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Presents the 'Standards for the Treatment and Diagnostic Assessment of Transsexuals' created by an expert commission of the German Society for Sexual Research. How the first standards of care, created in 1979, have a limited applicability a German context; Diagnosis standards for transsexuality; The need for precise differential diagnosis in the field of gender identity disorders; Psychotherapy and professional recommendation; Requirements for somatic treatment and hormonal therapy; Requirements for sex reassignment surgery.

Objectives: Objective assessment of sexual preferences may be of relevance in the treatment and prognosis of child sexual offenders. Previous research has indicated that this can be achieved by pattern classification of brain responses to sexual child and adult images. Our recent research showed that human face processing is tuned to sexual age preferences. This observation prompted us to test whether paedophilia can be inferred based on the haemodynamic brain responses to adult and child faces., Methods: Twenty-four men sexually attracted to prepubescent boys or girls (paedophiles) and 32 men sexually attracted to men or women (teleiophiles) were exposed to images of child and adult, male and female faces during a functional magnetic resonance imaging (fMRI) session., Results: A cross-validated, automatic pattern classification algorithm of brain responses to facial stimuli yielded four misclassified participants (three false positives), corresponding to a specificity of 91% and a sensitivity of 95%., Conclusions: These results indicate that the functional response to facial stimuli can be reliably used for fMRI-based classification of paedophilia, bypassing the problem of showing child sexual stimuli to paedophiles.

Men's sexual health can be impaired by a variety of sexual disorders, including numerous sexual dysfunctions (primary or due to general medical conditions or their treatment), but also paraphilias and gender identity disorders. These different disorders are often interwoven. This paper offers an overview of the prevalence, symptoms, and etiological factors of major sexual-medical disorders and of the basics of diagnostics and therapy. Special emphasis is given to the couple dimension and the biopsychosocial foundation of human sexuality, which requires an interdisciplinary approach. The paper argues for an improvement of continuing education in sexual medicine for healthcare providers in an effort to satisfy patients' needs for preservation or restoration of sexual health as a major component of quality of life.

Context: Accurately assessing sexual preference is important in the treatment of child sex offenders. Phallometry is the standard method to identify sexual preference; however, this measure has been criticized for its intrusiveness and limited reliability., Objective: To evaluate whether spatial response pattern to sexual stimuli as revealed by a change in the blood oxygen level-dependent signal facilitates the identification of pedophiles., Design: During functional magnetic resonance imaging, pedophilic and nonpedophilic participants were briefly exposed to same- and opposite-sex images of nude children and adults. We calculated differences in blood oxygen level-dependent signals to child and adult sexual stimuli for each participant. The corresponding contrast images were entered into a group analysis to calculate whole-brain difference maps between groups. We calculated an expression value that corresponded to the group result for each participant. These expression values were submitted to 2 different classification algorithms: Fisher linear discriminant analysis and κ -nearest neighbor analysis. This classification procedure was cross-validated using the leave-one-out method., Setting: Section of Sexual Medicine, Medical School, Christian Albrechts University of Kiel, Kiel, Germany., Participants: We recruited 24 participants with pedophilia who were sexually attracted to either prepubescent girls (n = 11) or prepubescent boys (n = 13) and 32 healthy male controls who were sexually attracted to either adult women (n = 18) or adult men (n = 14)., Main Outcome Measures: Sensitivity and specificity scores of the 2 classification algorithms., Results: The highest classification accuracy was achieved by Fisher linear discriminant analysis, which showed a mean accuracy of 95% (100% specificity, 88% sensitivity)., Conclusions: Functional brain response patterns to sexual stimuli contain sufficient information to identify pedophiles with high accuracy. The automatic classification of these patterns is a promising objective tool to clinically diagnose pedophilia.

Introduction: The assessment of sexual orientation is of importance to the diagnosis and treatment of sex offenders and paraphilic disorders. Phallometry is considered gold standard in objectifying sexual orientation, yet this measurement has been criticized because of its intrusiveness and limited reliability., Aim: To evaluate whether the spatial response pattern to sexual stimuli as revealed by a change in blood oxygen level-dependent (BOLD) signal can be used for individual classification of sexual orientation., Methods: We used a preexisting functional MRI (fMRI) data set that had been acquired in a nonclinical sample of 12 heterosexual men and 14 homosexual men. During fMRI, participants were briefly exposed to pictures of same-sex and opposite-sex genitals. Data analysis involved four steps: (i) differences in the BOLD response to female and male sexual stimuli were calculated for each subject; (ii) these contrast images were entered into a group analysis to calculate whole-brain difference maps between homosexual and heterosexual participants; (iii) a single expression value was computed for each subject expressing its correspondence to the group result; and (iv) based on these expression values, Fisher's linear discriminant analysis and the kappa-nearest neighbor classification method were used to predict the sexual orientation of each subject., Mean Outcome Measure: Sensitivity and specificity of the two classification methods in predicting individual sexual orientation., Results: Both classification methods performed well in predicting individual sexual orientation with a mean accuracy of >85% (Fisher's linear discriminant analysis: 92% sensitivity, 85% specificity; kappa-nearest neighbor classification: 88% sensitivity, 92% specificity)., Conclusion: Despite the small sample size, the functional response patterns of the brain to sexual stimuli contained sufficient information to predict individual sexual orientation with high accuracy. These results suggest that fMRI-based classification methods hold promise for the diagnosis of paraphilic disorders (e.g., pedophilia).

Sex determination can be particularly crucial in forensic casework such as rape cases or cases of missing persons. Biological traces have to be genetically typed and the classification of the sex is of great importance for further investigations. Lately, several papers were published on reliability of sex determination by genetic typing of amelogenin gene-specific fragments. Problems may arise not only from false detection (or non-detection) of amelogenin-specific fragments, but also in cases of chimerism (bone marrow transplants) or micro chimerism (pregnant women carrying male fetuses), and from the possible discrepancies between the biological gender and the (forensic relevant) legal gender in the personal identity documents. The phenotype based classification of the legal gender may contradict the genetic sex under several conditions as there are genetic diversity, intersex conditions and transsexualism. The forensic relevance of the possible misinterpretation (sex is not necessarily legal gender) should not be underestimated.

Over the last two-and-a-half years a committee of experts, consisting of members of the three leading German sexology associations, developed guidelines for treating and assessing transsexuals. Their purpose is to improve the care for patients with sex identity disorders and to ensure that such care is of uniform quality to avoid erroneous decisions to the disadvantage of those affected. The guidelines are set out in full.

To elucidate the relationship between body build, androgens, and transsexual gender identity, anthropometric measurements were assessed in 15 hormonally untreated female-to-male-transsexuals (FMT). Nineteen healthy women (CF) (X = 22 years; 2 months), and 21 healthy men (CM) (X = 23; 7) were enrolled as controls. Baseline levels of testosterone (T; ng/dl), androstenedione (A4; ng/dl), dehydroepiandrosterone sulfate (DHEAS; ng/ml), and sex-hormone binding globulin (SHBG; microgram/ml) were assessed in 12 FMT, 15 CF, and in all CM. No control was under hormonal medication (including contraceptives). Absolute measurements in FMT were in accordance with their biological sex: they showed only small differences from the CF. However, FMT differed from CF in 7 of 14 sex-dimorphic indices of masculinity/femininity in body build. Of these 14 indices, 9 did not show a difference between FMT and CM. Hence, FMT presented a more masculine body build, particularly in fat distribution and bone proportions. Levels of T and A4 were significantly higher in FMT than in CF (T: 54.0 +/- 13.8 vs. 41.1 +/- 12.8; A4: 244.8 +/- 73.0 vs. 190.5 +/- 49.3), while DHEAS was higher in CM (3335 +/- 951) than in CF (2333 +/- 793) and in FMT (2679 +/- 1089). Altogether, 83.3% of FMT and 33.3% of CF were above normal values for at least one measured androgen. SHBG in FMT (1.21 +/- 0.70) and CF (1.87 +/- 0.91) was higher than in CM (0.49 +/- 0.18) and tended to be higher in CF than in FMT. Unbound T (T/SHBG ratio) was higher in FMT (72.0 +/- 67.6) than in CF (26.4 +/- 15.1) and correlated positively with manly body shape. Findings are discussed in relation to etiology of transsexualism.

From the introduction of the law on recognition of transsexuals (TSG) in 1980, over 1400 decisions were made by German regional district judges up to 1990. In over 90% of the cases the desired gender was accepted and attested officially. In the near future, a growing number of requests has to be expected. Generally, transsexual patients desire surgery to achieve a complete sex change. Since the foundation of an interdisciplinary gender dysphoria identity committee at our institution in 1989, we have developed criteria on indications, operative techniques and follow-up, which would overtax a urology department, but which can be managed by an interdisciplinary team. Operative techniques may be regarded as well standardized in male-to-female transsexuals and may be performed by the urologist alone; in female-to-male transsexuals sex transformation remains complex interdisciplinary challenge to urologists and plastic surgeons, mainly due to urethral complications. Continuous psychiatric guidance and endocrinological monitoring of the patients facilitates indications for surgery and perioperative management.

The quantity of empirical data on contents and sources of sexual knowledge and sex-typical attitudes at preschool children is out of all proportion to the importance of this age for the formation of sexual behaviour and the establishment of relations between the sexes in family and society in the course of ontogenesis. The results of standardized interviews of 190 boys and 176 girls aged four to seven years at urban and rural nursery schools on their sexual knowledge and on their ideas of properties, roles and functions of the sexes (sex role ideas) will help fill this gap. Compared to previous retrospective studies on elder children and adolescents, sexual knowledge has become more wide-spread and correct and increasingly comes from the desired sources of information. The emotional and educational factors involved in impairing the information, however, are not yet sufficiently developed and the incidence of attitudes promoting an equal cooperation between the sexes is rather limited. The necessity of enabling the educators for sexual education is again emphasized.