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The question of whether gender identity disorder, also known as
transsexualism, goes hand in hand with psychiatric problems
has been investigated in a number of studies.
1–10
Still, the
relationship between psychiatric morbidity and transsexualism
remains a hot topic for researchers. Furthermore, the classification
of gender identity disorder or transsexualism in the forthcoming
DSM-5 and ICD-11 as a mental disorder is being questioned.
11
The aetiology of gender identity disorder also remains unclear.
The relationship between this disorder and psychiatric morbidity
is of great clinical importance, as follow-up studies have
demonstrated that psychiatric comorbidity is one of the major
negative prognostic features for the outcome of gender reassign-
ment surgery.
12,13
Furthermore, debate on whether psychiatric
comorbidity and psychosocial dysfunctioning are a consequence
rather than a cause of gender identity disorder is ongoing.
However, research shows contradictory findings concerning the
prevalence of coexisting psychiatric problems. Some studies of
psychological functioning of individuals with gender identity
disorder report a high prevalence of psychiatric comorbidity,
1–4
whereas other studies show results comparable with the general
population.
5–8
Furthermore, differenc es in psychiatric comorbidity
and psychosocial functioning have been described between people
depending on the direction of their gender reassignment (male to
female v. female to male), and between individuals with early
(pre-pubertal) onset and late (post-pubertal) onset gender
identity disorder; most studies found more psychological
problems in male to female reassignment,
2,7–9
whereas Bodlund
et al reported more personalit y disorders in people who had
undergone female to male procedures.
10
Although there is no
single, generally accepted definition of early- and late-onset
transsexual development as yet,
14
some studies have found that
people with late-onset transsexualism showed more psychiatric
problems than those with early-onset transsexualism.
15
The contradictory findings of the aforementioned studies are
due partially to methodological differences, different ways of
collecting data and differences in chosen instruments. Moreover,
some studies suffer from serious flaws such as selection bias. As
long as 30 years ago, Lothstein criticised the lack of systematic
assessment and objective data collection.
16
During recent decades
the quality of research on gender identity disorder has improved
substantially, resulting in larger and more reliable data-sets;
nevertheless, large, prospective multicentre European studies w ith
systematic data collection are still lacking. Our study is intended
to fill this gap as part of the European Network for the
Investigation of Gender Incongruence (ENIGI), an international
collaboration initiated to set up diagnostic protocols and
assessment batteries.
17
The major aim of our study was to
investigate the prevalence of psychiatric problems in individuals
with gender identity disorder seeking gender reassignment
therapy. We compared different groups in terms of direction of
gender reassignment, time of onset, comparison with the general
population and clinic attended.
Method
Four countries participate in the ENIGI network: The Netherlands,
Belgium, Germany and Norway.
17
Data were collected in
Amsterdam, Ghent, Hamburg and Oslo between January 2007
and October 2010. The study was approved by the local ethics
committees.
Participants
Adults seeking gender reassignment therapy and surgery at the
four gender clinics were asked to participate. Patients were
1
Psychiatric characteristics in transsexual
individuals: multicentre study in four European
countries
Gunter Heylens, Els Elaut, Baudewijntje P. C. Kreukels, Muirne C. S. Paap, Susanne Cerwenka,
Hertha Richter-Appelt, Peggy T. Cohen-Kettenis, Ira R. Haraldsen and Griet De Cuypere
Background
Research into the relationship between gender identity
disorder and psychiatric problems has shown contradictory
results.
Aims
To investigate psychiatric problems in adults fulfilling DSM-IV-
TR criteria for a diagnosis of gender identity disorder.
Method
Data were collected within the European Network for the
Investigation of Gender Incongruence using the Mini
International Neuropsychiatric Interview – Plus and the
Structured Clinical Interview for DSM-IV Axis II Disorders
(n = 305).
Results
In 38% of the individuals with gender identity disorder a
current DSM-IV-TR Axis I diagnosis was found, mainly
affective disorders and anxiety disorders. Furthermore,
almost 70% had a current and lifetime diagnosis. All four
countries showed a similar prevalence, except for affective
and anxiety disorders, and no difference was found between
individuals with early-onset and late-onset disorder. An Axis II
diagnosis was found in 15% of all individuals with gender
identity disorder, which is comparable to the general
population.
Conclusions
People with gender identity disorder show more psychiatric
problems than the general population; mostly affective and
anxiety problems are found.
Declaration of interest
None.
The British Journal of Psychiatry
1–6. doi: 10.1192/bjp.bp.112.121954
excluded from the study if they were experiencing psychosis at the
time of assessment, were under 17 years old or had insufficient
command of the language of the country in which they lived. Both
self- administered questionnaires and clinical interviews were used
in all gender identity clinics. All data were collected within the first
6 months of the diagnostic phase. All clinicians involved were
trained psychologists or psychiatrists with experience in the field
of gender identity disorder.
Measures
Gender identity disorder
Clinicians used a self-constructed scoring sheet with 23 items
based on the DSM-IV-TR symptoms and diagnostic criteria for
gender identity disorder and gender identity disorder in childhood
(see the online supplement to this paper).
18,19
These items
consisted of a combination of a symptom and an ‘aspect’ (severity,
onset, duration, frequency and persistence); see Paap et al for a
detailed analysis of this instrument).
18
Gender dysphoria
The Utrecht Gender Dysphoria Scale (UGDS) was used to
measure the degree of experienced gender dysphoria.
20
Axis I disorders
The Mini International Neuropsychiatric Interview – Plus version
5.0.0 (MINI-Plus) was used to measure Axis I diagnoses.
21
This is
a short, structured diagnostic interview for DSM-IV psychiatric
disorders, allowing clinicians to assess Axis I diagnoses at the time
of the interview (‘current diagnosis’) and disorders that have a
longer history (‘current and lifetime diagnosis’).
Axis II disorders
The Structured Clinical Interview for DSM-IV Axis II Personalit y
Disorders (SCID-II) was used to assess Axis II diagnoses; this is
a semi-structured clinical interv iew.
22
For logistic reasons the
SCID-II was not administered in The Netherlands. As a
consequence, results regarding Axis II disorders are based on data
from Ghent, Hamburg and Oslo only.
Terminology
In this paper we use the term ‘gender identity disorder’ only when
we refer to the clinical diagnosis.
Onset
Disorders were labelled as ‘early-onset’ when they met both
criteria A and B for a diagnosis of gender identity disorder in
childhood (see the online supplement); if they fulfilled neither
criterion, they were categorised as ‘late-onset’ gender identity
disorder. A residual group comprised cases fulfilling only one
criterion (A or B).
14
Statistical analysis
Chi-squared tests were used to test for differences in the
occurrence of psychiatric problems among groups. The variables
we tested included: gender (male to female v. female to male),
country (Belgium, Germany, The Netherlands, Norway) and onset
age (early v. late). Analyses were performed separately for Axis I
and Axis II disorders. Axis I disorders were divided into six
clusters: affective, anxiety, eating, substance-related, psychotic
and other disorders. If marked differences were found for a certain
group of disorders, a logistic regression analysis was performed
with the psychiatric disorder as dependent variable and the group
variables as independent variables to gain more insight in the
relative contributions of each of the group variables in predicting
whether or not the disorder was present. All analyses were
conducted using SPSS version 16.0.1 for Windows.
Results
During the inclusion period 846 persons applied for treatment at
the four gender clinics. Of these applicants, 125 were excluded
from the study owing to an insufficient command of the language
of the questionnaires (n = 57, 46%), refusal to participate (n = 37,
30%), clear psychotic symptoms at the time of application (n = 16,
13%) or for other reasons (n = 15, 11%). Consequently, 721
individuals completed at least one diagnostic instrument (Fig.
1). Some instruments were not completed owing to withdrawal
(failing to attend consultations) or refusal to participate in the
clinical interviews. Sample characteristics with regard to gender
ratio, onset age and age at assessment are shown in Table 1. At
the end of the inclusion period 305 individuals fulfilled criteria
for early- or late-onset gender identit y disorder and had been
assessed by means of the MINI-Plus and/or the SCID-II. Forty-
one applicants did not fulfil the gender identity disorder criteria
and 140 were categorised into the residual gender identity disorder
group. Of our final sample of 305 participants, 182 (59.7%)
requested male to female and 123 (40.3%) female to male
reassignment.
Axis I disorders
Almost 70% of the final sample of 305 participants showed one
or more Axis I disorders current and lifetime (Table 2), mostly
affective and anxiety disorders (respectively 60% and 28%).
Prevalence rates were similar in both genders. No association
2
Heylens et al
Applicants attending
gender identity clinic
n =846
Applicants included
n =721
Applicants completing
assessment measure
n =486
Excluded: n = 125
(language difficiulties 57,
refusal to participate 37,
psychotic symptoms 16,
other reasons, 15)
Withdrawals
n =235
Participants with gender
identity disorder
(early or late onset)
assessed w ith MINI-Plus
and/or SCID-II
n =305
Participants with
no gender disorder
n =41
Residual group
n = 140
Fig. 1 Selection procedure and numbers of participants: early
onset (fulfilled both DSM-IV criteria A and B in childho od); late
onset (neither DSM-IV criterion); residual group (one criterion).
MINI-Plus, Mini International Neuropsychiatric Interview – Plus;
SCID-II, Structured Clinical Interview for DSM Axis II Disorders.
Psychiatric characteristics in transsexualism
was found between the presence of a current and lifetime Axis I
diagnosis and age at assessment (P = 0.189). Patients with a
current Axis I diagnosis were younger than those without one
(P = 0.017). The degree of gender dysphoria was not associated
with the presence of an Axis I diagnosis in general, neither was
it associated with specific diagnoses such as depressive episode,
panic attack, agoraphobia or substance-related problems. In the
total cohort there was no difference in the prevalence of Axis I
disorders between the early- and late-onset subgroups and this
was true for both genders (P = 0.6 for the total cohort, P =0.4 for
themaletofemalegroupandP = 0.9 for the female to male group).
With regard to the prevalence of Axis I disorders among the
four countries, we found a difference between countries among
male to female transsexual subgroups, both for current and
current and lifetime diagnoses (P=0.001 for current diagnoses,
P = 0.009 for current and lifetime diagnoses). Male to female
transsexual patients in Germany and Norway showed higher
prevalence rates compared with those in Belgium and The
Netherlands. No difference was found between the female to male
transsexual subgroups. Differences between countries were found
for the affective cluster (P = 0.001 for both current and lifetime
and current) and anxiety cluster (P = 0.029 for current and
lifetime, P = 0.028 for current). In Germany, up to 80% of
participants with the diagnosis of gender identity disorder showed
affective symptoms currently or in the past compared with
approximately 50% in the other countries. The Dutch patients
had fewer anxiety symptoms currently or in the past compared
with the other countries (20% rather than 30–40%).
In almost 30% of the participants suicide risk was identified
(meaning they had suicidal ideations and/or plans during the
3
Table 1 Sample ch aracteristics with regard to ge nder ratio, ons et age and age at asse ssment
Belgium
n =63
Germany
n =57
The Netherlands
n = 147
Norway
n =38
All countries
n = 305 P
a
Gender ratio (MtF:FtM) 2.15:1 1.04:1 2.27:1 0.47:1 1.48:1 50.0001
MtF, n 43 29 102 8 182
FtM, n 20 28 45 30 123
Age at onset, n (%)
Early onset
MtF 25 (58) 13 (45) 50 (49) 4 (50) 92 (51)
FtM 20 (100) 24 (86) 37 (82) 29 (97) 110 (89)
Late onset
MtF 90 (49) 0.01
b
FtM 13 (11)
Age at assessment, years: mean (s.d.)
MtF 35.6 (9.9) 34.6 (11.8) 36.5 (13.2) 21.6 (3.7) 35.3 (12.3) 50.0001
c
FtM 29.9 (9.0) 29.2 (10.8) 31.2 (11.3) 22.8 (5.4) 28.5 (10.1)
FtM, female to male reassignment; MtF, male to female reassignment.
a. Differences between countries for the MtF plus FtM groups combined.
b. Early v. late onset.
c. Kruskal–Wallis test.
Table 2 Axis I comorbidity in the f our countries assessed with the Mini Interna tional Neuropsychiatric Interview – Plus
Belgium Germany The Netherlands Norway All countries P
a
Gender, n
MtF 43 28 102 7 180
FtM 20 25 45 28 118
One or more Axis I disorders, n (%)
Current NS
MtF 13 (30) 15 (54) 34 (33) 7 (100) 69 (38)
FtM 8 (40) 12 (48) 16 (36) 8 (29) 44 (37)
Current and lifetime NS
MtF 25 (58) 25 (89) 66 (65) 7 (100) 123 (68)
FtM 19 (95) 18 (72) 30 (67) 17 (61) 84 (71)
Affective disorders, n (%)
Current 8 (13) 21 (40) 37 (25) 15 (43) 81 (27) 0.005
Current and lifetime 29 (46) 43 (81) 88 (60) 19 (54) 179 (60) 50.0001
Anxiety disorders, n (%)
Current 14 (22) 13 (24) 15 (10) 8 (23) 50 (17) 0.035
Current and lifetime 24 (38) 20 (38) 31 (21) 10 (29) 85 (28) 0.020
Substance-related disorders, n (%)
Current 4 (6) 4 (8) 14 (10) 2 (6) 24 (8) NS
Current and lifetime 16 (25) 6 (11) 23 (16) 2 (6) 47 (16) 0.028
Eating disorders, n (%)
Current 1 (2) 1 (2) 0 (0) 0 (0) 2 (1) NS
Current and lifetime 1 (2) 2 (4) 1 (1) 2 (6) 6 (2) NS
Psychotic disorder s, n (%)
Current and lifetime 0 (0) 0 (0) 3 (2) 1 (3) 4 (1) NS
FtM, female to male reassignment; MtF, male to female reassignment; NS, not significant.
a. Difference between countries for the MtF plus FtM groups combined.
Heylens et al
preceding month and/or had ever attempted suicide). Female to
male and male to female subgroups reported similar degrees of
suicidal ideation (P = 0.671). There was no difference between
the early- and late-onset groups (P = 0.165). Suicide risk was
not associated with having an Axis II diagnosis (P = 0.536). No
difference was found between the four countries.
A logistic regression was performed with ‘affective disorder’ as
a dependent variable to gain a better understanding of the factors
that might be associated with the differences between the
countries. We chose to retain only significant effects in the final
model. A forward step-wise strategy was used, adding the
following variables one at a time: assessment age (430 years v.
430 years), onset age, gender and country. Interaction effects
between variables were also calculated and added to the model.
Our final model contained the variables country, gender and
country6gender. The main effects of country and gender were
no longer significant when the interaction effect was added. The
interaction effect indicated that people undergoing male to
female reassignment were more likely to have an affective disorder
in Germany (odds ratio (OR) = 11.4, P = 0.013) and Norway
(OR = 20.0, P = 0.014); Belgium was used as the reference category.
No difference between the countries was found for the female to
male subgroups.
Axis II disorders
Schizoid, avoidant and borderline personality disorders were most
prevalent, in 5%, 4% and 7% of our sample respectively. The
overall prevalence rate for personality disorders was 15%
(Table 3). No difference was found between the male to female
transsexual group (12% had one or more personality disorders)
and the female to male group (one or more personality disorders
in 18%). The Axis II prevalence rates were similar in the three
countries. In the total cohort and in the male to female subgroup
there was no difference in prevalence of Axis II disorders between
the early- and late-onset groups. In the female to male group,
individuals with late-onset disorder had significantly more
personality disorders (P = 0.003). Individuals showing borderline
personality disorder were younger at the time of application to
the clinic (P = 0.009); this group also showed a trend towards
stronger gender dysphoria (P = 0.073). Personality disorders were
also clustered in three groups. Cluster C disorders were most
common (63% of all personality disorders), followed by cluster
B (45%) and cluster A (41%). No difference was found
between the four countries with regard to clusters of personality
disorders.
Discussion
Overall, we found that Axis I disorders were more common in
applicants for treatment of gender identity disorder compared
with the general populations of the participating countries.
23–26
On closer inspection we found that this difference was mainly
due to affective and anxiety disorders, with the gender identity
disorder group showing higher rates than the general population.
This was the case in all four countries and for both male to female
and female to male reassignment groups. Other Axis I clusters
were found to be equally prevalent compared with the general
population. Although the prevalence rates of affective and anxiety
disorders in the general population differed slightly between the
four countries, this cannot fully account for the differences we
found in our population. A new study would be needed to assess
which factors (e.g. patient and clinician characteristics or social
differences among the countries) might explain these findings.
The incongruence between gender identity and social life and/
or bodily characteristics experienced by individuals diagnosed
with gender identity disorder can cause much distress that may
lead to affective and anxiety problems and even disorders.
Follow-up studies often show a resolution of depressive and
anxious symptoms throughout the treatment process.
27–29
Furthermore, the phenomenon of ‘minority stress’ can also
explain the high prevalence of affective disorders. Social
discrimination and stigmatisation may cause a diminished quality
of life, particularly with regard to mental health.
30
The findings with regard to the prevalence of suicide risk
confirm results on this topic.
8,31,32
Terada et al reported that the
high prevalence of suicidality in their gender identity disorder
population was not related to psychiatric comorbidity.
32
This
suggests that gender identity disorder is an independent risk factor
for suicidal behaviour and this could be interpreted as an
(inappropriate) coping strategy.
31
In a report on suicide and
suicide risk in transgender populations, Haas et al emphasised
high suicide and suicide attempt rates.
32
Besides the high
prevalence of depression, anxiety and substance misuse in these
populations, factors such as parental rejection and discrimination
are linked to elevated risk of suicidal behaviour. A longitudinal
study in lesbian, gay, bisexual and transgender youth by Liu &
Mustanski showed that childhood gender non-conformity and
victimisation were associated with increased risk of self-harm
and suicidal ideation.
33
In our study, suicidality was assessed using
the MINI-Plus interview, which was also used to measure Axis I
disorders; we therefore could not investigate whether there was
an association between suicide risk and having an Axis I disorder.
No association was found between suicide risk and the presence of
personality disorder, which again illustrates that gender identity
disorder may be an independent risk factor for suicidality.
Major psychiatric disorders such as bipolar disorder or
psychosis were rarely found and did not exceed prevalence in
the general population.
23–25
Since the presence of psychosis was
explicitly defined as an exclusion criterion, there was a severe bias.
However, the low number of applicants (16 of 846) excluded for
this reason does not suggest that our findings were a severe
underestimation of the true prevalence.
Comparison between the prevalence of Axis I disorders in our
study and rates in the general population should be interpreted
with caution: epidemiological studies in different countries use
4
Table 3 Axis II disorders assessed with the Structured Clinical Interview for DSM-IV Axis II Personality Disorders
Belgium
n =60
Germany
n =55
Norway
n =29
All countries
n = 144 P
a
One or more Axis II disorders, n (%) 10 (17) 10 (18) 2 (7) 22 (15) NS
Cluster A 4 (7) 3 (6) 2 (7) 9 (6) NS
Cluster B 5 (8) 3 (6) 2 (7) 10 (7) NS
Cluster C 8 (13) 6 (11) 0 (0) 14 (10) NS
NS, not significant.
a. Difference between countries.
Psychiatric characteristics in transsexualism
different instruments and sometimes data on certain clinical
categories are simply missing. Still, it is clear that the prevalence
of both current and current and lifetime Axis I disorders in our
study population is higher than in the general population of all
four countries. This difference is mainly due to the high
prevalence (up to three times higher compared with the general
population) of affective and anxiety disorders. For example,
current affective problems occur at rates between 6% (Belgium
and The Netherlands) and 11–12% (Germany and Norway) in
the general population, whereas in our sample prevalence rates
ranged from 13% and 25% (Belgium and The Netherlands) to
40% and 35% (Germany and Norway).
23–26
The European Study
of the Epidemiology of Mental Disorders (ESEMeD) project,
conducted in six European countries (including Belgium,
Germany and The Netherlands), found a lifetime prevalence of
any mental disorder in 25% of respondents, a much lower
percentage than in our cohort (see above). Any mood disorder
and any anxiety disorder were found in 14%. Women were twice
as likely to have any mental problem compared with men, espe-
cially with regard to mood and anxiety disorders which occurred
two to three times more frequently in women.
34
In our sample
Axis I disorders were equally distributed in the male to female
and female to male reassignment subgroups, except in Norway
where they were more common in the female to male group.
The low degree of psychopathology with regard to personality
disorders replicates the findings of some earlier studies,
35
but
contradicts the high prevalence of such disorders found in similar
studies by Hepp et al and Madeddu et al: both studies also used
the SCID-II interview and included only people with gender
identity disorder,
4,36
as we did in our study. A potential
explanation for our findings contradicting those of Hepp et al
and Madeddu et al could be that some individuals with a
personality disorder were more reluctant to participate in our
study owing to a lack of confidence in professional caregivers.
Our findings accord wi th prevalence rates of personality disorders
in the general population of Germany (10.0%) and Norway
(13.4%).
37,38
No information on prevalence exists for Belgium;
however, in The Netherlands the prevalence is 13.5%.
39
Moreover,
the distribution in clusters of personality disorders found in this
study resembles the distribution found in epidemiological studies
in Germany, Norway and The Netherlands.
37–39
Statistics on the
Axis II data should be interpreted with caution, owing to the
low numbers in most disorder categories.
In contrast to some reports (and the general impression
among clinicians) that individuals with late-onset gender identity
disorder are more psychiatrically affected,
15
no difference
concerning psychiatric comorbidity, whether Axis I and Axis II,
was found between individuals with early- v. late-onset disorder.
The only exception was among the female to male reassignment
group, in which those with late-onset disorder showed more Axis
II problems than those with early-onset disorder, but numbers
were very small (only four individuals in the late-onset group)
and this finding needs to be replicated in a larger study.
In conclusion, our findings show that individuals with gender
identity disorder have more psychiatric problems than the general
population: mostly these are affective and anxiety problems.
Although more decisive conclusions cannot be drawn owing to
the cross-sectional design of our study, psychopathological
symptoms seem to be closely related to the individual’s long-
standing and strongly felt identification with the other gender.
Further research should focus on long-term follow-up studies
using standardised diagnostic and therapeutic protocols in order
to determine whether the Axis I diagnosis rate decreases with
treatment and whether such a decrease manifests in any particular
subcategor y of patient. This might lead to a better understanding
of the nature of gender identity disorder and of the psychiatric
symptoms experienced in connection with this disorder.
Acknowledgements
The authors wish to thank all clinicians who participated in this study, collected the data
and were responsible for the data entry
.
Gunter Heylens, MD, Els Elaut, MSc, Department of Sexology and Gender
Problems, University Hospital Ghent, Belgium; Baudewijntje P. C. Kreukels, PhD,
Department of Medical Psychology, VU University Hospital, Amsterdam, The
Netherlands; Muirne C. S. Paap, PhD, Department of Research Methodology,
Measurement and Data Analysis, Behavioural Sciences, Susanne Cerwenka, Mr.Sc,
Hertha Richter-Appelt, PhD, Department of Sex Research and Forensic Psychiatry,
University Medical Centre Hamburg-Eppendorf, Germany; Peggy T. Cohen-Kettenis,
PhD, Department of Medical Psychology, VU University Hospital Amsterdam, The
Netherlands; Ira R. Haraldsen, MD, PhD, Department of Neuropsychiatry and
Psychosomatic Medicine, Rikshospitalet Oslo, Norway; Griet De Cuypere, MD, PhD,
Department of Sexology and Gender Problems, University Hospital Ghent, Belgium
Correspondence: Gunter Heylens, Department of Sexol ogy and Gender
Problems, University Hospital Ghent De Pintelaan 185, 9000 Ghent, Belgium.
Email: gunte r.heylens@uzgent.be
First received 18 Oct 2012, final revision 31 Jan 2013, accepted 4 Mar 2013
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