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Archives of Sexual Behavior
The Official Publication of the
International Academy of Sex Research
ISSN 0004-0002
Arch Sex Behav
DOI 10.1007/s10508-012-0052-2
Measures of Clinical Health among
Female-to-Male Transgender Persons as a
Function of Sexual Orientation
S.Colton Meier, Seth T.Pardo, Christine
Labuski & Julia Babcock
1 23
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ORIGINAL PAPER
Measures of Clinical Health among Female-to-Male Transgender
Persons as a Function of Sexual Orientation
S. Colton Meier
•
Seth T. Pardo
•
Christine Labuski
•
Julia Babcock
Received: 7 January 2011 / Revised: 28 October 2012 / Accepted: 31 October 2012
Ó Springer Science+Business Media New York 2013
Abstract The present study examined the sexual orienta-
tion classification system that was used in the DSM-IV-TR for
categorizing those who met the Gender Identity Disorder diag-
nostic criteria in order to determine the extent to which female-
to-male transgender persons (FTMs) differ on psychological
variables as a function of sexual orientation. Participants were
605 self-identified FTMs from 19 different countries (83 % U.S.)
who completed an internet survey assessing their sexual ori-
entation, sexualidentity, symptoms of depression and anxiety,
stress(DepressionAnxietyStress Scales),socialsupport(Mul-
tidimensional Scale of Perceived Social Support), and health
related quality of life (SF-36v2 Health Survey). Over half the
sample (52 %) reported sexual attractions to both men and
women. The most common sexual identity label reported was
‘‘queer.’’ Forty percent of FTMs who had begun to transition
reported a shift in sexual orientation; this shift was associated
with testosterone use. Overall, FTMs ranged from normal to
above average on all psychological measures. FTMs did not sig-
nificantly differ by sexual attraction on any mental health vari-
ables, except for anxiety. FTMs attracted to both men and
women reported more symptoms of anxiety than those
attracted to men only. Results from the present study did
not support a sexual orientation classification system in
FTMs with regard to psychological well-being.
Keywords Transgender Gender Identity Disorder
Transsexualism Sexual orientation
Introduction
Despite a wealthof socialscientific and clinical data, as well as
a growing body of sound theoretical development, gender iden-
tities persistently become confused with sexual orientation in
both lay and scholarly discourse (Devor, 1993b;Feinberg,1996;
Halberstam, 1998;Rubin,1975; Valentine, 2007). Contempo-
rary scholars, particularly feminist and LGBT researchers
whose workfocuses on the complex ways that these categories
are actually lived (Bockting, Benner, & Coleman, 2009;Devor,
1993b;Diamond,2002;Feinberg,1996;Halberstam,1998),
routinely critique psychology and psychiatry for clinging to out-
dated conflations of sex, gender, and sexual orientation (Dre-
scher, 2010; Wilson, 2000; Winters, 2007).
A person’s sexual orientation refers to their‘‘relatively stable
tendency to seek sexual partners of the same gender, other
gender, or both genders’’(Diamond, 2001,p.174;emphasis
added) whileone’s sexualidentity is the labela personascribes
to their sexuality (Savin-Williams, 2006). These concepts rely
on unchanging sex/gender realities and therefore fail to ade-
quately capture the increasingly unstable experiences of a grow-
ing number of individuals in the contemporary United States
(Diamond, 2008; Vrangalova & Savin-Williams, 2012).
Gender affirmation surgeries, which can range from $3,000
to $100,000 and are typically not covered by most insurance
plans, are economically unavailable to many transgender peo-
ple. Less costly hormones and body modifications (such as
breast binders and prosthetic genitalia) allow more individuals
to live in the gender with which they identify, presenting a
dilemma for would-be categorizers of this population. More-
over, the number of transgender individualswhodelay,forego,
and/or purposely‘‘mix-up’’these elements of gendertransition
S. C. Meier (&) J. Babcock
Department of Psychology, University of Houston, 126 Heyne
Building, Houston, TX 77204-5022, USA
e-mail: ftmresearch@gmail.com
S. T. Pardo
The Rockway Institute, Alliant International University,
San Francisco, CA, USA
C. Labuski
Faculty of Sociology, Virginia Polytechnic Institute and State
University, Blacksburg, VA, USA
123
Arch Sex Behav
DOI 10.1007/s10508-012-0052-2
Author's personal copy
pose an even greater challenge to concepts of sexual identity
that rely on stable and unchanging experience.
The transgender partner adds an additional level of com-
plexity to theories about sexual orientation. Transgender is
broadly defined as‘‘any individual whose gender-related iden-
tification or external presentation either violates conventional
conceptualizationsofmaleorfemale ormixesdifferentaspects
of male and female role and identity’’(Diamond & Butterworth,
2008, p. 365). In evaluating the sexual orientation of transgender
persons, then, one must keep in mind the referent point with
regard to labels: if using birth assigned sex as the referent, then
a female-to-male transgender man (FTM) who is attracted to
males is heterosexual, but if using gender identity as the referent,
that FTM would be gay. Some trans people find it disrespectful,
and even ego-dystonic, to be referred to as ‘‘non-homosexual’’
when they actively identify as gay.
FTMs (or trans men) are individuals who were assigned a
female birth sex, but experience their gender as male; this
term includes those who have experienced gender dysphoria
(Devor, 1997b). Some FTMs choose to forego a medical tran-
sition while others have achieved full legal recognition as
males (Devor, 1997b); some in the latter category consider
themselves men rather than transgender or transsexual (De-
vor, 1993a; Newfield, Hart, Dibble, & Kohler, 2006). Despite
being assigned female, FTMs with male identities and attrac-
tions towards women may see themselves as‘‘straight’’ while
those attracted to men may identify as‘‘gay’’(Bockting et al.,
2009; Devor, 1993a, 1993b). Thus far, researchers have not
maintained consistency when dealing with these differences:
while most studies classify transgender persons as non-homo-
sexual or homosexual relative to their birth sex (Chivers & Bailey,
2000; Johansson, Sundbom, Hojerback, & Bodlund, 2010),
others have used gender identity to categorize participants
(Bockting et al., 2009; Schleifer, 2006).
The past two decades have seen a growing interest in doc-
umenting the sexual behaviors and identities of transgender
populations (Bockting et al., 2009; Diamond & Butterworth,
2008; Lawrence, 2010; Rachlin, 1999). Much of this research
has suggested that transgender typologies (e.g., Blanchard,
1985, 1989 and the DSM-IV-TR) based on sexual orientation
(homosexual/non-homosexual) may not adequately capture
the full range and complexity of FTM sexuality (Devor, 1993b;
Johansson et al., 2010;Lawrence,2010)asthis population varies
acrosssexual orientation, gender identity, degrees of body modi-
fication, use of hormonal therapies, and economic access to trans/
LGBT resources (Rachlin, Hansbury, & Pardo, 2010).
Sexual Orientation Specifiers
For the purpose of this article, we classify sexual orientation
by attractions, as introduced by the DSM-IV-TR’s specifiers
for the Gender Identity Disorder (GID) diagnosis. This has
resulted in four categories: FTMs who report attractions to
women (AW), those who report attractions to men (AM),
those who report attractions to both men and women (AB),
and those who are attracted to neither (AN).
Research exploring the role of sexual orientation in trans
people includes Blanchard’s (1985, 1989) early work with
male-to-female transgender women (MTFs). Although his
theory remains controversial (Dreger, 2008; Nuttbrock et al.,
2011), it is still used as the diagnostic schema for gender dys-
phoric persons (Lawrence, 2004, 2007, 2010). The current
study attempts to examine the utility of the DSM-IV-TR’s
typology in a community sample of FTMs.
While empirical support exists for use of sexual orienta-
tion specfiers in the MTF population, much less exists for use
with FTMs (Lawrence, 2008). Early research on sexual ori-
entation with this latter population found that those diagnosed
with GID reported almost exclusive sexual attractions toward
women (APA, 2000; Lawrence, 2010; Pauly, 1974). But
someresearchsuggeststhat AM FTMsare moreprevalent than
previously thought (Coleman, Bockting, & Gooren, 1993).
Case studies have presented FTMs who were attracted to men
both before and after transition (Coleman & Bockting, 1988;
Coleman et al., 1993) and research with community samples
has highlighted the experiences of AB and AM FTMs (Bock-
ting et al., 2009; dickey, Burnes, & Singh, 2012). One study
examined the identity development of AM FTMs and found
that they were more likely to be bisexual than exclusively
attractedtomen(Bocktingetal.,2009).Itislikelythatprevious
clinically based research may have overlooked these realities
given that AB and AM FTMs may have withheld information
about their sexual orientation in order to facilitate medical treat-
ment from providers. Cultural homophobia and taboos may
have also played roles (Bolin, 1994; Bullough & Bullough,
1998; Denny, Green, & Cole, 2007;Lev,2004; Meyerowitz,
2002; Sullivan, 1990).
Complications with the Present Specifier System
Examination of the sexual orientation specifiers for use in the
FTM population has understandably produced mixed results
(Bockting et al., 2009; Chivers & Bailey, 2000). Studies have
found AW FTMs to be more ‘‘masculine,’’ have more cross-
gender identification as children, and to prefer more feminine
partners more than AM FTMs (Chivers & Bailey, 2000;
Zucker et al., 2012). The groups did not differ on desire for
masculine characteristics or body modification. Smith, van
Goozen, Kuiper, and Cohen-Kettenis (2005)foundevidence
that AM FTMs reported more shyness and psychoneuroticism
than AW FTMs. Even with this information, researchers chal-
lenge the utility of a sexual orientation schema for determining
high-risk FTM candidates for gender-related surgery (Bockting
et al., 2009; Coleman et al., 1993); this is further complicated
by labels and partner preferences that may change after hormone
Arch Sex Behav
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therapy or surgery (Bockting et al., 2009;Daskalos,1998;De-
vor, 1993a;Hines,2007; Schleifer, 2006).
Psychosocial Well-Being
For the sexual orientation typology to be generally useful for
clinical work with FTMs, differences in psychosocial well-being
should be pronounced. Depression is very common among trans-
gender persons and LGB populations, due to the high prevalence
of victimization, discrimination, social stigma, negative social
responses, and family rejection (Clements-Nolle, Marx, & Katz,
2006; Herek, Gillis, & Cogan, 2009; Ryan, Huebner, Diaz, &
Sanchez, 2009). It is likely, therefore, that FTMs who are attracted
to men (gay or bisexual by gender identity) would beatagreater
risk for depression.
LGB persons commonly experience anxiety regarding com-
ing out related to a belief that being gay is wrong (Beck, 1995;
Sandfort, de Graaf, Bijl, & Schanbel, 2001), and research among
these populations has found them to be at greater risk for anxiety
disorders and symptoms than their heterosexual counterparts
(Hereket al., 2009;Whisman,2008).Anxiety is theorized as one
of the first stages of identity formation among trans people
(Devor, 2004) and cross-sectional studies have found testos-
terone use to be related to less anxiety (Gomez-Gil et al., 2012;
Meier, Fitzgerald,Pardo,&Babcock,2011). Similar to depres-
sion, we propose that those who are both FTM and gay or bisex-
ual are likely to be at higher risk for anxiety.
Social acceptance of AM FTMs is more difficult than
among AW FTMs. Coleman et al. (1993) speculated that the
social support of AM FTMs declines due to the‘‘double adjust-
ment’’(i.e., trans and gay) that must be made by families who are
conditioned by heteronormative social scripts (Lev, 2005). Non-
transgender (NT) gay men have more depression and less sense
of belonging to a community than NT heterosexual men (McLaren,
Jude, & McLachlan, 2007), and NT bisexual people are socially
rejected more often than monosexuals reporting lower levels of
connection to their community than gay and lesbian adults
(Balsam&Mohr,2007).
Though AM and AB FTMs may face rejection from NT
gay and bisexual men (especially if they are not perceived as
men), there are some potential problems with assuming that
they have less social support than do AW FTMs. Some AW
FTMs initially come out in the context of a supportive lesbian
community, having recognized their sexual attraction first.
But,AMFTMsmay also identifyas lesbian fora periodoftime
during their development (Bockting et al., 2009;Coleman
et al., 1993; Schleifer, 2006). The emphasis on female–female
attractions as integral to lesbian identity (Diamond, 2005)may
be related to the rejection that some FTMs experience from
these communities once they come out as straight trans-iden-
tified men (Bockting et al., 2009; Devor, 1997a;Green,2004
).
Little research to date has examined differences in quality
of life (QOL) between FTMs of differing sexual orientations.
The only studies to have examined FTM’s QOL found that it
was diminished relative to male and female NT counterparts
(Newfield et al., 2006) and testosterone use was related to
higher QOL (Meier et al., 2011). In an online sample of FTMs,
those age 18–34 years reported lower QOL than the national
normative sample and older FTMs’ scores did not differ from
normative data (Newfield et al., 2006). Even though younger
FTMs’ scores were significantly lower, their scores were within
less than one SD of the national sample (M = 47.76; national
average = 50;SD = 10;normsfrom Ware,Kosinski, & Keller,
1994).
It has been suggested that AM FTMs have lower QOL
because they are discriminated against by potential sex part-
ners. As AM FTMs enter the gay community, they face social
and sexual rejection, especially if they have not had genital
surgery (Schilt, 2009). Although the World Professional
Association for Transgender Health recommends providers
do not discriminate against trans people of varying sexual attrac-
tions, historical and anecdotal reports claim that healthcare pro-
fessionals may refuse to care for gay trans people, leading to
prolonged transition periods for some AM FTMs (Lev, 2005;
Meyer et al., 2001).
Aside from small case studies, no peer-reviewed research
has examined AB FTMs, although some studies have grouped
them with AM FTMs (Bockting et al., 2009; Chivers & Bailey,
2000). Though this parallels some research with NT bisexual
persons (Ross, Dobinson, & Eady, 2010), others have high-
lighted the importance of separating bisexual persons from those
whoidentifyasgay(Balsam&Mohr,2007; Herek et al., 2009).
Research examining NT bisexual persons found them to report
poorer mental health than heterosexual, gay, and lesbian persons,
including feeling greater self-stigma related to their sexual ori-
entation (Herek et al., 2009;Rossetal.,2010). If AB FTMs’
psychological well-being is similar to that of NT bisexuals, AB
FTMs may experience increased levels of depression, anxiety,
and stress, lower QOL, and decreased support from their com-
munities and families.
The Present Study
The current study examined the prevalence of different sex-
ual orientations, sexual orientation labels, and shifts in the
FTM community, and tested for group differences among
FTMs who were‘‘attracted-to-women,’’‘‘attracted-to-men,’’
or‘‘attracted-to-both.’’Insodoing,thisstudyexaminedtheclin-
ical utility of using the sexual orientation typology for FTMs.
This project focused on measuring psychologically relevant
variables in FTMsof different partner preferences.Thepresent
hypotheses, informed by previous research (Ross et al., 2010;
Smith et al., 2005), were that AM trans men would report
higher levels of depression, anxiety, and stress, and lower
quality of life and social support than AW FTMs. Second, it
was hypothesized that ABs would also report higher levels of
Arch Sex Behav
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depression, anxiety, and stress, and lower quality of life and
social support than AWs and AMs. Multiple significant dif-
ferences between groups would support sexual orientation
classifications of FTMs.
Method
Participants
Data from 605 FTMs were collected for this study, but 503
participants were included in the multivariate analyses. Par-
ticipants were dropped from all analyses due to failure to meet
theminimumagerequirementof 18 years (n = 12)and asexual
participants were excluded based on small sample size (n =
12). Additionally, participants were dropped from the multi-
variate analyses because of incomplete surveys (n = 78).
Sample demographics are shown by sexual attraction in
Table 1. Most participants reported living in the United States
(83 %; n = 482). Of the 18 other countries (n = 99), 41 % were
from Europe; 41 % Canada and Mexico; 12 % Australia; 5 %
Asia; and 1 % South America. The mean age of the sample
was 27 years (SD = 8.03; range, 18 to 71). The majority
(82 %) of the sample was White. Most (83 %) of the sample
had at least some college education and the majority of the
sample reported working full or part-time jobs (55 %), while
29 % indicated they were students. Over half (63 %) of the
sample reported a gross annual income of $25,000 or less.
About a third of participants (31 %) were living without dis-
closing their transgender history or, colloquially,‘‘stealth.’’
Just over two-thirds (67 %) of the sample reported taking
testosterone at the time of the survey. The majority (89 %) of
these participantswere using intramuscular injection of testos-
terone, with other participants reporting using gel, subcutane-
ous injection, cream, patches, or implants. Reported injection
frequencies ranged from weekly to every 4 weeks. Of those who
had not taken testosterone, the majority (86 %) desired to do so in
the future. A total of 238 (41 %) participants reported having had
chest reconstructive surgery (CRS), including double incision,
peri-areolar, or liposuction, and 21 (4 %) reported having had
genital reconstructive surgery (GRS), including phalloplasty,
metoidioplasty, vaginectomy, centurion, and/or testicular implants.
Of the FTMs who have not undergone the procedure, 92 %
desired CRS and 39 % desired GRS.
At the time of the assessment, most (52 %) participants
reported attractions to both men and women, 31 % reported
attractions to women only, and 17 % reported attractions to
men only. Although all participants were classified into one of
three sexual orientation groups, participants used many dif-
ferent words to define their sexual orientation. The most
common word used was‘‘queer’’(n = 183; 31 %). See Table 2
for the distribution of self-reported sexual orientation iden-
tities by attraction. Of those who had begun their transition at
the time of the assessment (N = 507), more than one-third
(40 %) reported a shift in sexual attractions (n = 203). Table 3
summarizes the direction of attraction shift among the par-
ticipants who had started their transition at the time of the
assessment.
Measures
Depression, Anxiety, Stress Scales
The DASS is a 42-item measure of depression, anxiety, and
stress experienced over the past week (Lovibond & Lovi-
bond, 1995a). The DASS demonstrates concurrent and con-
struct validity in the acceptable to excellent range (Antony,
Bieling, Cox, Enns, & Swinson, 1998). The DASS uses a
4-point Likert response scale, 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. The scale has been shown to correlate .74 with
the Beck Depression Inventory and .81 with the Beck Anxiety
Inventory (Lovibond & Lovibond, 1995b). Reliability for the
total scale was excellent (a = .96). The Cronbach’s reliability
coefficients for the subscales were .96 (depression), .87 (anxi-
ety), and .92 (stress), suggesting good to excellent internal
consistency. Higher scores on each scale indicate more symp-
toms of depression and anxiety and higher levels of stress.
Multidimensional Scale of Perceived Social Support
The MSPSS is a 12-item scale that assesses social support
from friends, family, and a significant other (Zimet, Dahlem,
Zimet, & Farley, 1988). This study used the total support
subscale. Responses werebased on a 7-point Likert scale rang-
ing from 1 (very strongly disagree) to 7 (very strongly agree).
The three subscales have adequate discriminant, concurrent,
andconstructvalidities(Clara,Cox, Enns,Murray, & Torgrud,
2003). Internal consistency for this subscale was good (a =
.90). Higher scores indicate higher levels of perceived social
support.
Short Form 36-Item Questionnaire Version 2
The SF-36v2 is a comprehensive measure of quality of life. It
has been used with FTM samples in previous research and is
valid for online use (Newfield et al., 2006). It yields eight sub-
scales with reliabilities in the .93 to .95 range for all subscales
(Ware, 2003). The current study used the General Health
subscale, which demonstrated good reliability (a = .84). The
5 items from the General Health subscale use a 5-point Likert
scale from 1 (poor) to 5 (excellent) and 1 (definitely true) to 5
(definitely false). Higher scores indicate higher levels of
quality of life.
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Sexual Attraction
FTMs were asked to indicate whether they were attracted to
men (AM), attracted to women (AW), attracted to both (AB),
or attracted to neither (AN). Sexual attraction was based on
what was reported at the time of the assessment. Participants
were also asked to define their sexual orientation in their own
words and to indicate if their sexual attractions had shifted,
Table 1 Demographic variables by sexual orientation
Variable AM
a
AB
b
AW
c
Statistical analysis
N (%) N (%) N (%)
Ethnicity v
2
(2) = 3.2
Hispanic 4 (4 %) 25 (8 %) 18 (10 %)
Race v
2
(10) = 19.4, p\.05
Black or API
d
2 (2 %) 6 (2 %) 16 (9 %)
i
Caucasian 88 (87 %) 245 (81 %) 140 (79 %)
Multi-racial and Other 10 (10 %) 50 (17 %) 22 (12 %)
Education v
2
(10) = 5.3
HS/GED or less 11 (11 %) 33 (11 %) 17 (10.0 %)
Associate’s or 8 (8 %) 14 (5 %) 14 (7.9 %)
Technical School
Some College 38 (38 %) 116 (39 %) 66 (37.1 %)
Bachelor’s 21 (21 %) 71 (24 %) 49 (27.5 %)
Post-Grad 21 (21 %) 66 (22 %) 31 (17.4 %)
Work Status v
2
(12) = 17.0
Full Time 28 (28 %) 130 (43 %) 73 (41 %)
Part Time 11 (11 %) 44 (15 %) 29 (16 %)
Unemployed 16 (16 %) 27 (9 %) 16 (9 %)
Disability 3 (3 %) 9 (3 %) 7 (4 %)
Student 38 (38 %) 83 (28 %) 50 (28 %)
Other
e
3 (3 %) 7 (2 %) 2 (1 %)
Income v
2
(20) = 39.4, p\.01
\$5,000 37 (37 %)
i
69 (23 %) 40 (23 %)
$5,000–24,999 35 (35 %) 116 (38 %) 70 (39 %)
[$25,000 27 (27 %) 115 (38 %) 67 (38 %)
HRT
f
v
2
(2) = 1.9
Yes 65 (64 %) 210 (70 %) 114 (64 %)
CRS
g
v
2
(2) = 1.3
Yes 46 (46 %) 119 (39 %) 73 (41 %)
GRS
h
v
2
(2) = 3.5
Yes 4 (4 %) 7 (2 %) 10 (6 %)
Non-Disclosing or‘‘Stealth’’ v
2
(2) = 3.1
Yes 26 (26 %) 88 (29 %) 63 (35 %)
Total 101 302 178
Values represent number of participants over the age of 18, excluding asexual participants (N = 581). Total percents may not add up to 100 due to missing
cases
a
Attracted to men
b
Attracted to men and women
c
Attracted to women
d
Asian Pacific Islander
e
Temporary, homemaker, or retired
f
Hormone replacement therapy: Testosterone
g
Chest reconstruction surgery
h
Genital reconstruction surgery
i
Significant difference
Arch Sex Behav
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including the direction of the shift, since the start of their
transition. For the purpose of this study, any participant who
selected ‘‘attracted to neither’’ (n = 12) was coded as ‘‘asex-
ual’’ and was not included in the analyses due to inadequate
sample size.
Procedure
As the FTM population is considered a‘‘hidden population,’’
use of the Internet for data collection is warranted (Rosser,
Oakes, Bockting, & Miner, 2007). Participants were recruited
via study advertisements circulated through online groups
and discussion forums on LiveJournal, YouTube, and Face-
book that were dedicated to FTM issues. FTM forum mod-
erators approved all research announcements prior to online
posting. Interested participants were directed to a secure web-
site. Inclusion criteria were persons who were assigned female at
birth and who currently identified as FTM or who once identified
as FTM but now identify as male (Newfield et al., 2006).
Participants read an online informed consent page prior to
completing the survey and provided consent to participate by
clicking an‘‘I consent’’button. Upon survey completion, par-
ticipants were entered into a lottery drawing for cash prizes. A
graduate student research award to the first author provided
funds for this research.
The online survey took approximately 25 minutes to com-
plete. The 160-question survey was hosted on a secure server
affiliated with the University of Houston. Data were collected
from a secure web-based server called Hosted Survey. The
Committee for the Protection of Human Subjects at the Uni-
versity of Houston approved subject recruitment. During the
survey, participants were required to answer every item on
each page in order to move to the next page. In order to insure
thatnoparticipantcouldsubmitmorethanoneresponseset,the
server denied access to the survey to anyone with the identical
IP address as a previous participant.
Data Analysis
The data were analyzed using PASW 18.0 (PASW Inc., Chi-
cago, IL). Independent samples chi-square and t-tests were
conducted to determine significant differences in demograph-
ics between sexual orientation groups, and independent sam-
ples chi-square tests were used to analyze whether or not there
was a reliableshift in sexual orientation after gendertransition.
An independent samples chi-square was conducted to deter-
mine the relationship between sexual orientation shift and
testosterone use, a logistic regression was conducted to deter-
mine if pre-transition sexual attraction and testosterone use
contributed independent variance to sexual attraction change,
and a between-subjects MANOVA was used to determine sig-
nificant differences in psychosocial well-being among sexual
orientation groups. The depression, anxiety, and stress variables
were all positively skewed and the social support and quality of
life variables were all negatively skewed; thus, a log-transfor-
mation was used for these data. For the MANOVA, the Pillai’s
Trace F value was used to adjust for deviations from normality
and unequal sample sizes. The psychosocial well-being table
presents non-transformed data.
Results
Univariate Analyses
Univariate analyses revealed that FTMs of varying sexual
attractions did not differ by any demographic variables except
income and race. Specifically, AW FTMs reported higher lev-
els of income than AM or AB FTMsand AW FTMs were more
likely to be Black or Asian than AM or AB FTMs. Refer to
Table 2 Sexual orientation labels by attractions
Labels AM
a
AB
b
AW
c
N (%) N (%) N (%)
Queer 20 (19.6) 116 (35.7) 47 (27.2)
Straight/heterosexual 12 (3.7) 109 (63.0)
Gay/homosexual/faggot 75 (73.5) 14 (4.3) 4 (2.3)
Pansexual 1 (1.0) 73 (22.5) 2 (1.2)
Bisexual 2 (2.0) 74 (22.8)
Flexible/fluid 4 (3.9) 9 (2.8) 3 (1.7)
Other
d
13 (4.0) 1 (0.6)
Lesbian 7 (2.2) 7 (4.0)
(Poly)sexual or genderqueer 7 (2.2)
Numbers will not add up to totals, as some participants listed more than
one label to describe their sexual orientation
a
Attracted to men
b
Attracted to men and women
c
Attracted to women
d
Other includes‘‘nothing,’’‘‘unsure,’’‘‘open,’’ or‘‘undefined’’
Table 3 Shifts in sexual attractions
Attractions After transition
AM AB AW
AM 49 14 5
(72 %) (21 %) (7 %)
Before AB 27 131 8
Transition (16 %) (79 %) (5 %)
AW 16 133 124
(6 %) (49 %) (45 %)
Values represent number of participants over the age of 18, excluding
asexual participants, and participants who had not started their transition
(n = 74). Here,‘‘transition’’includes identifying as male, living as male,
hormone, and/or surgical treatment
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Table 1 for the relevant statisticalanalyses.Participantsdid not
differ by age, F(2, 578)\1.
In order to examine if the participants reported a change in
their sexual orientation after transition, a 3 (Group: Sexual
Orientation before Transition) 9 2 (Sexual Orientation Shift
after Transition: Yes vs. No) chi-square analysis was conducted,
v
2
(2) = 53.02, p\.001, indicating non-independence. Results
from three paired contrast analyses showed that those who were
AW before transition were more likely to report a change in
sexual attraction after transition than the other two groups (pre-
transition AM vs. AB v
2
(1)\1, AM vs. AW 14.4, p\.001, and
AB vs. AW, v
2
(1) = 46.2, p\.001).
A separate analysis was conducted to determine whether tes-
tosterone was relatedtoshiftsin sexual attraction.A chi-square
testdemonstrateda significant relationshipbetweensexualori-
entationshift(Yes vs. No) andtestosteroneuse (Yes vs. No),v
2
(1) = 22.81, p\.001.
A logistic regression analyses was conducted order to deter-
mine if pre-transition sexual attraction (AW vs. AM vs. AB) and
testosterone use (Yes vs. No) contribute independent variance to
the outcome of sexual attraction change (Change vs. No Change).
A test of the full model against a constant only model was sig-
nificant for pre-transition sexual attraction, v
2
(2) = 49.49, p\
.0001, but not for testosterone use, v
2
(1)\1. Specifically, rel-
ative to participants who did not report a change sexual attrac-
tion, the odds of a shift in sexual attraction were significantly
higher for participants who self-reported being AW pre-tran-
sition (OR = 4.35; 95 % CI = 2.78 6.67, p\.0001).
Psychosocial Well-Being
As expected, depression, anxiety, and stress were positively
correlated; social support and quality of life were also posi-
tively correlated; depression, anxiety, and stress scores were
each negatively correlated with social support and quality of
life (Table 4). The significant correlations provide evidence
for good discriminant validity and the small to moderate cor-
relations indicated that the scales measured related, yet distinct
constructs. Thus, the dependent variables were appropriate for
use in multivariate analyses of variance (MANOVAs).
The means and standard deviations of the dependent vari-
ablesfor thethree groups areshownin Table 5. Mean scores for
almost all variables in each group fell within the normal range
fordepressivesymptoms,anxietysymptoms,andstress. Of the
542 participants who completed the DASS, 37 (7 %) scored in
the severe range and 30 (6 %) scored in the extreme range of
depressive symptoms. For anxiety symptoms, 21 (4 %) scored
in the severe range and 20 (4 %) scored in the extreme range.
For stress, 22 (4 %) participants scored in the severe range and
5 (1 %) scored in the extreme range.
Bivariate correlations were conducted to determine if there
was a relationship between the psychosocial well-being variables
and length of time on testosterone. Depression, anxiety, and
stress were each negatively correlated with length of time
on testosterone, r(524) =-.16, p\.001; r(526) =-.20, p\
.001; r(526) =-.17, p\.001. A positive correlation was
found between time on testosterone and social support, r(543) =
.17, p\.001. No significant relationship was found between
length of time on testosterone and general health quality of life
r(491) = .07.
Multivariate Analyses
To test whether FTMs of varying sexual orientations differed on
clinical variables, we conducted a between-subjects MANOVA
of sexual orientation on the dependent variables of depression,
anxiety, stress, social support, and quality of life. As predicted,
there emerged an overall significant effect of sexual orientation,
F(10, 994) = 3.02, p\.01. Specifically, AB FTMs reported
more symptoms of anxiety than AM FTMs (contrast estimate
.14; p\.01) (see Table 6). There was no significant difference
between AW FTMs and either AM or AB FTMs.
There was no main effect of sexual orientation group on
depression, F(2,502) =
2.99, stress, F(2, 502) = 2.40, perceived
social support, F(2, 502) = 2.06, or health related quality of life,
F(2, 502) = 1.80.
Discussion
The current study highlights the diversity of sexual attrac-
tions experienced in a community sample of FTMs and the
data demonstrate generally healthy levels of psychosocial
well-being. While it was expected that the majority of FTMs
would report an exclusive attraction towards women (APA,
2000; Chivers & Bailey, 2000), the majority of FTMs were
attracted to both men and women. Further, half of previously
AW FTMs reported a shift in attractions to both men and
women. Together, these trends both support the more recent
research on the greater sexual fluidity observed among natal
females (Diamond, 2008; Diamond, Pardo, & Butterworth,
2011), and complicate the idea that attraction towards other
men is rare among FTMs.
Over the past 25 years, there has been an increasing accep-
tance towards non-heterosexual sexual attractions and a
greater range of observable gender nonconforming expres-
sions (Bockting et al., 2009; Devor, 1993a). In the present
study, many FTMs described their sexual attractions using a
variety of labels, including‘‘queer,’’an identity term that indi-
cates a desire to be understood outside of a classificatory
system altogether (Gamson, 1995). Therefore, although it is
difficult to construct more clinically or ‘‘research-friendly’’
categories of sexual orientations among the transgender popu-
lation, if a classification system based on sexual orientation is
used for this population, it must be more comprehensive than
Arch Sex Behav
123
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existing typologies and consider including attractions to other
transgender persons.
Overall, findings from the psychological analyses sug-
gested that FTMs of differing sexual orientations are more
alike than different. For example, the only significant differ-
ence in these profiles was that AB FTMs reported slightly
more anxiety than did AM FTMs, a finding consistent with the
research literature. Gay and bisexual NT men, for example,
havebeen found to report more symptoms of anxiety than their
heterosexual counterparts (Cochran, Sullivan, & Mays, 2003;
Fergusson, Harwood, & Beautrais, 1999). Moreover, in accor-
dance with minority stress theory (Meyer, 1995), FTMs of dif-
fering sexual attractions in the current sample may share similar
amounts of stress from being transgender in a largely sex-gender
congruent society.
The nature and size of the community sample itself may
help to explain the higher than anticipated AB and AM prev-
alence and the relatively healthy psychosocial outcomes.
While the large sample size may more adequately represent
thispopulation,thenon-clinicalnatureof thisstudymayrender
direct comparisons with clinical samples difficult. Further,
these results may be linked to the younger age and overwhelm-
ingly white racial prevalence of the current sample. Significant
racial health disparities have been found in transgender samples,
including higher rates of HIV and lower rates of health insurance
among trans people of color (Bith-Melander et al., 2010; Kenagy,
2005; Xavier, Bobbin, Singer, & Budd, 2005).
Shift in Sexual Attractions
In the present study, 40 % of participants who had transitioned
reported a shift in their sexual attraction and these shifts were
significantly associated with testosterone use. However, fur-
ther examination of predictors of sexual attraction shifts revealed
that once we accounted for pre-transition sexual attraction,
testosterone use was no longer predictive of a shift. Specifically,
those FTMs who were AW pre-transition were most likely to
report a change in their sexual attraction, regardless of testos-
terone use. The most common change in sexual attractions in
FTMs appears to be an increase in attractions to men. Given that
the current study was correlational, it is not clear what caused the
shifts in sexual attraction or whether the attractions reported had
been present prior to transition were always present, but not
expressed.
FTMs are more open to exploring a range of sexual attrac-
tions when their gender identity is in alignment with their
bodies (Schleifer, 2006). In addition, pre-transition FTMs may
not have pursued attractions to birth-assigned males because
they did not want to be objectified as female-bodied persons
(Devor, 1993a). Thus, it is possible that being perceived as
male by sexual partners minimizes concerns over unequal or
sexist treatment within the context of a sexual relationship,
that, coupled with an increased sex drive due to testosterone,
mayallowFTMstomoreeasilyexplore attractions to men
(Devor, 1993a;Dozier,2005; Schleifer, 2006). Male-pre-
senting AM FTMs who have had chest surgery and/or use
testosterone,butwhohavenotundergonegenitalmodification,
do not report elevated identity confusion or any intimacy dis-
ruption with their NT male sexual partners (Coleman & Bock-
ting, 1988; 1991). Moreover, FTMs who have not had genital
modifications have incorporated their vaginas into erotic activ-
ities with other gay men.
Psychosocial Well-Being
One of the primary aims of this study was to determine if there
were differences in psychological well-being among FTMs
with varying sexual orientations. In contrast with earlier lit-
erature using clinical samples, the between group median
psychological well-being scores of this sample were all in the
normative range (Lovibond & Lovibond, 1995a; Ware, Ko-
sinski, & Dewey,
2000; Zimet et al., 1988). A majority of the
sample did not fall in the clinical range for depression or
anxiety, and the sample overall had higher quality of life
scores than the U.S. national average (Ware et al., 2000).
These data do not support the claim that FTMs are overall
Table 4 Correlation Matrix (Pearson’s)
Depression Anxiety Stress Social
Support
Quality
of Life
Depression –
Anxiety .57*** –
Stress .65*** .70*** –
Social Support -.33*** -.23*** -.19*** –
Quality of Life -.31*** -.37*** -.33*** .20*** –
*** p\.001
Table 5 Means and SD for dependent variables by sexual attraction
Dependent
Variable
AM AW AB Norms
M (SD) M (SD) M (SD)
Depression
a
8.81 (9.27) 7.53 (8.88) 9.13 (8.98) 0–9
Anxiety
a
** 4.20 (5.53)
d
4.80 (5.20) 5.57 (5.82)
d
0–7
Stress
a
9.27 (7.45) 9.77 (7.66) 10.97 (7.75) 0–14
Social
Support
b
4.89 (1.12) 5.18 (1.21) 5.17 (1.05) 5.8
(.86)
Quality of
Life
c
58.85 (24.81) 64.77 (23.25) 60.81 (20.48) 50 (10)
All values presented are based on untransformed data
** p\.01
a
Absolute range 0–42
b
Absolute range 1–7
c
Absolute range 0–100
d
Indicates which groups are significantly different
Arch Sex Behav
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more likely than the general population to suffer from mental
disorders (Bodlund, Kullgren, Sundbom, & Hojerback, 1993;
De Cuypere, Janes, & Rubens, 1995; Hepp, Kramer, Schny-
der, Miller, & Delsignore, 2005). Finally, these data were
consistent with more recent peer-reviewed reports that found
fewer psychiatric problems in transgender samples than those
from just a decade ago (Cole, O’Boyle, Emory, & Meyer,
1997; Hoshiai et al., 2010; Lawrence & Zucker, 2012). While
this study did not assess psychological distress prior to tran-
sition, a significant correlation suggested that the longer FTMs
are on testosterone, the fewer negative psychological symp-
toms and more social support they report receiving.
The large number of participants enabled us to detect small
differences between groups. In general, there were few differ-
ences noted across the psychosocial well-being variables exam-
ined. Indeed, the only statistically significant difference observed
was that AB FTMs reported more anxiety symptoms than AM
FTMs. Because our data revealed small effect sizes, however,
and because the overall mean and median scores of the groups
wereinthemildto normalranges,eventhis difference,maynot
be clinically significant.
A possible explanation for the difference in anxiety is that
AB FTMs are a double minority (Coleman et al., 1993)and,as
such, they may experience challenges unique to both trans and
bisexual individuals; these include invisibility, lack of valida-
tion, and marginalization, including from LGB and trans
populations (Fox, 2003). These exclusions can interrupt the
social reintegration that follows a gender transition, leaving
one feeling unseen and/or unwitnessed by support groups and
healthcare professionals (DiPlacidio, 1998; Herek et al., 2009;
Meyer, 2003).
Limitations
Potential limitations of this study stem from the use of the
internet for participant recruitment and participation. First, it
is impossible to verify that all participants actually identify as
FTM or were assigned female at birth. Second, it is possible
that participants displayed a positive response bias, given that
past research has pathologized transgender identities (Lev,
2004).Third,though our sample was large, non-clinically based,
and diverse in many aspects, it was largely white. Fourth, the
participants’ high educational level and willingness to partici-
pate in sexuality research may index a more liberal or‘‘adventur-
ous’’set of attitudes than would a more representative sample of
FTMs. As FTMs tend to use online groups to seek information
and navigate their transition, the participants in this study may
represent a particular subset of FTMs. Fifth, the study lacked a
concurrent NT heterosexual control group. Without any type of
comparison groups (those with a ‘‘clinical problem’’ or a non-
clinical group) matched to our sample, it is difficult to interpret
the lower scores found in this study.
Other significant limitations of this study include the clas-
sification scheme used for measuring sexual orientation and
the lack of diagnostic tools. Although the sexual orientation
measure used in the current study was informed by the DSM-
IV-TR’s classification scheme, scales that provide more options
and that measure differences over time may better capture the
diversity of FTMs’ sexual attractions.In addition, formal diag-
noses of depression and anxiety could not be made in this sam-
ple. Therefore, while the differences found in this study indi-
cated that AB FTMs report more symptoms of anxiety than
AM FTMs, the findings did not indicate that AB FTMs were
more likely to be clinically depressed or anxious.
Clinical Implications
As this study demonstrates, there was a greater range of attrac-
tions among FTMsthan‘‘straight’’or‘‘gay.’’Inaddition, a large
portion (40 %) of FTMs surveyed reported a shift in sexual
attraction. Following this study, it remains questionable how
useful it is to have only four (if any) sexual orientation speci-
fiers in the DSM. The DSM-5 proposed revisions to the GID
diagnosisactuallyincludetheremovalofthesexualorientation
specifiers (APA, 2012).
Second, the literature is mixed on how to reference sexual
orientation labels among transgender populations (APA, 2009).
In the present study, FTMs who self-labeled as ‘‘homosexual’’
generally reported exclusive attractions towards men. Indeed,
participants primarily used sexual orientation labels consistent
with their gender identity rather than their birth sex as the ref-
erent. Thus, assigned sex-based sexual orientation labels do not
seem related to FTMs’ lived experience and may not be clini-
cally or therapeutically appropriate.
Third,because thisstudy’s designand samplewere not clin-
ical in nature, the data were limited regarding how many par-
ticipants met the formal criteria for GID. Several prospective
reports,however,demonstrate thatclinicaldistress–ahallmark
of GID–dissipates following a medically necessary gender tran-
sition (Cohen-Kettenis & Gooren, 1999;deVries,Steensma
Doreleijers, & Cohen-Kettenis, 2010; Smith et al., 2005). The
most recent WPATH recommendations state that a GID
diagnosis is not a required medical indication for initiating a
Table 6 Multivariate analysis of variance for sexual orientation
Source F(2, 501) Partial g
2
Power
Overall 3.02**
Univariate tests
Depression 2.99 .01 .58
Anxiety 4.65** .02 .78
Stress 2.40 .01 .48
Social Support 2.06 .01 .42
Quality of Life 1.79 .01 .38
Analyses were conducted on log transformed data
** p\.01
Arch Sex Behav
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transition, including beginning to live in one’s asserted gender
role. The relevanceof a GID diagnosisin a discussionof sexual
orientation shifts or psychosocial well-being is unclear.
As of the writing of this manuscript, the sexual orientation
specifier for the DSM-5 Gender Dysphoria diagnosis will
most likely be removed. The results of the current study sup-
port the removal of this specifier. However, it has been sug-
gested that there may be different developmental trajecto-
ries and causal mechanisms for gender dysphoria as a func-
tion of sexual attraction in MTFs (Blanchard, 1989;Luders
et al., 2011). At present, the role that sexual attraction plays in the
development of gender dysphoria in FTMs remains unclear.
Future Directions and Conclusion
Reports of shifts in sexual orientation among trans people are
not a new phenomenon (Daskalos, 1998). In this study, the
majority of FTMs who experienced shifts in sexual attrac-
tions reported that these attractions shifted away from women
and towards either men or men and women both, as in Swaab
(2004), and these shifts were significantly related to testos-
terone use. While exogenous testosterone may have played a
role, further analysis regarding its mechanisms is warranted.
Additional questions of interest include whether and to what
extent AM FTMs represent a historically underrepresented
group or an expansion of the range of attractions available to
this population, due to changing hormones, virilization, and/
or increased sex drive.
Prior research remains inconclusive regarding whether shifts
in partner preferences are biological, social, or some combina-
tion thereof. Perhaps the process of masculinization, both social
and physical, allows FTMs to enjoy the full range of their
already-present attractions, because their bodies no longer
restrict their intimate relationships (Devor, 1993b). The
observed shift in sexual attractions may support Diamond’s
(2008) contention that birth-assigned females have more‘‘fluid’’
sexual orientations.
In sum, it is recommended that researchers and clinicians do
not use sexual orientation as a method of diagnostic specifica-
tion in community samples of FTMs. Moreover, it is both clin-
ically and theoretically important to acknowledge a more fluid
rangeofsexualattractionsamongstFTMs.Currentdatasupport
that there are more psychological similarities than differ-
ences between FTMs of all sexual attractions, and that this
larger, non-clinical sample reveals a population with good
mental health.
Acknowledgments This work was supported by the Graduate Student
Research Proposal Award from the Texas Psychological Foundation, the
Student Research Award from the LGBT Special Interest Group of the
Association of Behavioral and Cognitive Therapies, and the Peggy Rudd
scholarship fromthe Houston Transgender Unity Committee. The authors
would like to thank Dr. Carla Sharp for her thoughtful comments
throughout the revision process.
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