Effects of Medical Interventions on Gender Dysphoria and Body Image: A Follow-Up Study.

OBJECTIVE: The aim of this study from the European Network for the Investigation of Gender Incongruence is to investigate the status of all individuals who had applied for gender confirming interventions from 2007 to 2009, irrespective of whether they received treatment. The current article describes the study protocol, the effect of medical treatment on gender dysphoria and body image, and the predictive value of (pre)treatment factors on posttreatment outcomes. METHODS: Data were collected on medical interventions, transition status, gender dysphoria (Utrecht Gender Dysphoria Scale), and body image (Body Image Scale for transsexuals). In total, 201 people participated in the study (37% of the original cohort). RESULTS: At follow-up, 29 participants (14%) did not receive medical interventions, 36 hormones only (18%), and 136 hormones and surgery (68%). Most transwomen had undergone genital surgery, and most transmen chest surgery. Overall, the levels of gender dysphoria and body dissatisfaction were significantly lower at follow-up compared with clinical entry. Satisfaction with therapy responsive and unresponsive body characteristics both improved. High dissatisfaction at admission and lower psychological functioning at follow-up were associated with persistent body dissatisfaction. CONCLUSIONS: Hormone-based interventions and surgery were followed by improvements in body satisfaction. The level of psychological symptoms and the degree of body satisfaction at baseline were significantly associated with body satisfaction at follow-up.

The Proposed ICD-11 Gender Incongruence of Childhood Diagnosis: A World Professional Association for Transgender Health Membership Survey.

ICD-11 (the eleventh edition of the World Health Organization International Statistical Classification of Diseases and Related Health Problems) is due for approval in 2018. For transgender health care, the most important proposals for ICD-11 are as follows: (1) the five ICD-10 diagnoses (most notably Transsexualism and Gender Identity Disorder of Childhood) currently in Chapter 5 (Mental and Behavioural Disorders) will be replaced by two Gender Incongruence diagnoses, one of Adolescence and Adulthood and the other of Childhood (GIC), and (2) these two diagnoses will be located in a new chapter provisionally named Conditions Related to Sexual Health. Debate on the GIC proposal has focused on whether there should be a diagnosis for young children exploring their identity and has drawn on a number of arguments for and against the proposal. The World Professional Association for Transgender Health conducted a survey to examine members' views concerning the GIC proposal, as well as an alternative framework employing non-pathologizing Z Codes. The survey was completed by 241 (32.6 %) out of 740 members. Findings indicated an even split among members regarding the GIC proposal (51.0 % [n = 123] opposing and 47.7 % [n = 115] supporting the proposal). However, non-US members were overall opposed to the proposal (63.9 % [n = 46] opposing, 36.1 % [n = 26] supporting). Across the sample as a whole, and among those expressing a view about Z Codes, there was substantial support for their use in healthcare provision for children with gender issues (35.7 % [n = 86] of the sample supporting vs. 8.3 % [n = 20] rejecting).

Measuring Gender Dysphoria: A Multicenter Examination and Comparison of the Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults.

This study examined two instruments measuring gender dysphoria within the multicenter study of the European Network for the Investigation of Gender Incongruence (ENIGI). The Utrecht Gender Dysphoria Scale (UGDS) and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) were examined for their definitions of gender dysphoria and their psychometric properties, and evaluated for their congruence in assessing the construct. The sample of 318 participants consisted of 178 male-to-females (MtF) and 140 female-to-males (FtM) who were recruited from the four ENIGI gender clinics. Both instruments were significantly correlated in the group of MtFs. For the FtM group, there was a trend in the same direction but smaller. Gender dysphoria was found to be defined differently in the two instruments, which led to slightly different findings regarding the subgroups. The UGDS detected a difference between the subgroups of early and late onset of gender identity disorder in the group of MtFs, whereas the GIDYQ-AA did not. For the FtM group, no significant effect of age of onset was found. Therefore, both instruments seem to capture not only similar but also different aspects of gender dysphoria. The UGDS focusses on bodily aspects, gender identity, and gender role, while the GIDYQ-AA addresses subjective, somatic, social, and sociolegal aspects. For future research, consistency in theory and definition of gender dysphoria is needed and should be in line with the DSM-5 diagnosis of gender dysphoria in adolescents and adults.

Body Satisfaction and Physical Appearance in Gender Dysphoria.

Gender dysphoria (GD) is often accompanied by dissatisfaction with physical appearance and body image problems. The aim of this study was to compare body satisfaction with perceived appearance by others in various GD subgroups. Data collection was part of the European Network for the Investigation of Gender Incongruence. Between 2007 and 2012, 660 adults who fulfilled the criteria of the DSM-IV gender identity disorder diagnosis (1.31:1 male-to-female [MtF]:female-to-male [FtM] ratio) were included into the study. Data were collected before the start of clinical gender-confirming interventions. Sexual orientation was measured via a semi-structured interview whereas onset age was based on clinician report. Body satisfaction was assessed using the Body Image Scale. Congruence of appearance with the experienced gender was measured by means of a clinician rating. Overall, FtMs had a more positive body image than MtFs. Besides genital dissatisfaction, problem areas for MtFs included posture, face, and hair, whereas FtMs were mainly dissatisfied with hip and chest regions. Clinicians evaluated the physical appearance to be more congruent with the experienced gender in FtMs than in MtFs. Within the MtF group, those with early onset GD and an androphilic sexual orientation had appearances more in line with their gender identity. In conclusion, body image problems in GD go beyond sex characteristics only. An incongruent physical appearance may result in more difficult psychological adaptation and in more exposure to discrimination and stigmatization.

Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study.

PURPOSE: Total phalloplasty is rarely performed today in males with severe penile deficiency, despite its successful use in the transgender population. Can phalloplasty replicate the complexity of penile anatomy and function on the long term? METHODS: Sexual quality of life (QoL) was assessed in 10 men (aged 20-43 years) at least 1 year after phalloplasty in a single institution (80 % radial forearm flap and 20 % anterolateral thigh flap). In all but one, an erectile prosthesis was implanted on average 1 year after phallic reconstruction. Sexual QoL outcomes were compared to those of men with hypospadias repair (n = 73) and control men (n = 50). RESULTS: After phalloplasty (mean 36.9 months, 14-92 months), all men were sexually active (80 % intercourse and 100 % masturbation with orgasm and ejaculation). However, 75 % indicated to be inhibited in seeking sexual contacts, compared to 40 % of hypospadias patients (p < 0.05) and 11 % of controls (p < 0.01). Although 90 % were satisfied with the final surgical result, dissatisfaction with some aspects of genital appearance was present in 50 %. Erogenous neophallus sensitivity was said to be less than previously hoped for. Six men developed urinary complications (urethral stricture and/or fistula), and one man underwent revision of the erectile implant because of dysfunction. Nevertheless, all indicated they would choose again for phalloplasty if necessary. CONCLUSIONS: Total phalloplasty opens new horizons for the treatment of men with penile deficiency, but limitations of the technique should be emphasized prior to surgery. An exploration of patient expectations and continued follow-up including psychological support is important for optimizing psychosexual comfort.

Sociodemographic Characteristics of Trans Persons in Belgium: A Secondary Data Analysis of Medical, State, and Social Data.

By performing secondary data analyses of existing medical, social, and state data, this study examined the sociodemographic profile of trans persons in Belgium and gains knowledge on those who are functionally invisible in traditional epidemiological studies or clinical samples. Based on medical interventions, post-operative transsexual persons were selected from a social survey data set, to compare their sociodemographic profile with available data on legal sex changes from the Belgian National Register and with published data on clinical samples of post-operative transsexual persons. Furthermore, based on self-chosen gender identity categories in the social survey data, transsexual participants were compared with the transgender participants (those people feeling neither female nor male, or both female and male, or otherwise). The sociodemographic data on the post-operative transsexual persons from the three datasets appeared to be very similar. Based on identity categories, the data on transsexual and transgender persons from the social survey showed differences in marital status and employment. Transsexual persons were significantly more often divorced than transgender persons. Both groups differed significantly in employment status. Information about transgender people (or the "in-between" group) is too often lacking from studies but can be obtained when identity instead of medical criteria are used in research.

Prevalence of Gender Nonconformity in Flanders, Belgium.

Gender nonconformity refers to the extent to which a person's gender identity, gender role and/or gender expression differs from the cultural norms prescribed for people of a particular sex, within a certain society and era. Most data on gender nonconformity focus on the prevalence of gender dysphoria (which also includes a distress factor) or on the number of legal sex changes. However, not every gender nonconforming individual experiences distress or applies for treatment. Population-based research on the broad spectrum of gender nonconformity is scarce and more information on the variance outside the gender binary is needed. This study aimed to examine the prevalence of gender incongruence (identifying stronger with the other sex than with the sex assigned at birth) and gender ambivalence (identifying equally with the other sex as with the sex assigned at birth) based on two population-based surveys, one of 1,832 Flemish persons and one of 2,472 sexual minority individuals in Flanders. In the general population, gender ambivalence was present in 2.2 % of male and 1.9 % of female participants, whereas gender incongruence was found in 0.7 % of men and 0.6 % of women. In sexual minority individuals, the prevalence of gender ambivalence and gender incongruence was 1.8 and 0.9 % in men and 4.1 and 2.1 % in women, respectively. With a current Flemish population of about 6 million, our results indicate a total of between 17,150 and 17,665 gender incongruent men and between 14,473 and 15,221 gender incongruent women in Flanders.

Psychiatric characteristics in transsexual individuals: multicentre study in four European countries.

BACKGROUND: Research into the relationship between gender identity disorder and psychiatric problems has shown contradictory results. AIMS: To investigate psychiatric problems in adults fulfilling DSM-IV-TR criteria for a diagnosis of gender identity disorder. METHOD: Data were collected within the European Network for the Investigation of Gender Incongruence using the Mini International Neuropsychiatric Interview - Plus and the Structured Clinical Interview for DSM-IV Axis II Disorders (n = 305). RESULTS: In 38% of the individuals with gender identity disorder a current DSM-IV-TR Axis I diagnosis was found, mainly affective disorders and anxiety disorders. Furthermore, almost 70% had a current and lifetime diagnosis. All four countries showed a similar prevalence, except for affective and anxiety disorders, and no difference was found between individuals with early-onset and late-onset disorder. An Axis II diagnosis was found in 15% of all individuals with gender identity disorder, which is comparable to the general population. CONCLUSIONS: People with gender identity disorder show more psychiatric problems than the general population; mostly affective and anxiety problems are found.

Vaginal dilation treatment in women with vaginal hypoplasia: a prospective one-year follow-up study.

OBJECTIVE: Vaginal dilation treatment has been shown to be a (cost) effective first-line alternative to surgery in normalizing vaginal length and improving sexual function in women with vaginal hypoplasia. There remains, however, a need for prospective studies, with long-term assessment of multiple outcomes. STUDY DESIGN: This was a prospective, single-centre observational study of 16 women with Mayer-Rokitansky-Küster-Hauser syndrome (n = 12) or 46,XY disorders of sex development (n = 4). All women underwent an outpatient vaginal dilation program supervised by a psychologist and physiotherapist. At baseline (T0), stop of treatment (T1) and 1 year follow-up (T2), semistructured interviews, and validated questionnaires assessed sexual function and distress, self-esteem, vaginal perceptions, and health-related quality of life. Gynecological examinations evaluated vaginal dimensions. RESULTS: Ten women completed the program, 3 are still in the program, and dilation failed in 3 and chose vaginoplasty. Sixty-nine percent reached a normal vaginal length (≥6.5 cm) in 5.8 ± 3.3 months. Seventy percent were sexually active with pleasurable experiences at T1, 57% at T2. The significant decrease in sexual distress at T1 (P < .05) was followed by a nonsignificant increase at T2. Depressive mood symptomatology remained high at T1 and T2, related to loss of bodily integrity and fertility. The majority refused further psychological counseling. CONCLUSION: Vaginal dilation treatment should remain the cornerstone of treatment in women with vaginal hypoplasia. However, the diagnosis remains to have a negative impact on emotional well-being in the long term. The role of psychological intervention as both a primary and adjuvant treatment needs clear evaluation.

Effects of different steps in gender reassignment therapy on psychopathology: a prospective study of persons with a gender identity disorder.

INTRODUCTION: At the start of gender reassignment therapy, persons with a gender identity disorder (GID) may deal with various forms of psychopathology. Until now, a limited number of publications focus on the effect of the different phases of treatment on this comorbidity and other psychosocial factors. AIMS: The aim of this study was to investigate how gender reassignment therapy affects psychopathology and other psychosocial factors. METHODS: This is a prospective study that assessed 57 individuals with GID by using the Symptom Checklist-90 (SCL-90) at three different points of time: at presentation, after the start of hormonal treatment, and after sex reassignment surgery (SRS). Questionnaires on psychosocial variables were used to evaluate the evolution between the presentation and the postoperative period. The data were statistically analyzed by using SPSS 19.0, with significance levels set at P < 0.05. MAIN OUTCOME MEASURES: The psychopathological parameters include overall psychoneurotic distress, anxiety, agoraphobia, depression, somatization, paranoid ideation/psychoticism, interpersonal sensitivity, hostility, and sleeping problems. The psychosocial parameters consist of relationship, living situation, employment, sexual contacts, social contacts, substance abuse, and suicide attempt. RESULTS: A difference in SCL-90 overall psychoneurotic distress was observed at the different points of assessments (P = 0.003), with the most prominent decrease occurring after the initiation of hormone therapy (P < 0.001). Significant decreases were found in the subscales such as anxiety, depression, interpersonal sensitivity, and hostility. Furthermore, the SCL-90 scores resembled those of a general population after hormone therapy was initiated. Analysis of the psychosocial variables showed no significant differences between pre- and postoperative assessments. CONCLUSIONS: A marked reduction in psychopathology occurs during the process of sex reassignment therapy, especially after the initiation of hormone therapy.

Sexual desire in trans persons: associations with sex reassignment treatment.

INTRODUCTION: Sex steroids and genital surgery are known to affect sexual desire, but little research has focused on the effects of cross-sex hormone therapy and sex reassignment surgery on sexual desire in trans persons. AIM: This study aims to explore associations between sex reassignment therapy (SRT) and sexual desire in a large cohort of trans persons. METHODS: A cross-sectional single specialized center study including 214 trans women (male-to-female trans persons) and 138 trans men (female-to-male trans persons). MAIN OUTCOME MEASURES: Questionnaires assessing demographics, medical history, frequency of sexual desire, hypoactive sexual desire disorder (HSDD), and treatment satisfaction. RESULTS: In retrospect, 62.4% of trans women reported a decrease in sexual desire after SRT. Seventy-three percent of trans women never or rarely experienced spontaneous and responsive sexual desire. A third reported associated personal or relational distress resulting in a prevalence of HSDD of 22%. Respondents who had undergone vaginoplasty experienced more spontaneous sexual desire compared with those who planned this surgery but had not yet undergone it (P = 0.03). In retrospect, the majority of trans men (71.0%) reported an increase in sexual desire after SRT. Thirty percent of trans men never or rarely felt sexual desire; 39.7% from time to time, and 30.6% often or always. Five percent of trans men met the criteria for HSDD. Trans men who were less satisfied with the phalloplasty had a higher prevalence of HSDD (P = 0.02). Trans persons who were more satisfied with the hormonal therapy had a lower prevalence of HSDD (P = 0.02). CONCLUSION: HSDD was more prevalent in trans women compared with trans men. The majority of trans women reported a decrease in sexual desire after SRT, whereas the opposite was observed in trans men. Our results show a significant sexual impact of surgical interventions and both hormonal and surgical treatment satisfaction on the sexual desire in trans persons.

Sexual behavior of gender-dysphoric individuals before gender-confirming interventions: a European multicenter study.

A transsexual course of development that starts before puberty (early onset) or during or after puberty, respectively (late onset), may lead to diverse challenges in coping with sexual activity. The authors explored the sexual behavior of 380 adult male-to-female and female-to-male individuals diagnosed according to DSM-IV-TR criteria who had not yet undergone gender-confirming interventions. Data originated from the European Network for the Investigation of Gender Incongruence Initiative, conducted in Belgium, Germany, The Netherlands, and Norway. Information on outcome variables was collected using self-administered questionnaires at first clinical presentation. Compared with late-onset male-to-females, early-onset individuals tended to show sexual attraction toward males more frequently (50.5%), involve genitals less frequently in partner-related sexual activity, and consider penile sensations and orgasm as more negative. Early-onset female-to-males predominantly reported sexual attraction toward females (84.0%), whereas those with a late-onset more frequently showed other sexual attractions (41.7%). The study (a) shows that early- and late-onset male-to-females differ considerably with regard to coping strategies involving their body during sexual relations and (b) reveals initial insights into developmental pathways of late-onset female-to-males.

Sexual quality of life after hormonal and surgical treatment, including phalloplasty, in men with micropenis: a review.

INTRODUCTION: The term micropenis encompasses a range of congenital and acquired conditions that result in an abnormally short penis. Small penis size may persist into adulthood, becoming a major cause of dissatisfaction. AIM: To review the literature pertaining to the effects of hormonal and surgical treatment on psychosexual functioning and quality of life (QoL) in individuals with micropenis who were raised male. MAIN OUTCOME MEASURES: Long-term psychosexual and QoL outcomes after hormonal and surgical treatment, including phalloplasty. METHODS: PubMed search for relevant publications (1955-2012) on the role of hormonal and surgical treatment in sexual QoL in adult men with micropenis. RESULTS: Multiple variations in the etiology of micropenis make it difficult to draw firm conclusions that fit all of the patients within this disparate population. However, the literature review supports the conclusions that (i) male gender assignment is preferable for most 46,XY infants with congenital micropenis because of the likelihood of male gender development and genitosexual function; (ii) small penis size persisting into adulthood and dissatisfaction with genital appearance jeopardize sexual QoL; (iii) there is no known intervention, apart from phalloplasty, to guarantee that the penis will become normal in size; (iv) early data suggest that the phalloplasty technique considered the gold standard for gender reassignment in the transgender population can also be transferred to 46,XY patients with micropenis; (v) psychological support should be an integral part of management in order to alleviate the distress and impairment of QoL experienced by these individuals. CONCLUSIONS: Further publication of series with large numbers and longer follow-up is needed. Specific outcome kits should be designed to measure more precisely patients' degrees of satisfaction with cosmetic, anatomical, and functional variables. Only if health-care professionals fully appreciate the impact of this condition can optimal care be provided.

Self-assessment of genital anatomy and sexual function within a Belgian, Dutch-speaking female population: a validation study.

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

Gender-Affirmative Surgery: A Collaborative Approach between the Surgeon and Mental Health Professional.

SUMMARY: Gender incongruence describes a condition in which an individual's gender identity does not align with their sex assigned at birth based on anatomic characteristics. Individuals with gender incongruence may request surgical interventions, and gender-affirmation surgery plays an important role for these individuals. The basis of care derives from principles elucidated in the Standards of Care, international guidelines that help inform clinical decision-making. Historically, mental health care professionals (MHCPs) and surgeons have worked collaboratively to select "appropriate" surgical candidates. However, as understanding of gender identity evolves, so does the relationship between the MHCP and the surgeon. The role of the MHCP has shifted from a requirement to verify an individual's identity to that of supporting and participating in a shared decision-making process between the individual and the health care team. This article discusses the evolution of the relationship between the MHCP and the surgeon and provides insight into the history of this relationship.

Gender identity disorder in twins: a review of the case report literature.

INTRODUCTION: The etiology of gender identity disorder (GID) remains largely unknown. In recent literature, increased attention has been attributed to possible biological factors in addition to psychological variables. AIM: To review the current literature on case studies of twins concordant or discordant for GID. METHODS: A systematic, comprehensive literature review. RESULTS: Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same-sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P=0.005). Of the seven opposite-sex twins, all were discordant for GID. CONCLUSIONS: These findings suggest a role for genetic factors in the development of GID.

Long-term psychosexual and anatomical outcome after vaginal dilation or vaginoplasty: a comparative study.

INTRODUCTION: In patients with disorders of sex development requiring creation of a neovagina, a number of techniques are available, including surgical vaginoplasty and self-dilation therapy. Vaginal dilation therapy has been recommended as a first-line treatment because of its less invasive character and high success rate. However, no data exist on long-term psychosexual functioning after vaginal dilation as compared with that after vaginal surgery. AIMS: The aim of this study is to compare the psychosexual and anatomical outcome of women with congenital vaginal hypoplasia followed in the same clinical setting after vaginoplasty with that after vaginal dilation. METHODS: The sexual quality of life of 35 women at least 2 years after vaginoplasty (N = 15), vaginal dilation therapy (N = 8), or coital dilation/no treatment (N = 12) was investigated and compared with the Dutch test validation population (as control). MAIN OUTCOME MEASURES: Psychosexual functioning was assessed with the female sexual Function index, the female sexual distress scale-revised, and a semi-structured interview. A gynecological examination was performed to determine the anatomical outcome after both vaginal treatment regimens. RESULTS: After either treatment, 26% of these women had a shortened vaginal length of less than 6.6 cm, i.e., more than two standard deviations below the published mean value (9.6 ± 1.5 cm). Irrespective of the treatment, 47% of the patients had (a) sexual dysfunction(s) and experienced sexual distress. However, after vaginoplasty, patients reported significantly more problems with lubrication (P = 0.025) than after self-dilation therapy. CONCLUSION: Both psychological and physical factors are predisposing for sexual difficulties. To optimize psychosexual comfort, the clinical management of women with vaginal hypoplasia needs to be multidisciplinary and individually tailored. With high success rates reported, vaginal dilation should remain the cornerstone of treatment.

Assessing the utility of diagnostic criteria: a multisite study on gender identity disorder.

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

Karyotyping, is it worthwhile in transsexualism?

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

Quality of life and sexual health after sex reassignment surgery in transsexual men.

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.