This research was supported by grants from the Nationaal Fonds Geestelijke Volksgezondheid, Stich... more This research was supported by grants from the Nationaal Fonds Geestelijke Volksgezondheid, Stichting Kinderpostzegels Nederland, Wetenschappelijk Onderzoek-en Documentatiecentrum van het Ministerie van Justitie. We thank J. E. Lochman (University of Alabama) and K. C. Wells (Duke University) for enabling us to use their manuals. We thank J. E. Lochman and E. Buskens (University Medical Center Utrecht, Department Julius Center) for their helpful suggestions and comments. We thank all the participating institutions: the Department of Child and Adolescent Psychiatry of the University Medical Center Utrecht; the Department of Child and Adolescent Psychiatry of the Psychiatric Center Zon & Schild (i.e., Symfora Group), called Fornhese, in Amersfoort, and the Meregaard in Almere; the Department of Child and Adolescent Psychiatry of the Psychiatric Hospital Veldwijk in Ermelo (recently fused into Meerkanten GGz), called the Riethorst; the Regional Institutions for Outpatient Mental Health Care in Utrecht (recently fused into Altrecht) and the Regional Institution for Outpatient Mental Health Care in Lelystad. We thank A. Planje-Spek and J. de Bruin for their contributions in conducting the UCPPtreatment, and R van Houtem for her assistance in data collection.
Journal of Child and Adolescent Psychopharmacology, 1995
Remoxipride is a dopamine antagonist with more selective affinity for the mesolimbic dopaminergic... more Remoxipride is a dopamine antagonist with more selective affinity for the mesolimbic dopaminergic system than conventional neuroleptic agents. The possible therapeutic and adverse effects of remoxipride were investigated in 7 adolescents with Tourette's syndrome in an open-label pilot study. The design included a 3-week baseline placebo washin period, an 8-week active treatment period, and a 3-week placebo washout period. Active treatment with remoxipride was administered in the dose range of 50-250 mg daily. Remoxipride treatment improved severity of illness ratings in 6 patients and diminished tic ratings in all 7 patients. During the placebo washout period, all patients deteriorated both on the severity of illness and on the tic ratings. In a sustained attention task, a slight reduction of workpace was observed, but accuracy and stability of performance were not affected. Verbal and visual memory functioning also remained intact. Adverse effects were few and mild in severity. Treatment-emergent nonspecific ST-T changes on the electrocardiogram were found in 3 patients and bradycardia in 2 patients. Although remoxipride has been withdrawn from the market in 1994 because of aplastic anemia, these preliminary findings suggest that Tourette's syndrome in adolescents might be improved by a dopamine antagonist with high specificity for D2 receptors in the mesolimbic system.
Abstract  Transseksuelen zijn mensen die zich sterk en persistent met het andere geslacht identif... more Abstract  Transseksuelen zijn mensen die zich sterk en persistent met het andere geslacht identificeren en een permanente onvrede hebben met hun anatomisch geslacht of zich zeer onbehaaglijk voelen in de genderrol behorend bij hun eigen biologisch geslacht (Cohen-Kettenis, 2000). In de dsm-iv wordt voor deze problematiek de term ‘genderidentiteitsstoornis’ gehanteerd.
I. Introductory Concepts (p. 1) II. Epidemiological Considerations (p. 2) III. Diagnostic Nomencl... more I. Introductory Concepts (p. 1) II. Epidemiological Considerations (p. 2) III. Diagnostic Nomenclature (p. 3) IV. The Mental Health Professional (p. 6) V. Assessment and Treatment of Children and Adolescents (p. 8) VI. Psychotherapy with Adults (p. 11) VII. Requirements for Hormone Therapy for Adults (p. 13) VIII. Effects of Hormone Therapy in Adults (p. 14) IX. The Real-life Experience (p. 17) X. Surgery (p. 18) XI. Breast Surgery (p. 19) XII. Genital Surgery (p. 20) XIII. Post-Transition Follow-up (p. 22) I. Introductory Concepts The Purpose of the Standards of Care. The major purpose of the Standards of Care (SOC) is to articulate this international organization's professional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders. Professionals may use this document to understand the parameters within which they may offer assistance to those with these conditions. Persons with gender identity disorders, their families, and social institutions may use the SOC to understand the current thinking of professionals. All readers should be aware of the limitations of knowledge in this area and of the hope that some of the clinical uncertainties will be resolved in the future through scientific investigation. The Overarching Treatment Goal. The general goal of psychotherapeutic, endocrine, or surgical therapy for persons with gender identity disorders is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment. The Standards of Care Are Clinical Guidelines. The SOC are intended to provide flexible directions for the treatment of persons with gender identity disorders. When eligibility
The Rorschach Comprehensive System was used to assess postoperative psychological functioning in ... more The Rorschach Comprehensive System was used to assess postoperative psychological functioning in transsexuals who applied for sex reassignment in adolescence. We investigated a group of 22 consecutive adolescent transsexuals, who were otherwise psychologically well adapted. Nineteen subjects provided valid Rorschach protocols before and after sex reassignment. The most notable change found was an increase in X+%, reflecting a decrease in both distorted perception and idiosyncratic perception. Little support was found for the idea of major psychological deterioration for the patients as a group. Rather, the results suggest stability in psychological functioning over time. The Rorschach findings are consistent with questionnaire data from earlier studies, with the exception that the Rorschach data may point to some improvement in reality testing.
Child and Adolescent Psychiatric Clinics of North America, 2011
Adolescents with gender dysphoria seek help for a variety of problems. Some have intense distress... more Adolescents with gender dysphoria seek help for a variety of problems. Some have intense distress about the incongruence between their natal sex and gender identity and expect that clinicians will provide them with hormones and gender reassignment (GR) surgery as quickly as possible. Others feel only some unease with or confusion about their gender identity and try to find ways to live with these feelings. The gender dysphoria may have started long before puberty or be recent. It might have been a response to certain experiences or have been present without a clear starting point. There are also huge differences between adolescents in their ability to handle the complexities and adversities that often accompany gender variance. The ways in which the environment has responded to their gender variant behavior can vary from accepting and supporting to rejecting and stigmatizing. When these adolescents present at clinics, they may have a broad range of coexisting psychiatric problems. In recent years, many of these youth have come to gender identity clinics with a straight focus on GR (ie, cross-sex hormone treatment and surgery). However, not only in adult gender identity clinics but also in clinics treating adolescents, nonclassic presentations increasingly need a diagnosis and some form of treatment. 1 In 1987, the first gender identity clinic for children and adolescents was opened in the Netherlands at what is now called the Center of Expertise on Gender Dysphoria. Since then more than 800 children and adolescents have attended the gender identity clinic. Meanwhile, ideas about treatment have greatly changed. Diagnostic protocols and instruments for adolescents have been developed, and medical interventions, The authors have nothing to disclose.
Two studies were undertaken to confirm the previous findings that homosexual men in general tend ... more Two studies were undertaken to confirm the previous findings that homosexual men in general tend to have a later than expected birth order and that extremely feminine homosexual men also tend to have a higher than expected proportion of brothers (ie, a higher sibling sex ratio). ...
Research on the psychological development of persons with Disorders of Sex Development (DSD) has ... more Research on the psychological development of persons with Disorders of Sex Development (DSD) has focused on understanding the influence of atypical sex hormone exposure during steroid-sensitive periods of prenatal brain development on the process of psychosexual differentiation (i.e., gender identity, gender role, and sexual orientation). In contrast, analysis of clinical management strategies has focused on gender assignment and the desirability and timing of genital surgery. This review focuses on the psychological issues that confront clinicians managing the care of persons born with DSD and their families. Particular attention is paid to processes and factors that potentially mediate or moderate psychosocial and psychosexual outcomes within and across developmental stages.
Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a dia... more Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13Â years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22Â years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.
The aim of this study was (a) to show that different measures of spatial cognition are modulated ... more The aim of this study was (a) to show that different measures of spatial cognition are modulated by the menstrual cycle and (b) to analyze which steroid is responsible for these cognitive alterations. The authors collected blood samples in 3-day intervals over six weeks from 12 young women with a regular menstrual cycle to analyze concentrations of estradiol, progesterone, testosterone, luteinizing hormone, and folliclestimulating hormone. The performance on 3 spatial tests was measured during the menstrual and the midluteal phase. A significant cycle difference in spatial ability as tested by the Mental Rotation Test was found, with high scores during the menstrual phase and low scores during the midluteal phase. Testosterone had a strong and positive influence on mental rotation performance, whereas estradiol had a negative one. These results clearly indicate that testosterone and estradiol are able to modulate spatial cognition during the menstrual cycle.
The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming ... more The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression. This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous revisions were in
This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male ... more This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male transsexuals and 105 male-to-female transsexuals in the Netherlands. Data were collected by means of structured interviews. The evaluation was made on the basis of subjective data only, that is on what the persons themselves reported on their gender identity, gender role, and physical condition. Allowing for the restrictive methodology of the (ex post facto) study, it is concluded that there is no reason to doubt the therapeutic effect of sex reassignment surgery. No specific differences were found between those who were still in medical treatment and those who had completed treatment. The findings obtained in the female-to-male transsexuals compare favorably with those obtained in male-to-female transsexuals. Finally, the conclusion is drawn that more attention ought to be paid to psychosocial guidance in addition to medical guidance.
1 fessional consensus about the psychiatric, psychological, medical, and surgical management of g... more 1 fessional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders. Professionals may use this document to understand the parameters within which they may offer assistance to those with these ...
This research was supported by grants from the Nationaal Fonds Geestelijke Volksgezondheid, Stich... more This research was supported by grants from the Nationaal Fonds Geestelijke Volksgezondheid, Stichting Kinderpostzegels Nederland, Wetenschappelijk Onderzoek-en Documentatiecentrum van het Ministerie van Justitie. We thank J. E. Lochman (University of Alabama) and K. C. Wells (Duke University) for enabling us to use their manuals. We thank J. E. Lochman and E. Buskens (University Medical Center Utrecht, Department Julius Center) for their helpful suggestions and comments. We thank all the participating institutions: the Department of Child and Adolescent Psychiatry of the University Medical Center Utrecht; the Department of Child and Adolescent Psychiatry of the Psychiatric Center Zon & Schild (i.e., Symfora Group), called Fornhese, in Amersfoort, and the Meregaard in Almere; the Department of Child and Adolescent Psychiatry of the Psychiatric Hospital Veldwijk in Ermelo (recently fused into Meerkanten GGz), called the Riethorst; the Regional Institutions for Outpatient Mental Health Care in Utrecht (recently fused into Altrecht) and the Regional Institution for Outpatient Mental Health Care in Lelystad. We thank A. Planje-Spek and J. de Bruin for their contributions in conducting the UCPPtreatment, and R van Houtem for her assistance in data collection.
Journal of Child and Adolescent Psychopharmacology, 1995
Remoxipride is a dopamine antagonist with more selective affinity for the mesolimbic dopaminergic... more Remoxipride is a dopamine antagonist with more selective affinity for the mesolimbic dopaminergic system than conventional neuroleptic agents. The possible therapeutic and adverse effects of remoxipride were investigated in 7 adolescents with Tourette's syndrome in an open-label pilot study. The design included a 3-week baseline placebo washin period, an 8-week active treatment period, and a 3-week placebo washout period. Active treatment with remoxipride was administered in the dose range of 50-250 mg daily. Remoxipride treatment improved severity of illness ratings in 6 patients and diminished tic ratings in all 7 patients. During the placebo washout period, all patients deteriorated both on the severity of illness and on the tic ratings. In a sustained attention task, a slight reduction of workpace was observed, but accuracy and stability of performance were not affected. Verbal and visual memory functioning also remained intact. Adverse effects were few and mild in severity. Treatment-emergent nonspecific ST-T changes on the electrocardiogram were found in 3 patients and bradycardia in 2 patients. Although remoxipride has been withdrawn from the market in 1994 because of aplastic anemia, these preliminary findings suggest that Tourette's syndrome in adolescents might be improved by a dopamine antagonist with high specificity for D2 receptors in the mesolimbic system.
Abstract  Transseksuelen zijn mensen die zich sterk en persistent met het andere geslacht identif... more Abstract  Transseksuelen zijn mensen die zich sterk en persistent met het andere geslacht identificeren en een permanente onvrede hebben met hun anatomisch geslacht of zich zeer onbehaaglijk voelen in de genderrol behorend bij hun eigen biologisch geslacht (Cohen-Kettenis, 2000). In de dsm-iv wordt voor deze problematiek de term ‘genderidentiteitsstoornis’ gehanteerd.
I. Introductory Concepts (p. 1) II. Epidemiological Considerations (p. 2) III. Diagnostic Nomencl... more I. Introductory Concepts (p. 1) II. Epidemiological Considerations (p. 2) III. Diagnostic Nomenclature (p. 3) IV. The Mental Health Professional (p. 6) V. Assessment and Treatment of Children and Adolescents (p. 8) VI. Psychotherapy with Adults (p. 11) VII. Requirements for Hormone Therapy for Adults (p. 13) VIII. Effects of Hormone Therapy in Adults (p. 14) IX. The Real-life Experience (p. 17) X. Surgery (p. 18) XI. Breast Surgery (p. 19) XII. Genital Surgery (p. 20) XIII. Post-Transition Follow-up (p. 22) I. Introductory Concepts The Purpose of the Standards of Care. The major purpose of the Standards of Care (SOC) is to articulate this international organization's professional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders. Professionals may use this document to understand the parameters within which they may offer assistance to those with these conditions. Persons with gender identity disorders, their families, and social institutions may use the SOC to understand the current thinking of professionals. All readers should be aware of the limitations of knowledge in this area and of the hope that some of the clinical uncertainties will be resolved in the future through scientific investigation. The Overarching Treatment Goal. The general goal of psychotherapeutic, endocrine, or surgical therapy for persons with gender identity disorders is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment. The Standards of Care Are Clinical Guidelines. The SOC are intended to provide flexible directions for the treatment of persons with gender identity disorders. When eligibility
The Rorschach Comprehensive System was used to assess postoperative psychological functioning in ... more The Rorschach Comprehensive System was used to assess postoperative psychological functioning in transsexuals who applied for sex reassignment in adolescence. We investigated a group of 22 consecutive adolescent transsexuals, who were otherwise psychologically well adapted. Nineteen subjects provided valid Rorschach protocols before and after sex reassignment. The most notable change found was an increase in X+%, reflecting a decrease in both distorted perception and idiosyncratic perception. Little support was found for the idea of major psychological deterioration for the patients as a group. Rather, the results suggest stability in psychological functioning over time. The Rorschach findings are consistent with questionnaire data from earlier studies, with the exception that the Rorschach data may point to some improvement in reality testing.
Child and Adolescent Psychiatric Clinics of North America, 2011
Adolescents with gender dysphoria seek help for a variety of problems. Some have intense distress... more Adolescents with gender dysphoria seek help for a variety of problems. Some have intense distress about the incongruence between their natal sex and gender identity and expect that clinicians will provide them with hormones and gender reassignment (GR) surgery as quickly as possible. Others feel only some unease with or confusion about their gender identity and try to find ways to live with these feelings. The gender dysphoria may have started long before puberty or be recent. It might have been a response to certain experiences or have been present without a clear starting point. There are also huge differences between adolescents in their ability to handle the complexities and adversities that often accompany gender variance. The ways in which the environment has responded to their gender variant behavior can vary from accepting and supporting to rejecting and stigmatizing. When these adolescents present at clinics, they may have a broad range of coexisting psychiatric problems. In recent years, many of these youth have come to gender identity clinics with a straight focus on GR (ie, cross-sex hormone treatment and surgery). However, not only in adult gender identity clinics but also in clinics treating adolescents, nonclassic presentations increasingly need a diagnosis and some form of treatment. 1 In 1987, the first gender identity clinic for children and adolescents was opened in the Netherlands at what is now called the Center of Expertise on Gender Dysphoria. Since then more than 800 children and adolescents have attended the gender identity clinic. Meanwhile, ideas about treatment have greatly changed. Diagnostic protocols and instruments for adolescents have been developed, and medical interventions, The authors have nothing to disclose.
Two studies were undertaken to confirm the previous findings that homosexual men in general tend ... more Two studies were undertaken to confirm the previous findings that homosexual men in general tend to have a later than expected birth order and that extremely feminine homosexual men also tend to have a higher than expected proportion of brothers (ie, a higher sibling sex ratio). ...
Research on the psychological development of persons with Disorders of Sex Development (DSD) has ... more Research on the psychological development of persons with Disorders of Sex Development (DSD) has focused on understanding the influence of atypical sex hormone exposure during steroid-sensitive periods of prenatal brain development on the process of psychosexual differentiation (i.e., gender identity, gender role, and sexual orientation). In contrast, analysis of clinical management strategies has focused on gender assignment and the desirability and timing of genital surgery. This review focuses on the psychological issues that confront clinicians managing the care of persons born with DSD and their families. Particular attention is paid to processes and factors that potentially mediate or moderate psychosocial and psychosexual outcomes within and across developmental stages.
Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a dia... more Puberty suppression by means of gonadotropin releasing hormone (GnRH) analogs is considered a diagnostic aid in gender dysphoric adolescents. However, there are also concerns about potential risks, such as poor outcome or post-surgical regret, adverse effects on metabolic and endocrine status, impaired increment of bone mass, and interference with brain development. This case report is on a 22-year follow-up of a female-to-male transsexual, treated with GnRH analogs at 13Â years of age and considered eligible for androgen treatment at age 17, and who had gender reassignment surgery at 20 and 22Â years of age. At follow-up, he indicated no regrets about his treatment. He was functioning well psychologically, intellectually, and socially; however, he experienced some feelings of sadness about choices he had made in a long-lasting intimate relationship. There were no clinical signs of a negative impact on brain development. He was physically in good health, and metabolic and endocrine parameters were within reference ranges. Bone mineral density was within the normal range for both sexes. His final height was short as compared to Dutch males; however, his body proportions were within normal range. This first report on long-term effects of puberty suppression suggests that negative side effects are limited and that it can be a useful additional tool in the diagnosis and treatment of gender dysphoric adolescents.
The aim of this study was (a) to show that different measures of spatial cognition are modulated ... more The aim of this study was (a) to show that different measures of spatial cognition are modulated by the menstrual cycle and (b) to analyze which steroid is responsible for these cognitive alterations. The authors collected blood samples in 3-day intervals over six weeks from 12 young women with a regular menstrual cycle to analyze concentrations of estradiol, progesterone, testosterone, luteinizing hormone, and folliclestimulating hormone. The performance on 3 spatial tests was measured during the menstrual and the midluteal phase. A significant cycle difference in spatial ability as tested by the Mental Rotation Test was found, with high scores during the menstrual phase and low scores during the midluteal phase. Testosterone had a strong and positive influence on mental rotation performance, whereas estradiol had a negative one. These results clearly indicate that testosterone and estradiol are able to modulate spatial cognition during the menstrual cycle.
The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming ... more The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression. This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous revisions were in
This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male ... more This is an evaluation of the therapeutic effect of sex reassignment surgery on 36 female-to-male transsexuals and 105 male-to-female transsexuals in the Netherlands. Data were collected by means of structured interviews. The evaluation was made on the basis of subjective data only, that is on what the persons themselves reported on their gender identity, gender role, and physical condition. Allowing for the restrictive methodology of the (ex post facto) study, it is concluded that there is no reason to doubt the therapeutic effect of sex reassignment surgery. No specific differences were found between those who were still in medical treatment and those who had completed treatment. The findings obtained in the female-to-male transsexuals compare favorably with those obtained in male-to-female transsexuals. Finally, the conclusion is drawn that more attention ought to be paid to psychosocial guidance in addition to medical guidance.
1 fessional consensus about the psychiatric, psychological, medical, and surgical management of g... more 1 fessional consensus about the psychiatric, psychological, medical, and surgical management of gender identity disorders. Professionals may use this document to understand the parameters within which they may offer assistance to those with these ...
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