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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 1-4

Approach to transgender individuals


1 Department of Endocrinology and Metabolism, Ege University, Izmir, Turkey
2 Department of Child Psychiatry, Ege University, Izmir, Turkey
3 Department of Psychiatry, Ege University, Izmir, Turkey

Date of Submission03-Jun-2016
Date of Acceptance24-Jul-2016
Date of Web Publication12-Jun-2017

Correspondence Address:
Nilufer O Kutbay
Department of Endocrinology and Metabolism, Ege University, Bornova, Izmir 35100
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-7782.207782

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  Abstract 

Background
Trans-sexualism is the desire to be a member of the opposite sex during normal somatic sexual development. In this study, we would like to share our endocrinological approach and general clinical features of the patients with gender identity disorder.
Patients and methods
General and clinical features of 63 patients who were referred to Endocrinology Department between October 2012 and March 2014 were investigated retrospectively. In the beginning of the therapy, and later periodically, the patients were physically examined and their basal hormones and biochemical data were evaluated.
Results
Forty-eight (76.2%) patients constituted the female-to-male (FtM) group, and 15 (23.8%) patients constituted the male-to-female (MtF) group. The mean age was 25.0±4.6 in the FtM group and 24.9±5.9 in the MtF group. In the FtM group, 28 patients used testosterone preparations as cross-sex hormone, whereas 20 did not. Five (10.4%) patients had already used this preparation before they applied to us. Seven patients underwent mastectomy and four underwent oophorectomy. Penile prosthesis was implanted in one patient with reconstructive surgery. In the MtF group, nine patients used estradiol preparation. In the MtF group, three patients underwent breast implant surgery. Reconstructive surgery or orchiectomy was not performed.
Conclusion
The cross-sex hormone therapy provides the development of secondary sex characteristics and must also be given as a replacement therapy after gonadectomy.

Keywords: gender identity disorder, hormone therapy, sex-reassignment, trans-sexualism


How to cite this article:
Kutbay NO, Yurekli BS, Baykan EK, Ozbaran NB, Elbi H, Saygili F. Approach to transgender individuals. Egypt J Intern Med 2017;29:1-4

How to cite this URL:
Kutbay NO, Yurekli BS, Baykan EK, Ozbaran NB, Elbi H, Saygili F. Approach to transgender individuals. Egypt J Intern Med [serial online] 2017 [cited 2017 Aug 23];29:1-4. Available from: http://www.esim.eg.net/text.asp?2017/29/1/1/207782


  Introduction Top


Sex identity can be described as a person’s fundamental sense of being a man, woman or of indeterminate sex [1]. Trans-sexualism is the desire to be a member of the opposite sex during normal somatic sexual development [2]. The diagnosis of gender identity disorder (GID) is specified by the Clinic of Psychiatry. The cases are assessed in terms of the persistency of this desire and other mental disorders. The rate of male-to-female (MtF) trans-sexuals to female-to-male (FtM) ones is 3 : 1 in the western countries. In this study, we would like to share our endocrinological approach and general clinical features of the patients with GID at Ege University, Department of Endocrinology.


  Patients and methods Top


General and clinical features of 63 patients who were diagnosed with GID in Psychiatry Department and referred to Endocrinology Department between October 2012 and March 2014 were investigated retrospectively. As for our hospital policy, the patients with GID are taken to therapy groups for 2 years by Psychiatry Department. In the beginning of the therapy and later periodically, the patients are physically examined and their basal hormones and biochemical data are evaluated. After 1 year of therapy, cross-sex hormone replacement treatment starts. In the patients with cross-sex hormone treatment, regular liver function test, complete blood count, and hormone profiles are obtained. However, the laboratory parameters before and after cross-sex hormone treatment of our patients were not statistically compared due to the low number of cases in our study.


  Results Top


Forty-eight (76.2%) individuals constituted the FtM group, and 15 (23.8%) individuals constituted the MtF group. The mean age was 25.0±4.6 years in FtM group and 24.9±5.9 years in MtF group. Polycystic ovary syndrome existed in 16.7% of the FtM group. Basic laboratory and basal hormone values are shown in [Table 1]. In the FtM group, 28 patients used testosterone preparations as cross-sex hormone, whereas 20 did not. Five (10.4%) patients had already used this preparation before they applied to us. Seven patients underwent mastectomy and four underwent oophorectomy. Penile prosthesis was implanted in one patient with reconstructive surgery.
Table 1 Basal biochemical and hormonal measurements

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In the MtF group, nine patients used estrogen preparation. The patients had usually preferred estradiol valerate, estradiol cypionate, and depot progesterone preparations in injection form as hormone therapy, and six had used antiandrogen before they were referred to us. Hormone usage rate was 60% before their applications. In our clinic, estradiol patch or 17β estradiol is preferred for estrogen therapy. In the MtF group, three patients underwent breast implant surgery. Reconstructive surgery or orchiectomy was not performed ([Table 2]).
Table 2 Features of our female-to-male and male-to-female trans-sexual patients

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  Discussion Top


Trans-sexualism is a GID defined as a persistent conflict between one’s biological sex and desired sex. One perceives inappropriateness of the individual’s biological sex and desires to live and be accepted as a member of the opposite sex [3].

Individuals with GID are sometimes accompanied by psychiatric comorbidities. Thus, possible GID cases and their parents should be evaluated by a psychiatrist as regards general and psychosocial development. The GID is diagnosed by a psychiatry specialist according to Diagnostic and statistical manual of mental disorders, 4th ed., text revised (DSM-IV-TR) and International Classification of Disease-10 (ICD-10) criteria. ICD-10 declares that GID is disparity between biological and desired sex of the individual and the constant desire for living and be accepted in opposite sex. The individual with GID seeks for hormonal therapy and sex-reassignment surgery to provide adjustment of body to the desired sex [4]. The term ‘Gender Identity Disorder’ in DSM-IV-TR was replaced with ‘Gender Dysphoria’ in DSM-V published in 2013 [5].

The statement of ‘trans-sexualism’ was first reported by Hirschfeld. The Harry Benjamin International Gender Dysphoria Association was founded in 1979 and this association reported the standards of the treatment and follow-up of GID for the first time in 1979. The European Society of Endocrinology, European Society of Pediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association of Transgender Health published a guideline related to endocrinological treatment of transgender individuals [6]. Gender dysphoria can be identified as a discomfort or distress, which is caused by a difference between a person’s sex identity and that person’s sex assigned at birth. Although trans-sexual, transgender, and gender-nonconforming people may experience gender dysphoria at times, many people who receive treatment will find a sex role and expression that is comfortable for them [7].

Olyslager and Conway [8] reported that the rate of trans-sexualism was 1/500 according to the data of sex-reassignment surgery. Rate of MtF trans-sexuals was 1/3.639 and that of FtM trans-sexuals was 1/22.714 according to the prevalence studies performed in New Zealand [9]. Forty-eight of our 63 (76.2%) patients were FtM trans-sexuals; 15 (23.8%) of them were MtF trans-sexuals ([Table 1] and [Table 2]). FtM trans-sexuals were more in number in our study population when compared with the literature data. Differences in cultural issues could be a reason for the diversity in the ratio of trans-sexuals. MtF trans-sexuals in our country take their hormone medications and sex-reassignment surgery without the support of Social Security Institution.

Biological and psychosocial factors may have a role in the etiology of trans-sexualism. Zhau et al. [10] has shown that there is a similarity of the bed nucleus of the stria terminalis (BNST) region in the brain between female and MtF trans-sexuals. BNST is a heterogeneous and complex limbic forebrain structure, which plays an important role in controlling autonomic, neuroendocrine, and behavioral responses. In men, the BNST volume is twice as large as that in women. A MtF trans-sexual has BNST volume similar to that of female [10]. Exposure to androgens in prenatal period could lead to the development of male gender identity. The possibility of being trans-sexual in girls with congenital adrenal hyperplasia is higher but the rate of trans-sexuality is 1–3% [11]. The hormone levels of our cases were compatible with their biologic sexes. There were a few studies in the literature indicating the association of polycystic ovary disease with FtM trans-sexuality [12],[13]. The rate of polycystic ovary disease was 16.7% in our FtM trans-sexual patients ([Table 2]).

The GID could be together with psychiatric problems. For this reason, patients should be evaluated with their parents as regards their psychosocial developments. Before hormonal drug therapy, diagnosis should be made by a psychiatry specialist in line with the ICD-10, DSM-IV, and DSM-V criteria. Approach to this group of patients should be multidisciplinary, including a psychiatrist, an endocrinologist, a gynecologist, and a urologist. After GID was diagnosed, possible side effects of hormonal should be explained to the patients [6].

After the evaluation by a psychiatry specialist, the real life experience (RLE) period, in which the individual lives according to the desired sex before irreversible hormonal and surgical therapies, begins. After that, endocrinologist starts cross-sex hormone therapy if there is no contradictory state. Hormone therapy is started at least 3 months after the RLE period. GID could be evaluated more accurately after pubertal signs begin. In the light of clinical evidence, hormonal therapy is not recommended for those under 16 years of age. The reversible and irreversible effects of hormone therapy should be explained and information about fertility should be given.

The aim of cross-sex hormone therapy is to provide regression of secondary sex characteristics of original sex. Besides, this type of therapy causes the features of desired sex to build. Cross-sex hormone therapy has some unwanted side effects such as thromboembolism and breast cancer. Thus, follow-up at regular intervals becomes very important in this respect [1].

Our cases were enrolled into a group therapy after personal interview by the psychiatry team. After this process, the patients were sent to Endocrinology Department for the hormone therapy. At the beginning of group therapy, physical examination and basal hormonal and biochemical evaluations were performed. After a year of group therapy, cross-sex hormone therapy was started. The patients were followed-up for the measurement of liver function test, lipid profile, complete blood count, and hormone levels.

It was witnessed that MtF patients were taking estrogens such as estradiol valerate and estradiol cypionate injection by themselves without a prescription. Unnecessarily, they also used progesterone pills. In our practice, oral or patch estradiol was used as replacement. Spironolactone (100–200 mg/day) and cyproterone acetate (50–100 mg/day) were preferred as antiandrogen therapy. Sex-reassignment surgery was recommended for patients over 18 years who lived RLE period, completed group therapy, and were taking cross-sex hormone therapy without any complications [14].In our country, the status of trans-sexuals in the Turkish Civil Code was arranged according to the Article 40. According to this article, any person who wants to alter his or her sex may invoke to be given permission for alteration of sex by applying to court in person. However, the applicant must be 18 years of age and unmarried. Besides, he/she must be in trans-sexual nature and prove indispensability of sex alteration in respect to his/her mental health and his/her permanent infertility through a report of a board of health provided from a medical education and research hospital. When an official health report confirming the sex alteration surgery has been conducted properly in line with its purpose, the court may decide to make the required correction in the civil status of the patient [15].

Studies by Asscheman et al. [16] did not show an increase in mortality rates in individuals receiving cross-sex hormones compared with the general population; however, they reported higher rates of completed suicide and death due to AIDS in MtF trans-sexual individuals. In addition, no increased morbidity/mortality was seen in FtM trans-sexual individuals.

Although cross-sex hormone therapy provides secondary sex characteristics, it also has a role in hormone replacement therapy after gonadectomy. Trans-sexual individuals should be followed-up for cardiovascular, bone health, and side effects of hormone therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA. Endocrine Society. An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2009; 94:3132–3154.  Back to cited text no. 1
    
2.
Costa EM, Mendonca BB. Clinical management of transsexual subjects. Arq Bras Endocrinol Metabol 2014; 58:188–196.  Back to cited text no. 2
    
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Childs JM. Transsexualism: some theological and ethical perspectives. Dialog J Theol 2009; 48:30–41.  Back to cited text no. 3
    
4.
International Statistical Classification of Diseases and Related Health Problems, Section V Mental and behavioural disorders, F64 Gender identity disorders, 10th Revision, Version 2015.  Back to cited text no. 4
    
5.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Press Inc; 2013.  Back to cited text no. 5
    
6.
Adrenal ve Gonadal Hastalıklar Kılavuzu 2014. Available at: http://www.turkendokrin.org/files/file/ADRENAL_TTK_web.pdf.  Back to cited text no. 6
    
7.
International Journal of Transgenderism. 2012; 13:165–232. doi:10.1080/15532739.2011.700873.  Back to cited text no. 7
    
8.
Olyslager F, Conway L. On the calculation of the prevalence of transsexualism. Chicago, Illinois, USA: WPATH 20th International Symposium; 6 September 2007.  Back to cited text no. 8
    
9.
Veale FV. Prevalence of transsexualism among New Zealand passport holders. Aust N Z J Psychiatry 2008; 42:887–889.  Back to cited text no. 9
    
10.
Zhau JN, Hofman MA, Gooren LJ, Swaab DF. A sex difference in the human brain and its relation to transsexuality. Nature 1995; 378:68–70.  Back to cited text no. 10
    
11.
Zucker KJ, Bradley SJ, Oliver G, Blake J, Fleming S, Hood J. Psychosexual development of women with congenital adrenal hyperplasia. Horm Behav 1996; 30:300–318.  Back to cited text no. 11
    
12.
Bosinski HAG, Peter M, Bonatz G, Arndt R, Heidenreich M, Sippell WG, Wille R. A higher rate of hyperandrogenic disorders in female-to-male transsexuals. Psychoneuroendocrinology 1997; 22:361–380.  Back to cited text no. 12
    
13.
Baba T, Endo T, Ikeda K, Shimizu A, Honnma H, Ikeda H et al. Distinctive features of female-to-male transsexualism and prevalence of gender identity disorders in Japan. J Sex Med 2011; 8:1686–1693.  Back to cited text no. 13
    
14.
Royal College of Psychiatrists. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. London: Royal College of Psychiatrists; 2013.  Back to cited text no. 14
    
15.
Turkish Civil Code, Law N. 4721, dated 7/12/2002, Article 40, Ankara.  Back to cited text no. 15
    
16.
Asscheman H, Giltay EJ, Megens JA, de Ronde WP, van Trotsenburg MA, Gooren LJ. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635–642.  Back to cited text no. 16
    



 
 
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