A Rare Case of 83-Year-Old Transgender Female: Can Thyroid Hormone Deficiency Be Involved in Transgenderism and Gender Dysphoria?

In the 
current report, we describe an 83-year-old biological male who self- identified 
as a female by legally changing his first and middle names to female ones and 
whose death certificate states his sex as a female. The medical history of this 
individual indicated complete penectomy without further specification. 
Postmortem physical examination revealed an absence of penis with a large 
scrotum, transposed urethral orifice, and small testes. The histological 
analysis of the testes identified abnormal epithelium in the seminiferous 
tubules that lacked germ and Sertoli cells as well as the interstitium without 
Leydig cells present. The exome sequencing of the individual’s DNA using the 
Next Generation Sequencing (NGS) Illumina platform revealed no genetic variants 
associated with either penile or urethral cancer that could have explained the 
complete penectomy, but pointed toward a potentially impaired production of T3 
and T4 thyroid hormones which could account for the observed testicular 
malformation. Overall, the data obtained raise an important question as to 
whether the thyroid hormone axis could be an important part of the hormonal 
architecture supporting male sexual behavior.


Introduction
Transgender (TG) is a broad term, which describes an individual whose gender How to cite this paper: Frolov, A., Polcaro, L., Lawson, C., Tan, Y. and Martin III, J.R. (2020) A Rare Case of 83-Year-Old Transgender Female: Can Thyroid Hormone Deficiency Be Involved in Transgenderism and self-identification is different from the assigned sex at birth. When the latter becomes overwhelming and causes a significant psychological impact, the term gender dysphoria (GD) is used thereby presenting itself as an extreme case of TGism.
The individuals with GD often seek a medical intervention, surgical or therapeutic, to correct the existing discordance between their gender self-identification and physical appearance [1].
As of 2016, approximately 1.4 million adults identify as TG in the United States [2]. The TG biological underlining is not well understood. Genetically, it appears that interplay between sex steroid receptor polymorphisms, particularly those of androgen and estrogen, which are associated with TG [3]. Yet the RYR3 variant was identified in the Han Chinese population with GD [4] and CYP17 single nucleotide polymorphism was linked to female-to-male TGism [5] whereas a common SRD5A2 polymorphism has been shown recently to be benign in TGism (ClinicalTrials.gov Identifier: NCT00435513). Chromosomal aberrations, such as in Klinefelter syndrome (47, XXY), could also be responsible for GD in some individuals since a 1.13% frequency of patients with Klinefelter syndrome was found in GD population [6].
Metabolically, GD has been linked to androgen insensitivity in biological males. Individuals with complete androgen insensitivity syndrome (CAIS) have a 46, XY karyotype, bilateral testes, and female external genitalia [7]. These individuals tend to be psychosocially female and oriented toward men [8]. Individuals with partial androgen insensitivity syndrome (PAIS) also have a 46, XY karyotype, but may have penoscrotal hypospadias, micropenis, bifid scrotum, and undescended testes [9].
Most recently, a large cohort association study involving 380 transgender females (TFs) and 344 control male subjects revealed an over-representation in TFs of several allele combinations including androgen receptor (AR) that were proposed to feminize male individuals thereby leading to TGism [10].
Therefore, the main objective of this study was to provide in-depth examination of the current TF body to gain additional important insights into the respective biological underlinings through a systematic approach including gross anatomical dissection, histological analysis, and genetic screen using NGS technology.

Genetic Analysis
The Next Generation Sequencing (NGS) and bioinformatics analysis were performed as previously described [12] [13] with the following modifications. DNA extracted from the tibia specimen procured from the embalmed TF body was sequenced to 30× depth of coverage (~4.5 Gb) on the Illumina HiSeq 2500 NGS platform in the 2 × 100 base read format. DNA extraction was performed by Paleo-DNA Laboratory (Lakehead University, Canada) and exome sequencing was conducted by Omega Bioservices (Norcross, GA). The cumulative exome coverage for > 25× depth of coverage was 93% indicating that almost all of the exome was accessible for probing. The variant call and annotation were performed by Genome Technology Access Center (GTAC, Washington University in St. Louis) using SnpSift varType and ANNOVAR. The resultant data were converted into the Microsoft Excel format and pathologic (deleterious) variants were identified through the five consecutive filtering steps described in [12] [13]. Functional annotation of the remaining variants was performed using UniProtKB Protein, Google Scholar, and PubMed database searches.

Anatomical Characterization
A body of an 83-year-old individual with the male sex assigned at birth was received through the Gift of Body Program at the Center for Anatomical Science and Education (CASE) of the SLU School of Medicine, USA. The records indicated that this individual self-identified as a female by legally changing his first and middle names to female ones later in his life and his death certificate listed his sex as a female. It was also self-reported by the body donor that in the adulthood he/she underwent a complete penectomy without further specification. The DOI: 10.4236/asm.2020. 102002 25 Advances in Sexual Medicine body was hairless with an exception of a sparse hair on the scalp (Figure 1(A)), had a large scrotum with no penis observed (Figure 1(B)), and the urethral orifice was identified posterior to the scrotum (Figure 1(C)). A scrotum dissection revealed that the ductus deferens, epididymis, and testes were all intact ( Figure  2(A)). However, the latter were much smaller than normal with the volume ~3.3 cm 3 (Figure 2(A)) versus ~7.5 cm 3 for the age matched normal individuals [14]. Dissection of the pelvic cavity revealed normal male anatomy with the seminal vesicles and ductus deferens located posterior to the bladder (Figure 2(B)). The prostate was also intact, positioned inferiorly to the bladder (Figure 2(C)).

Histological Analysis
Histological analysis of testicular tissue revealed abnormal seminiferous tubule epithelium. As compared to the age matched control body, the epithelium was devoid of germ and Sertoli cells and Leydig cells were not observed in the interstitium ( Figure 2(D)).

Bone Densitometry
Because the results of histological analysis were indicative of testicular malformation and, consequently, hormone deficiency with the latter being commonly linked to osteoporosis, the bone mineral density in the cadaveric body was as-

Genetic Analysis
The assessment of this individual karyotype was impossible due to incompatibility of the available methodologies with the biological material procured from the embalmed cadaveric body. However, the measured individual's height of 1.73 m was significantly lower as compared to that of 1.83 m average for the Klinefelter syndrome patients [15], which along with the absence of other phenotypic characteristics such as gynecomastia [15] (Figure 1(A)) allows, although incomplete, exclusion of the respective 47, XXY chromosomal aberration from further consideration.
The putative genetic underlining of the present TF case was addressed by sequencing the entire coding regions of DNA (exome) extracted from the embalmed cadaveric tissue using NGS Illumina platform as described previously [12] [13]. The rare genetic variants (minor allele frequency, MAF ≤ 0.01) linked to deleterious (pathological) amino acid substitutions in the mutant proteins were identified through the five sequential, stringent filtering steps described in [12] [13]. In total, the genetic screen yielded 144 deleterious (pathological) variants of 137 genes with none of them associated with either penile or urethral cancer, or the genes known to regulate the androgen hormone axis (Table S1).  However, six genetic variants, TPO, BBS12, DNAH9, ITF81, OFD1, and TAPT1 could be linked directly to our case (Table 1) due to their involvement in the regulation of a thyroid hormone production (TPO) and male sex organ development through the control of cilia function (BBS12, DNAH9, ITF81, OFD1, and TAPT1) [12].

Discussion
The condition presented in the current report could be described as TGism with its progression to GD. The latter conclusion was based on the absence of genetic variants known to be associated with either penile or urethral cancer which puts forward an elective surgery as a primary cause for the reported complete penectomy.   It is hypothesized herein that one of the important underlinings of the above condition could be linked to the impaired T3 and T4 thyroid hormone production which could negatively affect a cross-talk between the thyroid and androgen hormone axes [16] [17] thereby potentially leading to anatomical and physiological alterations similar to those in PAIS [9]. This hypothesis is based on: 1) a presence of TPO deleterious (pathological) variant that control the T3 and T4 production and the absence of the variants that regulate the androgen hormone axis (Table 1); 2) the observed testicular malformation at both the anatomical and histological levels ( Figure 2); and 3) the T-score values derived for the lumbar spine (−3.1) and femoral neck (−3.4) being comparable to those of patients with PAIS [18] while being much worse than those of older male subjects with low testosterone levels, respectively −0.48 and −1.56 [19]. Importantly, the T3 and T4 thyroid deficiency has been recently reported in a patient with GD and normal, 46, XX, female karyotype [20]. With this regard, the data presented in the current report raise a very important question is to whether the thyroid hormone deficiency could be viewed as one of the important biological underlinings of TGism and GD. It should also be noted, that prenatal maternal thyroid deficiency has been previously linked to impacting sexuality [21] [22].
The detected deleterious (pathological) BBS12, DNAH9, ITF81, OFD1, and TAPT1 variants known to negatively affect cilia development and function could serve as a prerequisite for other male sex organ malformations ambiguously present in the current case, such as hypospadias (Figure 1(B)) [12] and complete penoscrotal transposition [23]. Intriguingly, in the model organisms, cilium has also been shown to be a major regulator of male sexual behavior such as mate searching and selection [24] [25] [26].

Conclusion
The results reported in the current study provide unique information for the hypothesis that thyroid hormone deficiency could be one of the important biological underlinings of TGism and GD that merits its further evaluation in a clinical setting. Advances in Sexual Medicine A. Frolov et al.

Supplementary Materials
The file contains Table S1 (Complete list of deleterious (pathologic) genetic variants associated with the current TF). Table S1. Complete list of deleterious (pathologic) genetic variants associated with the current TF.

Gene
Protein Function ABCA13 ATP-binding cassette sub-family A member 13. ATPase activity, coupled to transmembrane movement of substances. Lipid transport. Neutrophil degranulation.

ABCC1
Multidrug resistance-associated protein 1. Mediates export of organic anions and drugs from the cytoplasm. Hydrolyzes ATP with low efficiency.

ABL1
Tyrosine-protein kinase ABL1. Non-receptor tyrosine-protein kinase that plays a role in many key processes linked to cell growth and survival such as cytoskeleton remodeling in response to extracellular stimuli, cell motility and adhesion, receptor endocytosis, autophagy, DNA damage response and apoptosis.

ADAMTS9
A disintegrin and metalloproteinase with thrombospondin motifs 9. Cleaves the large aggregating proteoglycans, aggrecan and versican. Has a protease-independent function in promoting the transport from the endoplasmic reticulum to the Golgi apparatus of a variety of secretory cargos.

CACNA2D3
Voltage-dependent calcium channel subunit alpha-2/delta-3. The alpha-2/delta subunit of voltage-dependent calcium channels regulates calcium current density and activation/inactivation kinetics of the calcium channel. Acts as a regulatory subunit for P/Q-type calcium channel (CACNA1A), CBLC E3 ubiquitin-protein ligase CBL-C. Acts as an E3 ubiquitin-protein ligase, which accepts ubiquitin from specific E2 ubiquitin-conjugating enzymes, and then transfers it to substrates promoting their degradation by the proteasome. Functionally coupled with the E2 ubiquitin-protein ligases UB2D1, UB2D2 and UB2D3. Regulator of EGFR mediated signal transduction; upon EGF activation, ubiquitinates EGFR. Isoform 1, but not isoform 2, inhibits EGF stimulated MAPK1 activation.

CCDC144NL CCDC144NL CCDC144NL
Putative coiled-coil domain-containing protein 144 N-terminal-like. Could be the product of a pseudogene. Shares high sequence similarity with the N-terminus of the CCDC144 family.

CCSER2
Serine-rich coiled-coil domain-containing protein 2. Microtubule-binding protein which might play a role in microtubule bundling.

CDC27
Cell division cycle protein 27 homolog. Component of the anaphase promoting complex/cyclosome (APC/C), a cell cycle-regulated E3 ubiquitin ligase that controls progression through mitosis and the G1 phase of the cell cycle.

CEPT1
Choline/ethanolaminephosphotransferase 1. Catalyzes both phosphatidylcholine and phosphatidylethanolamine biosynthesis from CDP-choline and CDP-ethanolamine, respectively. Involved in protein-dependent process of phospholipid transport to distribute phosphatidyl choline to the lumenal surface.

CGN
Cingulin. Probably plays a role in the formation and regulation of the tight junction (TJ) paracellular permeability barrier.

CNGA2
Cyclic nucleotide-gated olfactory channel. Odorant signal transduction is probably mediated by a G-protein coupled cascade using cAMP as second messenger.

CNTRL
Centriolin. Involved in cell cycle progression and cytokinesis. During the late steps of cytokinesis, anchors exocyst and SNARE complexes at the midbody, thereby allowing secretory vesicle-mediated abscission.

COL11A1
Collagen alpha-1(XI) chain. May play an important role in fibrillogenesis by controlling lateral growth of collagen II fibrils.

CYP1A2
Cytochrome P450 1A2. Cytochromes P450 are a group of heme-thiolate monooxygenases. In liver microsomes, this enzyme is involved in an NADPH-dependent electron transport pathway. It oxidizes a variety of structurally unrelated compounds, including steroids, fatty acids, and xenobiotics.

DNAH9
Dynein heavy chain 9, axonemal. Force generating protein of respiratory cilia. Produces force towards the minus ends of microtubules. Dynein has ATPase activity; the force-producing power stroke is thought to occur on release of ADP.

DPH6
Diphthine--ammonia ligase. Amidase that catalyzes the last step of diphthamide biosynthesis using ammonium and ATP.

EFTUD1
Elongation factor-like GTPase 1. Involved in the biogenesis of the 60S ribosomal subunit and translational activation of ribosomes. FAM104A Protein FAM104A. Highest level of expression is in sperm.

FAM63A
Protein FAM63A, aka MINDY1. Ubiquitin carboxyl-terminal hydrolase MINDY-1. Hydrolase that can specifically remove "Lys-48"-linked conjugated ubiquitin from proteins. May play a regulatory role at the level of protein turnover.

FOXD4L6
Forkhead box protein D4-like 6. Transcription factor. Anatomical structure morphogenesis. Cell differentiation. GRHL3 Grainyhead-like protein 3 homolog. Transcription factor playing important roles in primary neurulation and in the differentiation of stratified epithelia of both ectodermal and endodermal origin.

GTF3C1
General transcription factor 3C polypeptide 1. Required for RNA polymerase III-mediated transcription.

GYG1
Glycogenin-1. Self-glucosylates, via an inter-subunit mechanism, to form an oligosaccharide primer that serves as substrate for glycogen synthase. Killer cell immunoglobulin-like receptor 2DS4. Receptor on natural killer (NK) cells for HLA-C alleles. Does not inhibit the activity of NK cells.

KRTAP10-6
Keratin-associated protein 10-6. In the hair cortex, hair keratin intermediate filaments are embedded in an interfilamentous matrix, consisting of hair keratin-associated proteins (KRTAP), which are essential for the formation of a rigid and resistant hair shaft through their extensive disulfide bond cross-linking with abundant cysteine residues of hair keratins.

LCN12
Epididymal-specific lipocalin-12. Binds all-trans retinoic acid and may act as a retinoid carrier protein within the epididymis. May play a role in male fertility (By similarity).

LDLRAD4
Low-density lipoprotein receptor class A domain-containing protein 4. Functions as a negative regulator of TGF-beta signaling and thereby probably plays a role in cell proliferation, differentiation, apoptosis, motility, extracellular matrix production and immunosuppression.
It is an important enzyme in HDL metabolism.

LPIN3
Phosphatidate phosphatase LPIN3. Regulates fatty acid metabolism. Magnesium-dependent phosphatidate phosphatase enzyme which catalyzes the conversion of phosphatidic acid to diacylglycerol during triglyceride, phosphatidylcholine and phosphatidylethanolamine biosynthesis (By similarity).

MAML3
Mastermind-like protein 3. Acts as a transcriptional coactivator for NOTCH proteins. Has been shown to amplify NOTCH-induced transcription of HES1.

MRGPRX1
Mas-related G-protein coupled receptor member X1. Orphan receptor activated by neuropeptides terminating in Arg-Phe or Arg-Phe-amideMay regulate the function of nociceptive neurons by modulation of pain perception.

MUC4 MUC4
Mucin-4. May play a role in tumor progression. Ability to promote tumor growth may be mainly due to repression of apoptosis as opposed to proliferation. Has anti-adhesive properties.

NCF1
Neutrophil cytosol factor 1. NCF2, NCF1, and a membrane bound cytochrome b558 are required for activation of the latent NADPH oxidase (necessary for superoxide production).

NEBL
Nebulette. Binds to actin and plays an important role in the assembly of the Z-disk. May functionally link sarcomeric actin to the desmin intermediate filaments in the heart muscle sarcomeres (PubMed: 27733623).

NFATC1
Isoform 2 might play a role in the assembly of focal adhesion (PubMed: 15004028).

NPTN
Neuroplastin. Probable homophilic and heterophilic cell adhesion molecule involved in long term potentiation at hippocampal excitatory synapses through activation of p38MAPK. May also regulate neurite outgrowth by activating the FGFR1 signaling pathway. May play a role in synaptic plasticity (By similarity).

NUP153
Nuclear pore complex protein Nup153. Component of the nuclear pore complex (NPC), a complex required for the trafficking across the nuclear envelope.

NUP58
Nucleoporin p58/p45. Component of the nuclear pore complex, a complex required for the trafficking across the nuclear membrane.

OFD1
Oral-facial-digital syndrome 1 protein. Component of the centrioles controlling mother and daughter centrioles length. Recruits to the centriole IFT88 and centriole distal appendage-specific proteins including CEP164. Involved in the biogenesis of the cilium, a centriole-associated function.
Plays an important role in development by regulating Wnt signaling and the specification of the left-right axis.
May be involved in the establishment and maintenance of specific neuronal connections in the brain.

PCK2
Phosphoenolpyruvate carboxykinase [GTP], mitochondrial. Catalyzes the conversion of oxaloacetate (OAA) to phosphoenolpyruvate (PEP), the rate-limiting step in the metabolic pathway that produces glucose from lactate and other precursors derived from the citric acid cycle.

PDCL3
Phosducin-like protein 3. Acts as a chaperone for the angiogenic VEGF receptor KDR/VEGFR2, controlling its abundance and inhibiting its ubiquitination and degradation. Modulates the activation of caspases during apoptosis.

PLA2G4C
Cytosolic phospholipase A2 gamma. Has a preference for arachidonic acid at the sn-2 position of phosphatidylcholine as compared with palmitic acid.

PLXNB3
Plexin-B3. Receptor for SEMA5A that plays a role in axon guidance, invasive growth and cell migration.
POTEC POTE ankyrin domain family member C. Highest expression level is in testis.
PRAMEF18 PRAME family member 18. Negative apoptosis regulation. Negative regulation of cell differentiation.
PRAMEF22 PRAME family member 22. Negative apoptosis regulation. Negative regulation of cell differentiation.

PRF1
Perforin-1. Plays a key role in secretory granule-dependent cell death, and in defense against virus-infected or neoplastic cells. Plays an important role in killing other cells that are recognized as non-self by the immune system, e.g. in transplant rejection or some forms of autoimmune disease.

PSMA8
Proteasome subunit alpha-type 8. Component of the spermatoproteasome, a form of the proteasome specifically found in testis that promotes degradation of histones, thereby participating actively to the exchange of histones during spermatogenesis.
RBMX RNA-binding motif protein, X chromosome. RNA-binding protein that plays several role in the regulation of pre-and post-transcriptional processes.

RBMXL1
RNA binding motif protein, X-linked-like-1. RNA-binding protein which may be involved in pre-mRNA splicing.

RGS11
Regulator of G-protein signaling 11. Inhibits signal transduction by increasing the GTPase activity of G protein alpha subunits thereby driving them into their inactive GDP-bound form.

RIT2
GTP-binding protein Rit2. Binds and exchanges GTP and GDP. Binds and modulates the activation of POU4F1 as gene expression regulator.

SCN9A
Sodium channel protein type 9 subunit alpha. Plays a role in pain mechanisms, especially in the development of inflammatory pain.

SPATA31C1
Putative spermatogenesis-associated protein 31C1. May play a role in spermatogenesis.

SPATA31C2
Putative spermatogenesis-associated protein 31C2. May play a role in spermatogenesis.

SPATS1
Spermatogenesis-associated serine-rich protein 1. Highest expression level is in testis.

TEX29
Testis-expressed protein 29. Highest expression level is in right testis.

TNXB
Tenascin-X. Appears to mediate interactions between cells and the extracellular matrix. Substrate-adhesion molecule that appears to inhibit cell migration. Accelerates collagen fibril formation. May play a role in supporting the growth of epithelial tumors.

TPO
Thyroid peroxidase. Iodination and coupling of the hormonogenic tyrosines in thyroglobulin to yield the thyroid hormones T3 and T4.

TUBGCP6
Gamma-tubulin complex component 6. Gamma-tubulin complex is necessary for microtubule nucleation at the centrosome.

TYRO3
Tyrosine-protein kinase receptor TYRO3. Regulates many physiological processes including cell survival, migration and differentiation.