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forensic anthropology, trans, gender incongruence, sex estimation methods, gender affirming interventions, pubertal suppressors, epiphyseal fusion, bone mineral density (BMD), bone turnover, Cross-sex hormonal therapy (CSHT), Facial Feminization Surgery (FFS), Facial Masculinization Surgery (FMS), Sex Reassignment Surgery (SRS)
Despite trans-identifying individuals being disproportionately affected by mistreatment, harassment, physical abuse, and violence, there are currently no forensic anthropology standards for determining whether an individual has undergone gender affirmative interventions from skeletal evaluation. The inability to estimate the sex of a skeletonized victim poses a critical challenge to the identification process. The purpose of this paper is four-fold: to identify (1) the skeletal indicators for identifying transsexual individuals, (2) which associated surgical devices can aid in confirming the individual has undergone gender affirmation surgery, (3) what differentiates trans surgeries from cis surgeries, and lastly, (4) a proposed method for “sexing” transsexuals. The long-term use of estrogen in transwomen and testosterone in transmen, following therapeutic use of gonadotrophin-releasing hormone analogues (GnRHa) from early adolescence and gonadectomy in early adulthood, results in lower apparent bone mineral density (BMD) and areal BMD values and z-scores than cis-gendered genotypic references. Long-term cross-sex hormonal therapy (CSHT), in gonadectomized trans individuals not having undergone pubertal suppression, causes bone mineral content (BMC), trabecular volumetric BMD, cortical bone area, thickness, and periosteal and endosteal circumference to fall short of cis male values in transwomen and exceed cis female values in transmen, consistent with previous evidence of the anabolic effects of testosterone on cortical bone. In addition, transmen may be genetically predisposed towards developing intermediate values for the crown widths of teeth and morphometric sexually dimorphic features of the hip. Since the evaluation of transsexual skeletal remains are likely to reveal “indeterminate” scores, it is critical to resort to other indicators of sex to successfully build a biological profile. The most reliable skeletal indicators of transwomen gender affirmation surgeries consist of the combined presentation of evidence for bone shaving, various osteotomies (using microplates and screws), and breast implants. The most durable post-mortem surgical devices that are more likely to lead to the positive identification of a transman are the combined presence of facial implants and bone grafts, and penile and scrotal prosthesis. Forensic anthropologists should be cautious not to confound evidence of surgical interventions with those used to treat traumatic, pathologic, or cosmetic procedures in the cis population. The more the presence of bilateral gender affirming indicators, the higher the likelihood of ascribing the correct “sex” to an unidentified trans individual. The present proposed method for “sexing” transsexuals serves, at best, as a tentative guide, for the forensic anthropologist, to recognizing associated surgical devices and markers of skeletal modification.