M A U T-^f
Y HOC VIET NAM THANG 1 1 - 5 0 2/2010
CHUYEN GIGfl TINH
r.u'.i:oO(\ gffijb 'mmfi^ -n.
TOM TAT
ur
Chuyen gidi tinh la tinh trang ma mgt ca nhan cd sU biet hda gidi tinh binh thUdng nhUng lai tin rang hg la thanh vien ciia gidi tinh kia.
Dieu nay ket hdp vdi mgt yeu cau dieu trj phau thuat va ngi tiet cap bach, kien dinh de thfch u'ng vdi gidi tinh kia. .^ ,^.
Oieu tn chuyen gidi bang hocmon nham muc dich giam cac dac tinh sinh due thir phat do hocmon tao ra va tao ra cac dac tinh sinh due thir phat ciia gidi tfnh kia. Dieu trj chuyen gidi bang phau thuat nham cat bd bg sinh due ngoai va tuyen sinh due ciia gidi tinh gdc va tao hinh bg sinh due ngoai ciia gidi tfnh kia. Odi vdi chuyen gidi tfnh (CGT) nam-thanh-nu", am dao mdi dUdc tao thanh tir da dUdng vat, da biu tao thanh moi Idn va tao hinh vu vdi cac tui nhan tao. Ddi vdi CGT nii-thanh-nam, dUdng vat cd the tao hinh tir am vat phi dai theo kieu metaidoioplasty (dUdng vat am vat), hoac tao hinh tli vat da cang tay. Biu cd the dUgc tao hinh tir moi Idn, vdi tinh hoan gia.
ii i • S/S.Miae
ABSTRACT
Transsexualism
Transsexualism is a condition in which a person with apparently normal somatic sexual differentiation is convinced that he or she is actually a member of the opposite sex. It is associated with an irresistible urge to be hormonally and surgically adapted to that sex.
Hormonal treatment aims at reducing the hormonally induced secondary sex characteristics of the original sex and at inducing the secondary sex characteristics of the new sex. Surgical treatment is removal of external genitalia and
<'>::•'•
Nguyen Thanh Nhir
gonads of the original sex and reconstruction of external genital organs of the desired sex. For male-to-female patients, the testis and penis must be removed and a neovagina is surgically constructed, usually using the penile skin and scrotal skin for the labia, and the breasts may be surgically augmented by implants. For femaie-to- male patients, the breasts, uterus and ovaries are surgically removed. The phallus may be reconstructed from the hypertrophied clitoris, a so-called metaidoioplasty, or free flaps removed from forearms. From the labia majora, a scrotum can be constructed in which testicular prostheses can be implanted.
I. OINHNGHTA J !>:;
Chuyen gidi tinh (CGT) la tinh trang ma mdt ca nhan cd su biet hda gidi tinh binh thudng nhung lai tin ring hg la thanh vien ciia gidi tinh kia. Dieu nay kit hgp vdi mdt yeu cau dieu tri phau thuat va ndi tilt cip bach, kien dinh de thich iing vdi gidi tinh kia ^.
Ba tieu chuin ciia CGT theo DSM-IV ':
1. Udc mudn dugc sdng va dugc chip nhan nhu la mdt thanh vien cua gidi tinh kia, vdi mong udc ca the hg gidng cang nhilu cang tdt vdi ca the ciia gidi tinh kia, bing phau thuat va hocmon.
2. Mong udc chuyen gidi tdn tai keo dai.
3. Su rdi loan nay khdng phai la trieu chiing ciia mdt benh ly tam than hay nhiem sac the. CGT la mdt tinh trang tu chan doan, khdng cd xet nghiem nao khac ngoai su bat an gidi tinh (gender dysphoria) keo dai it nhat 2 nam, chi giam bdt khi vl mat tam ly xa hdi, giai phlu va ndi tilt, ngudi CGT dugc
BV Binh Ddn TP HCM
93
HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
thira nhan thudc ve gidi tinh kia. Tinh trang tu chin doan dugc khang dinh bang khao sat tam ly, bao gdm mdt giai doan "thir nghiem song thuc". Giai doan nay bat dau khi ngudi CGT dugc tri lieu ndi tilt va hg dugc yeu sau sdng ngoai xa hdi nhu mdt ngudi tbugc gidi tinh kia, trudc khi dugc phlu thuat chinh gidi ' .
II. NGUYEN NHAN
Nguyen nhan vin chua rd '^'^'^. thdng tin mdi nhit vl tan suat cgt tai ha lan la 1/11.900 d nam va 1/30.400 d nil ^.
III. BIEU HIEN LAM SANG
kham lam sang, dinh lugng ndi tiet td sinh due va nhilm sac the gidi tinh chi giiip khing dinh gidi tinh sinh hgc binh thudng ^'^.
IV. OIEU TRj
Qui trinh dieu tri chuyen gidi tinh ^:
,, • Tam ly lieu phap: 6 thang.
• Ndi tiet lieu phap: 2 nam. 40%) benh nhan bd cugc do cac khd khan se gap.
. • Phau thuat ca quan sinh due: cat bd ca quan sinh due cua gidi tinh sinh hgc va tao hinh ca quan sinh due ciia gidi tinh mdi.
Ddng thdi, benh nhan van dugc tiep tuc ndi tiet va tam ly lieu phap sudt ddi.
I. Cac can thiep thuc the
Can cd mdt khoang thdi gian vira du de ngudi CGT va gia dinh hg thich img vdi viec chuyen tir gidi tinh nay sang gidi tinh kia.
Ben canh ly do tam ly, ca the ciing can mdt thdi gian de thich iing vdi mdi trudng ndi tiet mdi. Thdi gian nay vao khoang 2 nam '''^.
• Cdc can thiip hoi phuc duac. Dd la viec sir dung cac chat ddng van luteinizing hormone releasing hormone (LHRH),
cyproterone acetate hay medroxyprogesterone de lie che su san xuit
estrogen hay testosterone nham giam cang
nhilu cang tdt cac dac tinh sinh due thii phat do ndi tilt to gay ra cua gidi tinh gdc .
• Cdc can thiip khong hdi phuc dup/c, bao gdm sir dung hocmon lam nam hda hay nil hda ca thi, vi du sir dung testosterone tren ngudi nil sinh hgc va estrogen tren ngudi nam sinh hgc, va phau thuat .
2. Dieu tri chuyin gioi bang hocmon Can thuc hien trudc khi phau thuat. Sir hai ldng vdi lieu phap ndi tiet giiip cimg co su nhan dang nhu la mdt thanh vien ciia gidi tinh kia cua ngudi CGT. Su khdng hai long vdi hieu qua ciia hocmon cd the bao hieu sir khdng san sang ciia ngudi CGT cho viec phau thuat. Mdt sd ngudi CGT hai long vdi lieu phap ndi tiet va khdng mudn phau thuat tao hinh "*.
Dieu tri chuyen gidi bang hormone nham hai muc dich "*:
1. Giam cac dac tinh sinh due thii phat do hocmon gay ra cang nhieu cang tdt, nhung hiem khi loai bd dugc hoan toan cac dac tinh nay.
2. Tao ra cac dac tinh sinh due thii phat cua gidi tinh kia.
• Nam-thanh-nir ^'^
Antiandrogens nhu Cyproterone acetate (50 mg/ngay), hoac Medroxyprogesterone acetate (5-10 mg/ngay) vdi hieu qua kem hon. Nonsteroidal antiandrogens (flutamide va nilutamide) ciing cd the dimg, nhung gay tang tiet gonadotrophin, lam tang tiet testosterone va estradiol. Spironolactone (100 mg 2 lan/ngay). Ddng van GnRH, dugc dung de lie che su tiet gonadotrophin. Finasteride (1-5 mg/ngay).
Estrogens cd the lam tang kich thudc vii, tai phan bd md gidng phan bd md nil gidi, giam siic ca than tren, da min, ldng it, giam hay ngung hdi dau, giam the tich tinh hoan, cuong duong ylu.
Sau 2 nam, khoang 40% - 50% ngudi
94
Y HOC VIET NAM THANG 11 - 5 0 2/2010
CGT hai ldng vdi dilu tri. Tuy nhien, cac thudc tren khdng anh hudng tdi gigng ndi, nen ngudi CGT nam-thanh-nii can dugc tri lieu rieng ve gigng ndi. ; > '^''•'
• NH-thdnh-nam ^''
Prodestins (Medroxyprogesterone acetate, 5-10 mg/ngay), dl ngung hanh kinh.
Testosterone. Gigng ndi trd nen tram sau 6-10 tuan, am vat nd to, vii teo nhe, tang long mat va than va hdi kieu nam. Tang siic ca than tren, tang can, tang ham mudn hoat ddng xa hdi va tinh due, giam md hdng.
• Nguy ca dim tdng cua lieu phdp npi tiit Mac dil tir vong khdng cao hon nhdm chiing ^, tuy nhien, lieu phap ndi tiet chuyen gidi cd the cd nhiing tac dung phu sau:
Tang khuynh hudng cue mau ddng (thuyen tac tinh mach vdi nguy ca thuyen tac phdi) tren ngudi CGT nam sinh hgc dieu tri bang estrogens va antiandrogens, phat trien u lanh tuyen yen tang tiet prolactine, vd sinh, tang can, tinh cam khdng dn dinh, benh gan, ngii gat, tang huyet ap va tieu dudng ^.
Tac dung phu tren ngudi CGT nil sinh hgc dugc dieu tri bang testosterone la vd sinh, mun trimg ca, tinh cam khdng dn dinh, tang ham mudn tinh due, hinh anh lipit mau kieu nam nen tang nguy ca benh tim mach ^'*.
3. Dieu tri chuyen gioi bang phau thuat
• Nam-thdnh-nif. Am dao mdi thudng dugc tao thanh tir da duong vat, va da biu tao
thanh mdi ldn. Neu vii khdng du to, can phlu thuat tao hinh vii.
• Nir-thanh-nam ^. Vii, tir cung va budng trimg phai dugc cat bd. Mdt sd hiem trudng hgp, am vat to cd the sir dung nhu duong vat. Cac trudng hgp khac, phlu thuat tao hinh duong vat tir am vat (metaidoioplasty) cd the dugc thuc hien.
Duong vat mdi cd the dugc tao hinh tir vat da cang chan hay cang tay. Cac phlu thuat nay giiip benh nhan cd the tieu diing. Biu cd thi dugc tao hinh tir mdi ldn, vdi tinh hoan gia.
Phau thuat gan the hang gia cd the dugc thuc hien de tao cuong duong vat. ,-. ii,
Dieu tri CGT tai Viet Nam
Van de ldn nhat d Viet nam la viec chuyen gidi tinh khdng dugc phap luat chip nhan (theo Nghi Dinh cua Chinh Phu, sd:
88/2008/ND-CP). Ben canh dd, tai Viet Nam van chua cd cac chuyen gia tam ly, ndi tiet chuyen ve ITnh vuc chuyen gidi tinh; mac dii viec thuc hien cac phau thuat tao hinh bd sinh due nam trong kha nang cua cac bac sT phau thuat Viet Nam.
Tai benh vien Binh Dan, mdt trudng hgp phau thuat tao hinh duong vat tir am vat da dugc thuc hien nam 2004 (hinh 1 va hinh 2) cho mdt trudng hgp nii sinh hgc tu sir dung hocmon de chuyen gidi (sd hd sa 204/09424). Sau md, benh nhan cd thi tilu diing dugc vdi duong vat mdi.
Hinh 1. Am vat phi dai truoc khi tao hinh Hinh 2. Duong vat dugc tao hinh metaidoioplasty metaidoioplasty ' - sau 2 nam
95
HOI NGHj KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM
V. KET LUAN
Mac dil can cd them chimg cir, dieu tri dimg din roi loan chuyen gidi dem lai su an toan hon cho ngudi CGT khdng dugc dieu tri, hg dl bi trim cam va tu sat. Mdt ddi ngii cac chuyen gia ve rdi loan chuyen gidi cd the dem lai sir cham sdc tdi uu cho ngudi CGT.
Nhiing ngudi CGT can su hd trg lau dai trong tri lieu hocmon chuyen gidi va khdng nen bi phan biet ddi xir khi hg cd yeu cau
i. 9
dugc cham sdc y te . .,
;]cnU fUj! :,OT;
TAI LIEU THAM KHAO ^ ' '"
1. American psychiatric association (1994).
Sexual and Gender Identity Disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4* Edition. 493-538.
2. Council of Europe (1993). Transsexualism, medicine and law. XXlllrd Colloquy on '•'^J European.- -^H 'I'^X^r'^-' •''-' •'"-• •••'•^-' ''^^^'^
3. Giltay EJ (1999). Effects of sex steroid on the vascular and immune systems, studies in transsexualsubjects and patients with rheumatic disease. PhD thesis. Amsterdam.
4. Gooren L (1990). The endocrinology of ' transsexualism: a review and commentary.
' Psychoneuroendocrinology; 15(1):3-14.
t'-,: ori d<;)_ ^Tji;,:.
5. Hage JJ, Bloem JJAM, Suliman HM (1993). Review of the litterature on the techniques for phalloplasty with emphasis on the applicability in female-to-male transsexuals. J Urol; 150:1093-1098.
6. The The Harry Benjamin International Gender Dysphoria Association's Standards of Care For Gender Identity Disorders, Sixth Version, 2001.
7. Karim RB (1996). Vaginoplasty in transsexuals. PhD thesis. Amsterdam.
8. Van Kesteren PJ, Gooren LJ, Megens JA (1996) An epidemiological and demographic study of transsexuals in The Netherlands.
Arch Sex Behav; 25(6):589-600.
9. T'Sjoen GGR (2006). Problem: gender dysphoria and disorders of sexual differentition. In Andrology for the clinician.
Springer, Berlin, 19-26.
10. Zhou JN, Hofman MA, Gooren LJ, Swaab DF (1995). A sex difference in the humanbrain and its relation to transsexuality.
Nature; 378(6552):68-70.
11. Wein: Campbell Walsh, Urology .Male Perineal Sling Implatation Techique. 9""
edition 2007; 174:
urirj
iTe;!;'
