[Transgender in Adolescence: State of the Art and Future Research Needs]. / Transgender im Jugendalter: Forschungsstand und zukünftiger Forschungsbedarf.

Transgender in adolescence is currently a widely discussed topic, additionally reflected by an increasing prevalence in clinical practice. The present review of the available literature on transgender, trans* , gender dysphoria or gender incongruence in youth reports results on the long-term results of medical interventions for the psychological well-being, prevalence, referral rates and sex ratio, developmental pathways, current developments and the role of the social environment. Finally, implications for clinical care and future research will be discussed.

[THE MEDICAL CARE OF TRANSGENDER PEOPLE].

INTRODUCTION: The phenomenon of the discrepancy between a person's sexual self-perception and his/her genetic sex has been known to medicine since the mid-19th century. Initially, this discrepancy was considered to be a mental disorder. Over time, advances in medical abilities in surgery, hormonal treatment and infertility, have enabled physicians to help those who are affected to fulfill their wish. The present notion is that transsexualism is a solvable problem (whether the desired wish is for a man to become a woman or vice versa). Treatment is both complicated (surgery) as well as chronic (hormones). In this review the various medical aspects of the different possible treatments are discussed, excluding the psychological part of this intriguing condition.

Between DSM and ICD: Paraphilias and the Transformation of Sexual Norms.

The simultaneous revision of the two major international classifications of disease, the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, serves as an opportunity to observe the dynamic processes through which social norms of sexuality are constructed and are subject to change in relation to social, political, and historical context. This article argues that the classifications of sexual disorders, which define pathological aspects of "sexually arousing fantasies, sexual urges or behaviors" are representations of contemporary sexual norms, gender identifications, and gender relations. It aims to demonstrate how changes in the medical treatment of sexual perversions/paraphilias passed, over the course of the 20th century, from a model of pathologization (and sometimes criminalization) of non-reproductive sexual behaviors to a model that reflects and privileges sexual well-being and responsibility, and pathologizes the absence or the limitation of consent in sexual relations.

[A validation study of the German version of the Hypersexual Behavior Inventory (HBI)]. / Eine Validierungsstudie der deutschen Version des Hypersexual Behavior Inventory (HBI).

Hypersexuality is characterized by recurrent and intense sexual fantasies, sexual urges, or sexual behaviors resulting in clinically significant personal distress or impairment in social, occupa-tional, or other important areas of functioning. The Hypersexual Behavior Inventory (HBI, Reid et al., 2011) is a 3-factor measure (coping, control and consequences) developed to assess hypersexual behaviour. The aim of the present study was to investigate the psychometric properties of the German version of the HBI. In a sample consisting of 1 749 men and women the questionnaire was used as part of an online survey. The questionnaire showed good reliability and validity. A confirmatory factor analysis supported the 3-factor structure of the original English version. The results and potential benefit of the HBI in research and clinical practice are discussed.

[Sexual disorders in the DSM-5]. / Seksuele stoornissen in de DSM-5.

BACKGROUND: In DSM-IV-TR, the subject of 'sexual and gender identity disorders' was dealt with in one chapter; in DSM-5, however, the subject is divided into three chapters, namely sexual dysfunctions , gender dysphoria, and paraphilic disorders. AIM: To discuss the above-mentioned changes. METHOD: The one-chapter version in DSM-IV is compared with the three-chapter contribution in DSM-5 and the differing criteria are tested for their clinical utility. RESULTS: There are minor changes in the chapter 'sexual dysfunctions'. The content of the chapters on 'gender dysphoria' and 'paraphilic disorders' differs substantially from the content of the sections on these subjects in DSM-IV. In the section on gender dysphoria the term 'sex' has been replaced by 'gender' and the term 'identity disorder' has been dropped. With regard to paraphilias, a distinction is now made between a paraphilia and a paraphilic disorder. The DSM-5 makes a new distinction between pathology (paraphilic disorder) on the one hand and other unusual or unconventional non-pathological sexual behavior on the other hand. In the DSM-5 the highly relevant clinical concept 'hypersexuality' has still not been incorporated as a separate category. CONCLUSION: In the DSM-5 many parts of the chapters on sexual disorders have been substantially revised.

[The history of the concept of gender identity disorder].

The Metamorphoses Greek myth includes a story about a woman raised as a male falling in love with another woman, and being transformed into a man prior to a wedding ceremony and staying with her. It is therefore considered that people who desire to live as though they have the opposite gender have existed since ancient times. People who express a sense of discomfort with their anatomical sex and related roles have been reported in the medical literature since the middle of the 19th century. However, homosexual, fetishism, gender identity disorder, and associated conditions were mixed together and regarded as types of sexual perversion that were considered ethically objectionable until the 1950s. The first performance of sex-reassignment surgery in 1952 attracted considerable attention, and the sexologist Harry Benjamin reported a case of 'a woman kept in the body of a man', which was called transsexualism. John William Money studied the sexual consciousness about disorders of sex development and advocated the concept of gender in 1957. Thereafter the disparity between anatomical sex and gender identity was referred to as the psychopathological condition of gender identity disorder, and this was used for its diagnostic name when it was introduced into DSM-III in 1980. However, gender identity disorder encompasses a spectrum of conditions, and DSM-III -R categorized it into three types: transsexualism, nontranssexualism, and not otherwise specified. The first two types were subsequently combined and standardized into the official diagnostic name of 'gender identity disorder' in DSM-IV. In contrast, gender identity disorder was categorized into four groups (including transsexualism and dual-role transvestism) in ICD-10. A draft proposal of DSM-5 has been submitted, in which the diagnostic name of gender identity disorder has been changed to gender dysphoria. Also, it refers to 'assigned gender' rather than to 'sex', and includes disorders of sexual development. Moreover, the subclassifications regarding sexual orientation have been deleted. The proposed DSM-5 reflects an attempt to include only a medical designation of people who have suffered due to the gender disparity, thereby respecting the concept of transgender in accepting the diversity of the role of gender. This indicates that transgender issues are now at a turning point.

The DSM diagnostic criteria for gender identity disorder in children.

In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as "disorder," as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.

Sexual orientation versus age of onset as bases for typologies (subtypes) for gender identity disorder in adolescents and adults.

The most widely used and influential typologies for transsexualism and gender identity disorder (GID) in adolescents and adults employ either sexual orientation or age of onset of GID-related symptoms as bases for categorization. This review compares these two typological approaches, with the goal of determining which one should be employed for the diagnosis of GID in Adolescents or Adults (or its successor diagnosis) in the forthcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Typologies based on sexual orientation and age of onset of GID-related symptoms are roughly comparable in ease and reliability of subtype assignment. Typologies based on sexual orientation, however, employ subtypes that are less ambiguous and better suited to objective confirmation and that offer more concise, comprehensive clinical description. Typologies based on sexual orientation are also superior in their ability to predict treatment-related outcomes and comorbid psychopathology and to facilitate research. Commonly expressed objections to typologies based on sexual orientation are unpersuasive when examined closely. The DSM should continue to employ subtypes based on sexual orientation for the diagnosis of GID in Adolescents or Adults or its successor diagnosis.

Queer diagnoses: parallels and contrasts in the history of homosexuality, gender variance, and the diagnostic and statistical manual.

The American Psychiatric Association (APA) is in the process of revising its Diagnostic and Statistical Manual (DSM), with the DSM-V having an anticipated publication date of 2012. As part of that ongoing process, in May 2008, APA announced its appointment of the Work Group on Sexual and Gender Identity Disorders (WGSGID). The announcement generated a flurry of concerned and anxious responses in the lesbian, gay, bisexual, and transgender (LGBT) community, mostly focused on the status of the diagnostic categories of Gender Identity Disorder (GID) (for both children and adolescents and adults). Activists argued, as in the case of homosexuality in the 1970s, that it is wrong to label expressions of gender variance as symptoms of a mental disorder and that perpetuating DSM-IV-TR's GID diagnoses in the DSM-V would further stigmatize and cause harm to transgender individuals. Other advocates in the trans community expressed concern that deleting GID would lead to denying medical and surgical care for transgender adults. This review explores how criticisms of the existing GID diagnoses parallel and contrast with earlier historical events that led APA to remove homosexuality from the DSM in 1973. It begins with a brief introduction to binary formulations that lead not only to linkages of sexual orientation and gender identity, but also to scientific and clinical etiological theories that implicitly moralize about matters of sexuality and gender. Next is a review of the history of how homosexuality came to be removed from the DSM-II in 1973 and how, not long thereafter, the GID diagnoses found their way into DSM-III in 1980. Similarities and differences in the relationships of homosexuality and gender identity to psychiatric and medical thinking are elucidated. Following a discussion of these issues, the author recommends changes in the DSM-V and some internal and public actions that the American Psychiatric Association should take.

The DSM diagnostic criteria for gender identity disorder in adolescents and adults.

Apart from some general issues related to the Gender Identity Disorder (GID) diagnosis, such as whether it should stay in the DSM-V or not, a number of problems specifically relate to the current criteria of the GID diagnosis for adolescents and adults. These problems concern the confusion caused by similarities and differences of the terms transsexualism and GID, the inability of the current criteria to capture the whole spectrum of gender variance phenomena, the potential risk of unnecessary physically invasive examinations to rule out intersex conditions (disorders of sex development), the necessity of the D criterion (distress and impairment), and the fact that the diagnosis still applies to those who already had hormonal and surgical treatment. If the diagnosis should not be deleted from the DSM, most of the criticism could be addressed in the DSM-V if the diagnosis would be renamed, the criteria would be adjusted in wording, and made more stringent. However, this would imply that the diagnosis would still be dichotomous and similar to earlier DSM versions. Another option is to follow a more dimensional approach, allowing for different degrees of gender dysphoria depending on the number of indicators. Considering the strong resistance against sexuality related specifiers, and the relative difficulty assessing sexual orientation in individuals pursuing hormonal and surgical interventions to change physical sex characteristics, it should be investigated whether other potentially relevant specifiers (e.g., onset age) are more appropriate.

From mental disorder to iatrogenic hypogonadism: dilemmas in conceptualizing gender identity variants as psychiatric conditions.

The categorization of gender identity variants (GIVs) as "mental disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association is highly controversial among professionals as well as among persons with GIV. After providing a brief history of GIV categorizations in the DSM, this paper presents some of the major issues of the ongoing debate: GIV as psychopathology versus natural variation; definition of "impairment" and "distress" for GID; associated psychopathology and its relation to stigma; the stigma impact of the mental-disorder label itself; the unusual character of "sex reassignment surgery" as a psychiatric treatment; and the consequences for health and mental-health services if the disorder label is removed. Finally, several categorization options are examined: Retaining the GID category, but possibly modifying its grouping with other syndromes; narrowing the definition to dysphoria and taking "disorder" out of the label; categorizing GID as a neurological or medical rather than a psychiatric disorder; removing GID from both the DSM and the International Classification of Diseases (ICD); and creating a special category for GIV in the DSM. I conclude that-as also evident in other DSM categories-the decision on the categorization of GIVs cannot be achieved on a purely scientific basis, and that a consensus for a pragmatic compromise needs to be arrived at that accommodates both scientific considerations and the service needs of persons with GIVs.

Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.

OBJECTIVE: Despite professional recommendations to consider gender-affirming hormone and surgical interventions for transgender individuals experiencing gender incongruence, the long-term effect of such interventions on mental health is largely unknown. The aim of this study was to ascertain the prevalence of mood and anxiety disorder health care visits and antidepressant and anxiolytic prescriptions in 2015 as a function of gender incongruence diagnosis and gender-affirming hormone and surgical treatment in the entire Swedish population. METHODS: This study used the Swedish Total Population Register (N=9,747,324), linked to the National Patient Register and the Prescribed Drug Register. Among individuals who received a diagnosis of gender incongruence (i.e., transsexualism or gender identity disorder) between 2005 and 2015 (N=2,679), mental health treatment in 2015 was examined as a function of length of time since gender-affirming hormone and surgical treatment. Outcome measures were mood and anxiety disorder health care visits, antidepressant and anxiolytic prescriptions, and hospitalization after a suicide attempt. RESULTS: Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03). However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98). CONCLUSIONS: In this first total population study of transgender individuals with a gender incongruence diagnosis, the longitudinal association between gender-affirming surgery and reduced likelihood of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them.

Sexual preferences and associated disorders: toward an extended model for description. / Preferencje seksualne i zwiazane z nimi zaburzenia: w strone rozszerzonego modelu opisu.

The notion of human sexual preferences relates to relatively stable patterns of sexual response and to directing sexual behaviors toward specific arousing stimuli, which are also important for sexual satisfaction. The preferences may pertain to the properties of the object or the sexual activity itself. Diagnosing sexual preferences, in its basic form, is conducted with the use of disorder criteria defined in diagnostic classifications (ICD-10, DSM-5). However, while employing these criteria enables the categorization of the patient's sexual preferences as normal or pathological, they seem clearly insufficient for describing complex sexual interest patterns in a comprehensive manner. The goal of this article is to present a detailed dimensional model for describing sexual preferences. This proposal assumes the description of two aspects of preference: a contentual aspect, defining the individual hierarchy of sexually attractive and aversive stimuli, and a formal aspect. The latter involves four dimensions: the diversity of stimuli falling within the pattern of the patient's sexual interest, preference changeability in time, the coherence between individual components of responding to sexual stimuli, and insight into one's own preferences. The proposed model supplements the basic description of sexual preferences conducted on the basis of diagnostic criteria. The model can be a tool useful for diagnostic practice, particularly in precise characterization of various difficulties experienced by patients in relation to the properties of their sexual interests. It can also inspire new research on features of human sexual response patterns which have been neglected in previous analyses.

[Diagnosis and treatment of gender identity disorder].

According to DSM-IV criteria, gender identity disorder(GID) is characterized as follows: 1) Strong, persistent cross-gender identification. 2) Persistent discomfort with one's assigned sex or the Sense of inappropriateness in that gender role. 3) Not due to an intersex condition. In this chapter, symptoms, diagnosis and treatment of GID are briefly described. Possible pathogenesis of GID is also discussed.

[Complex diagnosis of chronic prostatitis complicated by disorders in sexual and reproductive functions]. / Kompleksna diahnostyka khronichnoho prostatytu, uskladnenoho porushenniamy kopuliatyvnoï ta reproduktyvnoï funktsii.

A comprehensive clinical-and-laboratory evaluation was carried out in 132 patients with chronic prostatitis, the major proportion of these presenting with concomitant urethritis. It has been ascertained that infectious agents (chlamidia, gonococci, myco- and ureaplasms, trichomonads) play an important part in the origination and development of chronic prostatitis. In the examined patients spermograms were studied, with normospermia having been recorded in 45 (34%) patients, grade I oligospermia in 41 (31%), grade II oligospermia in 29 (22%), grade III oligospermia in 13 (10%), azospermia in 4 (3%) patients. There was no relatedness of changes revealed in qualitative characteristics of the ejaculate to etiology of chronic prostatitis. A comparative study was done on those parameters characterizing local (cell-mediated, humoral) immunity of the reproductive tract in patients with chronic prostatitis of different etiological (infectious) origin. Disturbances in local immunologic vigor in varying etiology chronic prostatitis have been shown to be of unidirectional character with no statistically significant difference in place.

Children and adolescents with gender identity disorder referred to a pediatric medical center.

OBJECTIVES: To describe the patients with gender identity disorder referred to a pediatric medical center. We identify changes in patients after creation of the multidisciplinary Gender Management Service by expanding the Disorders of Sex Development clinic to include transgender patients. METHODS: Data gathered on 97 consecutive patients <21 years, with initial visits between January 1998 and February 2010, who fulfilled the following criteria: long-standing cross-gender behaviors, provided letters from current mental health professional, and parental support. Main descriptive measures included gender, age, Tanner stage, history of gender identity development, and psychiatric comorbidity. RESULTS: Genotypic male:female ratio was 43:54 (0.8:1); there was a slight preponderance of female patients but not significant from 1:1. Age of presentation was 14.8 ± 3.4 years (mean ± SD) without sex difference (P = .11). Tanner stage at presentation was 4.1 ± 1.4 for genotypic female patients and 3.6 ± 1.5 for genotypic male patients (P = .02). Age at start of medical treatment was 15.6 ± 2.8 years. Forty-three patients (44.3%) presented with significant psychiatric history, including 20 reporting self-mutilation (20.6%) and suicide attempts (9.3%). CONCLUSIONS: After establishment of a multidisciplinary gender clinic, the gender identity disorder population increased fourfold. Complex clinical presentations required additional mental health support as the patient population grew. Mean age and Tanner Stage were too advanced for pubertal suppressive therapy to be an affordable option for most patients. Two-thirds of patients were started on cross-sex hormone therapy. Greater awareness of the benefit of early medical intervention is needed. Psychological and physical effects of pubertal suppression and/or cross-sex hormones in our patients require further investigation.