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Hormonal interventions are an often-sought option for transgender individuals seeking to medically transition to an authentic gender. Current literature stresses that the effects and associated risks of hormone regimens should be monitored and well understood by health care providers (Feldman & Bockting, 200315. Feldman , J. and Bockting , W. 2003 . Transgender health . Minnesota Medicine , 86 [PubMed]View all references). However, the positive psychological effects following hormone replacement therapy as a gender affirming treatment have not been adequately researched. This study examined the relationship of hormone replacement therapy, specifically testosterone, with various mental health outcomes in an Internet sample of more than 400 self-identified female-to-male transsexuals. Results of the study indicate that female-to-male transsexuals who receive testosterone have lower levels of depression, anxiety, and stress, and higher levels of social support and health related quality of life. Testosterone use was not related to problems with drugs, alcohol, or suicidality. Overall findings provide clear evidence that HRT is associated with improved mental health outcomes in female-to-male transsexuals.
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Journal of Gay & Lesbian Mental Health
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The Effects of Hormonal Gender
Affirmation Treatment on Mental Health
in Female-to-Male Transsexuals
Stacey L. Colton Meier MA a , Kara M. Fitzgerald MA a , Seth T. Pardo
MA b & Julia Babcock PhD a
a Department of Psychology, University of Houston, Houston, Texas,
b Department of Human Development, Cornell University, Ithaca,
New York, USA
Available online: 05 Jul 2011
To cite this article: Stacey L. Colton Meier MA , Kara M. Fitzgerald MA , Seth T. Pardo MA & Julia
Babcock PhD (2011): The Effects of Hormonal Gender Affirmation Treatment on Mental Health in
Female-to-Male Transsexuals, Journal of Gay & Lesbian Mental Health, 15:3, 281-299
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Journal of Gay & Lesbian Mental Health, 15:281–299, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 1935-9705 print / 1935-9713 online
DOI: 10.1080/19359705.2011.581195
The Effects of Hormonal Gender
Affirmation Treatment on Mental Health
in Female-to-Male Transsexuals
Department of Psychology, University of Houston, Houston, Texas, USA
Department of Human Development, Cornell University, Ithaca, New York, USA
Department of Psychology, University of Houston, Houston, Texas, USA
Hormonal interventions are an often-sought option for transgender
individuals seeking to medically transition to an authentic gender.
Current literature stresses that the effects and associated risks of hor-
mone regimens should be monitored and well understood by health
care providers (Feldman & Bockting, 2003). However, the positive
psychological effects following hormone replacement therapy as a
gender affirming treatment have not been adequately researched.
This study examined the relationship of hormone replacement ther-
apy, specifically testosterone, with various mental health outcomes
in an Internet sample of more than 400 self-identified female-to-
male transsexuals. Results of the study indicate that female-to-male
transsexuals who receive testosterone have lower levels of depres-
sion, anxiety, and stress, and higher levels of social support and
health related quality of life. Testosterone use was not related to
problems with drugs, alcohol, or suicidality. Overall findings pro-
vide clear evidence that HRT is associated with improved mental
health outcomes in female-to-male transsexuals.
These authors contributed equally to this work.
The authors would like to thank Jamison Green, Lore Dickey, Sean Moundas, and Robert
Meier for their thoughtful comments on earlier editions of this manuscript. This work was
supported by a Graduate Student Research Proposal Award from the Texas Psychological
Address correspondence to Stacey L. Colton Meier, MA, Department of Psychology,
University of Houston, 126 Heyne Building, Houston, TX 77204-5022. E-mail: ftmresearch@
Downloaded by [Seth Pardo] at 15:23 09 October 2011
282 S. L. Colton Meier et al.
KEYWORDS gender affirmation treatment, transgender, hormone
replacement therapy, testosterone, female-to-male transsexual, FTM
In the United States, health care is an enormous industry, affecting a great
many people. Current estimates suggest that health care expenditures in the
United States reached $2.2 trillion in 2007, 46% derived from public funds
(Centers for Disease Control, 2010). However, research has indicated that
there are large discrepancies in access to health care across a number of
variables, including ethnicity, sexual identity, and gender identity (Shipherd,
Green, & Abramovitz, 2010).
Because of difficulties with inconsistent definitions and the potential
“invisibility” of transgender people, data about access to and utilization of
health care by this population are often not available (Hussey, 2006). Current
research is extremely variable in determining prevalence of the transgender
population. One frequently cited study estimates that the lower bound for
prevalence is at least one in 500 (Olyslager & Conway, 2007). Prevalence es-
timates of FTMs have been found to range from 1 in 833 to 1 in 542,500 and
MTFs from 1 in 555 to 1 in 549,000 (Meier & Labuski, in press). The incon-
sistency in prevalence data highlights the dearth of information concerning
transgender individuals in general.
The race to improve such information concerning the female-to-male
transsexual (FTM) population is plagued by a number of issues as well. The
vast majority of research has been conducted with male-to-female transsex-
uals (MTFs) (Green, 2004; Meyerowitz, 2004). Conversely, less research has
focused on FTMs, or those individuals who were assigned female at birth
but identify as male but have not yet physically or socially transitioned to
live as male (Devor, 1997). Of the research that examines both FTMs and
MTFs, important differences emerge that indicate that FTMs may experience
less discrimination and be more satisfied with medical treatment that aids
in their transition (Kuiper & Cohen-Kettenis, 1988; Schilt & Wiswall, 2008).
These findings highlight the importance of separate analysis and research
specific to the FTM population and further contribute to a dearth of ade-
quate research.
With respect to health care, there is likewise a lack of information con-
cerning transgender access and utilization of health care services. In the
existing literature, country-wide data for these figures largely do not exist.
Within the United States, these data have been collected and compiled incon-
sistently across states, resulting in just a few sources of information. One such
document suggests that while over half of transgender individuals in Virginia
had access to a primary care doctor, about half of these primary care doc-
tors were not thought to be knowledgeable about transgender health issues
(Xavier, Honnold, & Bradford, 2007). This resulted in a similar percentage
of transgender individuals having to educate their doctors themselves. In
addition, more than one-third of these individuals had experienced a degree
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Hormone Treatment of Female-to-Male Transsexuals 283
of discomfort in discussing their transgender status or needs to their primary
care doctors. Level of discomfort was considerably higher when considering
a nonprimary-care doctor in half of the participants, with reasons for discom-
fort including fear of insensitivity, of being denied treatment, and of ridicule
or hostility. While little is known about access and utilization of health care,
or even specific health care needs of transgender individuals, it is evident
that this is not a negligible group of individuals and that much more needs
to be known and effectively communicated to health care providers.
Due to the paucity of research specific to the transgender population,
clinical care for trans persons may not be evidence based but rather anecdotal
or based on nonrepresentative narratives. For example, Shipherd, Green, and
Abramovitz (2010) report that differential access to health care exists across
many minority populations, including the transgender population. Utilization
of health care services is reduced in this population, with perceived barriers
including cost, fear of mental health services in general, and perceived stigma
associated with mental health services. These findings underscore the need
for increased education and outreach to the transgender community about
the nature of the services in general.
An additional barrier to health care access exists in that transsexual-
specific medical care is rarely covered by insurance in the United States
(Bockting, Robinson, Benner, & Scheltema, 2004; Schneider, Bockting,
Ehrbar, Lawrence, Rachlin, & Zucker, 2008). This represents a systemic differ-
ence, which cannot be ameliorated via increased information. Furthermore,
differential access to services can occur because health care professionals of-
ten question their own cultural competence working with this group. How-
ever, many of the presenting mental health concerns for this population
are common among the general population. As the presenting problems
may oftentimes be the same, concerns about competency on the part of the
providers are likely unfounded. Thus, for diagnostic accuracy and improved
long-term outcomes, it is crucial that health care providers become better in-
formed to help overcome barriers to treatment and to more effectively treat
FTMs (Shipherd et al., 2010).
A common reason FTMs seek medical attention related specifically to
transsexual status is to receive gender affirmation treatment (GAT). Medical
gender affirmation treatments are those that align physical sex with trans-
gender individuals’ identities and can take the form of surgical interventions
and/or hormonal regimens (Gorton, Buth, & Spade, 2005).
Surgical interventions are those designed to physically change gender-
determined body parts from that of one gender to another in an irreversible
manner. While the specific procedures involved herein are beyond the scope
of this paper, Feldman and Goldberg (2006) and Ettner, Monstrey, and Eyler
(2007) provide a comprehensive review of the current surgical procedures.
GAT surgical interventions are available in a number of societies, and
they are sometimes covered under national healthcare schemes; this is not
the case in every country. As previously mentioned, in the United States,
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284 S. L. Colton Meier et al.
transgender-specific health care needs are rarely, if ever, covered by in-
surance (Bockting, Robinson, Forbeg, & Scheltema, 2005), and these in-
terventions can be quite costly, particularly surgical intervention. Surgical
procedures sought as a part of GAT can range from around $6,000 for breast
reduction and chest reconstruction in FTMs to more than $75,000 for genital
reconstruction surgery. Despite the fact that many similar procedures are
covered by insurance for nontransgender individuals in the event of illness
or injury, they are rarely covered by insurance for transgender individuals
(Horton, 2008).
Due to this lack of insurance coverage, coupled with the often exor-
bitant costs of such surgical interventions, hormone replacement therapy
(HRT) is a more commonly accessible intervention. In the United States, as
in many other industrialized nations, most individuals who desire to make
a gender transition select hormonal regimens solely or as an initial step
(Rachlin, Green, & Lombardi, 2008). HRT is thought to function through
activating effects, which influence the circulation of cross-sex steroid hor-
mone blood levels (Slabbekoorn, van Goozen, Megens, Gooren, & Cohen-
Kettenis, 1999). The aim of HRT for transgender persons is to diminish the
secondary sex characteristics of the original sex (e.g., fat distribution) and
to engender and/or enhance the secondary sex characteristics (e.g., hair
growth, muscle) of the sex with which the individual currently identifies
(Gooren, 2005). For FTMs undergoing HRT, the agent of choice is usually
an injectable testosterone, such as cypionate, administered through intra-
muscular injection, which serves to enhance the development of facial and
body-hair growth, deepening of the voice to a male range, increased muscle
development, and cessation of menses (Gorton et al., 2005). Through these
mechanisms of change, HRT is often the first step towards self-authentication
via medical gender transition. The cost of such hormonal treatments tends
to be much lower than surgical interventions, making these hormonal inter-
ventions far more accessible to trans individuals.
Research on GAT to date has focused on a number of areas, including
cognitive, physical, and psychological changes. This research is important
in informing the transgender community of the effects of various HRT pro-
cedures. Also, it is an important step in increasing information available
to doctors, such that treatments may be demystified to patients and their
health care providers. However, despite the limited accessibility of surgical
interventions, the bulk of the previous research on the effects of GAT has
focused on surgical treatment, with unfortunately few studies to date having
examined psychological changes associated with administration of the much
more accessible HRT.
While there has been some work investigating HRT-related cognitive
changes (van Goozen, Cohen-Kettenis, Gooren, Frijda, & van de Poll, 1995;
Slabbekorn et al., 1999; van Goozen, Slabbekoorn, Gooren, Sanders, &
Cohen-Kettenis, 2002) and physical modifications associated with cross-
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Hormone Treatment of Female-to-Male Transsexuals 285
sex HRT have been well-documented (Meyer, Webb, Stuart, Finkelstein,
Lawrence, & Walker, 1986; Gorton et al., 2005), these findings are beyond
the scope of this paper. Unfortunately, few research studies have investigated
psychological effects (Slabbekoorn, van Goozen, Megens, Gooren, & Cohen-
Kettenis, 2001). Despite the relative paucity of research, the overarching con-
clusion seems to be that cross-sex HRT has an effect on the psychological
and emotional functioning of transsexuals.
Prior research on surgical and hormonal treatment among transgender
women (MTFs) found effects on mood and cognitive function. Kuiper and
Cohen-Kettenis (1988) found that MTFs who had undergone HRT and genital
reconstruction for a neo-vagina reported increased well-being. Leavitt and
colleagues found that MTFs who were taking estrogen showed decreased
depression and anxiety (Leavitt, Berger, Hoeppner, & Northrop, 1980). Fur-
thermore, research has been conducted on the effects of hormones in non-
transgender individuals on psychological functioning, with Buchanan, Eccles,
and Becker (1992) finding a consistent moderate estrogen level associated
with feelings of satisfaction. Similarly, HRT with estrogen has been associated
with increased emotional stability in MTFs (Leavitt et al., 1980). Van Goozen
and colleagues (1995) found differential effects associated with cross-gender
HRT in MTFs and FTMs. MTFs showed decreases in irritable mood and
sexual arousal, whereas FTMs showed increased proneness to anger and
aggression, as well as sexual arousal.
Slabbekoorn and colleagues (2001) investigated the psychological and
emotional results of HRT in both FTMs and MTFs. This study found that,
in general, as well as relative to their own expectations, MTFs experienced
more negative emotions regardless of HRT status and experienced more pos-
itive emotions and anger readiness associated with hormones. Conversely,
FTMs experienced more aggressive and sexual feelings but less affect inten-
sity. While this study provides an important source of evidence as to the
changes in transsexuals associated with HRT, the lack of use of standardized
measures of the psychological variables lessens the generalizability of the
results. Furthermore, the effects of HRT noted above only scratch the surface
of potential clinically relevant effects, such as those that share a more direct
relationship with health and mental health.
Notwithstanding this sampling of findings, the paucity of research on
the effects of HRT, compounded with the relative lack of research on FTM
as compared to MTF transsexuals, has resulted in very little research on the
effects of testosterone on FTMs (Newfield, Hart, Dibble, & Kohler, 2006).
The impact of ignorance about the effects of testosterone is exacerbated by
the current manner in which individuals can gain access to gender affirming
medical treatments.
Health care providers working with transgender individuals are faced
with determining the most effective way to manage transgender-specific
medical concerns when comorbid psychological complaints exist, such as
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286 S. L. Colton Meier et al.
depression and anxiety. The World Professional Association for Transgen-
der Health’s (WPATH) Standards of Care document provides eligibility and
readiness requirements for gender affirming medical interventions (Meyer
et al., 2001). Among the readiness requirements is the subjective assessment
by a health care provider that mental health would improve if the person’s
gender identity and physical body were aligned and consistent over time.
While this document states that individuals with severe psychiatric conditions
that affect reality testing need to be treated for those conditions prior to con-
sidering any gender affirming medical interventions, it also states that this
decision ultimately rests with the health care provider. Standard practice has
been to treat nearly any comorbid psychological conditions, including de-
pression and anxiety, prior to considering any of the medical steps involved
in gender reassignment (Hale, 2007). The notion herein is that gender reas-
signment constitutes a psychologically taxing process. However, this notion
has not been thoroughly investigated to date. While the seventh edition of
this document is schedule to be released preceding the publication of the
Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition (DSM-
5), the importance of educating health care professionals as to the effects
and implications of GAT treatments remains of paramount significance.
In addition to gaining familiarity with treatment-related effects of HRT
and other gender affirming treatments that are specific to transgender indi-
viduals, it is also crucial that physical health care professionals gain an un-
derstanding of additional medically relevant factors commonly experienced
by FTMs. Research indicates that depression is common in as much as 60%
of transgender youth (Clements-Nolle, Marx, & Katz, 2006). Similar to the
well-established role of incidence of victimization and discrimination in de-
pression in the gay, lesbian, and bisexual (GLB) population (Clements-Nolle
et al., 2006), these factors are thought to play an analogous role in the high
levels of depression in the transgender population.
Transgender individuals are also at risk for elevated anxiety, especially
during the coming out process. Anxiety related to coming out has been well
documented in the GLBT community in general (Safren & Rogers, 2001). No
research to date has measured anxiety levels in FTMs; instead, studies usually
have used a more general measure of psychological functioning (Smith, van
Goozen, Kuiper, & Cohen-Kettenis, 2005). However, anxiety is viewed as
so integral to the transsexual identity formation process that it is considered
the first stage in Devor’s (2004) model of transsexual identity formation.
This stage, abiding anxiety, is characterized by discomfort surrounding one’s
gender. The societal expectations for what it means to be a certain gender, in
addition to social consequences (actual and perceived) of being “different,”
are theorized to contribute to this sense of anxiety.
Furthermore, rates of attempted suicide and problematic substance use
are high among transsexuals. For example, suicide prevalence in transgender
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Hormone Treatment of Female-to-Male Transsexuals 287
adults is reportedly as high as 32% (Clements-Nolle et al., 2006). Similarly,
transgender youth reported high rates of self-harm behaviors, with suicide
attempts being reported in 26% of these individuals (Grossman & D’Augelli,
2007). Rates of substance use have also been found to be particularly high in
the transgender population, with some researchers suggesting a vulnerability
to substance abuse in this population (Clements, Wilkinson, Kitano, & Marx,
1999; Cole, O’Boyle, Emory, & Meyer, 1997). More specifically, rates of heavy
alcohol use have ranged from 8–31%, with illicit drug use ranging from
3–71% (Bocking et al., 2005; Garofalo, Deleon, Osmer, Doll, & Harper, 2006;
Ramirez-Valles, Garcia, Campbell, Diaz, & Heckathorn, 2008).
The role of social support as a potential buffer to the aforementioned
negative psychological symptoms has been well borne out in the literature
(Cobb, 1976; Cohen & Wills, 1985; Pinto, Rog´
erio, Melendez, & Spector,
2008). To date, no empirical studies have examined social support in the FTM
community. Support from family has been shown to have a protective effect
against negative mental health outcomes for gender-variant children (Ryan,
Huebner, Diaz, & Sanchez, 2009). Gauthier and Chaudoir (2004) discuss the
importance of the internet as a potential source of social support for FTMs
and posit that FTMs can find understanding and acceptance in cyberspace
that may not exist in their day-to-day life.
Preliminary assessment of quality of life in FTMs indicates testosterone
treatment may improve their quality of life (Newfield et al., 2006). Overall
quality of life has been found to be lower in FTMs who have not begun
HRT, when compared to both male and female nontransgender individuals
(Newfield et al., 2006). No empirical studies to date have examined change
in quality of life following testosterone administration on FTMs.
Support for the notion that mental health will improve with HRT comes
from numerous studies suggesting affective distress and associated behaviors
can be related to issues involving discrimination, abuse, and decreased body
image (Clements-Nolle et al., 2006; Grossman et al., 2007). Similarly, Safren
and Heimberg (1999) found that when controlling for psychosocial predictors
of current distress, the differences between heterosexual and sexual minority
youths in levels of depression, hopelessness, and past and present suicidality
were nullified. It would follow that as sources of distress, including feelings
of discomfort with physical sex characteristics, are alleviated by HRT, levels
of associated affective distress should decrease.
Based on the general dearth of information on the FTM population
in general, specifically concerning the effects of testosterone use, the most
accessible form of GAT, the aim of the current study is to determine the
psychological variables associated with receiving HRT. Due to the increases
in depression and anxiety, as well as reduced quality of life in FTMs not on
HRT, it is hypothesized that (1) FTMs who are currently taking testosterone
(+HRT) will report lower levels of depression, anxiety, and stress than those
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288 S. L. Colton Meier et al.
who are not (HRT) and (2) FTMs who are currently taking testosterone
(+HRT) will report higher levels of social support and quality of life than
those who are not (HRT).
An additional aim of this study was to conduct a preliminary investiga-
tion of associated psychological factors, such as suicidality and problematic
alcohol and substance use, in their relationship to HRT status.
Participants and Procedures
FTM participants were recruited in spring 2008 to participate in an online
survey that took 10–25 minutes to complete. The anonymous online survey
was hosted on a secure server. The Committee for the Protection of Human
Subjects at the University of Houston approved subject recruitment. Study
advertisements were posted on online groups and discussion forums that
were dedicated to FTM members. Participants also may have learned of the
study through local FTM support groups, and all interested participants were
given the URL to a secure website. Data were collected over a period of
three months.
Participants read a consent form prior to study participation, and the in-
vestigator’s contact information was provided in case participants had ques-
tions at any time before, during, or after study participation. In order to
maintain anonymity, names and contact information of the participants were
not collected. Agreement to participate in the study was provided by clicking
an “I consent” button on the consent page. To prevent duplicate responses,
only one survey was permitted from each unique IP address, though these
were kept anonymous.
Respondents provided demographic information and then completed
questionnaires assessing clinical symptoms of depression, anxiety, and stress;
current perceived social support; and health-related quality of life. Upon
survey completion, participants were entered into a lottery drawing for cash
prizes. Funds for this research were provided by a graduate student research
award from the Texas Psychological Foundation.
Data from 448 FTMs were collected for this study. Sixty-two participants
were dropped from the analyses because of incomplete surveys, and 17
participants were dropped for failure to meet the minimum age requirement
of 18. Thus, n =369 participants were included in the present analyses. The
mean age of the current sample was 28 years (range 18–68). The majority
of the sample was White (76.7%) and reported at least some college level of
education (88%). The majority of the sample reported working full- or part-
time jobs (51.6%), and 30.2% indicated they were students. Most participants
reported living in the United States (85%). Sixty-five percent reported a gross
annual income of $25,000 or less. Sixty-six percent of the sample reported
taking testosterone at the time of the survey. Half of the sample (50%)
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Hormone Treatment of Female-to-Male Transsexuals 289
reported attractions towards both men and women. Forty-one percent of the
sample reported having had chest reconstruction surgery, and 6% reported
having genital surgery. All of the participants who had genital reconstruction
reported being on HRT and having had chest surgery. Although most of the
participants who reported having had chest surgery without genital surgery
were on HRT, a small number were not (n =7).
Participants reported information on their age, ethnicity, education, work
status, income, HRT status, surgical status (chest and genital surgeries), his-
tory of suicide attempts, and history of alcohol and substance problems. See
Table 1 for a summary of the demographics of the present sample.
Questions assessing HRT status, and history of suicide, alcohol, and drug
use were: “Are you currently using hormones?” “Have you ever attempted
suicide?” “Have you or anyone else felt that you have had a problem with
alcohol?” “Have you or anyone else felt that you have had a problem with a
substance (other than alcohol)?” Respondents chose “Yes” or “No” for each
The Depression, Anxiety, and Stress Scale (DASS) is a 42-item measure of
depression, anxiety, and stress experienced over the previous week (Lovi-
bond & Lovibond, 1995). The DASS utilizes a four-point Likert response
scale, wherein participants decided whether the item applied to them from
0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the
time) over the past week. Prior research confirms concurrent and construct
validity in the acceptable to excellent range (Antony, Bieling, Cox, Enns, &
Swinson, 1998). Consistent with recent research (Crawford & Henry, 2003),
reliability for the total scale was excellent (α=.96). The Cronbach’s reliabil-
ity coefficients for the subscales were .95 (depression), .86 (anxiety), and .92
(stress), suggesting good to excellent internal consistency. Higher scores on
each scale indicate more depression, more anxiety, and more stress. Refer
to Table 2 for the normative scores for each subscale.
The Multidimensional Scale of Perceived Social Support (MSPSS) is a 12-
item scale developed to assess social support from friends, family, and a
significant other (MSPSS; Zimet, Dahlern, Zimet, & Farley, 1988). However,
for the purposes of this study, the total score was used. Responses are
based on a 7-point Likert scale, ranging from 1 (Very strongly disagree) to 4
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290 S. L. Colton Meier et al.
TABLE 1 Summary of Demographic Information
Variable Sample (n =369)
Age M=28.5, Range 18–68
Caucasian 76.7
Latino/Hispanic 2.7
African American 3.5
Asian American 0.8
Pacific Islander 0.5
Native American/Alaskan Native 0.3
Biracial 13
Other 2.4
HS diploma/GED or less 10
Some college 40.9
Associate’s degree 3.8
Technical/Trade School 0.8
Bachelor’s degree 22.8
Postgraduate 21.7
Work Status
Full time 37.7
Part time 14.6
Temporary/seasonal 1.4
Unemployed 11.9
Disability 4.1
Retired 0.3
Student 29.3
Gross Annual Income
none 10.8
Less than $5,000 16.3
$5,000–14,999 22
$15,000–24,999 13.6
$25,000–29,999 6.2
$30,000–39,999 11.4
$40,000–49,999 5.4
$50,000–74,999 8.1
$75,000–99,999 3.5
$100,000–over 2.7
Testosterone Therapy
+HRT 66
HRT 34
(Neutral) to 7 (Very strongly agree). The Cronbach’s reliability for the total
support subscale was good (α=.89), and higher scores indicate higher
levels of perceived social support.
The Short Form 36-item Questionnaire version 2 (SF-36v2; Ware, Kosinski,
& Dewey, 2000) is a reliable quality of life measure and has been validated
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Hormone Treatment of Female-to-Male Transsexuals 291
TABLE 2 Multivariate Results including Normative Data
Outcome Variable +HRT HRT TOTAL NORMS
Depression∗∗∗ 6.5 13.7 9 0–9
Anxiety∗∗∗ 4.4 8.0 5.6 0–7
Stress∗∗∗ 9 15.1 11.1 0–14
Quality of life∗∗∗ 65.2 53.7 61.3 50 (10)
Perceived social support∗∗∗ 5.3 4.8 5.1 5.8 (.86)
Suicide attempts (ever)# 42% 46% 43% 32%
Alcohol problems 27% 19% 24% 8–31%
Substance use problems 19% 19% 19% 3–71%
∗∗∗p<.001, # based on n =367.
Norms for depression, anxiety, stress, social support, quality of life, are based on the general population
norms, whereas norms for suicide attempts and substance problems are based on research from the
transgender population.
MANOVA: Overall significant main effect of HRT on mental health, F(5, 363) =12.89, p<.001.
with online FTM samples (Newfield et al., 2006). It yields eight subscales
with reliabilities ranging from .93 to .95 (Ware, 2003). The current study uses
the general health subscale, which demonstrated good reliability (α=.85).
Higher scores indicate higher levels of quality of life.
The distributions for depression, anxiety, and stress were positively skewed
and the distributions for social support and quality of life were negatively
skewed, so the data were log transformed. The table presents untransformed
data. See Table 2 for a display of the untransformed means for the groups.
To test the hypotheses (that FTMs differed on clinical variables based
on HRT status), a two-way multivariate analysis of variance (MANOVA) was
conducted with HRT status (+or ) as the qualitative between-subjects
factor and depression, anxiety, stress, social support, and quality of life as
quantitative dependent variables.
As expected, depression, anxiety, and stress were positively correlated; social
support and quality of life were also positively correlated; and depression,
anxiety, and stress scores were each negatively correlated with social support
and quality of life (see Table 3). The significant correlations provide evidence
for good discriminant validity, and the small to moderate correlations indicate
that the scales measure related, yet distinct, constructs. Thus, the dependent
variables are appropriate for use in a MANOVA.
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292 S. L. Colton Meier et al.
TABLE 3 Correlation Matrix
Depression Anxiety Stress Social Support
Anxiety .63∗∗∗
Stress .65∗∗∗ .73∗∗∗
Social support 0.38∗∗∗ .24∗∗∗ .24∗∗∗
Quality of life .35∗∗∗ .37∗∗∗ .33∗∗∗ .25∗∗∗
The means of the dependent variables for the two groups are presented
in Table 2. Mean scores for almost all variables in each group fall within
the normal range for depressive symptoms, anxiety symptoms, and stress.
The means of depression and stress of FTMs who were not on testosterone
fell just outside of normal, in the mild range. Both groups reported lower
than average levels of social support. Overall, FTMs reported relatively high
levels of quality of life. Almost half of the sample reported a history of at
least one suicide attempt, which was higher than expected. Overall rates of
problematic alcohol and substance use were within the expected ranges (see
Table 2).
Multivariate Analyses
To test whether FTMs differed on clinical variables based on HRT status, a
between-subjects MANOVA was run with HRT status (2 levels: +HRT and
HRT) on depression, anxiety, stress, social support, and quality of life. As
predicted, an overall multivariate effect of HRT status was found in which
FTMs differed on mental health measures based on HRT status (F(5, 363) =
12.89, p<.001). Specifically, FTMs who were on testosterone reported lower
levels of depression, anxiety, and stress and higher levels of social support
and health-related quality of life than those who were not on testosterone.
A main effect of depression was found F(1, 367) =57.34, p<.001,
where FTMs who were on testosterone reported significantly lower levels of
depression than those who were not on testosterone. Main effects of anxiety
and stress were found were in the same direction (anxiety: F(1, 367) =37.71,
p<.001; stress F(1, 367) =38.14, p<.001).
Social support was found to differ significantly between groups, with
FTMs on testosterone reporting higher levels of perceived social support
than those not on testosterone (F(1, 367) =13.03, p<.001). A main ef-
fect of health-related quality of life was found wherein FTMs who were on
testosterone reported higher quality of life scores than those who were not
on testosterone, (F(1, 367) =17.95, p<.001).
Chi-square tests were used to determine whether or not there was a
significant difference in reported history of one or more suicide attempts
between FTMs who were on HRT and those who were not. Forty-two percent
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Hormone Treatment of Female-to-Male Transsexuals 293
of +HRT FTMs reported a history of a suicide attempt, and 46% of HRT
FTMs reported the same. The difference was not statistically significant, χ2
(1, 367) =.53, p>.05.
A similar set of analyses was conducted to determine whether or not
FTMs who were on HRT and those who were not differed on reported
history of problems with alcohol or other substance use. Histories of alcohol
problems were reported by 27% of +HRT FTMs and 19% of HRT FTMs.
This difference was not found to be statistically significant, χ2(1, 369) =
2.3, p>.05. Nineteen percent of both groups reported having a history of
substance use problems, χ2(1, 369) =.002, p>.05.
All hypotheses in the current study received strong empirical support. FTMs
who were on HRT with testosterone had significantly lower reported levels
of depression, anxiety, and stress than their FTM counterparts not taking
testosterone. FTMs on testosterone had generally a higher reported quality
of life and higher levels of perceived social support compared with their
FTM counterparts not currently taking testosterone. Thus, for FTMs, HRT
in the form of testosterone is associated with fewer negative psychological
symptoms, and in addition is related to greater levels of protective factors
and sources of resiliency, such as perceived social support and a higher
quality of life.
It is noteworthy that the levels of negative psychological symptoms were
atypical in this particular sample, as they were lower than those reported in
previous internet studies of FTMs (Clements-Nolle et al., 2006; Newfield
et al., 2006). For example, Clements-Nolle and colleagues (2006) found the
incidence of clinical depression in their sample of 500 transgender individuals
to be as high as 60%. While that sample included MTFs, the incidence of
depression remains well above that reported in the current study. Newfield
and colleagues (2006) reported lower overall quality of life in a sample of
FTMs. This may be because the current study reported on one aspect of
quality of life only, while Newfield and colleagues discussed overall quality
of life. While the sample endorsed fewer negative symptoms overall, levels
of these composite domains still varied significantly between groups.
Despite differences found in the levels of psychological variables, no
significant group differences were found in suicidality or problematic sub-
stance use. That is, FTMs taking testosterone did not differ from their FTM
counterparts not taking testosterone in number of past suicide attempts or
in problematic substance use. The lack of significant findings with respect
to suicidality may be in part due to the manner in which this was assessed.
For the purposes of this study, suicidality was queried only in terms of past
attempts. Because a previous suicide attempt is a single event in the past, it
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294 S. L. Colton Meier et al.
is not something that can be affected by current use of HRT. More research
is needed in this area to elucidate levels of suicidal ideation and poten-
tial changes therein, as well as changes in number of attempts following
treatment with HRT.
Similarly, the lack of significant findings with respect to problematic
substance use between groups is likely due to the manner in which this
was assessed. Substance use and abuse is often a long-standing pattern, the
underpinnings of which are both psychological and physiological, adding a
layer of complexity to the potential effect of testosterone on this domain.
Also, time since beginning testosterone was not recorded, and as such it was
impossible to determine whether or not respondents were more likely to
reduce problematic substance use at any point following use of testosterone.
Further research would be necessary to fully investigate this relationship.
The significance of the findings from the current study can be best un-
derstood in light of prior research. Despite an established greater propensity
towards negative psychological symptoms in FTMs regardless of GAT status,
the etiology of this relationship is not well understood and is often over-
looked. For example, it is unclear if negative psychological symptoms are in
part due to the perceived mismatch between body and gender, or if direc-
tionality extends in the other direction. Consequently, something that is not
commonly emphasized is an understanding of the potential positive psycho-
logical effects that hormone regimens may be associated with in addition to
their effects on secondary sex characteristics.
One possible explanation for the main effect of testosterone in the
study is related to gender dysphoria, or the notion that transgender indi-
viduals may experience negative psychological symptoms related to the fact
that they do not identify with their present gender (Sember, 2000). From
this line of reasoning, FTMs may experience fewer negative psychological
symptoms when receiving HRT because it serves to lessen the incongru-
ence between external sex characteristics and internal gender identity. This,
in turn, may lessen the negative psychological symptoms associated with
gender dysphoria. That is, lesser degree of incongruence may be linked
directly or via other mediating factors, such as self-worth, self-acceptance,
perceived social acceptance, and so forth, to psychological sequelae such
as anxiety, depression, and stress. Much more research would be needed
to elucidate the verity of gender dysphoria as a mediating factor in this
An alternative explanation for these results may be linked to the sys-
tem involving the requirements for the prescription of HRT to FTMs. If a
prerequisite for prescribing HRT is a certain degree of psychological health
and/or an absence of certain comorbid psychological conditions, it is pos-
sible that those individuals with a lesser predisposition to depression and
anxiety are those more frequently prescribed HRT. Thus, the directionality
of the association between HRT and psychological health is unknown.
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Hormone Treatment of Female-to-Male Transsexuals 295
It is clear that positive psychological effects were associated with HRT.
This comes with a host of implications for clinical practice. The results offer
strong support for the claim made by Levy, Crown, and Reid (2003) that
withholding HRT agents from a transsexual can be associated with increased
risk of depression and suicide. The current findings suggest prescription of
HRT to FTMs may serve to alleviate some of the negative psychological
symptoms associated with gender dysphoria, including depression, anxiety,
and stress, as well as increasing protective factors such as social support and
quality of life.
The current study provides some of the first evidence of the effects of
testosterone on psychological symptoms for FTMs largely from the United
States. Given the current role of health professionals in transsexuals’ access to
HRT in the United States, it is crucial that the positive effects of testosterone
be taken into account by these individuals. As previously stated, it is often
presumed, without adequate evidence base, that transitioning represents a
potentially psychologically taxing process and should be limited in individ-
uals with impaired reality testing. Depression and anxiety are not typically
thought to impair reality testing, and have been shown to be improved in
individuals on HRT. A clinical implication is that a diagnosis of depression
and/or anxiety should not contraindicate HRT.
Furthermore, as health care professionals have been placed in a role to
potentially limit access to hormone treatments, they bear the onus to become
better educated regarding transsexual issues, in order to operate in the best
interest of the individual. There is a lack of exposure to and information
on transsexual and transgender issues among health care professionals. It
is crucial that mental health professionals be well-educated in transsexual
health issues and needs, so as to prevent undue suffering in the forms
of discrimination, micro-aggression, or medical mismanagement among this
This study provides clear evidence that HRT is associated with improved
mental health outcomes in FTMs. Current findings adds to the body of cur-
rent literature that strongly encourages health care providers to be aware of
possible hormonal and surgical interventions that may be indicated for use
with transgender individuals. The effects and associated risks of these hor-
mone regimens should well understood by health care providers (Feldman
& Bockting, 2003).
While the implications for better education of health care professionals
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of this study may be limited by the demographics of our sample (mostly
U.S. residents, White, and highly educated). As such, a more representa-
tive sample in future research may serve to extend the generalizability of
such findings. Future research to elucidate the many remaining questions
also could be well served by investigation of the effects of testosterone on
psychological symptoms and functioning in one sample over time.
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... One study found that female-to-male transgender people had less depression, anxiety, stress and more social support and higher quality of life after hormone therapy. In other words, social support increases the quality of life of female to male transgender people (Colton Meier et al., 2011). In fact, social and family support are protective factors against emotional distress (Gómez-Gil et al., 2012). ...
... One study found that female-to-male transgender people had less depression, anxiety, stress and more social support and higher quality of life after hormone therapy. In other words, social support increases the quality of life of female to male transgender people (Colton Meier et al., 2011). In fact, social and family support are protective factors against emotional distress (Gómez-Gil et al., 2012). ...
Purpose: One of the strategies for treating gender dysphoria is cross-sex hormone therapy (CHT). Our study aimed to explore the differences in the psychopathology of people with gender dysphoria who received the hormone with those who did not this treatment. We also wanted to explore discrimination and rejection among people with gender dysphoria. Methods: We administered a demographic questionnaire and a structured clinical interview for DSM Axis I disorders (SCID_I) to all participants. Our study sample consisted of 41 people with gender dysphoria (20 MtF and 21 FtM), of whom 21 received Cross-sex hormone therapy (CHT) and 20 did not. Results: Results indicated that they were on CHT had lower psychological problems than those who did not receive hormone therapy. CHT was influenced by gender dysphoria's psychological health. On the other hand, gender dysphoria that doesn't receive CHT, had further depression, anxiety, obsession-compulsion, and in general Axis-I disorders. We also found that male-to-female people with gender dysphoria were more likely to suffer from discrimination and rejection. Conclusions: We concluded that CHT could affect the mental health of people with gender dysphoria. Our knowledge of the role of discrimination, ridicule and rejection on the psychological pathology of people with gender dysphoria can help specialists to find the best treatment for these people.
Introduction Experiences of discrimination and bias in healthcare contribute to health disparities for lesbian, gay, bisexual, transgender, and queer populations. To avoid discrimination, many go to great lengths to find healthcare providers who they trust and who are knowledgeable about their health needs. This study examines whether access to an affirming provider improves health outcomes for lesbian, gay, bisexual, transgender, and queer populations across a range of preventive health and chronic disease management outcomes. Methods This cross-sectional study uses Poisson regression models to examine original survey data (n=1,120) from Wave 1 of the Vanderbilt University Social Networks, Aging, and Policy Study, a panel study examining older (aged 50–76 years) lesbian, gay, bisexual, transgender, and queer adults’ health and aging, collected between April 2020 and September 2021. Results Overall, access to an affirming provider is associated with greater uptake of preventive health screenings and improved management of mental health conditions. Participants with an affirming provider are more likely to have ever and recently received several types of preventive care than participants reporting a usual source of care that is not affirming, including past year provider visit, influenza vaccination, colorectal cancer screening, and HIV test. Access to an affirming provider is also associated with better management of mental health conditions. Conclusions Inclusive care is essential for reducing health disparities among lesbian, gay, bisexual, transgender, and queer populations. Health systems can reduce disparities by expanding continuing education opportunities; adopting nondiscrimination policies for patients and employees; and ensuring that necessary care is covered by health insurance.
Data on unmet mental health needs is limited for transgender men. This analysis aims to determine the prevalence and correlates of lifetime suicidal ideation and suicide attempt among transgender men in San Francisco. Between 2014 and 2015, 122 transgender men aged ≥18 years from the San Francisco Bay Area were recruited using a hybrid venue- and peer referral-based sampling method (starfish sampling) to participate in a survey that included mental health indicators. Multivariable Poisson regression models determined associations of lifetime suicidal ideation and lifetime suicide attempt, separately, with demographic, substance use, and psychosocial factors. Mean age of participants was 29.6 years (range 18–56); 22% identified as transgender men of color (6 Asian, 8 Black/African American, 4 Hispanic/Latinx, and 9 other/mixed race); 52% reported ever receiving a depression diagnosis. Overall, 81% ( n = 98) reported suicidal ideation, of whom 48% ( n = 47) reported suicide attempt. Identification as a transgender man of color (adjusted prevalence ratio [PR] 1.23, p = .03) and prior depression diagnosis (PR 1.46, p < .01) were associated with lifetime suicidal ideation. Perceived social support was associated with a decreased risk of suicidal ideation (PR 0.82, p = .02). Prior depression diagnosis (PR 2.23, p < .01) and low to moderate (≤3 episodes vs. none) binge alcohol use in the last 6 months (PR 1.60, p = .03) were correlates of lifetime suicide attempt. Suicidal behaviors were highly prevalent among this community-derived sample of transgender men. Targeted mental health-focused interventions, specifically among ethnic minorities, may help to address these disparities in this underserved group.
This book discusses the global prevalence as well as the geographic distribution of HIV-1 and HIV-2 infections and updates on recent shared global initiatives. The demographic trends in HIV in the United States, especially regarding gender, sexuality, race, ethnicity, age, injection-drug use, socioeconomic status, and recent initiatives are reviewed. Special attention is paid to HIV among communities of color, as well as women, children, and adolescences. The role of HIV in men who have sex with men and the transgender community is reviewed in detail. HIV Testing and Counselling lists and describes the various types of HIV testing available. The book also presents an overview of HIV counselling. HIV testing terminology and algorithms are presented to the reader along with descriptive figures. Laboratory markers for HIV are reviewed. The chapter describes who should be tested, as well as pre and post-test counselling elements. A section of the chapter is dedicated to special populations and environments (blood supply screening, prenatal screening, testing settings) Strategies to improve uptake of HIV testing are discussed.
Gender diverse youth and emerging adults in the U.S. experience alarmingly high rates of suicidality. In this chapter we use data from the 2015 U.S. Transgender Survey, the largest national sample of gender diverse individuals in the U.S., to examine variation in suicidality and correlates of suicidality among gender diverse individuals aged 18–24. Theoretically guided by the ideation-to-action suicide framework, we examine differences in socio-demographic factors, external minority stressors, gender-affirming and transition-related variables, social support, and physical/psychiatric comorbidities, across four gender identity groups: transgender men (n = 3,737), transgender women (n = 2,090), nonbinary individuals assigned male at birth (AMAB) (n = 838), and nonbinary individuals assigned female at birth (AFAB) (n = 5,099). We examine suicide ideation (lifetime and past year) and suicide attempt (lifetime and past year) among those who reported ideation. Our findings corroborate high rates of suicidality among gender diverse emerging adults, including higher rates of suicidality among respondents assigned female at birth. In multivariable models, psychiatric comorbidity is a strong independent correlate of ideation but not attempt, while external minority stressors associated with suicide capacity are strong independent correlates of attempt. We discuss both the theoretical and methodological implications of our results for future research on suicidality among the gender diverse population.KeywordsSuicidalityGender diverseIdeation-to-action framework
Several polls have documented Americans’ general attitudes toward transgender people, yet we know little about Americans’ willingness to grant broader rights and privileges to this growing population. Using data from a nationally representative survey experiment, we distinguish between formal rights—rights that are legally conveyed—and informal privileges—those that are not as consistently tied to the law, but nonetheless can have wide-ranging implications for people’s lives. We consider (1) how respondents’ sociodemographic characteristics are associated with attitudes toward rights and privileges; and (2) how a transgender person’s characteristics affect people’s willingness to grant these rights and privileges. Overall, we find that respondents are much more likely to grant formal rights (i.e., employment protections, right to service) than informal privileges (i.e., bathroom access) to transgender people. This pattern implies that even if people are willing to offer legal protections to transgender people, more subtle forms of prejudice may persist. These beliefs are patterned along demographic lines such as respondent sex, respondent age, and respondent sexual orientation. Moreover, respondents are less willing to grant both formal rights and informal privileges to transgender people who are described as gender non-conforming. Implications for demographic research on transgender populations are discussed.KeywordsTransgenderFormal rightsInformal privilegesAttitudesExperiment
Few studies have analyzed mortality rates among transgender (trans) populations in the United States and compared them to the rates of non-trans populations. Using private insurance data from 2011 to 2019, we estimated age-specific all-cause mortality rates among a subset of trans people enrolled in private insurance and compared them to a 10% randomly selected non-trans cohort. Overall, we found that trans people were nearly twice as likely to die over the period as their non-trans counterparts. When stratifying by gender, we found key disparities within trans populations, with people on the trans feminine to nonbinary spectrum being at the greatest risk of mortality compared to non-trans males and females. While we found that people on the trans masculine to nonbinary spectrum were at a similar risk of overall mortality compared to non-trans females, their overall mortality rate was statistically smaller than that of non-trans males. These findings provide evidence that some trans and non-trans populations experience substantially different mortality conditions across the life course and necessitate further study.
Background: In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office. Objective: Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting. Conclusion: This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.
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The development of a self-report measure of subjectively assessed social support, the Multidimensional Scale of Perceived Social Support (MSPSS), is described. Subjects included 136 female and 139 male university undergraduates. Three subscales, each addressing a different source of support, were identified and found to have strong factorial validity: (a) Family, (b) Friends, and (c) Significant Other. In addition, the research demonstrated that the MSPSS has good internal and test-retest reliability as well as moderate construct validity. As predicted, high levels of perceived social support were associated with low levels of depression and anxiety symptomatology as measured by the Hopkins Symptom Checklist. Gender differences with respect to the MSPSS are also presented. The value of the MSPSS as a research instrument is discussed, along with implications for future research.
Objective: To qualitatively describe the level of HIV risk behaviors and access to HIV-prevention and health services among transgendered individuals in San Francisco. Methods: Eleven focus groups were conducted with 100 Male-To-Female and Female-To-Male transgendered individuals. Focus groups were transcribed, reviewed, and comments were coded into categories that emerged naturally from the data. Unduplicated comments were enumerated and summarized. Findings: HIV risk behaviors such as unprotected sex, commercial sex work, and injection drug use were common. Low self-esteem, economic necessity, and substance abuse were cited as common barriers to adopting and maintaining safer behaviors. Many individuals did not access prevention and health services because of competing priorities and the insensitivity of service providers. Participants' recommendations for improving services include hiring transgendered persons to develop and implement programs and training existing providers in transgender sensitivity and standards of care.
Written by a leading activist in the transgender movement, Becoming a Visible Man is an artful and compelling inquiry into the politics of gender. Jamison Green combines candid autobiography with informed analysis to offer unique insight into the multiple challenges of the female-to-male transsexual experience, ranging from encounters with prejudice and strained relationships with family to the development of an FTM community and the realities of surgical sex reassignment. For more than a decade, Green has provided educational programs on gender-variance issues for corporations, law-enforcement agencies, social-science conferences and classes, continuing legal education, religious education, and medical venues. His comprehensive knowledge of the processes and problems encountered by transgendered and transsexual people-as well as his legal advocacy work to help ensure that gender-variant people have access to the same rights and opportunities as others-enable him to explain the issues as no transsexual author has previously done. Brimming with frank and often poignant recollections of Green's own experiences-including his childhood struggles with identity and his years as a lesbian parent prior to his sex-reassignment surgery-the book examines transsexualism as a human condition, and sex reassignment as one of the choices that some people feel compelled to make in order to manage their gender variance. Relating the FTM psyche and experience to the social and political forces at work in American society, Becoming a Visible Man also speaks consciously of universal principles that concern us all, particularly the need to live one's life honestly, openly, and passionately. © 2004 Jamison Green Published by Vanderbilt University Press. All rights reserved.
Female-to-male transsexuals (FTMs) are aware that manhood is a test that is separate from simple anatomical maleness. Failure to pass the test carries a penalty of exclusion from the desired rank as well as stigmatization as deviant for having attempted such a feat. Armed with this awareness, they are utilizing modern technology to form a community of virtual support, a study group of sorts, that will facilitate passing that test. This project identifies, through content analysis, various themes of concerns of female-to-male transsexuals who post on the Internet. The themes include concerns about gender status production, including issues such as “passing,” surgical worries, legal avenues and blockades, and social support. These themes relate directly to FTMs’ real-world ideologies about themselves as men. They recognize their central problem as one which debates the nature of manhood as either an ascribed or achieved status, and in self-reflexive fashion are able to see themselves as non-deviant in one gender category, yet deviant to onlookers while in another gender category. For FTMs, the fear is that even if medical and legal obstacles can be overcome, social obstacles and social stigmatization may not. Yet, in their cyber-community, a number of FTMs have found acceptance and understanding to be less elusive than what they find in the real world.