Colleges week 9-12
28/11/2022................................................................................................................................................... 2
Introduction of the course....................................................................................................................................2
Etiology of gender dysphoria...............................................................................................................................2
Gender incongruence: classifications, diagnostics, and criteria..........................................................................3
29/11/2022................................................................................................................................................... 4
Gender dysphoria in children and adolescents....................................................................................................4
Long-term outcomes in gender diverse adolescents............................................................................................6
Transwomen orgasms..........................................................................................................................................7
1/12/2022..................................................................................................................................................... 7
Deep vein thrombosis and hemostasis (in transgender care) + pharmacology...................................................7
2/12/2022................................................................................................................................................... 10
Autism and gender diversity..............................................................................................................................10
NBGQ identity.....................................................................................................................................................11
Vragenuur..........................................................................................................................................................12
05/12/2022.................................................................................................................................................. 12
Biology of sex differences, and disorders of sexual development......................................................................12
Endocrine treatment of transgender adults.......................................................................................................14
06/12/2022.................................................................................................................................................. 16
Endocrine treatment of transgender adolescents.............................................................................................16
Cancer risk and mortality...................................................................................................................................18
Bone health........................................................................................................................................................19
08/12/2022.................................................................................................................................................. 21
Toxicology...........................................................................................................................................................21
09/12/2022.................................................................................................................................................. 24
Hormone use, sleep and mood...........................................................................................................................24
Cardiovascular risk in transgender people.........................................................................................................25
12/12/2022.................................................................................................................................................. 26
Fertility in transmasculine..................................................................................................................................26
Fertility transfeminine........................................................................................................................................28
13/12/2022.................................................................................................................................................. 29
Functionality after gender-affirming genital surgery in trans men...................................................................29
Mastectomy and gender-affirming genital surgery in trans men......................................................................30
19/12/2022.................................................................................................................................................. 32
1
, Sexology.............................................................................................................................................................32
Facial surgery.....................................................................................................................................................34
28/11/2022
Introduction of the course
GP waiting list intake endocrinologist = 2-3 years
Diagnostic process psychologist = 6 months
Hormone treatment endocrinologist = 12 months
Surgery: gynaecoloog, plastic surgeon, urologist
Etiology of gender dysphoria
Definition = an incongruence between the experienced gender and the sex assigned at birth
- With distress = gender dysphoria
Harms of research in gender dysphoria: pathologization, stigmatizing, discrimination, risk of
oversimplification, looking for a ‘cure’
Jongens zijn beter met ruimtelijk inzicht, omdat al vanaf jongs af aan jongens speelgoed aan
hun gegeven wordt, zoals speelgoed waarbij je dingen opbouwt
Vaak verschillen tussen genders gevonden bij onderzoeken naar bepaalde eigenschappen,
maar ook heel vaak veel overeenkomsten
Amygdala, hippocampus en insula geven verschillen in volume en weefseldichtheid bij
mannen en vrouwen
implicated in sex-biased neuropsychiatric conditions: depression woman/autism man
Mosaic in the human brain:
- Niet echt dimorfisme extensive overlap between distributions
- Internal consistency extremely rare
- Human brains cannot be categorized into two distinct classes: male of female brain,
regardless of the cause of observed sex/gender differences in brain
Bij transvrouwen: eerst XY en testes wel gevormd zoals bij cisgenders, maar daarna is er
geen/minder T en
Sexual differentiation hypothesis = androgens from testes act early in the development to
cause some regions of the male’s brain to develop differently from those in the female
In 1e trimester is er geslachtsdelen ontwikkeling, in 2e en 3e trimester ontwikkeling van
hersenen
Heteroseksuele vrouw heeft kleinere nucleus dan man, en van een transvrouw lijkt de
nucleus ook op de nucleus van de cisvrouw (rechtsonder lijkt dus op linksboven)
Body perception hypothesis = differences between trans- and cisgender groups in networks
involved in body perception Cause or consequence of gender incongruence?
- TG people seem to present with own unique brain phenotype, rather than shifting
towards one end of male-female spectrum
2
, - More than one explanation
Organizing effects in brain are similar with experienced gender
Not only influence brain on gender, but also gender on brain
Gender incongruence: classifications, diagnostics, and criteria
Genderspectrum & terminology
Sex
- Physical aspects of biological sex
- Chromosomes & physical anatomy
Gender
- The way someone identifies
- Psychosocial aspects – gender role, gender expression
- A social construct
Difference gender role and gender identity
Gender role = behaviour, interests and preferences that in a specific culture and period of
time are perceived as more typical male or female
Gender identity = subjective feeling to belong to one of the two or an alternative gender
Verschillende aspecten gender unicorn
- Gender identity
- Gender expression – feminine, masculine, other
- Sex assigned at birth
- Physically attracted to
- Emotionally attracted to
o Has nothing to do with someone’s gender identity
Genderspectrum
- Shift from binary to variation
- Shift from pathology to diversity
Gender dysphoria: classifications & criteria
ICD 11
- Gender gedrag en voorkeuren is onvoldoende basis om de diagnose te kunnen
stellen
- Diagnosis cannot be assigned prior to the onset of puberty
DSM-5
- A: Er moet incongruentie zijn tussen ervaren gender en geslacht bij geboorte
- B: Incongruentie moet gepaard gaan met klinisch significant lijden
- Diagnose: twee of meer van bepaalde criteria + gepaard met stress/lijdensdruk
3
, -
Changes DSM-5
- Naming: gender dysphoria instead of gender identity disorder
- Positioning in the DSM: separate from paraphilias and sexual dysfunctions
- Letting go of thinking about ‘sex’ and ‘gender’ as binary constructs
- Stricter criteria for gender dysphoria diagnosis in children
DD genderdysphoria: sexuality, hard to give yourself a label because of homophobia
Diagnostics & indication (for medical treatment) at Amsterdam UMC
Change of perspective
1. Gender is a spectrum
2. Gender dysphoria/incongruence is also a spectrum
3. Treatment wishes are not always traditional
Process UMC
- Diagnostics and advice
o Gather information (about nature and degree of gender dysphoria, exploring
treatment wishes and expectations, mapping one’s coping) + fully inform
someone about the treatment process
o Purpose = come to a well-informed decision and indication for gender
affirmative treatment
- Hormone and social transition phase
- Surgical phase (can also be the first step in case of mastectomy)
Indication criteria
- Diagnosis gender dysphoria
- Sufficient capacity, stability, and adequate coping
- Competence and informed consent
- Preferably a social network for support
- Psychiatric comorbidity doesn’t have to be a contra-indication, but parallel care is
then desirable/a requirement
29/11/2022
Gender dysphoria in children and adolescents
Gender role/expression: gender stereotypical behaviors, interests, preferences, personality,
characteristics
Gender identity: the subjective feeling of belonging to or being one of the genders (or
another gender)
4
28/11/2022................................................................................................................................................... 2
Introduction of the course....................................................................................................................................2
Etiology of gender dysphoria...............................................................................................................................2
Gender incongruence: classifications, diagnostics, and criteria..........................................................................3
29/11/2022................................................................................................................................................... 4
Gender dysphoria in children and adolescents....................................................................................................4
Long-term outcomes in gender diverse adolescents............................................................................................6
Transwomen orgasms..........................................................................................................................................7
1/12/2022..................................................................................................................................................... 7
Deep vein thrombosis and hemostasis (in transgender care) + pharmacology...................................................7
2/12/2022................................................................................................................................................... 10
Autism and gender diversity..............................................................................................................................10
NBGQ identity.....................................................................................................................................................11
Vragenuur..........................................................................................................................................................12
05/12/2022.................................................................................................................................................. 12
Biology of sex differences, and disorders of sexual development......................................................................12
Endocrine treatment of transgender adults.......................................................................................................14
06/12/2022.................................................................................................................................................. 16
Endocrine treatment of transgender adolescents.............................................................................................16
Cancer risk and mortality...................................................................................................................................18
Bone health........................................................................................................................................................19
08/12/2022.................................................................................................................................................. 21
Toxicology...........................................................................................................................................................21
09/12/2022.................................................................................................................................................. 24
Hormone use, sleep and mood...........................................................................................................................24
Cardiovascular risk in transgender people.........................................................................................................25
12/12/2022.................................................................................................................................................. 26
Fertility in transmasculine..................................................................................................................................26
Fertility transfeminine........................................................................................................................................28
13/12/2022.................................................................................................................................................. 29
Functionality after gender-affirming genital surgery in trans men...................................................................29
Mastectomy and gender-affirming genital surgery in trans men......................................................................30
19/12/2022.................................................................................................................................................. 32
1
, Sexology.............................................................................................................................................................32
Facial surgery.....................................................................................................................................................34
28/11/2022
Introduction of the course
GP waiting list intake endocrinologist = 2-3 years
Diagnostic process psychologist = 6 months
Hormone treatment endocrinologist = 12 months
Surgery: gynaecoloog, plastic surgeon, urologist
Etiology of gender dysphoria
Definition = an incongruence between the experienced gender and the sex assigned at birth
- With distress = gender dysphoria
Harms of research in gender dysphoria: pathologization, stigmatizing, discrimination, risk of
oversimplification, looking for a ‘cure’
Jongens zijn beter met ruimtelijk inzicht, omdat al vanaf jongs af aan jongens speelgoed aan
hun gegeven wordt, zoals speelgoed waarbij je dingen opbouwt
Vaak verschillen tussen genders gevonden bij onderzoeken naar bepaalde eigenschappen,
maar ook heel vaak veel overeenkomsten
Amygdala, hippocampus en insula geven verschillen in volume en weefseldichtheid bij
mannen en vrouwen
implicated in sex-biased neuropsychiatric conditions: depression woman/autism man
Mosaic in the human brain:
- Niet echt dimorfisme extensive overlap between distributions
- Internal consistency extremely rare
- Human brains cannot be categorized into two distinct classes: male of female brain,
regardless of the cause of observed sex/gender differences in brain
Bij transvrouwen: eerst XY en testes wel gevormd zoals bij cisgenders, maar daarna is er
geen/minder T en
Sexual differentiation hypothesis = androgens from testes act early in the development to
cause some regions of the male’s brain to develop differently from those in the female
In 1e trimester is er geslachtsdelen ontwikkeling, in 2e en 3e trimester ontwikkeling van
hersenen
Heteroseksuele vrouw heeft kleinere nucleus dan man, en van een transvrouw lijkt de
nucleus ook op de nucleus van de cisvrouw (rechtsonder lijkt dus op linksboven)
Body perception hypothesis = differences between trans- and cisgender groups in networks
involved in body perception Cause or consequence of gender incongruence?
- TG people seem to present with own unique brain phenotype, rather than shifting
towards one end of male-female spectrum
2
, - More than one explanation
Organizing effects in brain are similar with experienced gender
Not only influence brain on gender, but also gender on brain
Gender incongruence: classifications, diagnostics, and criteria
Genderspectrum & terminology
Sex
- Physical aspects of biological sex
- Chromosomes & physical anatomy
Gender
- The way someone identifies
- Psychosocial aspects – gender role, gender expression
- A social construct
Difference gender role and gender identity
Gender role = behaviour, interests and preferences that in a specific culture and period of
time are perceived as more typical male or female
Gender identity = subjective feeling to belong to one of the two or an alternative gender
Verschillende aspecten gender unicorn
- Gender identity
- Gender expression – feminine, masculine, other
- Sex assigned at birth
- Physically attracted to
- Emotionally attracted to
o Has nothing to do with someone’s gender identity
Genderspectrum
- Shift from binary to variation
- Shift from pathology to diversity
Gender dysphoria: classifications & criteria
ICD 11
- Gender gedrag en voorkeuren is onvoldoende basis om de diagnose te kunnen
stellen
- Diagnosis cannot be assigned prior to the onset of puberty
DSM-5
- A: Er moet incongruentie zijn tussen ervaren gender en geslacht bij geboorte
- B: Incongruentie moet gepaard gaan met klinisch significant lijden
- Diagnose: twee of meer van bepaalde criteria + gepaard met stress/lijdensdruk
3
, -
Changes DSM-5
- Naming: gender dysphoria instead of gender identity disorder
- Positioning in the DSM: separate from paraphilias and sexual dysfunctions
- Letting go of thinking about ‘sex’ and ‘gender’ as binary constructs
- Stricter criteria for gender dysphoria diagnosis in children
DD genderdysphoria: sexuality, hard to give yourself a label because of homophobia
Diagnostics & indication (for medical treatment) at Amsterdam UMC
Change of perspective
1. Gender is a spectrum
2. Gender dysphoria/incongruence is also a spectrum
3. Treatment wishes are not always traditional
Process UMC
- Diagnostics and advice
o Gather information (about nature and degree of gender dysphoria, exploring
treatment wishes and expectations, mapping one’s coping) + fully inform
someone about the treatment process
o Purpose = come to a well-informed decision and indication for gender
affirmative treatment
- Hormone and social transition phase
- Surgical phase (can also be the first step in case of mastectomy)
Indication criteria
- Diagnosis gender dysphoria
- Sufficient capacity, stability, and adequate coping
- Competence and informed consent
- Preferably a social network for support
- Psychiatric comorbidity doesn’t have to be a contra-indication, but parallel care is
then desirable/a requirement
29/11/2022
Gender dysphoria in children and adolescents
Gender role/expression: gender stereotypical behaviors, interests, preferences, personality,
characteristics
Gender identity: the subjective feeling of belonging to or being one of the genders (or
another gender)
4
