Objective: Past decades have seen an increase in gender dysphoria subjects seeking hormonal treatment^1,2. We report motor and vocal tics following testosterone therapy introduction for a gender transition from female to male in a 16-year-old patient.

Background: Male sex hormones influence tic disorders. Tourette syndrome (TS) has a male-to-female ratio of 4:1³  and is known to worsen during puberty when testosterone production increases. TS also worsens dramatically during steroid abuse, with a decrease following withdrawal⁴ or treatments used to reduce dihydrotestosterone⁵.

Method: Case-report

Results: The patient was born as a girl but identified as a male since the age of 4 years (y). No history of tics. He began gender transition at 16y with intramuscular testosterone injections. Several days after the first injection, he began presenting motor tics consisting of finger movements.

Tics were initially trivialized but increasingly interfered with daily life. The standard protocol for gender transition continued with incremental testosterone doses. Tics progressively became more violent, initiating self-injuries. They were preceded by a sensation of tension. Tics were mainly complex motor tics with intermittent onomatopoeias, and were followed by a sensation of relief. Tics aside, the neurological exam was normal as well as a comprehensive blood test and a brain MRI.

Aripiprazole was introduced. After 3 months, tics remained uncontrolled and a mastectomy was performed, resulting in improvements to the patient’s psychological state and tics. Aripiprazole was stopped. Several weeks following mastectomy, tics gradually decreased and disappeared 18 months after onset. The only remaining treatment was testosterone injections.

Conclusion: The association between testosterone and the emergence of tics is sustained by the appearance of tics following the initiation of hormonal treatment and their increase parallel to hormonal augmentation. The disappearance of tics despite the maintenance of the same androgen doses also mimics the natural history of tics, which tend to appear in early adolescence and resolve in young adults even if the level of androgen stays high.

This case report supports a strong influence of testosterone in the genesis of tics.

References: 1. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018 Apr;15(4):582-590.
2. Cheung AS, Ooi O, Leemaqz S,et al. Sociodemographic and Clinical Characteristics of Transgender Adults in Australia. Transgend Health. 2018 Dec 26;3(1):229-238.
3. Knight T, Steeves T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: a systematic review and meta-analysis. Pediatr Neurol. 2012 Aug;47(2):77-90.
4. Leckman JF, Scahill L. Possible exacerbation of tics by androgenic steroids. N Engl J Med. 1990 Jun 7;322(23):1674.
5. Muroni A, Paba S, Puligheddu M, Marrosu F, Bortolato M. A preliminary study of finasteride in Tourette syndrome. Mov Disord. 2011 Sep;26(11):2146-7.

« Back to 2023 International Congress

MDS Abstracts - https://www.mdsabstracts.org/abstract/tourettism-occurring-during-gender-transition-with-testosterone-therapy/