempoderamento interseccional

The social and academic visibility of transsexual men happened later than that of transgender women. Even more invisible are the transition experiences of Black trans men as they aggregate the gender-race intersection. This qualitative study aimed to analyze how Black transgender men experience their gender transition in light of the concept of intersectionality. In total, four men, aged 22-33 years, who declared themselves Black and transsexual participated in this study. Semi-structured interviews were conducted, followed by thematic analysis. Results indicate that the social recognition of transmasculine identities crosses racism when it intersects with transphobia. To the extent that they are recognized as men, they receive the racist attribute of "dangerous." Low employability is one of the perverse consequences of this reading, which articulates two axes of subordination: transgender and race. Breaking this cycle of intersectional disempowerment urgently requires public policies

La visibilité sociale et académique des hommes transgenres est arrivée tardivement, par rapport aux femmes transgenres. Plus invisibles encore sont les expériences de transition des hommes noirs transgenres, qui cumulent l'intersection entre le sexe et la race. Cette étude qualitative visait à analyser la manière dont les hommes transsexuels noirs vivent leurs expériences de transition de genre à la lumière du concept d'intersectionnalité. Quatre hommes qui se sont déclarés noirs et transsexuels, âgés de 22 à 33 ans, ont participé à l'enquête. Des entretiens semi-structurés ont été menés, suivis d'une analyse thématique. Les résultats montrent que la reconnaissance sociale des identités transmasculines passe par le racisme, lorsqu'il s'entrecroise avec la transphobie. Au fur et à mesure que le sujet est lu comme un homme, il reçoit l'attribut raciste de « dangereux ¼. La faible employabilité est l'une des conséquences perverses de cette lecture qui articule les deux axes de subordination: le transgenre et la race. Il est urgent que les politiques publiques brisent ce cycle de désautonomisation intersectionnelle

La visibilidad social y académica de los hombres transexuales llegó tarde en comparación con la de las mujeres transexuales. Aún más invisibles son las experiencias de transición de los hombres negros trans, que agregan la intersección género-raza. Este estudio cualitativo tuvo por objetivo analizar las vivencias de los hombres negros transexuales respecto a la transición de género a la luz del concepto de interseccionalidad. Participaron cuatro hombres que se declararon negros y transexuales, de entre 22 y 33 años de edad. Se realizaron entrevistas semiestructuradas, y posteriormente análisis temáticos. Los resultados muestran que el reconocimiento social de las identidades transmasculinas se da mediante el racismo cuando este se cruza con la transfobia. Cuando el sujeto es visto como un hombre, recibe el atributo racista de "peligroso". La baja empleabilidad es una de las consecuencias perversas de esta lectura que articula los dos ejes de subordinación: la transexualidad y la raza. Es urgente que las políticas públicas rompan este ciclo de desempoderamiento interseccional.

Brain sexual differentiation and effects of cross-sex hormone therapy in transpeople: A resting-state functional magnetic resonance study.

OBJECTIVES: It is hypothesized that transpeople show sex-atypical differentiation of the brain. Various structural neuroimaging studies provide support for this notion, but little is known about the sexual differentiation of functional resting-state networks in transpeople. In this study we therefore aimed to determine whether brain functional connectivity (FC) patterns in transpeople are sex-typical or sex-atypical, before and after the start of cross-sex hormone therapy (CHT). METHODS: We acquired resting-state functional magnetic resonance data in 36 transpeople (22 with female sex assigned at birth), first during gonadal suppression, and again four months after start of CHT, and in 37 cisgender people (20 females), both sessions without any hormonal intervention. We used independent component analysis to identify the default mode network (DMN), salience network (SN), and left and right working memory network (WMN). These spatial maps were used for group comparisons. RESULTS: Within the DMN, SN, and left WMN similar FC patterns were found across groups. However, within the right WMN, cisgender males showed significantly greater FC in the right caudate nucleus than cisgender females. There was no such sex difference in FC among the transgender groups and they did not differ significantly from either of the cisgender groups. CHT (in transgender participants) and circulating sex steroids (in cisgender participants) did not affect FC. CONCLUSION: Our findings may suggest that cisgender males and females experience a dissimilar (early) differentiation of the right WMN and that such differentiation is less pronounced in transpeople.

Em defesa de Outra psicanálise: sobre o real em questão nas soluções transexuais / En défense d'Autre psychanalyse: sur le réel en question dans les solutions transsexuelles / En defensa de Otro psicoanálisis: sobre lo real en cuestión en las soluciones transexuales / In defense of Other psychoanalysis: on the real in at issue in transsexual solutions

Resumo Apresenta-se a lógica da sexuação, de Jacques Lacan, em contraposição à noção de gênero, construída como matriz de inteligibilidade da transexualidade. Desenvolve-se a abordagem lacaniana do sinthome como alternativa para se pensar soluções singulares aos impasses sexuais pelo viés da despatologização. Conclui-se que a transexualidade, em vez de inelutável forçamento psicótico, pode ser uma solução inventiva articulada à clínica do sinthome.

Résumé On présente la logique de la sexuation de Jacques Lacan en opposition à la notion de genre, érigée en matrice de l'intelligibilité de la transsexualité. L'approche lacanienne du sinthome est développée comme une alternative afin de penser à des solutions uniques aux impasses sexuelles, a travers le biais de la dépatologisation. On conclut que la transsexualité, au lieu du forçage psychotique inéluctable, peut être une solution inventive articulée à la clinique du sinthome.

Resumen Se presenta la lógica de la sexuación de Jacques Lacan en contraposición a la noción de género, construida como matriz de inteligibilidad de la transexualidad. Se desarrolla el abordaje lacaniano del sinthome como una alternativa para pensar soluciones singulares a los impasses sexuales, por el sesgo de la despatologización. Se concluye que la transexualidad, en vez de ineluctable forzamiento psicótico, puede ser una solución inventiva articulada a la clínica del sinthome.

Abstract The logic of sexuation, by Jacques Lacan, is presented in opposition to the notion of gender, constructed as the matrix for transsexuality intelligibility. The Lacanian approach of sinthome is developed as an alternative to think on singular solutions for sexual impasses, through the depathologization bias. It is concluded that transsexuality, instead of an inescapable psychotic forcing, may be an inventive solution coordinated to the clinic of the sinthome.

A anatomia é o destino: a psicanálise e o sintoma transexual / L'anatomie est le destin: la psychanalyse et le symptôme transsexuel / The anatomy is destiny: psychoanalysis and the transsexual symptom

O artigo distingue a clínica do transexual e o discurso da atualidade sobre o transexualismo. Essa solução parece ter se tornado o paradigma da sexualidade na contemporaneidade. O próprio sexo se torna um direito e isso implica em admitir que a escolha do sexo é livre. Por ser presidida pela linguagem, a sexuação nada deveria ao corpo anatômico. Do ponto de vista psicanalítico, o simbólico pode ser transmitido sem estar encarnado? Sabemos que tudo o que diz respeito à experiência humana está aparelhado sob a forma de um discurso. O corpo também. Aliviado do constrangimento fálico, que diz respeito ao discurso do mestre (o Édipo, em Freud), o corpo está livre? Sabemos que não. Em que discurso ele é capturado? O que nós, psicanalistas, temos a dizer a respeito dessa nova ilusão.

Je propose une distinction entre une clinique du transsexuel et le discours de nos jours à propos du transsexualisme. Cette solution semble avoir changé le paradigme de la sexualité dans la contemporanéité. Le sexe lui-même devient un droit, ce qu’implique d'admettre que le choix du sexe est libre. Pour la raison qu'il est organisé par la langue, la sexuation ne doit rien au corps anatomique. Du point de vue psychanalytique, peut le symbolique être transmissans être incarné? Nous savons que tout ce qui concerne l'expérience humaine s'appareille sous un discours. Le corps aussi. Celui-ci, libéré de la contrainte phallique à l'égard du discours du maître (l’Œdipe, chez Freud), est-il libre? Nous savons qu'il n'en est pas. Dans quel discours, est-il figé? Qu'est-ce que nous, les psychanalystes, pouvons dire de cette nouvelle illusion.

I propose a distinction between a transsexual's clinic and today's discourse about transsexualism. This solution seems to have become the paradigm of sexuality in contemporary times. Sex itselfbecomes a right and this implies admitting that the sexual choice is a free one. Due to it being presided over by language, sexuation would owe nothing to the anatomical body. According to the psychoanalytical point of view, can the symbolic be transmitted without being incarnated? We know that everything that relates to human experience is trapped in discourse. So is the body. Can the latter, once freed of phallic constraint, which concerns the master's discourse (the Oedipus, in Freud), be said to be free? We know it can't. In what discourse is it caught? What do we, psychoanalysts, have to say about this new illusion.

O corpo estranho / Strange body / Le corps étrange / El cuerpo extraño

Frente às novas técnicas de manipulação dos corpos propiciadas pelo desenvolvimento da ciência e da tecnologia na contemporaneidade, este artigo discute as relações entre corpo, sexualidade e sintoma, a partir das contribuições da psicanálise. Discute-se, em especial, o fenômeno do transexualismo tal como vem sendo abordado atualmente, em virtude da adoção de procedimentos na área da saúde pública que visam atender à demanda de mudança de sexo por meio de técnicas hormonocirúrgicas.

In view of new techniques for dealing with the body, as offered by science and technology in contemporary society, this article contains a discussion of relationships between body, sexuality and symptoms, based on contributions by psychoanalysis. In particular the phenomenon of transsexualism as seen today is discussed, in view of the adoption of procedures by public health systems designed to meet demands for sex change through hormonal and surgical techniques.

Face aux nouvelles techniques de manipulation du corps qui résultent du développement de la science et de la technologie dans la société contemporaine, cet article analyse le rapport entre le corps, la sexualité et le symptôme à partir des contributions de la psychanalyse. Il aborde en particulier le phénomène du transsexualisme de la façon comme il est discuté aujourd'hui en raison de l'adoption de procédures dans le domaine de la santé publique qui visent à répondre à la demande de changement de sexe à l'aide de techniques chirurgicales et hormonales.

Frente a las nuevas técnicas de manipulación de los cuerpos que es proporcionado por el desarrollo de la ciencia y de la tecnología en la sociedad contemporánea, en este artículo se analizan las relaciónes entre el cuerpo, la sexualidad y los síntomas, a partir de los aportes del psicoanálisis. El artículo analiza en particular el fenómeno del transexualismo, tal y como está siendo abordado en la actualidad, en virtud de la adopción de procedimientos en el ámbito de la salud pública destinados a satisfacer la demanda por cambio de sexo a través de técnicas hormonales y quirúrgicas.