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.

Trastorno de identidad de género: Parte I. Definición, epidemiología, etiología, rol del endocrinólogo en diagnóstico y tratamiento / Gender identity disorders: definition, etiology,epidemiology and role of the endocrinologist in theirmanagement

Gender identity disorders (GID) or transsexuality have been a latent issue in Chile 20 years after the first sex reassignment treatment in 1973. Sexual minority groups have posed the problem and even present a bill for civil sexual change. Since the nineties, the number of consultants due to gender identity problems has increased steadily, including children and adolescents. The lack of medical expertise in the area, requires urgent training programs. The first part of this manuscript will deal with the definition, epidemiology, etiology and role of the endocrinologist in the process of sexual reassignment among patients with gender identity disorders. We review sexual differentiation, brain sexual dimorphism and Sexual Development Disorders (SDD) aiming to understand the neurobiological causes of GID and to perform a better differential diagnosis with Sexual Development Disorders. GID are not a psychiatric disease. However the suffering caused by stigmatization, exclusion andabuse generate emotional problems (gender dysphoria). SDD has a genetic and hormonal basis in most cases. Its clinical expression at birth can cause an erroneous civil sex assignation or a discordant civil sex with the sexual identity of the person when there is a surgical correction. GIS without gender dysphoria was excluded as a mental disease from DSM-V and it will also be excluded from the eleventh version of the international classification of diseases. It will maintained as a condition that should be differentiated from SDD and whose treatment should be financed by health systems.

Documento de posicionamiento: disforia de género en la infancia y la adolescencia. Grupo de Identidad y Diferenciación Sexual de la Sociedad Española de Endocrinología y Nutrición (GIDSEEN) / Position statement: Gender dysphoria in childhood and adolescence. Working Group on Gender Identity and Sexual Development of the Spanish Society of Endocrinology and Nutrition (GIDSEEN)

La disforia de género (DG) en la infancia y adolescencia es una condición compleja, siendo importante la detección precoz y el tratamiento integral, ya que con ello se mejora la calidad de vida, disminuye la comorbilidad mental y la propia DG. En este documento de posicionamiento, el Grupo de Identidad y Diferenciación Sexual de la Sociedad Española de Endocrinología y Nutrición (GIDSEEN), integrado por especialistas de Endocrinología, Psicología, Psiquiatría, Pediatría y Sociología, establece unas recomendaciones sobre la evaluación y tratamiento de la DG en niños y adolescentes. El manejo interdisciplinar de la DG debe llevarse a cabo en unidades con equipos especializados (UTIG) y considerando que cualquier intervención sanitaria debe seguir los principios del rigor científico, la experiencia acumulada, los principios éticos y deontológicos y la prudencia necesaria ante tratamientos crónicos, agresivos e irreversibles

Gender dysphoria (GD) in childhood and adolescence is a complex condition where early detection and comprehensive treatment are essential to improve quality of life, decrease mental comorbidity, and improve GD. In this position statement, the Working Group on Gender Identity and Sexual Development of the Spanish Society of Endocrinology and Nutrition (GIDSEEN), consisting of specialists in Endocrinology, Psychology, Psychiatry, Pediatrics and Sociology, sets out recommendations for evaluation and treatment of GD in children and adolescents. Interdisciplinary management of GD should be carried out at specialized units (UTIGs), considering that any clinical intervention should follow the principles of scientific rigor, experience, ethical and deontological principles, and the necessary caution in front of chronic, aggressive, and irreversible treatments

Hiperprolactinemia y tratamiento antipsicótico. Manifestaciones clínicas y manejo / Hyperprolactinemia and antipsychotic treatment. Clinical manifestations and management

La hiperprolactinemia (HPRL) ha sido considerada hasta hace poco un efecto secundario inevitable e inherente al tratamiento antipsicótico y probablemente por ello sus efectos clínicos sean poco evaluados en la práctica clínica habitual. En esta revisión se evaluará el diferente potencial elevador de prolactina de los fármacos antipsicóticos (AP) y aquellas situaciones clínicas e individuales en las que hay que tener especiales precauciones a la hora de utilizar AP con potencial elevador de prolactina. Las consecuencias clínicas más comunes y conocidas de la HPRL por uso de AP son los síntomas sexuales y reproductivos, con diferentes características según género, pero recientemente se ha presentado mayor evidencia de una afectación también en la densidad mineral ósea, carcinogénesis y sistema cardiovascular. Aunque estos efectos precisan actualmente de mayor evidencia, se han de tener en cuenta a la hora de prescribir fármacos AP especialmente en pacientes susceptibles a desarrollarlos. Se considera de especial interés prevenir y minimizar los efectos de la HPRL por uso de AP así como, una vez instaurada, valorar su gravedad y afectación clínica y poderla manejar, y en su caso tratar, considerando la actuación de otras disciplinas (AU)

Hyperprolactinemia (HPRL) has until recently been considered an unavoidable side effect inherent to antipsychotic treatment, and has probably been the reason why its clinical effects are underestimated in daily clinical practice. In this review we evaluate the different prolactin raising potential of the antipsychotic (AP) drugs, as well as the clinical and individual situations where special precautions must be taken when using these medications. The most common and better known clinical consequences of HPRL-induced by APs are sexual and reproductive symptoms, with different characteristics depending on gender, but recently more evidence has also been provided on an involvement in bone mineral density, carcinogenesis and the cardiovascular system. Though these effects still require more evidence, they are important to be taken into account when prescribing APs drugs in susceptible patients. It is essential to prevent and minimize the effect of HPRL-induced by APs and, once established, to consider its severity and clinical effects, and to provide a proper management, treatment and the involvement of other disciplines (AU)

Breast cancer: reviewing the past to give direction for the future.

Since the 1970s, significant advances have been made in the diagnosis and treatment of breast cancer. Incidence rates increased during the 1980s and 1990s but began to decrease about 2% each year for women aged 50 years and older beginning in the year 2000, with a 7% decrease in the year 2002 (Siegel, Naishadham, & Jemal, 2013). Mortality rates in the United States also have decreased since 1990, particularly in women younger than 50 years. The declining incidence of breast cancer and improved mortality rates have been attributed to early detection, improved treatment, and research investigating factors associated with an increased risk of breast cancer. However, challenges such as limited effective treatment for symptoms resulting from estrogen deprivation still exist.

[Constructing a multicenter collaboration system].

Providing medical care for Gender Identity Disorder (GID) poses enormous challenges and difficulties. The one obstacle to overcome is building a pluralistic treatment system in collaboration with experts from various fields of medicine as outlined in "Guidelines for Treatment and Diagnosis of GID version 3rd" established by the Japanese Society of Psychiatry and Neurology. Another obstacle includes the multilayered decision tree in deployment of physical as well as psychiatric treatment. Offering continuous supports of the pluralistic treatment system following the multilayered decision tree poses a major obstacle. In this report, we examined these obstacles from a perspective of the actually accessible healthcare resources and came up with a proposal of constructing a multicenter collaboration system. As one of concrete example of a solution to these obstacles, we demonstrated our activity of "Kansai GID network." By sustaining these activities, many obstacles posed in the treatment of GID could be overcome. We hope substantial and comprehensive treatment systems for GID shall be promptly established in Japan.

[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.

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.

Abordaje multidisciplinar de la transexualidad: desde atención primaria a la Unidad de Trastornos de Identidad de Género de Madrid (UTIG MADRID) / Multidisciplinary approach to Transsexuality: From Primary Care to the Gender Identity Disorders Unit in Madrid (GIDU-Madrid)

La transexualidad es un fenómeno emergente en nuestra sociedad, por el cual una persona de un sexo biológico se siente pertenecer al contrario. El abordaje realizado desde la Unidad de Trastornos de Identidad de Género del Hospital Ramón y Cajal parte de un enfoque multidisciplinar y se basa en que el tratamiento no debe limitarse al médico (hormonal y cirugía de reasignación de sexo) sino que es fundamental la intervención psicológica. Este proceso multidisciplinar exige varias fases de evaluación psicológica. La intervención psicológica debe ser individualizada y los objetivos terapéuticos que se plantean son, entre otros, apoyo en dificultades cognitivas o emocionales, desarrollo de estrategias de afrontamiento y adherencia al tratamiento médico (AU)

Transsexuality is an emergent phenomenon in our society. It means, that a person belonging to one biological sex feels that he/she belongs to the opposite one. The Gender Identity Disorder Unit of Madrid is achieving a cross-disciplinary approach. This approach is not just based on medical treatment, or hormonal or surgical treatments, but psychological treatment is also essential. This cross-disciplinary process requires several stages of psychological assessment. Psychological treatment must be individualized. The therapeutic goals should be: Support in cognitive and emotional difficulties, the development of coping skills, and adherence to the medical treatment (AU)

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.

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.

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.

Sexualidad y reproducción, un campo importante de la endocrinología / Sexuality and reproduction, an important field in endocrinology

El Grupo de Trabajo sobre Trastornos de Identidad de Género fue creado como respuesta a la, cada vez más frecuente, necesidad de asistencia médica del transexualismo. Después de algunos años, el grupo decidió extenderse hacia el campo de la sexualidad y la reproducción, porque este tema no está suficientemente desarrollado por los endocrinólogos españoles. La sobrecarga asistencial provocada por otras enfermedades más prevalentes, el papel secundario adjudicado a los endocrinólogos por instituciones públicas y privadas, o las dificultades diagnósticas y terapéuticas, pueden haber contribuido a la falta de endocrinólogos interesados en este campo. Por ello, nuestro grupo de trabajo intenta abordar cuadros clínicos cuyo origen o consecuencia están, directa o indirectamente, relacionados con alteraciones de la función gonadal (masculina o femenina). Estas alteraciones, principalmente hormonales, precipitarán diversos trastornos en múltiples órganos y sistemas. Estos diferentes cuadros han propiciado que otras disciplinas (ginecología, urología, medicina interna, cardiología, traumatología, dermatología, geriatría, etc.) asuman el protagonismo, tanto a escala asistencial como en el terreno de la investigación. Así, nosotros creemos que el desarrollo asistencial, docente e investigador de enfermedades con un sustrato hormonal (y específicamente gonadal) tiene que contar con un punto de vista endocrinológico, y esta tarea es la razón de ser de las actividades de nuestro grupo

The Gender Dysphoria Working Group was created in response to an increasing need for the medical care of transsexualism. After several years, the Group decided to extend its activity to the field of sexuality and reproduction because insufficient attention is paid to this topic by Spanish endocrinologists. Factors contributing to the lack of endocrinologists interested in this field include the burden of medical care produced by other, more prevalent diseases, the secondary role assigned to endocrinologists by public and private institutions, and the diagnostic and therapeutic difficulties associated with this field. Therefore, our Working Group aims to deal with clinic pictures whose origins or consequences are directly or undirectly related to alterations in gonadal function (male or female). These alterations, which are mainly hormonal, precipitate diverse disorders in many organs and systems. Because the clinical pictures are so varied, other disciplines (gynecology, urology, internal medicine, cardiology, traumatology, dermatology, geriatrics, etc.) have taken on the leading role in the clinical and research settings. We believe that the field of endocrinology should play a role in the clinical, teaching and research activity performed as a result of diseases with a hormonal substratum (and specifically gonadal), a task which is the raison d'être for the activities of our Group

Actualizaciones en terapia sexual / Update in sex therapy

Dada la relevancia que ha presentado históricamente la terapia sexual, a partir de Masters y Johnson y el desarrollo de sus abordajes en disfunciones sexuales, se realiza una revisión del estado actual de las teorías, tratamientos y técnicas de los últimos 24 años en materia. Los hallazgos indican que las investigaciones son relativamente escasas y que los modelos explicativos no han sido suficientemente desarrollados por los psicólogos investigadores. Aún así todos los datos apuntan a señalar que una amplia variedad de técnicas y tratamientos específicos para disfunciones sexuales resultan eficaces. Por último, habría que destacar la necesidad de que la psicología mantenga su presencia en el área y continué investigando en conjunto con otras ciencias, de modo de mantenerse vigente y sumar esfuerzos en un terreno especialmente importante para los individuos.

Management of secondary-progressive multiple sclerosis.

The majority of patients with relapse-onset multiple sclerosis (MS) will go on to develop secondary-progressive MS (SPMS) disease, with approximately 50% developing SPMS after 10 years. It remains unknown whether the relapsing and progressive phases of MS differ qualitatively. The pathogenesis of SPMS is poorly understood. The specific role that inflammation plays in disease progression is not well defined. Immunosuppressive therapies, which are capable of reducing or stopping clinical relapses and suppressing MRI activity, generally do not stop disease progression. Recent natural history studies suggest that disease progression occurs regardless of the presence of superimposed relapses. However, poor recovery from clinical relapses does account for the acquisition of disability. Therefore, stopping relapses with appropriate therapy delays the acquisition of disability but does not necessarily delay or prevent the development of SPMS. At present, the only disease-modifying therapies licensed for use in SPMS are interferon-beta-1b in Europe and the US, and mitoxantrone in the US. These agents can only be recommended for patients who continue to have relapses. Symptomatic therapies remain the cornerstone of treatment for patients with SPMS. Delivering high-quality, effective symptomatic therapies requires a multidisciplinary approach. The aim of symptomatic therapies should not only be to reduce neurological impairments but also to decrease disability and handicap and to improve the emotional well-being and health-related quality of life of patients with SPMS.