ORIGINAL RESEARCH—INTERSEX AND GENDER IDENTITY DISORDERS: A Report from a Single Institute's 14-Year Experience in Treatment of Male-to-Female Transsexuals

IntroductionGender identity disorder or transsexualism is a complex clinical condition, and prevailing social context strongly impacts the form of its manifestations. Sex reassignment surgery (SRS) is the crucial step of a long and complex therapeutic process starting with preliminary psychiatric evaluation and culminating in definitive gender identity conversion.AimThe aim of our study is to arrive at a clinical and psychosocial profile of male-to-female transsexuals in Italy through analysis of their personal and clinical experience and evaluation of their postsurgical satisfaction levels SRS.MethodsFrom January 1992 to September 2006, 163 male patients who had undergone gender-transforming surgery at our institution were requested to complete a patient satisfaction questionnaire.Main Outcome MeasuresThe questionnaire consisted of 38 questions covering nine main topics: general data, employment status, family status, personal relationships, social and cultural aspects, presurgical preparation, surgical procedure, and postsurgical sex life and overall satisfaction.ResultsAverage age was 31 years old. Seventy-two percent had a high educational level, and 63% were steadily employed. Half of the patients had contemplated suicide at some time in their lives before surgery and 4% had actually attempted suicide. Family and colleague emotional support levels were satisfactory. All patients had been adequately informed of surgical procedure beforehand. Eighty-nine percent engaged in postsurgical sexual activities. Seventy-five percent had a more satisfactory sex life after SRS, with main complications being pain during intercourse and lack of lubrication. Seventy-eight percent were satisfied with their neovagina's esthetic appearance, whereas only 56% were satisfied with depth. Almost all of the patients were satisfied with their new sexual status and expressed no regrets.ConclusionsOur patients' high level of satisfaction was due to a combination of a well-conducted preoperative preparation program, competent surgical skills, and consistent postoperative follow-up. Imbimbo C, Verze P, Palmieri A, Longo N, Fusco F, Arcaniolo D, and Mirone V. A Report from a single institute's fourteen year experience in treatment of male-to-female transsexuals. J Sex Med 2009;6:2736–2745.     

ORIGINAL RESEARCH—INTERSEX AND GENDER IDENTITY DISORDERS: Gender Reassignment Surgery in Male-to-Female Transsexualism: A Retrospective 3-Month Follow-up Study with Anatomical Remarks

IntroductionGreater acceptance of sexual minorities has enabled people with transsexualism access to adequate treatment and social integration. Gender reassignment surgery is a complex phase in the care of transsexual patients. In response to a greater volume of patients, surgical techniques have evolved and the outcome in patients with male-to-female transsexualism is now a very accurate imitation of female genitalia, enabling sexual intercourse with orgasm.AimTo evaluate the results of surgical reassignment of genitalia in male-to-female transsexuals.MethodsA retrospective 3-month follow-up study of patients' opinions following gender reassignment surgery in 129 patients having a primary procedure (eight of whom had later sigmoideocolpoplasty) and five patients undergoing reoperation following an initial unsuccessful procedure at other units. All patients were male transsexuals. The surgical techniques are described in detail.Main Outcome MeasuresSexual functions and complications 3 months after surgery.ResultsAll patients were satisfied with the first phase operation. Thirteen patients (9.7%) underwent successful sigmoideocolpoplasty. Main complications were as follows: rectal lesions developing during preparation of the vaginal canal (1.5%); bleeding from the stump of the shortened urethra in the first 48 hours postoperatively requiring secondary suturing (4.5%); temporary urinary retention requiring repeated insertion of urinary catheters for up to 6 days (5.2%); and healing of the suture between the perineum and the posterior aspect of the vaginal introitus healing by secondary intention (5.2%). The neoclitoris had erogenous sensitivity in 93.9% of patients and 65.3% reached orgasm in the first 3 months.ConclusionsSurgical conversion of the genitalia is a safe and important phase of the treatment of male-to-female transsexuals. Jarolím L, ?edý J, Schmidt M, Naňka O, Foltán R, and Kawaciuk I. Gender reassignment surgery in male-to-female transsexualism: A retrospective 3-month follow-up study with anatomical remarks. J Sex Med 2009;6:1635–1644.     

ORIGINAL RESEARCH—INTERSEX AND GENDER IDENTITY DISORDERS: Neuroimaging Differences in Spatial Cognition between Men and Male-to-Female Transsexuals Before and During Hormone Therapy

IntroductionNeuropsychological abnormalities in transsexual patients have been reported in comparison with subjects without gender identity disorder (GID), suggesting differences in underlying neurobiological processes. However, these results have not consistently been confirmed. Furthermore, studies on cognitive effects of cross-sex hormone therapy also yield heterogeneous results.AimWe hypothesized that untreated transsexual patients differ from men without GID in activation pattern associated with a mental rotation task and that these differences may further increase after commencing of hormonal treatment.MethodThe present study investigated 11 male-to-female transsexual (MFTS) patients prior to cross-sex hormone therapy and 11 MFTS patients during hormone therapy in comparison with healthy men without GID. Using functional magnetic resonance imaging at 3-Tesla, a mental rotation paradigm with proven sexual dimorphism was applied to all subjects. Data were analyzed with SPM5.Main Outcome MeasuresPatterns of brain activation associated with a mental rotation task.ResultsThe classical mental rotation network was activated in all three groups, but significant differences within this network were observed. Men without GID exhibited significantly greater activation of the left parietal cortex (BA 40), a key region for mental rotation processes. Both transsexual groups revealed stronger activation of temporo-occipital regions in comparison with men without GID.ConclusionsOur results confirmed previously reported deviances of brain activation patterns in transsexual men from men without GID and also corroborated these findings in a group of transsexual patients receiving cross-sex hormone therapy. The present study indicates that there are a priori differences between men and transsexual patients caused by different neurobiological processes or task-solving strategies and that these differences remain stable over the course of hormonal treatment. Schöning S, Engelien A, Bauer C, Kugel H, Kersting A, Roestel C, Zwitserlood P, Pyka M, Dannlowski U, Lehmann W, Heindel W, Arolt V, and Konrad C. Neuroimaging differences in spatial cognition between men and male-to-female transsexuals before and during hormone therapy.     

ORIGINAL RESEARCH—OUTCOMES ASSESSMENT: Development and Validation of a 6-Item Version of the Female Sexual Function Index (FSFI) as a Diagnostic Tool for Female Sexual Dysfunction

IntroductionA limiting step in the evaluation of female sexual dysfunction (FSD) is the availability of a rapid screening procedure. Often, practitioners avoid investigating sexual symptoms due to concerns of insufficient time or lack of proper tools to address FSD.AimThe purpose of this study was to prepare and validate an abridged form of the most popular psychometric diagnostic test (Female Sexual Function Index, FSFI-19) to provide a fast screener of FSD for easy use in outpatient visits, epidemiological studies, and assessment of treatment response.MethodsWe interviewed and administered the FSFI-19 to 200 women attending outpatient clinics for sexual and reproductive medicine. Forty women were excluded because they had no sexual activity or failed to attend the retest visit. Patients were evaluated on two subsequent visits to validate the abridged form of the questionnaire. Overall, 105 were found to suffer from a FSD.Main Outcome MeasureWe assessed, individually, the sensibility and sensitivity of all questions of the full-length FSFI. We then estimated the performance of each item with respect to the specific sexual domain they address. By selecting the best combination of performing items in each domain, we built an abridged, 6-item form of the FSFI.ResultsThe Receiver Operating Characteristic curves of the FSFI-6 showed that women who scored ≤19 were classified as having FSD. Using the cut-off of 19, the sensitivity and specificity of the test were, 0.93 and 0.94, respectively. Reliability, internal consistency, and stability on retest were also good.ConclusionsThe abridged FSFI-6 is a valuable tool for screening women that are likely to suffer from FSD. In six simple questions, taking no more than 3 minutes, a score of less than 19 indicates the need for further investigations, including the full-length FSFI-19 and a dedicated interview. In conclusion, this is a novel tool that can help any doctor to disclose FSD rapidly and efficiently. Isidori AM, Pozza C, Esposito K, Giugliano D, Morano S, Vignozzi L, Corona G, Lenzi A, and Jannini EA. Development and validation of a 6-item version of the Female Sexual Function Index (FSFI) as a diagnostic tool for female sexual dysfunction.     

ORIGINAL RESEARCH–SURGERY: Treatment of Penile Deep Dorsal Venous Leakage of Erectile Dysfunction by Embedding the Deep Dorsal Vein of the Penis: A Single Center Experience with 17 Patients

IntroductionThe common surgery for venous leakage was not very successful; unsatisfactory long-term results have reduced the indications for venous surgery for erectile dysfunction (ED).AimsTo assess the outcomes of embedding the deep dorsal vein of the penis (EDDVP), a new surgical technique used in patients with penile deep dorsal venous leakage of ED.MethodsBetween December 2001 and November 2007, 17 patients diagnosed with penile deep dorsal venous leakage of ED underwent embedding the deep dorsal vein of the penis.Main Outcome MeasuresAll cases were available for follow up by using the abridged 5-item version of the International Index of Erectile Function (IIEF-5) scoring system and penile color Doppler ultrasound. Dynamic cavernosography were also assessed in three patients at 3 months postoperatively.ResultsAfter surgery, 14 patients were able to achieve satisfactory intercourse and three had sufficient erection after oral sildenafil (50–100 mg). The IIEF-5 scoring changed from a preoperative mean IIEF-5 score of 8.8 ± 3.9 to 20.8 ± 4.1 (P < 0.05). Peak systolic velocity (average of right and left cavernosal arteries) changed from 41.9 ± 7.7 cm/second to 44.2 ± 9.2 cm/second (P > 0.05), resistance index changed from 0.79 ± 0.1 to 1.00 ± 0.0 (P < 0.05), and venous velocity changed from 8.4 ± 4.0 cm/second to 0.0 ± 0.0 cm/second (P < 0.05). Dynamic cavernosography demonstrated a smooth flow of the deep dorsal vein during the flaccid phase. During the tumescent phase, the deep dorsal vein of the penis was compressed between the dilated sinusoidal spaces and the tunica albuginea and resulted in venous drainage blockade. And then the hardness of erection was improved and maintained.ConclusionsThe new surgical technique of EDDVP is a simple operative procedure, which seems to be efficient in the treatment of penile deep dorsal venous leakage of ED. Zhang B, Chen J, Xiao H, Zhang Y, Cai L, Tao X, Qi T, and Ban D. Treatment of penile deep dorsal venous leakage of erectile dysfunction by embedding the deep dorsal vein of the penis: A single center experience with 17 patients. J Sex Med 2009;6:1467–1473.     

ORIGINAL RESEARCH—PEYRONIE'S DISEASE: Use of Penile Extender Device in the Treatment of Penile Curvature as a Result of Peyronie's Disease. Results of a Phase II Prospective Study

IntroductionPilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronie's disease.AimTo test this hypothesis in a Phase II study using a commonly marketed brand of penile extender.MethodsPeyronie's disease patients with a curvature not exceeding 50° with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an “important” reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points.Main Outcome MeasuresPatients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire.ResultsPenile curvature decreased from an average of 31° to 27° at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from “no change” to “mild improvement.”ConclusionsIn our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50°, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment. Gontero P, Di Marco M, Giubilei G, Bartoletti R, Pappagallo G, Tizzani A, and Mondaini N. Use of penile extender device in the treatment of penile curvature as a result of Peyronie's disease. Results of a phase II prospective study. J Sex Med 2009;6:558–566.     

ORIGINAL RESEARCH–WOMEN'S SEXUAL HEALTH: Clinically Relevant Changes in Sexual Desire,Satisfying Sexual Activity and Personal Distress as Measured by the Profile of Female Sexual Function,Sexual Activity Log,and Personal Distress Scale in Postmenopausal Women with Hypoactive Sexual Desire Disorder

IntroductionTransdermal testosterone patch (TTP) treatment produced statistically significant improvements in a satisfying sexual activity (SSA), sexual desire, and personal distress in postmenopausal women suffering from hypoactive sexual desire disorder (HSDD), but clinical significance of these changes was not determined.AimTo quantify the magnitude of change in three principal outcomes measures determined by HSDD patients as associated with the perception of meaningful benefit with TTP therapy.MethodsThe criteria for defining responders were determined using anchoring methodology and receiver operating characteristics analysis to establish minimum important differences (MIDs) in a representative subsample of 132 patients in two randomized, controlled trials in surgically menopausal women with HSDD (N = 1,094). Perceived benefit was established based upon the question “Overall, would you say that you experienced a meaningful benefit from the study patches?”. These data defined responders and established MIDs for changes in sexual desire, SSA, and personal distress. The MIDs were applied to the two trials to establish responder rates in each treatment group.Main Outcome MeasuresChanges in score that correspond to the MID for sexual desire, SSA, and personal distress, and responder rates in each treatment group based upon these values.ResultsIncreases in frequency of SSA of greater than 1 activity/4 weeks, increases in sexual desire score of ≥8.9, and decreases in the personal distress score of ≥20.0 were identified as threshold improvements best able to differentiate responders and nonresponders. The responder rate was significantly higher (P < 0.001) in the testosterone group vs. placebo for all three outcomes measures (sexual desire, 50% vs. 34%; SSA, 44% vs. 30%; personal distress, 51% vs. 39%).ConclusionsChanges in sexual desire, SSA, and personal distress observed with TTP treatment in surgically menopausal women with HSDD were clinically significant and were associated with a meaningful treatment benefit. DeRogatis LR, Graziottin A, Bitzer J, Schmitt S, Koochaki PE, and Rodenberg C. Clinically relevant changes in sexual desire, satisfying sexual activity and personal distress as measured by the profile of female sexual function, sexual activity log, and personal distress scale in postmenopausal women with hypoactive sexual desire disorder. J Sex Med 2009;6:175–183.